Balancing Benefits/Risks of Bleed in VTE

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Today we discussed an unfortunate complex case of pulmonary embolism with recent ICH. How should we balance the benefits and risks of ICH in patients with VTE? 

1. What is the risk of ICH depending on the anticoagulant? See the table below which is based on data from a large number of studies from the 90s and older (Stroke. 1995; 26: 1471). In general, aspirin doubles the risk in elderly patients, and OAC increases the annual risk by 10 times. This is not to mention

2. What is the risk of death with PE with and without anticoagulation? Contemporary data to answer this question is not available in a randomized fashion, so most data are observational and likely heavily swayed by comorbid conditions which would influence the decision to anticoagulate. In general, overall mortality in this population can be as high as 30% over 5 years. Over the short term, this is mainly due to recurrence of VTE and shock. Over the long term, death is usually due to something else (only ~5% are due to PE itself). Treatment reduces this risk of death by 50-70% (Chest 2012; 141(2): e419S).

3. When should anticoagulation be restarted after an ICH? A very challenging question, and one without much data to inform our approach. The minutiae of this question is discussed nicely in a cleveland clinic review from 2010 (Cleve Clin J Med 2010; 77(11): 791). AHA Guidelines for the resumption of anticoagulation after an ICU recommend 10 days off anticoagulation, then resumption on day 10 post-bleed (Stroke. 2007 Jun; 38(6):2001-23.).