Non surgical mx CCF

Biventricular pacing +/- implantable cardiodefibrillator Cardiac resyncronisation therapy

Issue: Supratherapeutic INR

Patients INR was 5.5 Nil evidence of bleeding

Why is this concerning? What do we do?

Supratherapeutic INR
Even patients stable many months can become excessively anticoagulated The most common causes of overanticoagulation include:
Drug interaction Wrong dosage of warfarin Vitamin K deficiency Diarrhoea Heart failure Fever Impaired liver function

Reversal of Warfarin
Clinical situation determines the desired rapidity of warfarin reversal
Quick reversal - Prothrombin complex concentrates* or FFP Slower reversal -Vitamin K (6-12h)

Anticoagulant effect of warfarin difficult to reestablish after large doses of vitamin K

*Prothrombinex-VF: Human antithrombin III, factor II, factor IX, factor V, factor VII and factor X, and porcine heparin.

eTG Guidelines
Elevated INR, no clinical evidence of bleeding INR <5 (but above theraputic range):
Lower dose/omit next dose of warfarin within 10% of therapeutic range

INR 5 to 9:
Cease warfarin Consider reasons for elevated INR/patient factors Give Vitamin K (phytomenodione)
1-2mg PO or 0.5-1mg IV

Monitor INR within 24hrs

eTG Guidelines
Elevated INR, no clinical evidence of bleeding INR > 9
Give vitamin K 2.5-5mg PO or 1mg IV (if high risk) Measure INR within 6-12hrs Resume warfarin at reduced dose once INR <5

Also consider
Prothrombinex-VF 25-50units/kg IV PLUS Fresh frozen plasma 150-300ml

Case
What did we do?
Ceased warfarin Gave vitamin K 1mg Monitor INR 2 days later INR 3.1

eTG Guidelines
What if the patient is bleeding? (and it is clinically significant) Cease warfarin

Give
Phytomenodione (vit K) 5-10mg IV PLUS Prothrombinex-VF 25-50units/kg (if available) PLUS FFP 150-300ml

Monitor continuously until INR<5, bleeding stops

Minor head trauma + anticoagulation

If patient is on antiplatelet/anticoagulation and suffers minor head trauma
Intracranial imaging

Retrospective study showed that out of 141 patients on anticoagulants presenting with minor head trauma, GCS 15
29% (41) had ICH 5 needed surgical evacuation 4 died

Elective surgery + warfarin

Give 3mg vitamin K 12-18h prior to elective surgery

178 patients on long term warfarin

INR <1.7 (100%) INR< 1.4 (94%)

Median time to restore INR 4 days (range 2-11)

No adverse reactions/symptomatic thromboembolic complication