Bleeding Events During Anticoagulation After Acute Pulmonary Embolism: Real-Life Experience

Background and Objectives: Pulmonary embolism (PE) is a potentially life-threatening disease. Although anticoagulant therapy reduces the risk of recurrent PE, it increases the risk of bleeding complications. Therefore, decisions regarding treatment duration are made individually, balancing recurrent venous thromboembolism (VTE) and bleeding risk. However, the optimal duration of anticoagulant therapy after acute PE remains challenging in clinical practice. The aim of this study was to evaluate bleeding rates during anticoagulant therapy and identify possible bleeding risk factors. Materials and Methods: A prospective study was conducted at a tertiary pulmonology center within a university hospital. A total of 201 consecutive patients (50.2% male) after a first episode of acute PE were included. Bleeding complications during anticoagulant therapy were recorded at follow-up visits and classified as major and minor. Potential risk factors associated with increased bleeding risk during anticoagulant therapy were analyzed. Results: During follow-up, 35 patients (17.4%) experienced bleeding complications, including 5 (2.5%) major and 30 (14.9%) minor bleeding events. Recurrent bleeding occurred in 6 patients (17.1%). The median time to first bleeding event was 3 months (IQR 1-7.5). Patients receiving extended anticoagulation beyond 6 months experienced more frequent bleeding events, predominantly non-major bleeding; however, bleeding incidence per patient-year did not differ significantly according to treatment duration (IRR 1.26, 95% CI 0.63-2.49). Other factors associated with increased bleeding risk included prior bleeding history, PE with no identifiable provoking factor, elevated B-type natriuretic peptide (BNP) levels and high early PE mortality risk at hospitalization. Conclusions: Bleeding during anticoagulant therapy after PE was frequent, but mostly non-major. More bleeding events (non-major) were observed among patients receiving longer anticoagulation, although this difference was attenuated after adjustment for anticoagulation exposure time. Prior bleeding, unprovoked PE, and markers of more severe PE were associated with increased bleeding risk. Findings suggest that prolonged anticoagulation is safe when clinically indicated, although regular reassessment of bleeding risk remains important.