Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study

Background: Data on non-vitamin K antagonist oral anticoagulant (NOAC) use in patients with atrial fibrillation (AF) and a history of falls are limited. Therefore, we investigated the impact of a history of falls on AF-related outcomes, and the benefit-risk profiles of NOACs in patients with a history of falls.

Methods: Using Belgian nationwide data, AF patients initiating anticoagulation between 2013 and 2019 were included. Previous falls that occurred ≤ 1 year before anticoagulant initiation were identified.

Results: Among 254,478 AF patients, 18,947 (7.4%) subjects had a history of falls, which was associated with higher risks of all-cause mortality (adjusted hazard ratio (aHR) 1.11, 95%CI (1.06-1.15)), major bleeding (aHR 1.07, 95%CI (1.01-1.14)), intracranial bleeding (aHR 1.30, 95%CI (1.16-1.47)) and new falls (aHR 1.63, 95%CI (1.55-1.71)), but not with thromboembolism. Among subjects with a history of falls, NOACs were associated with lower risks of stroke or systemic embolism (aHR 0.70, 95%CI (0.57-0.87)), ischemic stroke (aHR 0.59, 95%CI (0.45-0.77)) and all-cause mortality (aHR 0.83, 95%CI (0.75-0.92)) compared to vitamin K antagonists (VKAs), while major, intracranial, and gastrointestinal bleeding risks were not significantly different. Major bleeding risks were significantly lower with apixaban (aHR 0.77, 95%CI (0.63-0.94)), but similar with other NOACs compared to VKAs. Apixaban was associated with lower major bleeding risks compared to dabigatran (aHR 0.78, 95%CI (0.62-0.98)), rivaroxaban (aHR 0.78, 95%CI (0.68-0.91)) and edoxaban (aHR 0.74, 95%CI (0.59-0.92)), but mortality risks were higher compared to dabigatran and edoxaban.

Conclusions: A history of falls was an independent predictor of bleeding and death. NOACs had better benefit-risk profiles than VKAs in patients with a history of falls, especially apixaban.