Restarting Anticoagulation and Outcomes after Major Gastrointestinal Bleeding in Atrial Fibrillation

Data regarding the outcomes of restarting anticoagulation in individuals that develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these individuals is associated with better outcomes. This is a retrospective cohort study that enrolled individuals that developed GIB while on anticoagulation from 2005-2010. Atrial fibrillation (AF) was defined by history and ECG on presentation. Gastrointestinal bleeding was defined as decrease in Hb 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 1329 (mean age 76, women 45%) developed major gastrointestinal bleeding. Warfarin was restarted in 653 (49.1%) cases. Restarting warfarin was associated with decreased thromboembolism (HR 0.71; 95% CI 0.54 - 0.93, p = 0.01) and reduced mortality (HR 0.67; 95% CI 0.56 - 0.81, p < 0.0001) but not recurrent GIB (HR 1.18; 95% CI 0.94 - 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 when compared with resuming after 30 day 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.

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