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Observational Study
. 2019 Dec;5(12):1384-1392.
doi: 10.1016/j.jacep.2019.07.011. Epub 2019 Oct 2.

Ischemic and Bleeding Outcomes in Patients With Atrial Fibrillation and Contraindications to Oral Anticoagulation

Benjamin A Steinberg  1 , Nicholas G Ballew  2 , Melissa A Greiner  2 , Steven J Lippmann  2 , Lesley H Curtis  3 , Emily C O'Brien  3 , Manesh R Patel  4 , Jonathan P Piccini  5
Affiliations
Observational Study

Ischemic and Bleeding Outcomes in Patients With Atrial Fibrillation and Contraindications to Oral Anticoagulation

Benjamin A Steinberg et al. JACC Clin Electrophysiol. 2019 Dec.

Abstract

Objectives: This study sought to describe clinical outcomes among patients with atrial fibrillation (AF) and contraindications to oral anticoagulation (OAC).

Background: Treatment with OAC prevents stroke and death in patients with AF, but may be contraindicated among patients at high bleeding risk.

Methods: This was an observational, longitudinal analysis of a nationally representative 5% Medicare sample of patients with chronic AF and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score ≥2. They were stratified by both the presence of high bleeding risk contraindications to OAC and by OAC use. We assessed 3-year ischemic and bleeding outcomes using multivariable Cox proportional hazards models adjusted for relevant patient characteristics.

Results: Among 26,684 AF patients not treated with OAC, 8,283 (31%) had a high bleeding risk contraindication, primarily a blood dyscrasia (75%) or history of gastrointestinal bleeding (40%). Without OAC, patients with contraindications had worse ischemic and bleeding outcomes at 3 years compared with those without contraindications. We also identified 12,454 patients with OAC contraindications who received OAC. Compared with patients not receiving OAC, use of OAC was associated with reduced mortality (adjusted hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.83), stroke (adjusted HR: 0.90; 95% CI: 0.83 to 0.99), and all-cause hospitalization (adjusted HR: 0.93; 95% CI: 0.90 to 0.96) but increased risk of intracranial hemorrhage (adjusted HR: 1.42; 95% CI: 1.17 to 1.72).

Conclusions: High bleeding risk contraindications to OAC are common among older patients with AF, and these patients have higher mortality compared with untreated patients without OAC contraindications. The use of OAC in these patients is associated with lower rates of all-cause stroke, hospitalization, and death but higher risk of intracranial hemorrhage.

Keywords: Medicare; anticoagulation; atrial fibrillation; contraindication; outcomes.

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Figures

CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Outomes Among for Atrial Fibrillation Patients by OAC Contraindications and OAC Use
(A and B) Unadjusted cumulative 3-year event rates for patients with atrial fibrillation who were not on oral anticoagulation (OAC) medication. Event rates are presented by contraindication status to OAC. For mortality, we calculated the event rate as the Kaplan-Meier estimator. For all other outcomes, we calculated the event rate using the cumulative incidence function, which accounts for competing risk of death. The vertical dashed gray lines note 1 and 2 years from the index date (January 1, 2008). (C) Adjusted hazard ratios for the associations between OAC use and outcomes, among only AF patients with at least 1 OAC contraindication. GI = gastrointestinal; HR = hazard ratio; ICH = intracranial hemorrhage; OAC = oral anticoagulation; TIA = transient ischemic attack.
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References

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