 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2 December 2003 | Volume 139 Issue 11 | Pages 893-900
Background: Clinicians should consider the clinical impact of anticoagulant-related bleeding when deciding on the duration of anticoagulant therapy in patients with venous thromboembolism.
Purpose: To provide reliable estimates of the clinical impact of anticoagulant-related bleeding, defined as the case-fatality rate of major bleeding and the risk for intracranial bleeding.
Data Sources: MEDLINE (January 1989 to May 2003), Cochrane Controlled Trial Registry, thromboembolism experts, and reference lists; English-language literature only.
Study Selection: Randomized, controlled trials and prospective cohort studies that investigated patients with venous thromboembolism who received oral anticoagulant therapy (target international normalized ratio, 2.0 to 3.0) for at least 3 months and that reported major bleeding and death as primary study outcomes.
Data Extraction: Two reviewers independently extracted data on the number of anticoagulant-related major and intracranial bleeding episodes and on whether these events were fatal or nonfatal.
Data Synthesis: The authors analyzed 33 studies involving 4374 patient-years of oral anticoagulant therapy. For all patients, the case-fatality rate of major bleeding was 13.4% (95% CI, 9.4% to 17.4%) and the rate of intracranial bleeding was 1.15 per 100 patient-years (CI, 1.14 to 1.16 per 100 patient-years). For patients who received anticoagulant therapy for more than 3 months, the case-fatality rate of major bleeding was 9.1% (CI, 2.5% to 21.7%), and the rate of intracranial bleeding was 0.65 per 100 patient-years (CI, 0.63 to 0.68 per 100 patient-years) after the initial 3 months of anticoagulation.
Conclusion: The clinical impact of anticoagulant-related major bleeding in patients with venous thromboembolism is considerable, and clinicians should take this into account when deciding whether to continue long-term oral anticoagulant therapy in an individual patient.
Editors' Notes
Context
Contribution
Implications
–The Editors
Author and Article Information
From McMaster University, Hamilton, Ontario, Canada; and University of British Columbia, Vancouver, British Columbia, Canada.
Acknowledgments: The authors thank Drs. Clive Kearon, Mark Crowther, Lehana Thabane, and Jack Hirsh for their helpful reviews of the manuscript.
Grant Support: Dr. Linkins is the recipient of a Fellowship Award from the Heart & Stroke Scientific Research Corporation of Canada/AstraZeneca Canada, Inc. Dr. Douketis is a recipient of a Research Scholarship from the Heart and Stroke Foundation of Canada.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: James D. Douketis, MD, FRCP(C), St. Joseph's Healthcare, Room F-541, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada; e-mail, jdouket{at}mcmaster.ca.
Current Author Addresses: Dr. Linkins: Henderson Research Centre, Room 220, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.
Dr. Choi: Department of Anesthesia, University of British Columbia, 2329 West Mall, Vancouver V6T 1Z4, British Columbia.
Dr. Douketis: St. Joseph's Healthcare, Room F-541, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
Author Contributions: Conception and design: L.A. Linkins, J.D. Douketis.
Analysis and interpretation of the data: L.A. Linkins, P.T. Choi, J.D. Douketis.
Drafting of the article: L.A. Linkins, J.D. Douketis.
Critical revision of the article for important intellectual content: L.A. Linkins, P.T. Choi, J.D. Douketis.
Final approval of the article: L.A. Linkins, P.T. Choi, J.D. Douketis.
Statistical expertise: P.T. Choi.
Administrative, technical, or logistic support: J.D. Douketis.
Collection and assembly of data: L.A. Linkins. ARTICLE
Clinical Impact of Bleeding in Patients Taking Oral Anticoagulant Therapy for Venous Thromboembolism
A Meta-Analysis
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  M. A. Rodger MD MSc, S. R. Kahn MD MSc, P. S. Wells MD MSc, D. A. Anderson MD, I. Chagnon MD, G. Le Gal MD PhD, S. Solymoss MD, M. Crowther MD, A. Perrier MD, R. White MD, et al. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy Can. Med. Assoc. J., August 26, 2008; 179(5): 417 - 426. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. Hozo and B. Djulbegovic When Is Diagnostic Testing Inappropriate or Irrational? Acceptable Regret Approach Med Decis Making, July 1, 2008; 28(4): 540 - 553. [Abstract] [PDF]
|
|
|
|
 |
|
 S. Schulman, R. J. Beyth, C. Kearon, and M. N. Levine Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 257S - 298S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. D. Douketis, P. B. Berger, A. S. Dunn, A. K. Jaffer, A. C. Spyropoulos, R. C. Becker, and J. Ansell The Perioperative Management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 299S - 339S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Kearon, S. R. Kahn, G. Agnelli, S. Goldhaber, G. E. Raskob, and A. J. Comerota Antithrombotic Therapy for Venous Thromboembolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 454S - 545S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Garcia Pharmacogenetic-guided and standard dosing did not differ for out-of-range INRs in patients initiating warfarin therapy Evid. Based Med., April 1, 2008; 13(2): 55 - 55. [Full Text] [PDF]
|
|
|
|
 |
|
 S. MADHWAL, A. M. LINCOFF, and D. D.K. ROLSTON Q: Should patients on long-term warfarin take aspirin for heart disease? Cleveland Clinic Journal of Medicine, March 1, 2008; 75(3): 206 - 208. [Full Text] [PDF]
|
|
|
|
 |
|
 M. P. Janjigian and B. E. Muhs Current Treatment of Acute Lower Extremity Deep Venous Thrombosis International Journal of Lower Extremity Wounds, March 1, 2008; 7(1): 15 - 20. [Abstract] [PDF]
|
|
|
|
 |
|
 J. D. Douketis, C. S. Gu, S. Schulman, A. Ghirarduzzi, V. Pengo, and P. Prandoni The Risk for Fatal Pulmonary Embolism after Discontinuing Anticoagulant Therapy for Venous Thromboembolism Ann Intern Med, December 4, 2007; 147(11): 766 - 774. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. W Eikelboom, J. S Ginsberg, and J. Hirsh Anticoagulation for venous thromboembolism BMJ, March 31, 2007; 334(7595): 645 - 645. [Full Text] [PDF]
|
|
|
|
 |
|
 P. K. Henke, C. G. Pearce, D. M. Moaveni, A. J. Moore, E. M. Lynch, C. Longo, M. Varma, N. A. Dewyer, K. B. Deatrick, G. R. Upchurch Jr, et al. Targeted Deletion of CCR2 Impairs Deep Vein Thombosis Resolution in a Mouse Model. J. Immunol., September 1, 2006; 177(5): 3388 - 3397. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Goodacre, M. Stevenson, A. Wailoo, F. Sampson, A.J. Sutton, and S. Thomas How should we diagnose suspected deep-vein thrombosis? QJM, June 1, 2006; 99(6): 377 - 388. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. van Walraven, A. Jennings, N. Oake, D. Fergusson, and A. J. Forster Effect of Study Setting on Anticoagulation Control: A Systematic Review and Metaregression Chest, May 1, 2006; 129(5): 1155 - 1166. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. D. Douketis, K. Arneklev, S. Z. Goldhaber, J. Spandorfer, F. Halperin, and J. Horrow Comparison of Bleeding in Patients With Nonvalvular Atrial Fibrillation Treated With Ximelagatran or Warfarin: Assessment of Incidence, Case-Fatality Rate, Time Course and Sites of Bleeding, and Risk Factors for Bleeding. Arch Intern Med, April 24, 2006; 166(8): 853 - 859. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber, and for the EMDEPU Study Group* Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism Ann Intern Med, February 7, 2006; 144(3): 157 - 164. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. C. Sox Better Care for Patients with Suspected Pulmonary Embolism Ann Intern Med, February 7, 2006; 144(3): 210 - 212. [Full Text] [PDF]
|
|
|
|
|
|
G. V Robinson Pulmonary embolism in hospital practice BMJ, January 21, 2006; 332(7534): 156 - 160. [Full Text] [PDF]
|
|
|
|
 |
|
 B. F. Gage Pharmacogenetics-Based Coumarin Therapy Hematology, January 1, 2006; 2006(1): 467 - 473. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Krakow and T. L. Ortel Continuing Anticoagulation Following Venous Thromboembolism JAMA, December 28, 2005; 294(24): 3088 - 3088. [Full Text] [PDF]
|
|
|
|
|
|
D. Ost Continuing Anticoagulation Following Venous Thromboembolism--Reply JAMA, December 28, 2005; 294(24): 3088 - 3089. [Full Text] [PDF]
|
|
|
|
 |
|
 R. A. Wilke, R. L. Berg, H. J. Vidaillet, M. D. Caldwell, J. K. Burmester, and M. A. Hillman Impact of Age, CYP2C9 Genotype and Concomitant Medication on the Rate of Rise for Prothrombin Time During the First 30 Days of Warfarin Therapy Clin. Med. Res., November 1, 2005; 3(4): 207 - 213. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Claes, F. Buntinx, J. Vijgen, J. Arnout, J. Vermylen, S. Fieuws, and H. Van Loon The Belgian Improvement Study on Oral Anticoagulation Therapy: a randomized clinical trial Eur. Heart J., October 2, 2005; 26(20): 2159 - 2165. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Aujesky, K. J. Smith, J. Cornuz, and M. S. Roberts Cost-Effectiveness of Low-Molecular-Weight Heparin for Treatment of Pulmonary Embolism Chest, September 1, 2005; 128(3): 1601 - 1610. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G. Hart, S. B. Tonarelli, and L. A. Pearce Avoiding Central Nervous System Bleeding During Antithrombotic Therapy: Recent Data and Ideas Stroke, July 1, 2005; 36(7): 1588 - 1593. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. A. Spinler, P. Dobesh, C. Macie, and J. Douketis Dose Capping Enoxaparin Is Unjustified and Denies Patients With Acute Coronary Syndromes a Potentially Effective Treatment Chest, June 1, 2005; 127(6): 2288 - 2290. [Full Text] [PDF]
|
|
|
|
|
|
P. S. Wells, D. R. Anderson, M. A. Rodger, M. A. Forgie, P. Florack, D. Touchie, B. Morrow, L. Gray, K. O'Rourke, G. Wells, et al. A Randomized Trial Comparing 2 Low-Molecular-Weight Heparins for the Outpatient Treatment of Deep Vein Thrombosis and Pulmonary Embolism Arch Intern Med, April 11, 2005; 165(7): 733 - 738. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. R. Zacharski, P. Prandoni, and M. Monreal Warfarin Versus Low-Molecular-Weight Heparin Therapy in Cancer Patients Oncologist, January 1, 2005; 10(1): 72 - 79. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. W. Rathbun, T. L. Whitsett, and G. E. Raskob Negative D-dimer Result To Exclude Recurrent Deep Venous Thrombosis: A Management Trial Ann Intern Med, December 7, 2004; 141(11): 839 - 845. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. W. Wakefield Secondary Prevention of Venous Thromboembolism with the Oral Direct Thrombin Inhibitor Ximelagatran Perspectives in Vascular Surgery and Endovascular Therapy, December 1, 2004; 16(4): 333 - 334. [Abstract] [PDF]
|
|
|
|
 |
|
 C. D Eckhoff, R. J DiDomenico, and N. L Shapiro Initiating Warfarin Therapy: 5 mg versus 10 mg Ann. Pharmacother., December 1, 2004; 38(12): 2115 - 2121. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. A. Smythe, W. E. Dager, and N. M. Patel Managing Complications of Anticoagulant Therapy Journal of Pharmacy Practice, October 1, 2004; 17(5): 327 - 346. [Abstract] [PDF]
|
|
|
|
|
|
M. N. Levine, G. Raskob, R. J. Beyth, C. Kearon, and S. Schulman Hemorrhagic Complications of Anticoagulant Treatment: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 287S - 310S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Kearon Long-Term Management of Patients After Venous Thromboembolism Circulation, August 31, 2004; 110(9_suppl_1): I-10 - I-18. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. M. Bates and J. S. Ginsberg Treatment of Deep-Vein Thrombosis N. Engl. J. Med., July 15, 2004; 351(3): 268 - 277. [Full Text] [PDF]
|
|
|
|
|
|
C. G. Elliott and L. J. Rubin Mars or Venus -- Is Sex a Risk Factor for Recurrent Venous Thromboembolism? N. Engl. J. Med., June 17, 2004; 350(25): 2614 - 2616. [Full Text] [PDF]
|
|
|
|
 |
|
 Learning More About Anticoagulant-Related Bleeding Risk in VTE Patients Journal Watch Cardiology, January 30, 2004; 2004(130): 3 - 3. [Full Text]
|
|
Article
