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Stroke-Specific Predictors of Major Bleeding in Anticoagulated Patients With Stroke and Atrial Fibrillation: A
Darda Chung1, Tae-Jin Song2, Bum Joon Kim3
1Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Insights
Stroke-specific factors, including NIH Stroke Scale scores and hypertension, independently predict major bleeding in atrial fibrillation patients on oral anticoagulants. These findings aid in balancing stroke prevention with bleeding risk management.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Established risk scores like CHA₂DS₂-VASc and HAS-BLED predict ischemic stroke and major bleeding in atrial fibrillation (AF) patients.
- However, specific predictors of major bleeding in patients with both stroke and AF, undergoing oral anticoagulant therapy (OACs), require further investigation.
Purpose of the Study:
- To identify stroke-specific predictors of major bleeding in patients with stroke and AF treated with OACs.
- To evaluate the independent association of clinical variables with major bleeding risk in this patient cohort.
Main Methods:
- Analysis of data from the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) registry (2013-2015).
- Inclusion of patients on OACs with available brain imaging and without intracranial bleeding related to the index stroke.
- Application of Cox regression and Kaplan-Meier analyses to assess associations between clinical variables and major bleeding events.
Main Results:
- In a cohort of 1,414 patients, 34 experienced major bleeding events during a median follow-up of 1.73 years.
- Independent predictors of major bleeding included higher initial National Institutes of Health Stroke Scale scores, hypertension, and persistent AF type.
- Lower initial hemoglobin levels were associated with a reduced risk of major bleeding. These associations, except for hypertension, remained significant after adjusting for HAS-BLED scores.
Conclusions:
- Major bleeding risk in anticoagulated patients with stroke and AF is independently associated with stroke-specific factors.
- Baseline patient characteristics, particularly stroke-related variables, are crucial for optimizing secondary prevention strategies.
- Consideration of these factors can help balance the benefits of recurrent stroke prevention with the minimization of bleeding complications.
Background And Purpose:
The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) scores have been validated in estimating the risks of ischemic stroke and major bleeding, respectively, in patients with atrial fibrillation (AF). This study investigated stroke-specific predictors of major bleeding in patients with stroke and AF who were taking oral anticoagulants (OACs).
Methods:
Subjects were selected from patients enrolled in the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) nationwide multicenter registry between 2013 and 2015. Patients were excluded if they were not taking OACs, had no brain imaging data, or had intracranial bleeding directly related to the index stroke. Major bleeding was defined according to International Society of Thrombosis and Haemostasis criteria. Cox regression analyses were performed to assess the associations between clinical variables and major bleeding and Kaplan-Meier estimates were performed to analyze event-free survival.
Results:
Of a total of 3,213 patients, 1,414 subjects (mean age of 72.6 years, 52.5% males) were enrolled in this study. Major bleeding was reported in 34 patients during the median follow-up period of 1.73 years. Multivariable analysis demonstrated that initial National Institutes of Health Stroke Scale scores (hazard ratio [HR] 1.07, p=0.006), hypertension (HR 3.18, p=0.030), persistent AF type (HR 2.51, p=0.016), and initial hemoglobin level (HR 0.74, p=0.001) were independently associated with major bleeding risk. Except for hypertension, these associations remained significant after adjusting for the HAS-BLED score. Intracranial atherosclerosis presented a trend of association without statistical significance (HR 2.21, p=0.050).
Conclusions:
This study found that major bleeding risk was independently associated with stroke-specific factors in anticoagulated patients with stroke and AF. This has the clinical implication that baseline characteristics of patients with stroke and AF should be considered in secondary prevention, which would bring the net clinical benefit of balancing recurrent stroke prevention with minimal bleeding complications.
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