Warfarin Treatment in Context of Falls ,Head Injury and Bruising

CASE BASED DISCUSSION

Maddasar Raja

Background
Warfarin treatment in context of falls and head injury in Elderly patients often poses a difficult clinical conundrum. Elderly patients represent a patient population at high Thromboembolic risk BUT also high Hemorrhagic risk. General tendency among Physicians to underuse anticoagulants in Elderly both because underestimation of Thromboembolic risk and Overestimation of bleeding risk.

Case Presentation
75 years old woman P/C : Acute Shortness of Breath Background
Recent Pulmonay Emboli Atrial Fibrillation Mild Hypothyroidism Essential Hypertension Acne Rosacea (Long standing) .

Medication
Untill 4 weeks before admission,had been on long term anticoagulation with Warfarin Warfarin was discontinued on previous admission beacause patient presented with a fall and minor head injury and partly due to Extensive Facial Bruising. Lansoprazole Paracetamol Adcal D Beclomethasone Inhaler Minocycline

On Examination
Apyrexial HR : 80/min Irregular BP : 138/76 RR: 18/min Sats 91% on air Chest clear to Auscultation Abdomen SNT No focal Neurology No signs of DVT or pelvic masses. Extensive pigmentation on the face which was Symmetrical Bilateral In photosensitive distribution concomitant pigmentation of sclera

Investigations
ECG : Confirmed AF ABG : Hypoxemia(P02 8.9)and Normal Ph and Pco2. CXR : Normal CTPA: Segmental filling defect indicating Pulmonary
Embolus.

Differential Diagnosis of Facial Pigmentation

Trauma Medication -Amiodarone,Thiazide,NSAIDS. Endocrine- Addisons Disease Malar Flush-Sun exposure ,Acne,Mitral stenosis,SLE Chloasma/Melasma- Oestrogen,pregnancy Lentigo maligna Neoplastic leisons Congenital pigmentation Vascualar leisions-port wine staining.

Treatment
Diagnosis of recurrent pulmonary emobolus and and Minocycline induced pigmentation was explained to the patient and management plan was agreed. Warfarin was recommenced Treatment dose of LMWH was prescribed untill therapeutic INR (2.0-3.0) had been achieved. Information was given to the regarding alternative options for managing Acne Rosacea.

Patient was discharged uneventfully and on Follow up pigmentation appeared to have improved since discontinuing Minocycline.

Discussion
Decision to withhold or initiate anticoagulation can be difficult to make in Elderly patients more at risk of falls. While each patient should be reviewed on their own merits ,the decision to stop anticoagulation in is this group of patients is well less supported by evidence. In an avergae patient with AF ,the risk of intracranial hemorrhage from a fall s much smaller than benefits gained from reduced risk of stroke. Another study (Markov Decision Analysis) findings :
The calculated risk of subdural hematoma from falling was such that a patient with 5% annual stroke risk from AF would need to fall 295 times a year for the fall risk to outweigh the stroke reduction benefits of warfarin

Guidelines from American Heart Physicians and American College of Chest physicians do not use fall risks in the decision to use anticoagulation. BAFTA Trial demonstrated an annual risk of stroke of 1.8% in warfarin arm versus 3.8 % in the Aspirin arm and absolute reduction of 2% in patients over 75 years of age. While there was no difference in the rates of ICH between aspirin and warfarin treated groups with the goal INR of 2.0-3.0. Minocycline induced Skin pigmentation is well recognized side effect that usually begins at 3 months but has prevalence of as high as 41% of patients at 1 year.This pigmentation of skin was mistaken as bruising in the above mentioned case.

Learning points
In clinical context of a patient on warfarin presenting with falls and head injury close attention should be performed to Medication history ,Side effects and individual risk benefit analysis while deciding whether or not to continue anticoagulant treatment. Regular review of long term medication with surveillance for side effects is essential Falls and age alone are not an indication for discontinuing Warfarin in patients at high risk of embolic stroke and this generally will out weigh the risk of intracranial bleeding. Hyperpigmentation is relatively common side effect of Minocycline especially with prolonged use and may mimic Bruising.