Oral anticoagulation in heart failure complicated by atrial fibrillation: a nationwide routine data study

BackgroundAim of this study was to test if oral anticoagulant (OAC) use in patients with heart failure (HF), accompanied by atrial fibrillation (AF), leads to a favorable outcome. Further, the specific impact of non-vitamin K oral anticoagulants (NOACs) is analyzed. MethodsAnonymous data from all patients with a health insurance at the largest entity which covers approximately 30% of the German population. Patients with a claims record for hospitalization with the main diagnosis of HF and AF from the years 2017 to 2019 were included. A hospital stay in the previous year was an exclusion criterion. Mortality and readmission for all-cause and stroke/intracranial bleeding (ICB) were analyzed 91-365 days after the index hospitalization. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome. Results180,316 cases were included [81 years (IQR 76 to 86), 55.6% female, CHA2DS2-VASc score [≥] 2 (96.81%)]. In 80.6%, OACs were prescribed (vitamin K antagonists (VKA): 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%; with multiple prescriptions per patient included). The mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9%. Risk of death was lower with the any OAC (HR 0.77, 95% CI 0.75 to 0.79) but without significant differences in OAC type (VKA: HR 0.73, 95% CI 0.71 to 0.76; FXaI: HR 0.77, 95% CI 0.75 to 0.78; DTI: HR 0.71, 95% CI 0.66 to 0.77). The total readmission rate (HR 0.97, 95% CI 0.94 to 0.99) and readmission for stroke/ICB (HR 0.71, 95% CI 0.65 to 0.77) was lower with OAC. ConclusionsRoutine data confirm the positive effect of OACs in HF-AF. There are no additional benefits regarding mortality with the use of NOACs. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIThis routine data analysis on a study population of 180,316 indicates a decreasing mortality rate, 91 to 365 days after index hospital stay, in patients with HF complicated by AF in case oral anticoagulants (OACs) were prescribed. C_LIO_LISecondly, the findings imply no additional benefits of new OACs (NOACs) compared to vitamin K antagonists. C_LI What are the clinical implications?O_LIOur study highlights the benefits of a permanent oral anticoagulation therapy in patients with heart failure (HF) complicated by atrial fibrillation (AF). C_LIO_LIFor patients with HF and AF, the results indicate room for personalizationin choosing the specific OAC type for anticoagulation as NOACs show no survival benefit over vitamin K antagonists. C_LI