Millions of people are treated with antithrombotic drugs and major hemorrhages are
the most threatening consequence. When this study was performed the prevalence in
the general population of people treated with vitamin K-antagonists (VKA) was approximately
1%, and major hemorrhagic events occurred in 2–3% of patients treated with VKA [
1
,
2
,
3
]. The mortality of intracranial hemorrhage (ICH) occurring on anticoagulant treatment
is 30–55%, with a very high morbidity in surviving patients [
1
,
2
,
3
]. When bleeding occurs, treatment to reverse anticoagulation should be started as
soon as possible. The reversal effect induced by oral or parenteral vitamin K is achieved
no earlier than after 12–24 h and therefore it is not useful in life-threatening bleedings.
Fresh frozen plasma (FFP) can be used but caution is necessary for the risk of volume
overload. Concentrates containing three or four factors (II, VII, IX, X) of the Prothrombin
Complex (CPC) can reverse the anticoagulation effect much more quickly [
4
,
5
,
6
,
- Sarode R.
- Milling T.J.
- Refaai M.A.
- Mangione A.
- Schneider A.
- Durn B.L.
- Goldstein J.N.
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.
Circulation. 2013; 128: 1234-1243
7
,
8
]. With this background, we performed an observational study in the Emergency Room
(ER) of IRCCS Ca’ Granda Policlinico Hospital in Milan in order to evaluate how reversal
therapies were used in patients taking VKA who bled. In our hospital, a protocol was
developed according broadly to the international guidelines for the neutralization
of VKA effects and is currently implemented with the supervision of a specialist of
the Hemophilia and Thrombosis Center, who can be consulted 24/24 h. Our therapeutic
options for reversal of VKA include vitamin K, CPC (3 or 4 factors) and Factor VII
(FVII), whose utilization is at present off-label. FFP is currently hardly used, because
CPC is the first-line therapy. In our protocol, the scheme of treatment of major bleeding
is: discontinuation of VKA for at least 15 days; vitamin K 10–20 mg i.v.; CPC 35–50
UI/kg (sometime, for 3 factor products, associated to FVII 20 UI/kg), strict monitoring
of the INR and the clinical course of the hemorrhage.Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Antithrombotic therapy for atrial fibrillation: 9 th ed American college of Chest physicians evidence-based clinical practice guideline Chest.141. 2012: e531S-e575S
- Lip G A novel user-friendly score (HAS-BLED) to assess 1 year risk of major bleeding in patients with atrial fibrillation: The Euro Heart.Survey Chest. 2010; 138: 1093-1100
- Death and disability from warfarin-associated intracranial and extracranial hemorrhages.Am. J. Med. 2007; 120: 700-705
- Emergency reversal of anticoagulation with a three-factor prothrombin complex concentrate in patients with intracranial haemorrhage Blood transfusion.Vol. 9. 2011: 148-155
- Thromboembolic safety and efficacy of prothrombin complex concentrates in the emergency reversal of warfarin coagulopathy.Thromb. Res. 2012; : 146-151
- 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.Circulation. 2013; 128: 1234-1243
- Three or four factor prothrombin complex concentrate for emergency anticoagulation reversal?.Blood Transfus. 2011; 9: 117-119
- Thrombogenicity of prothrombin complex concentrates.Thromb. Res. 1999; 95: s13-s17
- Bleeding risk in very old patients on vitamin K antagonist treatment: results of a prospective collaborative study on elderly patients followed by Italian centres for anticoagulation.Circulation. 2011; 124: 824-829
- Comparison of the CHADS2, CHA2DS2-VASc and HAS-BLED scores for the prediction of clinically relevant bleeding in anticoagulated patients with atrial fibrillation: the AMADEUS trial.Thromb. Haemost. 2013 Nov; 110: 1074-1079https://doi.org/10.1160/TH13-07-0552
Article info
Publication history
Published online: July 18, 2018
Accepted:
July 12,
2018
Received:
July 9,
2018
Identification
Copyright
© 2018 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
