Oral anticoagulation in heart failure complicated by atrial fibrillation: Outcomes in routine data

Background Aim of this study was to test if oral anticoagulant (OAC) use in patients with heart failure (HF), accompanied by atrial fibrillation (AF), leads to a favorable outcome. Further, the specific impact of non-vitamin K oral anticoagulants (NOACs) is analyzed. Methods Anonymous data from all patients with a health insurance at the largest entity which covers approximately 30% of the German population. Patients with a claims record for hospitalization with the main diagnosis of HF and AF from the years 2017 to 2019 were included. A hospital stay in the previous year was an exclusion criterion. Mortality and readmission for all-cause and stroke/intracranial bleeding (ICB) were analyzed 91-365 days after the index hospitalization. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome. Results 180,316 cases were included [81 years (IQR 76 to 86), 55.6% female, CHA 2 DS 2 -VASc score ≥ 2 (96.81%)]. In 80.6%, OACs were prescribed (vitamin K antagonists (VKA): 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%; with multiple prescriptions per patient included). The mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9%. Risk of death was lower with the any OAC (HR 0.77, 95% CI 0.75 to 0.79) but without significant differences in OAC type (VKA: HR 0.73, 95% CI 0.71 to 0.76; FXaI: HR 0.77, 95% CI 0.75 to 0.78; DTI: HR 0.71, 95% CI 0.66 to 0.77). The total readmission rate (HR 0.97, 95% CI 0.94 to 0.99) and readmission for stroke/ICB (HR 0.71, 95% CI 0.65 to 0.77) was lower with OAC. Conclusions Routine data confirm the positive effect of OACs in HF-AF. There are no additional benefits regarding mortality with the use of NOACs. Clinical Perspective What is new? This routine data analysis on a study population of 180,316 indicates a decreasing mortality rate, 91 to 365 days after index hospital stay, in patients with HF complicated by AF in case oral anticoagulants (OACs) were prescribed. Secondly, the findings imply no additional benefits of new OACs (NOACs) compared to vitamin K antagonists. What are the clinical implications? Our study highlights the benefits of a permanent oral anticoagulation therapy in patients with heart failure (HF) complicated by atrial fibrillation (AF). For patients with HF and AF, the results indicate room for personalizationin choosing the specific OAC type for anticoagulation as NOACs show no survival benefit over vitamin K antagonists.