Incidence, predictors of bleeding and prognosis of bleeding in anticoagulated nonagenarian patients with atrial fibrillation

Highlights

• The incidence rate of major bleeding in nonagenarian patients underwent oral anticoagulation therapy (OAT) is low.

• Different predictors of bleeding were found for  vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). 3) HAS-BLED was not a predictor of major bleeding in our study with nonagenarians.

Abstract

Background

The prevalence of atrial fibrillation (AF) increases with age. The prescription of anticoagulation in very elderly patients is controversial and sometimes underused. Our objective is to report the incidence and predictors of major bleeding in anticoagulated nonagenarian patients with non valvular atrial fibrillation (NVAF).

Methods

We analyzed a large multicentre registry of anticoagulated nonagenarian patients diagnosed with NVAF from three health areas of Spain, between 2013 and 2017. Predictors of major bleeding were studied with a competing risk analysis and the impact of major bleeding with a time-dependent mortality analysis.

Results

The incidence rate of major bleeding was 5 per100 person-year (95% Confidence Interval [CI]: 4.59–6.35), similar in the group of patients with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). In the VKAs group we found as predictors of major bleeding: previous admission for bleeding (sub-distribution hazard ratio [sHR] 3.25, 95% CI: 1.48–7.13), creatinine (sHR 1.38, 95% CI: 1.16–1.64,) and control out-of-range INR (sHR 1.90, 95% CI: 1.02–3.55). In DOAC group, male sex (sHR 1.92, 95% CI: 1.18–3.13) and the history of previous admission for bleeding (sHR 2.60, 95% CI 1.33–5.06) were found as a predictor. The HAS-BLED was not associated with major bleeding. Major bleeding was associated with increased mortality in both VKAs and DOAC groups without significant differences.

Conclusions

We found an incidence rate of major bleeding with relative low values, similar in those treated with VKAs and those treated with DOAC, with different predictors of major bleeding in each group. Major bleeding was associated with increased mortality, with no significant difference by oral anticoagulation therapy (OAT).

Introduction

Atrial fibrillation (AF) is a pathology whose prevalence increases with age [1]. The guidelines classify the patient ≥75 years as high ischemic risk, so there would be an indication for anticoagulation, after an adequate analysis of the ischemic-hemorrhagic balance. This situation supposes a frequent dilemma for the clinician. Because with the progressive aging of the population, it has become a daily scene. The conflict is that, although oral anticoagulation therapy (OAT) reduces the risk of embolic events in patients with AF, it also increases the risk of bleeding, with an independent impact on mortality [2].

Additionally, for decision-making, in elderly patients, we must bear in mind account polypharmacy [3] and possible comorbidities that condition great variability between patients. Although recent studies indicate that the benefit of anticoagulation extends to older patients [4], real-life data reveals that the prescription of OAT is inversely proportional to the age. OAT is underutilized in elderly patients due to clinician's perception that such therapy is not safe [5]. In fact, 25–65% of elderly patients with AF in the real world are not prescribed OAT [6].

The evidence available in very old patients is scarce. For all these reasons, there is a need to improve evidence on this field. With our study, we intend to contribute to increase the knowledge regarding anticoagulation in elderly patients by analyzing the incidence, predictors and prognosis of major bleeding in anticoagulated nonagenarian patients with nonvalvular atrial fibrillation (NVAF).