Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Open Heart. 2024 Oct 14;11(2):e002975. doi: 10.1136/openhrt-2024-002975.
Heart failure (HF) is not included in atrial fibrillation (AF) bleeding risk prediction scores, reflecting uncertainty regarding its importance as a risk factor for major haemorrhage. We aimed to report the relative risk of first major haemorrhage in people with HF and AF compared with people with AF without HF ('AF only').
English primary care cohort study of 2 178 162 people aged ≥45 years in the Clinical Practice Research Datalink from January 2000 to December 2018, linked to secondary care and mortality databases. We used traditional survival analysis and competing risks methods, accounting for all-cause mortality and anticoagulation.
Over 7.56 years median follow-up, 60 270 people were diagnosed with HF and AF of whom 4996 (8.3%) had a major haemorrhage and 36 170 died (60.0%), compared with 8256 (6.4%) and 34 375 (27.2%), respectively, among 126 251 people with AF only. Less than half those with AF were prescribed an anticoagulant (45.6% from 2014 onwards), although 75.7% were prescribed an antiplatelet or anticoagulant. In a fully adjusted Cox model, the HR for major haemorrhage was higher among people with HF and AF (2.52, 95% CI 2.44 to 2.61) than AF only (1.87, 95% CI 1.82 to 1.92), even in a subgroup analysis of people prescribed anticoagulation. However, in a Fine and Gray competing risk model, the HR of major haemorrhage was similar for people with AF only (1.82, 95% CI 1.77 to 1.87) or HF and AF (1.71, 95% CI 1.66 to 1.78).
People with HF and AF are at increased risk of major haemorrhage compared with those with AF only and current prediction scores may underestimate the risk of haemorrhage in HF and AF. However, people with HF and AF are more likely to die than have a major haemorrhage and therefore an individual's expected prognosis should be carefully considered when predicting future bleeding risk.
心力衰竭（HF）并未纳入心房颤动（AF）出血风险预测评分，这反映了HF 作为大出血风险因素的重要性存在不确定性。我们旨在报告 HF 合并 AF 患者与单纯 AF 患者（“AF 仅”）相比首次大出血的相对风险。
本研究为一项在 2000 年 1 月至 2018 年 12 月期间于临床实践研究数据链（Clinical Practice Research Datalink）中纳入的年龄≥45 岁的 2178162 名英国人的初级保健队列研究，该研究与二级保健和死亡率数据库相关联。我们使用传统生存分析和竞争风险方法，同时考虑全因死亡率和抗凝治疗。
在中位随访 7.56 年内，有 60270 人被诊断为 HF 合并 AF，其中 4996 人（8.3%）发生大出血，36170 人死亡（60.0%），相比之下，126251 名单纯 AF 患者中分别有 8256 人（6.4%）和 34375 人（27.2%）发生大出血和死亡。尽管 75.7%的患者被开了抗血小板或抗凝药物，但仅有不到一半的 AF 患者被开了抗凝药物（2014 年以后为 45.6%）。在经过充分调整的 Cox 模型中，HF 合并 AF 患者的大出血风险更高（2.52，95%CI 2.44 至 2.61），高于单纯 AF 患者（1.87，95%CI 1.82 至 1.92），即使在接受抗凝治疗的亚组分析中也是如此。然而，在 Fine 和 Gray 竞争风险模型中，单纯 AF 患者（1.82，95%CI 1.77 至 1.87）或 HF 合并 AF 患者（1.71，95%CI 1.66 至 1.78）的大出血风险 HR 相似。
与单纯 AF 患者相比，HF 合并 AF 患者发生大出血的风险更高，而当前的预测评分可能低估了 HF 合并 AF 患者的出血风险。然而，HF 合并 AF 患者的死亡风险高于大出血风险，因此在预测未来出血风险时，应仔细考虑个体的预期预后。
