Decision to restart anticoagulation after a bleeding event

Feature	Characteristics that favor restarting the anticoagulant	Characteristics that favor not restarting the anticoagulant
Risk of thromboembolism of the anticoagulant is not restarted
Strength of indication for anticoagulation	A prior thromboembolic event, especially arterial, may indicate a greater thromboembolic risk and greater benefit of restarting the anticoagulant.	Use of anticoagulation for primary prophylaxis, especially for VTE during a transient period of increased risk, may indicate less benefit of restarting the anticoagulant.
Persistence of thromboembolic risk	Persistent thromboembolic risk may indicate a greater benefit of restarting the anticoagulant. Examples: Prosthetic heart valve Atrial fibrillation High-risk thrombophilia (eg, APS, hereditary AT deficiency)	Transient thromboembolic risk that has been eliminated may indicate less benefit of restarting the anticoagulant. Examples: Provoked VTE PNH treated with anti-complement therapy or HCT
Risk of bleeding if the anticoagulant is restarted
Type of bleeding	Bleeding in a less life-threatening site (eg, epistaxis, dental) may indicate a lower risk of life-threatening bleeding from restarting the anticoagulant.	Intracerebral bleeding, especially lobar or with evidence of microbleeds on CNS imaging, indicate a greater risk of serious rebleeding.
Persistence of bleeding risk	A bleeding source that has been eliminated indicates a lower risk of rebleeding. Examples: CNS bleeding in the setting of severe HTN that has been treated Thrombocytopenia due to ITP that has been treated successfully	A persistent source of bleeding may indicate a persistent increased risk of rebleeding. Examples: Multiple gastrointestinal telangiectasias CNS microbleeds
Anticoagulant-related issues	Bleeding with a supratherapeutic INR due to a medication interaction may be addressed by switching to a DOAC.	Bleeding with prophylactic-dose anticoagulation or a concurrent bleeding disorder may indicate a higher risk of rebleeding.
Patient values and preferences
Concern about recurrent events	Patients who place a higher value on avoiding recurrent thromboembolism may choose to restart the anticoagulant.	Patients who place a higher value on avoiding recurrent bleeding may choose not to restart the anticoagulant.

Clinical judgment is required to make an individualized decision that weighs all of the relevant factors for each specific patient. Consultation with a specialist with expertise in anticoagulation may be appropriate. Refer to UpToDate for thromboembolic risks according to the underlying condition(s); risks of rebleeding according to the initial bleeding site(s); choice of anticoagulant; and optimal time to reinitiate anticoagulation.

VTE: venous thromboembolism; APS: antiphospholipid syndrome; AT: antithrombin; HCT: hematopoietic cell transplantation; CNS: central nervous system; HTN: hypertension; ITP: immune thrombocytopenia; INR: international normalized ratio; DOAC: direct oral anticoagulant.

Graphic 111237 Version 1.0

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Decision to restart anticoagulation after a bleeding event