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. 2022 May 2;5(5):e2213945.
doi: 10.1001/jamanetworkopen.2022.13945.

Thromboembolic Risk in Patients With Pneumonia and New-Onset Atrial Fibrillation Not Receiving Anticoagulation Therapy

Mette Søgaard  1   2 , Flemming Skjøth  2   3 , Peter B Nielsen  1   2 , Jesper Smit  4 , Michael Dalager-Pedersen  4 , Torben B Larsen  1   2 , Gregory Y H Lip  2   5
Affiliations

Thromboembolic Risk in Patients With Pneumonia and New-Onset Atrial Fibrillation Not Receiving Anticoagulation Therapy

Mette Søgaard et al. JAMA Netw Open. .

Abstract

Importance: New-onset atrial fibrillation (AF) is commonly reported in patients with severe infections. However, the absolute risk of thromboembolic events without anticoagulation remains unknown.

Objective: To investigate the thromboembolic risks associated with AF in patients with pneumonia, assess the risk of recurrent AF, and examine the association of initiation of anticoagulation therapy with new-onset AF.

Design, setting, and participants: This population-based cohort study used linked Danish nationwide registries. Participants included patients hospitalized with incident community-acquired pneumonia in Denmark from 1998 to 2018. Statistical analysis was performed from August 15, 2021, to March 12, 2022.

Exposures: New-onset AF.

Main outcomes and measures: Thromboembolic events, recurrent AF, and all-cause death. Estimated risks were calculated for thromboembolism without anticoagulation therapy, new hospital or outpatient clinic contact with AF, initiation of anticoagulation therapy, and all-cause death at 1 and 3 years of follow-up. Death was treated as a competing risk, and inverse probability of censoring weights was used to account for patient censoring if they initiated anticoagulation therapy conditioned on AF.

Results: Among 274 196 patients hospitalized for community-acquired pneumonia, 6553 patients (mean age [SD], 79.1 [11.0] years; 3405 women [52.0%]) developed new-onset AF. The 1-year risk of thromboembolism was 0.8% (95% CI, 0.8%-0.8%) in patients without AF vs 2.1% (95% CI, 1.8%-2.5%) in patients with new-onset AF without anticoagulation; this risk was 1.4% (95% CI, 1.0%-2.0%) among patients with AF with intermediate stroke risk and 2.8% (95% CI, 2.3%-3.4%) in patients with AF with high stroke risk. Three-year risks were 3.5% (95% CI, 2.8%-4.3%) among patients with intermediate stroke risk and 5.3% (95% CI, 4.4%-6.5%) among patients with high stroke risk. Among patients with new-onset AF, 32.9% (95% CI, 31.8%-34.1%) had a new hospital contact with AF, and 14.0% (95% CI, 13.2%-14.9%) initiated anticoagulation therapy during the 3 years after incident AF diagnosis. At 3 years, the all-cause mortality rate was 25.7% (95% CI, 25.6%-25.9%) in patients with pneumonia without AF vs 49.8% (95% CI, 48.6%-51.1%) in patients with new-onset AF.

Conclusions and relevance: This cohort study found that new-onset AF after community-acquired pneumonia was associated with an increased risk of thromboembolism, which may warrant anticoagulation therapy. Approximately one-third of patients had a new hospital or outpatient clinic contact for AF during the 3-year follow-up, suggesting that AF triggered by acute infections is not a transient, self-terminating condition that reverses with resolution of the infection.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Søgaard reported receiving personal fees for consulting from Bayer AG outside the submitted work. Dr Skjøth reported receiving personal fees from Bayer outside the submitted work. Dr Nielsen reported receiving personal fees from Boehringer Ingelheim, BMS/Pfizer, Bayer, and Daiichi-Sankyo; and research grants from Bayer and Daiichi-Sankyo outside the submitted work. Dr Larsen reported receiving personal fees from Pfizer, Bristol Meyers Squibb, Bayer AG, and Merck Sharp & Dome during the conduct of the study. Dr Lip reported being a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo. No other disclosures were reported.

Figures

Figure.
Figure.. Risk of Thromboembolic Events in Patients Not Receiving Anticoagulation Therapy After Community-Acquired Pneumonia According to Development of New-Onset Atrial Fibrillation (AF)
Patients with new-onset AF were censored when they started anticoagulation therapy and death was treated as a competing risk. Patient data were weighted by the inverse probability of censoring.
See this image and copyright information in PMC

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