Case Presentation: This is a 77 year old woman with a history of severe aortic stenosis, severe mitral regurgitation, and chronic atrial fibrillation (afib) on coumadin. In 2017, she underwent bioprosthetic aortic valve replacement, mitral valve repair, biatrial ablation (Maze procedure), and left atrial appendage ligation (WATCHMAN procedure), after which she was to continue coumadin and aspirin for an “undetermined” period. In 2023, she presented with weakness and melena, with severe anemia (hemoglobin 6.5g/dL) and an INR of 5. Chart review found that in the six years since her surgery, cardiologists repeatedly documented that she was doing well and should continue aspirin and coumadin. However, chart review also revealed excessive bleeding after dental extraction, multiple EGDs demonstrating gastritis, and repeated supratherapeutic INR values.
Discussion: Hospitalists are frequently faced with decisions that require balancing two competing medical priorities; in this case, the cardiac need for anticoagulation and the risk of ongoing gastrointestinal bleeding and anemia. These decisions can be made even more complex when there are multiple indications for anticoagulation, as in this patient. First, with regard to the patient’s bioprosthetic aortic valve, 2020 ACC/AHA guidelines recommend that all patients with bioprosthetic surgical aortic valves receive aspirin daily. Second, for patients with afib undergoing a WATCHMAN procedure, the same 2020 ACC/AHA guidelines suggest anticoagulation therapy for at least three months. Patients with contraindications to anticoagulation were excluded from the original WATCHMAN trials (PROTECT-AF & PREVAIL) but have been included in more recent studies, which demonstrate non-inferiority of stroke risk reduction without anticoagulation after the initial post-operative period. There is currently an ongoing prospective trial (ASAP-TOO) of patients with contraindication to anticoagulation who undergo WATCHMAN comparing monotherapy with antiplatelet agent versus no therapy. This patient had a well-defined indication for indefinite daily aspirin and a strong recommendation for at least three months of additional anticoagulation post WATCHMAN procedure, however given her elevated bleeding risk, it was warranted to discontinue coumadin after the initial three months.
Conclusions: In clinical practice, it is common for anticoagulation to be continued indefinitely, with the general thought being that benefits outweigh risks. Clinicians should regularly discuss the risk/benefit ratio with their patients and must include a thorough review of the patient’s medical history, beyond the condition related to the indication for anticoagulation. By focusing on a single organ system, clinicians may miss the bigger picture, leading to complications as seen in this case. Although there is a trend towards minimizing changes to chronic medications during hospitalizations, hospitalists are often uniquely positioned to complete complex risk/benefit assessments and should not hesitate to provide advice to their patients when changes are necessary. In this case, the clinical picture indicated a clear change in the risk/benefit ratio, and the patient was advised to stop coumadin. Given the regularity with which hospitalists care for cardiac patients on dual or even triple anticoagulation, it is essential that we remain up to date on the most recent relevant guidelines and continue to think critically about the safety of and indications for these medicines.