Anticoagulation During the Cold Harmattan Season:Need for Extra Caution

With increasing availability of valve surgery, a pool of patients requiring chronic anticoagulation is emerging in our environment. The lower blood coagulability with low temperatures, though rare, can occur, putting patients at risk of bleeding. Recently, the author lost two patients with prosthetic valves on anticoagulation at the peak of the cold harmattan season. Before their death, despite dose reduction, the International Normalised Ratio (INR) kept increasing and they were reported to have died suddenly at home. This triggered the need to draw attention of clinicians especially in the tropics to this difficulty, so as to anticipate and confront it when necessary. Case 1 was a 42-year-old male hypertensive on life-style measures with Moduretic once daily and weekly 20 mg Propranolol to control his blood pressure. He had surgery in India for aortic aneurysm with placement of prosthetic valve in 2013, and was placed on an oral anticoagulant - Acitrom. In 2015 while on 3 mg daily dose, he had an INR of 2.8. By October, INR rose to 3.95 prompting a dose reduction to 2 mg daily. Early in January 2016 (peak of cold harmattan season), the INR went higher to 4.19. He was asked to skip doses on Saturday and Sunday. After a forthnight he was reported to have died suddenly at home and no autopsy was done. Case 2 was a 40-year-old female with mitral stenosis. She had mitral valve surgery with prosthetic valve placement in India in 2010 where she was put on warfarin. In 2015, she had episode of ecchymosis and INR returned 2.07. With dose reduction, the INR dipped to 1.21 prompting a dose increase to 6 mg. The INR increased to 2.73. By October of 2015, her INR rose to 3.72, prompting de-escalation to 5 mg daily. While on this, she presented in a peripheral centre with haemoptysis where her Warfarin was further de-escalated and Co-trimoxazole prescribed. Again, within a fortnight she was reported to have died suddenly; and no autopsy was done The curious similarity here is the increasing INR despite anticoagulant de-escalation in the cold harmattan season. This experience has not been reported locally to the knowledge of the author. Some workers have reported that clotting times are longer with cold; clotting times being 3 times longer at 27 degrees Centigrade than 37 degrees.1 The phenomenon of decreasing temperature progressively delaying thrombus initiation began at 30 degrees Centigrade, progressing rapidly below that; and reaching statistical significance at 24 degrees.2 However, significant inter-individual variability in this response has been observed and explains conflicting result of studies on this subject.3 One could understand, therefore, why such observation may be made in Jos where harmattan temperatures can drop to single digits.