on August 26, 2004
Published online before print August 26, 2004, doi: 10.1161/01.STR.0000141933.75462.c2
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Submitted on June 8, 2004
From the Pharmacy Practice Department (T.I.S.), University of Kansas School of Pharmacy, Lawrence, Kan; the Departments of Pharmacy Practice and Medicine (P.A.H.), University of Kansas Schools of Pharmacy & Medicine, Kansas City, Kan; the Department of Surgery (T.F.K.), University of Iowa College of Medicine, Iowa City, Iowa; the Department of Preventive Medicine and Internal Medicine (E.F.E.), University of Kansas School of Medicine, Kansas City, Kan. * To whom correspondence should be addressed. E-mail: Shireman{at}ku.edu.
Background and Purpose--Bleeding risks from combined antiplatelet-warfarin therapy have not been well-described in clinical practice. We examined antiplatelet therapy among warfarin users and the impact on major bleeding rates. Methods--Retrospective cohort analysis of persons discharged on warfarin after an atrial fibrillation admission using data from Medicare’s National Stroke Project. Data included Medicare claims, enrollment information, and medical record abstracted data. Logistic regression and Cox proportional hazards models were used to predict concurrent antiplatelet use and hospitalization with a major acute bleed within 90 days after discharge from the index AF admission. Results--10 093 warfarin patients met inclusion criteria with a mean age of 77 years; 19.4% received antiplatelet therapy. Antiplatelet use was less common among women, older persons, and persons with cancer, terminal diagnoses, dementia, and bleeding history. Persons with coronary disease were more likely to receive an antiplatelet agent. Antiplatelets increased major bleeding rates from 1.3% to 1.9% (P=0.052). In the multivariate analysis, factors associated with bleeding events included age (OR, 1.03; 95% CI, 1.002 to 1.05), anemia (OR, 2.52; 95% CI, 1.64 to 3.88), a history of bleeding (OR, 2.40; 95% CI, 1.71 to 3.38), and concurrent antiplatelet therapy (OR, 1.53; 95% CI, 1.05 to 2.22). Conclusions--Although concerns about increased bleeding risk with combined warfarin-antiplatelet therapy are not unfounded, the risk of bleeding is moderately increased. The decision to use concurrent antiplatelet therapy appears to be tempered by cardiac and bleeding risk factors.
Revised on July 20, 2004
Accepted on July 27, 2004
Combined Anticoagulant-Antiplatelet Use and Major Bleeding Events in Elderly Atrial Fibrillation Patients
Theresa I. Shireman PhD, RPh*;
Key words: anticoagulants • atrial fibrillation • blood • platelet aggregation inhibitors
This article has been cited by other articles:
 |
|
 |
|
  P. Kirchhof, J. Bax, C. Blomstrom-Lundquist, H. Calkins, A. J. Camm, R. Cappato, F. Cosio, H. Crijns, H.-C. Diener, A. Goette, et al. Early and comprehensive management of atrial fibrillation: Proceedings from the 2nd AFNET/EHRA consensus conference on atrial fibrillation entitled 'research perspectives in atrial fibrillation' Europace, July 1, 2009; 11(7): 860 - 885. [Full Text] [PDF]
|
|
|
|
 |
|
 M. A. Crandall, D. J. Bradley, D. L. Packer, and S. J. Asirvatham Contemporary Management of Atrial Fibrillation: Update on Anticoagulation and Invasive Management Strategies Mayo Clin. Proc., July 1, 2009; 84(7): 643 - 662. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Kirchhof, J. Bax, C. Blomstrom-Lundquist, H. Calkins, A. John Camm, R. Cappato, F. Cosio, H. Crijns, H.-C. Diener, A. Goette, et al. Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference 'research perspectives in AF' Eur. Heart J., June 17, 2009; (2009) ehp235v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Sourgounis, J. Lipiecki, T. S. Lo, and M. Hamon Coronary Stents and Chronic Anticoagulation Circulation, March 31, 2009; 119(12): 1682 - 1688. [Full Text] [PDF]
|
|
|
|
 |
|
 A. H. Friedlander, T. T. Yoshikawa, D. S. Chang, Z. Feliciano, and C. Scully Atrial Fibrillation: Pathogenesis, Medical-Surgical Management and Dental Implications J Am Dent Assoc, February 1, 2009; 140(2): 167 - 177. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A M Veitch, T P Baglin, A H Gershlick, S M Harnden, R Tighe, and S Cairns Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures Gut, September 1, 2008; 57(9): 1322 - 1329. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Schulman, R. J. Beyth, C. Kearon, and M. N. Levine Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 257S - 298S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. G. Johnson, K. Rogers, T. Delate, and D. M. Witt Outcomes Associated With Combined Antiplatelet and Anticoagulant Therapy Chest, April 1, 2008; 133(4): 948 - 954. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Y H Lip Don't add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation BMJ, March 15, 2008; 336(7644): 614 - 615. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Hughes, G.Y.H. Lip, and on behalf of the Guideline Development Group for t Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review QJM, October 1, 2007; 100(10): 599 - 607. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G. Hart, L. A. Pearce, and M. I. Aguilar Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation Ann Intern Med, June 19, 2007; 146(12): 857 - 867. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Hylek, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation Circulation, May 29, 2007; 115(21): 2689 - 2696. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. A. Lane and G. Y. H. Lip Maintaining Therapeutic Anticoagulation: The Importance of Keeping "Within Range" Chest, May 1, 2007; 131(5): 1277 - 1279. [Full Text] [PDF]
|
|
|
|
|
|
S. G. Johnson, D. M. Witt, T. R. Eddy, T. Delate, and for the Clinical Pharmacy Anticoagulation Service Warfarin and Antiplatelet Combination Use Among Commercially Insured Patients Enrolled in an Anticoagulation Management Service Chest, May 1, 2007; 131(5): 1500 - 1507. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. T. Akins, H. A. Feldman, R. G. Zoble, D. Newman, S. G. Spitzer, H.-C. Diener, and G. W. Albers Secondary Stroke Prevention With Ximelagatran Versus Warfarin in Patients With Atrial Fibrillation: Pooled Analysis of SPORTIF III and V Clinical Trials Stroke, March 1, 2007; 38(3): 874 - 880. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Dentali, J. D. Douketis, W. Lim, and M. Crowther Combined Aspirin-Oral Anticoagulant Therapy Compared With Oral Anticoagulant Therapy Alone Among Patients at Risk for Cardiovascular Disease: A Meta-analysis of Randomized Trials Arch Intern Med, January 22, 2007; 167(2): 117 - 124. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L Kalra, G Y H Lip, and on behalf of the Guideline Development Group for t Antithrombotic treatment in atrial fibrillation Heart, January 1, 2007; 93(1): 39 - 44. [Full Text] [PDF]
|
|
|
|
|
|
M. I. Aguilar, R. G. Hart, C. S. Kase, W. D. Freeman, B. J. Hoeben, R. C. Garcia, J. E. Ansell, S. A. Mayer, B. Norrving, J. Rosand, et al. Treatment of Warfarin-Associated Intracerebral Hemorrhage: Literature Review and Expert Opinion Mayo Clin. Proc., January 1, 2007; 82(1): 82 - 92. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Kakar, D. Lane, and G. Y. H. Lip Bleeding risk stratification models in deciding on anticoagulation in patients with atrial fibrillation: a useful complement to stroke risk stratification schema. Chest, November 1, 2006; 130(5): 1296 - 1299. [Full Text] [PDF]
|
|
|
|
|
|
T. I. Shireman, J. D. Mahnken, P. A. Howard, T. F. Kresowik, Q. Hou, and E. F. Ellerbeck Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest, November 1, 2006; 130(5): 1390 - 1396. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Writing Committee Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society Europace, September 1, 2006; 8(9): 651 - 745. [Full Text] [PDF]
|
|
|
|
 |
|
 V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society J. Am. Coll. Cardiol., August 15, 2006; 48(4): e149 - e246. [Full Text] [PDF]
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Circulation, August 15, 2006; 114(7): e257 - e354. [Full Text] [PDF]
|
|
|
|
|
|
R. G. Hart, S. B. Tonarelli, and L. A. Pearce Avoiding Central Nervous System Bleeding During Antithrombotic Therapy: Recent Data and Ideas Stroke, July 1, 2005; 36(7): 1588 - 1593. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. S Gami Anticoagulant plus antiplatelet treatment increased the risk of bleeding in atrial fibrillation Evid. Based Med., April 1, 2005; 10(2): 56 - 56. [Full Text] [PDF]
|
|
|
|
 |
|
 Concomitant Anticoagulant-Antiplatelet Therapy in Elderly AF Patients Journal Watch Cardiology, November 26, 2004; 2004(1126): 5 - 5. [Full Text]
|
|