Arrhythmias and Conduction Disturbances
Restarting Anticoagulation and Outcomes After Major Gastrointestinal Bleeding in Atrial Fibrillation

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Data regarding the outcomes of restarting anticoagulation in patients who develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these patients is associated with better outcomes. This is a retrospective cohort study that enrolled subjects who developed GIB while on anticoagulation from 2005 to 2010. Atrial fibrillation was defined by history and electrocardiography on presentation. GIB was defined as a decrease in hemoglobin by 2 g, visible bleeding, or positive endoscopic evaluation. Time-to-event adjusted analyses were performed to find an association of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality. Stratified analysis by duration of interruption of warfarin was also performed. Overall, 1,329 patients (mean age 76 years, women 45%) developed major GIB. Warfarin was restarted in 653 cases (49.1%). Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.54 to 0.93, p = 0.01) and reduced mortality (HR 0.67, 95% CI 0.56 to 0.81, p <0.0001) but not recurrent GIB (HR 1.18, 95% CI 0.94 to 1.10, p = 0.47). When the outcomes were stratified by duration of warfarin interruption, restarting warfarin after 7 days was not associated with increased risk of GIB but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption. Decision to restart warfarin after an episode of major GIB is associated with improved survival and decreased thromboembolism without increased risk of GIB after 7 days of interruption.

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Methods

This is a retrospective cohort study that evaluated the patients enrolled at the anticoagulation clinic of Henry Ford Health System with a large catchment area serving all socioeconomic strata, covering majority of Southeast Michigan, United States. Patients who developed major GIB (defined in the following) while taking warfarin and then had evidence of resolution of major GIB (defined as stability of hemoglobin levels with <1 g decrease of hemoglobin for 48 hours) were included in the study.

Results

Overall, 1,329 patients (mean age 75 ± 11 years, women 47%) developed GIB during January 2005 to December 2010. There were 653 patients (49%) who were restarted on warfarin after a median duration of 50 days (interquartile range 21 to 78). The median CHADS2 and HAS-BLED scores were 3. Endoscopic evaluation was performed in 883 cases (66.4%). Chronic AF was present in 751 (52.6%), persistent AF in 345 (25.9%), and paroxysmal AF in 233 patients (17.5%). Caucasians, patients with concomitant upper

Discussion

This study provides incidences of thromboembolism, mortality, and recurrent GIB in patients who developed GIB while on anticoagulation for nonvalvular AF. The study also demonstrated that lower risks of thromboembolism and mortality were associated with resuming anticoagulation. There were also no significant differences in risk of GIB between resuming warfarin after 1 week of interruption of warfarin compared with restarting warfarin after 1 month; however, risk of recurrent GIB was

Disclosures

The authors have no conflicts of interest to disclose.

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The authors acknowledge the support from the Department of Internal Medicine of Henry Ford Health System for providing funding for administrative data collection.

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