Introduction: Left ventricular-assist devices (LVAD) have increased survival and quality of life of patients with heart failure. Patients with LVAD have increased risks of ischemic and hemorrhagic cerebrovascular events due to device thrombosis and combined use of antiplatelet and anticoagulant agents. The safety of transient interruption of combined antithrombotic therapy after stroke is unknown.
Hypothesis: Time to resumption of combined antiplatelet and anticoagulant therapy after stroke is not associated with the incidence of recurrent cerebrovascular event.
Methods: We defined the study cohort of patients who received an LVAD using ICD-9 codes. We obtained data for patients with new cerebrovascular events while on a Heartmate-II or Heartware LVAD, and excluded those deceased from the initial event. We divided patient-events into two cohorts based on the index event: ischemic (TIA, stroke) or hemorrhagic (all intracranial hemorrhages, ICH). We used Fisher’s exact test to assess the association between recurrent ischemic event or ICH and time off combined antithrombotic therapy. We pre-specified variables for adjustment in the logistic regression analysis: age, cardiovascular risk factors, LVAD model, indication and endpoint, NIHSS score, INR and LDH levels, and baseline and change in antithrombotic therapy.
Results: The study included 48 patient-events between 2011 and 2016: 23 (48%) were ischemic (9 (40%) TIA and 14 (60%) infarcts) and 25 (52%) hemorrhagic. The ischemic event cohort had 9 (39%) recurrences, including 6 (67%) ischemic and 3 (33%) ICH. Median time to recurrence was 118 (IQR 78-388) days. All patients continued on antiplatelet, and maximum time off anticoagulant was 2 (median 0) days. Time off combined therapy was not associated with ischemic (p=0.43) or hemorrhagic recurrence (p=1.00). The ICH cohort had three (12%) recurrences: 1 (33%) ischemic and 2 (67%) hemorrhagic. Median time to recurrence was 158 (IQR 32-586) days. Median time off combined therapy was 7 (0-15) days, and not associated with ischemic (p=0.43) or hemorrhagic recurrence (p=0.83).
Conclusion: In patients with LVAD, transient interruption of combined antithrombotic therapy after stroke is not associated with increased risk of recurrent cerebrovascular events.