Effect of Heart Failure Type on Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients on Oral Anticoagulation

Abstract

Background Heart failure (HF) increases ischemic stroke (IS) risk in atrial fibrillation (AF) patients. Differential effect of heart failure type on thromboembolic and bleeding risk while on oral anticoagulation (OAC) is unknown. Methods We used Medicare data for beneficiaries with new AF diagnosed during 2011-13 to identify patients with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and no HF. The primary outcome of admission for IS was evaluated using Cox proportional hazards regression models that controlled for patient demographics, comorbidities (including CHA2DS2-Vasc score), and OAC use. Secondary outcomes included mortality, admissions for gastrointestinal bleeding (GIB), intracranial hemorrhage (ICH), acute myocardial infarction (AMI), or HF. Results The 3 groups included 47840, 32360 and 718392 patients respectively. Patients with HFrEF and HFpEF had higher comorbidity burden, thromboembolic and bleeding risk ( Table 1 ). In multivariable analysis adjusting for patient characteristics and OAC as a time-dependent covariate, HFrEF and HFpEF were associated with higher risk of IS, HF and AMI compared to no HF ( Table 2 ). HFrEF was associated with higher all-cause mortality and HF-hospitalization risk compared with HFpEF ( Table 2 ) Conclusion In AF patients, HFrEF and HFpEF are both associated with higher risk of stroke, HF and AMI admissions, even after adjusting for OAC, compared with patients without HF.