Identificación de factores de riesgo de sangrado mayor en pacientes con fibrilación auricular tratados con anticoagulantes orales directos: una revisión sistemática y metanálisis

BACKGROUND: Major bleeding (MB) remains a serious complication in atrial fibrillation (AF) patients treated with direct oral anticoagulants (DOACs), but effect estimates for individual factors vary across studies and have not been synthesized in a DOAC-specific framework. OBJECTIVES: To provide a comprehensive DOAC-specific synthesis of risk factors associated with MB in AF patients. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library from their inception to December 2024. We included studies of DOAC-treated AF patients that reported associations between patient characteristics and MB. Random-effects meta-analyses were conducted when at least 2 studies evaluated the same risk factors using comparable definitions. Prespecified subgroup analyses were performed for the MB outcome and for individual DOAC agents. RESULTS: Eighty-three studies involving 970 248 patients were included. Twenty-one variables were associated with MB. We confirmed several well-known risk factors for MB, including a history of bleeding, alcohol use, age ≥65 years, frailty, and high HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), and Drugs/alcohol concomitantly) score. Importantly, this DOAC-focused synthesis also highlighted additional and previously underemphasized risk factors, including cancer, myocardial infarction or peripheral artery disease, heart failure, coronary artery disease, and the use of psychotropic or antiarrhythmic drugs. Overweight status and statin use were associated with a lower MB risk, although these findings should be interpreted with caution. CONCLUSION: This meta-analysis provides an integrated, DOAC-specific, quantitative overview of MB risk factors across multiple clinical and treatment domains. The pooled estimates provide a contemporary evidence base to prioritize variables for refinement, recalibration, and validation of MB risk assessment strategies in DOAC-treated AF populations.

Resumen tomado de PubMed (NCBI) para el registro citado, en el idioma original. La versión de referencia es la de la publicación original.

El resumen se deja sin traducir para conservar la redacción original de los autores.

Se sintetizaron 83 estudios con 970 248 pacientes con fibrilación auricular bajo anticoagulantes orales directos; 21 variables se asociaron con sangrado mayor. Se confirmaron factores conocidos (antecedente de sangrado, consumo de alcohol, edad ≥ 65 años, fragilidad, puntuación HAS-BLED alta) y se señalaron otros antes subestimados: cáncer, infarto de miocardio o enfermedad arterial periférica, insuficiencia cardíaca, cardiopatía coronaria y uso de psicofármacos o antiarrítmicos. El sobrepeso y las estatinas se asociaron con menor riesgo; los autores piden interpretarlos con cautela.

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