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Anticoagulation in Device-Detected AF With or Without Vascular Disease
Quick Takes
- Among patients with device-detected atrial fibrillation (DDAF), nearly half had concomitant vascular disease at baseline.
- There was no statistically significant difference in the benefits or risk of anticoagulation therapy between DDAF patients with and without baseline vascular disease.
- There was a trend towards greater reduction in the composite of ischemic events among DDAF patients with vascular disease than those without vascular disease.
Study Questions:
What is the impact of concomitant vascular disease on the benefits and risks of anticoagulation for patients with device-detected atrial fibrillation (DDAF)?
Methods:
The authors combined data from the NOAH-AFNET 6 (n = 2,534) and ARTESiA (n = 4,012) patients where anticoagulation to no anticoagulation was compared in patients with DDAF. Concomitant vascular disease was defined as the presence of prior stroke or transient ischemic attack, coronary artery disease, or peripheral artery disease. Efficacy outcomes matched those from both trials, a composite of stroke, systemic arterial embolism, myocardial infarction, pulmonary embolism, or cardiovascular death. Safety outcomes were major bleeding and the composite of major bleeding and death.
Results:
Both trials included a significant proportion of patients with concomitant vascular disease (46-56%). In meta-analysis, the incidence rate ratio (IRR) of anticoagulation therapy for the composite efficacy outcome was 0.75 (95% confidence interval [CI], 0.61-0.92) and 1.01 (95% CI, 0.76-1.36) for patients with and without vascular disease, respectively (p for interaction = 0.08). The safety outcomes of major bleeding showed that an IRR of anticoagulation therapy was 1.55 (95% CI, 1.10-2.20) and 1.93 (95% CI, 0.72-5.20) for patients with and without vascular disease, respectively. The safety composite outcome of major bleeding or death showed an IRR of 1.12 (95% CI, 0.95-1.30) and 1.25 (95% CI, 0.98-1.58) for patients with and without vascular disease, respectively.
Conclusions:
The authors conclude that patients with DDAF and vascular disease are at higher risk of stroke and cardiovascular events than those without vascular disease. Furthermore, they concluded that patients with vascular disease and DDAF may derive greater benefit from anticoagulation than patients without vascular disease.
Perspective:
For patients with clinical AF, anticoagulation is strongly recommended given its clear benefit in reducing stroke and systemic embolism. However, that benefit is less clear for patients with DDAF. This analysis of two key trials explored the benefits and risks of anticoagulation therapy based on the presence or absence of concomitant vascular disease. When pooled together using a meta-analytic approach, the study found a trend towards greater reduction in the composite of ischemic outcomes in patients with as compared to without concomitant vascular disease; however, this did not quite reach statistical significance. Both groups of patients experienced higher risks of bleeding with anticoagulation therapy, but this was only significant for patients with a history of vascular disease. Based on these findings, anticoagulation therapy should not be recommended routinely for patients with DDAF, even among those with concomitant vascular disease. However, the threshold to start anticoagulation therapy may be lower in patients with concomitant vascular disease if other stroke risk factors are present and the risk of anticoagulant-related bleeding is sufficiently low.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Vascular Medicine
Keywords: Anticoagulants, Atrial Fibrillation, Stroke, Vascular Diseases
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