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Risk of Falls and Major Bleeds in Patients on Oral Anticoagulation Therapy
Study Questions:
Do patients at high fall risk taking oral anticoagulation have an increased risk of major bleeding?
Methods:
The authors reported data on consecutive patients discharged from the University Hospital in Lausanne, Switzerland, between January 1, 2008 and March 31, 2009, who were receiving a vitamin K antagonist. Outcome of interest was time to first major bleed within the 12-month follow-up, after adjusting for demographic factors, comorbidity, alcohol use, concomitant antiplatelet agent use, as well as history of stroke or transient ischemic attack. Risk of falls was assessed using two validated screening questions, asking about: 1) a history of falls in the prior year, or 2) problems with gait, balance, or mobility. These two questions were associated with a future fall likelihood ratio of 2.3-2.8, and 1.7-2.4, respectively. A positive response to either question identified subjects at high risk of fall.
Results:
The authors identified 515 consecutive, prospectively-enrolled, adult medical patients receiving oral anticoagulation upon discharge, among whom 35 had a first major bleed during the 12-month follow-up (7.5 per 100 patient-years). Of the entire cohort, 308 (59.8%) were at high risk for falls, and had a nonsignificantly higher crude incidence rate of major bleeding (8.0 vs. 6.8 per 100 patient-years compared with low-risk subjects, p = 0.64). High fall risk, as identified by the screening questions, was not statistically significantly associated with bleeding risk (hazard ratio, 1.09; 95% confidence interval, 0.54-2.21). Of the 35 bleeding episodes, only three occurred directly after a fall (0.6 per 100 patient-years).
Conclusions:
The authors concluded that in this patient cohort, patients on oral anticoagulants who are at high risk of falls did not have a significantly increased risk of major bleeds. The authors further opined that these findings suggest that being at risk of falls is not a valid reason to avoid anticoagulants in medical patients.
Perspective:
Concern about potential bleeding, usually due to fall risk, is most often cited as a reason to avoid oral anticoagulant therapy, particularly in patients with atrial fibrillation. This becomes increasingly true in older patients, in whom the perceived fall risk is greater. The current study adds to the literature suggesting that our ability to identify patients at risk for bleeding due to falls is poor, and therefore, frequently overestimated by most clinicians. Furthermore, the decision making surrounding the use of oral anticoagulants in elderly patients often neglects the fact that stroke risk from atrial fibrillation increases significantly with age. This study, and others in the same area, suggests that clinical estimates of fall risk should not play a major role in determining appropriateness of anticoagulant therapy.
Keywords: Vitamin K, Risk, Stroke, Follow-Up Studies, Ischemic Attack, Transient, Platelet Aggregation Inhibitors, Demography, Warfarin, Comorbidity, Blood Coagulation, Incidence, Cardiovascular Diseases, Gait, Confidence Intervals, Hemorrhage
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