AF Patients With Contraindication to Oral Anticoagulation

Study Questions:

What is the prevalence of contraindication to oral anticoagulation (OAC) among patients with atrial fibrillation (AF)?

Methods:

Administrative databases of patients with commercial or Medicare supplemental health insurance were analyzed. Patients were included if claim included a diagnostic code for AF and a contraindication to OAC. Unless a patient died in the hospital, patients were required to have at least 12 months of continuous enrollment. Patients with postoperative AF or those who resumed OAC or subcutaneous heparin within this time frame were excluded.

Results:

Among a total of 1,300,643 patients, 161,606 (12.4%) had a contraindication to OAC. After excluding patients as described above, 43,251 patients comprised the study population. Forty-three percent of these patients had a CHA2DS2-VASc score ≥4. The incidences of ischemic and hemorrhagic stroke were 4.1% and 3.6%, respectively. For patients with a history of intracranial/intracerebral hemorrhage (ICH), the incidences of ischemic and hemorrhagic stroke were 12% and 20%, respectively. The annual mortality rates among the study cohort and those with prior ICH were 13% and 23%, respectively.

Conclusions:

The authors concluded that AF patients with a contraindication to OAC are common and are at high risk for both ischemic and hemorrhagic strokes, and death.

Perspective:

Studies utilizing warfarin and novel OACs have clearly shown the benefit of OACs in patients with AF and at risk for thromboembolism. However, these studies did not include patients with a contraindication to OACs; and hence, the utility/safety of OACs in this population remains unexplored. This study confirms that such patients are common and remain at high risk for both ischemic and hemorrhagic events. There is a dire unmet need as to the optimal treatment of patients with a contraindication to OACs. Left atrial appendage occlusion devices do allow patients to avoid long-term OAC; however, periprocedural and short-term post-procedure anticoagulation are still required. There are emerging data suggesting that post-procedure anticoagulation may be attenuated in patients at risk of bleeding, but definitive studies are lacking in this realm.


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