Anticoagulant Reversal — ABIM Board MCQ

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ModerateHematologyAnticoagulant ReversalABIM Board

A 70‑year‑old man with atrial fibrillation and prior ischemic stroke is taking warfarin (INR goal 2–3). He presents with an acute intracranial hemorrhage and an INR of 2.8. Which reversal strategy is most appropriate?

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Reveal the answer and explanation

Correct answer: B — Four‑factor prothrombin complex concentrate plus vitamin K

Option B is correct. The 2022 AHA/ASA guideline recommends 4‑factor PCC over FFP for VKA‑associated spontaneous ICH (especially with INR ≥ 2.0), with intravenous vitamin K immediately after PCC to prevent INR rebound and support sustained hemostasis. Fresh frozen plasma alone (Option C) is slower, requires larger volumes, and is inferior for rapid INR correction. Vitamin K alone (Option A) is too slow in acute ICH. Protamine (Option D) reverses heparin, not warfarin. Idarucizumab (Option E) reverses dabigatran, not warfarin.

Reference: 2022 AHA/ASA Guideline for Management of Spontaneous ICH (Section Anticoagulant‑Related Hemorrhage) and Kcentra FDA label, 2023.