240 Outcomes with Novel Oral Anticoagulants(NOACs) Bleeding in Atrial Fibrillation (AF) Patients at Liverpool Hospital – a Single Centre Experience

Abstract

NOACs are widely used for AF stroke prevention but Factor-Xa-Inhibitor(FXaI) reversing agent is not widely available and expensive. Retrospective analysis of AF patients on apixaban or rivaroxaban who underwent FXaI levels from the haematology database between 2015-2018 was performed. CHADS2VASc,HAS-BLEED,indication for level, bleeding, treatment and death were assessed. Reversal was performed with Pro-thrombinex±FEIBA±FFP. 592 patients underwent FXa-I levels and 178(30.0%) had a bleeding indication. 108(29.6%) were on apixaban and 70(30.8%) rivaroxaban (p=0.782). Mean CHADS2VASc=3.81±1.66 and HAS-BLED=1.96±0.93 with no difference between bleeding vs non-bleeding indications (p=0.78). 48.3%(86/178) bleeding patients were treated with factor reversal. Successful reversal with Prothrombinex+FEIBA in 100% and Prothrombinex alone 89.2%. No thrombotic complications occurred. 50% recommenced FXaI and 25% stopped/changed. 20.2% (36/178) had blood transfusion. Significantly more bleeding occurred in patients≥75 years (32.9% vs 24.1%,p=0.036), CHADS2VASc>3 (61.6% vs 37.5%,p<0.001) and HAS-BLED>3 (53.8% vs 41.2%,p=0.029). Renal impairment (eGFR<50 ml/min/1.73m2) did not increase bleeding-risk (p=0.361). Death from bleeding 13.5% (24/178) are mostly intra-cerebral/intra-abdominal(91.7%;22/24) and significantly more with apixaban-treatment (18.5% vs 5.7%,p=0.014).Tabled 1Apixaban n(%)Rivaroxaban n(%)Total n(%)P-valuePatients on FXa-I365(61.7)227(38.3)592(100)0.001Bleeding108(29.6)70(30.8)178(30.1)0.782Transfusion17(15.7)19(27.1)36(20.2)1.000Total received Reversal52(48.2)34(48.6)86(48.3)0.085Death20(18.5)4(5.7)24(13.4)0.014Reversal given and died16(30.8)4(11.8)20(23.3)0.066No Reversal given and died4(7.1)0(0)4(4.3)0.152 Open table in a new tab AF patients on FXa-inhibitors who bled had higher CHADS2VASc and HAS-BLED scores and often ≥75 years. Reversal was successful with factor replacement but deaths still occurred from intracerebral/intra-abdominal bleeding.