How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage?
OBJECTIVE
To identify the risk of thromboembolism after withholding or reversing the effect of warfarin therapy following a major hemorrhage.


METHODS
Retrospective medical record review.


METHODS
Tertiary-care hospital.


METHODS
Twenty-eight patients with prosthetic heart valves receiving warfarin were hospitalized for major hemorrhage from 1990 to 1997. The mean +/- SD age was 61 +/- 11 years (15 men and 13 women). Twenty patients had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic valves, 2 patients had Starr Edwards valves, and 2 patients had Bjork-Shiley valves. Valves were in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aortic positions in 4 patients. The average interval from valve surgery to index bleeding was 7 years. Twenty-five patients had GI or retroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage, and 1 patient had a subdural hematoma.


METHODS
Vitamin K was administered to five patients and fresh frozen plasma was given to seven patients to reverse anticoagulation. The mean duration of anticoagulation withholding was 15 +/- 4 days.


RESULTS
None of the patients had thromboembolic complications. There were four in-hospital deaths. Twenty-two of the 24 hospital survivors resumed warfarin therapy at hospital discharge. At 6-month follow-up, 10 of 19 patients remaining on warfarin therapy had recurrent GI bleeding.


CONCLUSIONS
Thromboembolic risk is low in prosthetic heart valve patients hospitalized with major hemorrhage when their warfarin therapy is reversed or withheld. Recurrent bleeding within 6 months of the resumption of anticoagulation is common, and aggressive treatment of the bleeding source and the risk-benefit ratio of continued anticoagulation need to be considered.
Ananthasubramaniam
K
K
Henry Ford Heart and Vascular Institute, Detroit, MI, USA.
Beattie
J N
JN
Rosman
H S
HS
Jayam
V
V
Borzak
S
S
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000150:complications*; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012008:Recurrence; D012189:Retrospective Studies; D013923:Thromboembolism / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin