Response to: Kumar N, Ahmed M. Letter to the editor in response to Komen et al. 2021.

Sir,

We would like to thank Drs Kumad and Ahmed for their interest in our work. They raise three main points. The first point they mention states that 90-day mortality after a gastrointestinal (GI) bleed in our patients with atrial fibrillation (AF) is lower compared to patients without a GI bleed. However, the patients in our cohort without a GI bleed were included based on hospitalizations for an ischaemic stroke or an intracranial haemorrhage. We believe our results are in line with what one might expect, namely that the 90-day mortality is lower after a GI bleed than after an ischaemic stroke or an intracranial haemorrhage.

The second point concerns anaemia. We agree with Kumad and Ahmed that a subgroup analysis including only patients with anaemia would be of interest. However, since ∼20% of our patients had a history of anaemia, and the confidence intervals in each of our analyses were wide, we lack statistical power to perform such analyses. We agree that such an analysis would be of interest in a larger database.

The third point concerns obesity. The work by Briasoulis et al. assessed the risk for a GI bleed in obese patients, comparing non-vitamin K antagonist oral anticoagulant (NOAC) to warfarin treatment and showed a significantly lower risk for NOACs compared to warfarin. However, our study does not concern the risk of suffering a GI bleed as it focuses on the risk for mortality after a GI bleed and if this was associated with the treatment preceding the event. In our study, it is not possible to derive whether any treatment was associated with an increased or decreased risk for a GI bleed, merely whether outcomes in the 90 days following the event differed with the treatment received before the event.

Conflict of interest: J.J.K. reports personal fees from Boehringer Ingelheim, outside the submitted work; O.H.K. reports grants from GSK and Lygature; personal fees from Roche, outside the submitted work; F.B. reports personal fees from Boehringer Ingelheim, St Jude Medical, Boston Scientific, Medtronic, and Biotronic, outside the submitted work. All other authors declare no conflict of interest.