Shorter hospital stays in epistaxis patients with atrial fibrillation when taking rivaroxaban or apixaban versus phenprocoumon

  • Petar Stankovic
  • Robert Georgiew
  • Cornelius Frommelt
  • Sabine Hammel
  • Jan Wittlinger
  • Stephan Hoch
  • Danilo Obradovic
  • Nikolaos Dagres
  • Thomas WilhelmEmail author


Patients taking oral anticoagulants (OACs) currently represent one-third of all patients treated for epistaxis and an upward trend is expected. New direct oral anticoagulants (DOACs) have been on the market for approximately 10 years. DOACs are favoured over Vitamin K-Antagonists (VKAs) in the current guidelines. There are barely studies that investigate the impact of DOACs on patients with epistaxis. A retrospective study was performed analysing all patients who had stationary treatment for epistaxis from 01.01.2011 to 01.01.2018 in a tertiary care centre. In a total of 466 patients, 46.1% were on OACs. The main indication was atrial fibrillation (AF, 67.4%).The number of DOACs taken surpassed that of the VKAs during the past 2 years. The length of hospital stay was significantly longer in the phenprocoumon group (3 ± 0.2 days) in comparison to both the rivaroxaban (2.3 ± 0.1) and the apixaban (2.2 ± 0.1) groups (p = 0.005). Posterior epistaxis occurred more frequently in the phenprocoumon group (10.8%) than in the rivaroxaban (0%) and apixaban (0%) groups (p = 0.03). A correlation between CHA2DS2–VASc score (risk score for apoplexy in patients with AF, p = 0.01), HAS-BLED score (score for assessment of major bleeding in patients taking anticoagulants with AF, p = 0.006), and length of hospital stay (p = 0.002) with recurrence of epistaxis was found. Shorter hospital stays and exclusively anterior bleeding was noted in AF patients taking rivaroxaban and apixaban, whereas AF patients taking phenprocoumon stayed in hospital longer and had more posterior bleeding.


Epistaxis Rivaroxaban Apixaban Phenprocoumon Atrial fibrillation 



This project was funded entirely by the Department of Otorhinolaryngology of the Sana Kliniken Leipziger Land, Germany.

Compliance with ethical standards

Conflict of interest

All authors have indicated that they have no conflict of interest.


  1. 1.
    Walker T, Macfarlane T, McGarry G (2007) The epidemiology and chronobiology of epistaxis: an investigation of Scottish hospital admissions 1995–2004. Clin Otolaryngol 32(5):361–365CrossRefPubMedGoogle Scholar
  2. 2.
    Destatis. Diagnosedaten der Krankenhäuser ab 2000 (Eckdaten der vollstationären Patienten und Patientinnen) (2018) Gesundheitsberichterstattung des Bundes.
  3. 3.
    Statistics NHe (2016)
  4. 4.
    Destatis (2015) Sterbefälle, Sterbeziffern (je 100.000 Einwohner, altersstandardisiert).
  5. 5.
    Andreotti F, Rocca B, Husted S, Ajjan RA, ten Berg J, Cattaneo M et al (2015) Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 36(46):3238–3249PubMedGoogle Scholar
  6. 6.
    Bermuller C, Bender M, Brogger C, Petereit F, Schulz M (2014) Epistaxis and anticoagulation—a medical and economic challenge?. Laryngorhinootologie 93(4):249–255PubMedGoogle Scholar
  7. 7.
    Biggs TC, Baruah P, Mainwaring J, Harries PG, Salib RJ (2013) Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients. J Laryngol Otol 127(5):483–488CrossRefPubMedGoogle Scholar
  8. 8.
    INTEGRATE (2017) Epistaxis 2016: national audit of management. J Laryngol Otol 131(12):1131–1141CrossRefGoogle Scholar
  9. 9.
    Smith J, Siddiq S, Dyer C, Rainsbury J, Kim D (2011) Epistaxis in patients taking oral anticoagulant and antiplatelet medication: prospective cohort study. J Laryngol Otol 125(12):38–42CrossRefPubMedGoogle Scholar
  10. 10.
  11. 11.
  12. 12.
  13. 13.
    Avezum A, Lopes RD, Schulte PJ, Lanas F, Gersh BJ, Hanna M et al (2015) Apixaban in comparison with warfarin in patients with atrial fibrillation and valvular heart disease: findings from the Apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial. Circulation 132(8):624–632CrossRefPubMedGoogle Scholar
  14. 14.
    Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, HackeW et al (2011) Rivaroxaban versus Warfarin in nonvalvular atrial fibrillation. New Engl J Med 365(10):883–891CrossRefPubMedGoogle Scholar
  15. 15.
    Musgrave KM, Powell J (2016) A systematic review of anti-thrombotic therapy in epistaxis. Rhinology 54(4):292–301CrossRefPubMedGoogle Scholar
  16. 16.
    Sauter TC, Hegazy K, Hautz WE, Krummrey G, Ricklin ME, Nagler M et al (2018) Epistaxis in anticoagulated patients: fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon. Clin Otolaryngol 43(1):103–108CrossRefPubMedGoogle Scholar
  17. 17.
    García Callejo FJ, Bécares Martínez C, Calvo González J, Martínez Beneyto P, Marco Sanz M, Marco Algarra J (2014) Epistaxis and dabigatran, a new non-vitamin K antagonist oral anticoagulant. Acta Otorrinolaringol Esp 65(6):346–354CrossRefPubMedGoogle Scholar
  18. 18.
    Werdan K, Braun-Dullaeus R, Presek P (2013) Anticoagulation in atrial fibrillation: NOAC’s the word. Dtsch Arztebl Int 110(31–32):523–524PubMedGoogle Scholar
  19. 19.
    Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 137(2):263–272CrossRefPubMedGoogle Scholar
  20. 20.
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010) A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138(5):1093–1100CrossRefPubMedGoogle Scholar
  21. 21.
    Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH et al (2012) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 33(21):2719–2747CrossRefPubMedGoogle Scholar
  22. 22.
    Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H et al (2016) Antithrombotic therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 149(2):315–352CrossRefPubMedGoogle Scholar
  23. 23.
    Granger CB, Alexander JH, McMurray JJV, Lopes RD, Hylek EM, Hanna M et al (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365(11):981–992CrossRefPubMedGoogle Scholar
  24. 24.
    Cohen O, Shoffel-Havakuk H, Warman M, Tzelnick S, Haimovich Y, Kohlberg GD et al (2017) Early and late recurrent epistaxis admissions: patterns of incidence and risk factors. Otolaryngol Head Neck Surg 157(3):424–431CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Otolaryngology, Head/Neck & Facial Plastic SurgerySana Kliniken Leipziger LandBornaGermany
  2. 2.Department of Otolaryngology, Head and Neck SurgeryPhillips-University MarburgMarburgGermany
  3. 3.Department of Cardiology, Heart Center LeipzigUniversity LeipzigLeipzigGermany
  4. 4.Department of Electrophysiology, Heart Center LeipzigUniversity LeipzigLeipzigGermany

Personalised recommendations