Bleeding Risk Scores in Atrial Fibrillation: Helpful or Harmful?

Edmiston, Marissa K.; Lewis, William R.

doi:10.1161/jaha.118.010582

Cited by 19 publications

(11 citation statements)

References 14 publications

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“…Indeed, risk stratification scores serve as tools to guide treatment decisions and must not be used as replacements for existing evidence and/or clinical judgement, i.e., bleeding risk scores should be used to identify patients who are at a higher risk of bleeding, to initiate closer monitoring strategies as advocated by the guidelines (34, 36). Yet, they are often used to justify withholding OAC therapy from patients who have an equal or higher risk of stroke (44). In their study, Friberg et al (45), demonstrated that the risk of ischaemic stroke without OAC was higher than the risk of bleeding with OAC, unless the risk of ischaemic stroke was very low (CHA 2 DS 2 -VASc = 0).…”

Section: Anticoagulation In Older Peoplementioning

confidence: 99%

Atrial Fibrillation in Older People: Concepts and Controversies

et al. 2019

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Atrial fibrillation (AF) is the commonest cardiac rhythm abnormality and has a significant disease burden. Amongst its devastating complications is stroke, the risk of which increases with age. The stroke risk in an older person with AF is therefore tremendous, and oral-anticoagulation (OAC) therapy is central to minimizing this risk. The presence of age-associated factors such as frailty and multi-morbidities add complexity to OAC prescription decisions in older patients and often, OAC is needlessly withheld from them despite a lack of evidence to support this practice. Generally, this is driven by an over-estimation of the bleeding risk. This review article provides an overview of the concepts and controversies in managing AF in older people, with respect to the existing evidence and current practice. A literature search was conducted on Pubmed and Cochrane using keywords, and relevant articles published by the 1st of May 2019 were included. The article will shed light on common misconceptions that appear to serve as rationale for precluding OAC and focus on clinical considerations that may aid OAC prescription decisions where appropriate, to optimize AF management using an integrated, multi-disciplinary care approach. This is crucial for all patients, particularly older individuals who are most vulnerable to the deleterious consequences of this condition.

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Section: Anticoagulation In Older Peoplementioning

confidence: 99%

Atrial Fibrillation in Older People: Concepts and Controversies

et al. 2019

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“…6 Among patients with AF, stroke risk is mitigated via the usage of anticoagulants; however, treatment can be associated with increased risk of bleeding. 7 Therefore, clinical management decisions regarding appropriate thromboprophylaxis for NVAF patients require the assessment of stroke risk and bleeding risk in each patient, using validated measures such as CHADS 2 and CHA 2 DS 2 -VASc (for stroke) and HAS-BLED (for bleeding) scores. 8 However, while anticoagulation has been demonstrated to effectively prevent stroke in patients with NVAF, [9][10][11] elderly patients are often undertreated, despite this population having a higher risk for stroke.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Background characteristics and anticoagulant usage patterns of elderly non-valvular atrial fibrillation patients in the ANAFIE registry: a prospective, multicentre, observational cohort study in Japan

et al. 2021

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ObjectiveTo explore anticoagulant usage patterns stratified by stroke and bleeding risk in elderly patients with non-valvular atrial fibrillation (NVAF).DesignProspective, multicentre, observational cohort study.SettingThe real-world All Nippon AF In the Elderly (ANAFIE) registry.ParticipantsJapanese patients aged ≥75 years with NVAF (n=32 726).Outcome measuresThe distribution of stroke and bleeding risk scores, and the selection of anticoagulant regimen for patients at high stroke and bleeding risk.ResultsOverall, 18 185 (55.6%) patients had a high risk of stroke (CHADS2 score ≥3). Of these, 12 561 (38.4% of the total ANAFIE population) had a low bleeding risk (HAS-BLED ≤2) and 5624 (17.2%) had a high bleeding risk (HAS-BLED ≥3). Significant differences were noted between the high versus low bleeding risk groups in sex, height, weight, systolic blood pressure and rates of abnormality of lipid metabolism, gastrointestinal disease, cerebrovascular disorders, chronic kidney disease, angina pectoris, respiratory disease, primary malignant tumour, dementia and fall history within the past year (all p<0.0001). Patients with high stroke and bleeding risks had a lower anticoagulant usage rate versus the low bleeding risk group, and 8.7% and 5.8%, respectively, were not receiving any anticoagulant (p<0.0001). Patients in the high bleeding risk group had a higher usage of warfarin versus the low bleeding risk group (p<0.0001); more patients (14.0%) in the high bleeding risk group receiving warfarin had time in the therapeutic range <40%, versus those in the low bleeding risk group (11.6%, p=0.0146). Direct-acting oral anticoagulants (DOACs) were used less in the high bleeding risk group, without notable differences in the DOAC dose distribution between the two groups.ConclusionsIn elderly NVAF patients at high stroke risk, significant demographic and clinical differences were observed according to bleeding risk. Administration of low-dose DOACs was frequent, but the dose distribution was unaffected by bleeding risk.Trial registration numberUMIN000024006 (http://www.umin.ac.jp/).

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“…Therefore, these scores, which already have modest accuracy and little value in the general population [14,34,[64][65][66], are unlikely to be useful in predicting bleeding in patients with active cancer. Indeed, in line with this idea, D'Souza et al [16] showed that the predictive value of the CHA 2 DS 2 VASc score was very limited, with 2-year incidences of bleeding leading to hospitalization of 4.3%, 4.4% and 6.8% in patients with CHA 2 DS 2 VASc of 0, 1 and 2-9, respectively, in a cohort of patients hospitalized with AF and with a history of recent (<5 years) cancer.…”

Section: How Should Hemorrhagic Risk Be Assessed In Patients With Canmentioning

confidence: 99%

Oral anticoagulation in patients with active cancer and atrial fibrillation: current challenges

Sorigué

2020

Polish Archives of Internal Medicine

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This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (CC BY-NC-SA 4.0), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited, distributed under the same license, and used for noncommercial purposes only.

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Bleeding Risk Scores in Atrial Fibrillation: Helpful or Harmful?

Cited by 19 publications

References 14 publications

Atrial Fibrillation in Older People: Concepts and Controversies

Atrial Fibrillation in Older People: Concepts and Controversies

Background characteristics and anticoagulant usage patterns of elderly non-valvular atrial fibrillation patients in the ANAFIE registry: a prospective, multicentre, observational cohort study in Japan

Oral anticoagulation in patients with active cancer and atrial fibrillation: current challenges

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