Stroke Symptoms in a Patient on 4-Factor Prothrombin Complex

We read with interest the article “Ischemic stroke symptoms after warfarin reversal with 4-factor prothrombin complex concentrate case report” published by Carson and Price in your esteemed journal. The authors have excellently described an 83-year-old lady sustaining wrist injury, receiving 4-factor prothrombin complex concentrate (4F PCC) before surgery. The patient has had left-sided hemiparesis which was treated with tissue plasminogen activator with complete improvement in deficits. ¹

The authors have administered 4F PCC at the dose of 25 units/kg anticipating the emergent surgery. Recently, multiple studies have demonstrated the efficacy of low-dose 4F PCC, even in patients requiring acute surgical intervention.^2,3 Administration of low-dose 4F PCC, at the dose of 15 units/kg, has been shown to effectively reverse coagulopathy, with lesser reported thromboembolic events.

To date, most of the studies have reported venous thromboembolic events after the administration of PCC. Attributing the administration of 4F PCC to the development of ischemic stroke as in this patient might not be causative.^4,5 Around 75 000 patients develop stroke while being admitted to the hospital in the United States. Risk factors of developing stroke in these patients are elevated diastolic blood pressure, atrial fibrillation, prosthetic heart valves, carotid stenosis, heart failure, and history of myocardial infarction.^4,6 As the authors have already mentioned, this patient has got significant risk factors that could solely attribute to the development of stroke. Although we agree with the authors regarding the association, we beg to defer from the authors regarding its causation.

Finally, a combined pharmacy- and physician-driven administration of 4F PCC is shown to improve the adequacy of administration, monitoring, cost of care, and outcome.^5,7,8 The involvement of a pharmacy and a pharmacy-driven protocol can reduce patient morbidity and cost of care by reducing avoidable administrations of this expensive agent. The pharmacy-driven protocol can also facilitate the administration of varying doses of 4F PCC as per the patient’s requirement.