Hemorrhage during long-term anticoagulant drug therapy. IV. Selection and management of patients.

Most serious hemorrhages that occur during long-term anticoagulant drug therapy are due either to poor patient selection or to poor management of the patient, or both. In each patient being considered for treatment, the risk of bleeding must be evaluated and classified as high, moderate or low. The clinician must especially assess the risk of intracranial hemorrhage in hypertensive patients, and must screen all patients for potential sources of gastrointestinal bleeding. There is ample time for such investigations, since initiating long-term anticoagulant therapy is not an emergency procedure. The desired level of prothrombin activity must be adjusted to the risks determined for each individual patient. There is no single "therapeutic range" applicable to all patients with their varying hemorrhagenic risks. Proper management includes sufficient laboratory testing to maintain the desired prothrombin level, and continued vigilance to detect signs of early bleeding.Preventable hemorrhage cannot be cited as evidence against the value of anticoagulant drug therapy.