Letter Regarding Article by Hylek et al, “Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation”

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HomeCirculationVol. 116, No. 20Letter Regarding Article by Hylek et al, “Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter Regarding Article by Hylek et al, “Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation” Ayumu Ono and Ichiko Kawamura Toshiro Fujita Ayumu OnoAyumu Ono Otsuki Hospital, Kochi, Japan Search for more papers by this author and Ichiko KawamuraIchiko Kawamura Otsuki Hospital, Kochi, Japan Search for more papers by this author Toshiro FujitaToshiro Fujita Department of Internal Medicine, University of Tokyo, Tokyo, Japan Search for more papers by this author Originally published13 Nov 2007https://doi.org/10.1161/CIRCULATIONAHA.107.727255Circulation. 2007;116:e538To the Editor:We read with great interest the recent publication by Hylek et al1 in which they concluded that the rate of bleeding complications during warfarin therapy was substantially higher than previously reported in elderly patients with atrial fibrillation. They emphasize that published rates of major hemorrhage derived from younger noninception cohorts underestimate the bleeding that occurs in clinical practice, and the higher rate of bleeding in their study is attributable to the higher risk of bleeding in the early phase of warfarin therapy and the advanced age of their study subjects. However, the results are not necessarily generalizable to other clinical settings, because the patients enrolled in this cohort have more risk factors for bleeding than representative patients receiving warfarin in clinical practice.First, the patients received aspirin combined with warfarin at a remarkably higher rate (40%) than reported previously.2 The frequent use of aspirin may contribute to the higher rate of bleeding in patients receiving warfarin, because previous studies have demonstrated that combined anticoagulant-antiplatelet use increases bleeding risk without additive prevention of thromboembolic events. In recent trials comparing ximelagatron and warfarin, the combination therapy of aspirin with either ximelagatron or warfarin did not reduce the risk of stroke, systemic embolism, or myocardial infarction, but the addition of aspirin to warfarin or ximelagatron was associated with increased risk of bleeding, which was especially obvious when aspirin and warfarin were combined.3Second, the study included patients receiving warfarin in spite of their potential contraindications for anticoagulation, such as active malignancy, prior bleeding, and dementia. In general, patients with risk factors for bleeding should be considered as ineligible for anticoagulation.When physicians use warfarin in eligible patients at high risk but without contraindications, thromboembolism-associated atrial fibrillation can be adequately and safely prevented even in elderly patients. In fact, recent inception cohorts in which warfarin was newly started in elderly patients without contraindications or concomitant use of antiplatelets reported lower rates of major bleeding (<3% per 100 person-years)4,5 than the study by Hylek et al (7.2% per 100 person-years).1DisclosuresNone. References 1 Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007; 115: 2689–2696.LinkGoogle Scholar2 Fang MC, Stafford RS, Ruskin JN, Singer DE. National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation. Arch Intern Med. 2004; 164: 55–60.CrossrefMedlineGoogle Scholar3 Gorelick PB. Combining aspirin with oral anticoagulant therapy: is this a safe and effective practice in patients with atrial fibrillation? Stroke. 2007; 38: 1652–1654.LinkGoogle Scholar4 Kalra L, Yu G, Perez I, Lakhani A, Donaldson N. Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness. BMJ. 2000: 320; 1236–1239.CrossrefMedlineGoogle Scholar5 Ruiz Ortiz M, Romo Penas E, Franco Zapata MF, Mesa Rubio D, Anguita Sanchez M, Lopez Granados A, Arizon del Prado JM, Valles Belsue F. Oral anticoagulation in patients aged 75 years or older with chronic non-valvar atrial fibrillation: effectiveness and safety in daily clinical practice. Heart. 2005; 91: 1225–1226.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Pani A, Pastori D, Senatore M, Romandini A, Colombo G, Agnelli F, Scaglione F and Colombo F (2020) Clinical and pharmacological characteristics of elderly patients admitted for bleeding: impact on in-hospital mortality, Annals of Medicine, 10.1080/07853890.2020.1808238, 52:7, (413-422), Online publication date: 2-Oct-2020. Bonnet-Zamponi D, Aumont M, Comets E, Bruhat C, Chauveheid M, Duval X, Huisse M, Diquet B, Berrut G, Mentre F, Delpierre S and Legrain S (2011) Heparin Bridging Therapy and Bleeding Events in Octogenarian Inpatients with Atrial Fibrillation Starting Anticoagulation: Results of an Ancillary Study, Journal of the American Geriatrics Society, 10.1111/j.1532-5415.2011.03649.x, 59:11, (2174-2178), Online publication date: 1-Nov-2011. November 13, 2007Vol 116, Issue 20 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.727255PMID: 17998467 Originally publishedNovember 13, 2007 PDF download Advertisement SubjectsAnticoagulantsArrhythmiasCerebrovascular Disease/Stroke