title: Predictors of major bleeding in peri-procedural anticoagulation management.
abstract: BACKGROUND
  Appropriate periprocedural management for chronically anticoagulated patients requires assessment of patient-specific thrombosis and bleeding risks. However, predictors of post-procedure bleeding are unknown.
  
  
  OBJECTIVE
  To determine the 3-month cumulative incidence and independent predictors of peri-procedural bleeding in chronically anticoagulated patients requiring temporary warfarin interruption for an invasive procedure.
  
  
  METHODS
  In a protocol driven, cohort study design, all patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation management (1997-2007; n = 2182), were followed forward in time to determine the 3-month cumulative incidence of peri-procedural bleeding (Kaplan-Meier product limit) and potential predictors of bleeding (Cox proportional hazards). Decisions to 'bridge' with low-molecular-weight heparin were based on estimated thromboembolism and bleeding risk.
  
  
  RESULTS
  Indications for chronic anticoagulation included venous thromboembolism (38%), atrial fibrillation (30%) and mechanical heart valves (27%). Of these, 1496 (69%) patients received bridging therapy. The 3-month cumulative incidence rates of major and overall bleeding were 2.1% and 5.1%, respectively. Major bleeding occurred more frequently in patients receiving bridging therapy (3% vs. 1%; P = 0.017). Independent predictors (hazard ratio; 95% confidence interval) of major bleeding included mitral mechanical heart valve (2.2; 1.1-4.3), active cancer (1.8; 1.0-3.1), prior bleeding history (2.6; 1.5-4.5) and re-initiation of heparin therapy within 24 h after the procedure (1.9; 1.1-3.4).
  
  
  CONCLUSIONS
  Factors predisposing to peri-procedural bleeding are primarily patient-specific. Premature heparin re-initiation is an avoidable provider-specific variable to consider.
authors: Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.
authors: A J
authors: AJ
authors: Tafur
authors: R
authors: R
authors: McBane
authors: W E
authors: WE
authors: Wysokinski
authors: S
authors: S
authors: Litin
authors: P
authors: P
authors: Daniels
authors: J
authors: J
authors: Slusser
authors: D
authors: D
authors: Hodge
authors: M G
authors: MG
authors: Beckman
authors: J A
authors: JA
authors: Heit
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D004334:Drug Administration Schedule; D057915:Drug Substitution; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced*; D006493:Heparin / Q000009:adverse effects; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D015999:Multivariate Analysis; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013927:Thrombosis / Q000517:prevention & control*; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D006493:Heparin