Capítulo de controversias en hemostasia y trombosis / Controversy chapter in haemostasia and thrombosis

RESUMO

Patients with gastrointestinal bleeding and high risk thromboembolitic disease (as in the first three months after a DVT or the first after an arterial embolism), should re-start anticoagulation with heparin, low dose, either iv or sc as soon as bleeding has stopped. Oral anticoagulants could be started a week after bleeding. There is not enough experience with LMWH (100 U anti Xa-Kg-day), but itïs more difficult to reverse while bleeding and renders it unsafe. Patients with acute Pulmonary embolism in their first month of treatmentshould be offered a inferior cava filter as a first option. Patients under anticoagulation with a moderate risk cardioembolic disease should switch to aspirin 325 mg per day plus gastroprotection, until the bleeding risk had disappeared. There is no need to confirm thet the bleeding disease (such as peptic ulcer) is cured before recommence anticoagulation. We suggest some general recomendations such as no alcohol or antiinflamatory drugs, treatment of Helycobacter Pilory, to target the INR at a lower level, and perhaps, to check anticoagulation more frequently. In a CNS bleeding in high risk thromboembolic patients, if there is an associated bleeding factor such as hipertention, trauma, INR higher than 5 or a stroke with haemorragic transformation, recommence anticoagulation after 7-14 days with iv heparin, and then oral anticoagulants at least 2 weeks after the bleeding episode. If the CNS bleeding is spontaneous, or associated with a tumor, a vascular malformation, or amyloidosis, then recommence anticoagulation only in very high risk patients and after 14-21 days of the acute episode. Moderate risk patients should wait at least a month until reiniciate anticoagulation. Finally, always reiniciate anticoagulation with the consent of the neurologist