Atrial Fib With Sepsis: Anticoagulation Ups Bleeds Without Cutting Stroke Risk 

Larry Hand

August 08, 2016

BOSTON, MA — A new analysis has found that hospital use of anticoagulants in patients with atrial fibrillation (AF) during sepsis varies and that use of anticoagulants does not lower the risk of ischemic stroke but increases risk of bleeding[1].

The study was published online August 3, 2016 in JAMA Cardiology.

"We should be cautious in the use of bridging anticoagulation for arterial thromboembolism prophylaxis during sepsis for patients who experience atrial fibrillation (either preexisting or new onset)," first author Dr Allan J Walkey (Boston University School of Medicine, MA) told heartwire from Medscape by email.

"Our analysis did not detect a lower stroke risk but showed a higher bleeding risk during hospitalization for patients who received either intravenous or subcutaneous anticoagulants for atrial fibrillation during sepsis," he said.

Walkey and colleagues conducted a retrospective cohort study of enhanced administrative claims data on about 20% of patients hospitalized with AF during sepsis in the US between July 1, 2010 and June 30, 2013.

Of 38,582 patients (mean age 74.9, 51% women) included in the analysis, 13,611 (35.3%) received an initial intravenous or subcutaneous anticoagulant and 24,971 (64.7%) did not. The anticoagulant dose, greater than normally used for prophylaxis of thromboembolism, was given on a median of hospital day 2.

The most common initial parenteral anticoagulant was enoxaparin, and the most common initial oral anticoagulant was warfarin.

The researchers found that patients who received parenteral anticoagulation during sepsis were younger (mean age 73.2) and less likely to have prior bleeding, acute hematologic failure, acute kidney failure, chronic kidney disease, cancer, or metabolic acidosis.

They found that unadjusted rates of ischemic stroke did not significantly differ between patients who received anticoagulants and patients who did not (relative risk 0.94). However, the rate of bleeding events was higher in those who received intravenous or subcutaneous anticoagulation than those who did not (8.6% vs 7.1% (RR 1.24).

The researchers found similar results after matching patients on propensity scores.

In addition, the researchers write, "Hospital practices for the use of parenteral anticoagulation in patients with AF during sepsis varied widely, with one-third of hospitals deviating significantly from mean rates of anticoagulation use."

In an accompanying editorial[2], Dr Gregg C Fonarow (University of California, Los Angeles) writes, "As there are potential unmeasured confounders, particularly with claims data, and other limitations with observational analyses, caution is needed in interpreting these findings.

"The study by Walkey and colleagues helps highlight the fact that there remains much to learn in terms of optimal management strategies for AF in many of the clinical settings in which this increasingly common and challenging arrhythmia is encountered," he wrote.

Walkey said he was surprised by the findings: "I anticipated that anticoagulants would be associated with reduced stroke rate and increased bleeding rate. I was surprised the stroke rate was not lower among patients with atrial fibrillation receiving anticoagulation during sepsis."

The National Institutes of Health supported this research. The authors report no relevant financial relationships. Fonarow reports serving as a consultant to AstraZeneca, Janssen Pharmaceutical, and Novartis.

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