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

Meyre, Pascal B; Blum, Steffen; Hennings, Elisa; Aeschbacher, Stefanie; Reichlin, Tobias; Rodondi, Nicolas; Beer, Jürg H; Stauber, Annina; Müller, Andreas; Sinnecker, Tim; Moutzouri, Elisavet; Paladini, Rebecca E; Moschovitis, Giorgio; Conte, Giulio; Auricchio, Angelo; Ramadani, Alexandra; Schwenkglenks, Matthias; Bonati, Leo H; Kühne, Michael; Osswald, Stefan; ... (2022). Bleeding and ischaemic events after first bleed in anticoagulated atrial fibrillation patients: risk and timing. European Heart Journal, 43(47), pp. 4899-4908. Oxford University Press 10.1093/eurheartj/ehac587

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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.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of General Internal Medicine (DAIM) > Clinic of General Internal Medicine
04 Faculty of Medicine > Medical Education > Institute of General Practice and Primary Care (BIHAM)
04 Faculty of Medicine > Department of General Internal Medicine (DAIM) > Clinic of General Internal Medicine > Centre of Competence for General Internal Medicine
04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology

UniBE Contributor:

Reichlin, Tobias Roman, Rodondi, Nicolas, Moutzouri Beifuss, Elisavet

Subjects:

600 Technology > 610 Medicine & health
300 Social sciences, sociology & anthropology > 360 Social problems & social services

ISSN:

0195-668X

Publisher:

Oxford University Press

Funders:

[4] Swiss National Science Foundation ; [116] Swiss Heart Foundation = Schweizerische Herzstiftung

Language:

English

Submitter:

Pubmed Import

Date Deposited:

28 Oct 2022 14:05

Last Modified:

21 Dec 2022 12:28

Publisher DOI:

10.1093/eurheartj/ehac587

PubMed ID:

36285887

Uncontrolled Keywords:

Atrial fibrillation bleeding death oral anticoagulation outcomes stroke

BORIS DOI:

10.48350/174183

URI:

https://boris.unibe.ch/id/eprint/174183

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