Clinical manifestations and outcomes of severe warfarin overanticoagulation: from the EWA study

<p><b>Introduction:</b> Severe warfarin overanticoagulation is a risk factor for bleeding, but there is little information on its manifestations, prognosis and factors affecting the outcome. We describe the manifestations and clinical outcomes of severe warfarin overanticoagulation in a large group of patients with atrial fibrillation (AF).</p> <p><b>Material and methods:</b> All international normalized ratio (INR) samples (<i>n</i> = 961,431) in the Turku University Hospital region between 2003 and 2015 were screened. A total of 412 AF patients with INR ≥9 were compared to 405 patients with stable warfarin anticoagulation for AF. Electronic patient records were manually reviewed to collect comprehensive data.</p> <p><b>Results:</b> Of the 412 patients with INR ≥9, bleeding was the primary manifestation in 105 (25.5%). Non-bleeding symptoms were recorded in 165 (40.0%) patients and 142 (34.5%) had no symptoms. A total of 17 (16.2%) patients with a bleed and 67 (21.8%) without bleeding died within 30 days after the event. Intracranial haemorrhage strongly predicted death within 30 days. Other significant predictors were non-bleeding symptoms, active malignancies, recent bleed, history of myocardial infarction, older age, renal dysfunction and a recent treatment episode.</p> <p><b>Conclusions:</b> Bleeds are not the major determinant of the poor prognosis in severe overanticoagulation, as coincidental INR ≥9 findings also associate with high mortality.KEY MESSAGES</p><p>Only a quarter of AF patients with INR ≥9 suffered a bleeding event and the clinical manifestation of INR ≥9 had a significant impact on patient outcome.</p><p>The 30-day mortality rate in patients with INR ≥9 was high ranging from 9.2 to 32.7%.</p><p>Several significant predictors of 30-day mortality after INR ≥9 were identified.</p><p></p> <p>Only a quarter of AF patients with INR ≥9 suffered a bleeding event and the clinical manifestation of INR ≥9 had a significant impact on patient outcome.</p> <p>The 30-day mortality rate in patients with INR ≥9 was high ranging from 9.2 to 32.7%.</p> <p>Several significant predictors of 30-day mortality after INR ≥9 were identified.</p>