Abstract

Aim: Warfarin-containing medications are commonly prescribed anticoagulants for preventing and treating arterial and venous thromboembolism. As such, it may present a risk of hemorrhage. In this study, we aimed to investigate the occurrence of hemorrhage associated with warfarin, along with the contributing factors, by analyzing data obtained from emergency requests.

Methods: Patients who presented to the emergency department within one year and requested an INR analysis have been included. Among these patients, the demographic characteristics and risk factors of patients using warfarin and having signs of hemorrhage and those with increased INR levels and hemorrhage symptoms without using warfarin were studied retrospectively.

Results: Two hundred and seventy-three patients were included in the study. Two hundred and eleven patients (76.9%) were taking warfarin, 94.8% of whom had initiated the drug for cardiac reasons. INR value below 2.5 were found in 39.3% of these patients. Only 8.1% were identified with hemorrhage.

Conclusion: Warfarin poses a significant challengefor clinicians and patients due to its associated risk of hemorrhage. In this study, the risk of major hemorrhage was generally low.

Keywords: emergency department, hemorrhage, INR, warfarin

Copyright and license

How to cite

1.
Güven O, Demireller M. Emergency department admissions and hemorrhage risk in patients on warfarin-containing drugs: a retrospective study. Northwestern Med J. 2024;4(1):41-7. https://doi.org/10.54307/2024.NWMJ.87

References

  1. Turkish Society of Hematology. Coumadin usage guide. 2019. Available at: https://www.thd.org.tr/thd_halk (Accessed on August 21, 2021).
  2. Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl): 160S-198S. https://doi.org/10.1378/chest.08-0670
  3. Hirsh J, Fuster V, Ansell J, Halperin JL; American Heart Association/American College of Cardiology Foundation. American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. J Am Coll Cardiol. 2003; 41(9): 1633-52. https://doi.org/10.1016/s0735-1097(03)00416-9
  4. Thacker SM, Grice GR, Milligan PE, Gage BF. Dosing anticoagulant therapy with coumarin drugs: is genotyping clinically useful? Yes. J Thromb Haemost. 2008; 6(9): 1445-9. https://doi.org/10.1111/j.1538-7836.2008.03074.x
  5. Kanagasabapathy P, Chowdary P, Gatt A. Alternatives to warfarin-the next generation of anticoagulants. Cardiovasc Ther. 2011; 29(6): e80-8. https://doi.org/10.1111/j.1755-5922.2010.00197.x
  6. Wittkowsky AK, Devine EB. Frequency and causes of overanticoagulation and underanticoagulation in patients treated with warfarin. Pharmacotherapy. 2004; 24(10): 1311-6. https://doi.org/10.1592/phco.24.14.1311.43144
  7. Lip GY, Andreotti F, Fauchier L, et al. Bleeding risk assessment and management in atrial fibrillation patients. Thromb Haemost. 2011; 106(6): 997-1011. https://doi.org/10.1160/TH11-10-0690
  8. Ertas F, Duygu H, Acet H, Eren NK, Nazli C, Ergene AO. Oral anticoagulant use in patients with atrial fibrillation. Turk Kardiyol Dern Ars. 2009; 37(3): 161-7.
  9. Lindh JD, Holm L, Dahl ML, Alfredsson L, Rane A. Incidence and predictors of severe bleeding during warfarin treatment. J Thromb Thrombolysis. 2008; 25(2): 151-9. https://doi.org/10.1007/s11239-007-0048-2
  10. Holbrook AM, Pereira JA, Labiris R, et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med. 2005; 165(10): 1095-106. https://doi.org/10.1001/archinte.165.10.1095
  11. DiMarco JP, Flaker G, Waldo AL, et al. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J. 2005; 149(4): 650-6. https://doi.org/10.1016/j.ahj.2004.11.015
  12. Ozturk M, Ipekci A, Kiyak SK, et al. Bleeding Complications in Warfarin-Treated Patients Admitted to the Emergency Department. J Clin Med Res. 2019; 11(2): 106-13. https://doi.org/10.14740/jocmr3669
  13. Eroğlu SE, Altınok DA, Özpolat Ç, Akoğlu H, Onur ÖE, Akoğlu ÜE. The investigation of the relation between INR levels and risk of complication in patients with a history of warfarin use. Marmara Medical Journal. 2012; 25(3): 138-42.
  14. Tran HA, Chunilal SD, Harper PL, et al. An update of consensus guidelines for warfarin reversal. Med J Aust. 2013; 198(4): 198-9. https://doi.org/10.5694/mja12.10614
  15. Hylek EM, Chang YC, Skates SJ, Hughes RA, Singer DE. Prospective study of the outcomes of ambulatory patients with excessive warfarin anticoagulation. Arch Intern Med. 2000; 160(11): 1612-7. https://doi.org/10.1001/archinte.160.11.1612
  16. Çat BG, Çavuş UY, Bakır M, Yılmaz D, Yıldırım S. Emergency Department Visits due to the Bleeding Complication of Warfarin. The Anatolian Journal of Family Medicine. 2020; 3(1): 59-63. https://doi.org/10.5505/anatoljfm.2019.25743
  17. Visser LE, Bleumink GS, Trienekens PH, Vulto AG, Hofman A, Stricker BHC. The risk of overanticoagulation in patients with heart failure on coumarin anticoagulants. Br J Haematol. 2004; 127(1): 85-9. https://doi.org/10.1111/j.1365-2141.2004.05162.x
  18. Meeker E, Dennehy CE, Weber EJ, Kayser SR. Emergency department management of patients on warfarin therapy. Ann Emerg Med. 2011; 58(2): 192-9. https://doi.org/10.1016/j.annemergmed.2011.01.018
  19. Shepherd AM, Hewick DS, Moreland TA, Stevenson IH. Age as a determinant of sensitivity to warfarin. Br J Clin Pharmacol. 1977; 4(3): 315-20. https://doi.org/10.1111/j.1365-2125.1977.tb00719.x
  20. Fihn SD, Callahan CM, Martin DC, McDonell MB, Henikoff JG, White RH. The risk for and severity of bleeding complications in elderly patients treated with warfarin. Ann Intern Med. 1996; 124(11): 970-9. https://doi.org/10.7326/0003-4819-124-11-199606010-00004