Yüksek INR Düzeylerine Rağmen Görülen İki İskemik İnme Olgusu

Yıl 2022, , 23 - 26, 30.04.2022

Melih Yüksel , Suna Eraybar , Halil Kaya , Mehmet Oğuzhan Ay

https://doi.org/10.51262/ejtox.1061039

Öz

Warfarin, dünya çapında tromboembolik vakaların tedavisinde ve önlenmesinde yaygın olarak kullanılan bir K vitamini antagonistidir. Terapötik aralığı dardır ve bunu uluslararası normalleştirilmiş oran (INR) ile takip edilir. Düşük INR seviyelerinde iskemik durumlar gözlenirken, daha yüksek INR seviyelerinde kanama görülür. Varfarin kullanan 45 yaşında kadın ve 79 yaşında erkek hasta nörolojik defisit ile acil servise başvurdu. Her iki hastada da radyolojik görüntüleme ile iskemik inme saptandı. Ancak INR düzeyleri laboratuvar testlerinde (11.44 ve 12.37 kU/L) anlamlı olarak daha yüksekti. Bu kadar yüksek INR seviyelerinde normal olarak kanama beklenmesine rağmen iskemik inme meydana geldi. Literatürde yayınlanan birçok çalışmanın aksine bu olgu sunumu sonuçları açısından ilginç bilgiler ortaya koymuştur.

Anahtar Kelimeler

İskemik inme, Yüksek INR seviyeleri, Warfarin doz aşımı, Acil Tıp

Destekleyen Kurum

yoktur

Proje Numarası

yoktur

Two Ischemic Stroke Cases Accuring Despite High INR Levels

Öz

Warfarin is a vitamin K antagonist commonly used in the treatment and prevention of thromboembolic cases worldwide. Its therapeutic range is narrow and is followed by the international normalized ratio (INR). Ischemic conditions are observed at low INR levels whereas bleeding is seen at higher INR levels. A 45-year-old woman and a 79-year-old man using warfarin were admitted to the emergency department with a neurological deficit. Ischemic stroke was revealed via radiological imaging in both patients. However, INR levels were significantly higher in laboratory tests (11.44 and 12.37 kU / L).Ischemic stroke occurred although bleeding is normally expected at such high INR levels. Contrary to many studies published in the literature, this case report revealed interesting information in terms of its conclusions.

Anahtar Kelimeler

İschemic stroke, Hıgh INR levels, Warfarine overdose, Emergency Medicine

Proje Numarası

yoktur

Kaynakça

• 1. Béné J, Rousselin C, Bagheri H, Vial T, Gautier S, Lambert M. Nonhemorrhagic joint disorders and vitamin K antagonists: an under-recognized adverse drug reaction? Fundam Clin Pharmacol. 2018 Dec;32(6):663-668.
• 2. Ezekowitz MD, Bridgers SL, James KE, Carliner NH, Colling CL, Gornick CC, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. N Engl J Med. 1992 Nov 12;327(20):1406-12
• 3. Fang MC, Go AS, Chang Y, Hylek EM, Henault LE, Jensvold NG, Singer DE. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007 Aug;120(8):700-5.
• 4. Heneghan C, Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and meta-analysis. Lancet. 2006 Feb 4;367(9508):404-11.
• 5. Hirsh J, Dalen JE, Anderson DR, Poller L, Bussey H, Ansell J, Deykin D, Brandt JT. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest. 1998 Nov;114(5 Suppl):445S-469S.
• 6. Hirsh J, Poller L. The international normalized ratio. A guide to understanding and correcting its problems. Arch Intern Med. 1994 Feb 14;154(3):282-8.
• 7. Hylek EM, Skates SJ, Sheehan MA, Singer DE. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med. 1996 Aug 22;335(8):540-6.
• 8. Kimmel SE. Warfarin therapy: in need of improvement after all these years. Expert Opin Pharmacother. 2008 Apr;9(5):677-86.
• 9. Levine M, Pizon AF, Padilla-Jones A, Ruha AM. Warfarin overdose: a 25-year experience. J Med Toxicol. 2014 Jun;10(2):156-64
• 10. Mahdizadeh F, Safari S. Concurrent Hand and Penile Gangrene following Prolonged Warfarin Use; a Case Report. Emerg (Tehran). 2017;5(1): e71
• 11. Marchandot B, Messas N, Jesel L, Trinh A, Kibler M, Reydel A et al. Unexpected Problems of Antithrombotic Therapy with An Unusual Side Effect of Vitamin K Antagonists after Mitral Valve Replacement. J Heart Valve Dis. 2017 May;26(3):309-313
• 12. Mendonca S, Gupta D, Valsan A, Tewari R. Warfarin related acute kidney injury: A case report. Indian J Nephrol. 2017 Jan-Feb;27(1):78-80
• 13. Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention. A population-based study. Ann Intern Med. 1999 Jan 5;130(1):14-22.
• 14. Sklar LR, Messman A. An Atypical Case of Warfarin-Induced Skin Necrosis. Clin Pract Cases Emerg Med. 2017 Oct 11;1(4):359-361