Outcomes of Urgent Warfarin Reversal With Frozen Plasma Versus Prothrombin Complex Concentrate in the Emergency Department

Hickey, Michael; Gatien, Mathieu; Taljaard, Monica; Aujnarain, Amiirah; Giulivi, Antonio; Perry, Jeffrey J.

doi:10.1161/circulationaha.113.001875

Cited by 127 publications

(72 citation statements)

References 20 publications

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“…24 One hour after the start of infusion, 69% Similarly, in a retrospective cohort study of FP vs Octaplex for anticoagulation reversal in the emergency department, the investigators found that the PCC resulted in faster reversal of warfarin with fewer adverse events, including heart failure and death, when compared with FP. 25 Frozen plasma…”

Section: Contraindicationsmentioning

confidence: 99%

Reversal of warfarin anticoagulation for urgent surgical procedures

Curtis

Schweitzer

Vlymen

2015

Can J Anesth/J Can Anesth

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Purpose Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. Anticoagulation must be reversed prior to most surgical procedures to prevent intraoperative bleeding. The purpose of this module is to review the options for urgent reversal of warfarin anticoagulation and the indications for each reversal agent. Selection of the appropriate agent is important to reduce unnecessary complications of treatment and to achieve optimal reversal of anticoagulation. Principal findings When urgent surgery is required for patients taking warfarin, intravenous vitamin K 1 should be used for procedures that can be delayed for six to 12 hr. Vitamin K 1 results in the activation of existing clotting factors rather than requiring the synthesis of new proteins, which allows for its relatively rapid onset of action. Intravenous vitamin K 1 acts more quickly than oral administration, with reversal of anticoagulation occurring within six to 12 hr vs 18-24 hr, respectively. If surgery cannot be delayed, prothrombin complex concentrates (PCCs) should be given, and intravenous vitamin K 1 should be infused concurrently to ensure sustained reversal of anticoagulation. The duration of action of both PCCs and plasma is six hours due to the short half-life of factor VII. Prothrombin complex concentrates contain small amounts of heparin and are contraindicated in patients with heparin-induced thrombocytopenia. Plasma should be used only if PCCs are unavailable or are contraindicated. Conclusion Reversal of warfarin anticoagulation can be achieved in a safe and timely manner when the appropriate agent is selected and administered correctly. Objectives of this Continuing Professional Development (CPD) module:After reading this module, the reader should be able to: 1. Identify the options for emergency reversal of warfarin anticoagulation; 2. Describe the dose, onset, and duration of action of agents that reverse warfarin anticoagulation; 3. List potential complications and contraindications of agents that reverse warfarin anticoagulation; 4. Choose the optimal agent for emergency reversal of warfarin anticoagulation, considering the timing of the operation and the risks and benefits of each agent.Despite increasing use of novel agents, warfarin remains the most widely prescribed oral anticoagulant in clinical use. A recent analysis of prescribing trends following regulatory approval for the newer agents showed that warfarin still accounted for over 75% of all the oral anticoagulants used. 1 Warfarin is indicated to reduce the risk of thromboembolic events in patients with atrial fibrillation, mechanical heart valves, and deep venous thrombosis, among other indications. Therefore, as the population ages, the use of anticoagulants, including warfarin, is projected to increase substantially.Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. In order to...

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Section: Contraindicationsmentioning

confidence: 99%

Reversal of warfarin anticoagulation for urgent surgical procedures

Curtis

Schweitzer

Vlymen

2015

Can J Anesth/J Can Anesth

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“…31 Heparin bridging is not necessary, apart from in patients with certain mechanical valves. In a recent metaanalysis, heparin bridging for invasive procedures and surgery in patients receiving vitamin K antagonists for AF, prosthetic heart valve or venous thromboembolism conferred a greater than five-fold increased risk for bleeding, whereas the risk of thromboembolic events was not significantly different between bridged and nonbridged patients.…”

Section: Peri-procedural Anticoagulationmentioning

confidence: 99%

Dental Procedures in Patients with Atrial Fibrillation and New Oral Anticoagulants

Tsolka

2014

Arrhythmia &Amp; Electrophysiology Review

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Novel oral anticoagulants (NOACs) represent new options for preventing stroke in patients with atrial fibrillation (AF), and have been approved for use in North America and Europe. They carry a 50 % lower risk of intracranial haemorrhage compared with warfarin, no clear interactions with food, fewer interactions with medications and no need for frequent laboratory monitoring and dose adjustments.Although they lack a specific reversal agent, their use is increasing in the western world, thus imposing upon the dentists the task of performing invasive procedures in this setting with a continually higher frequency. Magnitude of the ProblemAF is the most common sustained arrhythmia in humans and affects 1-2 % of the general population worldwide. It affects three to six million people in the US, 1,2 while in Asian countries its incidence is slightly lower. The prevalence of AF increases with age, from approximately 2 % in the general population, to 5-15 % at 80 years. 2,7,8 Thus, AF represents a modern epidemic, and the practicing dentist is expected to deal with these patients at a continually increasing frequency.AF is associated with significant morbidity, including a two-to seven-fold increased risk for stroke (average 5 % per year). [9][10][11][12] In the Framingham Study the percentage of strokes attributable to AF increases steeply from 1.5 % at 50-59 years of age to 23.5 % at 80-89 years of age.11 Approximately 20 % of all strokes are due to AF, 13 and paroxysmal AF carries the same stroke risk as permanent or persistent AF.14 Thus, chronic anticoagulation is necessary for patients with AF and CHA 2 DS 2 VASc score ≥2, whereas no anticoagulation may only be recommended in patients with negligible risk and a score of 0. The novel oral anticoagulants are now recommended for nonvalvular AF as a potential alternative to warfarin by both the European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) (see Table 1). Dabigatran is preferred to warfarin for non-valvular AF by the ESC 13 and the Canadian Cardiology Society. 15 NOACs are direct thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban, edoxaban) inhibitors. They carry a 50 % lower risk of intracranial haemorrhage compared with warfarin, no clear interactions with food, fewer interactions with medications and no need for frequent laboratory monitoring and dose adjustments. [16][17][18] Their main disadvantages are the lack of a reliable, specific antidote, specific assays to measure anticoagulant effect, and considerably higher cost than warfarin.19 NOACs do not interact with food but with inhibitors (or inducers) of P-glycoprotein transporters and cytochrome P450 (CYP) 3A4.A practical guide by the European Heart Rhythm Association (EHRA) has been published and a website created (www.NOACforAF.eu). 20The use of NOACs is continually increasing in the western world and, apart from AF, they are also used both for therapy and prevention of venous thromboembolism, 21,22 i.e. pulmonary embolism and deep ve...

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“…8,9 Consequently, until now, most of the evidence supporting the use of PCC for VKA reversal came from observational studies. 2,[10][11][12][13] In this issue of Circulation, Sarode et al 14 report the results of a phase III, open-label, noninferiority, randomized, controlled trial that compared a 4-factor PCC with fresh frozen plasma for urgent reversal of VKA-associated coagulopathy in 216 patients with acute bleeding. Despite the modest sample size and the fact that the trial enrolled 69 centers in the United States and Eastern Europe, the study took >2 years to complete.…”

Section: Article See P 1234mentioning

confidence: 99%