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Restarting Anticoagulation and Outcomes After Major Gastrointestinal Bleeding in Atrial Fibrillation
Study Questions:
What outcomes are associated with restarting anticoagulation among patients who develop gastrointestinal bleeding (GIB) while taking warfarin for nonvalvular atrial fibrillation (AF)?
Methods:
This was a retrospective cohort study of individuals who developed major GIB while on warfarin. Patients were included in the analysis if warfarin was discontinued for at least 2 days. Time to event-adjusted analyses was performed to investigate associations of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality.
Results:
Of 1,329 patients who developed GIB, warfarin was restarted in 653 individuals. Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.54-0.93; p = 0.01) and reduced mortality (HR, 0.67; 95% CI, 0.56-0.81, p < 0.0001), but not recurrent GIB (HR, 1.18; 95% CI, 0.94-1.10; p = 0.47). Patients who restarted warfarin earlier and within 7 days of GIB had a higher risk of recurrent GIB.
Conclusions:
The authors concluded that restarting warfarin more than 7 days following a major GIB is associated with improved survival and decreased thromboembolism without an increased risk of recurrent GIB.
Perspective:
Although limited by a retrospective design and a single-center experience, the current analysis provides valuable information about outcomes associated with the use of warfarin following major GIB. The authors observed that approximately one-half of patients did not restart warfarin after a major bleed, even though resuming anticoagulation was associated with better outcomes. The current analysis would suggest that warfarin is best restarted after 7 days following a major GIB to improve outcomes without increasing the risk of recurrent bleeding.
Clinical Topics: Anticoagulation Management
Keywords: Thromboembolism, Incidence, Blood Coagulation, Risk, Warfarin, Confidence Intervals, Gastrointestinal Hemorrhage
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