DOAC at Discharge Linked to Lower AF Adverse Events

Key Takeaways

• Among 16,641 hospitalized adults with newly diagnosed AF, 43.2% were discharged on a DOAC.
• Discharge DOAC use was associated with significantly lower 3-year major adverse cardiovascular events (MACE) than no DOAC at discharge.
• Net adverse clinical events (NACE) were also significantly lower at 3 years with discharge DOAC use.
• Landmark analyses showed lower MACE and NACE at both 30 days and 3 years among patients discharged on a DOAC.

Newly diagnosed atrial fibrillation during acute hospitalization creates a narrow discharge decision point, with early bleeding risk during recovery weighed against longer-term stroke prevention. That tension can be especially acute when atrial fibrillation emerges alongside another illness or procedure and the inpatient course is still evolving as discharge approaches. Data guiding direct oral anticoagulant initiation at discharge have remained limited, prompting investigators to examine postdischarge outcomes within Baylor Scott & White Health.

A retrospective Baylor Scott & White Health cohort, reported in the American Journal of Cardiology, compared adults with newly diagnosed atrial fibrillation (AF) who began a direct oral anticoagulant (DOAC) at discharge with those who did not. The cohort included 16,641 adults, with a mean age of 75.1 years, and 41.8% were women. Major adverse cardiovascular events (MACE) comprised all-cause death, nonfatal myocardial infarction, or ischemic stroke/transient ischemic attack, while net adverse clinical events (NACE) combined MACE with major bleeding. Adjusted Cox proportional hazards models and landmark cumulative incidence analyses were used to assess outcomes after discharge.

After adjustment, discharge DOAC use was associated with lower 3-year risk of MACE than no DOAC at discharge, with HR 0.61 (95% CI 0.58-0.65; p<0.001). Lower 3-year NACE was also reported with discharge DOAC use, with HR 0.64 (95% CI 0.61-0.68; p<0.001).

Landmark analyses showed lower MACE and NACE at both 30 days and 3 years among patients discharged on a DOAC. For specificity, 30-day MACE was lower with discharge DOAC use, with HR 0.61 (95% CI 0.57-0.65), while the remaining landmark findings were directionally concordant across early and longer-term follow-up.

Because this was a retrospective observational cohort, the findings support association rather than causation. The authors closed by underscoring individualized anticoagulation decision-making during acute hospitalization.

Clinician Questions

Which hospitalized patients were included in the discharge DOAC analysis for newly diagnosed atrial fibrillation?

The cohort included adults within the Baylor Scott & White Health system whose atrial fibrillation was newly identified from 3 days before hospital admission through hospital discharge. These findings therefore apply to newly recognized inpatient atrial fibrillation within that window, not to longstanding atrial fibrillation diagnosed earlier.

Why were both 30-day and 3-year outcomes examined after discharge DOAC initiation in newly diagnosed atrial fibrillation?

The investigators framed anticoagulation in this setting as a time-based tradeoff between early bleeding risk during recovery and longer-term stroke prevention. Reporting both 30-day and 3-year outcomes, with landmark analyses, allowed assessment of whether the association with discharge DOAC use was limited to the immediate postdischarge period or persisted over time.

What did the NACE endpoint include in the discharge DOAC cohort for newly diagnosed atrial fibrillation?

Net adverse clinical events included major adverse cardiovascular events or major bleeding. Major adverse cardiovascular events comprised all-cause death, nonfatal myocardial infarction, or ischemic stroke/transient ischemic attack.