Safety and efficacy of direct oral anticoagulants in stroke prevention in patients with atrial fibrillation complicated with anemia and/or thrombocytopenia: a retrospective cohort study

Wenlin Xu; Jiana Chen; Shuyi Wu; Nianxu Huang; Xia Chen; Wang Zhang; Wei Hu; Jun Su; Hengfen Dai; Ping Gu; Xiaohong Huang; Xiaoming Du; Ruijuan Li; Qiaowei Zheng; Xiangsheng Lin; Yanxia Zhang; Lang Zou; Yuxin Liu; Min Zhang; Xiumei Liu; Zhu Zhu; Jinhua Zhang

doi:10.1186/s12959-023-00563-7

Safety and efficacy of direct oral anticoagulants in stroke prevention in patients with atrial fibrillation complicated with anemia and/or thrombocytopenia: a retrospective cohort study

Thromb J. 2023 Nov 21;21(1):118. doi: 10.1186/s12959-023-00563-7.

Authors

Wenlin Xu¹, Jiana Chen¹, Shuyi Wu¹, Nianxu Huang², Xia Chen³, Wang Zhang⁴, Wei Hu⁵, Jun Su⁶, Hengfen Dai⁷, Ping Gu⁸, Xiaohong Huang⁹, Xiaoming Du¹⁰, Ruijuan Li¹¹, Qiaowei Zheng¹², Xiangsheng Lin¹³, Yanxia Zhang¹⁴, Lang Zou¹⁵, Yuxin Liu¹⁶, Min Zhang¹⁷, Xiumei Liu¹⁸, Zhu Zhu¹⁹, Jinhua Zhang²⁰

Affiliations

¹ Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
² Department of Pharmacy, Taikang Tongji (Wuhan) Hospital, Wuhan, 430000, China.
³ Chendu Qingbaijiang Maternal & Child Health Care Hospital, Chengdu, China.
⁴ Department of Pharmacy, The First People's Hospital of Changde City, Changde, Hunan, 415000, China.
⁵ Department of Pharmacy, Xinyang Central Hospital, Xinyang Hospital Affiliated to Zhengzhou University, Xinyang, Henan, 464000, China.
⁶ Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233004, China.
⁷ Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, Fujian, 350009, China.
⁸ Department of Pharmacy, Suining Central Hospital, Suining, Sichuan, 629000, China.
⁹ Department of Pharmacy, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, 363000, China.
¹⁰ Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, 110004, China.
¹¹ Department of Pharmacy, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, China.
¹² Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, China.
¹³ Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fuzhou, Fujian, 350400, China.
¹⁴ Department of Pharmacy, The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, 154002, China.
¹⁵ Department of Pharmacy, Second Affiliated Hospital, Army Medical University, Chongqing, 400037, China.
¹⁶ Department of Pharmacy, Huaihe Hospital of Henan University, Kaifeng, Henan, 475000, China.
¹⁷ Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Qingdao, Shandong, 266041, China.
¹⁸ Department of Pharmacy, People's Hospital of He'nan University of Chinese Medicine (People's Hospital of Zhengzhou), Zhengzhou, China.
¹⁹ Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, China.
²⁰ Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China. pollyzhang2006@126.com.

Abstract

Background: There are limited data about the clinical benefits and harm of direct oral anticoagulants (DOACs) in stroke prevention in patients with atrial fibrillation (AF) complicated with anemia or thrombocytopenia.

Methods: This is a multi-center retrospective cohort study involving 5469 AF patients from 15 hospitals in China. Patients were divided into three groups according to hemoglobin and platelet levels: Group 1 (hemoglobin male ≥ 130 g/L; female ≥ 120 g/L and platelet ≥ 100 × 10⁹/L), Group 2 (hemoglobin male < 130 g/L; female < 120 g/L or platelet < 100 × 10⁹/L), and Group 3 (hemoglobin male < 130 g/L; female < 120 g/L and platelet < 100 × 10⁹/L). Patients in each category are further divided into two groups according to their stroke prevention strategies: rivaroxaban or dabigatran. Clinical results include major, minor, total bleeding, thrombosis, and the composite outcome of major bleeding and thrombosis.

Results: Higher hemoglobin levels were associated with a reduced risk of total bleeding and major bleeding, while platelet counts were not associated with any event. Compared with Group 1, Group 2 had a higher risk of major bleeding (aOR 1.70, 95%CI 1.12-2.57, P = 0.012), and the composite endpoint of major bleeding and thrombosis (aOR 1.70, 95%CI 1.19-2.44, P = 0.004). Compared with Group 1, Group 3 had a higher total bleeding risk (aOR 2.15, 95%CI 1.14-4.05, P = 0.018). Compared with dabigatran, rivaroxaban was associated with higher composite risk in Group 1 (aOR 2.91, 95% CI 1.66-5.16, P < 0.001) and Group 2 (aOR 3.05, 95%CI 1.46-6.39, P = 0.003), but there was no significant difference in Group 3 (aOR 1.78, 95%CI 0.23-13.54, P = 0.577).

Conclusions: Higher hemoglobin levels are associated with a reduced risk of total bleeding and major bleeding in patients with AF. Dabigatran was associated with better clinical outcomes than rivaroxaban in patients with anemia or thrombocytopenia but not in those with anemia and thrombocytopenia.

Keywords: Anemia; Atrial fibrillation; DOACs; Hemoglobin; Platelet; Thrombocytopenia.