Study objectives: To identify the risk of
thromboembolism after withholding or reversing the effect of warfarin
therapy following a major hemorrhage.
Retrospective medical record review.
patients with prosthetic heart valves receiving warfarin were
hospitalized for major hemorrhage from 1990 to 1997. The mean ± SD
age was 61 ± 11 years (15 men and 13 women). Twenty patients
had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic
valves, 2 patients had Starr Edwards valves, and 2 patients had
Bjork-Shiley valves. Valves were in the mitral position in 12 patients,
the aortic position in 12 patients, and both mitral and aortic
positions in 4 patients. The average interval from valve surgery to
index bleeding was 7 years. Twenty-five patients had GI or
retroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage,
and 1 patient had a subdural hematoma.
Vitamin K was administered to five patients and fresh frozen plasma was
given to seven patients to reverse anticoagulation. The mean
duration of anticoagulation withholding was 15 ± 4 days.
Measurements and results: None of the patients had
thromboembolic complications. There were four in-hospital deaths.
Twenty-two of the 24 hospital survivors resumed warfarin therapy at
hospital discharge. At 6-month follow-up, 10 of 19 patients remaining
on warfarin therapy had recurrent GI bleeding.
Conclusions: Thromboembolic risk is low in prosthetic heart
valve patients hospitalized with major hemorrhage when their warfarin
therapy is reversed or withheld. Recurrent bleeding within 6 months of
the resumption of anticoagulation is common, and aggressive treatment
of the bleeding source and the risk-benefit ratio of continued
anticoagulation need to be considered.