To bleed or to clot: Stroke prevention strategies in patients with atrial fibrillation or flutter after bleeding
Gorgis S, Ahluwalia G, Hana A, Fram G, Dabbagh M, Dhillon D, Murad A, Khan A, O'Neill WW, Kaatz S, and Wang DD. To bleed or to clot: Stroke prevention strategies in patients with atrial fibrillation or flutter after bleeding. Journal of the American College of Cardiology 2020; 75(11):472.
J Am Coll Cardiol
Background Patients with atrial fibrillation or atrial flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding events. A common dilemma is deciding when to safely restart AC after bleeding. Studies have shown better outcomes with reinitiation of AC 7 days after stabilization of gastrointestinal bleeds and 4 weeks after intracranial hemorrhage. Our aim was to assess stroke prevention strategies upon discharge in patients with AF hospitalized with a bleeding event. Methods We retrospectively identified patients with AF on AC who were admitted with a bleeding event. The type of AC, form of bleeding, and CHADS2VASC were collected. Stroke prevention strategies on discharge were noted. Results Between January 2016 and August 2019, 174 patient with AF were hospitalized with a bleeding event. Nearly 10% of patients died, emphasizing the severity of this clinical situation. AC was restarted in 40% of patients upon discharge, 8.6% of patients were referred for LAA closure, and the remaining 40% were discharged without a stroke prevention strategy. CHADS2VASC did not differ among the groups. Of patients discharged on AC, 16% had a repeat bleeding episode requiring hospitalization within 30 days. Conclusion A significant portion of patients with AF hospitalized with a bleed were discharged with no definitive stroke prevention strategy. Barriers to restarting oral anticoagulation should lead to consideration of LAA closure as an alternative.