Key result
Anaemia in AF linked to ~54% higher risk of death and MACE.
Why the study?
While the relationship between anaemia and bleeding in AF patients on OACs is well established, its prothrombotic role and ethnic variations remain unclear.
Does anaemia increase the risk of mortality, MACE, and major bleeding in patients with atrial fibrillation?
Cohort (n=10,857)
Yes
Does anaemia increase the risk of mortality, MACE, and major bleeding in patients with atrial fibrillation?
Anaemia in patients with atrial fibrillation is associated with significant undertreatment with oral anticoagulants and an increased risk of mortality, adverse cardiovascular events, and major bleeding across both European and Asian populations.
Urges OAC risk-benefit reassessment in anaemic AF; extends poor outcomes to Asian cohorts and leaves optimal strategy open.
Background Anaemia is a common comorbidity in patients with atrial fibrillation (AF) receiving oral anticoagulants (OACs). While its relationship with bleeding is well established, the prothrombotic role and ethnic variations remain unclear. Methods We analysed two large prospective AF registries from Europe (EORP‐AF) and East Asia (APHRS‐AF). Patients were classified by anaemia status at enrolment. Logistic regression assessed clinical correlates and treatment patterns, while multivariable Cox models and propensity score matching (PSM) evaluated outcomes. Restricted cubic spline analyses explored the haemoglobin–risk relationship across ethnic groups. The primary outcome was a composite of all‐cause death and major adverse cardiovascular events (MACE); secondary outcomes included individual components and major bleeding (MB). Results Among 10,857 patients with AF (mean age 69 ± 11 years, 40.0% women), 3372 (31.0%) had anaemia, which clustered with multimorbidity and frailty. Anaemic patients were less likely to receive OACs (OR 0.67, 95% CI 0.58–0.78) and rhythm‐control (OR 0.91, 95% CI 0.81–1.02). Anaemia was independently associated with higher risk of the composite outcome (HR 1.54, 95% CI 1.34–1.78), all‐cause death (HR 1.81, 95% CI 1.51–2.15), MACE (HR 1.39, 95% CI 1.16–1.66), CV death (HR 1.90, 95% CI 1.43–2.54) and MB (HR 1.79, 95% CI 1.31–2.46) consistent also after PSM. Risk increased progressively with anaemia severity, particularly below 10 g/dL. Associations were consistent across Asian and European cohorts. Conclusion Anaemia identifies a vulnerable AF phenotype associated with excess mortality, adverse cardiovascular outcomes and increased bleeding risk, which remains frequently undertreated. Risk rises with anaemia severity, and although biological effects appear consistent across ethnicities, treatment disparities persist. Anaemia should refine, not restrict, therapy within integrated AF care.
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Rigutini et al. (2026) conducted a cohort in Atrial fibrillation (n=10,857). Anaemia vs. No anaemia was evaluated on Composite of all-cause death and major adverse cardiovascular events (MACE) (HR 1.54, 95% CI 1.34-1.78). Anaemia in patients with atrial fibrillation was independently associated with a higher risk of the composite of all-cause death and MACE (HR 1.54; 95% CI 1.34-1.78).
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