The effect of excessive anticoagulation on mortality and morbidity in hospitalized patients with anticoagulant-related major hemorrhage.
BACKGROUND
We aimed to determine the effect of excessive anticoagulation on morbidity and mortality in hospitalized patients with major anticoagulant-associated hemorrhage.


METHODS
We prospectively identified 101 consecutive inpatients admitted to Brigham and Women's Hospital with major bleeding occurring during administration of warfarin sodium, unfractionated heparin (UFH), or low-molecular-weight heparin (LMWH).


RESULTS
Fifty patients had excessive and 51 had nonexcessive anticoagulation. The overall mortality at 60 days was 26% (13/50) in the excessive group compared with 10% (5/51) in the nonexcessive group (P =.03). Excessive warfarin therapy was associated with an increased 60-day mortality (P =.049), in contrast to excessive anticoagulation with UFH or LMWH alone (P =.27) or UFH or LMWH as a "bridge" to warfarin therapy (P =.10). Multivariate regression identified excessive anticoagulation as an independent predictor of 60-day mortality (adjusted hazard ratio [HR], 4.17; 95% confidence interval [CI], 1.39-12.49; P =.01), along with intracranial hemorrhage (adjusted HR, 6.16; 95% CI, 1.75-21.67; P =.005) and active cancer (adjusted HR, 3.79; 95% CI, 1.13-12.70; P =.03). Excessive anticoagulation was also a significant predictor of the combined nonfatal end point of stroke, myocardial infarction, hypotension, critical anemia, and surgical or angiographic intervention at 30 days (HR, 2.17; 95% CI, 1.25-3.78; P =.006).


CONCLUSIONS
In a cohort of patients with anticoagulation-associated hemorrhage, excessive anticoagulation contributed independently to increased morbidity and mortality.
Koo
Sophia
S
Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Kucher
Nils
N
Nguyen
Paul L
PL
Fanikos
John
J
Marks
Peter W
PW
Goldhaber
Samuel Z
SZ
D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced* / Q000401:mortality; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014859:Warfarin / Q000009:adverse effects
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin; D006493:Heparin