Original Article

Utility of Hemoccult Testing Before Therapeutic Anticoagulation in Venous Thromboembolism

Authors: Ryan Urbas, DO, Marwan Badri, MD, Nicole E. Albert,DO, Catherine Prince, DO, PhD, Barani Mayilvaganan, MD


Objectives: Fecal occult blood testing (FOBT) is performed routinely before starting therapeutic anticoagulation in patients despite it never being validated to predict gastrointestinal bleeding (GIB) risk. Our objective was to determine the utility in checking the guaiac FOBT test (gFOBT) before initiating therapeutic anticoagulation in patients with a new diagnosis of venous thromboembolism (VTE).

Methods: This was a retrospective chart review that examined patients with a diagnosis of VTE admitted during a 2-year period in one mid-sized tertiary care center. The gFOBT was performed before initiating anticoagulation, excluding patients with overt GIB, and analysis was performed to determine GIB outcomes. In addition, demographics, laboratory data, and comorbidities were recorded at the time of admission, and an admission hypertension, abnormal renal/liver function, stroke history, GIB history or predisposition, labile international normalization ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) score was recorded to determine other factors that were predictive of new-onset GIB when starting anticoagulation.

Results: Initially, 718 patients with a new diagnosis of VTE were screened for 2 years. Ultimately, 375 patients were prescribed anticoagulation therapy and 244 had documented gFOBT. Of these 375, 14 (3.73%) had a GIB episode. A positive gFOBT was present on admission in 85.7% of those who bled (P < 0.001). The negative predictive value of gFOBT was 99.02%; however, the positive predictive value was only 30.77%. A HAS-BLED score >2 at admission significantly predicted GIB during admission as well (median 2.4 for those with GIB and 1.6 for those without GIB, P = 0.02).

Conclusions: Despite its beneficial negative predictive value, gFOBT before initiating therapeutic anticoagulation is unlikely to change the management of patients without evidence of overt GIB.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-891.
2. Pereira-Da-Silva T, Souto Moura T, Azevedo L, et al. Restraints to anticoagulation prescription in atrial fibrillation and attitude towards the new oral anticoagulants. Acta Med Port 2013;26:127-132.
3. Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age Ageing 2011;40:675-683.
4. Gattellari M, Worthington J, Zwar N, et al. Barriers to the use of anticoagulation for nonvalvular atrial fibrillation: a representative survey of Australian family physicians. Stroke 2008;39:227-230.
5. Singer DE, Chang Y, Borowsky LH, et al. A new risk scheme to predict ischemic stroke and other thromboembolism in atrial fibrillation: the ATRIA study stroke risk score. J Am Heart Assoc 2013;2:e000250.
6. Pisters R, Lane DA, Nieuwlaat R, et al. 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 2010;138:1093-1100.
7. Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006;151:713-719.
8. Apostolakis S, Lane DA, Guo Y, et al. Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol 2013;61:386-387.
9. Bennett CJ, Moskovitz J, Mayo DD, et al. 100: fecal occult blood testing does not predict major gastrointestinal bleeding in heparinized patients. http://www.annemergmed.com/article/S0196-0644(09)00757-4/abstract. Accessed February 24, 2017.
10. Allison JE, Sakoda LC, Levin TR, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. J Natl Cancer Inst 2007;99:1462-1470.
11. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348:1472-1477.
12. Kronborg O, Fenger C, Olsen J, et al. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996;348:1467-1471.
13. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993;328:1365-1371.
14. Levin B, Hess K, Johnson C. Screening for colorectal cancer. A comparison of 3 fecal occult blood tests. Arch Intern Med 1997;157:970-976.
15. Van Dam J, Bond JH, Sivak MV, Jr. Fecal occult blood screening for colorectal cancer. Arch Intern Med 1995;155:2389-2402.
16. Hewitson P, Glasziou P, Watson E, et al. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol 2008;103:1541-1549.
17. Roldá V, Marí F, Ferná H, et al. Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a “-world” population with atrial fibrillation receiving anticoagulant therapy. Chest 2013;143:179-184.
18. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-1151.
19. EINSTEIN-PE Investigators., Bü HR, Prins MH, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012;366:1287-1297.
20. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093-2104.
21. Terdiman JP, Ostroff JW. Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome. Am J Med 1998;104:349-354.
22. ACTIVE Investigators, Connolly SJ, Pogue J, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009;360:2066-2078.
23. Hansen ML, Sørensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010;170:1433-1441.