Point-of-care reversal treatment in phenprocoumon-related intracerebral hemorrhage.
OBJECTIVE
Rapid reversal of the anticoagulatory effect of vitamin K antagonists represents the primary emergency treatment for oral anticoagulant-related intracerebral hemorrhage (OAC-ICH). Predicting the amount of prothrombin complex concentrate (PCC) needed to reverse OAC in individual patients is difficult, and repeated international normalized ratio (INR) measurements in central laboratories (CLs) are time-consuming. Accuracy and effectiveness of point-of-care INR coagulometers (POCs) for INR reversal in OAC-ICH have not been evaluated.


METHODS
In phase 1, the agreement of emergency POC and CL INR measurements was determined. In phase 2, stepwise OAC reversal was performed with PCC using a predetermined dosing schedule. Concordance of POC and CL INR measurements during reversal and time gain due to POC were determined.


RESULTS
In phase 1 (n = 165), Bland-Altman analysis showed close agreement between POCs and CLs (mean INR deviation 0.04). In phase 2 (n = 26), POCs caused a median initial net time gain of 24 minutes for the start of treatment with PCC. Median time for POC-documented complete OAC reversal was 28 minutes, compared with 120 minutes for CLs. Bland-Altman analysis between POCs and CLs revealed a mean INR deviation of 0.13 during stepwise PCC administration. POCs tended to slightly overestimate the INR, especially at higher INR levels. Remarkably, POC-guided reversal led to a median reduction of 30.5% of PCC dose compared with the a priori dose calculation. Hematomas enlarged in 20% of patients.


CONCLUSIONS
POC INR monitoring is a fast, effective, and economic means of PCC dose-titration in OAC-ICH. Larger studies examining the clinical efficacy of this procedure are warranted.
Department of Neurology, University Heidelberg, Heidelberg, Germany.
Timolaos
T
Rizos
Ekkehart
E
Jenetzky
Christian
C
Herweh
Andreas
A
Hug
Werner
W
Hacke
Thorsten
T
Steiner
Roland
R
Veltkamp
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000378:metabolism / Q000627:therapeutic use*; D001779:Blood Coagulation Factors / Q000378:metabolism; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000378:metabolism* / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D006406:Hematoma / Q000188:drug therapy / Q000209:etiology / Q000473:pathology; D006801:Humans; D019934:International Normalized Ratio / Q000379:methods; D008297:Male; D010644:Phenprocoumon / Q000378:metabolism / Q000627:therapeutic use*; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome
D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates; D010644:Phenprocoumon