Time to Anticoagulation Reversal at a Large, Academic, Regional Referral Center

Introduction: Timely anticoagulation reversal is critical in patients with major bleeding. No guideline recommendations exist for target times to anticoagulation reversal. Retrospective studies of patients with intracranial hemorrhage (ICH) suggested that a target door-to-treatment time of 60 minutes or less is associated with decreased mortality and lower rates of discharge to hospice but did not evaluate time to reversal in other types of major bleeding. The purpose of this study was to determine the time from anticoagulation reversal order to administration in patients with major bleeding of all types and to identify potential operational or clinical barriers that could result in delayed administration.


Methods: This was a retrospective chart review at a large academic level 1 trauma center of adult patients that received anticoagulation reversal with four-factor prothrombin complex concentrate (4F-PCC), andexanet alfa (AA), or idarucizumab from January 1, 2024 to December 31, 2024. Patients were excluded if they received anticoagulation reversal for non-urgent procedures, intra-operatively, or for non-anticoagulant reversal indications. The primary outcome was the average time from anticoagulation reversal order to administration.


Results: A total of 96 patients were included. Patients were primarily female (52.1%), median age of 75, on apixaban prior to admission (72.9%), presented with ICH (41.7%), and located in the ED (57.3%). Most patients received 4F-PCC (75.0%) for anticoagulation reversal. Median time from order to administration was 51.5 minutes (35, 67.5). Median time from order to administration was significantly shorter for patients who received 4F-PCC vs AA [47 min (34, 66) vs 62 min (47, 71); p=0.03]. For patient’s presenting to the ED, median time from door to anticoagulant reversal was 145 min, however, there was no difference in median time from order to anticoagulation reversal for patients located in the ED vs the ICU (45 min (33, 68) vs 57 min (38, 69); p=0.2].


Conclusions: Overall median time to anticoagulation reversal for all major bleeding types met current recommendations for time to administration in 60 minutes or less, however, median door to anticoagulation reversal for patients located in the ED did not achieve this goal.