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J R Soc Med 2004;97:308-309
doi:10.1258/jrsm.97.6.308-a
© 2004 Royal Society of Medicine

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J R Soc Med 2004;97:308-309
© 2004 The Royal Society of Medicine

Dilemmas in managing intracerebral haemorrhage and thromboembolism

R Fuller1 N J Dudley2 J Maule3   T Stewart4

1 Elderly Services, General Infirmary at Leeds, Leeds LS1 3EX, UK
2 St James's University Hospital, Leeds LS9 7TF, UK
3 Centre for Decision Research, Leeds University Business School, Leeds LS2 9JT, UK
4 Department of Statistical Sciences, University of Cape Town, 7701 Rondebosch, South Africa Correspondence to: Dr R Fuller E-mail: ftworf{at}aol.com

Dr Shah and Dr Dawson's dilemma (March 2004 JRSM1) of managing intracerebral haemorrhage (ICH) in a patient previously anticoagulated for a prosthetic heart valve will be familiar to many clinicians. Whilst re-anticoagulation would be current practice, this is based on perceptions that the benefits of thromboembolism prevention surpass the risks of re-haemorrhage.2 Such decisions are prone to recall or availability bias, given the varying risks of valve thromboembolism and the fragmentary evidence base on risks of rebleeding with further antithrombotics/anticoagulants.

Clinical trials are unlikely to resolve this dilemma, not least because of the difficulty of recruiting sufficient participants. Decision analysis presents an alternative solution—developing a framework in which to combine variations in multiple probabilities within a mathematical model. Such techniques allow examination of current practices where no consensus exists, using a range of values/scenarios to test the feasibility of the model. These techniques have already seen successful use in re-examining evidence-based guidelines and in assessing decision-making in atrial fibrillation and intracerebral haemorrhage.3,4

We are currently constructing a decision model to explore the dilemma faced by Shah and Dawson, testing the effects of using anticoagulants and antiplatelet agents in patients with mechanical valves and ICH. A key test of decision modelling outcomes is to review them against current practices, and it is noteworthy that recent case reports have highlighted the potential short-term use of antiplatelet agents such as aspirin and clopidogrel in place of immediate anticoagulation following cerebral bleeding.5

REFERENCES

  1. Shah N, Dawson SL. Intracerebral haemorrhage, prosthetic heart valve and anticoagulation. J R Soc Med.2004; 97:129 -30[Free Full Text]

  2. Crawley F, Bevan D, Wren D. Management of intracranial bleeding associated with anticoagulation: balancing the risk of further bleeding against thromboembolism from prosthetic heart valves. J Neurol Neurosurg Psychiatry2000; 69:396 -8[Abstract/Free Full Text]

  3. Sarasin FP. Decision analysis and the implementation of evidence-based medicine. Quart J Med1999; 92:669 -71

  4. Eckman MH, Rosand J, Knudsen KA, Singer DE, Greenberg SM et al. Can patients be anticoagulated after intracerebral haemorrhage? A decision analysis. Stroke2003; 34:1710 -16[Abstract/Free Full Text]

  5. Timperley J, Clarke NRA, Banning AP. New antiplatelet agents and prosthetic heart valves. Quart J Med2002; 95:706 -7


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