Key result
Warfarin triggers spontaneous multi-site hemorrhage despite therapeutic INR in an elderly patient.
Case Report (n=1)
No
Severe, life-threatening spontaneous hemorrhage can occur within days of initiating warfarin in very elderly patients with renal dysfunction even when the PT-INR remains within the therapeutic range, warranting close monitoring and readiness to reverse anticoagulation.
Answers are grounded in this paper and cite their sources.
May warrant extra vigilance for early bleeding in very elderly patients with renal impairment starting warfarin; leaves open generalizability and optimal dosing strategies.
A 94 year-old Japanese woman with renal dysfunction was admitted to our hospital for congestive heart failure caused by atrial fibrillation with rapid ventricular response. Considering the risk of stroke, warfarin was commenced. However, she developed shock following brachial and retroperitoneal hemorrhage 4 days after starting warfarin despite not being over-anticoagulated. She recovered after receiving blood transfusion and intravenous vitamin K2. Bleeding during warfarin administration occurs more frequently in older individuals with lower glomerular filtration rates, especially within the first 30 days of warfarin treatment. Physicians should therefore check for unexpected bleeding after commencing warfarin and be prepared to reverse anticoagulation.
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Akuzawa et al. (2018) conducted a case report in Congestive heart failure caused by atrial fibrillation with rapid ventricular response and renal dysfunction (n=1). Warfarin was evaluated on Spontaneous brachial and retroperitoneal hemorrhage resulting in hemorrhagic shock. Warfarin (2 mg/day) was associated with spontaneous brachial and retroperitoneal hemorrhage 4 days after initiation at a therapeutic PT-INR of 2.22 in a 94-year-old woman with renal dysfunction.
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