Stroke and Bleeding Risk in Long-Term Care Residents With Atrial Fibrillation Who Discontinue Anticoagulation

@article{kapoor2026stroke,
  title = {{Stroke and Bleeding Risk in Long-Term Care Residents With Atrial Fibrillation Who Discontinue Anticoagulation}},
  author = {Alok Kapoor and Zhiyong Chen and Jay Patel and Zehao Ye and Honghuang Lin and Geoffrey Barnes and Sybil Crawford and Jerry H. Gurwitz},
  journal = {JAMA Network Open},
  year = {2026},
  month = oct,
  doi = {10.1001/jamanetworkopen.2026.40964},
  url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855823},
  note = {CC BY-NC-ND 4.0},
}

TY  - JOUR
TI  - Stroke and Bleeding Risk in Long-Term Care Residents With Atrial Fibrillation Who Discontinue Anticoagulation
AU  - Alok Kapoor
AU  - Zhiyong Chen
AU  - Jay Patel
AU  - Zehao Ye
AU  - Honghuang Lin
AU  - Geoffrey Barnes
AU  - Sybil Crawford
AU  - Jerry H. Gurwitz
PY  - 2026
DA  - 2026/10/26
JO  - JAMA Network Open
DO  - 10.1001/jamanetworkopen.2026.40964
UR  - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855823
AB  - Importance: Atrial fibrillation (AF) leads to more than 100 000 cases of stroke yearly and is particularly prevalent in long-term care (LTC) residents. Anticoagulation (AC) is the mainstay of stroke prevention, but given its risks, clinicians and residents may consider discontinuation at the time of LTC entry.  Objective: To estimate the association between AC discontinuation and stroke and bleeding risk among LTC residents with AF.  Design, Setting, and Participants: This comparative effectiveness research study with target trial emulation used claims data (2020-2021) from LTC facilities in the US serving Medicare beneficiaries. Medicare beneficiaries with AF receiving AC who entered LTC between April 1 and December 31, 2020, were included; those with additional indications for AC, including prosthetic heart valve or venous thromboembolism, were excluded. Analysis was performed in August 2026.  Exposure: Discontinuer vs continuer assignment.  Main Outcomes and Measures: The main outcomes were stroke (including ischemic stroke, transient ischemic attack, and systemic embolism) and bleeding, assessed using Medicare claims. A target trial emulation was conducted with clone censor weighting (CCW) analysis. Specifically, eligible LTC residents were assigned (cloned) to each of 2 strategies: AC discontinuation or AC continuation. Clones were then censored when they deviated from their assigned strategy, and inverse probability of censoring weighting was applied to address informative censoring: residents who deviated differing systematically from those who did not. Subdistribution hazard ratios (sHRs) for stroke and bleeding were then calculated to account for competing mortality and a cause-specific hazard ratio (HR) for death.  Results: This study included 15 426 LTC residents (mean [SD] age, 82.6 [7.6] years). Most were female (62.6%). AC discontinuers had 187 strokes, 297 bleeding events, and 3684 deaths over a mean (SD) of 128.9 (177.9) days. AC continuers had 321 strokes, 493 bleeding events, and 5475 deaths over a mean (SD) of 279.6 (204.9) days. Discontinuers had similar stroke risk (sHR, 1.07; 95% CI, 0.93-1.23) and bleeding risk (sHR, 1.02; 95% CI, 0.92-1.13) compared with continuers, but discontinuers had higher mortality risk (HR, 1.27; 95% CI, 1.23-1.31).  Conclusions and Relevance: In this target trial emulation with CCW in a cohort of LTC residents with AF, AC discontinuation was not associated with higher stroke or bleeding risk. Very high mortality, unmeasured confounding, and reliance on claims-based outcome ascertainment may have limited the ability to better understand the consequences of AC discontinuation on stroke and bleeding.
SN  - 2574-3805
ER  -