Comparison of anticoagulation reversal strategies for warfarin associated acute gastrointestinal bleeding

Objective

Gastrointestinal bleeding (GIB) is a common complication associated with warfarin use. However, the optimal approach for anticoagulation reversal—whether with prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), vitamin K (intravenous or oral), or no reversal—remains unclear as current literature and society guidelines do not provide definitive recommendations.

Methods

A retrospective analysis of emergency department patients with warfarin-associated GIB who presented to an academic health system was performed, comparing reversal with PCC, FFP, vitamin K only, or no reversal agent. The primary outcome was 30-day all-cause mortality. Secondary outcomes included rebleeding events and 30-day thrombotic events. Standardized guidelines for reporting were followed (STROBE).

Results

Of 815 patients, within 12 h of presentation, 10.7 % received reversal with PCC (with or without vitamin K), 12.9 % with FFP (with or without vitamin K), and 34.9 % with vitamin K alone; 41.5 % of patients received no reversal agent. Compared to all other groups, patients receiving PCC had significantly higher 30-day mortality (18.4 % [PCC] vs 5.7 % [FFP] vs 4.6 % [vitamin K] vs 5.6 % [no reversal], p < 0.001), which remained significant after adjusting for hemodynamic instability and ICU admission. There were no significant differences in rates of thrombotic event within 30 days (3.4 % vs 3.8 % vs 1.4 % vs 1.2 %, p = 0.20).

Conclusions

Patients who received PCC had a threefold increase in mortality compared to FFP, vitamin K alone, or no reversal, even after adjusting for severity of the bleeding. Further research is necessary to understand factors leading to this observed mortality difference among patients with warfarin related GIB.