In most cases, restarting OAC after a bleeding event provides net clinical benefit After a patient has a bleeding event on OAC, the indication for OAC should be reassessed to determine whether continued therapy is warranted on the basis of established clinical practice guidelines. The following are the possible conditions for which OAC may no longer be indicated:
- Nonvalvular AF with CHA2DS2-VASc (Congestive heart failure, Hypertension, Age [>65 = 1 point, ≥75 = 2 points], Diabetes, previous Stroke/transient ischemic attack [2 points]) score <2 in men and <3 in women
- Temporary indication for OAC (e.g., postsurgical prophylaxis, OAC after an anterior MI without left ventricular thrombus, post-LAA closure device placement)
- Recovered acute stress cardiomyopathy (e.g., Takotsubo cardiomyopathy)
- First time provoked VTE >3 months ago
- Bioprosthetic valve placement in the absence of AF >3 months ago
If there is an ongoing indication for OAC, the clinician must evaluate the net clinical benefit of OAC in the context of a recent bleed to decide whether the risk of bleeding temporarily or permanently outweighs the benefit of treatment or thromboprophylaxis with OAC. This risk-benefit assessment should be conducted in consultation with other practitioners (e.g., surgeons, interventionalists, neurologists) and in discussion with patients or caregivers. Several validated bleeding assessment tools are available, but none has been studied in the specific situation of active or very recent bleeding.
There are many patient characteristics (e.g. age, sex) and other factors that contribute to the risk-benefit assessment of restarting anticoagulation. Reversible factors that may have contributed to the bleed, such as a high INR in a patient on a VKA, concomitant antiplatelet therapy, acute or worsening renal insufficiency leading to elevated OAC levels, or significant drug interactions that could increase DOAC levels, should be addressed prior to restarting therapy. Determining the appropriateness of the drug and dose for individual patients on the basis of indication, age, weight, and renal function is important to minimize the potential for adverse events. If the patient is on dual antiplatelet therapy, re-evaluating whether such therapy is needed or whether aspirin can be discontinued is reasonable (50). Bleed characteristics that contribute substantially to the risks associated with restarting anticoagulation include: 1) the location of the bleed (i.e., critical or noncritical site); 2) the source of bleeding and whether it was definitively identified and treated; 3) the mechanism of the bleed (i.e., traumatic or spontaneous); and 4) whether further surgical or procedural interventions are planned. Finally, the indication for anticoagulation must be considered, as patients who are at high thrombotic risk will likely benefit from restarting anticoagulation, even if the risk of rebleeding is high. TABLE provides indications for anticoagulation with high thrombotic risk.