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Bleeding on Anticoagulation — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyBleeding on AnticoagulationEECC

A 68-year-old man with AF on apixaban 5 mg bd develops persistent epistaxis requiring ENT assessment. His haemoglobin drops from 135 to 108 g/L. The ENT team achieves haemostasis with cautery. Should apixaban be permanently discontinued?

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Correct answer: E — No — manage the bleeding source, consider temporary DOAC interruption; restart anticoagulation once haemostasis is achieved if the stroke risk (CHA₂DS₂-VA) outweighs the recurrence bleeding risk

Bleeding events on anticoagulation are common and do not automatically mandate permanent cessation. The 2024 ESC AF Guidelines recommend a structured approach: (1) assess bleeding severity and source — treat the cause (ENT cautery in this case); (2) temporary DOAC interruption during active bleeding; (3) reassess the risk-benefit balance (stroke risk vs bleeding risk) — in most patients with CHA₂DS₂-VA ≥2, the stroke risk from stopping OAC exceeds the recurrence bleeding risk; (4) address modifiable bleeding risk factors (HAS-BLED components: uncontrolled hypertension, excess alcohol, concomitant antiplatelets/NSAIDs, labile INR for warfarin); (5) restart anticoagulation (same or alternative DOAC) once the bleeding source is treated. The PAUSE trial demonstrated low thromboembolic risk with temporary DOAC interruption.

Reference: ESC (2024): AF Guidelines; PAUSE Trial