Restarting Anticoagulation/Antiplatelet Therapy Post-ICH

Introduction to Anticoagulation and Antiplatelet Therapy

The American College of Cardiology recommends that parenteral anticoagulation can be started within 1-3 days with close monitoring in patients at very high risk of myocardial infarction who have suffered intracranial hemorrhage, particularly using unfractionated heparin due to its short half-life and reversibility 1, 2
The 2020 ACC Expert Consensus provides guidance that parenteral anticoagulants can be initiated within 1-3 days in patients with high thrombotic risk once hemostasis is achieved and the patient is clinically stable 1, 2

For patients at very high thrombotic risk, unfractionated heparin by IV infusion is specifically recommended because protamine sulfate can rapidly reverse anticoagulation if rebleeding occurs 1, 2, 3
The American Heart Association/American Stroke Association stroke guidelines state that urgent anticoagulation for the management of non-cerebrovascular conditions is not recommended for patients with moderate-to-severe strokes due to an increased risk of serious intracranial hemorrhagic complications (Class III; Level of Evidence A) 8, 9, 10

Recent 2023 guidelines indicate antiplatelet therapy can be restarted beyond 24 hours after ICH symptom onset in patients with prior indications 4, 5
The RESTART trial demonstrated that resuming antiplatelet therapy after ICH did not increase recurrent ICH risk (adjusted HR 0.71, 95% CI 0.48-1.05) and reduced major adverse cardiovascular events 6

For anticoagulation needs, start unfractionated heparin IV at 1-3 days post-ICH with continuous monitoring 1, 2, 3
For antiplatelet needs, consider aspirin monotherapy starting at 24 hours to a few days post-ICH 4, 5

Day 1-3: Start IV unfractionated heparin with aPTT monitoring every 4-6 hours 1, 2
Day 7-10: Transition to oral anticoagulation if no rebleeding 7
Involve neurology, cardiology, and neurosurgery in decision-making 1, 2