Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case–control study

ObjectivesWe studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin.DesignThis was a retrospective nested case–control study from the Finni...

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Published in:BMJ open 2023-11, Vol.13 (11), p.e071342-e071342
Main Authors: Helin, Tuukka Antero, Raatikainen, Pekka, Lehto, Mika, Haukka, Jari, Lassila, Riitta
Format: Article
Language:English
Subjects:
Anemia
Anticoagulants
Bleeding disorders & coagulopathies
Blood tests
Cardiac arrhythmia
Cardiovascular Medicine
Creatinine
Hemoglobin
Ischemia
Laboratories
Leukocytes
Mortality
Patients
Stroke
Thromboembolism
Transient ischemic attack
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Raatikainen, Pekka
Lehto, Mika
Haukka, Jari
Lassila, Riitta
description ObjectivesWe studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin.DesignThis was a retrospective nested case–control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.SettingNational FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007–31 December 2011.ParticipantsA total of 54 568 warfarin-anticoagulated patients.ResultsThe number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111–141 g/L vs 123–147 g/L, p
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Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.SettingNational FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007–31 December 2011.ParticipantsA total of 54 568 warfarin-anticoagulated patients.ResultsThe number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111–141 g/L vs 123–147 g/L, p&lt;0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8–2.6 vs 2.1–2.7, p&lt;0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4.ConclusionsThe deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.</description><identifier>ISSN: 2044-6055</identifier><identifier>EISSN: 2044-6055</identifier><identifier>DOI: 10.1136/bmjopen-2022-071342</identifier><identifier>PMID: 37918932</identifier><language>eng</language><publisher>London: British Medical Journal Publishing Group</publisher><subject>Anemia ; Anticoagulants ; Bleeding disorders &amp; coagulopathies ; Blood tests ; Cardiac arrhythmia ; Cardiovascular Medicine ; Creatinine ; Hemoglobin ; Ischemia ; Laboratories ; Leukocytes ; Mortality ; Patients ; Stroke ; Thromboembolism ; Transient ischemic attack</subject><ispartof>BMJ open, 2023-11, Vol.13 (11), p.e071342-e071342</ispartof><rights>Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</rights><rights>2023 Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. 2023</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-b467t-994902ceb9a01abd1775083ec387981fdbff8f3478fe801269c8d36401941f703</cites><orcidid>0000-0002-8691-5142 ; 0000-0003-1450-6208 ; 0000-0002-5273-8088</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.proquest.com/docview/2885236426/fulltextPDF?pq-origsite=primo$$EPDF$$P50$$Gproquest$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.proquest.com/docview/2885236426?pq-origsite=primo$$EHTML$$P50$$Gproquest$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,885,3194,25753,27924,27925,37012,37013,44590,53791,53793,55341,55350,75126,77596,77597,77660,77686</link.rule.ids></links><search><creatorcontrib>Helin, Tuukka Antero</creatorcontrib><creatorcontrib>Raatikainen, Pekka</creatorcontrib><creatorcontrib>Lehto, Mika</creatorcontrib><creatorcontrib>Haukka, Jari</creatorcontrib><creatorcontrib>Lassila, Riitta</creatorcontrib><title>Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case–control study</title><title>BMJ open</title><addtitle>BMJ Open</addtitle><description>ObjectivesWe studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin.DesignThis was a retrospective nested case–control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.SettingNational FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007–31 December 2011.ParticipantsA total of 54 568 warfarin-anticoagulated patients.ResultsThe number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111–141 g/L vs 123–147 g/L, p&lt;0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8–2.6 vs 2.1–2.7, p&lt;0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4.ConclusionsThe deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. 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Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.SettingNational FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007–31 December 2011.ParticipantsA total of 54 568 warfarin-anticoagulated patients.ResultsThe number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111–141 g/L vs 123–147 g/L, p&lt;0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8–2.6 vs 2.1–2.7, p&lt;0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4.ConclusionsThe deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.</abstract><cop>London</cop><pub>British Medical Journal Publishing Group</pub><pmid>37918932</pmid><doi>10.1136/bmjopen-2022-071342</doi><orcidid>https://orcid.org/0000-0002-8691-5142</orcidid><orcidid>https://orcid.org/0000-0003-1450-6208</orcidid><orcidid>https://orcid.org/0000-0002-5273-8088</orcidid><oa>free_for_read</oa></addata></record>
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subjects Anemia
Anticoagulants
Bleeding disorders & coagulopathies
Blood tests
Cardiac arrhythmia
Cardiovascular Medicine
Creatinine
Hemoglobin
Ischemia
Laboratories
Leukocytes
Mortality
Patients
Stroke
Thromboembolism
Transient ischemic attack
title Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case–control study
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