Socioeconomic Status and Risk of Bleeding After Mechanical Aortic Valve Replacement

J Am Coll Cardiol. 2022 Jun 28;79(25):2502-2513. doi: 10.1016/j.jacc.2022.04.030.


Background: Whether low socioeconomic status (SES) is associated with increased risk of anticoagulation-related adverse events in patients with mechanical heart valves is unknown.

Objectives: This study sought to investigate the impact of patients' SES on the risk of bleeding after mechanical aortic valve replacement (AVR).

Methods: This nationwide population-based cohort study included all patients aged 18-70 years who underwent mechanical AVR in Sweden from 1997 to 2018. Data were obtained from the SWEDEHEART register and other national health data registers. The exposure was quartiles of household disposable income. The primary outcome was hospitalization for a bleeding event.

Results: Among 5974 patients, the absolute risk for bleeding after 20 years of follow-up was 20% (95% CI: 17%-24%) in the lowest income quartile (Q1) and 16% (95% CI: 13%-20%) in the highest quartile (Q4). The risk of bleeding decreased with increasing income level and was significantly lower in patients in income level Q3 (HR: 0.77; 95% CI: 0.60-0.99) and Q4 (HR: 0.68; 95% CI: 0.50-0.92) than Q1. The risk of death from intracranial hemorrhage was five times higher in the lowest income quartile than the age- and sex-matched general Swedish population (standardized mortality ratio: 5.0; 95% CI: 3.3-7.4).

Conclusions: We observed a strong association between SES and risk of bleeding among patients who underwent mechanical AVR. These findings suggest suboptimal anticoagulation treatment in patients with lower SES and the need for strategies to optimize anticoagulation treatment in patients with a mechanical heart valve. (Health-Data Register Studies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).

Keywords: anticoagulation; aortic valve replacement; bleeding; socioeconomic status.

MeSH terms

  • Anticoagulants / adverse effects
  • Aortic Valve / surgery
  • Cohort Studies
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis*
  • Hemorrhage / epidemiology
  • Hemorrhage / etiology
  • Humans
  • Social Class
  • Treatment Outcome


  • Anticoagulants

Associated data