Prevalence of modifiable bleeding risk factors in patient with nonvalvular atrial fibrillation and heart failure

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite the clear benefit from direct oral anticoagulants (DOAC) in patients with nonvalvular atrial fibrillation (NVAF) and heart failure (HF), major bleeding events may be devastating when they do occur. Identification and correction of potentially modifiable conditions associated with bleeding risk can minimize hemorrhagic complications of DOAC therapy. Data on prevalence of modifiable bleeding risk factors in a cohort of patients treated with DOACs with coexisted NVAF and HF are lacking. The purpose of the study was to assess the rate of high-bleeding risk according to HAS-BLED and prevalence of modifiable HAS-BLED score components in patients with NVAF and HF receiving oral anticoagulants. Methods The study involved consecutive patients with NVAF and HF taking DOACs (rivaroxaban, apixaban, dabigatran) hospitalized with HF decompensation between January 2020 and May 2022. Bleeding risk was stratified by HAS-BLED score. Modifiable and nonmodifiable bleeding risk factors were identified. Numerical data were expressed as median (interquartile range). P<0.05 was considered significant. Results A total of 388 patients (age 73.5 years [66-82], 59.3% males, non-paroxysmal NVAF – 58.8%, CHA2DS2-VASc score 4 [4-5]) were included. Most patients had NYHA class III-IV symptoms (67.9%). Prior myocardial infarction was identified in 37.6%. Median ejection fraction (EF) was 44.5% (34-52). The median HAS-BLED score was 2 (1-3). 26.3% of patients had HAS-BLED score ≥3. The subgroup of patients with NVAF and HF with EF ≤40% had higher bleeding risk compared to those with EF >40% (HAS-BLED ≥3 in 32.1% vs 20.4%, P<0.05). Modifiable and nonmodifiable HAS-BLED score components were identified from study population. Anemia (50.5%), heavy alcohol use or concomitant treatment with antiplatelets, nonsteroidal anti-inflammatory drugs, or paracetamol (21.6%), abnormal renal/liver function (19.6%), uncontrolled hypertension (9.8%) were identified as modifiable bleeding risk factors. Increasing age (78.9%), prior stoke (13.4%) were identified as nonmodifiable bleeding risk factors without significant differences between subgroups of HF. Overall, 10% of patients had nonmodifiable bleeding risk factors only, and 88% had modifiable bleeding risk factors (with or without nonmodifiable risk factors). Abnormal renal/liver function and concomitant treatment/alcohol were more frequent in the subgroup of patients with EF ≤ 40% compared to those with EF > 40% (24.7% vs 10.6%, 28.4% vs 16.8%, respectively; P<0.05). Conclusion Every fourth patient with NVAF and HF has high bleeding risk that can be minimized by modifying risk factors in up to 90% of patients. Anemia was the most frequent modifiable bleeding risk factor.