Assessment of in-hospital mortality in patients with upper gastrointestinal bleeding on antithrombotic treatment

Antithrombotic agents have been linked to a higher risk of gastrointestinal bleeding, but their impact on in-hospital mortality remains controversial, with observational studies variably reporting increased, unchanged, or reduced mortality. This systematic review and meta-analysis assessed the influence of antithrombotic on in-hospital mortality in patients with upper gastrointestinal bleeding.

Following Cochrane and PRISMA recommendations, we included observational studies of adult patients admitted for acute upper gastrointestinal bleeding comparing in-hospital all-cause mortality between those receiving antithrombotic therapy (antiplatelets, anticoagulants, or both) at admission and those not. Studies in which antithrombotic therapy was initiated de novo during admission were excluded. Seventeen studies published between 2004 and 2025 were included (18,712 patients; 6,558 on antithrombotic therapy at presentation, 12,154 not). The primary outcome was in-hospital all-cause mortality, extended to 30-day mortality where in-hospital data were not separately reported.

Antithrombotic therapy at admission was not associated with increased in-hospital mortality, with a trend towards a protective association (OR 0.79; 95% CI 0.62-1.01). Subgroup analyses showed a significant protective effect for antiplatelet agents (OR 0.67; 95% CI 0.47-0.95), no significant influence for anticoagulants (OR 1.09; 95% CI 0.72-1.64), and significantly lower mortality in studies restricted to non-variceal bleeding (OR 0.60; 95% CI 0.41-0.87).

Antithrombotic therapy at admission was not associated with increased in-hospital mortality in acute upper gastrointestinal bleeding, with a protective trend overall and significant protection in antiplatelet users and non-variceal bleeding. Given the observational design, findings should be interpreted as a prognostic association supporting standard management.