Annual Scientific Meeting
Introduction: Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). There is limited data on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality.
Methods: We performed a systematic review and meta-analysis to determine the risk of recurrent GIB, thromboembolism and mortality after resuming anticoagulation following GIB. PubMed, Embase and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism and mortality following initial hospitalization for GIB.
Results: A total of 5,354 studies were reviewed of which 10 were included in the meta-analysis (Figure 1). There were 2,080 patients who resumed anticoagulation and 2,296 patients who stopped their anticoagulation post index GIB (Table 1). Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, p=0.035, I2=55.5%) though recurrent GIB leading to death was rare (Figure 2). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, p=0.001, I2=62.7%) and a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, p=0.000, I2=14.2%) (Figure 2). Optimal timing of re-initiation of anticoagulation varied, but as early as 2 weeks from index GIB or hospital discharge may be ideal.
Discussion: While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality. Re-initiation of anticoagulation as early as 2 weeks post-GIB may be optimal.