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Risk of major hemorrhage for outpatients treated with warfarin
D A McMahan1, D M Smith, M A Carey
1Richard L. Roudebush VAMC, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
Objective:
To determine the incidence of major hemorrhage among outpatients started on warfarin therapy after the recommendation in 1986 for reduced-intensity anticoagulation therapy was made, and to identify baseline patient characteristics that predict those patients who will have a major hemorrhage.
Design:
Retrospective cohort study.
Setting:
A university-affiliated Veterans Affairs Medical Center.
Patients:
Five hundred seventy-nine patients who were discharged from the hospital after being started on warfarin therapy.
Measurements And Main Results:
The primary outcome variable was major hemorrhage. In our cohort of 579 patients, there were 40 first-time major hemorrhages with only one fatal bleed. The cumulative incidence was 7% at 1 year. The average monthly incidence of major hemorrhage was 0.82% during the first 3 months of treatment and decreased to 0.36% thereafter. Three independent predictors of major hemorrhage were identified: a history of alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed. Age, comorbidities, medications known to influence prothrombin levels, and baseline laboratory values were not associated with major hemorrhage.
Conclusions:
The incidence of major hemorrhage in this population of outpatients treated with warfarin was lower than previous estimates of major hemorrhage measured before the recommendation for reduced-intensity anticoagulation therapy was made, but still higher than estimates reported from clinical trials. Alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed were associated with increased risk of major hemorrhage.