P353Anticoagulation profile if an as required oral anticoagulation strategy is used in patients with complex cardiac devices

Abstract

Abstract Introduction Once atrial fibrillation (AF) is detected and the threshold for oral anticoagulation (OAC) is met, patients are committed to lifelong anticoagulation. Stroke risk stratification tools, such as CHA2DS2-VAS score, do not incorporate AF burden. However, studies suggest a lower stroke risk in paroxysmal AF (pAF) and low AF burden when compared to persistent AF (persAF). Moreover, small feasibility studies have explored "as required" OAC guided by episode duration and/or AF burden in carefully selected, low-risk patients with infrequent episodes of AF. The reduction of OAC observed with stringent inclusion criteria may not be translated to real-world patients. Purpose We sought to investigate the impact of OAC reduction if an "as required" strategy is applied to an unselected population of patients with complex cardiac devices (implantable cardiac defibrillators [ICD] and cardiac resynchronisation therapy [CRT-D]). Methods All transmissions and electrograms of patients with CRT and ICD on remote monitoring were examined retrospectively. The first recorded AF episode longer than 6 minutes determined the start of follow-up. A weekly AF burden of 100% was considered persAF. We estimated the time on oral anticoagulation on an "as required" basis according to criteria used in previous studies: 1) OAC was initiated if the weekly burden was more than 0.6% (60 minutes); 2) OAC was discontinued if the weekly burden remained below 0.6 % in the following 4 weeks. Medical records were reviewed for baseline characteristics at the time of the first episode of AF. Results 106(32%) had evidence of AF from 331 patients screened. Of these, 89% were male, age 64 ± 12 years, BMI 30 ± 6 kg/m2, LA diameter 4.5 ± 0.8 cm, ejection fraction (EF) 38 ± 17 and 58% had an ICD. 46 (43%) had persAF and 60 (57%) had pAF. The CHA2DS2VASc was 1 or higher in 104 patients (98%) corresponding to 393 patient-years of OAC if standard care was used. "As required" strategy led to a significant reduction in time on OAC to 248 patient years (62.3%, p < 0.0001). The reduction was greater in pAF group (86.5%, p < 0.0001) than in persAF (46.3%, p < 0.0001)(Figure). Moreover, persAF patients had a higher number of episodes requiring OAC (3.6 ± 3.26 vs 2.2 ± 1.9) and of longer duration (mean difference 0.85 years, CI 0.5-1.1, p < 0.0001). Conclusion In an unselected cohort of patients with complex cardiac devices "as required" OAC strategy led to a significant reduction in the total time of OAC, which was more marked in patients with pAF. Abstract Figure