All-cause mortality after major gastrointestinal bleeding among patients receiving direct oral anticoagulants: a systematic review and meta-analysis
Nicholas L.J. Chornenki a), Roupen Odabashian b), Marc Carrier c) d), Faizan Khan e), Jenneke Lenteejens f), Fabian Stucki g), Tzu-Fei Wang c) d), Tobias Tritschler g), Deborah M. Siegal c) d)
a) Division of Hematology, University of British Columbia, Vancouver, Canada
b) Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, United States
c) Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
d) Ottawa Hospital Research Institute, Ottawa, Canada
e) University of Calgary, Calgary, Canada
f) Radboudumc University Medical Center, Nijmegen, Netherlands
g) Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
Abstract
Background
Although gastrointestinal (GI) bleeding represents the single most frequent site of anticoagulant-related major bleeding, outcomes after major GI bleeding including mortality are not well characterized and severity may be underappreciated. We aimed to determine 30-day all-cause mortality in adults with major GI bleeding on a direct oral anticoagulant (DOAC).
Methods
We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception to May 9, 2024 for randomized controlled trials and cohort studies that reported 30-day all-cause mortality after major GI bleeding in adults treated with a DOAC for venous thromboembolism or atrial fibrillation. Risk of bias was assessed using a modified QUIPS tool for prognostic studies. 30-day all-cause mortality was calculated using the random-effects inverse-variance method.
Results
We included 20 studies comprising 3987 DOAC-treated patients with major GI bleeds. The pooled estimate of 30-day all-cause mortality was 8.4 % (95 % confidence interval [CI], 4.9–12.5; I2 = 83 %). In subgroup analyses, 30-day all-cause mortality was 10.3 % (95 % CI, 6.5–14.7; I2 = 24 %) in prospective studies (9 studies, 675 major GI bleeds), 7.3 % (95 % CI, 2.2–14.4; I2 = 90 %) in retrospective studies (11 studies, 3312 major GI bleeds), 12.9 % (95 % CI, 6.3–21.1; I2 = 44 %) in considered at high risk of bias (9 studies, 387 major GI bleeds), and 6.1 % (95 % CI, 2.9–10.1; I2 = 89 %) in those at low risk of bias (10 studies, 3562 major GI bleeds).
Conclusion
DOAC-related major GI bleeding appears to be associated with significant 30-day all-cause mortality. Further research is needed regarding the causes and contributors to mortality in this population to identify patients at high risk and develop mitigation strategies.