OAC reduces the risk of stroke with AF or HFrEF despite the higher risk of bleeding

Treatment with oral anticoagulation is associated with a significantly lower incidence of stroke in patients with heart failure with reduced ejection fraction (HFrEF) or atrial fibrillation (AF), according to research published in Stroke.

Although the current guidelines recommend oral anticoagulation to reduce the risk of stroke in patients with AF, this form of therapy has not consistently proven to be superior to anti-platelet therapy in preventing cardiovascular events in patients with HFrEF.

In a meta-analysis, the researchers attempted to further clarify the role of oral anticoagulation in preventing ischemic stroke in patients with AF and HFrEF. The analysis included 21 randomized clinical trials in which patients with oral anticoagulation were compared with a control group. A total of 19,332 patients had atrial fibrillation (mean follow-up time 23.1 months) and 9866 patients had HFrEF (mean follow-up time 23.9 months).

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The incidence of stroke was the primary endpoint of the study, while secondary endpoints included the incidence of ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction (MI), and major bleeding.

In all 21 studies, a total of 1113 strokes occurred during follow-up, of which 339 were in the pooled oral anticoagulation group and 774 in the control group. Compared to the control group, oral anticoagulation was associated with a significant reduction in all strokes over a mean follow-up period of 1.92 years (2.8% vs. 5.8%; odds ratio). [OR], 0.54; 95% CI 0.46-0.63; absolute risk reduction [ARR]2.1%; 95% CI, 2% is 2.5%).

In the 18 studies that reported 846 ischemic strokes, the use of oral anticoagulation was associated with a significant reduction in ischemic stroke compared to the results in the control group (1.9% and 5.2%; OR 0.46; 95 % CI 0.38-0.54.). ; ARR 2.1%; 95% CI 2% to 2.5%).

In 16 studies that reported 79 hemorrhagic strokes, oral anticoagulation was not associated with an increase in hemorrhagic strokes compared to the control group results (0.29% vs. 0.19%; OR 1.23; 95% – KI 0.76 – 1.99; absolute risk increase) [ARI], 0.068%; 95% CI, 0.067% to -0.2%.

In contrast, the use of oral anticoagulation in the pooled analysis was not associated with a reduced all-cause mortality compared to the results of the control group (11% vs. 12%; OR 0.95; 95% CI 0.88-1.02; ARR 0.57.). %; 95% CI, -0.2% to 1.3%).

With regard to MI, the use of oral anticoagulation showed superiority over the control group in reducing MI rates (2.2% vs. 2.9%; OR 0.83; 95% CI 0.71-0.98 ; ARR 0.42%; 95% CI 0.06% bis). 0.78%).

The use of oral anticoagulation was associated with an increase in major bleeding in 17 studies (3.4% vs. 2.1%; OR 1.53; 95% CI 1.08-2.16; ARI 0.85%; 95% % CI 0.45% to 1%). . Despite this increase, oral anticoagulation was not associated with an increased risk of fatal bleeding in patients with AF or HFrEF.

One limitation of this analysis was the inclusion of studies that differed in terms of their International Normalized Ratio (INR) goals. The studies also differed in their definitions of major bleeding.

The researchers added that “the differences in the primary endpoints used by studies of HFrEF compared to AF may have contributed to different conclusions about the relative effectiveness of oral anticoagulation, particularly the inclusion of all-cause mortality in most HFrEF” Studies “.


Reddin C, Richter C, Loughlin E, et al. Association of oral anticoagulation with stroke in atrial fibrillation or heart failure: a comparative meta-analysis. Stroke. Published online July 20, 2021. doi: 10.1161 / STROKEAHA.120.033910

This article originally appeared on The Cardiology Advisor

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