Key result
Resuming anticoagulation after major AF bleeding carries a ~7% annual recurrence risk, linked to CKD.
Why the study?
The frequency of anticoagulant therapy resumption after bleeding in high-risk AF patients and the clinical factors associated with recurrent bleeding needed evaluation.
What are the clinical factors associated with recurrence of hemorrhagic complications in high-risk AF patients who resume anticoagulant therapy after a bleeding episode?
Cohort (n=290)
No
What are the clinical factors associated with recurrence of hemorrhagic complications in high-risk AF patients who resume anticoagulant therapy after a bleeding episode?
Resuming anticoagulant therapy after major bleeding in high-risk AF patients is common, but recurrent bleeding occurs frequently and is associated with higher comorbidity burden, CKD, and prior gastrointestinal lesions.
Answers are grounded in this paper and cite their sources.
Recurrent bleeding risk after anticoagulation resumption in high-risk AF warrants individualized assessment; hypothesis-generating and should not yet change practice.
AIM: To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode. MATERIALS AND METHODS: In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding. RESULTS: The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530). CONCLUSION: During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.
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Mironova et al. (2020) conducted a cohort in Atrial fibrillation with high risk of stroke and thromboembolism (n=290). Resumption of anticoagulant therapy after major bleeding vs. Non-resumption of anticoagulant therapy was evaluated on Recurrence of major or clinically significant bleeding. Resumption of anticoagulant therapy after a major bleeding episode in high-risk atrial fibrillation patients resulted in a recurrent bleeding rate of 7.06 per 100 patient-years, which was significantly associated with higher comorbidity, chronic kidney disease, and gastrointestinal lesions.
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