Benjamin A Steinberg1, Nicholas G Ballew2, Melissa A Greiner2, Steven J Lippmann2, Lesley H Curtis3, Emily C O'Brien3, Manesh R Patel4, Jonathan P Piccini5. 1. Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah. Electronic address: benjamin.steinberg@hsc.utah.edu. 2. Department of Population Health Sciences, Duke University, Durham, North Carolina. 3. Department of Population Health Sciences, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina. 4. Duke Clinical Research Institute, Durham, North Carolina; Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, North Carolina. 5. Department of Population Health Sciences, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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.
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 AFpatients 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.
Authors: Ron Pisters; Deirdre A Lane; Robby Nieuwlaat; Cees B de Vos; Harry J G M Crijns; Gregory Y H Lip Journal: Chest Date: 2010-03-18 Impact factor: 9.410
Authors: Elena Birman-Deych; Amy D Waterman; Yan Yan; David S Nilasena; Martha J Radford; Brian F Gage Journal: Med Care Date: 2005-05 Impact factor: 2.983
Authors: Jonathan P Piccini; Moritz F Sinner; Melissa A Greiner; Bradley G Hammill; João D Fontes; James P Daubert; Patrick T Ellinor; Adrian F Hernandez; Allan J Walkey; Susan R Heckbert; Emelia J Benjamin; Lesley H Curtis Journal: Circulation Date: 2012-09-26 Impact factor: 29.690
Authors: Jonathan P Piccini; Bradley G Hammill; Moritz F Sinner; Paul N Jensen; Adrian F Hernandez; Susan R Heckbert; Emelia J Benjamin; Lesley H Curtis Journal: Circ Cardiovasc Qual Outcomes Date: 2012-01-10
Authors: Stuart J Connolly; John Eikelboom; Campbell Joyner; Hans-Christoph Diener; Robert Hart; Sergey Golitsyn; Greg Flaker; Alvaro Avezum; Stefan H Hohnloser; Rafael Diaz; Mario Talajic; Jun Zhu; Prem Pais; Andrzej Budaj; Alexander Parkhomenko; Petr Jansky; Patrick Commerford; Ru San Tan; Kui-Hian Sim; Basil S Lewis; Walter Van Mieghem; Gregory Y H Lip; Jae Hyung Kim; Fernando Lanas-Zanetti; Antonio Gonzalez-Hermosillo; Antonio L Dans; Muhammad Munawar; Martin O'Donnell; John Lawrence; Gayle Lewis; Rizwan Afzal; Salim Yusuf Journal: N Engl J Med Date: 2011-02-10 Impact factor: 91.245
Authors: Vivek Y Reddy; Shephal K Doshi; Saibal Kar; Douglas N Gibson; Matthew J Price; Kenneth Huber; Rodney P Horton; Maurice Buchbinder; Petr Neuzil; Nicole T Gordon; David R Holmes Journal: J Am Coll Cardiol Date: 2017-11-04 Impact factor: 24.094