Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding

ABSTRACT

Introduction: Oral anticoagulants (OACs) are established treatments to reduce thromboembolic risk in patients with atrial fibrillation (AF). Due to their mechanisms of action, they are associated with increased bleeding risk. Evaluation with bleeding risk scores may be useful to identify patients at high risk. However, the approach in patients who have suffered a recent bleeding event while on OACs is a contentious issue. If a decision is made to re-initiate OACs, the optimal timing for this remains controversial.

Areas covered: Bleeding risk scores were designed to evaluate risk in patients with AF and indications for OACs. Some practical schemes were created to manage bleeding in this population. The types of bleeding were classified as minor, major non-life-threatening and major life-threatening bleeding. In AF patients suffering from severe acute bleeding, it is recommended to withhold OACs until the underlying cause is identified and treated. Each case will require an individualized decision to restarting OAC therapy after consideration of the risks, benefits, alternatives and patient’s choice in the matter.

Expert opinion: Management of major bleeding and restarting OACs in patients with a recent major bleeding poses a special challenge due to high bleeding and thrombotic risk. This will be discussed in this review.

KEYWORDS:

• Atrial fibrillation
• gastrointestinal bleeding
• intracranial hemorrhage
• major bleeding
• non-vitamin K antagonist oral anticoagulants
• oral anticoagulants
• vitamin K antagonists

Article highlights

• Decisions on restarting OACs in patients with a history of major bleeding pose a special challenge due to high bleeding and thrombotic risk.

• Reinitiating OACs after bleeding seems to be clinically justified and associated with a net clinical benefit in comparison to withholding OACs.

• Absolute contraindications to long-term anticoagulation are rare.

• Bleeding risk is dynamic and it needs to be re-assessed regularly.

• All patients after bleedings should be assessed by a multidisciplinary panel before treatment and require some degree of individualized management.

• Eliminating the source of bleeding is crucial. In case of bleedings due to secondary or reversible causes, OACs can be restarted once the cause of the bleed has been corrected.

Declaration of interest

G Lip has consulted for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi Sankyo. They have also been a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim and Daiichi Sankyo. No fees have been directly collected personally. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.