A Real-World Picture of Rehospitalization Following Stroke and Major Bleeding in Patients With Afib

More than 5 million people in the United States have atrial fibrillation (AF), approximately 70% of which are non-valvular AF cases. The risk of stroke in AF patients is estimated to be five times higher than in non-AF patients. The clinical and economic burdens associated with stroke are significant, with the rate of re-hospitalization among stroke survivors estimated at 40% at 1 year. Less is known about the rehospitalization rate of patients with non-valvular atrial fibrillation (NVAF) following major bleeding. Although there are numerous approved oral anticoagulants for NVAF, determining the appropriate agent to minimize stroke risk in older adults with NVAF remains a challenge due to the fact that elderly persons have many comorbidities to contend with and were not adequately represented in clinical trials, particularly in RE-LY.

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To estimate the impact of rehospitalization following stroke and major bleeding in a real-world context, Gerald V. Naccarelli, MD, Pennsylvania State University Hershey Heart and Vascular Institute, Hershey, PA, and colleagues conducted a retrospective claims analysis of adults with NVAF in commercial and Medicare health plans between 2008 and 2012. They presented these results in a poster session at the AHA 2014 Scientific Sessions.

They identified a total of 40,654 managed care patients with NVAF, of whom 75% were aged 65 years or older and had a mean CHADS₂ score of 2.1. More than half (53%) of the study population was receiving anticoagulation therapy, with warfarin being the most common (n=17,216), followed by dabigatran (n=3750) and rivaroxaban (n=677). The 30-day and 1-year rates of all-cause, stroke-related, and major bleeding-related hospitalizations were calculated for patients who were admitted initially for a stroke or major bleeding. Overall rates were calculated by counting both initial and subsequent admissions. Rehospitalization rates were calculated by counting all readmissions.

In patients with stroke (n=5512), 52% were rehospitalized during the first year after discharge, with a 1-year rate of all-cause re-hospitalizations estimated at 172 per 100 person-years. In patients with major bleeding (n=8452), 54% were rehospitalized during the first year, with a 1-year rate of all-cause rehospitalizations estimated at 177.1 per 100 person-years. The overall rate of hospitalizations for major bleeding (excluding intracranial hemorrhage) was higher compared to the overall rate of hospitalizations for stroke (13.4 vs 9.3 per 100 person-years). The results also found 22% of all-cause re-hospitalizations were related to stroke and 18% were related to major bleeding during the first year. In the first year following first major bleeding, 10% of all-cause rehospitalizations were related to stroke, and 25% were related to major bleeding.

The results of their analysis suggest that given the high risk of rehospitalization for both stroke and major bleeding events in patients with NVAF, interventions should target prevention of stroke and major bleeding, the investigators concluded. “These data will be of interest to clinicians and payers who have an increasing number of [oral anticoagulation] treatment options available with different efficacy and safety profiles,” the team concluded.

—Allison Musante

This study was supported by Bristol-Myers Squibb and Pfizer.