Predictors of major bleeding in peri‐procedural anticoagulation management

Abstract

Summary. Background: Appropriate periprocedural management for chronically anticoagulated patients requires assessment of patient‐specific thrombosis and bleeding risks. However, predictors of post‐procedure bleeding are unknown. Objectives: To determine the 3‐month cumulative incidence and independent predictors of peri‐procedural bleeding in chronically anticoagulated patients requiring temporary warfarin interruption for an invasive procedure. Methods: In a protocol driven, cohort study design, all patients referred to the Mayo Clinic Thrombophilia Center for peri‐procedural anticoagulation management (1997–2007; n = 2182), were followed forward in time to determine the 3‐month cumulative incidence of peri‐procedural bleeding (Kaplan–Meier product limit) and potential predictors of bleeding (Cox proportional hazards). Decisions to ‘bridge’ with low‐molecular‐weight heparin were based on estimated thromboembolism and bleeding risk. Results: Indications for chronic anticoagulation included venous thromboembolism (38%), atrial fibrillation (30%) and mechanical heart valves (27%). Of these, 1496 (69%) patients received bridging therapy. The 3‐month cumulative incidence rates of major and overall bleeding were 2.1% and 5.1%, respectively. Major bleeding occurred more frequently in patients receiving bridging therapy (3% vs. 1%; P = 0.017). Independent predictors (hazard ratio; 95% confidence interval) of major bleeding included mitral mechanical heart valve (2.2; 1.1–4.3), active cancer (1.8; 1.0–3.1), prior bleeding history (2.6; 1.5–4.5) and re‐initiation of heparin therapy within 24 h after the procedure (1.9; 1.1–3.4). Conclusion: Factors predisposing to peri‐procedural bleeding are primarily patient‐specific. Premature heparin re‐initiation is an avoidable provider‐specific variable to consider.

Perioperative management of patients on chronic antithrombotic therapy

“…In a recent cohort study, patientspecific variables that were associated with an increased risk for bleeding included a history of bleeding, a mechanical heart valve in the mitral position, the presence of active cancer, and thrombocytopenia. 19 A bleeding risk score that used these 4 parameters, referred to as "BleedMAP," was shown to correlate with an increased risk for periprocedural bleeding. 19 The HAS-BLED score, ie, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (Ͼ 65 years), Drugs/alcohol concomitantly, which originally was developed for use in the nonperioperative setting, recently has been shown to predict bleeds during the bridging of patients on chronic anticoagulation.…”

“…19 A bleeding risk score that used these 4 parameters, referred to as "BleedMAP," was shown to correlate with an increased risk for periprocedural bleeding. 19 The HAS-BLED score, ie, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (Ͼ 65 years), Drugs/alcohol concomitantly, which originally was developed for use in the nonperioperative setting, recently has been shown to predict bleeds during the bridging of patients on chronic anticoagulation. 20 This scoring system uses the presence or absence of hypertension, abnormal renal or liver function, previous stroke, bleeding history or predisposition, labile international normalized ratio (INR), older age (Ͼ 65 years), or drug/alcohol use concomitantly to assess bleeding risk.…”

Management of peri‐operative anti‐thrombotic therapy

“…Initiation of low molecular weight heparin therapy at 24 h was an independent risk factor for major bleeding and doubled the risk compared with starting it 48 h or later [47].…”

Advanced drug delivery systems for antithrombotic agents

“…Current approaches to thromboprophylaxis in such patients, although successful, necessitate a careful and oft-times difficult balance between the estimated risk of thrombosis with drug interruption and the risk of bleeding due to premature resumption of thromboprophylaxis. [1][2][3] Stroke and delayed onset cognitive dysfunction attributed to thromboemboli remain a serious and increasingly recognized late complication of surgery. The risk of causing or accentuating bleeding also constrains the use of plasminogen activators (PAs) in patients with submassive pulmonary embolism and thrombotic stroke.…”