In patients with atrial
fibrillation antithrombotic prophylaxis for stroke is associated with an
increased risk of bleeding. Cerebrovascular risk-benefit ratio for oral
anticoagulation therapies continues to be debated. Macro and/or microhematomas
as well as visible or cryptic ones may appear unexpectedly in any anatomic
region.
The diagnostic
and prognostic value of subcutaneous hematomas (petechia, ecchymosis, bruise)
potentially predisposing intracerebral micro- or macrobleeding might be
reconsidered. Hypothetically, subcutaneous hemorrhagic events are “transparent”
signs and reflect the coexistence of remote vulnerable sites that are potential
bleeding sources. Obviously vigilance is needed for early signs of drug-related
petechiae evaluation to determine whether it is a local/superficial subtlety or
a systemic problem. Any bleeding complication, regardless of its scale and anatomical
location, might be treated as a worrisome clinical symptom requiring subtle
correction of antithrombotic regimen. The focus of this article is to review
the current knowledge of drug-related hemorrhage with special emphasis on
underlying mechanisms and links between the visible bleeding (predominantly
subcutaneous) and remote (such as cerebral) hemorrhagic sources. To mitigate
inappropriate therapy, we should consider new conceptual insights and more
individualized approaches to achieve an optimal balance of efficacy and safety.
We hypothesize that bleeding complications occur as a result of two factors –
impact of antithrombotic drugs and related detrimental effect on microvascular
network. Most likely the microvasculature undergoes pro-hemorrhagic medication
stress leading to unfavorable vascular wall “fenestration” with ensuing
consequences. If so, it suggests the presence of dual substrate responsible for
hemorrhagic events.
Credits: Dr. Petras Stirbys