NOACs help improve outcomes in AF patients with vascular disease

A history of vascular disease appears to contribute to worse long-term outcomes in patients with atrial fibrillation (AF), but treatment with oral anticoagulation (OAC) helps, suggests a recent study.

“Patients with vascular comorbidity received oral anticoagulation less frequently and, when given, were more likely to receive vitamin K antagonist (VKA) than a nonvitamin K antagonist oral anticoagulation (NOAC),” the researchers said.

“They also received antiplatelet agents more frequently, either alone or in combination with oral anticoagulants. When anticoagulated, these patients tended to have better outcomes with NOACs than when treated with VKA,” they added.

A total of 51,574 adults with newly diagnosed AF were enrolled in this prospective observational registry (GARFIELD-AF) and followed for 24 months. Adjusted hazard ratios (HR) obtained via Cox proportional hazard modeling were used to analyse the associations between vascular disease and clinical outcomes.

Finally, the researchers compared outcomes of OAC vs no OAC, as well as of NOAC vs VKA treatment, by overlap propensity-weighted Cox proportional hazard models.

Nearly one in four AF patients (25.9 percent) had comorbid vascular disease. Those with vascular disease seldom received OAC relative to those without such comorbidity (63 percent vs 73 percent). [Am J Med 2023;136:1187-1195.E15]

AF patients with vascular disease were also at an increased risk of all-cause mortality (HR, 1.30, 95 percent confidence interval [CI], 1.16‒1.47) and cardiovascular mortality (HR, 1.59, 95 percent CI, 1.28‒1.97) over 2 years of follow-up.

Use of OAC resulted in a significant reduction in all-cause mortality and nonhaemorrhagic stroke, as well as in an increased risk of major bleeding in nonvascular disease. Notably, similar but nonsignificant trends were observed for stroke and major bleeding in vascular disease.

“However, the difference in treatment effects between patients with and without vascular disease was not significant,” the researchers said. “Further studies in a larger patient population are required to confirm this result.”

In addition, AF patients with vascular disease who had been treated with NOACs showed a markedly lower risk of all-cause mortality (HR, 0.74, 95 percent CI, 0.61‒0.90) and major bleeding (HR, 0.45, 95 percent CI, 0.29‒0.70) than those treated with VKAs.

Atherosclerotic disease

AF patients are susceptible to atherosclerotic disease, as seen in up to 25 percent in AF registries and in at least 30 percent in recent trials on optimal OAC. Such comorbid conditions create challenges in the management of each as antiplatelet therapy is recommended for vascular disease and anticoagulation for AF. [J Am Coll Cardiol 2017;69:777-785; Europace 2014;16:6-14; J Am Heart Assoc 2013;2e000110]

“Antiplatelet and oral anticoagulation combined continue to be prescribed as therapy for these patients, whether chosen as a medical approach or as a subsequent treatment after interventional therapy,” according to the researchers.

Earlier trials that examined the optimal antithrombotic treatment of percutaneous coronary intervention in AF patients with or without acute coronary syndromes reported improved outcomes with the modification of both antiplatelets (ie, aspirin discontinuation) and anticoagulation (ie, switching from VKA to NOACs). [JAMA Cardiol 2020;5:582-589; JAMA Cardiol 2022;7:787-794]

The current study was limited by potential selection bias as only patients with newly diagnosed AF of <6 weeks duration and a perceived increased stroke risk were analysed.