When is reversal of anticoagulation required and how is it achieved in patients with atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Answer

In the presence of acute major bleeding, emergent reversal of anticoagulation is required. Fresh frozen plasma is often utilized to reverse the effects of warfarin, but it takes 6-24 hours to achieve compete reversal. In more emergent settings, prothrombin complex concentrates (PCCs) can be used, because they provide complete reversal of anticoagulation in 15-20 minutes. [94]

For patients taking newer oral anticoagulants, several reversal agents have been developed; however, it should be noted that these newer anticoagulants have short half-lives (5-17 hours), and reversal is rarely indicated. Idarucizumab (Praxbind) is a monoclonal antibody fragment which binds with high affinity to dabigatran. Its efficacy was studied in the RE-VERSE AD trial (Reversal Effects of Idarucizumab on Active Dabigatran) in which 90 patients who were taking dabigatran and presented with serious bleeding or had a need for an urgent invasive procedure (< 8 hours) were given two doses of idarucizumab 15 minutes apart. As measured by laboratory testing, idarucizumab completely normalized coagulation parameters in 90% of patients within the first 10-30 minutes. Five thrombotic events and 18 deaths were reported, but there was no control group to compare the relative risk of thrombosis and death. [92]

Andexanet alfa targets and sequesters factor Xa inhibitors (rivaraoxaban, apixaban, edoxaban). This agent is currently under clinical trials and is not FDA approved. [93, 95]


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