Anticoagulation therapy and outcomes in patients with atrial fibrillation and serious mental illness: A systematic review and meta-analysis

A systematic review was conducted to investigate prevalence, management and outcomes of atrial fibrillation (AF) in people with Serious Mental Illnesses (SMI) versus the general population. MEDLINE, EMBASE, and PsycINFO were searched for primary research written in English and published between 2004 and 2022. A total of 1459 studies were identified in the initial search of which 16 met the inclusion criteria. Studies (n = 4) reporting on ischaemic stroke and major bleeding events were included in the meta-analysis. Two independent reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Scale. Discrepancies were resolved by consulting a third reviewer. Low rates of AF were reported among people with SMI suggesting under-recognition or recording gaps. People with SMI and AF were less likely to receive oral anticoagulation therapy compared to the general population. When receiving warfarin, those with bipolar disorder experienced poor anticoagulation control as measured by time in INR therapeutic range. Pooled analysis of risk estimates showed that in patients with identified AF, SMI was not significantly associated with an increased risk of stroke (HR: 1.09; 95%CI: 0.85 to 1.40; I2 = 60%, p = 0.04) or major bleeding (HR: 1.11; 95%CI: 0.95 to 1.28; I2 = 57%, p = 0.03) when adjusted for underlying stroke and bleeding risks using the CHA2DS2VASc and HASBLED scales respectively. More research is needed to examine the prevalence, management and outcomes of AF in this population, and to evaluate the effect of the introduction of the novel anti-coagulants on these metrics over time.