PO-03-005 BEST ANTICOAGULATION STRATEGY FOR STROKE PROPHYLAXIS IN ATRIAL FIBRILLATION PATIENTS WITH AMYLOIDOSIS

Abstract

A considerable proportion of elderly patients are known to have coexistent atrial fibrillation (AF) and amyloidosis. Both conditions increase stroke risk. We evaluated the best anticoagulation strategy in a series of AF patients with amyloidosis. Consecutive AF patients with coexistent amyloidosis undergoing catheter ablation at our center were included in the analysis. Based on the stroke-prophylaxis approach they were divided into 2 groups; group 1: left atrial appendage occlusion (LAAO) with Watchman and group 2: oral anticoagulation. Following LAAO, all patients remained on half dose non-vitamin K oral anticoagulants (NOAC) for 3 months. Transesophageal echocardiogram (TEE) was performed at 45 days to assess completeness of closure. If the occlusion was complete, patients were kept on aspirin, 81 mg/day starting after the 3rd month for long-term. In case of ‘smoke’ in the left atrium (LA) or enlarged LA, they were prescribed half-dose NOAC (figure 1). NOACs included apixaban and rivaroxaban. Group 2 patients remained on full-dose NOAC during the 3-year study period. All patients were prospectively followed up for 3 years. A total of 96 patients were included in the analysis; group 1: 61 and group 2: 34. CHA2DS2-VASc score was comparable between the groups (gr. 1: 3.4±1.8 and gr. 2: 3.7±1.6, p=0.18). The most commonly used NOACs were apixaban (53, 55.2%) and rivaroxaban (38, 39.6%). After the 45-day TEE, 37 patients from group 1 remained on baby-aspirin and 34 on half-dose NOAC. Of the 34, 5 (14.7%) patients had leaks <5 mm, 17 (50%) had large LA (mean diameter 5.2±1.4 cm) and 12 (35.3%) patients had LA smoke. At 3-year follow-up, three stroke and one transient ischemic attack were reported in group 1 patients on baby-aspirin (4/37, 10.8%), whereas no stroke or bleeding complications occurred in the 34 patients on half-dose NOAC (p=0.04). In group 2 patients on full-dose OAC, a total of 5 (5/34, 14.7%) bleeding events (1 subdural hematoma and 4 GI bleedings) were recorded. Additionally, stroke was reported in one patient that happened during brief discontinuation of OAC for another medical procedure. In our series of patients with coexistent AF and amyloidosis, half-dose NOAC following LAA occlusion procedure appeared to be the safer stroke-prophylaxis strategy.