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. |