AFIRE Study | Hidden Risks After Bleeding in Coronary Disease and Atrial Fibrillation

Patients with atrial fibrillation (AF) and stable coronary disease who suffer from major bleeding present an extremely high risk of subsequent cardiovascular events. Preventing bleeding is necessary, and so is preventing the risk of subsequent cardiovascular events and death.

sangrado en enfermedad coronaria y fibrilación auricular

The association between coronary angioplasty, early bleeding, and an increase in death and infarction rates after a hemorrhagic event is well established. The unknown was whether the same could occur in a patient with stable coronary disease.

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) Study assessed 2215 patients with AF and stable coronary disease treated with rivaroxaban monotherapy or in combination with an antiplatelet agent.

Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as a composite of stroke, systemic embolism, infarction, unstable angina requiring revascularization, and all-cause mortality.

Out of the 2215 patients, 386 (17.4%) experienced a bleeding event, and 63 (16.3%) of them suffered from a cardiovascular event. MACCE incidence was twice as high among those who bled vs. those who did not (8.38% vs. 4.20%, hazard ratio: 2.1; p < 0.001).

Among the unlucky patients who experienced both events, the vast majority (73%) bled first and then had a cardiovascular event. Only in the remaining 27% was the sequence reversed.

Read also: Ten Commandments for 2021 Guidelines on Valvular Heart Disease.

The temporal association between events was demonstrated in a multivariate analysis, which indicated that the highest danger was within 30 days of bleeding.


In patients with AF and stable coronary disease, major bleeding is strongly linked with subsequent cardiovascular events. Preventing bleeding is important because of its inherent risk and the subsequent risk of cardiovascular events and death.

Original Title: Bleeding and Subsequent Cardiovascular Events and Death in Atrial Fibrillation With Stable Coronary Artery Disease: Insights From the AFIRE Trial.

Reference: Koichi Kaikita et al. Circ Cardiovasc Interv. 2021 Nov;14(11):e010476. doi: 10.1161/CIRCINTERVENTIONS.120.010476.

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