Yonsei Med J.  2019 Jan;60(1):65-72. 10.3349/ymj.2019.60.1.65.

Antithrombotic Medication and the Risk of Vitreous Hemorrhage in Atrial Fibrillation: Korean National Health Insurance Service National Cohort

• Kim KE
• Yang PS
• Jang E
• Kim S
• Joung B

• KMID: 2428279
• DOI: http://doi.org/10.3349/ymj.2019.60.1.65

Abstract

PURPOSE
Antithrombotic therapy could be related with nuisance bleeding. This study investigated whether vitreous hemorrhage (VH) is associated with specific types of antithrombotic medication in patients with atrial fibrillation (AF).
MATERIALS AND METHODS
In the Korean National Health Insurance Service National Sample Cohort, we identified 9352 antiplatelet/anticoagulant-treated AF patients. The occurrence of VH was compared between warfarin (n=1493) and a propensity score (PS)-matched antiplatelet group (n=1493) and between warfarin (n=1493) and a PS-matched warfarin+antiplatelet group (n=1493).
RESULTS
The outcomes of VH were lower in the warfarin than in the matched antiplatelet (1.45 vs. 3.72 events/1000 patient-years) and matched warfarin+antiplatelet groups (1.45 vs. 6.87 events/1000 patient-years). Compared with warfarin, the risk of VH increased with antiplatelet [adjusted hazard ratio (aHR) 3.90; 95% confidence interval (CI) 1.22-12.4, p=0.022] and warfarin+antiplatelet agents (aHR 4.39, 95% CI 1.74-11.2, p=0.002). Compared with warfarin only, warfarin+antiplatelet agents increased the risk of VH in patients ≥65 years, regardless of gender and hypertension. The risk of VH was significantly higher with dual antiplatelet therapy (aHR: 5.02, 95% CI: 1.56-16.2, p=0.007) or in dual (aHR: 5.02, 95% CI: 1.74-14.5, p=0.003) or triple therapy using warfarin and antiplatelet agents than with warfarin monotherapy (aHR: 6.12, 95% CI: 1.76-21.3, p=0.004).
CONCLUSION
Dual antiplatelet or triple therapy increased the risk of VH significantly, compared to warfarin monotherapy. Considering the low efficacy of preventing ischemic stroke and high risk of bleeding, dual or triple therapy using warfarin and antiplatelet agents should be avoided to prevent VH in AF patients.

Keyword

Vitreous hemorrhage; antiplatelet; anticoagulant; atrial fibrillation

MeSH Terms

Atrial Fibrillation*
Cohort Studies*
Hemorrhage
Humans
Hypertension
National Health Programs*
Platelet Aggregation Inhibitors
Propensity Score
Stroke
Vitreous Hemorrhage*
Warfarin
Platelet Aggregation Inhibitors
Warfarin

Figure

• 

  Fig. 1 Study cohort. NHIS-NSC, National Health Insurance Service-National Sample Cohort. AF, atrial fibrillation; PS, propensity score.

• 

  Fig. 2 Cumulative incidence of vitreous hemorrhage (VH). (A) Warfarin vs. antiplatelet agents. (B) Warfarin vs. warfarin+antiplatelet agents.

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  Fig. 3 Risk of VH according to different warfarin or antiplatelet agent combinations. VH, vitreous hemorrhage; CI, confidence interval; HR, hazard ratio.

• 

  Fig. 4 Subpopulation analysis in patients with diverse comorbidities. The point estimates of vitreous hemorrhage risk in group with antiplatelet (A) or warfarin+antiplatelet combination (B) compared with reference (warfarin). HTN, hypertension; DM, diabetes mellitus; HF, heart failure; TIA, transient ischemic attack; HR, hazard ratio; CI, confidence interval.

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