Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage.

Intracerebral haemorrhage is the most dreaded complication of anticoagulant treatment with vitamin K antagonists. Immediate reversal of the anticoagulant effect of the vitamin K antagonist may be indicated in this situation and can be achieved by administration of vitamin K-dependent coagulation factors, either by transfusion of plasma or by administration of prothrombin complex concentrate (PCC). In this article, the authors compared administration of plasma, PCC or both with no reversal treatment in patients who presented with intracerebral haemorrhage in a retrospective analysis of data from several registries.

More than 1500 patients on vitamin K antagonists and an INR of >1.3 were included in the analysis. Case-fatality rate was 62% in patients receiving no reversal treatment (N = 454), 46% in patients receiving FFP alone (N = 377), 37% in patients who received PCC only (N = 585) and 28% in patients who received both treatments (N = 131). Four-factor PCC was associated with a slightly higher case-fatality rate than 3-factor PCC.

This is a basically interesting paper but the results should be interpreted with a lot of caution. The assignment to each of the interventions was not random and major treatment bias could have taken place. Also, it is not clear why combined plasma and PCC is a logical treatment and would result in a better outcome compared to PCC alone. One may wonder whether this may indicate that PCC was not adequately dosed in some situations. The superiority of PCC over plasma for the immediate reversal of vitamin K antagonist treatment confirms a recent randomised controlled study (Goldstein et al., Lancet 2015;385:2077-87).

– Marcel Levi