Fresh Frozen Plasma versus Prothrombin Complex Concentrate for Warfarin Reversal in the Emergency Department: A Retrospective Cohort Study of Clinical Outcomes and Costs

Aim: Rapid reversal of warfarin-associated coagulopathy is a frequent challenge in emergency departments (EDs).Four-factor prothrombin complex concentrates (PCCs) correct the international normalized ratio (INR) more rapidly than fresh frozen plasma (FFP), but their clinical and economic impact in routine practice, particularly in resource-limited settings, remains uncertain.Materials and Methods: This retrospective cohort study was conducted in the ED of a tertiary university hospital.Adult warfarin-treated patients presenting with INR >1.2 and who received FFP alone or PCC (Cofact) alone for supratherapeutic INR and/or warfarin-associated bleeding were included.Clinical, laboratory, and direct product cost data were abstracted from electronic records.Primary outcomes were INR reduction (ΔINR) and achievement of target INR thresholds (≤1.5 and ≤1.8).Secondary outcomes included acute kidney injury (AKI), hospital and intensive care unit (ICU) length of stay, ED disposition, in-hospital mortality, and direct product costs.Multivariable logistic regression was used to explore independent associations. Results:We analyzed 119 patients (92 FFP, 27 PCC).PCC was associated with a lower final INR and a greater ΔINR than FFP.PCC-treated patients were more likely to have gastrointestinal bleeding and markers of greater illness severity.AKI occurred more frequently in patients receiving PCC, and PCC use was independently associated with AKI after adjustment for age and presenting INR.PCC recipients had longer hospital stays, higher ICU utilization, and a numerically higher in-hospital mortality, although mortality estimates were imprecise.Both direct product costs and the cost per unit reduction in INR were substantially higher with PCC. Conclusions:In this real-world ED cohort, PCC achieved superior laboratory reversal compared with FFP but was preferentially used in patients who were clinically sicker.While PCC was associated with higher AKI rates, longer hospital stays, and greater direct product costs, these findings likely reflect baseline illness severity and confounding by indication rather than a direct effect of the reversal agent.Our results are primarily hypothesis-generating and underscore the need for larger prospective, multicenter studies with comprehensive costeffectiveness and safety analyses.