Parenteral anticoagulation may not benefit AF patients with sepsis
medwireNews: The risk–benefit balance of parenteral anticoagulation may not be favourable in patients with atrial fibrillation (AF) who are hospitalised with sepsis, a study suggests.
In an accompanying editor’s note, Gregg Fonarow (University of California, Los Angeles, USA) says: “Current guidelines for management of AF do not address this population despite the frequency with which these patients are encountered in clinical practice.”
He calls for further research, ideally including randomised trials, to shed further light on the issue.
As reported in JAMA Cardiology, the researchers identified a total of 113,511 AF patients who were hospitalised with sepsis over a 3-year period in the USA. Of the 38,582 patients included in the primary analysis, 35.3% received parenteral anticoagulation at larger doses than would be used to prevent venous thromboembolism.
Hospitals used parenteral anticoagulation, most commonly enoxaparin, in about a third of patients on average, but the rates in individual hospitals varied from around 10% to 80%. The rates of bleeding and stroke were 8.6% and 1.3%, respectively, in anticoagulated patients, and 7.1% and 1.4% in those not given an anticoagulant.
Parenteral anticoagulation was associated with a significant 21% increased risk of bleeding in 13,505 patients who were matched for propensity to receive anticoagulation to an equal number of patients not given an anticoagulant.
However, Allan Walkey (Boston University School of Medicine, Massachusetts, USA) and co-researchers found that this increased bleeding risk was not offset by the expected protective effect against stroke, with anticoagulated patients having only a nonsignificant 6% reduction in risk.
Of note, the CHA2DS2-VASc stroke risk score performed very poorly in this patient population.
Fonarow advises cautious interpretation of the findings, given the retrospective, nonrandomised study design. He also notes the researchers’ exploratory analysis, in which they found that parenteral anticoagulation was associated with a significant stroke risk reduction among patients with pre-existing AF who received oral anticoagulation on initial hospital admission.
“Thus, there may be certain patients with AF and certain anticoagulation strategies for which the benefit to risk ratio is favorable during hospitalization for sepsis”, he suggests.
“However, as also seen in recent randomized clinical trials of bridging anticoagulation therapy, there may also be clinical circumstances in which increased risks of bleeding are not offset by a large enough reduction in risk of stroke.”
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