Optimal timing of vitamin K antagonist resumption after upper gastrointestinal bleeding

Ammar Majeed; Niklas Wallvik; Joakim Eriksson; Jonas Höijer; Matteo Bottai; Margareta Holmström; Sam Schulman

doi:10.1160/TH16-07-0498

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2017; 117(03): 491-499
DOI: 10.1160/TH16-07-0498

Coagulation and Fibrinolysis

Schattauer GmbH

Optimal timing of vitamin K antagonist resumption after upper gastrointestinal bleeding

A risk modelling analysis

Authors

Ammar Majeed

¹Department of Medicine, Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden

²Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden

³Department of Gastroenterology, The Alfred Health, Melbourne, Australia
Niklas Wallvik

⁴Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Joakim Eriksson

⁴Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Jonas Höijer

⁵Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
Matteo Bottai

⁵Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
Margareta Holmström

¹Department of Medicine, Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
Sam Schulman

¹Department of Medicine, Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden

⁶Department of Medicine, McMaster University, and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada

Abstract

Summary

The optimal timing of vitamin K antagonists (VKAs) resumption after an upper gastrointestinal (GI) bleeding, in patients with continued indication for oral anticoagulation, is uncertain. We included consecutive cases of VKA-associated upper GI bleeding from three hospitals retrospectively. Data on the bleeding location, timing of VKA resumption, recurrent GI bleeding and thromboembolic events were collected. A model was constructed to evaluate the ‘total risk’, based on the sum of the cumulative rates of recurrent GI bleeding and thromboembolic events, depending on the timing of VKA resumption. A total of 121 (58 %) of 207 patients with VKA-associated upper GI bleeding were restarted on anticoagulation after a median (interquartile range) of one (0.2–3.4) week after the index bleeding. Restarting VKAs was associated with a reduced risk of thromboembolism (HR 0.19; 95 % CI, 0.07–0.55) and death (HR 0.61; 95 % CI, 0.39–0.94), but with an increased risk of recurrent GI bleeding (HR 2.5; 95 % CI, 1.4–4.5). The composite risk obtained from the combined statistical model of recurrent GI bleeding, and thromboembolism decreased if VKAs were resumed after three weeks and reached a nadir at six weeks after the index GI bleeding. On this background we will discuss how the disutility of the outcomes may influence the decision regarding timing of resumption. In conclusion, the optimal timing of VKA resumption after VKA-associated upper GI bleeding appears to be between 3–6 weeks after the index bleeding event but has to take into account the degree of thromboembolic risk, patient values and preferences.

Keywords

Gastrointestinal bleeding - Warfarin - thromboembolism - stroke - mortality

Full Text

References

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