Restarting Anticoagulation After Bleeding

Restart anticoagulation when the benefit from preventing clots outweighs the risk of rebleeding, once the cause of bleeding has been found and treated. For most patients with a strong indication, restarting reduces death and stroke, and prolonged withholding often causes harm.

Weigh the decision. Clot risk (CHA2DS2-VASc, recent venous thromboembolism, mechanical valve) against bleeding site, severity, whether the cause was fixed, and modifiable risks (blood pressure, alcohol, antiplatelet and non-steroidal drugs, anaemia, kidney function).

• Gastrointestinal bleeding: restart at 7 days after haemostasis (range 7 to 14 days) in most patients with atrial fibrillation or recent venous thromboembolism, earlier for mechanical valves, once the source has been treated and haemoglobin is stable.
• Intracranial haemorrhage: individual decision with neurology, usually 4 to 8 weeks after the event for atrial fibrillation (earlier, 1 to 2 weeks, for mechanical mitral valves under specialist direction), once blood pressure is controlled and imaging is stable.
• Venous thromboembolism within the last 3 months with an absolute contraindication: consider a retrievable inferior vena cava filter and restart as soon as bleeding allows.
• Minor bleeding: continue, or omit 1 to 2 doses, and treat the cause.
• Choice of agent after gastrointestinal bleeding: apixaban is preferred; avoid rivaroxaban and high-dose dabigatran. Do not use reduced doses outside the label criteria.
• Warfarin restart: usual dose without a loading dose, with INR in 3 to 5 days and a target at the lower end of the range for the indication.
• When long-term anticoagulation is contraindicated in atrial fibrillation: left atrial appendage closure should be considered.

Reduce rebleeding risk. Treat the source (endoscopic therapy, Helicobacter pylori eradication), proton pump inhibitor (pantoprazole 40 mg once daily) for gastrointestinal bleeding history, blood pressure under 130/80 mmHg, stop non-steroidal drugs and unneeded antiplatelet drugs, reduce alcohol, and treat anaemia.

Kidney impairment. Choose agents and doses for clearance, and recheck before restarting.

Cancer. Restart after tumour bleeding control; apixaban or low molecular weight heparin preferred.

Older adults. Frailty and falls alone do not justify withholding anticoagulation; address falls risk.

Special groups. Pregnant women restart heparin when obstetric bleeding is controlled. In East Africa, limited endoscopy may delay source control, and anticoagulation restart should follow stabilisation and agreement of the treating team.

Monitoring. Haemoglobin at 1 week, 1 month and then every 3 months for the first year, with creatinine, INR where relevant, and blood pressure.

Referral and escalation. Seek haematology, gastroenterology, neurology or cardiology advice for intracranial haemorrhage, recurrent bleeding, mechanical valves and unresolved sources.

Stopping. Permanent discontinuation is reserved for recurrent life-threatening bleeding with no correctable cause, and the decision should be shared with the patient and documented.