Clinical Case Database / Category: Patient Management

Anticoagulation, adverse effects and antidotes

Publication details

Dr Wenchee Siow, Dr Fatts Chowdhury, Dr Gavin Cho
Foundation Years Journal, volume 9, issue 3, p.38 (123Doc Education, London, March 2015)


Warfarin has been the most commonly prescribed oral anticoagulant for many years until the recent introduction of the novel anticoagulants such as Dabigatran and Rivaroxaban. The presence of a mechanical heart valve is an indication for anticoagulation. The main side effect of warfarin is bleeding, with intracerebral haemorrhage being one of the most serious bleeding risk requiring immediate reversal management. This patient had immediate warfarin reversal but developed pulmonary emboli as a result. This case highlights the difficulties managing a patient with concurrent haemorrhage and thrombosis.

Access the Clinical Cases Database

A subscription is required to read the full article. Please subscribe using one of the options below.

Foundation Years Clinical Cases Database£29.006 months
Add to cart
Foundation Years Clinical Cases Database£39.0012 months
Add to cart


Dr Wenchee Siow

Haematology ST7, Northwick Park Hospital,
Watford Road, Harrow, Middlesex, HA1 3UJ.

Dr Fatts Chowdhury

Consultant Haematologist, Northwick Park Hospital
Watford Road, Harrow, Middlesex, HA1 3UJ.

Dr Gavin Cho (Corresponding author)

Consultant Haematologist, Northwick Park Hospital
Watford Road, Harrow, Middlesex, HA1 3UJ.


1. Hart R, Bradley S, Anderson C. Oral anticoagulants and intracranial haemorrhage: facts and hypothesis. Stroke 26, 1995: 1471-1477
2. Goldstein J, Greenberg S. Should anticoagulation be resumed after intracerebral haemorrhage? Cleveland Clinic Journal of Medicine. 11/2010: 77(11):791-9
3. Schulman S, Beyth R, Kearon C, Levine M. Haemorrhagic complications of Anticoagulant and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008;133;257-298
4. Cannegieter SC, Rosendaal FR, Wintzen AR. Optimal Oral Anticoagulant in Patients with Mechanical Heart Valves. The New England Journal of Medicine 1995; 333:11-17
5. Makris M, Van Veen J, Tait A, Mumford A, Laffan M. Guideline on the management of bleeding in patients on antithrombotic agents. British Journal of Haematology 2012, 160, 35-46.
6. Keeling D, Baglin T, Tait C, Perry D et al. Guidelines on oral anticoagulation with warfarin-Fourth Editioin. British Journal of Haematology 2011. 1365-2141.
7. Octaplex SPC.
8. Rosovsky R and Crowther M. What is the evidence for the off-label use of recombinant factor VIIa in the acute reversal of warfarin? ASH Education Book January 1, 2008 no.1 36-38
9. Novoseven SPC.
10. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation.
11. Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation.
12. Rivaroxaban for the prevention of stoke and systemic embolism in people with atrial fibriallation.
13. N Korn. How do you decide which oral direct inhibitor to prescribe. Thrombus. Summer 2014. Vol 18. Number 2
14. Connolly S, Ezekowitz M, Yusuf S, Eikelboom J et al. Dabigatran versus warfarin in patients with atrial fibrillation. NEJM 2009 ;361:1139-1151
15. Patel M, Mahaffey M, Garg J, Pan G et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. NEJM 2011;365:883-891
16. Granger C, Alexander J, McMurray J, Lopes R et al. Apixaban versus warfarin in patients with atrial fibrillation. NEJM 2011;365: 981-992
17. Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults.
18. Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults.
19. Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism.
20. Huttner HB, Schellinger PD, Hartmann M et al. Hematoma Growth and Outcome in Treated Neurocritical Care Patients with Intracerecral Haemorrhage Related to Oral Anticoagulant Therapy. Stroke 2006;37:1465-1470.
21. Cannegieter S, Rosendaal F, Briet E. Thromboembolic and Bleeding Complications in Patients with Mechanical Heart Valve Prosthesis. Circulation 1994;89:635-41
22. Butler A, Tait R. Restarting anticoagulation in prosthetic heart valve patients after intracranial haemorrhage. British Journal of Haematology. Dec 1998 Vol 103 1064-1066


Conflict Of Interest

The Journal requires that authors disclose any potential conflict of interest that they may have. This is clearly stated in the Journal’s published “Guidelines for Authors”. The Journal follows the Guidelines against Conflict of Interest published in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (

Financial Statement

The authors of this article have not been paid. The Journal is financed by subscriptions and advertising. The Journal does not receive money from any other sources. The decision to accept or refuse this article for publication was free from financial considerations and was solely the responsibility of the Editorial Panel and Editor-in-Chief.

Patient Consent statement

All pictures and investigations shown in this article are shown with the patients’ consent. We require Authors to maintain patients’ anonymity and to obtain consent to report investigations and pictures involving human subjects when anonymity may be compromised. The Journal follows the Guidelines of the Uniform Requirements for Manuscripts ( The Journal requires in its Guidelines for Authors a statement from Authors that “the subject gave informed consent”.

Animal & Human Rights

When reporting experiments on human subjects, the Journal requires authors to indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2008.

About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

The database is fully searchable, or can be browsed by medical specialty. Abstracts can be read free of charge, however a subscription is required in order to read the complete cases.