Anxiety May Increase Stroke, Intracranial Hemorrhage in Atrial Fibrillation

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After adjustment for patient-level percentage of time in therapeutic anticoagulant range when receiving warfarin, the association between anxiety and stroke was sustained.
After adjustment for patient-level percentage of time in therapeutic anticoagulant range when receiving warfarin, the association between anxiety and stroke was sustained.

Anxiety may increase the risk for ischemic stroke and intracranial hemorrhage in patients with atrial fibrillation (AF) who begin warfarin therapy, according to a study published in the Journal of the American Heart Association.

The Cardiovascular Research Network WAVE (Community-Based Control and Persistence of Warfarin Therapy and Associated Rates and Predictors of Adverse Clinical Events in Atrial Fibrillation and Venous Thromboembolism) Study recruited patients with AF initiating warfarin therapy between 2004 and 2007 (N=25,570).

Investigators assessed electronic health records to identify rates of diagnosed anxiety (n=897), depression (n=2322), or combined anxiety and depression (n=904) in enrolled patients. In addition, International Classification of Diseases, Ninth Revision, codes were used to identify stroke and bleeding outcomes.

In the cohort, a total of 490 (1.9%) patients experienced an ischemic stroke or intracranial hemorrhage (1.52 events per 100 person-years) during the median follow-up of 339 days. According to the multivariable analysis, a higher adjusted rate of combined ischemic stroke and intracranial hemorrhage was observed in patients with an anxiety diagnosis (adjusted hazard ratio [HR], 1.52; 95% CI, 1.01-2.28).

After adjustment for patient-level percentage of time in therapeutic anticoagulant range when receiving warfarin, findings were sustained (HR, 1.56; 95% CI, 1.03-2.36). However, depression alone or in combination with anxiety was not associated with a higher risk for combined ischemic stroke and intracranial hemorrhage (adjusted HR, 1.20 [95% CI, 0.89-1.61] and adjusted HR, 0.93 [95% CI, 0.63-1.70], respectively).

A limitation of this analysis was the inability to identify confounding variables, including genetic, socioeconomic, or mental health factors, that may have affected stroke and hemorrhage risk. In addition, the researchers were unable to evaluate the role of physical inactivity or smoking in the association between anxiety or depression and adverse events.

These findings suggest that "[d]iagnosed anxiety might be useful for further stratification of stroke and bleeding risk" and may assist in structuring optimal therapy in warfarin-initiating patients with AF.

Reference

Baumgartner C, Fan D, Fang MC, et al. Anxiety, depression, and adverse clinical outcomes in patients with atrial fibrillation starting warfarin: Cardiovascular Research Network WAVE Study. J Am Heart Assoc. 2018;7:e007814.

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