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CLINICAL RESEARCH: HEART RHYTHM DISORDERS

Racial/Ethnic Differences in the Risk of Intracranial Hemorrhage Among Patients With Atrial Fibrillation

Albert Yuh-Jer Shen, MS, MD, FACC^_*,_*, Janis F. Yao, MS, Somjot S. Brar, MD^_*, Michael B. Jorgensen, MD, FACC^_* and Wansu Chen, MS

^_* Department of Cardiology and the Center for Medical Education
Department of Research and Evaluation, Kaiser Permanente Medical Center (KPMC), Pasadena, California

Manuscript received November 7, 2006; revised manuscript received January 8, 2007, accepted January 17, 2007.

^_* Reprint requests and correspondence: Dr. Albert Yuh-Jer Shen, Department of Cardiology, 1526 Edgemont Street, 2nd Floor, Kaiser Foundation Hospitals, Los Angeles, California 90027 (Email: albert.y-j.shen{at}kp.org).

Objectives: This study was designed to study racial/ethnic differences in the risk for intracranial hemorrhage (ICH) and the effect of warfarin on ICH risk among patients with atrial fibrillation (AF).

Background: Nonwhites are at greater risk for ICH than whites in the general population. Whether this applies to patients with AF and whether warfarin therapy is associated with comparable risk of ICH in nonwhites are unknown.

Methods: We retrospectively identified a multiethnic stroke-free cohort hospitalized with nonrheumatic AF. Warfarin use and anticoagulation intensity were assessed by searching pharmacy and laboratory records. Crude ICH event rates were calculated by Poisson regression. Cox proportional hazard models were constructed to assess the independent effect of race/ethnicity on ICH after adjusting for age, gender, hypertension, diabetes, heart failure, and warfarin exposure.

Results: Between 1995 and 2000, we identified 18,867 qualifying AF hospitalizations (78.5% white, 8% black, 9.5% Hispanic, and 3.9% Asian) and 173 qualifying ICH events over 3.3 years follow-up. Achieved anticoagulation intensity was lower among blacks but not different between the other groups. Warfarin was associated with increased ICH risk in all races, but the magnitude of risk was greater among nonwhites. There were no gender differences. The hazard ratio for ICH with whites as referent was 4.06 for Asians (95% confidence interval [CI] 2.47 to 6.65), 2.06 for Hispanics (95% CI 1.31 to 3.24), and 2.04 (95% CI 1.25 to 3.35) for blacks.

Conclusions: Nonwhites with AF were at greater risk for warfarin-related ICH. Blacks, Hispanics, and Asians were at successively greater ICH risk than whites.

Abbreviations and Acronyms   AF = atrial fibrillation   CI = confidence interval   DM = diabetes mellitus   HF = heart failure   ICD-9 = International Classification of Disease, 9th Revision, Clinical Modification   ICH = intracranial hemorrhage   INR = international normalized ratio

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