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Introduction Anticoagulation in infective endocarditis (IE) remains controversial. British National Formulary (BNF) guidance lists acute bacterial endocarditis as a contraindication to all heparin therapies, 1 predominantly due to concerns of increased risk of intracerebral haemorrhage in patients receiving therapeutic anticoagulation,2–3 although recent observational studies have challenged this association.4–5 Many patients receive prophylactic doses of anticoagulation for venous thromboembolism (VTE) prevention during inpatient treatment; however, it is unknown if the presence of IE significantly increases the risk of bleeding.Methods Retrospective observational study of 222 patients referred to a multidisciplinary endocarditis team over a two-year period at a large UK teaching hospital. Patients with definite IE were compared with those in whom IE was rejected. Bleeding events were recorded as a binary outcome and classified using Bleeding Academic Research Consortium (BARC) criteria ( figure 1). Anticoagulation strategy, length of hospital stay and infecting organism were also analysed.Results Bleeding occurred in 24.3% of patients. The highest bleeding rate was observed in patients with definite IE receiving therapeutic anticoagulation (32%), while the lowest rate occurred in patients with definite IE receiving prophylactic anticoagulation (20%). No association was found between anticoagulation strategy, IE diagnosis and bleeding risk (p=0.753). Most bleeding events were minor (BARC type 1 or 2). Major bleeding (BARC ≥3A) occurred in 7.2% of all patients, and fatal bleeding was rare (0.5%). Length of hospital stay was significantly associated with bleeding risk (p=0.036), particularly beyond 40 days. Staphylococcus aureus was the most frequently associated organism among bleeding cases.Conclusions Treatment with prophylactic anticoagulation did not significantly increase the risk of bleeding in patients with infective endocarditis compared to patients without infective endocarditis. These findings support the use of prophylactic anticoagulation for VTE prevention in patients with IE.References British National Formulary (available online): https://bnf.nice.org.uk/drugs/heparin-unfractionated/#contra-indications).Selfon-Suty C, Delahay F, Tattevin P, Federspiel C, Le Moing V, Chirouze C, et al. Symptomatic and asymptomatic neurological complicatins of infective endocarditis: impact on surgical management and prognosis. PLos One. 2016 Jul 11;11(7):e0158522.Garcia-Cabrera E, Fernandez-Hidalgo N, Almirante B, Ivanova-Georgieva R, Noureddine M, Plata A, et al. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicentre observational study. Circulation 2013. June 11;127(23):2272–84. Doi: 10.1161.CIRCULATIONAHA.112.000813.Davis KA, Guang G, Petty SA, Tan WA, Malaver D, Peacock JE. The effect of preexisting anticogulation on cerebrovasuclar events in left-sided infective endocarditis. Am J Med. 2020. Mar;133(3):360–369. Doi: 10.1016/j.amjmed.2019.07.059.Delgado V, Marsan NA, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023. Oct 14;44(39):3948–4042. Doi: 10.1093/eurheartj/ehad193.Abstract 495 Figure 1