title: Risk factors for recurrent spontaneous epistaxis.
abstract: OBJECTIVE
  To identify risk factors associated with spontaneous recurrent epistaxis.
  
  
  METHODS
  This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence.
  
  
  RESULTS
  Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event.
  
  
  CONCLUSIONS
  Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.
authors.affiliation: Department of Internal Medicine, Marshfield Clinic, Marshfield, WI. Electronic address: abrich.victor@mayo.edu.
authors.forename: Victor
authors.initials: V
authors.lastname: Abrich
authors.affiliation: Department of Internal Medicine, Marshfield Clinic, Marshfield, WI.
authors.forename: Annabelle
authors.initials: A
authors.lastname: Brozek
authors.affiliation: Department of Otolaryngology, Marshfield Clinic, Marshfield, WI.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Boyle
authors.affiliation: Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI.
authors.forename: Po-Huang
authors.initials: PH
authors.lastname: Chyou
authors.affiliation: Department of Internal Medicine, Marshfield Clinic, Marshfield, WI.
authors.forename: Steven H
authors.initials: SH
authors.lastname: Yale
mesh_terms: D000368:Aged; D004844:Epistaxis / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D061270:Nasal Septal Perforation / Q000150:complications; D009300:Nasal Septum / Q000002:abnormalities; D012008:Recurrence; D012141:Respiratory Tract Infections / Q000150:complications; D012189:Retrospective Studies; D012220:Rhinitis / Q000150:complications; D012307:Risk Factors; D012852:Sinusitis / Q000150:complications