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

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.