Propensity Score Adjusted Comparison of Three-Factor versus Four-Factor Prothrombin Complex Concentrate for Emergent Warfarin Reversal: A Retrospective Cohort Study

Abstract Background Prothrombin Complex Concentrates are prescribed for emergent warfarin reversal (EWR). Few direct comparisons with three-factor prothrombin complex concentrate (PCC3) and four-factor prothrombin complex concentrate (PCC4) exist. Patients in an academic level one trauma center who received PCC3 or PCC4 for EWR were identified. Patient characteristics, PCC dose and time of dose, pre- and post-INR and time of measurement, plasma and vitamin K doses, and patient outcomes were collected. Patients whose pre-PCC International Normalized Ratio (INR) was > 6 hours before PCC dose or the pre-post PCC INR was > 12 hours were excluded. The primary outcome was achieving an INR ≤ 1.5 post PCC. Secondary outcomes were the change in INR over time, post PCC INR, thromboembolic events (TE), and death during hospital stay. Logistic regression modelled the primary outcome with and without a propensity score adjustment accounting for age, sex, actual body weight, dose, initial INR value, and time between INR measurements. Data are reported as median (IQR) or n (%) with p < 0.05 considered significant. Results Eighty patients were included (PCC3 = 57, PCC4 = 23). More PCC4 patients achieved goal INR (87.0% vs. 31.6%, odds ratio (OR) = 14.4, 95% CI: 3.80-54.93, p < 0.001). The result was similar after adjusting for possible confounders (AOR = 10.7, 95% CI: 2.17–51.24, p < 0.001). The post-PCC INR was lower in the PCC4 group (1.3 (1.3–1.5) vs. 1.7 (1.5-2.0), p < 0.001. The INR change was greater for PCC4 (2.3 (1.3–3.3) vs. 1.1 (0.6-2.0), p = 0.003). Death during hospital stay (p = 0.52) and TE (p = 1.00) were not significantly different. Conclusions PCC4 was associated with a higher achievement of goal INR than PCC3. This relationship was observed in the unadjusted, propensity score adjusted, and time stratified results.