Gastrointestinal Bleeding (GI Bleeding)
GI bleeding is a relatively common hemorrhagic complication of chronic OAC therapy. Anticoagulant therapy is permanently discontinued in a substantial proportion of patients despite evidence of benefit with reinitiating the OAC. . . . . The timing of anticoagulation reinitiation has not been systematically studied and is highly variable, although a prospective study in which anticoagulation was restarted at the time of discharge in patients with a median length of stay of 5 days (including patients in whom no source of bleeding was found) demonstrated fewer TEs at 90 days with no increase in bleeding events; in AF patients, restarting warfarin >7 days after a bleed was associated with improved survival and decreased thromboembolism without an increased risk of recurrent GI bleeding (97,98). Therefore, in most cases of GI bleeding, the writing committee favors reinitiation of anticoagulation in patients with an indication for OAC once bleeding has been controlled (including patients in whom no discrete source of bleeding was identified).
Intracranial Hemorrhage
Intracranial hemorrhage is the most feared complication of anticoagulant therapy. Although rare, intracranial hemorrhage while on OAC can be catastrophic, with 30-day mortality rates approaching 50% (99). Approximately 20% of spontaneous intracranial hemorrhage is related to anticoagulation therapy. Therefore, a cautious, individualized approach to restarting OAC after intracranial hemorrhage is warranted. Factors associated with a higher risk of recurrence include the mechanism of intracranial hemorrhage (i.e., spontaneous vs. traumatic), lobar location of the initial bleed (suggesting amyloid angiopathy), the presence and number of microbleeds on magnetic resonance imaging, and ongoing anticoagulation (100)
Limited data exist on the reinitiation of OAC after an intracranial hemorrhage. Depending on bleed characteristics, risk factor modification, and the indication for anticoagulation, restarting OAC after a nonlobar intracranial hemorrhage may be considered (100). . . .
Please review the complete paragraph above on p 19 of the pdf.
The timing of anticoagulation reinitiation following an intracranial hemorrhage has not been systematically studied and varies widely in observational studies (72 h to 30 weeks), reflecting a lack of consensus. However, in patients without mechanical heart valves, guidelines recommend avoiding anticoagulation for at least 4 weeks, and if indicated, aspirin monotherapy may be restarted in the days after an intracranial hemorrhage (100). In a large, retrospective study that demonstrated benefit associated with OAC reinitiation, the median time to restart OAC was approximately 1 month after the bleeding event (101). Therefore, the writing committee favors delaying the resumption of anticoagulation for at least 4 weeks in patients without high thrombotic risk.
Restarting Anticoagulation After a Surgery/Procedure
If anticoagulation was discontinued and/or reversed for an urgent or emergent surgery/procedure without a preceding bleeding event and adequate postprocedural hemostasis was achieved, anticoagulation should likely be restarted expeditiously. For procedures that carry a low postprocedural bleeding risk, anticoagulation can likely be restarted 24 hours after the procedure. If the postprocedural bleeding risk is higher, therapeutic dose anticoagulation should be delayed for 48 to 72 hours (10). Anticoagulants may be considered once hemostasis is achieved, in consultation with the surgeon or proceduralist. If a DOAC is used postprocedurally, bridging anticoagulation should not be used. For surgeries/procedures performed to control bleeding, restarting anticoagulation after the procedure may carry a higher bleeding risk. This depends on the characteristics of the bleed and the surgical management. If the source of bleeding was identified and completely corrected with adequate hemostasis, restarting anticoagulation in a similar fashion as discussed in the previous text may be reasonable. Individualized strategies with close clinical monitoring apply for patients in whom bleeding was not successfully controlled by surgical/ procedural management.
Resources:
(1) 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants [Full Text HTML] [Full Text PDF]
A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Article In Press
(2) 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 69:871–898. [PubMed Citation] [Full Text HTML] [Full Text PDF]. Volume 69, Issue 7, February 2017
DOI: 10.1016/j.jacc.2016.11.024
(4) 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[Full Text HTML] [Full Text PDF] Google Scholar
(5) (2016) Prevention of bleeding in patients with atrial fibrillation undergoing PCI [PubMed Abstract] [Full Text HTML] [Full Text PDF]. N Engl J Med 375:2423–2434.
