Outcomes of Patients With Atrial Fibrillation Newly Recommended for Oral Anticoagulation Under the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society Guideline

Abstract

BackgroundIn March 2014, the American Heart Association updated their guidelines for the management of oral anticoagulation (OAC) in atrial fibrillation, recommending OAC for all patients with CHA 2 DS 2‐VASc ≥2. Previously, only patients with CHADS 2 ≥2 were recommended for anticoagulation. This study compared effectiveness and safety outcomes of OAC among patients who would receive OAC using the 2014 guidelines but not the 2011 guidelines.Methods and ResultsUsing claims data from a 5% sample of 2013–2014 Medicare beneficiaries, we identified patients with initially diagnosed atrial fibrillation between 2013 and 2014 and selected those who would receive OAC under the 2014 guidelines but not the 2011 guidelines (those with CHA 2 DS 2‐VASc score ≥2 or CHADS 2 score <2). Patients were categorized according to their use of OAC after first atrial fibrillation diagnosis (2937 users and 2914 nonusers). Primary outcomes included the composite of ischemic stroke, systemic embolism and death, and any bleeding event. Cox proportional hazard models were constructed to compare the risk of primary outcomes between the 2 groups, while controlling for patient demographic and clinical characteristics. There was no difference in the combined risk of stroke, systemic embolism, and death between the treatment groups (hazard ratio, 1.00; 95% confidence interval, 0.84–1.20). The risk of bleeding was higher for patients receiving OAC than for patients not receiving OAC (hazard ratio, 1.70, 95% confidence interval, 1.46–1.97).ConclusionsThe benefit of OAC is not well defined in this patient population, and new studies that minimize residual confounding are needed to fully understand the risk/benefit of OAC in patients with atrial fibrillation and low to moderate stroke risk.

Management of antithrombotic therapy in patients with atrial fibrillation and acute coronary syndromes

“…Also, the 2019 updated North American AF guidelines, suggest that use of DAPT alone may be enough for AF/ACS patients who have a CHA 2 DS 2 -VASc score of 0 to 1, with constant reassessment for anticoagulation over time [5]. An observational study showed that, for an AF patient with a CHA 2 DS 2 -VASc score of 2 to 4 or a CHADS 2 score <2, OAC administration did not result in a reduction of composite ischaemic and thrombotic events and led to more bleeding instead [92]. DAPT had a higher protective effect against stroke than aspirin alone, but lesser when compared to OAC [25].…”

Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome—Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy?

“…Moreover, DAPT yielded a highly significant reduction in the risk of intracranial hemorrhage, although this finding might have been amplified by the use of warfarin instead of NOAC in the TAT group [ 17 , 18 ]. In a recent claim-based large observational study, the benefit of OAC in AF patients with a CHA 2 DS 2 VASc score 2–4 and a CHADS 2 score <2 before the use of OAC did not result in a lower composite risk of stroke, systemic embolism, and death (hazard ratio, HR: 1.00), yet it was associated with a higher risk of bleeding (HR: 1.70, 95% confidence interval (CI), 1.46–1.97) [ 19 ]. Finally, a temporary suspension of oral anticoagulation has been proved reasonably safe in some clinical settings: in the BRIDGE trial, patients undergoing invasive procedures who discontinued warfarin with no bridging with dalteparin did not show any increase of thromboembolic events despite almost 10 days of likely sub-therapeutic International Normalized Ratio (INR) [ 20 ].…”