Skip to main content
SpringerLink
Log in

The clinical impact of bleeding during oral anticoagulant therapy

Assessment of morbidity, mortality and post-bleed anticoagulant management

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

Although the risk for bleeding during long-term warfarin therapy is established, little is known about the clinical impact following warfarin-associated bleeding and the management of anticoagulant resumption after a bleed. We performed a retrospective chart review of patients who suffered a warfarin-associated bleed that required hospitalization or that occurred during hospitalization. We determined the proportion of patients who required a blood product transfusion, a surgical or other invasive procedure or admission to an intensive care unit, and the duration of hospitalization. We also determined the case-fatality rate of bleeding and described post-bleed resumption of anticoagulation. We studied 142 patients (70 women) hospitalized with warfarin-associated bleeding with a mean age of 73 years. The most prevalent sites of bleeding were the gastrointestinal tract (40.8%) and urinary tract (14.1%). Of all bleeding episodes, 72 (50.1%) were classified as major bleeds. There were 66 (46.4%) patients who required either endoscopy, surgery or admission to an intensive care unit, and the mean duration of hospitalization was 23 days. The case fatality rate of major bleeding was 9.5%. Among patients in whom warfarin was restarted, 8.3% suffered recurrent bleeding. Warfarin-associated bleeding appears to confer considerable morbidity related to transfusion and hospitalization, approximately 1 in 10 major bleeds are fatal, and 1 in 12 patients will re-bleeding after warfarin resumption.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Wysowski DK, Swartz L (2007) Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. Arch Intern Med 167:1414–1419

    Article  PubMed  Google Scholar 

  2. Palaretti G, Leali N, Coccheri S et al (1996) Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Study on complications or oral anticoagulant therapy. Lancet 348:423–428

    Article  Google Scholar 

  3. Fihn SD, McDonell M, Martin D et al (1993) Risk factors for complications of chronic anticoagulation. A multicenter study. Ann Intern Med 118:511–520

    PubMed  CAS  Google Scholar 

  4. Schenk JF, Morsforf S, Pindur G et al (1999) Analysis and occurrence of adverse events with oral anticoagulation therapy. Semin Thromb Hemost 25:65–71

    Article  PubMed  CAS  Google Scholar 

  5. Landefeld CS, Beyth RJ (1993) Anticoagulation-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med 95:315–328

    Article  PubMed  CAS  Google Scholar 

  6. Connolly SJ, Ezekowitz MD, Yusuf S et al (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361:1139–1151

    Article  PubMed  CAS  Google Scholar 

  7. Executive Steering Committee; on behalf of the SPORTIF III Investigators (2003) Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet 362:1691–1698

    Article  Google Scholar 

  8. Executive Steering Committee; for the SPORTIF V Investigators (2005) Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA 293:690–698

    Article  Google Scholar 

  9. Van der Meer FJM, Rosendaal FR, Van der Broucke JP, Briet E (1993) Bleeding complications in oral anticoagulation therapy. Arch Intern Med 153:1557–1562

    Article  PubMed  Google Scholar 

  10. Spencer FA, Gore JM, Lessard D, Douketis JD, Emery C, Goldberg RJ (2008) Patient outcomes after deep vein thrombosis and pulmonary embolism: the Worcester Venous Thromboembolism Study. Arch Intern Med 168:425–430

    Article  PubMed  Google Scholar 

  11. Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Horrow J (2006) Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelgatran or warfarin. Assessment of incidence, case fatality rate, time course, anatomic sites and risk factors for bleeding. Arch Intern Med 166:853–859

    Article  PubMed  CAS  Google Scholar 

  12. Linkins LA, Choi P, Douketis JD (2003) Clinical impact of bleeding in patients taking oral anticoagulation therapy for venous thromboembolism: a meta analysis. Ann Intern Med 139:893–900

    PubMed  Google Scholar 

  13. Carrier M, Le Gal G, Wells PS, Rodger MA (2010) Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 152:578–589

    PubMed  Google Scholar 

  14. Punthkee X, Doobay J, Annd SS (2002) Oral-anticoagulation-related intracerebral hemorrhage. Thromb Res 108:31–36

    Article  Google Scholar 

  15. Hylek EM, Singer DE (1994) Risk factors for intracranial haemorrhage in outpatients taking warfarin. Ann Intern Med 120:897–902

    PubMed  CAS  Google Scholar 

  16. Douketis JD, Berger PH, Dunn AS et al (2008) The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 133(6 Suppl):299S–339S

    Article  PubMed  CAS  Google Scholar 

  17. Douketis JD, Gu CS, Schulman S, Ghirarduzzi A, Pengo V, Prandoni P (2007) The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med 147:138–143

    Google Scholar 

  18. Claassen DO, Kazemi N, Zubkov AY et al (2008) Restarting anticoagulation therapy after warfarin-associated intracerebral hemorrhage. Arch Neurol 65:1313–1318

    Article  PubMed  Google Scholar 

  19. Hawryluk GW, Austin JW, Furlan JC et al (2010) Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk. J Thromb Haemost 8:1500–1508

    Article  PubMed  CAS  Google Scholar 

  20. Kawamata T, Takeshita M, Kubo O et al (1995) Management of intracranial hemorrhage associated with anticoagulant therapy. Surg Neurol 44:438–442

    Article  PubMed  CAS  Google Scholar 

  21. Ananthasubramaniam K, Beattie JN, Rosman HS et al (2001) How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage? Chest 119:478–484

    Article  PubMed  CAS  Google Scholar 

  22. Amlani S, Nadarajah T, Afzal R et al (2010) Mortality and morbidity following a major bleed in a registry population with acute ST elevation myocardial infarction. J Thromb Thrombolysis 30:434–440

    Article  PubMed  Google Scholar 

  23. Eikelboom JW, Quinlan DJ, O’Donnell M (2009) Major bleeding, mortality, and efficacy of fondaparinux in venous thromboembolism prevention trials. Circulation 120:2006–2011

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pharmacoepidemiology and Pharmacotherapy, University Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands

    Minna Guerrouij

  2. Department of Medicine, McMaster University, St. Joseph’s Hospital, Room F-544, 50 Charlton Ave. East, Hamilton, ON, L8N 4A6, Canada

    Minna Guerrouij, Chitman S. Uppal, Ali Alklabi & James D. Douketis

Authors
  1. Minna Guerrouij
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chitman S. Uppal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ali Alklabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. James D. Douketis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James D. Douketis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Guerrouij, M., Uppal, C.S., Alklabi, A. et al. The clinical impact of bleeding during oral anticoagulant therapy. J Thromb Thrombolysis 31, 419–423 (2011). https://doi.org/10.1007/s11239-010-0536-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-010-0536-7

Keywords

Search

Navigation