Academic Emergency Medicine
Background: The Safety of Oral Anticoagulants Registry (SOAR) aims to describe the diversity in presentation and treatment strategies in patients with oral anticoagulant (OAC)-related acute hemorrhage (AH) or bleeding concern (BC; defined as OAC-driven treatment for, or delay to, a procedure, or prolonged observation) presenting to the emergency department. In this secondary analysis we report on patients receiving reversal or clotting factor repletion therapy. Methods: SOAR is a prospective, observational study of OAC-treated patients presenting with AH or BC requiring acute intervention. 31 US hospitals participated. Results: Of 1513 patients enrolled, the OAC was warfarin in 37.3% or a direct OAC (DOAC) in 63% (13% dabigatran, 50% FXa inhibitors). Mean age was 71.1 years and 53% were male. The most common indications for OAC were atrial fibrillation (AF) and venous thromboembolism, but other indications included prosthetic heart valve, heart failure, post-MI, and post-stroke not AF-related. Overall, 78% had AH (19% of which were life-threatening) and 22% had BC; 42% required red blood cell transfusion. Mortality was higher for AH (7.3%) than for BC (5.5%), but length of stay (4.5+/-7.4 for AH and 4.1+/-6.6 days for BC [median+/-SD]) were similar. Factor repletion with fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), a single factor, or a combination of these was given to 42% of AH and 28% of BC patients. In patients on dabigatran, the specific reversal agent idarucizumab was given in 57% of AH (9% also received FFP and 3% PCC) and 43% of BC (2% also received FFP; none received PCC). Four anti-FXa-treated patients with AH were treated with andexanet alfa, which became available shortly before the conclusion of enrollment. Meanwhile, factor repletion was administered to 43% of AH patients on apixaban or rivaroxaban. In patients on warfarin, 23% of AH and 20% of BC did not receive vitamin K, while, in contrast, vitamin K was given to 9% and 7% of dabigatran and anti-FXa patients with AH, respectively, and to 12% of anti-FXa-treated patients with BC. Conclusion: Emergency physicians commonly treat anticoagulated patients with factor repletion or specific reversal agents when faced with AH or BC. Vitamin K is not completely utilized in warfarin-treated patients and is used unnecessarily in DOAC-treated patients.
Pollack CV, Peacock WF, Jahromi B, Bernstein RA, Clark CL, et al. Reversal and repletion strategies related to oral anticoagulation in United States Emergency Departments. Acad Emer Med 2019; 26:S160.