Incidence and outcomes of patients with atrial fibrillation and major bleeding complications: from the TREAT-AF study
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Incidence and outcomes of patients with atrial fibrillation and major bleeding complications: from the TREAT-AF study Alexander C. Perino 1,2 & Daniel W. Kaiser 1 & Randall J. Lee 3 & Jun Fan 2 & Mariam Askari 2 & Susan K. Schmitt 2 & Mintu P. Turakhia 1,2,4 Received: 10 April 2020 / Accepted: 10 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose Optimal stroke prevention strategies for patients with atrial fibrillation (AF) who experience a major bleed are poorly defined. We sought to estimate the effectiveness and safety of oral anticoagulation (OAC) represcription after an OAC contraindication. Methods TREAT-AF is a retrospective cohort study of patients with newly diagnosed AF (2004–2012), treated in the Veterans Health Administration. From this cohort, we identified patients with a contraindication to OAC after AF diagnoses, defined as incident intracranial bleeding, non-intracranial bleeding requiring hospitalization, or unrepaired cerebral aneurysm or aortic dissection. We used multivariate Cox proportional hazards to estimate the association of OAC prescription in the 90 days following OAC contraindication to ischemic stroke and rebleeding. Results Among 167,190 patients with newly diagnosed AF (70 ± 11 years, 1.7% female, CHA2DS2-VASc 2.7 ± 1.7), 19,285 patients (11.5%) had an incident bleed (n = 18,342) or an unrepaired cerebral aneurysm or aortic dissection (n = 943). For OACcontraindicated patients with a CHA2DS2-VASc ≥2 (N = 16,194), OAC was represcribed in 4075 patients (25%) and was associated with a higher risk of non-intracranial bleeding (HR 1.49; 95% CI 1.37–1.61; p < 0.0001) but no difference in intracranial bleeding. There was a trend toward decreased stroke risk (HR 0.85; 95% CI 0.71–1.02; p 0.09). Conclusions Development of contraindication to OAC after diagnosis of AF is common (11.5%), with most events requiring hospitalization. OAC reinitiation was associated with non-intracranial bleeding risk, with a trend toward reduced stroke risk. These data suggest that stroke prevention approaches after major bleeding events could be beneficial if bleeding risk can be successfully mitigated. Keywords Atrial fibrillation . Bleeding . Cardiology . Oral anticoagulation
Abbreviations AF atrial fibrillation
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10840-020-00873-0) contains supplementary material, which is available to authorized users. * Mintu P. Turakhia [email protected] 1
Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
2
Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave 111C, Palo Alto, CA 94304, USA
3
Department of Medicine and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
4
Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
DOAC eGFR GI OAC TIA VA
direct oral anticoagulants estimated glomerular filtration rate gastrointestinal oral anticoagulation tra
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