8/28/2017 Risk factors for bleeding with anticoagulant therapy - UpToDate

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Risk factors for bleeding with anticoagulant therapy and estimated risk of
major bleeding in low, moderate, and high risk categories

Risk factors*
Age >65 years

Age >75 years

Previous bleeding

Cancer

Metastatic cancer

Renal failure

Liver failure

Thrombocytopenia

Previous stroke

Diabetes

Anemia

Antiplatelet therapy

Poor anticoagulant control

Comorbidity and reduced functional capacity

Recent surgery ¶

Frequent falls

Alcohol abuse

Estimated absolute risk of major bleeding (%)

Categorization of risk Low risk ◊ (0 risk Moderate risk ◊ (1 High risk ◊ (≥2 risk
of bleeding Δ factors) risk factor) factors)

Anticoagulation 0 to 3 months §

Baseline risk (%) 0.6 1.2 4.8

Increased risk (%) 1 2 8

Total risk (%) 1.6 § 3.2 12.8 ¥

Anticoagulation after first 3 months ‡

Baseline risk 0.3 † 0.6 ≥2.5

(%/years)

Increased risk 0.5 1 ≥4

(%/years)

Total risk 0.8** 1.6** ≥6.5

(%/years)

* The increase in bleeding associated with a risk factor will vary with (1) severity of the risk factor (eg, location
and extent of metastatic disease, platelet count), (2) temporal relationships (eg, interval from surgery or a
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8/28/2017 Risk factors for bleeding with anticoagulant therapy - UpToDate

previous bleeding episode), and (3) how effectively a previous cause of bleeding was corrected (eg, upper-GI
bleeding).
¶ Important for parenteral anticoagulation (eg, first 10 days), but less important for long-term or extended
anticoagulation.
Δ Although there is evidence that risk of bleeding increases with the prevalence of risk factors, this
categorization scheme has not been validated. Furthermore, a single risk factor, when severe, will result in a high
risk of bleeding (eg, major surgery within the past two days, severe thrombocytopenia).
◊ Compared with low risk patients, moderate risk patients are assumed to have a twofold risk and high risk
patients an eightfold risk of major bleeding.
§ The 1.6% corresponds to the average of major bleeding with initial UFH or LMWH therapy followed by VKA
therapy. We estimated baseline risk by assuming a 2.6 relative risk of major bleeding with anticoagulation (refer
to footnote ‡).
¥ Consistent with frequency of major bleeding observed by Hull et al in high risk patients [1].
‡ We estimate that anticoagulation is associated with a 2.6-fold increase in major bleeding based on comparison
of extended anticoagulation with no extended anticoagulation. The relative risk of major bleeding during the first
three months of therapy may be greater than during extended VKA therapy because (1) the intensity of
anticoagulation with initial parenteral therapy may be greater than with VKA therapy; (2) anticoagulant control
will be less stable during the first three months; and (3) predispositions to anticoagulant-induced bleeding may
be uncovered during the first three months of therapy. However, studies of patients with acute coronary
syndromes do not suggest a ≥2.6 relative risk of major bleeding with parenteral anticoagulation (eg, UFH or
LMWH) compared with control.
† Our estimated baseline risk of major bleeding for low risk patients (and adjusted up for moderate and high risk
groups as per footnote ◊).
** Consistent with frequency of major bleeding during prospective studies of extended anticoagulation for VTE.

Reference:
1. Hull RD, Raskob GE, Rosenbloom D, et al. Heparin for 5 days as compared with 10 days in the initial
treatment of proximal venous thrombosis. N Engl J Med 1990; 322:1260.
Reproduced from: Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines. Chest 2012; 141:e419S. Table used with the permission of Elsevier Inc. All rights reserved.

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