Periprocedural Management and Approach to Bleeding in Patients Taking Dabigatran
Case Presentation: A 78-year–old man with atrial fibrillation, hypertension, and a history of ischemic stroke 2 years earlier presents to the emergency department with hematemesis and melena. He is taking dabigatran (150 mg twice daily) for stroke prevention, and his last dose was taken 12 hours earlier. His hemoglobin is 5.9 g/dL, platelet count is 185×109/L, and calculated creatinine clearance is 26 mL/min. The activated partial thromboplastin time (aPTT) is 83 s and the thrombin time (TT) is >150 s. How would you manage this patient?
The Randomized Evaluation of Long-Term Anticoagulant Therapy trial conducted in 18 113 patients with atrial fibrillation demonstrated that, compared with warfarin, dabigatran at a dose of 150 mg twice daily reduced the risk of stroke or systemic embolism by one third and was associated with a similar rate of major bleeding; at a dose of 110 mg twice daily, the risk of stroke or systemic embolism with dabigatran was similar to that with warfarin, but dabigatran reduced the risk of major bleeding by one fifth.1 Both doses of dabigatran reduced the risk of intracranial bleeding by two thirds compared with warfarin. The risk of stroke was consistently reduced in all of the patient subgroups, but in those over the age of 75 years, the higher dose of dabigatran was associated with an increased risk of extracranial bleeding.2
Prescribing guidelines for dabigatran vary by country and should be reviewed before starting the drug. The majority of atrial fibrillation patients with ≥1 additional risk factor for stroke are eligible for dabigatran. Absolute contraindications are uncommon, but include impaired renal function with a calculated creatinine clearance <15 mL/min in the United States or <30 mL/min in the rest of the world. Dabigatran has not been evaluated in patients with valvular atrial fibrillation or …