Are major bleeding events from falls more likely in patients on warfarin?

Roger Garvin, Ellen Howard

Research output: Contribution to journalReview article

7 Scopus citations

Abstract

Increased risk of falling is often given as a reason for not recommending anticoagulation for atrial fibrillation in frail or elderly patients. However, no studies directly address the risk for major bleeding in anticoagulated patients who fall. One retrospective study of 2633 falls in 1861 hospital inpatients compared the rate of major hemorrhage between those taking anticoagulation therapy with those not taking it. Major hemorrhage was defined as bruising or cuts requiring immediate attention from a physician. The rate of major hemorrhage was 6.2% for patients taking warfarin and 11.3% for patients receiving no therapy. Patients with INR=2-3 had a major hemorrhage rate of 6.9% compared with 10.1% for those with INR <1.3. Criteria for using warfarin were not reported; there may have been selection bias in favor of prescribing warfarin for patients judged less likely to fall. A smaller study of 400 consecutive falls among 264 post-stroke patients in a rehab hospital found no difference in minor injury rates (19% vs 18%, NS); no major hemorrhagic complications were seen following 131 falls in the anticoagulation group (93 patients) and 269 falls in the group not on anticoagulation (175 patients). Patients on anticoagulation had an average protime of 16.1 seconds (INR was not reported). The calculated risk of major hemorrhage in an anticoagulated patient from a single fall was 2.3% or less. The study was limited because most falls were from a seated position or partially controlled by an attendant; few patients fell from a standing position. Another study presented a Markov decision analysis (comparison of risk estimates in separate disease states) evaluating whether risk from falls should influence choice of anticoagulation therapy in elderly patients with atrial fibrillation. Risk of intracranial bleeding from falls was calculated from prospective cohort studies and retrospective case series from anticoagulation clinics, and stroke reduction benefit from anticoagulation was taken from a meta-analysis of 5 randomized controlled trials. Sensitivity analyses were performed to test the results of the decision analysis. The calculated risk of subdural hematoma from falling was such that a patient with a 5% annual stroke risk from atrial fibrillation would need to fall 295 times in a year for the fall risk to outweigh the stroke reduction benefit of warfarin.

Original languageEnglish (US)
Pages (from-to)159-160
Number of pages2
JournalJournal of Family Practice
Volume55
Issue number2
StatePublished - Feb 1 2006

ASJC Scopus subject areas

  • Family Practice

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