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Oral anticoagulation contraindication, increased mortality risk more likely in older patients with AF
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Older patients with atrial fibrillation were more likely to have high bleeding risk contraindications with oral anticoagulation and higher mortality compared with patients who were not treated with oral anticoagulation and did not have contraindications, according to a observational, longitudinal analysis published in JACC: Clinical Electrophysiology.
The use of oral anticoagulation in this older population reduced rates of hospitalization, stroke and death and increased the risk for intracranial hemorrhage, according to the study.
Benjamin A. Steinberg, MD, MHS, FHRS, assistant professor of medicine in the division of cardiovascular medicine at University of Utah Health Sciences Center in Salt Lake City, and colleagues analyzed data from a Medicare sample of patients with prevalent AF and a CHA2DS2-VASc score of 2 or greater.
Patients were categorized as having a contraindication (n = 8,283; mean age; 82 years; 62% women) or no contraindication to oral anticoagulation (n = 18,401; mean age, 81 years; 60% women). An oral anticoagulation contraindication was defined as the presence of one or more of the following: severe, chronic blood dyscrasia; intracranial mass; intracranial hemorrhage; severe/major gastrointestinal bleeding; and end-stage liver disease.
Patients were also categorized as taking oral anticoagulation (n = 12,454; mean age, 80 years; 57% women) or not taking the medication (n = 8,283; mean age, 82 years; 62% women).
The primary analysis focused on contraindications and outcomes among patients not taking oral anticoagulation, whereas the secondary analysis focused on the use of oral anticoagulation and contraindications.
Of the patients with AF who were not treated with oral anticoagulation (n = 26,684), 31% had a contraindication of high bleeding risk, which was primarily a history of gastrointestinal bleeding (40%) and/or blood dyscrasia (75%). Patients with contraindications who were not treated with oral anticoagulation had worse bleeding and ischemic outcomes at 3 years compared with those who did not have contraindications.
Patients who used oral anticoagulation had reduced stroke (adjusted HR = 0.9; 95% CI, 0.83-0.99), mortality (aHR = 0.79; 95% CI, 0.76-0.83) and all-cause hospitalization (aHR = 0.93; 95% CI, 0.9-0.96) compared with those who did not take the medication. The use of oral anticoagulation was associated with an increased risk for intracranial hemorrhage (aHR = 1.42; 95% CI, 1.17-1.72).
“Further research should identify subgroups in which the net clinical benefit favors oral anticoagulation in these high bleeding risk patients vs. other potential treatment modalities such as left atrial appendage occlusion,” Steinberg and colleagues wrote. – by Darlene Dobkowski
Disclosures: The study was supported by a grant from Boston Scientific. Steinberg reports he received research support from Boston Scientific and Janssen and consults for Biosense Webster, Janssen and Merit Medical. Please see the study for all other authors’ relevant financial disclosures.
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