Management of major bleeding and outcomes in patients treated with direct oral anticoagulants: results from the START-Event registry

Intern Emerg Med. 2018 Oct;13(7):1051-1058. doi: 10.1007/s11739-018-1877-z. Epub 2018 May 22.


The management of major bleeding in patients treated with direct oral anticoagulants (DOACs) is still not well established. START-Events, a branch of the START registry (Survey on anTicoagulated pAtients RegisTer) (NCT02219984), aims to describe the actual management of bleeding or recurrent thrombotic events in routine clinical practice. We here present the results of the management of bleeding patients. The START-Event registry is a prospective, observational, multicenter, international study. Baseline characteristics (demographic, clinical, risk factors) of patients, laboratory data at admission and during follow-up, site of bleeding, therapeutic strategies, and outcomes at the time of hospital discharge and after 6 months were recorded on a web-based case report form. Between January 2015 and December 2016, 117 patients with major bleeding events were enrolled. Non-valvular atrial fibrillation (NVAF) was the indication for treatment in 84% (62% males); 53 patients had intracranial bleeding (13 fatal), 42 had gastrointestinal bleeding (1 fatal), and 22 had bleeding in other sites. Therapeutic interventions for the management of bleeding were performed in 71% of patients. Therapeutic strategies with/without surgery or invasive procedures included: fluid replacement or red blood cells transfusion, prothrombin complex concentrates (3 or 4 factors), antifibrinolytic drugs, and the administration of idarucizumab. Creatinine, blood cell count, and PT/aPTT were the most frequent tests requested, while specific DOAC measurements were performed in 23% of patients. Mortality during hospitalization was 11.9%, at 6-month follow-up 15.5%. Our data confirm a high heterogeneity in the management of bleeding complications in patients treated with DOACs.

Keywords: Bleeding; Direct oral anticoagulant; Idarucizumab.

Publication types

  • Observational Study

MeSH terms

  • Administration, Oral
  • Aged
  • Aged, 80 and over
  • Anticoagulants / pharmacokinetics*
  • Anticoagulants / therapeutic use
  • Atrial Fibrillation / drug therapy
  • Blood Coagulation Factors / analysis
  • Dabigatran / pharmacokinetics
  • Dabigatran / therapeutic use
  • Female
  • Hemorrhage / chemically induced
  • Hemorrhage / epidemiology
  • Hemorrhage / mortality*
  • Humans
  • Male
  • Prospective Studies
  • Pyrazoles / pharmacokinetics
  • Pyrazoles / therapeutic use
  • Pyridones / pharmacokinetics
  • Pyridones / therapeutic use
  • Registries / statistics & numerical data
  • Rivaroxaban / pharmacokinetics
  • Rivaroxaban / therapeutic use
  • Treatment Outcome
  • Ventricular Fibrillation / drug therapy


  • Anticoagulants
  • Blood Coagulation Factors
  • Pyrazoles
  • Pyridones
  • prothrombin complex concentrates
  • apixaban
  • Rivaroxaban
  • Dabigatran