Risk of Major Hemorrhage for Outpatients Treated with Warfarin

Authors

  • Deborah A. McMahan MD,

    1. Richard L. Roudebush VAMC,
    2. Division of General Internal Medicine, Department of Medicine, Indiana University School of Medicine,
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  • David M. Smith MD,

    1. Richard L. Roudebush VAMC,
    2. Division of General Internal Medicine, Department of Medicine, Indiana University School of Medicine,
    3. Regenstrief Institute for Health Care, Indianapolis, IN.
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  • Mark A. Carey MS,

    1. Division of Biostatistics, Department of Medicine, Indiana University School of Medicine,
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  • Xiao Hua Zhou PhD

    1. Division of Biostatistics, Department of Medicine, Indiana University School of Medicine,
    2. Regenstrief Institute for Health Care, Indianapolis, IN.
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Dr. McMahan: Medical Group of Fort Wayne, Lutheran Medical Park, 7836 W. Jefferson Blvd., Fort Wayne, IN 46804.

Abstract

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.

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