February 28, 2021Canadian Medical Association JournalOpen Access

Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding

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Why the study?

Data on resuming oral anticoagulants after bleeding derived primarily from patients taking warfarin, with limited data available for direct oral anticoagulants.

Does the resumption of oral anticoagulants reduce thrombosis and mortality, and what is the risk of rebleeding, in older adults after an anticoagulant-related bleeding event?

Population

6793 adults aged 66 years or older hospitalized for bleeding while receiving oral anticoagulants in Ontario

Comparison

Resumption of oral anticoagulants vs non-resumption

Design

Population-based cohort study

Authors

DLDerek LittleMcMaster University RSRinku SutradharUniversity of Toronto JCJoshua O. CerasuoloHealth Sciences North

Discussion

Member takes

Implication

Resuming OACs after bleeding was associated with lower thrombosis and mortality but higher rebleeding; leaves open net-benefit strategies pending randomized trials.

Structured PICO

Does the resumption of oral anticoagulants reduce thrombosis and mortality, and what is the risk of rebleeding, in older adults after an anticoagulant-related bleeding event?

Population

6,793 adults aged 66 years or older (median age 82, 52% male) admitted to hospital for bleeding while receiving oral anticoagulants (warfarin, apixaban, rivaroxaban, or dabigatran). Most common indications for anticoagulation were atrial fibrillation (81.8%) and venous thromboembolism (20.1%). Index bleeds included gastrointestinal (63.3%), intracranial (11.9%), and other (25.0%).

Intervention

Resumption of oral anticoagulants (warfarin or direct oral anticoagulants) within 365 days of the index bleed, treated as a time-varying covariate.

Comparator

No resumption of oral anticoagulants within 365 days of the index bleed.

Outcome

Bleeding, thrombosis, and all-cause mortality (treated as competing events and analyzed using cause-specific hazard ratios after a 100-day blanking period).hard clinical

In older adults with OAC-related bleeding, resuming anticoagulation is associated with a significant reduction in thrombosis and all-cause mortality, despite an increased risk of recurrent bleeding.

Limitations

Residual unmeasured confounding may be present
Unable to determine causes of death
Limited to bleeding events associated with hospital admission
Assumed prescriptions claimed were taken by the patient and unable to fully account for over-the-counter ASA/NSAID use
Blanking period excluded patients who had an event within 100 days
Results may not be generalizable to younger populations (<66 years)
Unable to evaluate outcomes based on the timing of resumption

Cite This Study

Little et al. (2021) studied this question.

synapsesocial.com/papers/6a7e28144bd90feed65d7a80 https://doi.org/10.1503/cmaj.201433

Topics

Anticoagulation in AF

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Implication

Resuming OACs after bleeding was associated with lower thrombosis and mortality but higher rebleeding; leaves open net-benefit strategies pending randomized trials.

Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding

Discussion

Member takes

Implication

Structured PICO

Limitations

Cite This Study

Topics

Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding

Discussion

Member takes

Implication

Structured PICO

Limitations

Cite This Study

Also Consider

Topics

Also Consider