• D A McMahan, D M Smith, M A Carey, and X H Zhou.
• Richard L. Roudebush VAMC, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
• J Gen Intern Med. 1998 May 1; 13 (5): 311316311-6.

ObjectiveTo determine the incidence of major hemorrhage among outpatients started on warfarin therapy after the recommendation in 1986 for reduced-intensity anticoagulation therapy was made, and to identify baseline patient characteristics that predict those patients who will have a major hemorrhage.DesignRetrospective cohort study.SettingA university-affiliated Veterans Affairs Medical Center.PatientsFive hundred seventy-nine patients who were discharged from the hospital after being started on warfarin therapy.Measurements And Main ResultsThe primary outcome variable was major hemorrhage. In our cohort of 579 patients, there were 40 first-time major hemorrhages with only one fatal bleed. The cumulative incidence was 7% at 1 year. The average monthly incidence of major hemorrhage was 0.82% during the first 3 months of treatment and decreased to 0.36% thereafter. Three independent predictors of major hemorrhage were identified: a history of alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed. Age, comorbidities, medications known to influence prothrombin levels, and baseline laboratory values were not associated with major hemorrhage.ConclusionsThe incidence of major hemorrhage in this population of outpatients treated with warfarin was lower than previous estimates of major hemorrhage measured before the recommendation for reduced-intensity anticoagulation therapy was made, but still higher than estimates reported from clinical trials. Alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed were associated with increased risk of major hemorrhage.

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