Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall

doi:10.1016/j.amjmed.2005.02.022

The American Journal of Medicine

Volume 118, Issue 6, June 2005, Pages 612-617

https://doi.org/10.1016/j.amjmed.2005.02.022 Get rights and content

Abstract

Purpose

Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking.

Methods

Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18 261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes.

Results

Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9–4.1) in patients at high risk for falls and 1.1 (1.0–1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3–3.1) in patients at high risk for falls and 0.34 (0.27–0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0–3.1) for neuropsychiatric disease, 2.1 (1.6–2.7) for prior stroke, and 1.9 (1.4–2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death.

Conclusion

Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.

Section snippets

Methods

The primary endpoint was hospitalization for an intracranial hemorrhage after the index hospital admission. The study was approved by the Washington University human subjects’ committee.

Cohort descriptions

Subjects at high risk for falls were older and had more comorbidities than other patients. In addition, they were significantly less likely to receive warfarin or aspirin therapy (Table 1).

Trial-like patients (n = 3236) were younger (mean age, 73 years) and healthier (mean number of bleeding risk factors, 0.6). Most of them were prescribed antithrombotic therapy (53.7% warfarin; 23.1% aspirin).

Data integrity and validation

We validated the fall-risk designation by examining ICD-9 codes for falling and for nonpathologic

Discussion

Despite their low use of warfarin (33.5%), patients at high risk for falls suffered 2.8 intracranial hemorrhages per 100 patient-years, more than twice the 1.1 intracranial hemorrhage rate of other participants and more than 5 times the 0.5 rate of trial-like participants. The increased risk of intracranial hemorrhage in patients at high risk for falls was due to their increased incidence of traumatic intracranial hemorrhage, which was increased four-fold compared to other patients, even after

Acknowledgment

The authors appreciate the assistance of the Iowa Foundation for Medical Care, the other Quality Improvement Organizations, and the Centers for Medicare & Medicaid Services (CMS) in providing data that made this research possible.

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Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study
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Data on non-vitamin K antagonist oral anticoagulant (NOAC) use in patients with atrial fibrillation (AF) and a history of falls are limited. Therefore, we investigated the impact of a history of falls on AF-related outcomes, and the benefit-risk profiles of NOACs in patients with a history of falls.
Using Belgian nationwide data, AF patients initiating anticoagulation between 2013 and 2019 were included. Previous falls that occurred ≤ 1 year before anticoagulant initiation were identified.
Among 254,478 AF patients, 18,947 (7.4%) subjects had a history of falls, which was associated with higher risks of all-cause mortality (adjusted hazard ratio (aHR) 1.11, 95%CI (1.06–1.15)), major bleeding (aHR 1.07, 95%CI (1.01–1.14)), intracranial bleeding (aHR 1.30, 95%CI (1.16–1.47)) and new falls (aHR 1.63, 95%CI (1.55–1.71)), but not with thromboembolism. Among subjects with a history of falls, NOACs were associated with lower risks of stroke or systemic embolism (aHR 0.70, 95%CI (0.57–0.87)), ischemic stroke (aHR 0.59, 95%CI (0.45–0.77)) and all-cause mortality (aHR 0.83, 95%CI (0.75–0.92)) compared to vitamin K antagonists (VKAs), while major, intracranial, and gastrointestinal bleeding risks were not significantly different. Major bleeding risks were significantly lower with apixaban (aHR 0.77, 95%CI (0.63–0.94)), but similar with other NOACs compared to VKAs. Apixaban was associated with lower major bleeding risks compared to dabigatran (aHR 0.78, 95%CI (0.62–0.98)), rivaroxaban (aHR 0.78, 95%CI (0.68–0.91)) and edoxaban (aHR 0.74, 95%CI (0.59–0.92)), but mortality risks were higher compared to dabigatran and edoxaban.
A history of falls was an independent predictor of bleeding and death. NOACs had better benefit-risk profiles than VKAs in patients with a history of falls, especially apixaban.
Barriers to Guideline-Directed Anticoagulation in Patients With Atrial Fibrillation: New Approaches to an Old Problem
2023, Canadian Journal of Cardiology
Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with guideline-directed use of anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease, and choice of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk, and implicit bias. For patients, negative preconceptions of therapy, impact of therapy on day-to-day life, and the nocebo effect pose significant barriers. Both groups are affected by poor education. Utility of a single-pronged approach directed toward clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies using shared-decision models. Further, there is emerging evidence for use of integrated models of care, which have shown efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app–based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation, with translated improved outcomes in clinical trials. This narrative review aims to investigate the physician and health system, patient, and drug therapy and disease barriers to uptake of guideline-directed anticoagulation in the treatment of nonvalvular atrial fibrillation.
L’optimisation de l’anticoagulation orientée sur les lignes directrices en matière de fibrillation auriculaire demeure un problème récurrent malgré des données probantes solides sur l’amélioration des résultats cliniques lors de l’utilisation de l’anticoagulation axée sur les lignes directrices. Des obstacles observés chez le médecin, le patient, en ce qui concerne la maladie et le choix du traitement, ont freiné les efforts pour accroître leur adoption. Des facteurs tels que l’inertie thérapeutique, l’aversion du risque hémorragique et les biais implicites nuisent souvent au jugement du clinicien. Chez les patients, les préconceptions négatives du traitement, les répercussions du traitement sur la vie quotidienne et l’effet nocébo constituent des obstacles importants. Le manque d’éducation concerne les deux groupes. L’utilité d’une approche à un volet orientée vers les cliniciens ou les patients a démontré des résultats variables, dont les répercussions les plus importantes sont reconnues dans les études fondées sur des modèles de prise de décision par consensus. De plus, il existe de nouvelles données sur l’utilisation de modèles de soins intégrés qui ont démontré une efficacité dans l’amélioration de l’évolution de l’état de santé du patient et sur l’utilisation des plateformes numériques, telles les interventions sur application mobile, qui peuvent aider le clinicien à améliorer l’adhésion du patient à l’anticoagulation et se traduire par de meilleurs résultats cliniques dans les essais cliniques. L’objectif de la présente revue narrative vise à se pencher sur le médecin et le système de soins de santé, le patient, le traitement médicamenteux et les obstacles de la maladie à l’adoption de l’anticoagulation orientée sur les lignes directrices dans le traitement de la fibrillation auriculaire non valvulaire.
The Aged Heart
2022, Emergency Medicine Clinics of North America
CHA<inf>2</inf>DS<inf>2</inf>-VASc and has-BLED scores do not accurately stratify risk for stroke or bleed in fall victims with atrial fibrillation
2022, American Journal of Emergency Medicine
Falls are the leading cause of morbidity and mortality in the elderly. Non-valvular Atrial fibrillation (AF) is present in up to 9% of this group and often requires oral anticoagulation (OAC). The CHA₂DS₂-VASc and HAS-BLED scores are validated tools assessing risk of ischemic stroke from AF and major bleeding (MB) from OAC. It is unclear if these predictions remain accurate in post-fall patients. This study seeks to determine the stroke and major bleeding rate in atrial fibrillation patients after a ground level fall and identify if validated risk scoring systems accurately stratify risk in this cohort.
Retrospective review of patients with AF presented to the emergency department after a fall. CHA₂DS₂-VASc and HAS-BLED scores were calculated. Follow up information was reviewed to 1 year. Patients were grouped according to discharge thromboprophylaxis plan (DTP): no treatment, Anti-platelet (AP), OAC, and AP + OAC. Outcomes were ischemic stroke, MB, or death at 1 year. Ischemic stroke and MB rates were calculated. Kruskal-Wallis, Χ², Fisher's exact, and multivariable logistic regression were used to evaluate for clinical associations.
192 patients were included. MB rate was 14.5 bleeds/100 person-years, and ischemic stroke rate was 10.9/100 person-years. There were no observed differences between DTPs. Overall, one-year mortality was 22.1%. On unadjusted analysis, CHA₂DS₂-VASc did associate with ischemic stroke (p = 0.03); HAS-BLED did not associate with MB (p = 0.17). After logistic regression accounting for known risk factors, neither system associated with ischemic stroke or MB.
Fall patients are at higher risk for both ischemic stroke and MB compared to previously published reports. Current risk assessment tools should be used with caution. Further study of risk factors is warranted to guide medication decisions in these patients.
Characteristics of warfarin under-prescription in older adults with atrial fibrillation
2021, IJC Heart and Vasculature
The prevalence of atrial fibrillation (AF) and atrial flutter (AFl) increases with age. Under-prescription of anticoagulants in older adults can lead to increased morbidity and mortality. We analyzed warfarin prescription patterns in older adults.
In this observational single-center study, we analyzed 2179 consecutive patients with admission diagnosis of AF or AFl. Patients were divided into “older” (≥ 75 years old) and “younger” (<75 years old) groups. Prescription patterns of warfarin were analyzed. Patients discharged from the hospital on a non-warfarin anticoagulation were excluded.
Of the 1988 patients analyzed, 46.9% were ≥75 years old, of which 50.8% were prescribed warfarin. There was no association between mean CHA₂DS₂-VASc score and warfarin prescription on discharge (OR = 1.06 (95% CI 0.93–1.21), p = 0.388) in the older group. After adjusting for hypertension, renal function, and Black race, warfarin prescription in older adults was independently associated with lower aspirin prescription rates (OR = 0.57 (95% CI 0.43–0.75), p < 0.001), lower body mass index (OR = 1.03 (95% CI 1.01–1.06), p = 0.018), and lower hemoglobin levels (OR = 1.11 (95% CI 1.04–1.19), p = 0.002).
In our study, older adults (≥75 years old) with AF and AFl tended to have lower rates of warfarin prescription despite higher CHA₂DS₂-VASc score and higher risk of thromboembolic events. Anemia, lower body weight, and aspirin use were characteristics associated with warfarin under-prescription.

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: Grant Support: Supported by the American Heart Association (0270099N). Disclaimer: The conclusions presented are solely those of the authors and do not represent those of the Quality Improvement Organizations, American Heart Association, or CMS. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of commercial products imply endorsement of them by the U. S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

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Clinical research studyIncidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Methods

Cohort descriptions

Data integrity and validation

Discussion

Acknowledgment

J Am Coll Cardiol.

Am J Cardiol.

Am J Med.

Public Health

Blood

Lancet

Oral anticoagulants vs aspirin in nonvalvular atrial fibrillationan individual patient meta-analysis

JAMA

Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III)randomized controlled trial

Lancet

Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillationa randomized trial

JAMA

The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation

N Engl J Med.

Stroke Prevention in Atrial Fibrillation (SPAF) Study. Final results

Circulation

Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with aspirinStroke Prevention in Atrial Fibrillation III Study

JAMA

Fixed minidose warfarin and aspirin alone and in combination vs adjusted-dose warfarin for stroke prevention in atrial fibrillationSecond Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study

Arch Intern Med.

Primary prevention of arterial thromboembolism in non-rheumatic atrial fibrillation in primary carerandomized controlled trial comparing two intensities of coumarin with aspirin

BMJ

Physician attitudes concerning warfarin for stroke prevention in atrial fibrillationresults of a survey of long-term care practitioners

J Am Geriatr Soc.

Is warfarin really underused in patients with atrial fibrillation?

J Gen Intern Med.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillationthe anticoagulation and risk factors in atrial fibrillation (ATRIA) study

Ann Intern Med.

Aspirin and risk of hemorrhagic strokea meta-analysis of randomized controlled trials

JAMA

Clinical research study
Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall