Endoscopy 2019; 51(04): S61
DOI: 10.1055/s-0039-1681349
ESGE Days 2019 oral presentations
Friday, April 5, 2019 14:30 – 16:30: GI bleeding Club C
Georg Thieme Verlag KG Stuttgart · New York

OPTIMAL TIMING OF RESUMPTION OF WARFARIN AND CLINICAL OUTCOMES AFTER GASTROINTESTINAL BLEEDING IN PATIENTS WITH ATRIAL FIBRILLATION

D Lee
1   Department of Internal Medicine, Sejong General Hospital, Bu-Cheon, Korea, Republic of
,
JU Lim
1   Department of Internal Medicine, Sejong General Hospital, Bu-Cheon, Korea, Republic of
,
BJ Kim
2   Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea, Republic of
,
SJ Kim
3   Department of Gastroenterology Nabeul, Je-Saeng Hospital, Seong Nam, Korea, Republic of
,
JH Kim
4   Department of Neurology, Ilsan Hospital, National Health Insurance Service, Goyang-shi, Korea, Republic of
,
TH Kim
1   Department of Internal Medicine, Sejong General Hospital, Bu-Cheon, Korea, Republic of
› Author Affiliations
Further Information

Publication History

Publication Date:
18 March 2019 (online)

Also available at
 
 

    Aims:

    According to the 2018 official statement of the Asian Pacific Association of Gastroenterology about management of patients on warfarin, early resumption can be considered, once primary endoscopic hemostasis was done well.

    Methods:

    We reviewed charts of 250consecutive AF patients with objectively verified GI bleeding (GIB) by endoscopy from 2011 to 2017 at 3tertiary centers. We assessed the risk of thromboembolism, all-cause mortality, recurrent GIB in the 3groups stratified by interruption periods of warfarin.

    Tab. 1:

    Hazard Ratios stratified by duration of interruption of warfarin for various outcomes

    ≤3 days (n = 68)

    4 – 6 days (n = 127)

    ≥7 days (n = 55)

    recurrent GIB at 90 days events, incidence rates per 100 person-year (95% CI), HR (95% CI), p value

    7, 44.61 (17.93 – 91.92), 1.98 (0.47 – 8.28), 0.35

    5, 16.72 (5.41 – 39.07), 1.31 (0.36 – 4.82), 0.68

    3, 22.92 (4.74 – 66.93), reference

    thromboembolism at 1 year events, incidence rates per 100 person-year (95% CI), HR (95% CI), p value

    2, 3.52 (0.43 – 12.81), 0.37 (0.08 – 1.43), 0.23

    5, 4.14 (1.31 – 9.63), 0.43 (0.13 – 1.40), 0.16

    6, 9.82 (3.63 – 21.31), reference

    mortality at 1 year events, incidence rates per 100 person-year (95% CI), HR (95% CI), p value

    5, 8.92 (2.88 – 20.69), 0.62 (0.06 – 7.0), 0.70

    5, 4.10 (1.32 – 9.64), 0.58 (0.08 – 4.26), 0.59

    3, 4.92 (1.01 – 14.30), reference

    Results:

    250 patients resumed warfarin after warfarin related GIB with a median of 5days (IQR 3 – 6). Table demonstrated the incidence rates and HRs of patients stratified by days of interruption of warfarin. The risk for recurrent GIB was not different significantly between the patients with restarting warfarin within 3days versus after 3days (HR 2.96, 95% confidence interval 0.60 – 14.58, p = 0.18). Restarting warfarin after 7 days increased the risk of thromboembolism by more than a factor of 3.61 (HR 3.61; 95% CI, 1.12 – 10.74; P = 0.03), whereas the risk of recurrent GIB event was reduced insignificantly by 44% (HR 0.56; 95% CI, 0.18 – 1.76 0.23 – 3.08; P = 0.32). Except for patients with a higher risk of thromboembolism which were defined as patients with valvular AF or patients who have scored 5 or more of CHADSVASC score (n = 42), restarting warfarin after 7days increased the risk of thromboembolism by more than a factor of 3.35 (HR 3.35; 95% CI, 0.95 – 11.88; P = 0.06), whereas the risk of recurrent GIB event was reduced insignificantly by 64% (HR 0.36; 95% CI, 0.09 – 1.49; P = 0.16).

    Conclusions:

    Late resumption of warfarin should be reconsidered in AF patients with GIB and high thromboembolic risk.


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