What is the management for a patient with a Left Ventricular Assist Device (LVAD) and elevated International Normalized Ratio (INR) with severe anemia and no clinical evidence of bleeding?

From the Guidelines

For a patient with a Left Ventricular Assist Device (LVAD), an INR of 10, and hemoglobin of 6.7 g/dL without clinical evidence of bleeding, immediate management should focus on reversing excessive anticoagulation and addressing the severe anemia, with the most recent guidelines suggesting rapid reversal of anticoagulation as soon as possible after diagnosis, regardless of INR result availability 1. The management strategy should prioritize the patient's high risk of life-threatening hemorrhage with an INR of 10, as well as the risk of pump thrombosis associated with complete reversal of anticoagulation in LVAD patients.

• Key considerations include:
  • Holding warfarin therapy completely to prevent further anticoagulation
  • Administering vitamin K and prothrombin complex concentrate to rapidly reverse anticoagulation, as supported by the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage, which recommends rapid reversal of anticoagulation as soon as possible after diagnosis 1
  • Transfusing packed red blood cells to address the critical anemia, aiming for a target hemoglobin of at least 8 g/dL
  • Monitoring the patient closely with serial hemoglobin measurements and INR checks every 6 hours until stabilized
  • Carefully restarting warfarin at 50% of the previous dose once the INR approaches 2.5-3.5, the typical target range for LVAD patients
• The choice of reversal agent, such as prothrombin complex concentrate, should be guided by the most recent evidence, which suggests that 4-F PCC is superior to FFP in rapidly reversing anticoagulation in patients with VKA-associated ICH and INR >1.9 1
• Despite the absence of overt bleeding, occult bleeding should be suspected and investigated with appropriate imaging and endoscopic studies once the patient is stabilized, as the risk of hemorrhage remains high in patients with such severe coagulopathy and anemia. The goal of management is to balance the risk of thrombosis and hemorrhage, with a focus on preventing life-threatening complications and improving the patient's quality of life, as supported by the most recent guidelines and evidence 1.

From the Research

Management of LVAD with Elevated INR and Low Hemoglobin

• The management of Left Ventricular Assist Device (LVAD) patients with an elevated International Normalized Ratio (INR) and low hemoglobin (Hb) is crucial to prevent bleeding and thrombotic complications 2, 3.
• A study published in 2017 found that LVAD patients with a higher proportion of time spent above therapeutic range were more likely to experience bleeding events 2.
• Another study published in 2023 reported a case of LVAD thrombosis in a patient with a supratherapeutic INR, highlighting the importance of balancing bleeding risk with thrombotic risk 3.

Anticoagulation Control in LVAD Patients

• Anticoagulation control is essential in LVAD patients to prevent thromboembolism and hemorrhage 4.
• A study published in 2017 found that only 20% of LVAD patients achieved anticoagulation control, defined as a percent time spent in target range (PTTR) > 60% for INR range of 2-3 4.
• Patients with PTTR ≥ 60% had a significantly lower risk of thromboembolism and hemorrhage compared to those with PTTR < 50% 4.

Reversal Strategies for Anticoagulation in LVAD Patients

• The safety and efficacy of anticoagulation reversal strategies in LVAD patients with acute intracranial hemorrhage are not well established 5.
• A study published in 2016 found that 4-factor prothrombin complex concentrate-assisted VKA reversal was safe and effective in LVAD patients with intracranial hemorrhage, with a shorter time to VKA reversal and lower fresh frozen plasma requirements compared to traditional agents alone 5.

Antiplatelet and Anticoagulation Strategies for LVAD

• Antiplatelet and anticoagulation strategies are crucial in LVAD management to prevent hemorrhagic and thrombotic complications 6.
• A comprehensive review published in 2021 discussed the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs, as well as considerations for anticoagulation and antiplatelet therapies prior to, during, and after LVAD implantation 6.