Geriatr Gerontol Int. 2026 Sep;26(9):e70817. doi: 10.1111/ggi.70817.
ABSTRACT
AIM: In older adults hospitalized with acute heart failure and atrial fibrillation, bleeding concern often drives withholding of oral anticoagulation at discharge. Whether withholding marks a genuinely lower bleeding-risk phenotype or residual clinical vulnerability is uncertain. We examined its association with post-discharge ischemic stroke, major bleeding, and death in a predominantly older cohort.
METHODS: We analyzed a registry of patients hospitalized with acute heart failure and atrial fibrillation. In a discharge-based analysis of patients discharged alive and free of stroke or major bleeding at discharge, we used stabilized inverse-probability-of-treatment weighting for discharge anticoagulation. Ischemic stroke and major bleeding were modeled with weighted Fine-Gray competing-risk regression (death as competing event) and death with weighted Cox regression, contrasting no anticoagulant versus anticoagulant. Age-restricted analyses (≥ 75, ≥ 80 years) and absolute risks were prespecified.
RESULTS: Among 560 patients (no anticoagulant 72, anticoagulant 488; mean age 78 years), withholding was associated with higher ischemic stroke (subdistribution hazard ratio 3.14, 95% confidence interval [CI] 1.26-7.81) and did not identify a lower bleeding-risk phenotype, with numerically higher major bleeding overall (1.98, 0.95-4.14) that reached significance among patients aged ≥ 80 years (2.41, 1.05-5.54). No significant association with death was observed (hazard ratio 1.34, 0.70-2.55). Three-year cumulative incidences of bleeding were 25.6% (no anticoagulant) versus 13.4% (anticoagulant).
CONCLUSION: Discharge anticoagulation withholding did not identify a lower post-discharge bleeding-risk phenotype but marked residual thromboembolic vulnerability, with a higher bleeding-risk trajectory, particularly among patients aged ≥ 80 years, supporting structured post-discharge anticoagulation reassessment in older adults.
PMID:42643151 | DOI:10.1111/ggi.70817