Management of Elevated INR in a Patient with Mitral Valve Replacement and Acute on Chronic Subdural Hematoma
Fresh frozen plasma should be administered immediately to correct the supratherapeutic INR of 4.4 in this patient with mitral valve replacement who has presented with acute on chronic subdural hematoma. 1
Immediate Management
- In the acute setting of subdural hematoma with elevated INR (4.4), rapid normalization of coagulation status is mandatory to prevent hematoma expansion 1
- Studies have shown that 30-40% of intracranial hemorrhages expand during the first 12-36 hours, which is associated with neurological worsening 1
- Elevated INRs are associated with larger hematoma volumes and enhance such expansions 1
- Fresh frozen plasma (FFP) is an appropriate choice for immediate reversal in this emergency situation 1
- Vitamin K should be administered alongside FFP to maintain the beneficial effect of coagulation correction 1
Rationale for Immediate Reversal
- The risk of hematoma expansion and neurological deterioration outweighs the short-term risk of thromboembolism in this scenario 1
- Guidelines clearly state that in cases of intracranial hemorrhage with therapeutic or supratherapeutic INR, it is imperative to normalize the INR as soon as possible 1
- When available, prothrombin complex concentrate (PCC) is preferred over FFP due to faster action and ease of administration, but FFP remains an acceptable alternative 1
Considerations for Patients with Mechanical Heart Valves
- While patients with mechanical mitral valve replacements are at high risk for thromboembolism, multiple studies have shown the safety of temporary anticoagulation reversal 1
- One study of 28 patients with prosthetic heart valves found no embolic events during a mean period of 15 days without anticoagulation 1
- Another study of 35 patients with intracranial hemorrhage while on warfarin showed no recurrent ischemic events among 14 patients with prosthetic valves after a median of 7 days without anticoagulation 1
- In a study of 141 patients with ICH while taking warfarin, the risk of an ischemic event during cessation of warfarin was only 2.9% in patients with a prosthetic heart valve 1
Post-Reversal Management
- After initial reversal, the appropriate duration of the period off anticoagulation should be determined based on neurological status and repeat imaging 1
- Most studies suggest that 7-10 days off anticoagulation is generally safe for patients with mechanical heart valves 1
- Close neurological monitoring is essential during this period 1
- Surgical intervention (burr hole or craniotomy) may be required based on the size of the hematoma and neurological status 2
Resumption of Anticoagulation
- Anticoagulation can typically be resumed after 7-10 days if repeat imaging shows no expansion of the hematoma 1
- When restarting anticoagulation, begin with the previous therapeutic dose of acenocoumarol (Acitrom) 1
- Consider bridging with heparin or LMWH until therapeutic INR is achieved, especially in this high-risk patient with a mechanical mitral valve 1
Common Pitfalls to Avoid
- Delaying reversal of anticoagulation in the setting of intracranial hemorrhage can lead to hematoma expansion and worse outcomes 1
- Resuming anticoagulation too early may increase the risk of recurrent bleeding 3
- Withholding anticoagulation for too long (>2-3 weeks) increases the risk of valve thrombosis 1, 3
- Using high-dose vitamin K alone without FFP or PCC may be insufficient for rapid reversal in emergency situations 1
By following these guidelines, you can effectively manage this patient with mitral valve replacement who has developed an acute on chronic subdural hematoma with an elevated INR, balancing the immediate need to prevent hematoma expansion against the long-term need for anticoagulation.