title: Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a 'real world' nationwide cohort study.
abstract: It was the aim of this study to determine the efficacy and safety of vitamin K antagonists (VKAs) and acetylsalicylic acid (ASA) in patients with non-valvular atrial fibrillation (AF), with separate analyses according to predicted thromboembolic and bleeding risk. By individual level-linkage of nationwide registries, we identified all patients discharged with non-valvular AF in Denmark (n=132,372). For every patient, the risk of stroke and bleeding was calculated by CHADS₂, CHA₂DS₂-VASc, and HAS-BLED. During follow-up, treatment with VKA and ASA was determined time-dependently. VKA consistently lowered the risk of thromboembolism compared to ASA and no treatment; the combination of VKA+ASA did not yield any additional benefit. In patients at high thromboembolic risk, hazard ratios (95% confidence interval) for thromboembolism were: 1.81 (1.73-1.90), 1.14 (1.06-1.23), and 1.86 (1.78-1.95) for ASA, VKA+ASA, and no treatment, respectively, compared to VKA. The risk of bleeding was increased with VKA, ASA, and VKA+ASA compared to no treatment, the hazard ratios were: 1.0 (VKA; reference), 0.93 (ASA; 0.89-0.97), 1.64 (VKA+ASA; 1.55-1.74), and 0.84 (no treatment; 0.81-0.88), respectively. There was a neutral or positive net clinical benefit (ischaemic stroke vs. intracranial haemorrhage) with VKA alone in patients with a CHADS₂ score of ≥ 0, and CHA₂DS₂-VASc score of ≥ 1. This large cohort study confirms the efficacy of VKA and no effect of ASA treatment on the risk of stroke/thromboembolism. Also, the risk of bleeding was increased with both VKA and ASA treatment, but the net clinical benefit was clearly positive, in favour of VKA in patients with increased risk of stroke/thromboembolism.
authors.affiliation: Department of Cardiology, Post 635, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark. jo@heart.dk
authors.forename: Jonas Bjerring
authors.initials: JB
authors.lastname: Olesen
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.forename: Jesper
authors.initials: J
authors.lastname: Lindhardsen
authors.forename: Deirdre A
authors.initials: DA
authors.lastname: Lane
authors.forename: Ole
authors.initials: O
authors.lastname: Ahlehoff
authors.forename: Morten Lock
authors.initials: ML
authors.lastname: Hansen
authors.forename: Jakob
authors.initials: J
authors.lastname: Raunsø
authors.forename: Janne Schurmann
authors.initials: JS
authors.lastname: Tolstrup
authors.forename: Peter Riis
authors.initials: PR
authors.lastname: Hansen
authors.forename: Gunnar Hilmar
authors.initials: GH
authors.lastname: Gislason
authors.forename: Christian
authors.initials: C
authors.lastname: Torp-Pedersen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology* / Q000503:physiopathology; D015331:Cohort Studies; D003718:Denmark; D004341:Drug Evaluation; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000494:pharmacology; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries; D018570:Risk Assessment; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D005343:Fibrinolytic Agents; D014812:Vitamin K; D001241:Aspirin