Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding

Witt, Daniel M.; Delate, Thomas; García, David; Clark, Nathan P.; Hylek, Elaine M.; Ageno, Walter; Dentali, Francesco; Crowther, Mark

doi:10.1001/archinternmed.2012.4261

Cited by 207 publications

(187 citation statements)

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“…In a retrospective analysis of 442 patients experiencing warfarin‐associated gastrointestinal bleeding, Witt et al reported warfarin discontinuation rates of 41.2% within 90 days of the index event. Patients who resumed warfarin within 90 days experienced substantially lower risks of thrombosis and all‐cause mortality 12. In another cohort study of AF patients experiencing a major gastrointestinal bleed in the Henry Ford Health System, Qureshi and colleagues reported warfarin discontinuation in 50.9% of patients.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic Strategies Following Major, Clinically Relevant Nonmajor, and Nuisance Bleeding in Atrial Fibrillation: Findings From ORBIT‐AF

O’Brien

Holmes

Thomas

et al. 2018

JAHA

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BackgroundOral anticoagulation (OAC) reduces stroke risk in atrial fibrillation, but bleeding is a frequent side effect. The decision to discontinue or modify medication regimens in response to a bleeding event may differ according to bleeding site and severity.Methods and ResultsWe used data from a large, national outpatient registry, ORBIT‐AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation; 2010–2011), to evaluate event characteristics and OAC management following the first bleeding event occurring during follow‐up. Bleeding events were classified into 3 categories: (1) International Society of Thrombosis and Hemostasis major bleeding, (2) clinically relevant nonmajor bleeding requiring medical attention, and (3) nuisance bleeding not requiring medical attention (eg, bruising, hemorrhoidal bleeding). Of 9743 patients enrolled in ORBIT‐AF with follow‐up data, 510 (3.23/100 subject‐years) experienced a major bleed, 615 (3.90/100 subject‐years), experienced a clinically relevant nonmajor bleed, and 1558 (9.87/100 subject‐years) experienced a nuisance bleed, among first bleeds over 2 years. Nearly one third of patients (31.6%) discontinued OAC therapy following a major bleeding event, 12.7% following a clinically relevant nonmajor bleed, and 4.5% following a nuisance bleed. Compared with those who experienced a clinically relevant nonmajor or nuisance bleed, patients who experienced a major bleed were more likely to be black and female and to have a history of heart failure and stroke. Those who discontinued were more likely to have central nervous system or gastrointestinal bleeding than those who persisted on OAC therapy.ConclusionsOverall, 1 in 3 patients who experienced a major bleed was no longer anticoagulated after the event. Those who discontinued OAC were more likely to have central nervous system or gastrointestinal bleeding than those who persisted on OAC.

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Section: Discussionmentioning

confidence: 99%

Therapeutic Strategies Following Major, Clinically Relevant Nonmajor, and Nuisance Bleeding in Atrial Fibrillation: Findings From ORBIT‐AF

O’Brien

Holmes

Thomas

et al. 2018

JAHA

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“…4 It has been suggested previously that the benefits of anticoagulation therapy outweigh the risks for those with GI bleeds. 5 Therefore, in cases such as this one, the need for some form of anticoagulation outweighs the risk of causing rebleeding, so it was appropriate to consider anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

Large Saddle Embolus: An Unusual Cause of Collapse

Cynthia

2017

IJRRT

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Abbreviations: GI, gastrointestinal; NOAC, new oral anti--coagulant; CTPA, computed tomography pulmonary angiogram; RCT, randomized control trial IntroductionPulmonary embolisms are a relatively common cardiovascular disorder, with approximately 1.83 per thousand per year, although the real number of cases may be higher due to the number of silent pulmonary embolisms.1 It can be a life-threatening condition, particularly if not diagnosed appropriately. One difficulty in diagnosing a pulmonary embolism is the variation in presentation, which can involve shortness of breath, cough (with or without hemoptysis), chest pain, collapse, fever, palpitations, or no symptoms at all. Although smaller clots may present asymptomatically, it may be possible for larger pulmonary embolisms to present relatively innocuously as well. Therefore, suspicion should always be high for a venous thromboembolic cause for an unusual presentation, such as an unprovoked collapse. The treatment for pulmonary embolisms remains conflicted, particularly in cases with complex comorbidities. Case presentationA 69year old Caucasian male was admitted with a new history of multiple collapses over the past three days. He had no palpitations and did not lose consciousness during these collapses. He described a mild shortness of breath while at rest, but no chest pain, cough, or haemoptysis.His past medical history was significant only for a small GI bleed a month ago, which was being managed with proton pump inhibitors. He was taking no other medications. He had no significant family history. He was a non-smoker and non-drinker. On examination, he was found to be clinically well, with all observations within normal ranges. His heart sounds were normal, and chest was clear to auscultation. However, because of the short history of shortness of breath and multiple collapses, a CT pulmonary angiogram was performed. The CT pulmonary angiogram was helpful to visualise the pulmonary arteries by injecting intravenous contrast and showed a large saddle thrombus where the thrombus causes a mass filling defect and appears dark in the pulmonary bifurcation (Figure 1). Despite the radiological diagnosis, the patient was haemodynamically stable, so thrombolysis was deemed unnecessary, as it is not indicated in a nonmassive pulmonary embolism.2 His clinical condition was closely monitored for any deterioration.There was some confusion as to what anticoagulant to use for his saddle embolus. Rivaroxaban, a newer oral anticoagulant (NOAC), is commonly used for pulmonary embolisms at this district hospital due to the advantage of its more fixed anticoagulant effect compared AbstractBackground: Pulmonary embolisms are a relatively common and potentially lifethreatening cardiovascular disorder. Diagnosis can be difficult due to variation in presentation, therefore suspicion should always be high for a venous thromboembolic cause for any unusual presentations, such as an unprovoked collapse. Treatment for pulmonary embolisms remains somewhat conflicted, particularly in ca...

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“…Patients who experienced extra-cranial bleeding might resume the initial anticoagulation therapy or switch to aspirin. 24 …”

Section: Decision Modelmentioning

confidence: 99%

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

You

2013

J GEN INTERN MED

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BACKGROUND:The decision as to whether to use more expensive novel oral anticoagulants (NOACs) or invest resources for quality improvement of warfarin therapy requires input from both clinical and economic analyses. OBJECTIVE: Cost-effectiveness of NOACs compared to warfarin therapy at various levels of patient-time in therapeutic range (TTR) in patients with atrial fibrillation was examined, from the healthcare provider's perspective. DESIGN, SUBJECTS AND INTERVENTION:A Markov model was used to compare life-long economic and treatment outcomes of warfarin and NOACs in a hypothetical cohort of 65-year-old atrial fibrillation patients with CHADS 2 scores of 2 or above. Model inputs were derived from clinical trials published in the literature. MAIN MEASURES: The outcome measure was incremental cost per quality-adjusted life-year (QALY) gained (ICER). KEY RESULTS: Using United States Dollar (USD) 50,000 as the threshold of willingness-to-pay per QALY, NOACs therapy was cost-effective when TTR of warfarin therapy was 60 % or below, or monthly cost of warfarin management increased by two-fold or more to achieve 70 % TTR. Warfarin therapy was cost-effective when TTR of warfarin was 70 % with up to a 1.5-fold increment in monthly cost of care, or when TTR reached 75 % with monthly cost of warfarin care increased up to three-fold. At TTR 60 %, 70 % and 75 %, NOACs was cost-effective when monthly drug cost was < USD 200, < USD 122-185 and < USD 85-145, respectively. 10,000 Monte Carlo simulations showed NOACs to be cost-effective 83.6 %, 50.7 % and 32.7 % of the time at TTR of 60 %, 70 % and 75 %, respectively. CONCLUSIONS: The acceptance of NOACs as costeffective was highly dependent upon drug cost, anticoagulation control for warfarin, and anticoagulation service cost.KEY WORDS: novel oral anticoagulants; warfarin; atrial fibrillation; cost-effectiveness.

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Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding

Abstract: The decision to not resume warfarin therapy in the 90 days following a GIB event is associated with increased risk for thrombosis and death. For many patients who have experienced warfarin-associated GIB, the benefits of resuming anticoagulant therapy will outweigh the risks.

Cited by 207 publications

References 16 publications

Therapeutic Strategies Following Major, Clinically Relevant Nonmajor, and Nuisance Bleeding in Atrial Fibrillation: Findings From ORBIT‐AF

Therapeutic Strategies Following Major, Clinically Relevant Nonmajor, and Nuisance Bleeding in Atrial Fibrillation: Findings From ORBIT‐AF

Large Saddle Embolus: An Unusual Cause of Collapse

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

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