Type and Timing of Reversal Agents in Patients Receiving Warfarin Who are Hospitalized for Major Bleeding

Background In patients with warfarin-induced major bleeding, prompt administration of reversal agents increases coagulation factors and may allow early surgical correction of bleeding. However even with reversal agents, mortality is high. In this analysis the type and timing of reversal agents were evaluated Methods Review of warfarin treated non-trauma patients admitted to a University Hospital with ISTH defined major bleeding between October 2009 and January 2013. Results 84 patients met entry criteria with a mean age 67.8 ± 14.3 years including 46 % females. The mean INR on admission was 3.6 ± 2.4. The site of major bleeding was central nervous system in 33 (39%), abdomen in 28 (33%), chest in 6 (7%) and other in 15 (18 %). Reversal agents including vitamin K, fresh frozen plasma (FFP), or prothrombin complex concentrate (PCC) were given to 83 patients. Forty patients required either major surgery (25 patients) or a therapeutic procedure (14 patients) to stop bleeding. Death occurred in 15 patients (18%) but the admission INR was not predictive of mortality (p=0.52, Kruskal-Wallis test). The INR was never completely corrected (INR<1.1) in 31 (37%) patients, 9 of whom died. Conclusions Patients with warfarin-induced major bleeding receive ineffective anticoagulation reversal, have delayed times to therapeutic procedures, and have a high mortality rate. Whether earlier administration of these agents or administration of newer agents would reduce hospital mortality requires further study.