Tableau 1:
Facteurs de risque d’hémorragie sous traitement anticoagulant et risque estimé d’hémorragie sévère dans les catégories risque faible, moyen et élevé. Copyright © 2021 American College of Chest Physicians. Reprinted from Kearon, C. (2016). Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST. 149(2):315–352.
Risk Factors for Bleeding with Anticoagulant Therapy and Estimated Risk of Major Bleeding in Low-, Moderate-, and High-Risk categoriesa |
Risk Factorsb |
Age >65 y184-193 |
Age >75 y184-188,190,192,194-202 |
Previous bleeding185,191-193,198,201-204 |
Cancer187,191,195,198,205 |
Metastatic cancer181,204 |
Renal failure185,191-193,196,199,201,206 |
Liver failure186,189,195,196 |
Thrombocytopenia195,204 |
Previous stroke185,192,195,207 |
Diabetes185,186,196,200,202 |
Anaemia185,189,195,198,202 |
Antiplatelet therapy186,195,196,202,208 |
Poor anticoagulant control189,196,203 |
Comorbidity and reduced functional capacity191,196,204 |
Recent surgery189,209,c |
Frequent falls195 |
Alcohol abuse191,192,195,202 |
Nonsteroidal anti-inflammatory drug210 |
Categorization of Risk of Bleedingd |
| Estimated Absolute Risk of Major Bleeding |
| Low Riske (0 Risk Factors) | Moderate Riske (1 Risk Factor) | High Riske (≥2 Risk Factors) |
Anticoagulation 0–3 mof | | | |
Baseline risk (%) | 0.6 | 1.2 | 4.8 |
Increased risk (%) | 1.0 | 2.0 | 8.0 |
Total risk (%) | 1.6g | 3.2 | 12.8h |
Anticoagulation after first 3 mof | | | |
Baseline risk (%/y) | 0.3i | 0.6 | ≥2.5 |
Increased risk (%/y) | 0.5 | 1.0 | ≥4.0 |
Total risk (%/y) | 0.8j | 1.6j | ≥6.5 |
AT9 = 9th Edition of the Antithrombotic Guideline.
aFrom AT9. Since AT9, references for bleeding with individual factors have been added193,206,210; nonsteroidal anti-inflammatory drug has been added as a risk factor; a systematic review has described the risk in VTE trial patients who were randomized to no antithrombotic therapy211; and several recent publications have compared clinical prediction rules for bleeding in various populations.193,212-216
bMost studies assessed risk factors for bleeding in patients who were on VKA therapy. The risk of bleeding with different anticoagulants is not addressed in this table. 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 episode197); and (3) how effectively a previous cause of bleeding was corrected (eg, upper GI bleeding).
cImportant for parenteral anticoagulation (eg, first 10 d), but less important for long-term or extended anticoagulation.
dAlthough there is evidence that risk of bleeding increases with the prevalence of risk factors,187,188,192,194,195,196,198,201,202,204,217,218 the categorization scheme suggested here has not been validated. Further-more, a single risk factor, when severe, will result in a high risk of bleeding (eg, major surgery within the past 2 d; severe thrombocytopenia).
eCompared with low-risk patients, moderate-risk patients are assumed to have a twofold risk and high-risk patients are assumed to have an eightfold risk of major bleeding.79,185,187,189,195,196,198,204
fWe estimate that anticoagulation is associated with a 2.6-fold increase in major bleeding based on comparison of extended anticoagulation with no extended anticoagulation (Table 6 in AT91). The relative risk of major bleeding during the first 3 mo of therapy may be greater that during extended VKA therapy because: (1) the intensity of anticoagulation with initial parenteral therapy may be greater that 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.189,198,203 However, studies of patients with acute coronary syndromes do not suggest a higher than 2.6 relative risk of major bleeding with parenteral anticoagulation (eg, UFH, LMWH) compared with control.219,220
g1.6% corresponds to the average of major bleeding with initial UFH or LMWH therapy followed by VKA therapy (Table 7 in AT91). We estimated baseline risk by assuming a 2.6 relative risk of major bleeding with anticoagulation (footnote f).
hConsistent with frequency of major bleeding observed by Hull in “high-risk” patients.209
iOur estimated baseline risk of major bleeding for low-risk patients (and adjusted up for moderate- and high-risk groups as per footnote e).
jConsistent with frequency of major bleeding during prospective studies of extended anticoagulation for VTE.64,65,80,189,221