Warfarin Reversal — EECC MCQ

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ModerateCardiac PharmacologyWarfarin ReversalEECC

A 70-year-old man on warfarin (INR target 2.5-3.5) for a mechanical mitral valve presents to the emergency department with a large intracerebral haemorrhage. His INR is 4.2. Which reversal agent is most appropriate?

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Reveal the answer and explanation

Correct answer: C — Four-factor prothrombin complex concentrate (PCC) with intravenous vitamin K

Life-threatening bleeding on warfarin requires urgent reversal with four-factor PCC (containing factors II, VII, IX, X and proteins C and S), which provides rapid, reliable INR normalisation within minutes (Class I). IV vitamin K (5-10 mg) should be administered concurrently for sustained reversal (onset 6-8 hours). FFP is no longer recommended as first-line due to slower administration, volume overload risk, and incomplete factor replacement. Idarucizumab is specific to dabigatran reversal. Andexanet alfa reverses factor Xa inhibitors (apixaban, rivaroxaban). Vitamin K alone has too slow an onset for life-threatening haemorrhage. In mechanical valve patients, the risk of thrombosis must be weighed against bleeding, and anticoagulation should be cautiously restarted once haemostasis is achieved.

Reference: BCSH Guidelines on Oral Anticoagulant Reversal; NICE NG24