Bleeding and ischaemic events after first bleed in anticoagulated atrial fibrillation patients: risk and timing

Abstract

Aims To determine the risk of subsequent adverse clinical outcomes in anticoagulated patients with atrial fibrillation (AF) who experienced a new bleeding event. Methods and results Anticoagulated AF patients were followed in two prospective cohort studies. Information on incident bleeding was systematically collected during yearly follow-up visits and events were adjudicated as major bleeding or clinically relevant non-major bleeding (CRNMB) according to the International Society on Thrombosis and Haemostasis guidelines. The primary outcome was a composite of stroke, myocardial infarction (MI), or all-cause death. Time-updated multivariable Cox proportional-hazards models were used to compare outcomes in patients with and without incident bleeding. Median follow-up was 4.08 years [interquartile range (IQR): 2.93–5.98]. Of the 3277 patients included (mean age 72 years, 28.5% women), 646 (19.7%) developed a new bleeding, 297 (9.1%) a major bleeding and 418 (12.8%) a CRNMB. The incidence of the primary outcome was 7.08 and 4.04 per 100 patient-years in patients with and without any bleeding [adjusted hazard ratio (aHR): 1.36, 95% confidence interval (CI): 1.16–1.61; P < 0.001; median time between a new bleeding and a primary outcome 306 days (IQR: 23–832)]. Recurrent bleeding occurred in 126 patients [incidence, 8.65 per 100 patient-years (95% CI: 7.26–10.30)]. In patients with and without a major bleeding, the incidence of the primary outcome was 11.00 and 4.06 per 100 patient-years [aHR: 2.04, 95% CI: 1.69–2.46; P < 0.001; median time to a primary outcome 142 days (IQR: 9–518)], and 59 had recurrent bleeding [11.61 per 100 patient-years (95% CI: 8.99–14.98)]. The incidence of the primary outcome was 5.29 and 4.55 in patients with and without CRNMB [aHR: 0.94, 95% CI: 0.76–1.15; P = 0.53; median time to a composite outcome 505 days (IQR: 153–1079)], and 87 had recurrent bleeding [8.43 per 100 patient-years (95% CI: 6.83–10.40)]. Patients who had their oral anticoagulation (OAC) discontinued after their first bleeding episode had a higher incidence of the primary composite than those who continued OAC (63/89 vs. 159/557 patients; aHR: 4.46, 95% CI: 3.16–6.31; P < 0.001). Conclusion In anticoagulated AF patients, major bleeding but not CRNMB was associated with a high risk of adverse outcomes, part of which may be explained by OAC discontinuation. Most events occurred late after the bleeding episode, emphasizing the importance of long-term follow-up in these patients.

Prevention of falls in the elderly and senile patients with cardiovascular diseases

“…Для пациентов с фибрилляцией предсердий, нуждающихся в антикоагулянтной терапии, тщательная оценка риска инсульта (например, CHA2DS2-VASc), кровотечения (например, HAS-BLED) и падений должна быть включена в совместное принятие решения об антикоагулянтной терапии [30]. Оральные антикоагулянты не следует отменять у пациентов с риском падения, и предпочтение следует отдавать прямым оральным антикоагулянтам [28,30] [36].…”

Treatment Patterns of Cancer-associated Thrombosis in the Netherlands: The Four Cities Study

“…Comparable findings were presented in a cohort study with patients with atrial fibrillation and anticoagulation, where major bleeding was associated with a high risk of adverse (thrombotic) outcomes, part of which may be explained by anticoagulation discontinuation. 33 This article is protected by copyright. All rights reserved.…”

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry

“…5 While many modifiable and nonmodifiable risks impact on bleeding events, a higher propensity to bleeding may be observed among Asian populations. 6 These bleeding events may be linked to other unfavorable outcomes such as further SSE, mortality, and recurrent bleeding, 7,8 although more limited data are available from large prospective Asian cohorts of patients with AF. Recent systematic reviews and meta-analyses have provided compelling evidence supporting the safety and favorable outcomes associated with resuming anticoagulation therapy following the resolution of correctable bleeding episodes including intracranial hemorrhage (ICH).…”