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Case Study: Stroke Risk and Active Bleeding

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A 74 -year-old man with atrial fibrillation presents with Hemoccult-positive stools. He is on warfarin but has been nonadherent, and is taking multiple drugs for diabetes and hypertension. He has mild mitral regurgitation and an ejection fraction of 32% and has had episodes of transient cerebral ischemia in the past.

Clinical Questions

1. What should be done acutely for this patient’s hemoccult-positive stools in terms of anticoagulation?
2. What is this patient’s risk of cerebral thromboembolism?
3. What is the risk of future bleeding?
4. What is the best anticoagulant for this patient going forward?

Acute Management

This patient presents a common clinical conundrum. He has a high risk of recurrent thromboembolic events yet presents with active bleeding. He also has multiple comorbid conditions, the management of which is made more difficult because of poor compliance.

The first step is to assess the danger and magnitude of acute bleeding, since his most urgent issue is the possibility of life-threatening hemorrhage. His hemoglobin level should be checked, as well as his mean corpuscular volume. The latter may give insight into the chronicity of his bleeding; microcytic anemia would suggest iron deficiency and a more chronic low-grade bleed.

The INR should be assessed and, if elevated, reversed with vitamin K. Oral vitamin K is usually acceptable except in cases of extremely elevated INR or life-threatening bleeding. This patient’s presentation with occult bleeding would be best treated with oral vitamin K to normalize the INR. Intravenous vitamin K has been associated with anaphylactic reactions related to the diluent and should be used only in more serious cases. Intramuscular vitamin K is no more effective than oral, as its absorption is unpredictable. If anticoagulation is to be used in the near future, the dose of vitamin K should be limited to 2.5 to 5 mg; doses in excess of 10 mg will significantly prolong the time required to achieve a therapeutic INR once warfarin is restarted.

The etiology of hemoccult-positive stools should be sought with endoscopic examination. If a discrete lesion is found and treated, the future risk of bleeding diminshes. Often no source of bleeding is located or diffuse gastropathy or colonic arteriovenous malformations are seen. In these instances, the risk of bleeding will be more unpredictable. Inhibition of gastric acid secretion with a proton pump inhibitor may be useful for upper GI bleeding.

Stroke Risk

This patient’s risk of thromboembolism is significant. According to the CHA2DS2-VASc scheme, his risk of stroke is nearly 5% per year. His competing risk of bleeding is nearly 4% per year according to the HAS-BLED system. While these risks are similar, most bleeding is not life-threatening and can be managed, whereas the ramifications of stroke can be devastating. The risks of medical noncompliance should again be discussed with the patient.

Bleeding Risk

Like many patients, this patient has not been taking warfarin as prescribed. The most common reason for noncompliance is the inconvenience of frequent INR checks. INR checks can be more convenient if fingersticks are used instead of venipuncture. Home monitoring can be performed, with the patient calling the physician for adjustment of warfarin dosing.

Patients should not be told that they cannot eat vitamin K-rich foods. As long as they consume relatively constant amounts regularly, their INRs should not be significantly affected. The cumulative warfarin dose may need to be higher, but they should not abstain from these foods.

Another reason for patient noncompliance with warfarin is widespread misconception of its dangers. Patients will often know of a case in which someone had an adverse event, without any knowledge of other details regarding the incident. Occasionally, patients complain that warfarin is “rat poison.” These patients need to be educated, often at every visit, regarding the difference between therapeutic and toxic doses of warfarin.

Better Anitcoagulation

Switching from warfarin to dabigatran, which does not require titration, may improve compliance. However, compliance with warfarin is easily ascertained by checking an INR; no similar testing for dabigatran is available or even required. A drawback of dabigatran is the lack of antidote in the event of life-threatening bleeding.