Clinical outcomes of direct oral anticoagulants after lower extremity arterial procedures

Objectives The use of postoperative anticoagulation is not uncommon for patients undergoing lower extremity arterial procedures as adjunctive therapy. Longer postoperative length of stay is necessary to achieve adequate therapeutic international normalized ratio with traditional protocols that call for the use of unfractionated heparin and warfarin therapy. We hypothesized the direct oral anticoagulants are an attractive alternative to provide adequate anticoagulation in patients who undergo lower extremity arterial procedures. Methods We retrospectively studied patients who had lower extremity arterial procedures between 2012 and 2015 to examine the safety and efficacy of the direct oral anticoagulants in a single institution. Patency, freedom from re-intervention, and major adverse limb event were evaluated. The direct oral anticoagulant agents used included dabigatran, rivaroxaban, and apixaban. The primary patency, adverse effects and freedom from re-intervention were then compared to a control group of patients who were treated with traditional heparin–warfarin therapy after lower extremity bypass procedures. Results Direct oral anticoagulants were utilized in a total of 23 patients (48% men; mean age 69 ± 11 years) during the study period. Indication for use of direct oral anticoagulant after procedure included use of polytetrafluoroethylene (PTFE) bypass graft below the knee joint or after lower extremity angioplasty with disadvantaged runoff. Mean follow-up of the drugs was 23 months (SD ± 16 months). At the end of follow-up, the direct oral anticoagulants have been discontinued in four patients, who are currently only on plavix. Among 82.6% of patients who were given direct oral anticoagulants for PTFE bypasses, graft patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. Patients (17.4%) treated with direct oral anticoagulants for disadvantaged runoff after balloon angioplasty of the lower extremity, patency, freedom from re-intervention, and major adverse limb event were 100%, 100%, and 0%, respectively. For the patients who underwent direct oral anticoagulant administration for disadvantaged runoff primary patency was 100%. One patient developed wound dehiscence which was unrelated to direct oral anticoagulant administration. Our control group consisted of 100 patients who were treated with heparin–warfarin therapy for 30 days after lower extremity bypass procedures. The graft patency, freedom from intervention, and major adverse limb event were 93%, 12%, and 0%, respectively. There was however no statistically significant difference in graft patency rate ( P = .34) or freedom from intervention ( P = .07) between the two groups. Conclusions The preliminary data suggest that there may be a role for using the direct oral anticoagulants with patients who undergo lower extremity arterial procedures for prevention of thrombosis and warrants further investigation.

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Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis

Open Heart ◽

10.1136/openhrt-2019-001026 ◽

2019 ◽

Vol 6 (1) ◽

pp. e001026 ◽

Cited By ~ 3

Author(s):

Napohn Chongprasertpon ◽

Aiste Zebrauskaite ◽

John Joseph Coughlan ◽

Abdalla Ibrahim ◽

Samer Arnous ◽

...

Keyword(s):

Coronary Angiography ◽

Anticoagulant Therapy ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Control Group ◽

Radial Compression ◽

Direct Oral Anticoagulant ◽

Diagnostic Coronary Angiography

PurposeWe sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy.BackgroundDirect oral anticoagulants have become a popular choice for the prevention of thromboembolism. Risk factors for thromboembolism are common among cardiovascular conditions and indications for direct oral anticoagulant therapy as well as coronary angiography often overlap in patients. It has been hypothesised that uninterrupted direct oral anticoagulant therapy would increase haemorrhagic and access site complications, however data in this area is limited.MethodsThis was a prospective observational analysis of 49 patients undergoing elective diagnostic coronary angiography while receiving uninterrupted anticoagulation with direct oral anticoagulants. This population was compared with a control group of 49 unselected patients presenting to the cardiology service for elective diagnostic coronary angiography. Continuous variables were analysed using the independent samples t-test and categorical variables using Pearson’s χ2 test.ResultsThe mean duration of radial compression for the control group was 235.8±62.8 min and for the uninterrupted direct oral anticoagulant group was 258.4±56.5 min. There was no significant difference in mean duration of radial compression (p=0.07; 95% CI=-1.4 to 46.5). There was also no difference in the complication rate between the two groups (p=1).ConclusionsWe observed similar complication rates and radial artery compression time postangiography in both groups. This small prospective observational study suggests that uninterrupted continuation of direct oral anticoagulants during coronary angiography is safe. Larger randomised control studies in this area would be beneficial.

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A single center retrospective cohort study comparing low-molecular-weight heparins to direct oral anticoagulants for the treatment of venous thromboembolism in patients with cancer – A real world experience

Journal of Oncology Pharmacy Practice ◽

10.1177/1078155218757856 ◽

2018 ◽

Vol 25 (4) ◽

pp. 793-800 ◽

Cited By ~ 5

Author(s):

Megan K Phelps ◽

Tracy E Wiczer ◽

H Paige Erdeljac ◽

Kelsey R Van Deusen ◽

Kyle Porter ◽

...

Keyword(s):

Molecular Weight ◽

Major Bleeding ◽

Oral Anticoagulant ◽

Low Molecular Weight Heparin ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Low Molecular Weight ◽

Direct Oral Anticoagulant ◽

Recurrent Cancer ◽

Cancer Associated Thrombosis

Introduction Low-molecular-weight heparins are the standard treatment for cancer-associated thrombosis. Recently, direct oral anticoagulants are a new option for thrombosis treatment; however, data supporting the use of direct oral anticoagulants for cancer-associated thrombosis are limited. Objectives The primary objective of this study was to determine the rate of recurrent cancer-associated thrombosis and major bleeding within 6 months of starting either low-molecular-weight heparin or direct oral anticoagulant for treatment of cancer-associated thrombosis. Secondary objectives were to determine the rates of clinically relevant-non-major bleeding and all-cause mortality. Patients/methods This is a retrospective cohort study including adults with cancer-associated thrombosis treated with low-molecular-weight heparin or direct oral anticoagulant between 2010 and 2016 at the Ohio State University. Medical records were reviewed for 6 months after initiation of anticoagulation or until the occurrence of recurrent cancer-associated thrombosis, major bleeding, cessation of anticoagulation of interest, or death, whichever occurred first. Results Four hundred and eighty patients were included (290 low-molecular-weight heparin and 190 direct oral anticoagulant). Patients treated with direct oral anticoagulant were found to carry “lower risk” features including cancer with lower VTE risk and lower rate of metastatic disease. After adjustment for baseline differences, there was no significant difference in the rate of recurrent cancer-associated thrombosis (7.2% low-molecular-weight heparin vs 6.3% direct oral anticoagulant, p = 0.71) or major bleeding (7.6% low-molecular-weight heparin vs 2.6% direct oral anticoagulant, p = 0.08). Conclusions Our study demonstrates that in a select population of cancer patients with VTE, direct oral anticoagulant use can be as effective and safe compared to the standard therapy with low-molecular-weight heparin.

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Personalized approach for direct oral anticoagulant prescription: from theory to practice

Terapevticheskii arkhiv ◽

10.26442/00403660.2019.07.000045 ◽

2019 ◽

Vol 91 (7) ◽

pp. 111-120

Author(s):

A I Skripka ◽

V V Kogay ◽

A I Listratov ◽

A A Sokolova ◽

D A Napalkov ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Direct Oral Anticoagulant ◽

Efficacy And Safety ◽

Future Perspectives ◽

Theory To Practice ◽

Personalized Approach

Data on possibilities of personalized approach for direct oral anticoagulants (DOAC) choice in patients with atrial fibrillation are presented in the article. We also review clinical and fundamental studies and future perspectives on pharmacogenetic and pharmacokinetic tests to predict the efficacy and safety of DOAC.

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The deep femoral artery, a readily available inflow vessel for lower limb revascularization: a single-center experience

Vascular ◽

10.1177/1708538113478719 ◽

2013 ◽

Vol 21 (2) ◽

pp. 75-78 ◽

Cited By ~ 1

Author(s):

Daniel Silverberg ◽

Basheer Sheick-Yousif ◽

Dmitry Yakubovitch ◽

Moshe Halak ◽

Jacob Schneiderman

Keyword(s):

Lower Extremity ◽

Femoral Artery ◽

Lower Limb ◽

Bypass Graft ◽

Graft Patency ◽

Primary Patency ◽

Single Center ◽

Deep Femoral Artery ◽

Single Center Experience

The deep femoral artery (DFA) offers several advantages as an inflow vessel in lower-extremity bypasses. We report a single-center experience using the DFA as an inflow artery for lower-extremity revascularization. We reviewed all patients who underwent a lower-extremity bypass utilizing the DFA as the inflow vessel. Demographics, indications for surgery, indication for use of the DFA, type of conduits and target vessels were recorded. Follow-up data included resolution of symptoms, bypass graft patency, major amputations and survival. Over 2.5 years, 23 patients were treated with a DFA-inflow bypass. Eighteen (78%) suffered from wounds and five (22%) from rest pain. The proximal, middle and distal DFA was used in 8, 14 and 1 patients, respectively. Indications for using the DFA were limited vein conduit (16) and a hostile groin (5). All patients experienced initial resolution of their ischemic symptoms. The primary patency at two years was 93%. The survival rate was 83%. In conclusion, the DFA is an excellent and underutilized alternative inflow artery in patients requiring lower limb revascularization. It offers excellent patency rates and should be considered in patients with hostile groins or insufficient lengths of a vein conduit.

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MO496PRESCRIPTION OF DIRECT ORAL ANTICOAGULANTS TO PATIENTS WITH MODERATE TO ADVANCED CKD : TOO LITTLE OR JUST RIGHT?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab087.0016 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Sophie Liabeuf ◽

Solène M Laville ◽

Brian Bieber ◽

Charlotte Tu ◽

Benedicte Stengel ◽

...

Keyword(s):

Kidney Disease ◽

Vitamin K ◽

Oral Anticoagulant ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Upward Trend ◽

Prescription Patterns ◽

The Usa

Abstract Background and Aims Prescription of anticoagulants in patients with chronic kidney disease (CKD) is challenging, since these patients are at high risk of thromboembolic episodes, but are also prone to bleeding events. Based on a number of pivotal trials, four direct oral anticoagulants (DOACs) have been approved for use in non-valvular atrial fibrillation (AF) since 2010. These DOACs have now supplanted vitamin K antagonists (VKAs) as first-line treatment in non-CKD patients. Following post-hoc analyses of randomized clinical trials of DOACs in CKD patients performed between 2011 and 2016, a 2018 Kidney Disease Improving Global Outcomes Controversies Conference stated that although there is not enough evidence to recommend DOACs in patients with advanced CKD, these medications are safer than VKAs and not inferior for stroke preventing in patients with AF and an estimated glomerular filtration rate (eGFR) between 30 and 50 ml/min/1.73 m2. Here, in a study of stage 3 to 5 CKD patients, we sought to describe multinational prescription patterns for oral anticoagulants in general and for VKAs vs. DOACs in particular. Method We analyzed data from the international CKD Outcomes and Practice Patterns Study (CKDopps) of non-dialysis CKD patients ≥ 18 years of age with an eGFR <60 mL/min/1.73 m² at study enrollment. Participants were selected from national samples of nephrologist-run CKD clinics in Brazil, France, Germany, and the USA between January 2013 and April 2019. The CKDopps is ongoing, and at least 3 years (for the USA, Germany, and Brazil) or 5 years (for France) of prospective follow-up are planned. We assessed prescription patterns for oral anticoagulants regardless of indication at baseline and during follow-up. Results Of the 8154 patients enrolled, 7092 had drug prescriptions data available at baseline, and 1080 (15%) of these had at least one prescription of an oral anticoagulant. At baseline, VKAs were the most frequently prescribed oral anticoagulants (n=984, 91%), and only 97 of the 1080 patients (9%) were on DOACs (91 on a direct factor Xa inhibitor and 6 on a direct thrombin inhibitor). This low DOAC prescription rate was observed in France, the USA, Brazil and Germany. There was an upward trend in DOAC prescription (relative to VKAs) over the course of the study. Over a median [interquartile range] follow-up period of 3 years [1.5-4.5], 287 incident oral anticoagulant prescriptions were reported, 177 started on VKAs and 110 started on DOACs. Among the patients receiving a VKA at baseline, only 44 switched to a DOAC. Conclusion In an international sample of non-dialysis CKD patients (eGFR <60 mL/min/1.73 m²), we observed low prescription of direct oral anticoagulants (9%) at baseline, relative to vitamin K antagonists (91%) across countries included in the analysis. However, there was an upward trend in DOAC prescriptions (relative to VKAs) over the course of the study. In view of the risk of significant adverse events associated with VKAs, the prescription of DOACs should be encouraged - particularly for CKD stage 3 patients and future studies of risk/benefit comparing VKAs and DOACs are necessary in CKD patients.

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Stroke Prevention by Anticoagulants in Daily Practice Depending on Atrial Fibrillation Pattern and Clinical Risk Factors

Stroke ◽

10.1161/strokeaha.120.032704 ◽

2021 ◽

Author(s):

Lamiae Grimaldi-Bensouda ◽

Jean-Yves Le Heuzey ◽

Jean Ferrières ◽

Didier Leys ◽

Jean-Marc Davy ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Vitamin K ◽

Oral Anticoagulant ◽

Hemorrhagic Stroke ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Clinical Risk Factors ◽

Direct Oral Anticoagulant

Background and Purpose: The objective of the study was to assess the effectiveness of individual direct oral anticoagulants versus vitamin K antagonists for primary prevention of stroke (ischemic and hemorrhagic) in routine clinical practice in patients with various clinical risk factors depending on their atrial fibrillation (AF) patterns. Methods: A nested case-referent study was conducted using data from 2 national registries of patients with stroke and AF. Stroke cases with previous history of AF were matched to up to 2 randomly selected referent patients with AF and no stroke. The association of individual anticoagulant use with ischemic or hemorrhagic stroke was studied in patients with or without permanent AF using multivariable conditional logistic models, controlled for clinically significant risk factors and multiple other cardiovascular risk factors. Results: In total, 2586 stroke cases with previous AF and 4810 nonstroke referent patients with AF were retained for the study. Direct oral anticoagulant users had lower odds of stroke of any type than vitamin K antagonist users: the adjusted-matched OR for ischemic stroke were 0.70 (95% CI, 0.50–0.98) for dabigatran, 0.68 (95% CI, 0.53–0.86) for rivaroxaban, and 0.73 (95% CI, 0.52–1.02) for apixaban while for hemorrhagic stroke they were 0.31 (95% CI, 0.14–0.68), 0.64 (95% CI, 0.39–1.06), and 0.70 (95% CI, 0.33–1.49), respectively. The effects of individual direct oral anticoagulants relative to vitamin K antagonists were similar in permanent AF and nonpermanent AF patients. Conclusions: Similar results were observed for each direct oral anticoagulant in real life as those observed in the pivotal clinical trials. The pattern of AF did not affect the outcome.

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The impact of the introduction of direct oral anticoagulants into a general practice and hospital anticoagulant services: two local service evaluations

British Journal of Healthcare Management ◽

10.12968/bjhc.2018.0060 ◽

2019 ◽

Vol 25 (6) ◽

pp. 1-12

Author(s):

Tom Cahill ◽

Julie Broughton ◽

Thomas Ferguson ◽

Stephen Jenkins

Keyword(s):

Secondary Care ◽

Oral Anticoagulant ◽

Care Service ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Patient Choice ◽

Direct Oral Anticoagulant ◽

Service Capacity ◽

The Impact ◽

Anticoagulation Service

Background/Aims Anticoagulants are indicated for stroke prevention in nonvalvular atrial fibrillation, and treatment and prevention of venous thromboembolism. The aim of this study was to describe the impact of introducing direct oral anticoagulants on anticoagulation services. Methods One primary and one secondary care anticoagulation service evaluation compared pre-direct oral anticoagulant (2012) and post-direct oral anticoagulant introduction (2015). Findings In the secondary care service, anticoagulant monitoring clinics decreased by 20% and service capacity increased by 38.5% post-direct oral anticoagulant introduction. Direct oral anticoagulants comprised 87.6% of newly-initiated anticoagulants post-direct oral anticoagulant introduction. In patients newly initiated on anticoagulation, a total of 62 anticoagulation-related inpatient admissions were recorded in 12.6% of patients in the pre-direct oral anticoagulant period, compared with a total of 21 anticoagulation-related admissions in 3.6% of patients in the post-direct oral anticoagulant period. In the primary care service, warfarin comprised 62.9% of all anticoagulants prescribed post-direct oral anticoagulant introduction. Overall, patients attended a mean of 14.2 anticoagulation service visits in 6 months pre-direct oral anticoagulant and 13.3 visits in 6 months post-direct oral anticoagulant introduction (non-direct oral anticoagulant-treated: 16.1/patient; direct oral anticoagulant treated: 0.8/patient). Few patients were offered a choice of anticoagulant; however, overall patient satisfaction was high in both services. Conclusions Direct oral anticoagulant introduction in secondary care was associated with increased service capacity and decreased patient visits. Patient choice was limited; however, satisfaction was high in both services.

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Risks and Benefits of Direct Oral Anticoagulants across the Spectrum of GFR among Incident and Prevalent Patients with Atrial Fibrillation

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.13811217 ◽

2018 ◽

Vol 13 (8) ◽

pp. 1144-1152 ◽

Cited By ~ 17

Author(s):

Jung-Im Shin ◽

Alex Secora ◽

G. Caleb Alexander ◽

Lesley A. Inker ◽

Josef Coresh ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Oral Anticoagulant ◽

Proportional Hazards ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cox Proportional Hazards ◽

Direct Oral Anticoagulant ◽

Bleeding Events ◽

Risk Of Bleeding

Background and objectivesAll randomized trials of direct oral anticoagulants in atrial fibrillation excluded patients with severe kidney disease. The safety and effectiveness of direct oral anticoagulants across the range of eGFR in real-world settings is unknown. Our objective is to quantify the risk of bleeding and benefit of ischemic stroke prevention for direct oral anticoagulants compared with warfarin in patients with atrial fibrillation with and without CKD.Design, setting, participants, & measurementsWe created a propensity score–matched cohort of 3206 patients with atrial fibrillation and direct oral anticoagulant use and 3206 patients with atrial fibrillation using warfarin from October of 2010 to February of 2017 in an electronic health record (Geisinger Health System). The risks of bleeding and ischemic stroke were compared between direct oral anticoagulant and warfarin users using Cox proportional hazards regression, stratified by eGFR (≥60 and <60 ml/min per 1.73 m2).ResultsThe mean (SD) age of the 6412 participants was 72 (12) years, 47% were women, and average eGFR was 69 (21) ml/min per 1.73 m2. There were 1181 bleeding events and 466 ischemic strokes over 7391 person-years of follow-up. Compared with warfarin use, the hazard ratios (HRs) (95% confidence interval [95% CI]) of bleeding associated with direct oral anticoagulant use were 1.01 (0.88 to 1.17) and 1.23 (1.02 to 1.48) for those with eGFR≥60 and eGFR<60 ml/min per 1.73 m2, respectively (P-interaction=0.10). There was no difference between direct oral anticoagulant and warfarin users in the risk of ischemic stroke: HRs (95% CI) of 0.94 (0.74 to 1.18) and 1.02 (0.76 to 1.37) for those with eGFR≥60 and eGFR<60 ml/min per 1.73 m2, respectively (P-interaction=0.70). Similar findings were observed with individual drugs.ConclusionsIn a large health care system, patients with eGFR<60 ml/min per 1.73 m2 who took direct oral anticoagulants for atrial fibrillation had slightly higher risk of bleeding compared with those on warfarin, but similar benefits from prevention of ischemic stroke.

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Direct Oral Anticoagulants in the Real World

Canadian Journal of Nursing Research ◽

10.1177/0844562117716852 ◽

2017 ◽

Vol 49 (3) ◽

pp. 105-107 ◽

Cited By ~ 3

Author(s):

Siavash Piran ◽

Jennifer Delaney ◽

Sam Schulman ◽

Mary Salib ◽

Mohamed Panju ◽

...

Keyword(s):

Real World ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Medication Use ◽

Laboratory Monitoring ◽

Direct Oral Anticoagulant ◽

Large Variability ◽

Item Questionnaire ◽

Perioperative Anticoagulation

Background Direct oral anticoagulants are convenient because of their fixed dosing and without laboratory monitoring. There are instructions on avoidance of moisture, no crushing of capsules, and administration with food for some direct oral anticoagulants. Whether patients adhere to this and are prescribed appropriate doses are unknown. Aims To assess direct oral anticoagulant dosing and medication use. Methods Patients ≥18 years old, receiving a direct oral anticoagulant for any diagnosis, were prospectively included. Nurses at our perioperative anticoagulation clinic helped patients complete a 12-item questionnaire. Results Ninety-three consecutive patients were recruited. Forty-nine were on dabigatran, 18 on apixaban, and 26 were on rivaroxaban. Sixty-two patients (67%) received appropriate direct oral anticoagulant dosing and administered the medication correctly. Eighteen patients (19%) administered the direct oral anticoagulant properly but at an inappropriate dose. Thirteen patients (14%) received an appropriate dose but administered the direct oral anticoagulant inappropriately: 10 (11%) removed dabigatran from its packaging before administration (exposing it to moisture); 2 (2%) did not take rivaroxaban with food; and 1 (1%) crushed the dabigatran capsule. Conclusion Our study demonstrates a large variability in how direct oral anticoagulants are dosed, and how patients take them. Improved medication literacy around direct oral anticoagulants is needed. Our study highlights opportunities that nurses have to improve patients’ medication literacy.

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Thrombotic events and rebleeding after hemorrhage in patients taking direct oral anticoagulants for non-valvular atrial fibrillation

PLoS ONE ◽

10.1371/journal.pone.0260585 ◽

2021 ◽

Vol 16 (11) ◽

pp. e0260585

Author(s):

Daisuke Yanagisawa ◽

Koichiro Abe ◽

Hirohito Amano ◽

Shogo Komatsuda ◽

Taku Honda ◽

...

Keyword(s):

Atrial Fibrillation ◽

Gastrointestinal Bleeding ◽

Anticoagulant Therapy ◽

Oral Anticoagulant ◽

Clinical Course ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Anticoagulation Therapy ◽

The Other ◽

Direct Oral Anticoagulant

Several direct oral anticoagulants have been developed to prevent cardiogenic thrombosis in patients with atrial fibrillation, on the other hand, have the complication of bleeding. Since clinical course after bleeding with direct oral anticoagulant remains unclear, the present retrospective cohort study was to clarify the course after hemorrhage among patients receiving direct oral anticoagulants. Among all 2005 patients prescribed dabigatran, rivaroxaban, apixaban, or edoxaban between April 2011 and June 2017, subjects comprised 96 patients with non-valvular atrial fibrillation who experienced relevant bleeding during direct oral anticoagulant therapy (Bleeding Academic Research Consortium type 2 or above). The clinical course after hemorrhage was reviewed to examine whether rebleeding or thrombotic events occurred up to the end of December 2019. Gastrointestinal bleeding was the most frequent cause of initial bleeding (57 patients, 59%). Rebleeding occurred in 11 patients (4.5%/year), with gastrointestinal bleeding in 10 and subarachnoid hemorrhage in 1. All rebleeding occurred in patients who resumed anticoagulation therapy. Another significant factor related with rebleeding included past history of gastrointestinal bleeding. On the other hand, major adverse cardiac and cerebrovascular events occurred in 6 patients older than 75 years old or more (2.5%/year), with systemic thrombosis in 4 and cardiac death in 2. All 4 patients with systemic thrombosis withheld anticoagulants after index bleeding, although only 10 patients withheld anticoagulation therapy. Rebleeding should be taken care of when anticoagulants are resumed after bleeding, particularly among patients who initially experienced gastrointestinal bleeding. Systemic thrombosis occurred at a high rate when anticoagulant therapy was withheld after bleeding.

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