Unfreezing the Accounts
“The Override Playbook”
The Big Picture
You’ve identified the rogue fraud detectors (Module 1). You’ve documented the damage — frozen checking accounts, seized investments, collapsed ATM networks, blocked construction projects, jammed vault doors, and friendly fire on employees (Module 2). Now the board of directors demands answers: How do we override this system? How do we unfreeze the accounts?
The answer comes in four tiers — from basic prevention to full emergency response. Think of it as the bank’s crisis management playbook.
The Four-Tier Override Playbook
Memory Aids
“Warfarin is the Workhorse” — In APS, warfarin works and DOACs don’t. When in doubt on boards, choose warfarin.
“Two-Three for Veins, Three-Four for Brains” — Venous: INR 2–3. Arterial (stroke): consider INR 3–4.
Test Yourself
Q1: A 40-year-old woman with triple-positive APS and DVT history, stable on warfarin INR 2.5 for 3 years. Asks about switching to rivaroxaban for convenience. Recommendation?
Show AnswerQ2: A 30-year-old woman with obstetric APS (two fetal losses at 14 and 18 weeks, no thrombosis) is planning pregnancy. Currently on LDA. Pregnancy management?
Show AnswerQ3: A patient with known APS develops rapid multi-organ failure after an infection. Renal failure, stroke, and ARDS over 3 days. Diagnosis and treatment?
Show AnswerSummary
- APS thrombosis = indefinite anticoagulation with warfarin (NOT time-limited)
- Venous APS: INR 2–3. Arterial APS: INR 2–3 or 3–4 (risk-dependent)
- DOACs contraindicated in triple-positive APS (TRAPS trial)
- Pregnancy: switch warfarin to heparin (teratogenic). Escort level depends on history.
- Refractory obstetric APS: escalate heparin + add HCQ ± prednisone
- CAPS: anticoag + steroids + plasma exchange ± IVIG — simultaneously
- HCQ is adjunctive for SLE-associated APS, refractory obstetric APS, and increasingly all APS