Clinical Studies
Major bleeding after hospitalization for deep-venous thrombosis

https://doi.org/10.1016/S0002-9343(99)00267-3Get rights and content

Abstract

PURPOSE: Most studies of oral anticoagulant-related bleeding have analyzed the incidence of adverse outcomes among patients with a variety of different conditions and without any comparison with a control group. We determined the incidence, time course, and risk factors associated with major bleeding after hospital discharge among patients with deep-vein thrombosis, and estimated the excess risk of bleeding associated with oral anticoagulant therapy.

METHODS: A total of 22,000 adults were hospitalized in California for 3 or more days with a diagnosis of deep-venous thrombosis between January 1, 1992, and September 30, 1994. We determined the risk factors associated with readmission for bleeding. We compared the incidence of readmission for bleeding with comparison cohorts of patients with pneumonia or cellulitis who were matched for age, gender, race, and length of hospital stay.

RESULTS: Of 21,250 patients with deep-venous thrombosis who were discharged without bleeding, 1.4% were readmitted for bleeding within 91 days; the rate was 2.7 times greater in the first 30 days than in the next 61 days. Risk factors for bleeding included hospitalization with gastrointestinal bleeding during the previous 18 months (relative hazard [RH] = 2.6, 95% confidence interval [CI]: 1.6 to 4.1), hospitalization with an alcohol-related diagnosis during the previous 18 months (RH = 2.6, 95% CI: 1.4 to 4.8), chronic renal disease (RH = 2.4, 95% CI: 1.4 to 4.2), female gender (RH = 1.7, 95% CI: 1.3 to 2.2), presence of a malignancy (RH = 1.6, 95% CI: 1.2 to 2.2), nonwhite race (RH = 1.6, 95% CI: 1.2 to 2.1), and age over 65 years (RH = 1.3, 95% CI: 1.0 to 1.7). Significantly more women (n = 40) had intracranial bleeding than men (n = 18, P = 0.02). In the comparison cohorts, the incidence of readmission for bleeding within 3 months of discharge was 0.7%, and the relative risk (RR) of readmission was greater in those with deep-venous thrombosis than in those with cellulitis (RR = 2.0, 95% CI: 1.6 to 2.5) or pneumonia (RR = 2.0, 95% CI: 1.7 to 2.5).

CONCLUSIONS: The incidence of rehospitalization for bleeding was greatest in the first 30 days after discharge, and was approximately twice that seen in patients hospitalized for cellulitis or pneumonia. Further studies are needed to determine why women and nonwhite patients are at increased risk for anticoagulant-related bleeding.

Section snippets

Discharge cohort

The Office of Statewide Health Planning and Development requires that all non-federal, licensed hospitals submit information about each inpatient after discharge, including demographic data, the principal diagnosis (“the condition chiefly responsible for occasioning the admission”), up to 24 secondary diagnoses, a principal procedure, and up to 20 secondary procedures. All procedures and diagnoses are coded using the International Classification of Diseases, 9th Revision, Clinical Modification

Results

Between January 1, 1992, and September 30, 1994, exactly 22,000 patients with venous thrombosis met the entry criteria (Figure 1). The demographic and clinical characteristics of these patients are included in Table 1. During the initial hospitalization, 646 (2.9%) of the 22,000 patients bled, 29 (4.4%) of whom died. Because many of the patients who bled during the initial hospitalization may not have been treated as outpatients with warfarin, they were not included in the analysis of our

Discussion

The decision to begin anticoagulation therapy in a patient with venous thrombosis requires weighing the risk of major bleeding against the benefits of treatment (19). That decision is usually not difficult, because the risk of fatal pulmonary embolism is high if treatment is withheld (20). Nevertheless, there are certain clinical situations, such as calf-vein thrombosis, when anticoagulant treatment is not mandatory, and it is acceptable to follow these patients using serial venous ultrasound

References (33)

  • M.N. Levine et al.

    Hemorrhagic complications of anticoagulant therapy

    Semin Thromb Hemost

    (1986)
  • M.M. Koopman et al.

    Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group

    NEJM

    (1996)
  • M. Levine et al.

    A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis

    NEJM

    (1996)
  • A.G. van den Belt et al.

    Replacing inpatient care by outpatient care in the treatment of deep venous thrombosis—an economic evaluation. TASMAN Study Group

    Thromb Haemost

    (1998)
  • Low-molecular-weight heparin in the treatment of patients with venous thromboembolism

    NEJM

    (1997)
  • G. Simonneau et al.

    A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group

    NEJM

    (1997)
  • Cited by (0)

    Dr. Beyth is a recipient of a National Institute of Aging Clinical Investigator Award (K08-AG00712-01A).

    View full text