Clinical management and outcome of major bleeding in patients on treatment with vitamin K antagonists

• Real-life study with 544 patients hospitalized for major bleeding while on VKAs1
• PCCs2 are used in 50% or less of VKAs-associated major bleeding and ICH.3
• The risk for death at 30 days was substantial (about 20%).
• Age over 85 years, low GCS score and shock were associated with death at 30 days.
• Higher incidence of ischemic stroke and of acute coronary syndrome.

BackgroundThe optimal management of major bleeding associated with vitamin K antagonists remains unclear.ObjectivesThe aim of the study was to assess the determinants of outcome of vitamin K antagonists-associated major bleeding and the outcome of bleeding in relation with the therapeutic management.MethodsPatients hospitalized for major bleeding while on vitamin K antagonists were included in a prospective, cohort study. Major bleeding was defined according to the criteria of the International Society of Thrombosis Haemostasis. The primary study outcome was death at 30 days from major bleeding.Results544 patients were included in this study, of which 282 with intracranial hemorrhage. Prothrombin complex concentrates were used in 51% and in 23% of patients with intracranial hemorrhage or non-intracranial major bleeding, respectively (p < 0.001); fresh frozen plasma was used in 7% and in 17% of patients with intracranial hemorrhage or non-intracranial major bleeding (p < 0.001).Death at 30 days occurred in 100 patients (18%), 72 patients with intracranial hemorrhage and 28 patients with non-intracranial major bleeding. Age over 85 years, low Glasgow Coma Scale score and shock were independent predictors of death at 30 days. Invasive procedures were associated with decreased risk of death.ConclusionsAmong the patients hospitalized for major bleeding while on vitamin K antagonists, the risk for death is substantial. The risk for death is associated with the clinical severity of major bleeding as assessed by the GCS score and by the presence of shock more than with the initial localization of major bleeding (ICH vs other sites).