Unfreezing the Accounts
“The Override Playbook”
You’ve identified the rogue fraud detectors (Module 1). You’ve documented the damage — frozen checking accounts, seized investments, collapsed small branch networks, blocked construction projects, jammed valve gates, 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
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 32-year-old woman has persistent lupus anticoagulant and high-titer aCL IgG on two tests 12 weeks apart. She has no history of pregnancy loss or thrombosis. Now planning pregnancy. What is the recommended management per ACR 2020 guidelines?
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) — “Two-Three for Veins, Three-Four for Brains”
- DOACs contraindicated in triple-positive APS (TRAPS trial) — warfarin is the workhorse
- 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