Fall Risk vs Major Bleeds While Anticoagulated

Earlier this year in April, I wrote (twice) about assessing stroke risk in atrial fibrillation & major bleeding risk while anticoagulated.  I tried to use a bit of cognitive behavioral therapy to point out rationale use of risk calculators to assist in determining those who would benefit from anticoagulation to prevent a stroke or pulmonary embolism.  It turns out that we can calculate stroke risk via CHA2DS2-VASc and bleeding risk via HAS-BLED.  However, we still tend to use high fall risk as our biggest excuse as to why we don't offer anticoagulation to more patients.  But if you look closely at the risk factors for HAS-BLED, neither history of fall(s) nor risk of falling is consider a risk factor for major bleeding.

Could it be that, counter-intuitive as it may be, falling does not make an impact on risk of major bleeding (however you may define this)?  In a prospective cohort study published in this month's American Journal of Medicine, the authors concluded that use of oral anticoagulation did not increase the risk of major bleeds in those patients at high risk for falling when monitored over the next 12mo.  

To arrive at their conclusion, the authors followed for one year 515 patients on warfarin, of whom 308 patients were considered at high risk of falls, assessed by a validated 2 question questionnaire: 1) did you fall last year? 2) did you notice any problem w/gait, balance & mobility.  Those answering yes to either question (or both) were considered at high risk for falling.  But in the end, there was no statistical significance in major bleeding between those who were considered at high risk for falling vs those considered low risk.

Bottom line, risk of falling has no impact on bleeding risk so given this current study & others, we need to avoid using fall risk as an excuse to avoid anticoagulation.  High risk HAS-BLED score exceeding CHA2DS2-Vasc score, I can understand.  But otherwise, we need to give our patients the best chance to avoid function loss (while not exposing them to excess bleeding risk).

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