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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
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The Risk for Bleeding in Patients With Atrial Fibrillation From Concomitant Use of Apixaban or Rivaroxaban With
Ghadeer K Dawwas1, James D Lewis2, Yacob G Tedla1
1Department of Medicine, Division of Epidemiology, Vanderbilt University School of Medicine, Nashville, Tennessee (G.K.D., Y.G.T.).
Annals of Internal Medicine
|February 23, 2026
Summary
Patients with atrial fibrillation (AF) taking factor Xa inhibitors experienced more bleeding when using diltiazem compared to metoprolol. This risk was higher with high-dose diltiazem, indicating a need for careful medication management.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Diltiazem inhibits cytochrome P450 3A4 and P-glycoprotein, potentially affecting factor Xa inhibitors.
- This interaction may increase bleeding risk in atrial fibrillation (AF) patients.
Purpose of the Study:
- To compare bleeding risk in AF patients using apixaban or rivaroxaban with diltiazem versus metoprolol.
- To assess the impact of diltiazem dosage on bleeding complications.
Main Methods:
- Retrospective cohort study using U.S. administrative health care data.
- Compared patients with AF on apixaban/rivaroxaban with diltiazem or metoprolol.
- Utilized propensity score matching for cohort comparison.
Main Results:
- Diltiazem use was associated with a higher risk of serious bleeding events compared to metoprolol (RD, 5.4 per 1000 person-years).
- Higher diltiazem doses correlated with increased bleeding risk (high dose RD, 9.2; low dose RD, 2.6).
Conclusions:
- Diltiazem use increases the risk of serious bleeding complications in AF patients on factor Xa inhibitors compared to metoprolol.
- This association was more pronounced with higher diltiazem dosages.
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