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Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA2DS2VASc scores: experience from the Stockholm region

  • Pharmacoepidemiology and Prescription
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Abstract

Purpose

This study evaluated the benefits of and possible contraindications to warfarin treatment in patients with atrial fibrillation (AF) prior to the introduction of new oral anticoagulants using health registry data from inpatient care, specialist ambulatory care, and primary care.

Methods

This is a cohort study including all patients in the region of Stockholm, Sweden (2.1 million inhabitants) with a diagnosis of non-valvular AF (n = 41 810) recorded during 2005–2009. The risks of suffering ischemic stroke, bleeding, or death with warfarin, aspirin, or no antithrombotic treatment during 2010 were related to CHA2DS2VASc scores, age, and complicating co-morbidities.

Results

One-year risks for ischemic stroke were 1.0–1.2 % with aspirin, 0–0.3 % with warfarin, and 0.1–0.2 % without treatment at CHA2DS2VASc scores 0–1. Among the aspirin-treated patients with CHA2DS2VASc scores ≥2, half had possible contraindications and high risks for ischemic stroke (5.2 %), bleeding (5.0 %), and death (19.3 %). The other half of the patients with no identified contraindications had a high risk for ischemic stroke (4.0 %) but a low bleeding risk (1.8 %) and a moderate mortality rate (8.4 %).

Conclusions

The present observations confirm earlier findings of undertreatment with warfarin and half of the high-risk patients treated with aspirin were obvious candidates for anticoagulant treatment. However, the other half of the patients had complicating co-morbidities, high bleeding risk, and poor prognosis. This and possible overtreatment of low-risk patients should be taken into account when considering more aggressive use of anticoagulant treatment.

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Acknowledgments

We are very grateful for help with the management and analysis of the databases received from Jamilette Miranda, Thomas Cars, and Gunnar Ljunggren at the Stockholm County Council.

Funding was from the Stockholm County Council. TF has also received grants from “Anna Wedholms stiftelse.” The funding source had no role in the design, analysis, or interpretation of the results, and thus, the authors were independent from the funding source.

STROBE statement

The study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations.

Conflict of Interest

All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare all authors had support from the Stockholm County Council. TF has also received grants from “Anna Wedholms stiftelse”; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work.

Author information

Authors and Affiliations

  1. Department of Medicine Solna, Clinical Pharmacology Unit, Karolinska University Hospital, Karolinska Institutet, 171 76, Stockholm, Sweden

    Tomas Forslund & Paul Hjemdahl

  2. Department of Medicine Solna, Centre for Pharmacoepidemiology, Department of Healthcare development, Public Healthcare Services Committee, Stockholm County Council, Karolinska Institutet, Stockholm, Sweden

    Björn Wettermark

  3. Centre for Family Medicine, Karolinska Institutet, Huddinge, Sweden

    Per Wändell & Jan Hasselström

  4. Department of Clinical Science and Education and the Karolinska Institutet Stroke Research Network at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

    Mia von Euler

Authors
  1. Tomas Forslund
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  2. Björn Wettermark
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  3. Per Wändell
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  4. Mia von Euler
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  5. Jan Hasselström
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  6. Paul Hjemdahl
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Corresponding author

Correspondence to Tomas Forslund.

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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Forslund, T., Wettermark, B., Wändell, P. et al. Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA2DS2VASc scores: experience from the Stockholm region. Eur J Clin Pharmacol 70, 1477–1485 (2014). https://doi.org/10.1007/s00228-014-1739-1

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  • DOI: https://doi.org/10.1007/s00228-014-1739-1

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