Restarting Anticoagulation in Patients with Frequent Falls

Risk-Benefit Analysis in Fall-Prone Patients

The American College of Cardiology recommends prioritizing a patient's thrombotic risk over fall risk when deciding to restart anticoagulation, as patients with high thrombotic risk indications, such as recent stroke/TIA within 3 months, benefit from anticoagulation even with high rebleeding risk 1, 2, 3
Patients with mechanical heart valves, especially in the mitral position, venous thromboembolism within 3 months, history of unprovoked or recurrent VTE, and left atrial or ventricular thrombus, should be considered for anticoagulation restart based on their thrombotic risk 2, 3

The American College of Cardiology suggests that once hemostasis is achieved and the patient is clinically stable, anticoagulation should be restarted based on thrombotic risk, with consideration of parenteral anticoagulation within 1-3 days and transition to apixaban once the bleeding source is controlled 1, 2, 3
Apixaban can be resumed at least 6 hours after bleeding is controlled, but restart should be delayed if bleeding occurred at a critical site, the source of bleeding is not yet identified, or the patient is at high risk of death/disability with rebleeding 1, 2, 3, 5

Implementing fall prevention measures, such as reviewing and minimizing medications that increase fall risk, addressing polypharmacy, and ensuring appropriate apixaban dosing, is recommended instead of withholding anticoagulation 6
A multidisciplinary care team should be involved in all decisions regarding anticoagulation restart, particularly when balancing high thrombotic risk against high rebleeding risk 1, 2, 3

The American College of Cardiology recommends considering permanent discontinuation of anticoagulation only if the patient has nonvalvular AF with a CHA₂DS₂-VASc score <2 (men) or <3 (women), a temporary indication has been completed, or the patient declines after informed discussion 1, 2, 3