Restarting of anticoagulation in patients with atrial fibrillation after major bleeding: A meta-analysis

What is known and objective Benefits and risks of restarting oral anticoagulants (OACs) in patients with atrial fibrillation after major bleeding remain unknown. A meta-analysis was performed to systematically evaluate the effects of restarting OACs on thromboembolism and bleeding events in these patients. Methods Relevant studies were obtained via systematically search of PubMed, Cochrane's Library and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses according to the types of OACs and sites of reoccurred bleeding were performed. Results and discussion Seven retrospective cohort studies with 12 197 patients were included. Restarting OACs was associated with reduced risk of thromboembolism (risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.42-0.87;P = .007). Subgroup analyses showed that restarting warfarin reduced risk of thromboembolism (RR = 0.59,P = .05), but not for the new oral anticoagulants (NOACs; RR = 1.37,P = .18). Moreover, restarting OACs did not affect the risk of reoccurred bleeding (RR = 0.98, 95% CI: 0.74-1.30,P = .89). Similar results were found for warfarin and NOACs, as well as for reoccurred intracranial haemorrhage or gastrointestinal bleeding. In addition, restarting OACs was associated with significantly reduced risk of all-cause mortality (RR = 0.42, 95% CI: 0.33-0.52,P < .001). Consistent results were found for warfarin and NOACs. What is new and conclusion Restarting of OACs after major bleeding in AF patients may be associated with reduced risks of thromboembolism and mortality without increasing reoccurrence of bleeding.