Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: Results from the GARFIELD‐AF Registry

Abstract

BackgroundOral anticoagulation (OAC) in atrial fibrillation (AF) reduces the risk of stroke/systemic embolism (SE). The impact of OAC discontinuation is less well documented. ObjectiveInvestigate outcomes of patients prospectively enrolled in the Global Anticoagulant Registry in the Field‐Atrial Fibrillation study who discontinued OAC. MethodsOral anticoagulation discontinuation was defined as cessation of treatment for ≥7 consecutive days. Adjusted outcome risks were assessed in 23 882 patients with 511 days of median follow‐up after discontinuation. ResultsPatients who discontinued (n = 3114, 13.0%) had a higher risk (hazard ratio [95% CI]) of all‐cause death (1.62 [1.25–2.09]), stroke/systemic embolism (SE) (2.21 [1.42–3.44]) and myocardial infarction (MI) (1.85 [1.09–3.13]) than patients who did not, whether OAC was restarted or not. This higher risk of outcomes after discontinuation was similar for patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) (p for interactions range = 0.145–0.778). Bleeding history (1.43 [1.14–1.80]), paroxysmal vs. persistent AF (1.15 [1.02–1.29]), emergency room care setting vs. office (1.37 [1.18–1.59]), major, clinically relevant nonmajor, and minor bleeding (10.02 [7.19–13.98], 2.70 [2.24–3.25] and 1.90 [1.61–2.23]), stroke/SE (4.09 [2.55–6.56]), MI (2.74 [1.69–4.43]), and left atrial appendage procedures (4.99 [1.82–13.70]) were predictors of discontinuation. Age (0.84 [0.81–0.88], per 10‐year increase), history of stroke/transient ischemic attack (0.81 [0.71–0.93]), diabetes (0.88 [0.80–0.97]), weeks from AF onset to treatment (0.96 [0.93–0.99] per week), and permanent vs. persistent AF (0.73 [0.63–0.86]) were predictors of lower discontinuation rates. ConclusionsIn GARFIELD‐AF, the rate of discontinuation was 13.0%. Discontinuation for ≥7 consecutive days was associated with significantly higher all‐cause mortality, stroke/SE, and MI risk. Caution should be exerted when considering any OAC discontinuation beyond 7 days.