Clinical outcomes of gastrointestinal bleeding management during anticoagulation therapy

Abstract

Background Acute gastrointestinal (GI) bleeding is not an uncommon complication of oral anticoagulation (OAC) therapy that requires medication cessation. However, drug cessation may cause fatal stroke or systemic embolization in patients at high thromboembolic risk. Here we sought to find an appropriate anticoagulation cessation strategy in cases of GI bleeding during OAC therapy. Methods This single-center retrospective cohort analysis was performed between 2010 and 2018. Patients were enrolled if the following three consecutive conditions were met: 1) electrocardiography electrocardiography-proven atrial fibrillation; 2) OAC therapy; and 3) GI bleeding. We divided the drug cessation strategy into the continuation and discontinuation groups. During 1-year follow-up, the rates of major thromboembolic and rebleeding events were calculated. Results One hundred and forty-six patients (continuation [n = 54] vs. discontinuation [n = 92] group) were enrolled. Patients in the discontinuation group were more likely to be older (69.8 ± 9.0 yrs vs. 74.9 ± 8.9 yrs, p = 0.001), while patients in the continuation group were more likely to have undergone cardiac valve surgery (51.9% vs. 20.7%, p<0.001). The presence of a mechanical mitral valve was a determinant of continuation strategy (38.9% vs. 7.5%, p<0.001). However, the mean CHA₂DS₂-VASc (3.4±1.3 vs. 4.1±1.6, p = 0.010) and Glasgow-Blatchford (8.0±2.4 vs. 8.9±2.5, p = 0.037) scores were higher in the discontinuation group. Two major embolic strokes occurred in each group (3.7% vs. 2.2%, p = 0.585). Four of 54 (7.4%) and five of 92 (5.4%) patients had rebleeding events during follow-up (p = 0.632). One embolic event in the continuation group and one rebleeding event in the discontinuation group were fatal. The Glasgow-Blatchford score was a predictor of 1-year rebleeding events (odds ratio [OR], 1.36; 95% confidence interval [CI], 0.68–2.20; p = 0.028). The high CHA₂DS₂-VASc score showed a strong trend (OR, 1.71; 95% CI, 0.92–3.20; p = 0.089) in 1-year thromboembolic events. Conclusion No single risk factor or drug cessation strategy was attributed to adverse clinical events after GI bleeding. The risk of future thrombotic or rebleeding events should be individualized and controlled for based on a pre-existing stratification system.

Gastrointestinal Bleeding Due to NOACs Use: Exploring the Molecular Mechanisms

“…On the contrary, another study by Yang et al [13] revealed that rivaroxaban and dabigatran resulted in more gastrointestinal bleeding compared to apixaban. The prevalence of gastrointestinal bleeding in patients treated with warfarin was 2.5-10.1% [14]. A meta-analysis performed by Loffredo et al [15] suggested that patients at high risk of gastrointestinal bleeding should avoid rivaroxaban and high doses of dabigatran and edoxaban.…”

“…The use of proton pump inhibitors can protect against major bleeding in NOAC patients [7]. Most of cases required NOAC dose adjustment or a temporary discontinuation of the drugs [14]. Only a few cases of fatal bleeding with hypovolemic shock or dangerous organ ischemia have been reported [14].…”

“…Most of cases required NOAC dose adjustment or a temporary discontinuation of the drugs [14]. Only a few cases of fatal bleeding with hypovolemic shock or dangerous organ ischemia have been reported [14]. Miller et al [24] performed a meta-analysis that included 28 randomized controlled trials (RCT) with a total of 129,357 patients.…”