“ A Bloody Mess”

Registrar: Dr M HarmseConsultant: Dr J v Rensburg

CASE

Mrs M, 58 y old lady from Vryburg

AML with multilineage dysplasia Admitted for second induction Complicated by DVT, started on Warfarin

INR >8

Phoned by sister:-trauma-disorientated

AAICH(Anticoagulant associated intracerebral hemorrhage)

INTRODUCTION

Wider use of Warfarin:-Warfarin related deaths-Permanent disability

-Mayo clinic Proceedings, Jan 2007; 82(1):82-89

INCIDENCE OF AAICH

-5x more in period 1988 - 1999-Paralleled 4X higher

warfarin prescribed in same period

-Most episodes of AAICH during therapeutic INR ( 2- 3)

-Birmingham atrial fibrillation treatment of the aged study, Lancet 2007; 370;493-503

AAICH RISK FACTORS

ESTABLISHED

-INR level-Hypertension (Systolic > 160 mmHg) -Advange age (> 75 years)-History of cerebrovascular disease

AAICH RISK FACTORS

POSSIBLE

- Aspirin use -Asian / Mexican American ethnisity-Tabacco smoking

-Heavy Alcohol consumption

WARFARIN, mechanism of action

II

VII

IX

X

1) ANTICOAGULATION

2)ANTIPLATELETS

1) ANTICOAGULATION

2)ANTIPLATELETS

REVERSAL OF ANTICOAGULATION

Additional optionsManagement of Hpt

Not a independent predictor of outcome

Keep systemic BP < 180 mmHg

(no data available)

Additional options

Should we restart with oral anti-coagulation?

AF PV

Should warfarin be restarted for AF/PV?

-Mayo clinic proceedings, Jan 2007;82(1);82-92

1. Warfarin: prevalance

2. Management of uncontrolled INR

3. AAICH: Emergency!

4. Restart?

How to fix a bloody mess!

Thank you