December 2017 – The risk of intracranial or GI hemorrhage in a debilitated ambulatory patient at risk for falling likely exceeds the benefit of stroke reduction.*
Most experts agree that anticoagulation should not be used in these cases
– Patient has a high risk of falling or is falling more frequently
– Eating decreases by 50% or varies significantly day today
– Liver failure develops
– The patient is not willing to test INR
– Active bleeding
Other risks include
– Age greater than 75, especially greater than 85
– Poor nutrition or low warfarin doses (less than 1 mg/day)
– Difficult to regulate INR (warfarin)
– Previous major bleeding episode
– Cancer, especially metastatic cancer
– Kidney disease with creatinine greater than 2.00
– Liver disease
– Low platelet count
– Previous hemorrhagic stroke
– Anemia
– Bleeding tendency
– Uncontrolled hypertension
– Use of aspirin, NSAID or clopidogrel
– Heavy alcohol use
HAS-BLED and CHADS2 are useful tools to estimate personal risk/benefit with your patients. Seeing their risk factors can improve prognostic awareness and result in better end-of-life planning.
*Mechanical mitral valve is an exception
