Background: Prescription of Non-vitamin K antagonist oral anticoagulants (NOACs) has been increasing. This brings new challenges in the management of bleeding events, which may be triggered or potentiated by excessive NOACs plasma concentration.

Aims: Description of an acute bleeding in a patient treated with dabigatran.

Methods: Collection of clinical data in SClínico® application.

Results: Woman, 87 years old, was found prostrate on the ground and brought to Emergency Room. Medical history: arterial hypertension and atrial fibrillation anticoagulated with dabigatran. At the admission she had hypotension (70/30mmHg), Glasgow Coma Scale E4V4M6 and a frontal acute bleeding incised wound. Acute cerebral haemorrhage was excluded by computed tomography (CT). Analytical study revealed acute renal failure, haemoglobin of 8,8g/dL (previous 10g/dL) and an altered coagulation study: aPTT 73,6s (24,0-34,0s), PT Rate 20% (>70%), INR 3.05, with dabigatran concentration >460ng/ml (52-275ng/ml). After fluid administration, tension profile has improved (109/52mmHg). As she was hemodynamically stable, the attending physician decide not to administer idarucizumab and to keep the patient under surveillance. The next day, brain CT scan was repeated, without further changes, but two red blood cell (RBC) units were transfused due to a decrease in haemoglobin (7g/dL). On the 3^rd and 4^th days of hospitalization, she had isolated self-limited episodes of hematuria and melena, respectively. Dabigatran levels, without antidote administration, returned to non-therapeutic levels on the 6^th day of hospitalization. The patient remained hospitalized for 15 days, without anticoagulation therapy, with progressive improvement of renal function and haemoglobin (9,2g/dL). No further bleeding occurred until discharge.

Conclusions: NOACs associated bleeding can be difficult to manage. In this case, the option of no administration of idarucizumab, its impact on patient bleeding and need of RBC transfusion, encourages clinical reflection on the topic. Thereby, it is important to create and work with interdisciplinary bleeding management teams.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/management-of-a-non-vitamin-k-antagonist-oral-anticoagulant-associated-bleeding-a-case-report/