Beriplex use for warfarin reversal
Using the BCSH guidelines, we can identify that this patient requires reversal of warfarin immediately, given the history of a possible fall (head injury) and the history of amnesia. Major bleeding is defined as limb or life-threatening bleeding that requires complete reversal within 6–8 h. Rapid correction is most effectively achieved by the administration of prothrombin complex concentrate (PCC), beriplex is the most commonly used in the uk. Complete reversal of the warfarin-induced anticoagulation is achieved within 10 min, however the infused clotting factors have a short half-life, the shortest being 6hrs. In view of this, guidelines suggest administration of 5mg of vitamin K intravenouslyi.
Guidelines state that all patients on warfarin presenting to Accident and Emergency departments with head injury should have their INR measured as soon as possible and a lower threshold for performing a head CT scan should be used. Anticoagulation should be reversed before the results of any investigations in patients with a strong suspicion of an intracerebral bleed (lose of consciousness, reduced GCS, amnesia)
The importance in this case was to recognise that on initial presentation the patient required urgent reversal of anticoagulation, given the symptoms of amnesia. The key is not to delay treatment in patients with a potential head injury in patients on warfarin, even in the case of a metallic heart valve.
Patients on anticoagulation have an increased mortality rate with intracerebral haemorrhage. One study found a rate of 48%, compared to 10% in patients not treated with anticoagulation. 40% of patients demonstrated progression of ICH resulting in a 68% mortality. Prompt reversal of anticoagulation, reduces the rate of progression of haemorrhage and mortality.ii
Metallic heart valves
The risk of patient with metallic heart valves and reversal of anticoagulation is thrombosis. The incidence of prosthetic valve thrombosis in patients not anticoagulated or taking antiplatelet drugs was 1.8% per patient-year. The incidence of thromboembolism resulting in death, stroke, or peripheral ischemia requiring surgery was 4% per patient-year. This was reduced to 1.0% per patient-year with warfarin. Thromboembolism following aortic valve replacement was significantly lower than mitral valve replacement (0.53% per patient-year vs 1.64% per patient-year).iii
There appears to be no clear consensus on management of these patients post intracerebral bleed. Management decisions should be discussed with the local cardiology and haematology team. Studies have suggested concern when using PCC in patients with metallic heart valves due to the fear of thrombotic complications. Reported incidence for thromboembolic events ranges from 0%-7%. Approaches to the management of these patients include complete reversal of warfarin and evidence suggests that no anticoagulation should be used for 7-14 days in patients with an intracerebral haemorrhage. The patient requires assessment on an individual basis, obviously some patients may have more risk factors, such as a mitral valve and AF, which may indicate early treatment with anticoagulation.iii
i BCSH guidelines. David Keeling, Trevor Baglin, Campbell Tait, Henry Watson, David Perry, Caroline Baglin, Steve Kitchen and MichaelMakrinGuidelines on oral anticoagulation with warfarin – fourth edition. (2011)
ii Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005 Nov;59(5):1131-7; discussion 1137-9.
iii Prashanth Panduranga, Mohammed Al-Mukhaini, Muhanna Al-Muslahi, Mohammed A Haque, and Abdullah Shehab. Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding. World J Cardiol. 2012 March 26; 4(3): 54–59.