Abstract 12793: Warfarin Use Prompting Significant Intervention in the Emergency Department: Acute Hemorrhage and Bleeding Concerns

IntroductionThe SOAR (Safety of Oral Anticoagulants Registry) project is an ongoing observational study of the impact of oral anticoagulation therapy in patients presenting for emergency department (ED) care.MethodsPatients are eligible for inclusion if they are taking any oral anticoagulant (OAC) and present with acute hemorrhage (AH) or an acute bleeding concern (BC; due to a need for a procedure or requiring prolonged observation) that requires substantial intervention (e.g., admission, reversal, or transfusion). The project is enrolling patients at 30 US hospitals and the prespecified warfarin cohort has filled.ResultsMore than 1,250 subjects have been enrolled; of the 564 subjects in the warfarin group, average (SD) age is 70.6 (13.1) y, and 53% are male. Concomitant aspirin was reported by 46.5%, and P2Y12 inhibitors by 8.4%. After initial care, 85.1% were hospitalized, 32.2% in ICU. There were 405 (71%) enrolled for an AH, with an average (SD) INR at presentation of 4.25 (3.79). In that group, 19.1% of presentations were potentially life-threatening; 23% had intracranial hemorrhage (ICH), and 43.3% had gastrointestinal bleeding. Nearly half of these patients received packed red blood cell transfusion and &gt 1/3 received fresh-frozen plasma (FFP); 107 (26.4%) received reversal therapy with a prothrombin complex concentrate (PCC). In patients with BC (n=159), age and comorbidity burden were higher, as was mean INR, 5.49 (4.09); 22.6% received FFP and 13.8% received PCC. Less than 75% of these warfarin-treated patients received IV vitamin K. Hospital length of stay was 6-7 days in the warfarin cohort, regardless of subgroup; at discharge, 23.8% of AH patients and 27.0% of BC patients were restarted on an OAC. Of 11 patients who died in-hospital, 10 were BC patients and 1 had an ICH.ConclusionsPresentation with AH or BC in ED patients taking warfarin is associated with advanced age, supratherapeutic INR, and concomitant antiplatelet therapy, and is often not managed per guidelines. Vitamin K, while not an acute reversal agent, is underutilized. Despite evidence indicating PCC is superior to FFP for factor repletion, FFP is often given acutely. BC patients received factor repletion less frequently and experienced higher in-hospital mortality than patients presenting with AH. There is room for improvement in the ED care of patients on OACs. Updated data will be presented.