READERS’ COMMENTS Restarting Anticoagulation After Major Gastrointestinal Bleeding We read the recent report of Qureshi et al1 reporting the outcomes of restarting anticoagulation after gastrointestinal bleeding (GIB) in patients with atrial fibrillation. The investigators found that patients who resumed taking warfarin in the first week were at a higher risk of recurrent GIB (incidence ratio of 19.3%), whereas a lower risk of thromboembolism and mortality was associated with this early reinitiation of warfarin. Because their findings are important to both current practice and future research, several limitations of this study deserve attention. Nearly 40% of patients with warfarin restarted presented an upper GIB. Recommendations in upper GIB emphasized early risk stratification, using validated prognostic scales, and early endoscopy (within 24 hours).2 So, it would be very important to know the mean Rockall risk score, the best score to estimate the risk of both rebleeding and mortality, to better understand the high rate of recurrent bleeding observed in this study. In the same way, the 3 most common approaches for reversal of

warfarin are (1) discontinuation of oral anticoagulant therapy, (2) oral or intravenous administration of agents that promote coagulation, and (3) direct reconstitution of the patient’s coagulation factors through intravenous administration. Although all patients presented with a major GIB on admission, only