To the Editor—I read with interest the article “The benefit of prothrombin complex concentrate in decreasing neurological deterioration in patients with warfarin-associated intracerebral haemorrhage” by Fong et al in the December 2014 issue of the Hong Kong Medical Journal.1 The Australian guidelines for warfarin reversal quoted in the article were outdated.2 The most recent Australian guidelin...

BACKGROUND The anticoagulated trauma patient presents a particular challenge to the critical care physician. Our understanding of these patients is defined and extrapolated by experience with patients on warfarin pre-injury. Today, many patients who would have been on warfarin are now prescribed the Direct Oral Anticoagulants (DOACs) a class of anticoagulants with entirely different mechanisms ...

BACKGROUND Vitamin K antagonists (eg, warfarin) remain the mainstay of anticoagulation therapy in the United States, with over 22 million prescriptions being filled annually. Unfortunately, warfarin therapy is difficult to manage and increases bleeding risk. The 2012 American College of Chest Physicians guidelines created a warfarin reversal algorithm that suggested the stringent use of intrave...

BACKGROUND AND PURPOSE The purpose of this study was to investigate time delays, adherence to guidelines, and their impact on outcomes in patients with warfarin-associated intracerebral hemorrhage transferred from community emergency departments to a comprehensive stroke center. METHODS We collected demographic, clinical, transfer time, treatment, and outcome data for patients transferred to ...

Case Presentation: A 74-year-old woman presents to the emergency department with bruising. She takes warfarin for atrial fibrillation. She has recently begun taking trimethoprim/ sulfamethoxazole. Her international normalized ratio (INR) is reported as 8.6. Supratherapeutic INR values are common in warfarin-treated patients. In this case, the antibiotic is the likely cause, but it is not unusua...

After a gap of almost 60 years following the development of warfarin, 2 new categories of oral anticoagulant agents have been approved for clinical use - the direct thrombin inhibitors and factor Xa inhibitors. These agents promise to be more convenient to administer with fixed dosing but still have equivalent efficacy and improved bleeding risk compared to warfarin. The clinical community is l...

Dear Editor, The points raised by Al-Kindi are well made and we accept concerns raised about the current lack of reliable reversal agents for the NOACs. This is also relevant to surgeons and interventionists, not least when performing percutaneous ablation therapy for atrial fibrillation, which is now routinely undertaken without discontinuing warfarin in those patients who are on this therapy....