Restarting of anticoagulation in patients with atrial fibrillation after major bleeding: A meta‐analysis

Zhou, Ying; Guo, Yanxiang; Liu, Dai-Hua; Feng, Haiyan; Liu, Jie

doi:10.1111/jcpt.13130

Cited by 7 publications

(6 citation statements)

References 26 publications

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“…[30][31][32][33] Furthermore, two metaanalyses concluded that among OAC-treated NVAF patients with a major bleed, restarting OAC therapy afterwards was associated with a reduced risk of stroke and mortality without increasing the risk of subsequent bleeding. 33,34 While our study did not evaluate the impact of restarting OACs on subsequent events after the major GI bleed, the higher stroke/SE risk may be related to the high OAC discontinuation rate after the index major GI bleeding event. The higher subsequent risk for both stroke/SE and major bleeding among those with an index major GI bleed compared with those without indicates serious consequences of a major GI bleed.…”

Section: Discussionmentioning

confidence: 96%

Burden of major gastrointestinal bleeding among oral anticoagulant-treated non-valvular atrial fibrillation patients

Deitelzweig

Keshishian

Kang

et al. 2021

Therap Adv Gastroenterol

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Background: Gastrointestinal (GI) bleeding is the most common type of major bleeding associated with oral anticoagulant (OAC) treatment. Patients with major bleeding are at an increased risk of a stroke if an OAC is not reinitiated. Methods: Non-valvular atrial fibrillation (NVAF) patients initiating OACs were identified from the Centers for Medicare and Medicaid Services ( CMS) Medicare data and four US commercial claims databases. Patients who had a major GI bleeding event (hospitalization with primary diagnosis of GI bleeding) while on an OAC were selected. A control cohort of patients without a major GI bleed during OAC treatment was matched to major GI bleeding patients using propensity scores. Stroke/systemic embolism (SE), major bleeding, and mortality (in the CMS population) were examined using Cox proportional hazards models with robust sandwich estimates. Results: A total of 15,888 patients with major GI bleeding and 833,052 patients without major GI bleeding were included in the study. Within 90 days of the major GI bleed, 58% of patients discontinued the initial OAC treatment. Patients with a major GI bleed had a higher risk of stroke/SE [hazard ratio (HR): 1.57, 95% confidence interval (CI): 1.42–1.74], major bleeding (HR: 2.79, 95% CI: 2.64–2.95), and all-cause mortality (HR: 1.29, 95% CI: 1.23–1.36) than patients without a major GI bleed. Conclusion: Patients with a major GI bleed on OAC had a high rate of OAC discontinuation and significantly higher risk of stroke/SE, major bleeding, and mortality after hospital discharge than those without. Effective management strategies are needed for patients with risk factors for major GI bleeding.

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Section: Discussionmentioning

confidence: 96%

Burden of major gastrointestinal bleeding among oral anticoagulant-treated non-valvular atrial fibrillation patients

Deitelzweig

Keshishian

Kang

et al. 2021

Therap Adv Gastroenterol

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“…And a recent retrograde cohort study reports that either warfarin or DOAC resumption after major gastrointestinal bleeding was associated with a decreased risk of thromboembolism, whereas warfarin and rivaroxaban resumption was associated with an increased risk of recurrent gastrointestinal bleeding [ 13 ]. Another meta-analysis of restarting of anticoagulation in patients with atrial fibrillation after major bleeding, published in 2020 and including 7 retrospective cohort studies enrolling total 12,197 patients, showed that restarting anticoagulation reduced risks of thromboembolism and mortality without increasing reoccurrence of bleeding [ 14 ]. Taken together with the previous studies, it seems the benefit of restarting anticoagulation after major bleeding exceeds the risk of massive re-bleeding or other fatal complications.…”

Section: Discussionmentioning

confidence: 99%

“…The optimal discontinuation period before resuming anticoagulant therapy after anticoagulation-associated major bleeding is also not clear [ 15 ]. In a recent meta-analysis study about restarting of oral anticoagulants after major bleeding in AF patients, the optimal timing for restarting cannot be analyzed because of the wide variation of restart timing among the included studies [ 14 ]. In a systematic review study conducted by Hawryluk et al [ 16 ], it was concluded that restarting anticoagulation 72 hours after ICH is a cut-off timing that separates the risks and benefits of ICH recurrence and thromboembolic complications.…”

Section: Discussionmentioning

confidence: 99%

Hemoptysis in Quadriplegia with Atrial Fibrillation Who Was Taking Edoxaban: a Case Report

et al. 2021

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The direct-acting oral anticoagulants (DOACs) would be the standard treatment for the prevention of stroke and thromboembolism in nonvalvular atrial fibrillation patients. The adverse effects of greatest concern are bleeding especially major bleeding. We present a case of a patient with a history of nonvalvular atrial fibrillation and pacemaker, who developed severe anemia after massive hemoptysis while taking DOAC; however, he has continued taking DOAC. Through this case, we have summarized the current management of major bleeding associated with anticoagulation and discuss the optimal regimen for restarting of anticoagulation therapy.

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“…Recent systematic reviews and meta-analyses have provided compelling evidence supporting the safety and favorable outcomes associated with resuming anticoagulation therapy following the resolution of correctable bleeding episodes including intracranial hemorrhage (ICH). 9 10 11 However, a considerable number of patients who experienced serious bleeding may discontinue treatment for stroke prevention indefinitely and further result in more embolic events. While the nonvitamin K antagonist oral anticoagulants (NOACs) are generally safer choices in term of bleeding when compared with vitamin K antagonists (e.g., warfarin), many patients globally (including in Thailand) had limited accessibility to NOACs due to limited health care coverage and reimbursement.…”

Section: Introductionmentioning

confidence: 99%

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry

Winijkul,

Kaewkumdee,

Yindeengam

et al. 2024

Thromb Haemost

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Background Bleeding events are often reported among patients with atrial fibrillation (AF), irrespective of antithrombotic use. This study is to determine clinical outcomes of patients with AF who survived from bleeding event. Methods We analyzed data from COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) Thailand registry. Outcomes of patients who experienced any bleeding were compared with patients who had never bleed. Time updated multivariate Cox-proportional hazard models were used to estimate the risk for clinical outcomes of patients with and without bleeding. Results Of total 3,405 patients (mean age: 67.8 ± 11.3 years; 41.9% female) in COOL-AF registry, 609 patients (17.9%) reported bleeding event occurs and 568 patients (93.3%) survived though hospital discharge. Patients who survived major bleeding (n = 126) were at increased risk for both death (adjusted hazard ratio [HR]: 4.44, 95% confidence interval [CI]: 2.91–6.75, p < 0.001) and stroke/systemic embolism (adjusted HR: 4.49, 95% CI: 2.19–9.24, p < 0.001). Minor bleeding also increased subsequent death (adjusted HR: 2.13, 95% CI: 1.56–2.90, p < 0.001). Up to 30% of patients who survived major bleeding and 6.3% of minor bleedings discontinued oral anticoagulation. Discontinuation was associated with very high death rate (42.1%), whereas patients who resumed oral anticoagulation after bleeding had lower mortality (10%). The most common causes of death in patients who survived a bleeding event were not related to cardiovascular causes nor bleeding. Conclusion Patients with AF who have bleeding events have an increased risk for subsequent death and stroke and systemic embolism. These patients should be identified as vulnerable clinically complex patients and require a holistic approach to their AF management.

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Restarting of anticoagulation in patients with atrial fibrillation after major bleeding: A meta‐analysis

Cited by 7 publications

References 26 publications

Burden of major gastrointestinal bleeding among oral anticoagulant-treated non-valvular atrial fibrillation patients

Burden of major gastrointestinal bleeding among oral anticoagulant-treated non-valvular atrial fibrillation patients

Hemoptysis in Quadriplegia with Atrial Fibrillation Who Was Taking Edoxaban: a Case Report

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry

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