Antithrombotic treatment in patients with heart failure and associated atrial fibrillation and vascular disease

a nationwide cohort study

Morten Lamberts, Gregory Y H Lip, Martin H Ruwald, Morten Lock Hansen, Cengiz Özcan, Søren L Kristensen, Lars Køber, Christian Torp-Pedersen, Gunnar H Gislason

    Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

    Resumé

    OBJECTIVES: The aim of this study was to investigate the impact of atrial fibrillation (AF) and antithrombotic treatment on the prognosis in patients with heart failure (HF) as well as vascular disease.

    BACKGROUND: HF, vascular disease, and AF are pathophysiologically related, and understanding antithrombotic treatment for these conditions is crucial.

    METHODS: In hospitalized patients with HF and coexisting vascular disease (coronary artery disease or peripheral arterial disease) followed from 1997 to 2009, AF status was categorized as prevalent AF, incident AF, or no AF. Risk of thromboembolism (TE), myocardial infarction (MI), and serious bleeding was assessed by Cox regression models (hazard ratio [HR] with 95% confidence interval [CI]) with antithrombotic therapy and AF as time-dependent variables.

    RESULTS: A total of 37,464 patients were included (age, 74.5 ± 10.7 years; 36.3% females) with a mean follow-up of 3 years during which 20.7% were categorized as prevalent AF and 17.2% as incident AF. Compared with vitamin K antagonist (VKA) in prevalent AF, VKA plus antiplatelet was not associated with a decreased risk of TE (HR: 0.91; 95% CI: 0.73 to 1.12) or MI (HR: 1.11; 95% CI: 0.96 to 1.28), whereas bleeding risk was significantly increased (HR: 1.31; 95% CI: 1.09 to 1.57). Corresponding estimates for incident AF were HRs of 0.77 (95% CI: 0.56 to 1.06), 1.07 (95% CI: 0.89 to 1.28), and 2.71 (95% CI: 1.33 to 2.21) for TE, MI, and bleeding, respectively. In no AF patients, no statistical differences were seen between antithrombotic therapies in TE or MI risk, whereas bleeding risk was significantly increased for VKA with and without single-antiplatelet therapy.

    CONCLUSIONS: In AF patients with coexisting HF and vascular disease, adding single-antiplatelet therapy to VKA therapy is not associated with additional benefit in thromboembolic or coronary risk, but notably increased bleeding risk.

    OriginalsprogEngelsk
    TidsskriftJournal of the American College of Cardiology
    Vol/bind63
    Udgave nummer24
    Sider (fra-til)2689-98
    Antal sider10
    ISSN0735-1097
    DOI
    StatusUdgivet - 24. jun. 2014

    Fingeraftryk

    Cohort Studies
    Confidence Intervals
    Proportional Hazards Models
    Coronary Artery Disease

    Citer dette

    Lamberts, Morten ; Lip, Gregory Y H ; Ruwald, Martin H ; Hansen, Morten Lock ; Özcan, Cengiz ; Kristensen, Søren L ; Køber, Lars ; Torp-Pedersen, Christian ; Gislason, Gunnar H. / Antithrombotic treatment in patients with heart failure and associated atrial fibrillation and vascular disease : a nationwide cohort study. I: Journal of the American College of Cardiology. 2014 ; Bind 63, Nr. 24. s. 2689-98.
    @article{815a9328f2df4f05be4eacb8f05ca162,
    title = "Antithrombotic treatment in patients with heart failure and associated atrial fibrillation and vascular disease: a nationwide cohort study",
    abstract = "OBJECTIVES: The aim of this study was to investigate the impact of atrial fibrillation (AF) and antithrombotic treatment on the prognosis in patients with heart failure (HF) as well as vascular disease.BACKGROUND: HF, vascular disease, and AF are pathophysiologically related, and understanding antithrombotic treatment for these conditions is crucial.METHODS: In hospitalized patients with HF and coexisting vascular disease (coronary artery disease or peripheral arterial disease) followed from 1997 to 2009, AF status was categorized as prevalent AF, incident AF, or no AF. Risk of thromboembolism (TE), myocardial infarction (MI), and serious bleeding was assessed by Cox regression models (hazard ratio [HR] with 95{\%} confidence interval [CI]) with antithrombotic therapy and AF as time-dependent variables.RESULTS: A total of 37,464 patients were included (age, 74.5 ± 10.7 years; 36.3{\%} females) with a mean follow-up of 3 years during which 20.7{\%} were categorized as prevalent AF and 17.2{\%} as incident AF. Compared with vitamin K antagonist (VKA) in prevalent AF, VKA plus antiplatelet was not associated with a decreased risk of TE (HR: 0.91; 95{\%} CI: 0.73 to 1.12) or MI (HR: 1.11; 95{\%} CI: 0.96 to 1.28), whereas bleeding risk was significantly increased (HR: 1.31; 95{\%} CI: 1.09 to 1.57). Corresponding estimates for incident AF were HRs of 0.77 (95{\%} CI: 0.56 to 1.06), 1.07 (95{\%} CI: 0.89 to 1.28), and 2.71 (95{\%} CI: 1.33 to 2.21) for TE, MI, and bleeding, respectively. In no AF patients, no statistical differences were seen between antithrombotic therapies in TE or MI risk, whereas bleeding risk was significantly increased for VKA with and without single-antiplatelet therapy.CONCLUSIONS: In AF patients with coexisting HF and vascular disease, adding single-antiplatelet therapy to VKA therapy is not associated with additional benefit in thromboembolic or coronary risk, but notably increased bleeding risk.",
    keywords = "Aged, Aged, 80 and over, Atrial Fibrillation, Cohort Studies, Denmark, Female, Fibrinolytic Agents, Follow-Up Studies, Heart Failure, Hospitalization, Humans, Male, Middle Aged, Registries, Retrospective Studies, Treatment Outcome, Vascular Diseases",
    author = "Morten Lamberts and Lip, {Gregory Y H} and Ruwald, {Martin H} and Hansen, {Morten Lock} and Cengiz {\"O}zcan and Kristensen, {S{\o}ren L} and Lars K{\o}ber and Christian Torp-Pedersen and Gislason, {Gunnar H}",
    note = "Copyright {\circledC} 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.",
    year = "2014",
    month = "6",
    day = "24",
    doi = "10.1016/j.jacc.2014.03.039",
    language = "English",
    volume = "63",
    pages = "2689--98",
    journal = "Journal of the American College of Cardiology",
    issn = "0735-1097",
    publisher = "Heinemann",
    number = "24",

    }

    Antithrombotic treatment in patients with heart failure and associated atrial fibrillation and vascular disease : a nationwide cohort study. / Lamberts, Morten; Lip, Gregory Y H; Ruwald, Martin H; Hansen, Morten Lock; Özcan, Cengiz; Kristensen, Søren L; Køber, Lars; Torp-Pedersen, Christian; Gislason, Gunnar H.

    I: Journal of the American College of Cardiology, Bind 63, Nr. 24, 24.06.2014, s. 2689-98.

    Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

    TY - JOUR

    T1 - Antithrombotic treatment in patients with heart failure and associated atrial fibrillation and vascular disease

    T2 - a nationwide cohort study

    AU - Lamberts, Morten

    AU - Lip, Gregory Y H

    AU - Ruwald, Martin H

    AU - Hansen, Morten Lock

    AU - Özcan, Cengiz

    AU - Kristensen, Søren L

    AU - Køber, Lars

    AU - Torp-Pedersen, Christian

    AU - Gislason, Gunnar H

    N1 - Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

    PY - 2014/6/24

    Y1 - 2014/6/24

    N2 - OBJECTIVES: The aim of this study was to investigate the impact of atrial fibrillation (AF) and antithrombotic treatment on the prognosis in patients with heart failure (HF) as well as vascular disease.BACKGROUND: HF, vascular disease, and AF are pathophysiologically related, and understanding antithrombotic treatment for these conditions is crucial.METHODS: In hospitalized patients with HF and coexisting vascular disease (coronary artery disease or peripheral arterial disease) followed from 1997 to 2009, AF status was categorized as prevalent AF, incident AF, or no AF. Risk of thromboembolism (TE), myocardial infarction (MI), and serious bleeding was assessed by Cox regression models (hazard ratio [HR] with 95% confidence interval [CI]) with antithrombotic therapy and AF as time-dependent variables.RESULTS: A total of 37,464 patients were included (age, 74.5 ± 10.7 years; 36.3% females) with a mean follow-up of 3 years during which 20.7% were categorized as prevalent AF and 17.2% as incident AF. Compared with vitamin K antagonist (VKA) in prevalent AF, VKA plus antiplatelet was not associated with a decreased risk of TE (HR: 0.91; 95% CI: 0.73 to 1.12) or MI (HR: 1.11; 95% CI: 0.96 to 1.28), whereas bleeding risk was significantly increased (HR: 1.31; 95% CI: 1.09 to 1.57). Corresponding estimates for incident AF were HRs of 0.77 (95% CI: 0.56 to 1.06), 1.07 (95% CI: 0.89 to 1.28), and 2.71 (95% CI: 1.33 to 2.21) for TE, MI, and bleeding, respectively. In no AF patients, no statistical differences were seen between antithrombotic therapies in TE or MI risk, whereas bleeding risk was significantly increased for VKA with and without single-antiplatelet therapy.CONCLUSIONS: In AF patients with coexisting HF and vascular disease, adding single-antiplatelet therapy to VKA therapy is not associated with additional benefit in thromboembolic or coronary risk, but notably increased bleeding risk.

    AB - OBJECTIVES: The aim of this study was to investigate the impact of atrial fibrillation (AF) and antithrombotic treatment on the prognosis in patients with heart failure (HF) as well as vascular disease.BACKGROUND: HF, vascular disease, and AF are pathophysiologically related, and understanding antithrombotic treatment for these conditions is crucial.METHODS: In hospitalized patients with HF and coexisting vascular disease (coronary artery disease or peripheral arterial disease) followed from 1997 to 2009, AF status was categorized as prevalent AF, incident AF, or no AF. Risk of thromboembolism (TE), myocardial infarction (MI), and serious bleeding was assessed by Cox regression models (hazard ratio [HR] with 95% confidence interval [CI]) with antithrombotic therapy and AF as time-dependent variables.RESULTS: A total of 37,464 patients were included (age, 74.5 ± 10.7 years; 36.3% females) with a mean follow-up of 3 years during which 20.7% were categorized as prevalent AF and 17.2% as incident AF. Compared with vitamin K antagonist (VKA) in prevalent AF, VKA plus antiplatelet was not associated with a decreased risk of TE (HR: 0.91; 95% CI: 0.73 to 1.12) or MI (HR: 1.11; 95% CI: 0.96 to 1.28), whereas bleeding risk was significantly increased (HR: 1.31; 95% CI: 1.09 to 1.57). Corresponding estimates for incident AF were HRs of 0.77 (95% CI: 0.56 to 1.06), 1.07 (95% CI: 0.89 to 1.28), and 2.71 (95% CI: 1.33 to 2.21) for TE, MI, and bleeding, respectively. In no AF patients, no statistical differences were seen between antithrombotic therapies in TE or MI risk, whereas bleeding risk was significantly increased for VKA with and without single-antiplatelet therapy.CONCLUSIONS: In AF patients with coexisting HF and vascular disease, adding single-antiplatelet therapy to VKA therapy is not associated with additional benefit in thromboembolic or coronary risk, but notably increased bleeding risk.

    KW - Aged

    KW - Aged, 80 and over

    KW - Atrial Fibrillation

    KW - Cohort Studies

    KW - Denmark

    KW - Female

    KW - Fibrinolytic Agents

    KW - Follow-Up Studies

    KW - Heart Failure

    KW - Hospitalization

    KW - Humans

    KW - Male

    KW - Middle Aged

    KW - Registries

    KW - Retrospective Studies

    KW - Treatment Outcome

    KW - Vascular Diseases

    U2 - 10.1016/j.jacc.2014.03.039

    DO - 10.1016/j.jacc.2014.03.039

    M3 - Journal article

    VL - 63

    SP - 2689

    EP - 2698

    JO - Journal of the American College of Cardiology

    JF - Journal of the American College of Cardiology

    SN - 0735-1097

    IS - 24

    ER -