title: The risks of thromboembolism vs. recurrent gastrointestinal bleeding after interruption of systemic anticoagulation in hospitalized inpatients with gastrointestinal bleeding: a prospective study.
abstract: OBJECTIVE
  Anticoagulants carry a significant risk of gastrointestinal bleeding (GIB). Data regarding the safety of anticoagulation continuation/cessation after GIB are limited. We sought to determine the safety and risk of continuation of anticoagulation after GIB.
  
  
  METHODS
  We conducted a prospective observational cohort study on consecutive patients admitted to the hospital who had GIB while on systemic anticoagulation. Patients were classified into two groups at hospital discharge after GIB: those who resumed anticoagulation and those who had anticoagulation discontinued. Patients in both groups were contacted by phone 90 days after discharge to determine the following outcomes: (i) thromboembolic events, (ii) hospital readmissions related to GIB, and (iii) mortality. Univariate and multivariate Cox proportional hazards were used to determine factors associated with thrombotic events, rebleeding, and death.
  
  
  RESULTS
  We identified 197 patients who developed GIB while on systemic anticoagulation (n=145, 74% on warfarin). Following index GIB, anticoagulation was discontinued in 76 patients (39%) at discharge. In-hospital transfusion requirements, need for intensive care unit care, and etiology of GIB were similar between the two groups. During the follow-up period, 7 (4%) patients suffered a thrombotic event and 27 (14%) patients were readmitted for GIB. Anticoagulation continuation was independently associated on multivariate regression with a lower risk of major thrombotic episodes within 90 days (hazard ratio (HR)=0.121, 95% confidence interval (CI)=0.006-0.812, P=0.03). Patients with any malignancy at time of GIB had an increased risk of thromboembolism in follow-up (HR=6.1, 95% CI=1.18-28.3, P=0.03). Anticoagulation continuation at discharge was not significantly associated with an increased risk of recurrent GIB at 90 days (HR=2.17, 95% CI=0.861-6.67, P=0.10) or death within 90 days (HR=0.632, 95% CI=0.216-1.89, P=0.40).
  
  
  CONCLUSIONS
  Restarting anticoagulation at discharge after GIB was associated with fewer thromboembolic events without a significantly increased risk of recurrent GIB at 90 days. The benefits of continuing anticoagulation at discharge may outweigh the risks of recurrent GIB.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: N
authors.initials: N
authors.lastname: Sengupta
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Feuerstein
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: V R
authors.initials: VR
authors.lastname: Patwardhan
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: E B
authors.initials: EB
authors.lastname: Tapper
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: G A
authors.initials: GA
authors.lastname: Ketwaroo
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Thaker
authors.affiliation: Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: D A
authors.initials: DA
authors.lastname: Leffler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001562:Benzimidazoles / Q000009:adverse effects; D015331:Cohort Studies; D000069604:Dabigatran; D017984:Enoxaparin / Q000009:adverse effects; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000188:drug therapy; D006493:Heparin; D006801:Humans; D002546:Ischemic Attack, Transient / Q000517:prevention & control*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009025:Morpholines / Q000009:adverse effects; D010359:Patient Readmission / Q000706:statistics & numerical data; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000517:prevention & control*; D011720:Pyrazoles / Q000009:adverse effects; D011728:Pyridones / Q000009:adverse effects; D012008:Recurrence; D000069552:Rivaroxaban; D020521:Stroke / Q000517:prevention & control*; D013876:Thiophenes / Q000009:adverse effects; D013923:Thromboembolism / Q000517:prevention & control; D020246:Venous Thrombosis / Q000517:prevention & control*; D014859:Warfarin / Q000009:adverse effects; D028761:Withholding Treatment / Q000706:statistics & numerical data*; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D017984:Enoxaparin; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D014859:Warfarin; D006493:Heparin; D000069552:Rivaroxaban; D000069604:Dabigatran