Anticoagulation Treatment For Atrial Fibrillation Research Articles

Oral anticoagulant treatment in atrial fibrillation: the AFIRMA real-world study using natural language processing and machine learning

IntroductionOral anticoagulation (OAC) is key in atrial fibrillation (AF) thromboprophylaxis, but Spain lacks substantial real-world evidence. We aimed to analyze the prevalence, clinical characteristics, and treatment patterns among patients with AF undertaking OAC, using natural language processing (NLP) and machine learning (ML). Materials and methodsThis retrospective study included AF patients on OAC from 15 Spanish hospitals (2014–2020). Using EHRead® (including NLP and ML), and SNOMED_CT, we extracted and analyzed patient demographics, comorbidities, and OAC treatment from electronic health records. AF prevalence was estimated, and a descriptive analysis was conducted. ResultsAmong 4,664,224 patients in our cohort, AF prevalence ranged from 1.9% to 2.9%. A total of 57,190 patients on OAC therapy were included, 80.7% receiving Vitamin K antagonists (VKA) and 19.3% Direct-acting OAC (DOAC). The median age was 78 and 76 years respectively, with males constituting 53% of the cohort. Comorbidities like hypertension (76.3%), diabetes (48.0%), heart failure (42.2%), and renal disease (18.7%) were common, and more frequent in VKA users. Over 50% had a high CHA2DS2-VASc score. The most frequent treatment switch was from DOAC to acenocoumarol (58.6% to 70.2%). In switches from VKA to DOAC, apixaban was the most chosen (35.2%). ConclusionsUtilizing NLP and ML to extract RWD, we established the most comprehensive Spanish cohort of AF patients with OAC to date. Analysis revealed a high AF prevalence, patient complexity, and a marked VKA preference over DOAC. Importantly, in VKA to DOAC transitions, apixaban was the favored option.

A case of non-traumatic rectus sheath hematoma in a post-kidney transplant patient undergoing catheter embolization during anticoagulation treatment for atrial fibrillation.

A 65-year-old man, a post living donor kidney transplant patient, was admitted to the intensive care unit (ICU) with a severe bacterial infection. He also tested positive for coronavirus disease and had a cough. On admission, heparin was administered for atrial fibrillation. On the third day of hospitalization, his general condition had recovered, and he was discharged from the ICU to the general ward. On the fourth day of hospitalization, he experienced abdominal pain, and a hard mass was palpated in the left lower abdomen. On the fifth day of hospitalization, contrast-enhanced computed tomography showed an extensive rectus sheath hematoma (RSH) extending from the left lower abdominal wall to the left side of the bladder, with extravasation from a small branch of the left inferior epigastric artery. Heparin was discontinued, and transcatheter arterial embolization was performed to control the bleeding. RSH is a rare disease, and cases of extensive hematoma in post-kidney transplant patients occur even less frequently. Patients taking anticoagulants and those with chronic kidney disease are at high risk for RSH, so physicians should be cognizant of this disease when these patients develop abdominal pain.

Comparing the Real-World and Clinical Trial Bleeding Rates Associated with Oral Anticoagulation Treatment for Atrial Fibrillation.

Background The prevention of stroke in patients with atrial fibrillation (AF) involves the use of oral anticoagulation, commonly in the form of direct oral anticoagulants (DOACs). However, it comes with an increased risk of bleeding, and therefore, counselling patients on their individual risks is important. Although the majority of patients initiated on DOACs have been represented within the clinical trials, some cohorts are under-represented in whom clinicians cannot practice evidence-based medicine. Methods Utilising the pooled clinical trial (CT) data sourced from Medidata Enterprise Data Store, five recent open-label industry-sponsored AF trials were compared with real-world data (RWD) sourced from the HealthVerity™ Marketplace with the occurrence of bleeding events as the primary outcome of interest. Results A total of 64,421 patients were included in the analysis, with 3207 patients from the clinical DOAC trials and 61,214 patients from the RWD cohort. Overall, the patients from the RWD cohort had more co-morbidities, were older (72.2 ± 11.9 vs. 65.3 ± 10.7 years old, p < 0.001), had higher mean CHA2DS2VASc (3.98 ± 1.9 vs. 2.87 ± 1.73, p < 0.001), and HAD-BLED scores (2.13 ± 1.02 vs. 1/04 ± 0.93, p < 0.001) when compared to the trial data. When comparing the incidence of the first major bleed at 12 months post-treatment initiation, rates in the RWD cohort were significantly higher (10.69 vs. 18.97 per 100 person-years). The impact of co-morbidities such as age, CHA2DS2VASc, and HAD-BLED scores was similar in both cohorts; however, there was an under-representation of older females and more co-morbid patients within the clinical trial cohort. Conclusions DOAC-treated patients have a higher bleeding incidence rate in the RWD cohort than in clinical trials. This can be explained by the older patient age group with more complex medical h istories and higher HAS-BLED scores. The under-representation of higher-risk patients and lower proportion of females within clinical trials should be addressed to better translate clinical trial data into real-world clinical practice.

542 USE OF ANGIOTENSIN RECEPTOR/NEPRYLISIN INHIBITORS (ARNI) IN WILD TYPE TTR CARDIAC AMYLOIDOSIS (WTATTR) AND HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF) : IS IT WORTH A TRY?

Abstract Background wtATTR is a therapeutic challenge. Although the majority of patients with wtATTR presents with HFpEF, some evolve to systolic disfunction. According to international guidelines, Tafamidis is the only recommended disease modifiyng agent in wtTTRCA. Therapies for neurohormonal antagonism have no established role and concerns have been raised about their safety. Observational studies have focused on beta blockers (bb), angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers. The role of ARNI has not been directly explored. We report results of the use of ARNI in three male patients with HFrEF in wtATTR who were not eligible to Tafamidis, due to advanced HF (NYHA III-IV). Cases wtATTR was diasgnosed in all three patients in 2019 when no drugs were yet available. Baseline median LVEF was 57%. At two years follow up (FU), at average age of 83 years old, patients developed systolic disfunction (median LVEF 21%). They were all symptomatic for dyspnoea (NYHA III-IV), median systolic blood pressure (SBP) was 103mmHg (95-120), median N-terminal fraction of pro-B-type natriuretic peptide (NTproBNP) levels were 11.500 pg/ml (10.263-13.000) and estimated glomerular filtration marked CKD between stages III-IV. Two out of three patients were in anticoagulant treatment for atrial fibrillation and all three were on low dose of bb. S/V 24/26 mg was introduced (T1) in all patients according to eGFR. At 8 months (T2) downgrade of NYHA class was observed in all three patients, none of them developed symptomatic hypotension. Average NTproBNP levels were reduced (average 6853 ng/l), despite of mild worsening of renal function, and reverse remodelling of LV with improvement of contractile function (EF 21% &amp;gt; 45%) was showen at ecocardiography (Tab 1). Conclusions A very remarkable clinical, laboratoristic and echographic improvement was observed after 8-months therapy with S/V. The result may be purely due to natriuretic effect of ARNI in patients so strictly reliant on volemic state because of severe dyastolic disfunction, or more complicated effects may be mediated by neprilisin on amiloyd protein. Further research and clinical studies are certanly warranted to guarantee patients with wtATTR HFrEF best possible care.

Acute pancreatitis secondary to spontaneous intramural duodenal hematoma: A case report and a review of the literature.

IntroductionIntramural duodenal hematoma is a rare entity, often secondary to traumatic origin, but more rarely spontaneous due to blood flow disorders, especially in the context of anticoagulant therapy.Case presentationWe report the case of a 66-year-old woman under anticoagulant treatment for atrial fibrillation, who was diagnosed with acute pancreatitis secondary to a spontaneous duodenal hematoma. The evolution was favorable under medical treatment.DiscussionIntramural duodenal hematoma is frequently associated with abdominal pain and hematemesis, more rarely, it can be responsible for an acute pancreatitis, which is considerate as an unusual complication. We report here a case of duodenal hematoma revealed by acute pancreatitis along with a review of the literature since 2011.ConclusionMonitoring of patients on oral anticoagulants helps prevent the occurrence of IDH and avoid its complications, which can be fatal.

Oral Anticoagulant Treatment in Atrial Fibrillation in Patients with Rheumatoid Arthritis - Results of an International Audit

Oral Anticoagulant Treatment in Atrial Fibrillation in Patients with Rheumatoid Arthritis - Results of an International Audit

Adherence to direct oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study.

BackgroundAdherence to direct oral anticoagulants (DOACs) in patients with atrial fibrillation in every day practice may be less than in clinical trials.AimsTo assess adherence to DOACs in atrial fibrillation patients in every day practice and identify predictors for non‐adherence.MethodsIndividual linked dispensing data of atrial fibrillation patients who used DOACs were obtained from the Foundation for Pharmaceutical Statistics covering the Netherlands between 2012 and 2016. One year adherence to DOAC was calculated for initial DOAC as proportion of days covered (PDC) ≥80% and the association between clinical variables and adherence was assessed using logistic regression. In addition, we measured non‐persistence, that is, patients who completely stopped their initial DOAC within 1 year follow‐up.ResultsA total of 4797 apixaban‐, 20 454 rivaroxaban‐ and 18 477 dabigatran users were included. The mean age was 69 years (n = 43 910), which was similar for the DOAC types. The overall proportion of patients with PDC ≥80% was 76%, which was highest for apixaban‐ (87%), followed by dabigatran‐ (80%) and rivaroxaban (69%) users. Multivariable analyses revealed that age ≤60 years, no concomitant drug use were predictors for non‐adherence. Of atrial fibrillation patients who continued treatment, 97% had a PDC ≥80%, compared with only 56% for those who discontinued their DOAC treatment within 1 year.ConclusionsNon‐adherence to DOACs was associated with age ≤60 years and no concomitant drugs use. Non‐adherence was higher in patients who later discontinued DOAC treatment. Results of our study support research into interventions to improve adherence.

Reduction in all-cause mortality in COVID-19 patients on chronic oral anticoagulation: A population-based propensity score matched study

BackgroundCoronavirus disease 2019 (COVID-19) global pandemic has strikingly high mortality rate with hypercoagulability state being part of the imputed mechanisms. We aimed to compare the rates of in hospital mortality in propensity score matched cohorts of COVID-19 patients in chronic anticoagulation versus those that were not. MethodsIn this population-based study in the Veneto Region, we retrospectively reviewed all patients aged 65 years or older, with a laboratory-confirmed COVID-19 diagnosis. We compared, after propensity score matching, those who received chronic anticoagulation for atrial fibrillation with those who did not. ResultsOverall, 4697 COVID-19 patients fulfilled inclusion criteria, and the propensity score matching yielded 559 patients per arm. All-cause mortality rate ratio was significantly higher among non-anticoagulated patients (32.2% vs 26.5%, p = 0.036). On time to event analysis, all-cause mortality was found lower among anticoagulated patients, although the estimate was not statistically significant. (HR 0.81, 95%CI 0.65–1.01, p = 0.054). ConclusionAmong elderly patients with COVID-19, those on chronic oral anticoagulant treatment for atrial fibrillation seem to be at lower risk of all-cause mortality compared to their propensity score matched non-anticoagulated counterpart. This finding needs to be confirmed in further studies.

Abstract 14790: Prospective Evaluation of the Effect of Smartphone Electrocardiogram Usage on Anticoagulant Medication Compliance: Results of the Better Outcomes of Anticoagulation Therapy by Observation of Atrial Rhythm (BOAT OART) Study

Introduction: Compliance with anticoagulation treatment for atrial fibrillation is variable. Smartphone electrocardiograms that provide accurate arrhythmia diagnosis may allow patients to have greater insight into their arrhythmia burden. Hypothesis: Our hypothesis was that regular use of a smartphone electrocardiogram would improve anticoagulant compliance. Methods: Patients were enrolled if they had atrial fibrillation with a CHA2DS2-VASc score of 2 or more, were eligible for anticoagulation and had a smartphone. Participants were randomly assigned to receive a smartphone electrocardiogram (AliveCor Kardia) or to the control group. All patients received 6 months of anticoagulant (apixaban) dispensed as 1-month pre-loaded pill boxes. Patients returned monthly to assess medication compliance and receive subsequent month medication. Monitor patients were encouraged to record their electrocardiogram 5 times a week. Results: A total of 100 patients were enrolled from July 2017 to August 2019, but 4 patients in the monitor arm withdrew prematurely. The monitor and control groups did not differ in age, gender, CHA2DS2-VASc score, comorbidities or atrial fibrillation burden. Medication compliance was 99.1%, with greater compliance in the monitor group (99.5 ± 0.86%) than the control group (98.8% ± 2.19%; p=0.03). In the monitor group, there was no association between missed doses and use or nonuse of the smartphone monitor on a given day. Overall monitor compliance was 87.0±14% with an average of 4.35 recorded electrocardiograms per week. Monitor group patients with 100% medication compliance had a higher average monitor compliance than those patients who missed doses (90.3±11% vs 83.5±15.8%; p=0.05). There were no major adverse events related to anticoagulation. Conclusions: Despite excellent overall anticoagulant medication compliance, this study indicates that smartphone electrocardiogram usage is associated with higher medication compliance. Greater monitor compliance was also associated with greater medication compliance. Future studies are necessary to determine if smartphone electrocardiograms can be used to maintain anticoagulant compliance long-term or improve compliance at onset of anticoagulation treatment.

Abstract 14782: Sex Comparisons in Anticoagulation Treatment for Atrial Fibrillation in a Large Rural Healthcare System

Introduction: Atrial fibrillation (AF) and flutter lead to increased risk of thromboembolism (TE). The CHA 2 DS 2 -VASc score is used to determine the risk of TE. Objective: We aim to evaluate the anticoagulation use across CHA 2 DS 2 -VASc scores calculated using a validated automatic calculator. Methods: An AF registry was created for patients with AF or atrial flutter who had seen a primary care or cardiology provider within the past 2 years (5/28/2018-5/28/2020). An automatic CHA 2 DS 2 -VASc calculator was integrated into the electronic medical record system at Essentia Health on 10/1/2019. High-risk of TE was defined as a score of ≥3 for females and a score of ≥2 for males. AF registry included demographics, anticoagulation prescription, CHA 2 DS 2 -VASc and ATRIA bleed score, contraindications, and presence of left atrial appendage (LAA) occlusion device. Results: A total of 10992 patients with AF or atrial flutter were included in the registry (74.8 ±11.8 years, 41.7% female). A total of 6703 (61.0%) had a CHA 2 DS 2 -VASc score calculated (mean score 3.9 ± 1.5). Mean ATRIA bleed score was 3.0 ± 2.0. Within these patients, 90.7% of males and 93.0% of females were at high-risk of TE. Of these high-risk patients, anticoagulation use was 82.7% for females and 83.5% for males and increased with increasing score (p&lt;0.01 for males, p&lt;0.01 for females) (Figure 1). Overall, 36.9% were prescribed NOAC, 47.0% warfarin, and 0.8% heparin. There was no sex difference in the prescription of NOAC (37.7% male vs. 35.9% female, p=0.1). Fewer than 1% had WATCHMAN LAA device (0.3% male vs. 0.4% female, p=0.5). Conclusion: Four out of 5 patients at increased risk of TE are prescribed an anticoagulant. Interventions to improve anticoagulation use in high-risk patients are needed. Figure 1. Anticoagulation prescription use in atrial fibrillation patients by CHA 2 DS 2 -VASc score and sex between 5/28/2018-5/28/2020 at Essentia Health (N=6703).

Risk factors of major bleeding in elderly atrial fibrillation patients from the ANAFIE registry

Abstract Background Bleeding is associated with shorter life expectancy during anticoagulant treatment in atrial fibrillation (AF) patients. Prior studies showed bleeding during anticoagulant treatment occurred more frequently in elderly AF patients than in younger AF patients. HAS-BLED score is a risk assessment tool for bleeding. However, since it was developed from the database of patients with warfarin, it has not been clarified whether this score is applicable in the era of direct oral anticoagulant (DOACs), especially for elderly AF patients. Purpose All Nippon AF In the Elderly (ANAFIE) registry was designed to obtain real-world information regarding patients with non-valvular AF (NVAF) aged ≥75 years, including current status of anticoagulant therapy and prognosis. The present study aimed to determine factors that associate with major bleeding for elderly NVAF patients using the dataset of ANAFIE registry conducted in Japan. Methods Total of 32,099 patients aged ≥75 years with NVAF were enrolled in ANAFIE registry, and followed for 2 years. Incidence rates of major bleeding for total population, &amp;lt;85 years old group and ≥85 years old group were estimated using Kaplan-Meier method. Cox proportional hazards model was used to determine independent predictors of major bleeding. The factors included in the model were selected by backward elimination procedure. Results Mean age was 81.5 years. 23,738 (74.0%) was &amp;lt;85 years old and 8,361 (26.0%) was ≥85 years old. 92.5% of whole population used anticoagulants including warfarin (27.6%) or DOACs (72.3%). Major bleeding occurred in 279 patients at 12 months with 189 in &amp;lt;85 years and 90 in ≥85 years old group. The cumulative incidence rate of major bleeding at 12 months by Kaplan-Meier method was 0.9% in whole patients, and was slightly higher in ≥85 years than in &amp;lt;85 years old group (1.1% vs 0.8%). In multivariate analysis of the whole patients, history of major bleeding (hazard ratio [HR]: 2.17), severe hepatic dysfunction (HR: 3.62), malignancy (HR: 1.52), falling within a year (HR: 2.07), antiplatelet use (HR: 1.37) and warfarin use (HR: 1.81) emerged as independent predictors of major bleeding. Severe hepatic dysfunction (HR: 9.17), HbA1c &amp;lt;6.0% (HR: 2.19) and dementia (HR: 2.00) were associated with major bleeding in patients only in aged ≥85 years. On the other hand, proton pump inhibitor use (HR: 1.36), creatinine clearance &amp;lt;30 mL/min (HR: 1.53) and polypharmacy (HR: 1.61) were associated with major bleeding only in those aged &amp;lt;85 years. Conclusion Among elderly (≥75 years old) Japanese NVAF patients in the era of DOACs, prior major bleeding, severe hepatic dysfunction, malignancy, falling within a year, antiplatelet use and warfarin use were identified as independent predictors of major bleeding. Impact of some predictors differed between the 2 age groups (&amp;lt;85 years vs ≥85 years). Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Management of Anticoagulant Treatment and Anticoagulation-Related Complications in Nonagenarians

Given the aging population, the burden of age-dependent diseases is growing. Despite this, elderly patients are often underrepresented in clinical trials and little data are available on current anticoagulant management and outcomes in this unique population, especially those aged 90 years or older. There is uncertainty, and a fear of "doing harm," that often leads to de-prescription of antithrombotic agents in nonagenarian patients. Decision-making concerning the use of anticoagulant treatment needs to balance the risk of thrombotic events against the risk of major bleeding, especially intracranial hemorrhage. In this perspective, the development of direct oral anticoagulants (DOACs), acting as direct and selective inhibitors of a specific step or enzyme of the coagulation cascade, has dramatically changed oral anticoagulant treatment. In fact, given the lower incidence of intracranial hemorrhage, the favorable overall efficacy and safety, and the lack of routine monitoring, DOACs are the currently recommended anticoagulant agents for the treatment of both atrial fibrillation and venous thromboembolism even in very elderly patients. However, given the limited data available on the management of anticoagulation in nonagenarians, a few unanswered questions remain. In this review, we focused on recent evidence for anticoagulant treatment in atrial fibrillation and venous thromboembolism along with management of anticoagulation-related bleeding in nonagenarians.

Is there a connection among atrial fibrillation, anticoagulant treatment, and dementia?

It is well-known that atrial fibrillation carries an increased risk of stroke and dementia. The connecting pathogenic common mechanism is the thromboembolic state provided by atrial fibrillation, which is responsible for the acute cerebral events, as well as more saddle anatomic lesions, which accumulating over time, could lead to a progressive cognitive decline. It is plausible, instinctively, that oral anticoagulation could decrease this risk, although the possibility of micro-haemorrhages, which cannot be ignored, could make anticoagulation in this contest even dangerous. In this regard, whether there are firm, well established, evidences documenting a significant reduction in stroke occurrence with anticoagulant treatment in atrial fibrillation, the same level of evidences are not supporting the treatment in preventing dementia. Bringing some more clarity to this issue could have some considerable advantages, also in term of healthcare cost containment, considering the high prevalence of atrial fibrillation and dementia in the elderly.

Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study

BackgroundIn contrast to vitamin K antagonists (VKA), direct oral anticoagulants (DOAC's) are not strictly monitored and dose titrated by anticoagulation clinics in the Netherlands. This may affect drug persistence of atrial fibrillation (AF) patients, whom often require lifelong treatment. ObjectivesTo assess persistence of DOACs and of VKAs in patients with AF. MethodsDispensing data from the Dutch Foundation of Pharmaceutical Statistics were used to monitor persistence of AF patients to DOAC from 1 January 2012‐1 April 2016. In addition, we estimated the persistence of AF patients to VKA between 1 January 2004 and 1 January 2012 in data from the Anticoagulation Clinic Leiden. Non‐persistence was defined as the cumulative incidence of patients who completely stopped DOAC, switched to another oral anticoagulant or stopped their VKA. ResultsDOAC users (n = 77 333) were younger than VKA users (n = 10 079; 70 vs 73 years). Non‐Persistence to DOAC (ie stopping with any oral anticoagulant) was 34% at 1 and 64% at 4 years, compared to 22% at one and 36% at 4 years for VKA. Approximately a Twenty‐five percent of those who had stopped their initial DOAC switched to another anticoagulant (VKA or another DOAC). Multivariable analyses revealed that young age, female sex, no concomitant drug use and non‐adherence were predictors for non‐persistence of DOAC. ConclusionsPersistence to DOAC was low and in line with other observational studies, and higher for VKA. Our results show a clear correlation between age <60 years and worse persistence, as well as with female and non‐adherence to DOAC.

Anticoagulant treatment of atrial fibrillation: uses and habits of cardiologists

espanolEl tratamiento anticoagulante (TACO) es uno de los pilares en la prevencion del accidente cerebrovascular.Objetivos: Conocer los habitos de inicio del TACO, las dificultades en su continuidad y la incorporacion de nuevos anticoagulantesorales (NAO). Analizar las conductas medicas.Material y Metodos: Encuesta cerrada a 107 cardiologos.Resultados: En el inicio del TACO, el 52,3% adopto una decision con el paciente. Fueron reconocidos diversos inconvenientespara su continuidad y el 85% eligio al costo como la dificultad para incorporar NAO. En pacientes de alto riesgo y FA de tiempoincierto, el 83,2% eligio TACO y control de frecuencia cardiaca. En pacientes de bajo riesgo con FA paroxistica, el 54,2% optopor el seguimiento. En pacientes con alto riesgo emboligeno y de sangrado, el 75,7% decidio TACO.Conclusiones: Se observo una tendencia a dar participacion al paciente en el inicio del TACO y multiples dificultades parasostenerlo. El precio de los NAO condiciona su uso. Las conductas medicas fueron concordantes con lo que indican las guias. EnglishThe anticoagulant treatment (ACOT) is one of the pillars in the prevention of stroke.Objectives: To know the habits of initiation of ACOT, difficulties in its continuity, incorporation of new anticoagulants (NOA),and analyze medical behaviors.Material and Methods: Survey closed to 107 cardiologists.Results: At the beginning of ACOT, 52.3% cardiologists adopted a decision with the patient, several inconveniences wererecognized for its continuity, and 85% chose the economic cost as a difficulty to incorporate NOA. In High risk and AF ofuncertain time: 83.2% cardiologists chose ACOT and frequency control. In Low risk with paroxysmal AF: 54.2% opted forfollow-up. In High risk embolism and bleeding: 75.7% decided ACOT.Conclusions: A tendency to involve the patient at the beginning of ACOT, and multiple difficulties to sustain it was observed.The use of NAO is conditioned by economic cost. The medical behaviors were consistent with the guidelines.

Oral Anticoagulant Treatment of Atrial Fibrillation in Chronic Kidney Disease Patients

Oral Anticoagulant Treatment of Atrial Fibrillation in Chronic Kidney Disease Patients

SAT-230 - Anticoagulant treatment for atrial fibrillation and decompensation rate in patients with liver cirrhosis

SAT-230 - Anticoagulant treatment for atrial fibrillation and decompensation rate in patients with liver cirrhosis

Anticoagulation strategies in patients with atrial fibrillation after PCI or with ACS : The end of triple therapy?

Clinicians struggle daily with the optimal regimen for patients with an indication for antiplatelet therapy after stenting and in patients needing oral anticoagulation treatment for atrial fibrillation (AF). This is not only difficult in patients with acute coronary syndrome (ACS) but also in the large number of patients with AF undergoing elective percutaneous coronary intervention (PCI). The challenge is to strike a balance between the increasing risk of bleeding events and ischemic or thrombotic events. Until recently, guidelines were based on expert consensus and afew small, many of them retrospective, trials. Aso-called triple therapy with avitaminK antagonist (VKA) and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended for patients with AF undergoing PCI in stable coronary artery disease or for those with ACS. However, severe bleeding complications remain amajor issue during triple therapy, particularly in the growing aging population. In the past year, randomized controlled trials (RCT) with direct-acting oral anticoagulants (DOACs) have modified the standard use of care, now favoring dual therapy with DOACs. This review elucidates the current influential RCTs on the new antiplatelet and anticoagulation strategies for patients with AF undergoing PCI or with ACS, and discusses whether triple therapy is still required.

Meta-analysis of safety and efficacy for direct oral anticoagulation treatment of non-valvular atrial fibrillation in relation to renal function

IntroductionWe performed a meta-analysis of the safety and efficacy of anticoagulation treatment for atrial fibrillation (AF) in relation to renal function. We also examined the change in estimated glomerular filtration rate (eGFR) from baseline and compared the outcomes for patients with stable and worsening renal function. Materials and methodsWe selected studies that used randomized controlled trials in which outcomes for direct oral anticoagulants (DOACs) (dabigatran, rivaroxaban, apixaban, or edoxaban) were compared with those for warfarin in AF patients with normal, mild or moderate renal function, except the severe one (creatinine clearance<30). ResultsWe assessed five clinical trials, involving 72,608 patients. Pooled analysis indicated that the risk of stroke was lower for DOACs than for warfarin among patients with mild renal impairment (Risk ratio, 0.79; 95% confidence interval, 0.68–0.91) and moderate renal impairment (0.80, 0.69–0.92). No major differences were found in patients with normal renal function. Additionally, DOACs were associated with fewer major bleeds among patients with normal (0.77, 0.70–0.84), mild (0.86, 0.77–0.95), and moderate renal impairment (0.73, 0.65–0.82). Among those treated with DOACs, a lower dosage was associated with lower risk of major bleeding (0.75, 0.68–0.83) and higher risk of stroke or systemic embolism (1.28, 1.12–1.47). Further, DOACs tended to be associated with a lower estimated glomerular filtration rate (eGFR) than warfarin even after 30months. Finally, we found significant differences in the risk of stroke (2.09, 1.64–2.68) and major bleeding (2.01, 1.66–2.42) between patients with stable and worsening renal function. ConclusionsDOACs have a greater clinical benefit than warfarin with respect to renal function. They are associated with a comparatively lower risk of stroke and major bleeding, as well lower eGFR. This suggests these agents are a better choice in patients with renal disease.

Delaying anticoagulation treatment for atrial fibrillation increases dementia risk, study suggests

Delaying anticoagulation treatment for atrial fibrillation increases dementia risk, study suggests