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

2. Terms of Use
The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP.
The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice.
Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement.
Copyright © 2016

3. She takes chronic anticoagulation.
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
BP 120/78, A Fib Ventricular Rate: 80 and afebrile
Exam:
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. Acute Subdural Hematoma

5. 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-Life
Fraction Remaining
% Remaining 1
1/2
50% 2
1/4
25%*** 3
1/8
12.5% 4
1/16
6.25% 5
1/32
3.125%

6. Rivaroxaban RESCUE: Four Factor vs Three Factor PCC (prothrombin complex concentrate)
Agent
Reduction 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):
doi: /jth Epub 2014 Jul 24.

7. 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:

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

10. Chart Review 2869 patient warfarin related intracranial hemorrhage
36% were subdural hematomas
Optimal Time for Resumption warfarin 10 to 30 weeks
*Majeed A1, Kim YK, Roberts RS, Holmström M, Schulman S. Optimal timing of resumption of warfarin
after intracranial hemorrhage. Stroke Dec;41(12): doi: /STROKEAHA
Epub 2010 Oct 28.

11. 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
*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: 

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

13. Produced by
and
COPYRIGHT © 2016, ALL RIGHTS RESERVED