Comparison of Bleeding Risks and All-Cause Death Between Warfarin and Direct Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Obstructive Pulmonary Disease: A Multicenter Retrospective Cohort Study.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) may influence bleeding in atrial fibrillation (AF). We evaluated bleeding and all-cause death risks under warfarin versus direct oral anticoagulants (DOACs).

METHODS

Based on a retrospective cohort from 12 centers of patients with AF on oral anticoagulation, we evaluated the associations of COPD and anticoagulant class with clinical outcomes using overlap-weighted logistic regression. Prespecified sensitivity and subgroup analyses were performed.

RESULTS

COPD was associated with higher bleeding risk only among patients treated with warfarin (total bleeding: odds ratio [OR] 2.53, 95% confidence interval [CI] 1.00–6.45; risk difference [RD] 9.05%, 95% CI 0.15%–22.50%; minor bleeding: OR 3.00, 95% CI 1.09–8.24; RD 8.53%, 95% CI 0.56%–21.53%). Among patients with AF and COPD, DOACs were associated with reduced risks of total bleeding (OR 0.08, 95% CI 0.01–0.50; RD –8.4%, 95% CI -22.0% to -5.3%) and minor bleeding (OR 0.01; RD -9.5%, 95% CI -23.1% to -4.5%) compared with warfarin. Subgroup analyses suggested that DOACs were associated with increased mortality at estimated glomerular filtration rate (eGFR) ≥60mL/min/1.73m² (OR 3.07, 95% CI 0.78–12.03; RD 9.9%) but lower mortality at eGFR <60mL/min/1.73m² (OR 0.20, 95% CI 0.05–0.78; RD -24.1%). Factor Xa inhibitors were associated with a higher major bleeding risk compared with dabigatran (OR 4.56, 95% CI 1.70–12.26; RD 10.2%, 95% CI 0.2%–20.1%; with a number needed to harm of 10).

CONCLUSION

In AF with comorbid COPD, DOACs minimize bleeding versus warfarin and may confer survival benefit in renal impairment. Differential bleeding risk should be considered when choosing among DOACs.