# Low bleeding acceptance is associated with increased death risk in patients with atrial fibrillation on oral anticoagulation

## TL;DR

Patients with atrial fibrillation who are less willing to accept bleeding risks while on anticoagulation face higher chances of stroke, death, or non-persistence with treatment.

## Contribution

This study introduces bleeding risk acceptance as a novel prognostic factor in atrial fibrillation patients on anticoagulation.

## Key findings

- Low bleeding acceptance is linked to higher mortality and cerebrovascular events.
- Patients with low bleeding acceptance are more likely to discontinue anticoagulant therapy.
- Bleeding acceptance, along with age and CHA2DS2-VASc score, predicts poor outcomes in AF patients.

## Abstract

Bleeding is the most feared complication of anticoagulation. We sought to investigate whether the bleeding risk acceptance has a prognostic value during long-term follow-up in the era of direct oral anticoagulants (DOACs) among patients with atrial fibrillation (AF). We studied 167 consecutive AF outpatients [aged 68.8 SD 10.6 years; 141 (84.4%) on DOACs]. The bleeding acceptance was assessed based on the Bleeding Ratio defined as the declared maximum number of major bleedings that a patient would be willing to accept to prevent one major stroke. We recorded cerebrovascular ischemic events, major or clinically relevant non-major bleeds (CRNMB), and mortality. A median Bleeding Ratio was 4 (IQR 2–5). During follow-up of 946 patient-years, cerebrovascular ischemic events and/or death were observed in 28 patients (3.3%/ year) and major bleeding or CRNMB in 33 (4.6%/ year). The Bleeding Ratio was lower in patients who experienced cerebrovascular events or death (p = 0.004), but not bleeding. Patients with the Bleeding Ratio 0–3 were more often non-persistent to the OAC therapy, and more likely to have cerebrovascular event or die than those with higher bleeding acceptance (odds ratio 2.55; 0.95% CI 1.08–6.02) which was driven by the impact on mortality. The multiple Cox proportional hazards model showed that lower Bleeding Ratio, higher CHA2DS2-VASc score, and older age predicted cerebrovascular events or death during follow-up. AF patients who are willing to accept fewer serious bleedings to avoid major stroke during anticoagulation are more likely to experience death and/or cerebrovascular ischemic events, but not bleeding, what might be related to non-persistence.

The online version contains supplementary material available at 10.1007/s11239-023-02878-8.

AF patients with lower bleeding acceptance show higher risk of mortality.Among AF patients, low bleeding acceptance is a predictor of stroke, TIA and/or death.Low bleeding acceptance may lead to non-persistence to the anticoagulant regimen, therefore affect prognosis in AF.Bleeding acceptance should be considered when planning anticoagulation along with conventional clinical risk scores.

AF patients with lower bleeding acceptance show higher risk of mortality.

Among AF patients, low bleeding acceptance is a predictor of stroke, TIA and/or death.

Low bleeding acceptance may lead to non-persistence to the anticoagulant regimen, therefore affect prognosis in AF.

Bleeding acceptance should be considered when planning anticoagulation along with conventional clinical risk scores.

The online version contains supplementary material available at 10.1007/s11239-023-02878-8.