Resumption of Warfarin After Intracranial Hemorrhage in Patients With Mechanical Heart Valves: A Systematic Review and Meta-Analysis

Background: Resuming anticoagulation in patients with mechanical heart valves after intracranial hemorrhage presents a clinical dilemma. The optimal timing must balance the risk of thromboembolism against hemorrhagic expansion. Prior studies have addressed this issue, but most were limited by small sample sizes. This systematic review and meta-analysis aimed to determine the optimal timing for anticoagulation resumption in this population. Methods: We conducted a systematic review and meta-analysis using PubMed, Embase, Web of Science, and Scopus from database inception to August 23, 2024. The target population included adults with intracranial hemorrhage who required anticoagulation for mechanical heart valves. Results: Thirteen studies involving 788 patients were included: 12 retrospective and 1 prospective observational study. While off anticoagulation, 32 patients developed ischemic stroke, with a pooled event rate of 5.23% (95% CI, 3.80-7.20%) and negligible heterogeneity (I2 = 0%). The pooled average time to stroke was 8.08 days (95% CI, 1.99-14.18). After anticoagulation resumption, 73 patients experienced hemorrhagic recurrence, corresponding to a pooled event rate of 10.95%, with nonsignificant heterogeneity (I2 = 40.4%). Conclusions: Withholding anticoagulation for up to 7 days after intracranial hemorrhage in patients with mechanical heart valves appears relatively safe. Hemorrhagic recurrence after resumption was more common than ischemic stroke during interruption. However, the included studies were observational and carried serious or critical risk of bias. Prospective multicenter studies, and ideally randomized trials, are needed to provide more definitive evidence.