title: Restarting anticoagulation and outcomes after major gastrointestinal bleeding in atrial fibrillation.
abstract: Data regarding the outcomes of restarting anticoagulation in patients who develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these patients is associated with better outcomes. This is a retrospective cohort study that enrolled subjects who developed GIB while on anticoagulation from 2005 to 2010. Atrial fibrillation was defined by history and electrocardiography on presentation. GIB was defined as a decrease in hemoglobin by 2 g, visible bleeding, or positive endoscopic evaluation. Time-to-event adjusted analyses were performed to find an association of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality. Stratified analysis by duration of interruption of warfarin was also performed. Overall, 1,329 patients (mean age 76 years, women 45%) developed major GIB. Warfarin was restarted in 653 cases (49.1%). Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.75 to 1.84, p = 0.47) [corrected] and reduced mortality (HR 0.67, 95% CI 0.56 to 0.81, p <0.0001) but not recurrent GIB (HR 1.18, 95% CI 0.94 to 1.10, p = 0.47). When the outcomes were stratified by duration of warfarin interruption, restarting warfarin after 7 days was not associated with increased risk of GIB but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption. Decision to restart warfarin after an episode of major GIB is associated with improved survival and decreased thromboembolism without increased risk of GIB after 7 days of interruption.
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina. Electronic address: WaqasTariq@gmail.com.
authors.forename: Waqas
authors.initials: W
authors.lastname: Qureshi
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Chetan
authors.initials: C
authors.lastname: Mittal
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Iani
authors.initials: I
authors.lastname: Patsias
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Kiran
authors.initials: K
authors.lastname: Garikapati
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Aishwarya
authors.initials: A
authors.lastname: Kuchipudi
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Gagandeep
authors.initials: G
authors.lastname: Cheema
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Elbatta
authors.affiliation: Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Zaid
authors.initials: Z
authors.lastname: Alirhayim
authors.affiliation: Section of Nephrology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: Fatima
authors.initials: F
authors.lastname: Khalid
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000401:mortality; D015331:Cohort Studies; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000150:complications / Q000401:mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin