# Echocardiographic hemodynamics correlate with differences in DOAC-specific bleeding and stroke rates in non-valvular atrial fibrillation

## TL;DR

This study finds that elevated right ventricular systolic pressure is linked to higher bleeding risks with certain anticoagulants but not apixaban in atrial fibrillation patients.

## Contribution

The study identifies a novel association between echocardiographic hemodynamics and DOAC-specific bleeding rates.

## Key findings

- Apixaban is associated with lower bleeding rates compared to rivaroxaban and dabigatran.
- Elevated RVSP increases bleeding risk with rivaroxaban and dabigatran but not apixaban.

## Abstract

Direct oral anticoagulants (DOACs) are widely used for stroke prevention in people with non-valvular atrial fibrillation/flutter (NVAF).Anticoagulants have different bleeding profiles. Apixaban is associated with the lowest bleeding risk. This study evaluates the interaction between DOAC use and right ventricular systolic pressure (RVSP) on echocardiogram and bleeding rates. It was hypothesized that elevated RVSP may be associated with excess bleeding based on anticoagulant-specific pharmacologic profiles.

A retrospective analysis of a database was conducted. Multivariable regression models for bleeding rates were developed using an analysis approach that adjusts for confounders among participants who had undergone an echocardiogram, and interaction terms for DOAC choice were incorporated. Stratum-specific estimates were calculated using linear computation.

Patients taking apixaban had lower bleeding rates than those taking rivaroxaban and dabigatran. Among those without elevated RVSP, there was no difference in bleeding rates. Where RVSP was ≥45mmHg, there was a 90% increase in bleeding rates with use of dabigatran (HR 1.99, p=0.024) and rivaroxaban (HR 1.86, p=0.042) compared to apixaban (Table 1D).

Elevated RVSP is associated with excess bleeding in patients taking rivaroxaban and dabigatran, but not apixaban, after controlling for confounding variables.

The online version contains supplementary material available at 10.1186/s12872-025-05239-w.