Anticoagulation and Risk for Falls in the Atrial Fibrillation Patient

Researchers evaluated the risk of cardiovascular outcomes in atrial fibrillation patients with a history of falls.

Patients with nonvalvular atrial fibrillation (AF) should receive an oral anticoagulant to prevent stroke or thromboembolism. However, many patients who have AF are elderly, and physicians most often cite a patient’s risk of falls, a risk that increases with age, as a reason for not prescribing oral anticoagulants. Researchers are still trying to tease out patients’ precise risk of bleeding if they fall while on oral anticoagulants, and various studies have reported different relationships. AF itself increases risk for falls, and various falls risk assessment tools may place patients in different risk categories. It’s a conundrum.

Researchers at the Loire Valley Atrial Fibrillation Project based in Tours, France, have taken a different approach. They enrolled individuals with nonvalvular AF who had a documented history of falls to evaluate the risk of cardiovascular outcomes in this “real world” cohort. Their study, which was conducted from 2000 to 2010, appears in the June 2014 issue of the American Journal of Medicine.

Among 7156 AF patients, only 76 (1.1%) had a prior history of falls/trauma. Patients with previous falls tended to be older and approximately half as likely to receive oral anticoagulation. They also had higher risk scores for stroke/thromboembolism, but not for bleeding.

Compared with patients with no prior history of falls, patients with previous falls were significantly more likely to experience stroke/thromboembolism or die. Risk of ischemic stroke/thromboembolism was increased by fivefold in this population, and bleeding and mortality risk was increased nearly fourfold compared with patients who had never fallen. This association held even when patients were receiving appropriate anticoagulants. The authors attribute the association to the probably of a greater number of comorbidities in patients with previous falls.

These researchers found no increased risk of hemorrhagic stroke in anticoagulated individuals.

The authors describe a Markov decision analysis that estimated that individuals taking warfarin must fall 295 times in one year for warfarin’s benefits to be outweighed by the risk of intracranial hemorrhage. The authors conclude that a prior history of actual falls may be a more clinically useful risk factor than merely being at risk for falls.