Task Force 4: Inpatient Management of Patients with MCSD - The ...

For patients who present with gastrointestinal bleeding, warfarin may be held or
even reversed, depending on the severity of the bleeding and INR. Antiplatelet therapy
is often discontinued as well. Anticoagulation and antiplatelet therapy typically continue
to be withheld until the source of the bleeding has been addressed or, if a source has
not been identified, until the bleeding subsides. Devices which require a higher INR
and/or have mechanical valves are likely at the highest risk for potential thrombotic
complications in these circumstances.
Recommendations for Management of Anticoagulation and Antiplatelet Therapy
for Patients who Present with Gastrointestinal Bleeding:
Class I:
1. Anticoagulation and antiplatelet therapy should be held in the setting of clinically
significant bleeding.
Level of Evidence: C.
2. Anticoagulation should be reversed in the setting of an elevated INR and clinically
significant bleeding.
Level of Evidence: C.
3. Anticoagulation and antiplatelet therapy should continue to be held until clinically
significant bleeding resolves in the absence of evidence of pump dysfunction.
Level of Evidence: C.
4. The patient, device parameters, and the pump housing (if applicable) should be
carefully monitored while anticoagulation and antiplatelet therapy is being withheld
or dose reduced.
Level of Evidence: C.
A source of the gastrointestinal bleeding should be sought after addressing the
level of anticoagulation, supporting the patients with transfusions, and serially following
blood counts. For the first episode of bleeding, all patients should have a
comprehensive assessment for a bleeding source with a focus on gastrointestinal
arteriovenous malformations for those with continuous flow devices. Consultation with
the gastrointestinal consultation team is often critical to focus this evaluation. A
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