Evaluation of antithrombotic use and COVID-19 outcomes in a nationwide atrial fibrillation cohort

Alex Handy; Amitava Banerjee; Angela M Wood; Caroline Dale; Cathie L M Sudlow; Christopher Tomlinson; Daniel Bean; Johan H Thygesen; Mehrdad A Mizani; Michail Katsoulis; Rohan Takhar; Sam Hollings; Spiros Denaxas; Venexia Walker; Richard Dobson; Reecha Sofat; CVD-COVID-UK Consortium

doi:10.1136/heartjnl-2021-320325

Evaluation of antithrombotic use and COVID-19 outcomes in a nationwide atrial fibrillation cohort

Heart. 2022 May 25;108(12):923-931. doi: 10.1136/heartjnl-2021-320325.

Authors

Alex Handy¹, Amitava Banerjee^{2

3

4}, Angela M Wood^{5

6

7

8}, Caroline Dale², Cathie L M Sudlow^{9

10

11}, Christopher Tomlinson^{2

3

12

13}, Daniel Bean^{14

15

16}, Johan H Thygesen², Mehrdad A Mizani², Michail Katsoulis^{2

17}, Rohan Takhar², Sam Hollings¹⁸, Spiros Denaxas^{2

9

13

19}, Venexia Walker²⁰, Richard Dobson^{2

13

14

15

16}, Reecha Sofat^{2

21}; CVD-COVID-UK Consortium

Affiliations

¹ Institute of Health Informatics, University College London, London, UK alex.handy.research@gmail.com.
² Institute of Health Informatics, University College London, London, UK.
³ University College London Hospitals National Health Service Trust, London, UK.
⁴ Barts Health National Health Service Trust, The Royal London Hospital, London, UK.
⁵ British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
⁶ British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK.
⁷ Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK.
⁸ National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK.
⁹ British Heart Foundation Data Science Centre, Health Data Research UK, London, UK.
¹⁰ Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
¹¹ Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK.
¹² UKRI Centre for Doctoral Training in AI-enabled Healthcare Systems, University College London, London, UK.
¹³ National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK.
¹⁴ Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
¹⁵ NIHR Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Trust, London, UK.
¹⁶ Health Data Research UK London, University College London, London, UK.
¹⁷ MRC Unit for Lifelong Health and Ageing and Centre for Longitudinal Studies, University College London, London, UK.
¹⁸ National Health Service Digital, Leeds, UK.
¹⁹ British Heart Foundation Research Accelerator, University College London, London, UK.
²⁰ Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK.
²¹ Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.

Abstract

Objective: To evaluate antithrombotic (AT) use in individuals with atrial fibrillation (AF) and at high risk of stroke (CHA₂DS₂-VASc score ≥2) and investigate whether pre-existing AT use may improve COVID-19 outcomes.

Methods: Individuals with AF and CHA₂DS₂-VASc score ≥2 on 1 January 2020 were identified using electronic health records for 56 million people in England and were followed up until 1 May 2021. Factors associated with pre-existing AT use were analysed using logistic regression. Differences in COVID-19-related hospitalisation and death were analysed using logistic and Cox regression in individuals with pre-existing AT use versus no AT use, anticoagulants (AC) versus antiplatelets (AP), and direct oral anticoagulants (DOACs) versus warfarin.

Results: From 972 971 individuals with AF (age 79 (±9.3), female 46.2%) and CHA₂DS₂-VASc score ≥2, 88.0% (n=856 336) had pre-existing AT use, 3.8% (n=37 418) had a COVID-19 hospitalisation and 2.2% (n=21 116) died, followed up to 1 May 2021. Factors associated with no AT use included comorbidities that may contraindicate AT use (liver disease and history of falls) and demographics (socioeconomic status and ethnicity). Pre-existing AT use was associated with lower odds of death (OR=0.92, 95% CI 0.87 to 0.96), but higher odds of hospitalisation (OR=1.20, 95% CI 1.15 to 1.26). AC versus AP was associated with lower odds of death (OR=0.93, 95% CI 0.87 to 0.98) and higher hospitalisation (OR=1.17, 95% CI 1.11 to 1.24). For DOACs versus warfarin, lower odds were observed for hospitalisation (OR=0.86, 95% CI 0.82 to 0.89) but not for death (OR=1.00, 95% CI 0.95 to 1.05).

Conclusions: Pre-existing AT use may be associated with lower odds of COVID-19 death and, while not evidence of causality, provides further incentive to improve AT coverage for eligible individuals with AF.

Keywords: COVID-19; atrial fibrillation; drug monitoring; electronic health records; epidemiology.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Anticoagulants / adverse effects
Atrial Fibrillation* / complications
Atrial Fibrillation* / drug therapy
Atrial Fibrillation* / epidemiology
COVID-19* / epidemiology
Female
Fibrinolytic Agents
Humans
Risk Assessment
Risk Factors
Stroke* / etiology
Warfarin

Substances

Anticoagulants
Fibrinolytic Agents
Warfarin

Abstract

Publication types

MeSH terms

Substances

Grants and funding