van Rein et al (Circulation 2019;139:775, PMID 30586754) evaluated bleeding rates
in a comprehensive national database of patients with atrial fibrillation (AF) who
were 50 years and older. Treatments included vitamin K antagonists (VKAs), direct
oral anticoagulants (DOACs), platelet inhibitors, and combinations of antithrombotic
drugs. Major bleeding was defined as bleeding requiring hospitalization or causing death. Overall, 272,315
patients with AF were followed for 1,373,131 patient-years (PYs); 31,459 major bleeds
occurred for an incidence rate (IR) of 2.3 per 100 PYs. Compared with VKA monotherapy,
the hazard ratio for major bleeding was 1.13 for dual antiplatelet therapy, 1.82 for
therapy with a VKA and an antiplatelet drug, 1.28 for DOAC therapy with an antiplatelet
drug, 3.73 for VKA triple therapy, and 2.28 for DOAC triple therapy. The IR for major
bleeding was 10.2 per 100 PYs in patients on triple therapy. Very high major bleeding
rates were found in patients on triple therapy who were older than 90 years (IR 22.8
per 100 PYs) or with a CHA2DS2-VASc score of >6 (IR 17.6 per 100 PYs) or with a history of major bleeding (IR 17.5
per 100 PYs). The authors conclude that patients with AF on triple therapy experienced high rates
of major bleeding in comparison with patients receiving dual therapy or monotherapy.
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Publication history
Published online: March 23, 2019
