Supratheraputic INR Even if stable many months can become excessively anticoagulated

The most common causes of overanticoagulation include interaction with another medication, wrong dosage of warfarin, vitamin K deficiency, diarrhea, heart failure, fever, and impaired liver function

Ask and check medication prescription compared to what is taken. Few randomized studies comparing the treatment options:
Recommended management of a supratherapeutic INR
INR
>Ther to 5.0

Bleeding present
No Lower warfarin dose, or

Recommended action*

Omit a dose and resume warfarin at a lower dose when INR is in therapeutic range, or No dose reduction needed if INR is minimally prolonged >5.0 to 9.0 No Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at a lower dose when INR is in therapeutic range, or Omit a dose and administer 1 to 2.5 mg oral vitamin K1 >9.0 No Hold warfarin and administer 2.5 to 5 mg oral vitamin K1. Monitor INR more frequently and administer more vitamin K1 as needed, Resume warfarin at a lower dose when INR is in therapeutic range Hold warfarin and administer 10 mg vitamin K1 by slow IV infusion; supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency. Monitor and repeat as needed.

Any

Serious or lifethreatening

INR: International Normalized Ratio; Ther: therapeutic INR range for the patient in question.

This option is preferred in patients at increased risk for bleeding (eg, history of bleeding, stroke, renal insufficiency, anemia, hypertension). (RISK OF MAJOR HAEMORRHAGE ~1%) Adapted from: Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

Stopping warfarin The next one to two doses of warfarin should be withheld, the INR should be monitored more frequently, and a lower maintenance dose of warfarin should be reinstituted when the INR falls into the therapeutic range. Monitor every 2 days. If more rapid reversal is required because of the need for urgent surgery, we suggest stopping warfarin and administering one or more oral doses of vitamin K (5 mg/dose) (Grade 2C). (See 'Surgery/invasive procedure' above.)

IV vit K
In a prospective single-arm study, 178 patients on long-term warfarin therapy stopped this treatment and received 3 mg of intravenous vitamin K 12 to 18 hours prior to elective surgery [54]. An INR 1.7 or 1.4 was achieved in 100 and 94 percent of the subjects on the day of surgery. Warfarin was re-started within 12 to 24 hours post-procedure at the previous therapeutic dose. Four patients (2.2 percent) had procedure-related major bleeding, although all four had an INR <1.5 and vitamin K-dependent factor levels >0.30 InternationalUnits/mL at

the time of the bleeding episode. No patient had an adverse reaction to the vitamin K infusion or a symptomatic thromboembolism during a six-week follow-up period. A therapeutic INR was re-established at a median time of four days post-procedure (range: 2 to 11 days).

Treatment with high doses of vitamin K may make it difficult to resume effective anticoagulation with warfarin for days to weeks after the episode has been controlled.

Devices Biventricular pacing is emerging as a safe and effective treatment to improve symptoms and haemodynamics in people with CHF. It should be considered (with or without an implantable cardioverter defibrillator (ICD)) in people with all of the following: NYHA functional class IIIIV on treatment (see

Table 1 on page four) heart failure with LVEF 35% QRS interval duration 120 ms sinus rhythm.

ICD implantation should be considered in people with CHF who meet any of the following criteria: history of cardiac arrest due to VF or ventricular

tachycardia (VT) spontaneous sustained VT in association with

structural CHD LVEF 30% when stabilised post MI or

revascularisation

NYHA functional class II-III, LVEF 35%.

In people in whom implantation of an ICD is planned to reduce the risk of sudden death, it is reasonable to also consider cardiac resynchronisation therapy (CRT) to reduce risk of death and heart failure events if the LVEF is 30% and the QRS duration is 150 ms (left bundle branch block morphology), with associated mild symptoms (NYHA Class II), despite optimal medical therapy. LV assist devices are used mainly as temporary bridges to cardiac transplantation or recovery after heart surgery.