Resumption of anticoagulation after intracranial bleeding in patients with prosthetic heart valves.

Letters to the Editor will be published, if suitable, as space permits. They should not exceed 1,000 words (typed double-spaced) in length, and may be subject to editing or abridgment. To the Editor: We would like to bring to your attention our recent dilemma of when to re-anticoagulate a patient with a hypertensive cerebral hemorrhage who concurrently has a prosthetic heart valve. The patient, a 63-year-old woman, had had her aortic heart valve replaced in 1978 with a modified Bjork-Shiley prosthetic valve and had been taking warfarin without bleeding complications. She was also hypertensive and treated with enalapril. She was admitted to a local community hospital after having been found unconscious and was later noted to have a right hemiparesis with attention, language, and memory abnormalities. Computed tomography (CT scan) showed a left thalamic hemorrhage that had extended into the third ventricle, the internal capsule, and the caudate nucleus. The anticoagulant was stopped after admission, and she was transferred to our service a few days later. We faced the difficult decision of whether to restart the warfarin and risk the possibility of rebleeding or to wait an indefinite period of time during which the risk of embolization would be great. An extensive literature search directed at guiding our strategy was fruitless. We decided to treat her with platelet antiaggregants for 2 weeks (empirically chosen) and then restart the warfarin. On Day 10, however, she became completely unresponsive to verbal stimuli, inattentive to her surroundings, and showed complete motor deficit. Repeat CT scan failed to show any new areas of bleeding, and she was therefore started on heparin i.v. drip at a rate of 800 units/hr without any preceding loading dose. In <24 hours she began to improve and eventually was switched from heparin to warfarin. No rebleeding occurred and her neurologic condition has remained stable. Literature supporting a rationale for re-anticoagulating patients in this setting is not available. Although the natural history of intracerebral hemorrhage suggests that this is a monophasic event, it is unknown whether the addition of anticoagulant drugs increases the risk of rebleeding. We suggest that reinstitution of anticoagulant therapy after the first 10 days following an intracerebral hemorrhage may be a rational option. If this form of therapy is contemplated, it appears prudent to use slowly increasing dose schedules rather than large initial doses. To the Editor: Recipients of prosthetic heart valves are anticoagulated because they …