İslam Mehmet Muzaffer, Ademoğlu Enis, Uygun Cemrenur, Delipoyraz Melike, Satıcı Merve Osoydan, Aksel Gökhan, Eroğlu Serkan Emre, Özdemir Serdar
Emergency Medicine Department, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey.
Afr J Emerg Med. 2023 Mar;13(1):8-14. doi: 10.1016/j.afjem.2022.12.001. Epub 2023 Jan 12.
One of the most anticipated adverse effects of warfarin is over-anticoagulation. There is little to no evidence on the treatment that should be administered in patients with an international normalized ratio (INR)≥10. The primary outcome of this study is to analyze the effects of various treatments on 30-day mortality in patients with INR≥10 and without major bleeding on 30-day all-cause mortality. The secondary outcome is to propose a model that predicts 30-day all-cause mortality in the same patient group.
Patients older than 18 years of age using warfarin and who had an INR≥10 were included in this retrospective cohort study. Patients with major bleeding on admission were excluded. Patients treated with only cessation of warfarin were named as "Group-1", patients who were treated with vitamin-K in addition to cessation of warfarin were named as "Group-2", and patients who were treated with cessation of warfarin and vitamin-K and fresh frozen plasma or prothrombin complex concentrate were named as "Group-3".
190 patients were included in the analysis. Seven (38.9%) patients in the first group, 3 (8.6%) in the second group, and 21 (15.3%) in the third group died within 30-days. In the post-hoc analysis, the difference between Group-1 and Group-2 was found to be significant(The performance of the model in predicting 30-day all-cause mortality was high (AUC=0.818 (95%CI = 0.716 to 0.920) and found to be compatible with the validation dataset 0.806 (95%CI = 0.631 to 0.981). Administration of vitamin K in addition to the cessation of warfarin was found to be a strong contributor to the model and an independent predictor of survival within 30 days().
Until randomized controlled studies are conducted, it may be reasonable to administer vitamin-K in addition to cessation of warfarin in non-bleeding patients with INR≥10.
华法林最令人担忧的不良反应之一是抗凝过度。对于国际标准化比值（INR）≥10的患者应采用何种治疗方法，几乎没有相关证据。本研究的主要结局是分析各种治疗方法对INR≥10且30天内无大出血的患者30天全因死亡率的影响。次要结局是建立一个模型，预测同一患者群体的30天全因死亡率。
本回顾性队列研究纳入了年龄在18岁以上、使用华法林且INR≥10的患者。入院时发生大出血的患者被排除。仅停用华法林治疗的患者被命名为“第1组”，除停用华法林外还接受维生素K治疗的患者被命名为“第2组”，停用华法林、接受维生素K以及新鲜冰冻血浆或凝血酶原复合物浓缩物治疗的患者被命名为“第3组”。
190例患者纳入分析。第1组7例（38.9%）患者、第2组3例（8.6%）患者和第3组21例（15.3%）患者在30天内死亡。事后分析发现，第1组和第2组之间的差异具有统计学意义（该模型预测30天全因死亡率的性能较高（AUC=0.818（95%CI=0.716至0.920）），且与验证数据集0.806（95%CI=0.631至0.981）相符。除停用华法林外给予维生素K被发现是该模型的一个重要因素，也是30天内存活的独立预测因素（）。
在进行随机对照研究之前，对于INR≥10的非出血患者，除停用华法林外给予维生素K可能是合理的。
