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Stop Anticoagulants for Nuisance Bleeding?

June 8, 2018

Written by Clay Smith

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Nuisance bleeding in patients with atrial fibrillation on oral anticoagulants did not portend subsequent major bleeding or increased risk for stroke/systemic embolism.

Why does this matter?
Patients taking oral anticoagulants (OAC) often have nuisance bleeding that is not major, not life-threatening.  Does this type of nuisance bleeding result in OAC discontinuation with subsequent stroke or portend major bleeding complications in such patients?

Pesky bleeding is just that
There were 6,771 patients followed in the ORBIT-AF study.  This was a retrospective look at that registry data.  Nuisance bleeding was defined as any minor bleeding not requiring medical attention, such as bruising, epistaxis, or hemorrhoidal bleeding.  Of the 6,771 patients, 20% had nuisance bleeding; over 96% kept taking the OAC despite this.  Overall, 4.3% had major bleeding, and 0.9% had stroke or systemic embolism (SSE).  Patients with nuisance bleeding were not at increased risk for subsequent major bleeding or SSE.  But patients with either nuisance bleed or clinically-relevant non-major bleed (requiring medical attention but not a priori “major bleeding” study criteria) had a slight increase in subsequent major bleeding within 6 months.  What this means for us in the ED is that we should not recommend stopping OACs if a patient reports only nuisance bleeding.  Rather, refer such patients to the prescriber or anticoagulation clinic, as some may need dosage adjustment.  Bleeding requiring medical attention warrants more vigilance and closer follow up.

Prognostic Significance of Nuisance Bleeding in Anticoagulated Patients with Atrial Fibrillation.  Circulation. 2018 Apr 20. pii: CIRCULATIONAHA.117.031354. doi: 10.1161/CIRCULATIONAHA.117.031354. [Epub ahead of print]

Peer reviewed by Thomas Davis

What are your thoughts?