BLEEDING RISKS, RISK-FACTORS AND MANAGEMENT OF BLEEDING COMPLICATIONSAFTER TREATMENT WITH ANTICOAGULANTS, SPECIFIC ANTITHROMBINS, THROMBOLYTICS IIB-IIIA RECEPTOR BLOCKERS

Assessment of the risks of new antithrombotic therapies is best undert aken by evaluating risk factors for bleeding in individual patients, a nd risks associated with specific antithrombotic agents. This forms th e basis for the development of a management strategy for major bleedin g complications. Patient-related risk factors for bleeding with oral a nticoagulants include: trauma, invasive procedures, history of bleedin g disorder; high anticoagulant intensity, concomitant use of antiplate let drugs, presence of underlying severe disease, advanced age, and pr ior history of cerebrovascular accident, or gastrointestinal bleeding. Weight-adjusted and other nomograms are more successful in achieving a balance between therapeutic effect and safety with intravenous hepar in. The most important complication of thrombolytic therapy is intracr anial haemorrhage, and the risks increase with agc >65 years weight un der 70 k, hypertension on admission and the use of tissue plasminogen activator: this profile is helpful in assessing risk-benefit ratio amo ngst individual patients. Recent experience with the experimental use of antithrombin agents such as hirudin, indicates a delicate dose-resp onse relationship as it relates to the risk of cerebral haemorrhage wh en used in conjunction with thrombolytic agents. A definitive answer r egarding the role of hirudin and the balance of safety and efficacy aw aits completion of ongoing trials. Novel IIb/IIIa platelet inhibitors appear to offer a significant therapeutic advance: major bleeding is v ariable and depends in part on the rise of concomitant procedures, and heparin therapy. It is important to identify the source and severity of bleeding with the use of antithrombotic therapy and its haemodynami c consequences in constructing a management plan. Well developed treat ment algorithms for patients with severe bleeding exist, and although laboratory testing may be helpful, it is on balance of marginal benefi t since patients usually require urgent therapy. Future investigation promises move readily available rapid and specific laboratory testing, and newer antithrombotic agents that are easier to administer and mon itor. Molecular targeting with fusion proteins that attract to a speci fic antigen, thereby delivering more effective and safe therapy, offer new promise.