1. Copyright © 2016 A Real Headache: Anticoagulation and A Subdural Hematoma COPYRIGHT © 2016, ALL RIGHTS RESERVED From the Publishers of

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3. Guys: Need your help. I am in our Emergency Department and have just seen a 70-year-old woman who fell. She has a history of chronic atrial fibrillation, hypertension, and diabetes. She takes chronic anticoagulation. Meds: rivaroxaban 20 mg, daily, atenolol 25 mg, metformin 500mg, BID PMHx: HBP, DM II, Non Valvular Afib SHx: non-smoker, no ETOH, married, lives with family Exam: BP 120/78, A Fib Ventricular Rate: 80 and afebrile Lungs clear Heart irregular rhythm, S1S2 normal, no murmurs No focal neurologic signs, alert and oriented Labs: N 134, K 3.4, Cr 1.2, CrCl 62cc/min, Hgb 12.8, Hct 38, WBC 8K, Plts 240K, UA neg, PT/ INR 11 sec/0.8, aPTT 32 sec ECG: atrial fibrillation Chest x-ray: unremarkable Guys: Need your help. I am in our Emergency Department and have just seen a 70-year-old woman who fell. She has a history of chronic atrial fibrillation, hypertension, and diabetes. She takes chronic anticoagulation. Meds: rivaroxaban 20 mg, daily, atenolol 25 mg, metformin 500mg, BID PMHx: HBP, DM II, Non Valvular Afib SHx: non-smoker, no ETOH, married, lives with family Exam: BP 120/78, A Fib Ventricular Rate: 80 and afebrile Lungs clear Heart irregular rhythm, S1S2 normal, no murmurs No focal neurologic signs, alert and oriented Labs: N 134, K 3.4, Cr 1.2, CrCl 62cc/min, Hgb 12.8, Hct 38, WBC 8K, Plts 240K, UA neg, PT/ INR 11 sec/0.8, aPTT 32 sec ECG: atrial fibrillation Chest x-ray: unremarkable Copyright © 2016

4. Do We Reverse the Anticoagulation? Last dose of rivaroxaban was 6 PM the evening prior to having CT scan of head CT performed at 11 AM 17 hours since last rivaroxaban dose Half-Life rivaroxaban 8 hours Clearance rivaroxaban: 30% renal, 60% liver Half-LifeFraction Remaining% Remaining 11/250% 21/425%*** 31/812.5% 41/166.25% 51/323.125%

5. Copyright © 2016 Rivaroxaban RESCUE: Four Factor vs Three Factor PCC (prothrombin complex concentrate) AgentReduction PT (sec) Beriplex (50 IU/kg) Four Factor (II,VII,IX,X) 2.5 sec – 3.5 sec Profilnine (50 IU/kg) Three Factor(II,IX,X) 0.6 – 1.0 sec Rivaroxaban 20mg, BID x 4 days 30 minute following infusion: effect noted on reducing the prothrombin time *Levi M et al. Comparison of three-factor and four-factor prothrombin complex concentrates regarding reversal of the anticoagulant effects of rivaroxaban in healthy volunteers. J Thromb Haemost. 2014 Sep;12(9):1428-36. doi: 10.1111/jth.12599. Epub 2014 Jul 24.

6. Correction: The Consult Guys—A Real Headache: Anticoagulation and a Subdural Hematoma In a recent Consult Guys video (1), the computed tomography image of the head originally included in the video at 1:56 showed a shift of midline structures in association with a hematoma. This has been replaced with a correct image, demonstrating a hematoma with no shift of midline structures. Reference 1.Merli GJ, Weitz HH. The Consult Guys—A Real Headache: Anticoagulation and a Subdural Hematoma [video]. Ann Intern Med. 2016;164. Accessed at http://annals.org/article.aspx?articleid=251 3874&resultClick=3 on 18 May 2016. [PMID: 27089084] doi: 10.7326/W16-0004 Reproduced with permission from Suyash Mohan, MD

7. Copyright © 2016 Case Her CHA2DS2-VASc Score is 4 with a 4.0% yearly risk of stroke. How do I manage her stroke risk and need for anticoagulation?

8. Patients received 5 g of intravenous idarucizumab, which was administered as two 50-ml bolus infusions, each containing 2.5 g of idarucizumab, no more than 15 minutes apart. The 5- g dose was calculated to reverse the total body load of dabigatran that was associated with the 99th percentile of the dabigatran levels measured in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. *Pollack C, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015; 373:511-520.

9. *Siegal DM, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015; 373:2413-2424. 400 mg, IV, Bolus (30mg/min) 400 mg, IV, Bolus (30mg/min) the Infusion 4mg/min for 120min (480mg total )

10. Chart Review 2869 patient warfarin related intracranial hemorrhage 36% were subdural hematomas Optimal Time for Resumption warfarin 10 to 30 weeks *Majeed A 1, Kim YK, Roberts RS, Holmström M, Schulman S. Optimal timing of resumption of warfarin after intracranial hemorrhage. Stroke. 2010 Dec;41(12):2860-6. doi: 10.1161/STROKEAHA.110.593087. Epub 2010 Oct 28.

11. *Nielsen PB et al.Restarting Anticoagulant Treatment After Intracranial Hemorrhage in Patients With Atrial Fibrillation and the Impact on Recurrent Stroke, Mortality, and Bleeding Circulation. 2015; 132: 517-525. 1752 Patients Danish Registry NV-Afib with ICH Rate of Ischemic Stroke: Restart OAC 13.6 Rate of Ischemic Stroke: ASA 25.7 Rate of Ischemic Stroke: No OAC 27.3

12. Copyright © 2016 Summary Patient with atrial fibrillation and traumatic subdural hematoma with minimal symptoms. When to restart anticoagulation? 7-14 days (risk/benefit taken into consideration)

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