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Modelling anticoagulation and health-related quality of life in those with atrial fibrillation: a secondary analysis of AFFIRM

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Abstract

Associations of anticoagulation with primary endpoints in longitudinal studies are impacted by selection bias and time-varying covariates (e.g. comorbidities). We demonstrate how time-varying covariates and selection bias influence association estimates between anticoagulation and health-related quality of life (HRQoL) in patients with atrial fibrillation. We performed a secondary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management trial quality of life substudy. Dichotomized warfarin use was ascertained at the study baseline, 2 months later, and annually for up to 6 years. HRQoL was measured at every time point using a self-reported ordinal 5-point Likert-scale (lower score and lower odds ratio represents better health-related quality of life). Static and time-varying covariates were ascertained throughout the study period. Confounder-adjusted generalized mixed model and generalized estimating equation regressions were used to demonstrate traditional association estimates between anticoagulation and HRQoL. Inverse probability of treatment and censorship weights were used to ascertain the influence of time-varying confounding and selection bias. Age-stratified analysis (age ≥ 70 years) evaluated for effect modification. 656 individuals were included in the analysis, 601 on warfarin at baseline. The association of warfarin use with better HRQoL over time strengthened when accounting for time-varying confounding and selection bias (OR 0.30, 95% CI 0.14–0.55) compared to traditional analyses (OR 0.61, 95% CI 0.38–0.97), and was most pronounced in those ≥ 70 years upon stratified analysis. Anticoagulation is associated with higher HRQoL in patients with atrial fibrillation, with time-varying confounding and selection bias likely influencing longitudinal estimates in anticoagulation-HRQoL research.

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Data availability

Data from the AFFIRM Quality of Life Substudy was obtained from the Biologic Specimen and Data Repository Information Coordinating Center (BioLincc) of the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH).

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Acknowledgements

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Funding

The research reported in this publication was supported (in part or in full) by the Utah Stimulating Access to Research in Residency Transition Scholar (StARRTS) under Award Number 1R38HL143605-01. (Eric L Stulberg and Alex R Zheutlin). Adam de Havenon reports NIH/NINDS funding (K23NS105924). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Department of Neurology, University of Utah School of Medicine, 175 Medical Dr N, Salt Lake City, UT, 84132, USA

    Eric L. Stulberg, Alen Delic & Adam de Havenon

  2. Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA

    Alexander R. Zheutlin

  3. Department of Cardiology, University of Utah School of Medicine, Salt Lake City, USA

    Benjamin A. Steinberg

  4. Department of Neurology, Brown Alpert School of Medicine, Providence, USA

    Shadi Yaghi

  5. Department of Neurology, Yale School of Medicine, New Haven, USA

    Richa Sharma & Adam de Havenon

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  1. Eric L. Stulberg
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Correspondence to Eric L. Stulberg.

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Eric L. Stulberg, Alen L. Delic, Alexander R. Zheutlin, Benjamin A. Steinberg, Shadi Yaghi, and Richa Sharma report no disclosures or conficts of interest. Adam de Havenon has received funding from Integra, Novo Nordisk, UpToDate and has equity in TitinKM and Certus.

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Stulberg, E.L., Delic, A., Zheutlin, A.R. et al. Modelling anticoagulation and health-related quality of life in those with atrial fibrillation: a secondary analysis of AFFIRM. Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02335-9

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  • DOI: https://doi.org/10.1007/s00392-023-02335-9

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