Anticoagulation Strategies in Mechanical Heart Valve Recipients with Concurrent Gastrointestinal Bleeding: A Retrospective Five-Year Comparative Cohort of Reversal, Restart Timing, and Ninety-Day Outcomes

Abstract

Patients with mechanical heart valves who develop gastrointestinal bleeding pose a specific clinical challenge: anticoagulation must be reversed to control bleeding, but withholding it for too long exposes the patient to potentially catastrophic valve thrombosis or systemic embolism. Optimal restart timing remains debated. We reviewed 246 consecutive episodes of GI bleeding in mechanical-valve recipients across five years at a tertiary cardiac centre. Anticoagulation was restarted within 7 days in 87 patients (35.4%), at 7-14 days in 98 (39.8%), and at more than 14 days or not at all during admission in 61 (24.8%). Recurrent GI bleeding within 90 days occurred in 24.1% of the early-restart group, 12.2% of the intermediate group, and 8.2% of the late group. Thromboembolic events showed the opposite pattern: 2.3% in the early-restart group, 5.1% in the intermediate group, and 13.1% in the late group (log-rank p = 0.004). The 7-to-14-day window appears to balance these competing risks most favourably for most patients. Independent predictors of recurrent bleeding included untreated H. pylori, NSAID re-exposure, concurrent antiplatelet therapy, and variceal source. Structured multidisciplinary protocols supporting restart in this window — with explicit attention to modifiable bleeding risk factors before restart — appear well placed to improve outcomes.

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