Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review

Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines

BACKGROUND

Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa).

AIM

To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed.

METHODS

This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data.

RESULTS

GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications.

CONCLUSIONS

The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.

Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study

Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.

Emergency management of stroke in the era of mechanical thrombectomy

Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.

A review of oral anticoagulants, old and new, in major bleeding and the need for urgent surgery

Oral anticoagulants, old and new, are effective therapies for prevention and treatment of venous thromboembolism and reduction of stroke risk in patients with atrial fibrillation. However, blocking elements of the clotting cascade carries an inherent risk of bleeding. Also, anticoagulated patients sometimes require urgent surgery or invasive procedures. This has led to the emergence of a body of scientific literature on the reversal of anticoagulation in these two settings. Traditionally, vitamin K antagonists (VKAs), which indirectly inactivate clotting factors II, VII, IX and X (and natural anticoagulant proteins C and S), had been the mainstay of oral anticoagulation for half a century. Only a few years ago, the US Food and Drug Administration (FDA) approved a specific VKA reversal agent, 4-Factor Prothrombin Complex Concentrate (4F-PCC). The last decade has seen the rise of non-Vitamin K oral anticoagulants (NOACs), which target specific factors, i.e. Factors IIa and Xa. Investigators have rapidly developed reversal agents for these agents as well, idarucizumab for the Factor IIa inhibitor dabigatran (Pradaxa) and andexanet alfa for the entire class of Factor Xa inhibitors (FXaIs), currently four drugs: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa) and betrixaban (Bevyxxa). Clinicians still use off-label PCC for reversing FXaIs in some settings, and a universal reversal agent, ciraparantag, remains in development. This review summarizes the safety and efficacy of these reversal agents in the setting of anticoagulant-associated major bleeding and the need for urgent surgery.

Periprocedural Use of Oral Anticoagulation Therapy in Patients Undergoing Atrial Fibrillation Ablation

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice today. For those who present with it, one of the most major risks associated with the condition is stroke. AF is associated with a fivefold increased risk of stroke and thromboembolism. Oral anticoagulation has been the cornerstone of stroke prevention in patients with AF. In some individuals who exhibit a higher risk of bleeding, other alternatives for stroke prevention have been sought, including the use of left atrial appendage occlusion devices and surgical exclusion of the left atrial appendage. Catheter ablation is an important treatment strategy in those patients for whom a rhythm control strategy has been selected. This article reviews some of the available anticoagulant drug options and their use prior to, during, and after catheter ablation.

Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Bleeding in Neurosurgical Patients: A Single-Center Experience

Objective: The number of patients presenting with warfarin-associated intracranial bleeding and needing neurosurgical intervention is growing. Prothrombin complex concentrate (PCC) is commonly used for anti-coagulation reversal before emergent surgery. We present our experience with PCC use in patients presenting with coagulopathy and needing urgent craniotomy. Methods: We retrospectively identified all patients presenting with intracranial bleeding and coagulopathy due to warfarin use, requiring urgent neurosurgical procedures, from January, 2014 (implementation of 4-PCC therapy) until December, 2016. For coagulation reversal, all patients received 4-PCC (Octaplex) and vitamin K. Results: Thirty-five consecutive patients (17 men; median age 72 years) were administered 4-PCC before emergent neurosurgical procedures. The majority of patients presented with traumatic subdural hematoma (62%) and spontaneous intracerebral hemorrhage (32%). All patients were taking warfarin. Median international normalized ratio (INR) on admission was 2.94 (range: 1.20 to 8.60). Median 4-PCC dose was 2000 I.U. (range: 500 I.U. to 3000 I.U.). There was a statically significant decrease in INR (p < 0.01), PT (p < 0.01), and PTT (p = 0.02) after 4-PCC administration. Postoperative INR values were ≤3.00 in all patients, and seven (20%) patients had normal INR values. There were no 4-PCC related complications. Four (11%) patients developed subdural/epidural hematoma and 20 (57%) patients died. Mortality was associated with lower Glasgow coma scale (GCS) score. Conclusions: The 4-PCC facilitates INR reversal and surgery in patients presenting with warfarin-associated coagulopathy and intracranial bleeding requiring urgent neurosurgical intervention.

Benefits and harms of 4-factor prothrombin complex concentrate for reversal of vitamin K antagonist associated bleeding: a systematic review and meta-analysis

Prothrombin complex concentrate (PCC) is used for reversal of vitamin K antagonists (VKA) in patients with bleeding complications. This study aims to assess benefits and harms of 4-factor PCC compared to fresh frozen plasma (FFP) or no treatment in VKA associated bleeding. PubMed, EMBASE and CENTRAL were searched from 1945 to August 2015. Studies reporting 4-factor PCC use for VKA associated bleeding and providing data on INR normalization, mortality or thromboembolic (TE) complications were eligible. Two authors screened titles and full articles for inclusion, extracted data, and assessed risk of bias. Mortality data were pooled using Mantel–Haenszel random effects meta-analysis. Nineteen studies were included (N = 2878); 18 cohort studies and one RCT. Six studies had good methodological quality, 9 moderate and 4 poor. Baseline INR values ranged from 2.2 to >20. The INR within 1 h after PCC administration ranged from 1.4 to 1.9, and after FFP administration from 2.2 to 12. PCC reduced the time to reach INR correction in comparison with FFP or no treatment. The observed mortality rate ranged from 0 to 43% (mean 17%) in the PCC, 4.8–54% (mean 16%) in the FFP and 23–69% (mean 51%) in the no treatment group. Meta-analysis of mortality data resulted in an OR of 0.64 (95% confidence interval [CI] 0.27–1.5) for PCC versus FFP and an OR 0.41 (95% CI 0.13–1.3) for PCC versus no treatment. TE complications were observed in 0–18% (mean 2.5%) of PCC and in 6.4% of FFP recipients. Four-factor PCC is an effective and safe option in reversal of VKA bleeding events.

Use of three procoagulants in improving bleeding outcomes in the warfarin patient with intracranial hemorrhage

: When patients on anticoagulation present with intracranial bleeding, stopping the bleeding is paramount. Despite the availability of multiple options to reverse anticoagulation, no study has directly compared the effectiveness of the procoagulants recombinant activated factor VII (rFVIIa), the rFVIIa and 3-factor prothrombin complex concentrate (PCC) combination, and 4-factor PCC on improving patient outcomes compared with a control. This study examined the medical records of 197 warfarin patients with intracranial hemorrhage, an initial international normalized ratio (INR) greater than 1.5, and who received rFVIIa (26), the combination (84), 4-PCC (50), or no procoagulant, the control group (37). Mortality, length of stay, location discharged, change in INR prior to and postdrug administration, plasma use, and number of thromboembolic complications were used to assess effectiveness. Although INR decreased in all groups (1.31 rFVIIa vs. 2.04 combination vs. 1.41 4-PCC vs. 1.20 control, P = 0.07), the combination group had the greatest percentage to reach an INR of less than 1.3 (46.2 vs. 73.8 vs. 58.0 vs. 43.2%, P = 0.004). The combination and control groups experienced a high, though nonsignificant, number of thromboembolic complications (5.6 vs. 19.0 vs. 7.7 vs. 12.9%, P = 0.533). The rFVIIa group used the most plasma and had the longest length of stay. Mortality did not differ significantly among groups. Although the combination improved INR compared with control, this had a high number of complications. Judicious use of procoagulants is recommended due to their expense and lack of significant improvement in outcomes compared with control.

Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug-drug and drug-food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.

Evidence-Based Care of Geriatric Trauma Patients

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

Intracerebral Hemorrhagic Expansion Occurs in Patients Using Non-Vitamin K Antagonist Oral Anticoagulants Comparable with Patients Using Warfarin

BACKGROUND

Non-vitamin K antagonist oral anticoagulant (NOAC) use has significantly reduced intracerebral hemorrhagic (ICH) risk compared with standard anticoagulant treatment. Hematoma expansion (HE) is a known predictor of mortality in warfarin-associated ICH. Little is known about HE in patients using NOACs.

METHODS

We conducted a retrospective chart review of patients with ICH admitted to Cedars-Sinai Medical Center from October 2010 to June 2016. We identified patients with concomitant administration of an oral anticoagulant and collected data including evidence of HE on imaging and modified Rankin Scale (mRS) at discharge. We defined HE as relative (≥33% increase) or absolute expansion (≥12 mL). We compared outcomes of patients with and without HE.

RESULTS

Out of 814 patients with ICH who were admitted, we identified 9 patients with recent NOAC use and 18 intentionally matched controls on warfarin. We found no significant differences in National Institutes of Health Stroke Scale or ICH score on presentation (median [interquartile range] 15 [5,21] versus 7 [1.25,19.5] [P = .41] and 2 [1,4] versus 1 [1,3] [P = .33]) between patients on NOACs and those on warfarin. Four out of the 9 patients on NOAC and 5 of the 18 patients on warfarin demonstrated HE, with no significant difference (P = .42). There were no significant differences in mRS on discharge between groups (P = .52).

CONCLUSIONS

In our coagulopathic NOAC patient population, HE occurs within 6 hours in 44% of patients. This case series did not have sufficient statistical power to detect significant differences between the groups. To our knowledge, this is one of the largest case series reporting on HE with concomitant NOAC use.

Management of neurologic complications of coagulopathies

Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.

Rapid Anticoagulation Reversal With Prothrombin Complex Concentrate Before Emergency Brain Tumor Surgery

BACKGROUND

Brain tumors may become symptomatic due to intracranial hypertension and patients may present to emergency departments in life-threatening conditions. Hence, emergency brain tumor surgery has to be considered, but sufficient hemostasis has to be present when initiating surgical procedures. Impaired hemostasis because of oral anticoagulation for the treatment of cardiovascular diseases is encountered in a growing number of patients. Here we present the first case series of anticoagulated patients receiving prothrombin complex concentrate (PCC) to rapidly restore hemostasis and facilitate emergency brain tumor surgery.

METHODS

We retrospectively analyzed our institutional database of neurosurgical patients receiving PCC from February 2007 to April 2013 (n=432) and identified 5 patients who received PCC before emergency brain tumor surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of hemostasis were analyzed.

RESULTS

Patients had a mean Glasgow Coma Scale score of 9.4 at admission. Mean international normalized ratio was 3.75±1.98 and after administration of PCC (mean, 3260±942 IU), international normalized ratio significantly decreased to 1.19±0.07 (P<0.0001). Emergency brain tumor surgery was initiated within 5.2 hours (range, 0 to 13.5 h) after PCC administration. Diagnostic histopathology revealed metastasis (n=2), meningioma (n=2), and ependymoma (n=1). No hemorrhagic or thromboembolic events occurred and 4 patients had a good neurological outcome at hospital discharge. One patient died on the 14th postoperative day because of respiratory failure following development of pneumonia.

CONCLUSIONS

In anticoagulated patients with brain tumors requiring immediate surgery due to life-threatening conditions, administration of PCC rapidly and safely restored hemostasis. PCC administration seems to be an effective option for anticoagulant reversal in this patient cohort. Further observational safety studies (eg, thromboembolic events) are warranted.

Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation and Associated Intracranial Hemorrhage: A Focused Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia and predisposes patients to an increased risk of embolic stroke. After nearly 60 years, warfarin is no longer the only effective therapeutic option for patients with AF. Large randomized trials have consistently shown that non-vitamin K oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban significantly reduce from the risk of intracranial hemorrhage (ICH) compared with warfarin. We provide a focused review regarding the NOACs and ICH in AF patients by summarizing findings of these large clinical trials, mechanisms of lower ICH, reversal strategies with specific agents, and monitoring strategies.

Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial

BACKGROUND

Rapid reversal of vitamin K antagonist (VKA)-induced anticoagulation is often necessary for patients needing urgent surgical or invasive procedures. The optimum means of VKA reversal has not been established in comparative clinical trials. We compared the efficacy and safety of four-factor prothrombin complex concentrate (4F-PCC) with that of plasma in VKA-treated patients needing urgent surgical or invasive procedures.

METHODS

In a multicentre, open-label, phase 3b randomised trial we enrolled patients aged 18 years or older needing rapid VKA reversal before an urgent surgical or invasive procedure. We randomly assigned patients in a 1:1 ratio to receive vitamin K concomitant with a single dose of either 4F-PCC (Beriplex/Kcentra/Confidex; CSL Behring, Marburg, Germany) or plasma, with dosing based on international normalised ratio (INR) and weight. The primary endpoint was effective haemostasis, and the co-primary endpoint was rapid INR reduction (≤1·3 at 0·5 h after infusion end). The analyses were intended to evaluate, in a hierarchical fashion, first non-inferiority (lower limit 95% CI greater than -10% for group difference) for both endpoints, then superiority (lower limit 95% CI >0%) if non-inferiority was achieved. Adverse events and serious adverse events were reported to days 10 and 45, respectively. This trial is registered at ClinicalTrials.gov, number NCT00803101.

FINDINGS

181 patients were randomised (4F-PCC n=90; plasma n=91). The intention-to-treat efficacy population comprised 168 patients (4F-PCC, n=87; plasma, n=81). Effective haemostasis was achieved in 78 (90%) patients in the 4F-PCC group compared with 61 (75%) patients in the plasma group, demonstrating both non-inferiority and superiority of 4F-PCC over plasma (difference 14·3%, 95% CI 2·8-25·8). Rapid INR reduction was achieved in 48 (55%) patients in the 4F-PCC group compared with eight (10%) patients in the plasma group, demonstrating both non-inferiority and superiority of 4F-PCC over plasma (difference 45·3%, 95% CI 31·9-56·4). The safety profile of 4F-PCC was generally similar to that of plasma; 49 (56%) patients receiving 4F-PCC had adverse events compared with 53 (60%) patients receiving plasma. Adverse events of interest were thromboembolic adverse events (six [7%] patients receiving 4F-PCC vs seven [8%] patients receiving plasma), fluid overload or similar cardiac events (three [3%] patients vs 11 [13%] patients), and late bleeding events (three [3%] patients vs four [5%] patients).

INTERPRETATION

4F-PCC is non-inferior and superior to plasma for rapid INR reversal and effective haemostasis in patients needing VKA reversal for urgent surgical or invasive procedures.

FUNDING

CSL Behring.

The emergent reversal of coagulopathies encountered in neurosurgery and neurology: a technical note

It is imperative for neurologists, neurosurgeons, and neurointensivists to know how to stop life-threatening hemorrhage in both surgical and non-surgical patients. However, knowing how to medically correct a coagulopathy has become increasingly challenging as more contemporary and sophisticated anticoagulation agents are developed and prescribed. In a time-sensitive and life-threatening situation, where there is little margin for error, the neurosurgeon may not have ready access to information about the drug or condition that caused the coagulopathy or the information on how to treat it. This thorough review of the literature provides a comprehensive overview of the medications and conditions that can lead to persistent and/or life-threatening intracranial hemorrhage.

Four factor prothrombin complex concentrate (human): review of the pharmacology and clinical application for vitamin K antagonist reversal

Vitamin K antagonists (VKAs) have been used for decades for the treatment and prophylaxis of thromboembolic events. Due to their wide range of therapeutic indications, they are the most prescribed oral anticoagulant worldwide. However, they are associated with bleeding complications due to their narrow therapeutic range, variability in individual dose responses and laboratory monitoring, and overdoses. Despite off-label use of 3-factor prothrombin complex concentrates and recombinant activated factor VII, until recently, vitamin K and plasma were the only recommended therapeutic options for reversing VKAs in the USA. In 2013, a 4-factor prothrombin complex concentrate (4F-PCC) was approved in the USA for VKA reversal in patients with bleeding or requiring emergency surgery and invasive procedure. Recent randomized controlled clinical trials have shown that 4F-PCC (Kcentra™) is non-inferior for hemostatic efficacy and superior for international normalized ratio correction as compared to plasma and has a similar safety profile.

Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage

Patients receiving anticoagulation therapy who present with any type of intracranial hemorrhage--including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)--require urgent correction of their coagulopathy to prevent hemorrhage expansion, limit tissue damage, and facilitate surgical intervention as necessary. The focus of this review is acute ICH, but the principles of management for anticoagulation-associated ICH (AAICH) apply to patients with all types of intracranial hemorrhage, whether acute or chronic. A number of therapies--including fresh frozen plasma (FFP), intravenous vitamin K, activated and inactivated prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa)--have been used alone or in combination to treat AAICH to reverse anticoagulation, help achieve hemodynamic stability, limit hematoma expansion, and prepare the patient for possible surgical intervention. However, there is a paucity of high-quality data to direct such therapy. The use of 3-factor PCC (activated and inactivated) and rFVIIa to treat AAICH constitutes off-label use of these therapies in the United States. However, in April 2013, the US Food and Drug Administration (FDA) approved Kcentra (a 4-factor PCC) for the urgent reversal of vitamin K antagonist (VKA) anticoagulation in adults with acute major bleeding. Plasma is the only other product approved for this use in the United States. (1) Inconsistent recommendations, significant barriers (e.g., clinician-, therapy-, or logistics-based barriers), and a lack of approved treatment pathways in some institutions can be potential impediments to timely and evidence-based management of AAICH with available therapies. Patient assessment, therapy selection, whether to use a reversal or factor repletion agent alone or in combination with other agents, determination of site-of-care management, eligibility for neurosurgery, and potential hematoma evacuation are the responsibilities of the neurosurgeon, but ultimate success requires a multidisciplinary approach with consultation from the emergency department (ED) physician, pharmacist, hematologist, intensivist, neurologist, and, in some cases, the trauma surgeon.

Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients

BACKGROUND

Oral anticoagulants are commonly used in the ageing population and therefore, spine surgeons are increasingly confronted with anticoagulated patients requiring surgical therapy. 'Bridging therapies' with heparins are established in elective settings, but the time frame for haemostasis restoration may be too long for patients presenting with acute spinal pathology and impending disability. The goal of this study was to analyse the feasibility of prothrombin complex concentrate (PCC) administration to facilitate emergency spinal surgery in anticoagulated patients.

METHOD

A retrospective analysis of the institutional database of neurosurgical patients receiving PCC from February 2007 to December 2013 (n = 485) identified 18 patients who received PCC prior to emergency spinal surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of haemostasis were analysed. Furthermore, haemorrhagic complications and thromboembolic events in the further course were evaluated.

RESULTS

Spinal pathologies requiring urgent neurosurgical decompression were spinal haematoma (n = 9), spinal metastasis (n = 5), vertebral body fracture (n = 2), and disc herniation (n = 2). The mean international normalized ratio (INR) on admission was 2.27 ± 1.20 and after administration of PCC (mean: 1,944 ± 953 I.U.), INR significantly decreased to 1.12 ± 0.10 (p < 0.001). Emergency surgery was initiated within 4.4 h after PCC administration (range: 0-16.6 h). Postoperatively, symptoms improved in 12 patients (66.7 %). There were two deaths (11 %), one caused by acute myocardial infarction on the fourth postoperative day. Bleeding complications occurred in two patients (epidural haemorrhage n = 1, rectal tumour haemorrhage n = 1).

CONCLUSIONS

The administration of PCC facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation.

Use of plasma in the management of central nervous system bleeding: evidence-based consensus recommendations

INTRODUCTION

Central nervous system (CNS) hemorrhage is a potentially life-threatening condition, especially in patients with acquired coagulopathy. In this setting, treatment of CNS bleeding includes hemostatic therapy to replenish coagulation factors. There is currently a debate over the hemostatic efficacy of plasma in many clinical settings, alongside increasing concern about transfusion-associated adverse events. Despite these concerns, plasma is widely used. Moreover, plasma transfusion practice is variable and there is currently no uniform approach to treatment of traumatic, surgical or spontaneous CNS hemorrhage. This study addresses the need for guidance on the indications and potential risks of plasma transfusion in these settings. An Expert Consensus Panel was convened to develop recommendations guiding the use of plasma to treat bleeding and/or coagulopathy associated with CNS hemorrhage. The panel did not advise on the best treatment available but rather proposed recommendations to be used in the formulation of local procedures to support emergency physicians in their decision-making process.

METHODS

Evidence was systematically gathered from the literature and rated using methods established by the Scottish Intercollegiate Guidelines Network. The evidence was used to develop graded consensus recommendations, which are presented along with the evidence-based rationale for each in this report.

RESULTS

Sixty-five articles were identified covering both vitamin K antagonist-anticoagulation reversal and treatment of bleeding/coagulopathy in non-anticoagulated patients. Recommendations were then developed in four clinical scenarios within each area, and agreed on unanimously by all members of the panel.

CONCLUSION

The Panel considered plasma to be reasonable therapy for CNS hemorrhage requiring urgent correction of coagulopathy, although physicians should be prepared for potential cardiopulmonary complications, and evidence suggests that alternative therapies have superior risk-benefit profiles. Plasma could not be recommended in the absence of hemorrhage or coagulopathy. Consideration of the absolute risks and benefits of plasma therapy before transfusion is imperative.

Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study

BACKGROUND

Patients experiencing major bleeding while taking vitamin K antagonists require rapid vitamin K antagonist reversal. We performed a prospective clinical trial to compare nonactivated 4-factor prothrombin complex concentrate (4F-PCC) with plasma for urgent vitamin K antagonist reversal.

METHODS AND RESULTS

In this phase IIIb, multicenter, open-label, noninferiority trial, nonsurgical patients were randomized to 4F-PCC (containing coagulation factors II, VII, IX, and X and proteins C and S) or plasma. Primary analyses examined whether 4F-PCC was noninferior to plasma for the coprimary end points of 24-hour hemostatic efficacy from start of infusion and international normalized ratio correction (≤1.3) at 0.5 hour after end of infusion. The intention-to-treat efficacy population comprised 202 patients (4F-PCC, n=98; plasma, n=104). Median (range) baseline international normalized ratio was 3.90 (1.8-20.0) for the 4F-PCC group and 3.60 (1.9-38.9) for the plasma group. Effective hemostasis was achieved in 72.4% of patients receiving 4F-PCC versus 65.4% receiving plasma, demonstrating noninferiority (difference, 7.1% [95% confidence interval, -5.8 to 19.9]). Rapid international normalized ratio reduction was achieved in 62.2% of patients receiving 4F-PCC versus 9.6% receiving plasma, demonstrating 4F-PCC superiority (difference, 52.6% [95% confidence interval, 39.4 to 65.9]). Assessed coagulation factors were higher in the 4F-PCC group than in the plasma group from 0.5 to 3 hours after infusion start (P<0.02). The safety profile (adverse events, serious adverse events, thromboembolic events, and deaths) was similar between groups; 66 of 103 (4F-PCC group) and 71 of 109 (plasma group) patients experienced ≥1 adverse event.

CONCLUSIONS

4F-PCC is an effective alternative to plasma for urgent reversal of vitamin K antagonist therapy in major bleeding events, as demonstrated by clinical assessments of bleeding and laboratory measurements of international normalized ratio and factor levels.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00708435.

Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates

Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.

Reversal of oral anticoagulation

Although the use of dabigatran and rivaroxaban are increasing, data on the reversal of their effects are limited. The lack of reliable monitoring methods and specific reversal agents renders treatment strategies empirical, and as a result, treatment consists mainly of supportive measures. Therefore, we performed a systematic search of the PubMed database to find studies and reviews pertaining to oral anticoagulation reversal strategies. This review discusses current anticoagulation reversal recommendations for the oral anticoagulants warfarin, dabigatran, and rivaroxaban for patients at a heightened risk of bleeding, actively bleeding, or those in need of preprocedural anticoagulation reversal. We highlight the literature that shaped these recommendations and provide directions for future research to address knowledge gaps. Although reliable recommendations are available for anticoagulation reversal in patients treated with warfarin, guidance on the reversal of dabigatran and rivaroxaban is varied and equivocal. Given the increasing use of the newer agents, focused research is needed to identify effective reversal strategies and develop and implement an accurate method (assay) to guide reversal of the newer agents. Determining patient-specific factors that influence the effectiveness of reversal treatments and comparing the effectiveness of various treatment strategies are pertinent areas for future anticoagulation reversal research.

Dengue hemorrhagic fever and severe thrombocytopenia in a patient on mandatory anticoagulation: balancing two life threatening conditions: a case report

Background

Managing a severe dengue infection is a challenge specially when complicated by other comorbidities. We report a patient with dengue haemorrhagic fever and spontaneous bleeding who required mandatory anticoagulation for a prosthetic mitral valve replacement. This is the first case report in published literature describing this therapeutic dilemma.

Case presentation

A fifty one year old Sri Lankan woman was diagnosed with dengue haemorrhagic fever with bleeding manifestations. During the critical phase of her illness, the platelet count dropped to 5,000/ɥl. She was also on warfarin 7 mg daily following a prosthetic mitral valve insertion. In managing the patient, the risk of bleeding had to be balanced against the risk of valve thrombosis without anticoagulation. Warfarin was withheld when the platelet count dropped to 100,000/ɥl and restarted when it recovered above 50,000/ɥl. The patient was off anticoagulation for 10 days.

Conclusions

We managed this patient with close observation and continuous risk benefit assessments of management decisions. However, experience with one patient cannot be generalized to others. Therefore, it is essential that clinicians share their experiences in managing such difficult patients.

Catheter ablation for paroxysmal and persistent atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia seen in cardiovascular departments. Treatments include medical interventions and catheter ablation. Due to uncertainties in medical therapies for AF, and the need to continue sinus rhythm, ablation has been recently considered as a viable alternative. Many new ablation methods based on pulmonary vein isolation (PVI) have been developed.

OBJECTIVES

The primary objective of this review was to assess the beneficial and harmful effects of catheter ablation (CA) in comparison with medical treatment in patients with paroxysmal and persistent AF. The secondary objective was to determine the best regimen of CA.

SEARCH METHODS

Searches were run on The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 3 2009, MEDLINE (1950 to August 2009), EMBASE (1980 to August 2009), the Chinese Biomedical Literature Database (1978 to August 2009) and the CKNI Chinese Paper Database (1994 to 2009) . Several journals published in Chinese were also handsearched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in people with paroxysmal and persistent AF treated by any type of CA method. Two reviewers independently selected the trials for inclusion.

DATA COLLECTION AND ANALYSIS

Assessments of risk of bias were performed by two reviewers, and relative risk (RR) and 95% confidence intervals (CI) were used for dichotomous variables. Meta-analysis were performed where appropriate.

MAIN RESULTS

A total of 32 RCTs (3,560 patients) were included. RCTs were small in size and of poor quality.CA compared with medical therapies: seven RCTs indicated that CA had a better effect in inhibiting recurrence of AF [RR 0.27; 95% CI 0.18, 0.41)] but there was significant heterogeneity. There was limited evidence to suggest that sinus rhythm was restored during CA (one small trial: RR 0.28, 95% CI 0.20-0.40), and at the end of follow-up (RR 1.87, 95% CI 1.31-2.67; I(2)=83%). There were no differences in mortality (RR, 0.50, 95% CI 0.04 to 5.65), fatal and non-fatal embolic complication (RR 1.01, 95% CI 0.18 to 5.68) or death from thrombo-embolic events (RR 3.04, 95% CI 0.13 to 73.43).Comparisons of different CAs; 25 RCTs compared CA of various kinds. Circumferential pulmonary vein ablation was better than segmental pulmonary vein ablation in improving symptoms of AF (p<=0.01) and in reducing the recurrence of AF (p<0.01). There is limited evidence to suggest which ablation method was the best.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that CA may be a better treatment option compared to medical therapies in the management of persistent AF. This review was also unable to recommend the best CA method.