Early DOAC Restart Tied to Higher Bleeding Risk

Oral anticoagulants are an important tool for preventing strokes in people with atrial fibrillation, but they also increase the risk for serious bleeding events. Now a new study, published in July in Heart, sheds some light on how soon a patient should resume taking blood thinners after a serious bleed.

Nour Al-Hussainy, MD, PhD, a cardiologist at Aalborg University Hospital in Aalborg, Denmark, who led the work, said bleeding events are quite common among patients taking blood thinners, and when they happen physicians face a dilemma about what to do. “Should they discontinue treatment? Continue it? Interrupt it? When should it restart?” Al-Hussainy said.

Until now, clinicians have had little evidence on the balance between preventing strokes and the risk for further bleeding events to help make that decision. So Al-Hussainy and her colleagues examined the medical records of more than 10,000 people in Denmark taking direct oral anticoagulants (DOACs) who had experienced a serious bleeding event requiring hospital treatment, such as an intracranial bleed, gastrointestinal bleed, or nosebleed.

They divided the patients into two groups — those who restarted DOAC within 60 days of hospitalization (the early restart group) and those who restarted more than 60 days after (late restarters).

Patients who restarted treatment early were 21% more likely to experience recurrent bleeding than those who restarted later, the researchers found. Although their risk for stroke was slightly lower, the CI ranged from moderate benefit to no clear difference, making the actual benefit uncertain (hazard ratio, 0.89; 95% CI, 0.74-1.08).

In other words, Al-Hussainy said, “You don’t gain much by restarting blood thinners early after a bleed.”

The study does not define the optimal time to resume anticoagulation after a bleed, she added, and more studies will be needed to determine how soon treatment can be restarted without increasing the risk for bleeding.

Marc Carrier, MD, head of Hematology at The Ottawa Hospital in Ottawa, Ontario, Canada, and president of Thrombosis Canada, said most prior studies have shown resuming anticoagulation is generally the right decision because the consequences of a stroke are usually more severe than all but the most serious bleeding events. But clinicians often find it difficult to communicate that balance to patients who have yet to experience a stroke but are understandably upset about the possibility of future bleeds.

The new research could help in those conversations. “Having these discussions is important, and this will help with tailoring when to resume anticoagulation,” he said.

Al-Hussainy said she hopes the study helps to bring some of the focus in those discussions back onto the potential side effects of anticoagulation. “We shouldn’t forget the bleeding risk associated with blood thinners,” she said.

Al-Hussainy and Carrier reported having no relevant financial conflicts of interest.

Brian Owens is a freelance journalist in New Brunswick, Canada.