Prognostic Significance of Nuisance Bleeding in Anticoagulated Patients With Atrial Fibrillation

Patient concern regarding bleeding side effects from oral anticoagulation therapy for atrial fibrillation: an analysis from the multicentre KiCS-AF registry

AIMS

The purpose of this study is to utilize patient-reported outcomes to determine the percentage of patients concerned about mild to moderate bleeding side effects of anticoagulants.

METHODS AND RESULTS

We consecutively enrolled 3312 newly diagnosed or referred patients for atrial fibrillation (AF) management from 11 sites within the Keio interhospital Cardiovascular Studies-Atrial Fibrillation registry between September 2012 and May 2018. Of these patients, 2636 (79.5%) were taking oral anticoagulants at enrollment. Using the Atrial Fibrillation Effect on Quality-of-life questionnaire (AFEQT), the patients who responded '1: not at all bothered' or '2: hardly bothered' on the seven-point scale regarding bleeding side effects were classified as the 'no OAC concern' group while those responding '3: a little bothered' to '7: extremely bothered' were classified as the 'OAC concern' group. On baseline analysis, 29.3% (n = 772) were 'concerned' about bleeding side effects. The proportion of women and patients with AF-related symptoms was higher in the oral anticoagulant (OAC) concern vs. no OAC concern group (36.9% vs. 29.8%, P < 0.0004 and 66.2% vs. 56.7%, P < 0.0001, respectively). The CHADS2 scores ≥ 2 were comparable between groups. Of the 430 patients in the 1-year follow-up analysis, the proportion of the continued OAC concern group (1 year from enrollment) was 41.6%. The dabigatran, rivaroxaban, and apixaban usage rates were comparable between the two groups in baseline and 1-year follow-up analysis.

CONCLUSION

Approximately one-third of all patients with AF on anticoagulant therapy were concerned regarding bleeding from short- and long-term anticoagulant use.

Comparison of bleeding risk scores and evaluation of major bleeding predictive factors in patients with major bleeding due to vitamin K antagonist use

Background

Major bleeding in the treatment of atrial fibrillation is closely associated with an increased risk of death and major adverse outcomes in both the short and long term, but all bleeding events are associated with a reduced quality of life. Bleeding events are also known to reduce medication adherence. In this sense, bleeding risk scores are important tools to help predict major bleeding. However, it is not clear which scoring system is superior.

Aim

In this study, our aim was to compare bleeding risk scores and to examine the factors associated with bleeding in patients with major bleeding while using vitamin K antagonists.

Methods

In this retrospective and single-center study, scoring, laboratory and demographic data were analyzed with SPSS 20.0 statistical program.

Results

The mean age of a total of 1434 patients included in our study was 68.2 ± 11.3 years, range was 39-93 years and 769 (53.6%) of these patients were male. Of 588 patients with major bleeding, 93 (15.8%) had intracranial hemorrhage. Logistic regression analysis comparing the scoring systems among themselves revealed that the GARFIELD-AF scoring system had a predictive effect on major bleeding independent of the effect of other scoring systems (OR: 1.532, 95% CI 1.348-1.741, p < 0.001). The area under the curve (AUC) for GARFIELD-AF was 0.690 (0.662-0.718) as a result of the ROC analysis considering the best cut-off point of 3.2% calculated for 2 years. AUC 0.659 (0.630-0.687) for HAS-BLED, AUC 0.636 (0.606-0.665) for ORBIT and AUC 0.611 (0.5810.642) for ATRIA. When we compare the patient group with the control group, it can be said that intracranial hemorrhage occurred independently of INR and TTR values, unlike in the major bleeding group (p:0.129, p:0.545).

Conclusion

In patients using vitamin K antagonists for atrial fibrillation, the GARFIELD-AF risk score was found to be superior to important bleeding risk scores such as HAS-BLED, ORBIT and ATRIA in terms of predicting major bleeding. It is an important result that intracranial hemorrhages, which have a special place among major hemorrhages, were independent of INR and TTR levels. It is noteworthy that 8.2% of patients with major bleeding had a history of minor bleeding in the last year.

A Multisite Retrospective Review of Direct Oral Anticoagulants Compared to Warfarin in Adult Fontan Patients

PURPOSE

Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds.

METHODS

We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin.

RESULTS

The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2).

CONCLUSION

In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.

Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies

Background

Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified.

Objectives

The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy.

Design

The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials.

Setting

The study was set in primary and secondary care in England from 2010 to 2017.

Participants

Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome.

Data sources

Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics.

Interventions

Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor.

Main outcome measures

Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events.

Results

The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195).

Conclusions

This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy.

Limitations

The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted.

Future work

Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions.

Trial registration

This trial is registered as ISRCTN76607611.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.

Bleeding and ischaemic events after first bleed in anticoagulated atrial fibrillation patients: risk and timing

AIMS

To determine the risk of subsequent adverse clinical outcomes in anticoagulated patients with atrial fibrillation (AF) who experienced a new bleeding event.

METHODS AND RESULTS

Anticoagulated AF patients were followed in two prospective cohort studies. Information on incident bleeding was systematically collected during yearly follow-up visits and events were adjudicated as major bleeding or clinically relevant non-major bleeding (CRNMB) according to the International Society on Thrombosis and Haemostasis guidelines. The primary outcome was a composite of stroke, myocardial infarction (MI), or all-cause death. Time-updated multivariable Cox proportional-hazards models were used to compare outcomes in patients with and without incident bleeding. Median follow-up was 4.08 years [interquartile range (IQR): 2.93-5.98]. Of the 3277 patients included (mean age 72 years, 28.5% women), 646 (19.7%) developed a new bleeding, 297 (9.1%) a major bleeding and 418 (12.8%) a CRNMB. The incidence of the primary outcome was 7.08 and 4.04 per 100 patient-years in patients with and without any bleeding [adjusted hazard ratio (aHR): 1.36, 95% confidence interval (CI): 1.16-1.61; P < 0.001; median time between a new bleeding and a primary outcome 306 days (IQR: 23-832)]. Recurrent bleeding occurred in 126 patients [incidence, 8.65 per 100 patient-years (95% CI: 7.26-10.30)]. In patients with and without a major bleeding, the incidence of the primary outcome was 11.00 and 4.06 per 100 patient-years [aHR: 2.04, 95% CI: 1.69-2.46; P < 0.001; median time to a primary outcome 142 days (IQR: 9-518)], and 59 had recurrent bleeding [11.61 per 100 patient-years (95% CI: 8.99-14.98)]. The incidence of the primary outcome was 5.29 and 4.55 in patients with and without CRNMB [aHR: 0.94, 95% CI: 0.76-1.15; P = 0.53; median time to a composite outcome 505 days (IQR: 153-1079)], and 87 had recurrent bleeding [8.43 per 100 patient-years (95% CI: 6.83-10.40)]. Patients who had their oral anticoagulation (OAC) discontinued after their first bleeding episode had a higher incidence of the primary composite than those who continued OAC (63/89 vs. 159/557 patients; aHR: 4.46, 95% CI: 3.16-6.31; P < 0.001).

CONCLUSION

In anticoagulated AF patients, major bleeding but not CRNMB was associated with a high risk of adverse outcomes, part of which may be explained by OAC discontinuation. Most events occurred late after the bleeding episode, emphasizing the importance of long-term follow-up in these patients.

Prognosis and the Effect of De-Escalation of Antiplatelet Therapy After Nuisance Bleeding in Patients With Myocardial Infarction

BACKGROUND

Data regarding prognosis and management after nuisance bleeding (NB) is limited. The purpose was to examine the prognostic significance of NB in patients receiving potent dual antiplatelet treatment (DAPT) after acute myocardial infarction and the impact of de-escalation of DAPT on clinical outcomes thereafter.

METHODS

From the TALOS-AMI trial (Ticagrelor Versus Clopidogrel in Stabilized Patients With Acute Myocardial Infarction)' 2583 patients were used to investigate the clinical impact of NB (defined as Bleeding Academic Research Consortium [BARC] 1 bleeding) during 1-month treatment with ticagrelor-based DAPT after acute myocardial infarction. We assessed the associations between NB within 1 month and BARC 2, 3, or 5 bleeding and major adverse cardiovascular event (a composite of cardiovascular death, myocardial infarction, stroke) from 1 to 12 months. We also evaluated the effect of de-escalation to clopidogrel in patients with or without NB.

RESULTS

NB occurred in 416 patients (16.7%) after 1 month of ticagrelor-based DAPT. At 1 year, NB was not associated with increase in BARC 2, 3, or 5 bleeding (hazard ratio [HR]' 1.29 [95% CI' 0.7-2.14]) and major adverse cardiovascular event (HR' 1.72 [95% CI' 0.87-3.39]). However, patients with NB had an increased risk of BARC 2, 3, or 5 bleeding at 6 months (HR, 1.94 [95% CI, 1.08-3.48]; P=0.026), which diminished over the next 6 months. De-escalation from ticagrelor to clopidogrel reduced the incidence of BARC 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in NB (HR' 0.31 [95% CI' 0.10-0.92]) and non-NB patients (HR' 0.58 [95% CI' 0.37-0.90]) without heterogeneity (P interaction=0.291). There was no increase in major adverse cardiovascular event after DAPT de-escalation, irrespective of NB.

CONCLUSIONS

NB was frequent in patients with acute myocardial infarction on 1-month ticagrelor-based DAPT and was associated with an early increase of bleeding. DAPT de-escalation after NB may reduce bleeding without increasing ischemic events.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02018055.

Direct oral anticoagulant dose selection: Challenging cases

Direct oral anticoagulants (DOACs) are given in fixed doses without routine laboratory monitoring of their anticoagulant effect based on the results of pivotal phase III trials. In some of these trials, patients were randomly allocated to receive a higher or lower dose of a DOAC, whereas in others, most patients were given a standard dose and only a subset deemed to be at risk of drug accumulation was given a lower dose. Treatment guidelines recommend dosing DOACs according to the way that they were tested in the trials, but for some patients, the optimal dosing remains uncertain. One example is patients with atrial fibrillation who are thought to have an unacceptably high risk of bleeding but do not meet the guideline criteria for dose reduction. A second is patients with venous thromboembolism who have completed 3 to 6 months of anticoagulation and are eligible for extended treatment with a standard or reduced dose of DOAC. In this review, we present a case-based approach to DOAC dose selection in these two settings.

Oral Anticoagulation Use in High-Risk Patients Is Improved by Elimination of False-Positive and Inactive Atrial Fibrillation Cases

BACKGROUND

Multiple registries have reported that >40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA₂DS₂-VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap.

METHODS

We retrospectively adjudicated 6514 patients with atrial fibrillation documented by at least one of: billing diagnosis, electronic medical record encounter diagnosis, electronic medical record problem list, or electrocardiogram interpretation.

RESULTS

After review, 4555/6514 (69.9%) had active atrial fibrillation, while 1201 had no documented history of atrial fibrillation and 758 had a history of atrial fibrillation that was no longer active. After removing the 1201 patients without a confirmed atrial fibrillation diagnosis, oral anticoagulant use in high-risk patients increased to 71.1% (P < .0001 compared with 62.9% at baseline). Oral anticoagulant use increased to 79.7% when the 758 inactive atrial fibrillation patients were also eliminated from the analysis (P < .0001 compared with baseline). In the active high-risk atrial fibrillation group, there was no significant difference in the use of oral anticoagulants between men (80.7%) and women (78.8%) with a CHA₂DS₂-VASc ≥2, or in women with a CHA₂DS₂-VASc ≥3 (79.9%).

CONCLUSIONS

Current registries and health system health records with unadjudicated diagnoses over-report the number of high-risk atrial fibrillation patients not taking oral anticoagulants. Expert adjudication identifies a smaller treatment gap than previously described.

Bleeding and related mortality with NOACs and VKAs in newly diagnosed atrial fibrillation: results from the GARFIELD-AF registry

In atrial fibrillation (AF), lower risks of death and bleeding with non-vitamin-K oral anticoagulants (NOACs) were reported in meta-analyses of controlled trials, but whether these findings hold true in real-world practice remains uncertain. Risks of bleeding and death were assessed in 52 032 patients with newly diagnosed AF enrolled in GARFIELD-AF (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation), a worldwide prospective registry. Baseline treatment was vitamin K antagonists (VKAs) with or without antiplatelet (AP) agents (VKA ± AP) (20 151; 39.3%), NOACs ± AP agents (14 103; 27.5%), AP agents only (10 748; 21.0%), or no antithrombotics (6219; 12.1%). One-year follow-up event rates (95% confidence interval [CI]) of minor, clinically relevant nonmajor (CRNM), and major bleedings were 2.29 (2.16-2.43), 1.10 (1.01-1.20), and 1.31 (1.21-1.41) per 100 patient-years, respectively. Bleeding risk was lower with NOACs than VKAs for any bleeding (hazard ratio (HR) [95% CI]), 0.85 [0.73-0.98]) or major bleeding (0.79 [0.60-1.04]). Compared with no bleeding, the risk of death was higher with minor bleeding (adjusted HR [aHR], 1.53 [1.07-2.19]), CRNM bleeding (aHR, 2.59 [1.80-3.73]), and major bleeding (aHR, 8.24 [6.76-10.04]). The all-cause mortality rate was lower with NOACs than with VKAs (aHR, 0.73 [0.62-0.85]). Forty-five percent (114) of all deaths occurred within 30 days, and 40% of these were from intracranial/intraspinal hemorrhage (ICH). The rates of any bleeding and all-cause death were lower with NOACs than with VKAs. Major bleeding was associated with the highest risk of death. CRNM bleeding and minor bleeding were associated with a higher risk of death compared to no bleeding. Death within 30 days after a major bleed was most frequently related to ICH. This trial was registered at www.clinicaltrials.gov as #NCT01090362.

Trade-off between the effects of embolic versus bleeding events on mortality in elderly patients with atrial fibrillation

INTRODUCTION AND OBJECTIVES

Clinical decision-making on anticoagulation in elderly patients with atrial fibrillation (AF) requires clinicians to consider not only the incidence of embolic and bleeding events, but also the risk of death following these adverse events. We aimed to analyze the trade-off between embolic and bleeding events with respect to mortality in elderly patients with AF.

METHODS

The study cohort comprised all patients aged ≥ 75 years from a Spanish health area diagnosed with AF between 2014 and 2017 (n=9365). The risk of death was investigated using Cox proportional hazards models, including embolic and bleeding events as time-dependent binary indicators.

RESULTS

During a median follow-up of 4.0 years, both embolic and bleeding events were associated with a higher risk of death (adjusted HR, 2.39; 95%CI, 2.12-2.69; and adjusted HR, 1.79; 95%CI, 1.64-1.96, respectively). The relative risk of death was 33% higher following an embolism than following a bleeding event (rRR, 1.33; 95%CI, 1.15-1.55), although for transient ischemic attack the risk was lower than for bleeding (rRR, 0.79; 95%CI, 0.63-0.99). The risk of death associated with intracranial hemorrhage was similar to that of major embolisms (RR, 1.00; 95%CI, 0.75-1.29).

CONCLUSIONS

In elderly AF patients, embolic events appeared to be associated with a higher risk of mortality than extracranial bleeding, except for transient ischemic attacks, which have a better prognosis. For ICH, the mortality risk was similar to that of major embolism.

Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation

Background

Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients.

Methods

SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA₂DS₂ -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding.

Results

At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding.

Conclusions

 Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.

Proton Pump Inhibitor Co-Therapy in Patients with Atrial Fibrillation Treated with Oral Anticoagulants and a Prior History of Upper Gastrointestinal Tract Bleeding

PURPOSE

The risk of gastrointestinal bleeding (GIB) can be mitigated by proton pump inhibitor (PPI) co-therapy in patients with atrial fibrillation (AF) treated with anticoagulants. We aimed to evaluate the effect of PPIs on the risk of GIB in Asian patients with AF, treated with oral anticoagulants (OACs), and with a prior history of upper GIB.

METHODS

Using a nationwide claims database, OAC-naïve patients with AF and a history of upper GIB before initiating OAC treatment between January 2010 and April 2018 were included. Patients were categorized into 10 groups according to the index OAC (warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban) and whether or not they received PPI co-therapy, and were followed up for incidence of major GIB.

RESULTS

Among a total of 42,048 patients, 40% were prescribed PPIs as co-therapy with OACs. Over a median 0.6 years (interquartile ranges 0.2-1.7 years) of follow-up, rivaroxaban use without PPIs showed the highest crude incidence of major GIB (2.62 per 100 person-years), followed by the use of warfarin without a PPI (2.20 per 100 person-years). Compared to the patients without PPI use, PPI co-therapy was associated with a significantly lower risk of major GIB, by 40% and 36%, in the rivaroxaban and warfarin groups, respectively. In dabigatran, apixaban, and edoxaban users, PPI co-therapy did not show a significant reduction in the risk of major GIB.

CONCLUSION

Among patients with AF receiving anticoagulant treatment and with a prior history of upper GIB, PPI co-therapy was associated with a significant reduction in the risk of major GIB in patients treated with rivaroxaban and warfarin.

High Frequency of Anticoagulation Management Errors Preceding Ischemic Strokes in Atrial Fibrillation

BACKGROUND AND AIMS

Anticoagulants are recommended to prevent cardioembolic stroke in most patients with atrial fibrillation (AF). Management errors with anticoagulation and use of aspirin instead of anticoagulants have been documented worldwide, especially with vitamin K antagonists. We assessed the rate of anticoagulant mismanagement errors in patients admitted with ischemic stroke, and the clinical correlates with stroke outcomes in the era of non-vitamin K oral anticoagulants.

METHODS

We performed a retrospective analysis of patients admitted with ischemic stroke and history of AF to a single-centre tertiary hospital stroke unit in Melbourne, Australia, between January 2016 and June 2019. We assessed management errors as defined using European Heart Rhythm Association criteria with anticoagulation in the two weeks prior to the index stroke.

RESULTS

A total of 306 patients with AF and ischemic stroke were included, of whom 196 (64%) had management errors. Patients with management errors were older (median age 84 versus 81 years [p=0.002]) and more often female (53% verse 38% [p=0.02]). Of those with management errors, 74 (37%) were not prescribed any anticoagulation despite increased stroke risk and absence of contraindications and 40 (20%) had anticoagulation inappropriately ceased. Mortality at 3-months was 32% in those with management errors, compared to 17% in the appropriately anticoagulated group (p=0.005).

CONCLUSIONS

Inappropriate management of anticoagulants is present in the majority of acute ischemic stroke in the 2 weeks preceding the event and is linked to higher mortality. Improved anticoagulation practice has the potential to substantially reduce stroke rates in patients with AF. This article is protected by copyright. All rights reserved.

Antithrombotic Medication and the Risk of Vitreous Hemorrhage in Atrial Fibrillation: Korean National Health Insurance Service National Cohort

PURPOSE

Antithrombotic therapy could be related with nuisance bleeding. This study investigated whether vitreous hemorrhage (VH) is associated with specific types of antithrombotic medication in patients with atrial fibrillation (AF).

MATERIALS AND METHODS

In the Korean National Health Insurance Service National Sample Cohort, we identified 9352 antiplatelet/anticoagulant-treated AF patients. The occurrence of VH was compared between warfarin (n=1493) and a propensity score (PS)-matched antiplatelet group (n=1493) and between warfarin (n=1493) and a PS-matched warfarin+antiplatelet group (n=1493).

RESULTS

The outcomes of VH were lower in the warfarin than in the matched antiplatelet (1.45 vs. 3.72 events/1000 patient-years) and matched warfarin+antiplatelet groups (1.45 vs. 6.87 events/1000 patient-years). Compared with warfarin, the risk of VH increased with antiplatelet [adjusted hazard ratio (aHR) 3.90; 95% confidence interval (CI) 1.22-12.4, p=0.022] and warfarin+antiplatelet agents (aHR 4.39, 95% CI 1.74-11.2, p=0.002). Compared with warfarin only, warfarin+antiplatelet agents increased the risk of VH in patients ≥65 years, regardless of gender and hypertension. The risk of VH was significantly higher with dual antiplatelet therapy (aHR: 5.02, 95% CI: 1.56-16.2, p=0.007) or in dual (aHR: 5.02, 95% CI: 1.74-14.5, p=0.003) or triple therapy using warfarin and antiplatelet agents than with warfarin monotherapy (aHR: 6.12, 95% CI: 1.76-21.3, p=0.004).

CONCLUSION

Dual antiplatelet or triple therapy increased the risk of VH significantly, compared to warfarin monotherapy. Considering the low efficacy of preventing ischemic stroke and high risk of bleeding, dual or triple therapy using warfarin and antiplatelet agents should be avoided to prevent VH in AF patients.

Outcomes Associated With Apixaban Use in Patients With End-Stage Kidney Disease and Atrial Fibrillation in the United States

BACKGROUND

Patients with end-stage kidney disease (ESKD) on dialysis were excluded from clinical trials of direct oral anticoagulants for atrial fibrillation (AF). Recent data have raised concerns regarding the safety of dabigatran and rivaroxaban, but apixaban has not been evaluated despite current labeling supporting its use in this population. The goal of this study was to determine patterns of apixaban use and its associated outcomes in dialysis-dependent patients with ESKD and AF.

METHODS

We performed a retrospective cohort study of Medicare beneficiaries included in the United States Renal Data System (October 2010 to December 2015). Eligible patients were those with ESKD and AF undergoing dialysis who initiated treatment with an oral anticoagulant. Because of the small number of dabigatran and rivaroxaban users, outcomes were only assessed in patients treated with apixaban or warfarin. Apixaban and warfarin patients were matched (1:3) based on prognostic score. Differences between groups in survival free of stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death were assessed using Kaplan-Meier analyses. Hazard ratios (HRs) and 95% CIs were derived from Cox regression analyses.

RESULTS

The study population consisted of 25 523 patients (45.7% women; 68.2±11.9 years of age), including 2351 patients on apixaban and 23 172 patients on warfarin. An annual increase in apixaban prescriptions was observed after its marketing approval at the end of 2012, such that 26.6% of new anticoagulant prescriptions in 2015 were for apixaban. In matched cohorts, there was no difference in the risks of stroke/systemic embolism between apixaban and warfarin (HR, 0.88; 95% CI, 0.69-1.12; P=0.29), but apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72; 95% CI, 0.59-0.87; P<0.001). In sensitivity analyses, standard-dose apixaban (5 mg twice a day; n=1034) was associated with significantly lower risks of stroke/systemic embolism and death as compared with either reduced-dose apixaban (2.5 mg twice a day; n=1317; HR, 0.61; 95% CI, 0.37-0.98; P=0.04 for stroke/systemic embolism; HR, 0.64; 95% CI, 0.45-0.92; P=0.01 for death) or warfarin (HR, 0.64; 95% CI, 0.42-0.97; P=0.04 for stroke/systemic embolism; HR, 0.63; 95% CI, 0.46-0.85; P=0.003 for death).

CONCLUSIONS

Among patients with ESKD and AF on dialysis, apixaban use may be associated with a lower risk of major bleeding compared with warfarin, with a standard 5 mg twice a day dose also associated with reductions in thromboembolic and mortality risk.

Management of Anticoagulation in Patients with Atrial Fibrillation Undergoing PCI: Double or Triple Therapy?

PURPOSE OF REVIEW

This review aims to discuss the use of antithrombotic therapy in patients with atrial fibrillation who undergo coronary stenting with emphasis on the use of double vs triple therapy.

RECENT FINDINGS

When combined with systemic anticoagulation, dual antiplatelet therapy results in an unacceptable increase in bleeding without any improvement in prevention of thrombotic events. Direct oral anticoagulants combined with single antiplatelet therapy have reduced bleeding compared with warfarin plus dual antiplatelet therapy. Triple anticoagulation therapy with warfarin or direct oral anticoagulants leads to an excess of bleeding and is not superior in preventing thrombotic events. Recent randomized, controlled trials have shown a significant reduction in major bleeding events in patients treated with dual antithrombotic therapy compared with triple therapy without any difference in efficacy. These findings call into question whether triple therapy should remain a part of standard practice.