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Heart. 2018 Jul;104(13):1093-1100. doi: 10.1136/heartjnl-2017-312720. Epub 2018 Jan 25.

Reasons for and consequences of oral anticoagulant underuse in atrial fibrillation with heart failure.

Author information

Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linköping, Sweden.



Atrial fibrillation (AF) is common in patients with heart failure (HF), and oral anticoagulants (OAC) are indicated. The aim was to assess prevalence of, predictors of and consequences of OAC non-use.


We included patients with AF, HF and no previous valve replacement from the Swedish Heart Failure Registry. High and low CHA2DS2-VASc and HAS-BLED scores were defined as above/below median. Multivariable logistic regressions were used to assess the associations between baseline characteristics and OAC use and between CHA2DS2-VASc and HAS-BLED scores and OAC use. Multivariable Cox regressions were used to assess associations between CHA2DS2-VASc and HAS-BLED scores, OAC use and two composite outcomes: all-cause death/stroke and all-cause death/major bleeding.


Of 21 865 patients, only 12 659 (58%) received OAC. Selected predictors of OAC non-use were treatment with platelet inhibitors, less use of HF treatments, paroxysmal AF, history of bleeding, no previous stroke, planned follow-up in primary care, older age, living alone, lower income and variables associated with more severe HF. For each 1-unit increase in CHA2DS2-VASc and HAS-BLED, the ORs (95% CI) of OAC use were 1.24 (1.21-1.27) and 0.32 (0.30-0.33), and the HRs for death/stroke were 1.08 (1.06-1.10) and for death/major bleeding 1.18 (1.15-1.21), respectively. For high versus low CHA2DS2-VASc and HAS-BLED, the ORs of OAC use were 1.23 (1.15-1.32) and 0.20 (0.19-0.21), and the HRs for death/stroke were 1.25 (1.19-1.30) and for death/major bleeding 1.28 (1.21-1.34), respectively.


Patients with AF and concomitant HF do not receive OAC on rational grounds. Bleeding risk inappropriately affects decision-making more than stroke risk.


atrial fibrillation; heart failure; medication adherence

[Indexed for MEDLINE]

Conflict of interest statement

Competing interests: GS: none related to this manuscript. Research grant from MSD Italy and Swedish Heart- Lung Foundation. US: none related to this manuscript. US was supported by grants from the Swedish Society of Medicine, Karolinska Institutet Foundations and Funds, the Mats Kleberg Foundation (grant number 2016-00015), the Swedish Heart-Lung Foundation (grant numbers 20160522 and 20160525), the Swedish Heart and Lung Association (grant number E101/16), Regional ALF agreement between Stockholm County Council and Karolinska Institutet (grant number 20160329), Åke Wiberg Foundation (grant number M16-0081) and Magnus Bergvall Foundation (grant number 2016-01396) LF: none related to this manuscript. Research grants and consultancy fees from Bayer, BMS, Pfizer and Sanofi. UD: none related to this manuscript. Research grant to the author’s institution from AstraZeneca and honoraria/consultancies to author’s institution from Novartis and AstraZeneca. LHL: there are no conflicts of interest related to the work submitted. Outside the work submitted, there are the following potential conflicts of interest: research grants to author’s institution, speaker’s and/or consulting fees: AstraZeneca, Novartis, Bayer, Vifor Pharma, Relypsa, Boston Scientific, StJude, Medtronic, HeartWare.

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