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Outcomes Among AF Patients With Good Anticoagulation Control
Study Questions:
What are the risks of stroke/thromboembolism, major bleeding, and future vitamin K antagonist (VKA) control for atrial fibrillation (AF) patients with good anticoagulation control?
Methods:
The authors used the Danish nationwide registry to identify patients initiated on VKA for stroke prevention in AF between 1997 and 2011. Patients were assessed for their VKA control using the time in therapeutic range (TTR) measure for the initial 6 months, then followed for a subsequent 12 months.
Results:
Among 4,772 AF patients who remained on VKA therapy 6 months after initiation, 1,691 (35.4%) had a TTR ≥70%. Among these patients, 513 (55.7%) had a TTR ≥70% in the 12-month follow-up period. Compared to patients with initial 6-month TTR ≥70%, a TTR <70% was not associated with an increased risk of stroke/thromboembolism (adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.77-1.70) or major bleeding (aHR, 1.12; 95% CI, 0.84-1.49) in the 12-month follow-up period. When using a time-dependent TTR analysis, a TTR <70% was associated with a higher risk of stroke/thromboembolism (aHR, 1.91; 95% CI, 1.30-2.82) and major bleeding (aHR, 1.34; 95% CI, 1.02-1.76).
Conclusions:
The authors concluded that a minority of AF patients treated with VKA achieve and maintain good control. Additionally, this level of VKA control had limited long-term prognostic value for stroke/thromboembolism or major bleeding risk.
Perspective:
A number of guidelines and guidance for management of AF stratify VKA versus direct oral anticoagulation recommendations based on the ability to achieve a TTR ≥70%. This analysis suggests that maintaining a TTR ≥70% may lower the risk of stroke/thromboembolism and major bleeding, but prior VKA control may not be an adequate predictor of future VKA control or adverse outcome risk. Therefore, it is reasonable for motivated patients to remain on VKA therapy if this matches their preferences. Efforts to improve or optimize VKA control should be undertaken for all AF patients who remain on VKA therapy to reduce their risk of stroke/thromboembolism and major bleeding.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Hemorrhage, Risk, Secondary Prevention, Stroke, Thromboembolism, Vitamin K
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