Antithrombotic Therapy for VTE Disease

Treatment Table 2. Risk Factors for Bleeding With Anticoagulant Therapy and Estimated Risk of Major Bleeding in Low-, Moderate-, and High-Risk Categories Risk Factorsa Age > 65 y Previous bleeding Cancer Metastatic cancer Renal failure Categorization of Risk of Bleedingc Liver failure Thrombocytopenia Previous stroke Diabetes Anemia Antiplatelet therapy Estimated Absolute Risk of Major Bleeding, % Low Riskd (0 Risk Factors) Anticoagulation 0-3 moe Baseline risk (%) Increased risk (%) Total risk (%) 0.6 1.0 1.6e Anticoagulation aſter first 3 mog Baseline risk (%/y) 0.3h Increased risk (%/y) 0.5 Total risk (%/y) a b c d e 0.8i Moderate Riskd (1 Risk Factor) 1.2 2.0 3.2 0.6 1.0 1.6i High Riskd (≥ 2 Risk Factors) 4.8 8.0 12.8f ≥ 2.5 ≥ 4.0 ≥ 6.5 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 previous bleeding episode), and (3) how effectively a previous cause of bleeding was corrected (eg, upper-GI bleeding). 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 2 d, severe thrombocytopenia). Important for parenteral anticoagulation (eg, first 10 d) but less important for long-term or extended anticoagulation. f Consistent with frequency of major bleeding observed in high-risk patients. g The 1.6% corresponds to the average of major bleeding with initial UFH or LMWH therapy followed by VKA therapy. Baseline risk was estimated by assuming a 2.6 relative risk of major bleeding with anticoagulation (footnote g in this table). 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. h Anticoagulation is associated with an estimate 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 3 mo 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 3 mo; and (3) predispositions to anticoagulant-induced bleeding may be uncovered during the first 3 mo 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. 10 i Consistent with frequency of major bleeding during prospective studies of extended anticoagulation. Our estimated baseline risk of major bleeding for low-risk patients (and adjusted up for moderate- and high-risk groups as per footnote d in this table). Poor anticoagulant control Comorbidity and reduced functional capacity Recent surgeryb Frequent falls Alcohol abuse

• Cover