Abstract
Background and objectivesThe number of patients treated with oral anticoagulation (OAC) is increasing and these patients are monitored by International Normalized Ratio (INR). Bleeding complications are common and we speculate if this is related to the limitation of INR only reflecting the initiation steps of the haemostatic process. The objective of the present review was to reassess the evidence for using INR as a tool to guide administration of prothrombin complex concentrates (PCC) to OAC patients. A Medline and Cochrane database search was conducted using the following keywords: prothrombin complex concentrate, reversal of oral anticoagulation and international normalized ratio (INR). Thirty-three articles were contracted and a total of ten studies were eligible after applying inclusion and exclusion criteria encompassing only 339 patients. No consensus regarding optimal target INR value to aim for when reversing OAC was found. In three of the studies it was reported that patients reaching their target INR continued to bleed, whereas three studies reviewed reported good haemostatic response also in patients that did not reach their target INR. The present review found limited evidence for the usefulness of INR as a tool to monitor and guide reversal of OAC induced coagulopathy in patients with PCC, which is expected given that it is a plasma-based assay only reflecting a limited part of the haemostatic process.
Highlights
More and more people in the economically developed world are treated with oral anticoagulants due to the increasing proportion of elderly and the well documented effectiveness of anticoagulants to prevent primary and secondary thromboembolic events [1,2]
Whole blood viscoelastical assays (VHA), such as thrombelastography (TEG) or rotational thrombelastometry (ROTEM), that analyze the viscoelastic properties of clot formation in whole blood, including the patient’s ability to generate the thrombin, thereby reflecting the entire haemostatic process, these may be valuable in addition to plasma-based coagulation assays in oral anticoagulation (OAC) patients [8]
Demeyere et al [10] compared the efficacy of intraoperative administration of prothrombin complex concentrates (PCC) or FFP in 40 OAC patients undergoing heart surgery of whom 20 patients received PCC based on weight, initial and target International Normalized Ratio (INR) (
Summary
More and more people in the economically developed world are treated with oral anticoagulants due to the increasing proportion of elderly and the well documented effectiveness of anticoagulants to prevent primary and secondary thromboembolic events [1,2]. VHA has been reported to better predict transfusion requirements than PT and INR and are recommended by recent international guidelines for massively bleeding patients [9]. The number of patients treated with oral anticoagulation (OAC) is increasing and these patients are monitored by International Normalized Ratio (INR). A Medline and Cochrane database search was conducted using the following keywords: prothrombin complex concentrate, reversal of oral anticoagulation and international normalized ratio (INR). The present review found limited evidence for the usefulness of INR as a tool to monitor and guide reversal of OAC induced coagulopathy in patients with PCC, which is expected given that it is a plasma-based assay only reflecting a limited part of the haemostatic process
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