What is the clinical evidence from this study?

Study design: Cohort. Population: New onset atrial fibrillation (n=7274). Intervention: High Area Deprivation Index (ADI ≥80%) vs. Lower Area Deprivation Index. Primary outcome: Major bleeding events (p=0.02).

March 18, 2021Open Access

Evaluating the effects of socioeconomic status on stroke and bleeding risk scores and clinical events in patients on oral anticoagulant for new onset atrial fibrillation

Key Result

Patients with incident atrial fibrillation on warfarin living in the most socioeconomically deprived neighborhoods (ADI ≥80%) had a significantly increased risk of major bleeding events.

Study Design

Type

Cohort (n=7,274)

Multicenter

Yes

Structured PICO

Does socioeconomic status defined by area deprivation index (ADI) predict ischemic and bleeding events in newly diagnosed atrial fibrillation patients treated with warfarin?

Population

7,274 newly diagnosed patients with atrial fibrillation who were treated with warfarin

Intervention

Stratification by socioeconomic status defined by area deprivation index (ADI)

Comparator

Patients in less deprived ADI quintiles

Outcome

Ischemic and bleeding events during the first year of therapyhard clinical

Socioeconomic status, measured by the Area Deprivation Index, significantly improves the prediction of ischemic events when added to the CHA2DS2-VASc score in patients with incident atrial fibrillation starting warfarin.

Main Result

p-value: p=0.02

Limitations

Retrospective identification of clinical events using ICD-9 and ICD-10 codes with unknown clinical validity of ICD-10 translations
Did not distinguish between paroxysmal versus persistent AF
Patients who sought out-of-network care may not have been captured
Unmeasured confounding variables such as smoking, renal failure, BMI, or blood pressure control were not considered

Abstract

BACKGROUND: The risk of thromboembolism and bleeding before initiation of oral anticoagulant (OAC) in atrial fibrillation patients is estimated by CHA2DS2-VASc and HAS-BLED scoring system, respectively. Patients' socioeconomic status (SES) could influence these risks, but its impact on the two risk scores' predictive performance with respect to clinical events remains unknown. Our objective was to determine if patient SES defined by area deprivation index (ADI), in conjunction with CHA2DS2-VASc and HAS-BLED scores, could guide oral anticoagulation therapy. METHODS AND FINDINGS: The study cohort included newly diagnosed patients with AF who were treated with warfarin. The cohort was stratified by the time in therapeutic range of INR (TTR), ADI, CHA2DS2-VASc, and HAS-BLED risk scores. TTR and ischemic and bleeding events during the first year of therapy were compared across subpopulations. Among 7274 patients, those living in the two most deprived quintiles (ADI ≥60%) had a significantly higher risk of ischemic events and those in the most deprived quintile (ADI≥80%) had a significantly increased risk of bleeding events. ADI significantly improved the predictive performance of CHA2DS2-VASc but not HAS-BLED risk scores. CONCLUSION: ADI can predict increased risk for ischemic and bleeding events in the first year of warfarin therapy in patients with incident AF.

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