Duration of Diabetes Mellitus and Risk of Thromboembolism and Bleeding in Atrial Fibrillation

Abstract

Background and Purpose-Guidelines advocate anticoagulant treatment to all patients with atrial fibrillation and concomitant diabetes mellitus. The potential refinement to thromboembolic risk stratification that may spring from subdividing diabetes mellitus is unexplored. The purpose was to investigate duration of diabetes mellitus as a predictor of thromboembolism and anticoagulant-related bleeding in patients with atrial fibrillation. Methods-Using nationwide Danish registries, we identified all patients discharged from hospital with an incident diagnosis of atrial fibrillation from 2000 to 2011. Hazard ratios with 95% confidence intervals for thromboembolism and bleeding according to years of diabetes mellitus duration in categories (0-4, 5-9, 10-14, and ≥15) and as a continuous variable using cubic splines were calculated by Cox regression. Results-The study population comprised 137 222 patients with atrial fibrillation, of which 12.4% had diabetes mellitus.Compared with patients without diabetes mellitus and after adjustment for anticoagulant treatment and CHA 2 DS 2 -VASc components (congestive heart failure, hypertension, age, previous stroke, vascular disease, and sex), the risk of thromboembolism was lowest in the 0 to 4 years duration category (hazard ratio, 1.11; 95% confidence interval, 1.03-1.20), and highest in the longest duration category of ≥15 years (hazard ratio, 1.48; 95% confidence interval, 1.29-1.70). When analyzed as a continuous variable, duration of diabetes mellitus was associated with risk of thromboembolism in a dose-response-dependent manner, but not with a higher risk of bleeding during anticoagulant treatment. Conclusions-In patients with atrial fibrillation, longer duration of diabetes mellitus was associated with a higher risk of thromboembolism, but not with a higher risk of anticoagulant-related bleeding. Considering the critical balance between preventing thromboembolism and avoiding bleeding, longer duration of diabetes mellitus may favor initiation of anticoagulant therapy.

Left atrial appendage occlusion for stroke prevention in diabetes mellitus patients with atrial fibrillation: Long‐term results

“…In the study of Overvad et al, during 4 years of diabetes in patients on OAC, the incidence rate of bleeding was 6.8, whereas in the present cohort of patients there were no episodes of severe bleeding. Overvad et al also found that indication of a lower bleeding risk with a longer duration of DM. In a study of patients with type 1 DM, the duration of DM was found to be a risk predictor for ischemic stroke, but not hemorrhagic stroke .…”

“…However, the observed bleeding rates in patients with versus without diabetes are inconsistent . In the study of Overvad et al, during 4 years of diabetes in patients on OAC, the incidence rate of bleeding was 6.8, whereas in the present cohort of patients there were no episodes of severe bleeding. Overvad et al also found that indication of a lower bleeding risk with a longer duration of DM.…”

“…Moreover, DM patients taking non‐vitamin K oral anticoagulants have a greater absolute thromboembolic risk reduction, but also an increased risk of bleeding . The longer the duration of DM in patients with AF, the greater the risk of thromboembolism …”

Type 2 diabetes increases the long‐term risk of heart failure and mortality in patients with atrial fibrillation

“…Although T2DM has been associated with increased incidence of AF in the general population and with a higher risk of stroke and thromboembolism among patients with AF, a limited number of studies have investigated the prevalence and prognostic impact of T2DM on non‐thromboembolic outcomes in individuals with AF. The reported prevalence of T2DM in contemporary observational studies and clinical trials of AF patients has shown a broad variation (i.e.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Cukrzyca jest czynnikiem ryzyka udaru mózgu i innych powikłań AF [284]. U pacjentów z AF dłuższy czas trwania cukrzycy wydaje się związany z większym ryzykiem powikłań zakrzepowo-zatorowych, natomiast nie zwiększa ryzyka krwawień związanych z OAC [285]. Niestety, intensywna kontrola glikemii nie wpływa na częstość występowania nowego AF [284], chociaż wydaje się, że leczenie metforminą wiąże się ze zmniejszeniem długoterminowego ryzyka AF u chorych na cukrzycę [286], a być może nawet z mniejszym ryzykiem udaru mózgu w długoterminowej obserwacji [13].…”