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Heartbeat: bleeding risk in atrial fibrillation patients on non-vitamin K oral anticoagulant medications
  1. Catherine M Otto
  1. Division of Cardiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Professor Catherine M Otto, Division of Cardiology, University of Washington, Seattle, WA 98195, USA; cmotto{at}

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In patients with atrial fibrillation (AF), the decision to recommend long-term anticoagulation is based on consideration of the relative risk of a thromboembolic event versus the risk of major bleeding. Current risk scores for bleeding on anticoagulation were developed for vitamin K antagonists (VKA) and antiplatelet therapy, yet now many patients are treated with non-VKA oral anticoagulants (NOACs). Barnett-Griness and colleagues1 used data from a large integrated healthcare organisation to develop a novel risk score for risk of bleeding in patients with AF treated with NOACs. The risk score was derived from data on 28 055 AF patients treated with apixaban and then tested in 19 569 patients treated with either dabigatran or rivaroxaban. Points were assigned for each identified risk factors and then added to provide an overall score: male sex (7), anaemia (6), thrombocytopenia (9), antiplatelet therapy (7), hypertension (8), prior major bleeding (5), fall risk (4), low serum cholesterol (0–5) and renal function (0–8). There was a strong relationship between the total risk score and 1 year probably of major bleeding (figure 1).

Figure 1

Points-based tool for predicting major bleeding event by 1 year. The histogram refers to the risk score distribution in the cohort. Each bar represents the proportion of subjects in the cohort that was assigned the relevant score range. The histogram was divided into quartiles; each quartile was coloured differently. For example, the middle 50% of the cohort had points score between 20 and 30. The 1 year major bleeding probability can be read by the predicted risk blue curve, using the right y-axis. for example, a points score of 50 is associated with ~6% risk.

In the accompanying editorial, Morrone and De Caterina2 summarise the numerous previous risk scores for bleeding in patients with AF, pointing out that all have limited predictive values and that the factors that predict risk of bleeding also tend to predict risk of thromboembolic events. Although the proposed new model provides some a somewhat improved risk estimate, older scores have easily remembered acronyms and are practical for daily clinical practice. Still, none of the existing scores is ideal so that continued research to improve outcomes in patients with AF is needed with the goal of minimising thromboembolic risk without increasing bleeding risk.

Population based data on disease incidence is needed to inform healthcare policy and planning and, perhaps, might lead to improved preventative strategies. In a study of heart failure (HF) incidence from 2006 to 2018 in New Zealand, Chan and colleagues3 found that overall HF incidence declined from 403 to 323 per 100 000 between 2006 and 2013. However, overall HF incidence plateaued from 2013 to 2018, with an increase in HF younger (age 20–49 years) individuals offsetting a decline in HF incidence in those age 80 years of age or older (figure 2). The increase in HF incidence in younger individuals occurred despite an overall reduction in the proportion of HF hospitalisation due to ischaemic heart disease from 35% in 2006 to 28% in 2018.

Figure 2

Age-standardised and age-specific rates of incident heart failure hospitalisation by history of IHD. Rates are age-standardised to revised 2013 European standard population. Trend lines calculated with joinpoint regression modelling. IHD, ischaemic heart disease.

As discussed in an editorial by Nedkoff and Weber,4 the causes of increased HF incidence in younger individuals are unknown. One hypothesis is that the increase in obesity and diabetes is leading to an increased incidence of HF. Other possible causes include genetic cardiomyopathies, or alcohol and methamphetamine use. Nedkoff and Weber4 point out that the incidence of HF in younger individuals is ‘50 times lower than rates in the oldest age groups. However, in absolute terms, this equates to nearly 600 people annually in the New Zealand population aged <50 years with onset of heart failure, with ongoing substantial risk of poor cardiovascular outcomes and increasing heart failure burden with ageing.’

In patients with cardiovascular conditions, the effects and risk of fasting during Ramadan vary with the specific type and severity of disease. In this issue of Heart, Akhtar and colleagues5 provide guidance for classifying patients as low-moderate versus high-very high risk and make recommendations to avoid dehydration, fluid overload or cardiac decompensation due to altered medication dosing schedules during Ramadan (figure 3).

Figure 3

Suggested pre-Ramadan and post-Ramadan checklist for reviewing patients with cardiovascular conditions. CKD, chronic kidney disease; DM, diabetes mellitus; IM, intramuscular; S/L, sublingual; U&E, urea and electrolytes. †See figure 1 in this article; ‡ see references 3, 9, 11–14 in this article; ‡‡see table in this article (created with

The Education in Heart article6 in this issue, discusses the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors in treatment of patients with heart failure which complements a state-of-the-art review article on this topic published recently in Heart.7 Two large, randomised, placebo-controlled trials of SGLT2 inhibitors in patients hospitalised for HF with reduced ejection fraction (HFrEF) demonstrated a reduction in mortality and morbidity as well as symptoms. Thus, although guideline updates are pending, the authors recommend the use of SGLT2 inhibitors in patients with HFrEF and provide practical guidance for starting and monitoring therapy (figure 4).

Figure 4

Summary of the benefits of SGLT2 inhibitors in patients with HFrEF. BP, blood pressure; eGFR, estimated glomerular filtration rate; HFrEF, heart failure and reduced ejection fraction; IV, intravenous; LV, left ventricle; NT-proBNP, N-terminal prohormone of B-type natriuretic peptide; T2DM, type 2 diabetes mellitus.

The Cardiology-in-Focus topic8 in this issue focuses on the ethics of allocating scare resources, such as extracorporeal membrane oxygenation (ECMO) during a pandemic or other crisis situation. The authors conclude that ‘An understanding of the practical constraints of ECMO is essential, as is an appreciation for the strengths and limitations of different ethical perspectives that drive decision-making in resource allocation, particularly the impact of utilitarian-prioritisation on justice and equity.’

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; internally peer reviewed.