Atrial fibrillation and risk of hip fracture: A population-based analysis of 113,600 individuals.

BACKGROUND: A number of cardiovascular diseases have been linked with bone health and an increased risk of osteoporotic fracture. Whether atrial fibrillation (AF) is associated with subsequent fracture risk is not known. METHODS: Administrative, clinical and hospitalisation information were linked over a 14-year period. From this longitudinal, population-based dataset of 113,600 individuals, time-dependent exposures using multivariate Cox proportional hazards regression models were employed to determine incidence rates and hazard ratios (HR) for hip fracture according to a history of AF. RESULTS: The annualised incidence rate for hip fracture was 7.4 per 1000 person-years (95% CI 7.1-7.7) in those without AF and 17.5 per 1000 person-years (95% CI 16.8-18.1) in those with AF. Compared to individuals without AF, those with AF were more likely to develop incident hip fracture in both men (unadjusted HR 2.39 [95% CI 1.96-2.91]) and women (unadjusted HR 2.91 [95% CI 2.55-3.34]). After adjusting for potential confounders, these associations were attenuated but remained statistically significant (adjusted HR 1.97 [95% CI 1.61-2.42] in men; adjusted HR 2.08 [95% CI 1.80-2.39] in women). CONCLUSIONS: A history of AF was associated with an increased risk of hip fracture in this large, population-based analysis. This association appeared to remain significant even after adjusting for potential confounders such as age, comorbidities and medication use. Patients with a history of AF may represent a clinical population in whom screening for and treatment of osteoporosis may be warranted to reduce the risk of subsequent fracture.

Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis.

Atrial fibrillation (AF) is common in patients on dialysis. Although randomized trials of anticoagulation for AF have demonstrated striking reductions in stroke, these trials did not recruit patients on dialysis. We thus undertook this systematic review and meta-analysis of observational studies including patients with AF on dialysis that reported associations of anticoagulation use. Twenty studies involving 529,741 subjects and 31,321 patients with AF on dialysis were identified. Anticoagulation was associated with a 45% (95% CI 13% to 88%) increased risk of any stroke, reflecting a nonsignificant 13% (95% CI -4% to 34%) increased ischemic stroke risk and 38% (95% CI 3% to 85%) increased hemorrhagic stroke risk. There was also a 44% (95% CI 38% to 56%) lower risk of any thromboembolism, and a 31% (95% CI 12% to 53%) increased risk of any bleeding but no clear association with cardiovascular death (relative risk 0.99, 95% CI 0.86 to 1.15) or all-cause mortality (relative risk 0.97, 95% CI 0.90 to 1.04). Incident event rates were similar or worse in patients on anticoagulation. In conclusion, these observational analyses provide little supporting evidence of benefit, and instead suggest harm, from anticoagulation in patients on dialysis with AF. These results raise the possibility that the effects of anticoagulation in patients with AF on dialysis may not be similar to the clear benefit of anticoagulation seen in patients with AF without end-stage renal disease. Randomized trials are required to definitively evaluate the safety and efficacy of anticoagulation for AF in the dialysis setting.