Anticoagulation For Stroke Prevention Research Articles

Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis

ObjectiveTo compare the efficacy, safety, and cost effectiveness of direct acting oral anticoagulants (DOACs) for patients with atrial fibrillation.DesignSystematic review, network meta-analysis, and cost effectiveness analysis.Data sourcesMedline, PreMedline, Embase, and...

Dissection of Cervical and Cerebral Arteries.

We aimed to summarize recent findings in cervical (CeAD) and intracranial artery dissection (IAD) research. Considered a disease of the young- and middle-aged, an analysis on the largest CeAD-population to date (n=2391) revealed that about 1 of 14 CeAD-patients was aged ≥60years. Distinct genetic variants were associated with CeAD. However, in clinical practice, genetic investigations are not helpful due to the small effect size. Despite the paucity of data from randomized-controlled trials in CeAD-stroke patients, both intravenous thrombolysis and endovascular treatment should be considered as acute treatment in such patients. Future research is needed to clarify which patients benefit most from each treatment modality. Whether to use antiplatelets or anticoagulants in stroke prevention in CeAD-patients is still a matter of debate. One randomized-controlled feasibility trial has been published, and another trial designed to show non-inferiority of aspirin to vitamin-K-antagonists is underway and will be terminated in late 2018. Non-vitamin-K-oral anticoagulants should not be used in CeAD outside a properly designed trial, as experience with these drugs in CeAD-patients is limited. With many IAD patients developing intracranial hemorrhage, antithrombotic therapy should be used with caution. Knowledge about CeAD and IAD has advanced substantially. Nevertheless, further research is mandatory, in particular regarding pathophysiology, acute treatment, and stroke-preventive therapy, as well as long-term outcome and prognosis.

Geographic Variation in the Use of Oral Anticoagulation Therapy in Stroke Prevention in Atrial Fibrillation.

Underuse of oral anticoagulation in stroke prevention in atrial fibrillation is common; however, it remains unknown how it varies geographically. The objective of this study was to evaluate geographic variation in oral anticoagulation use and in the initiation of new oral anticoagulants (NOACs). Using 2013 to 2014 claims data from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated NOACs (n=8659), warfarin (n=11 771) or no oral anticoagulation therapy (n=18 226) in 2013 to 2014. Each patient was assigned to 1 of the 306 Dartmouth hospital-referral regions based on his/her zip code. We constructed logistic regressions to calculate the mean adjusted probability of initiating oral anticoagulation and the mean adjusted probability of initiating an NOAC among patients on oral anticoagulation in each hospital-referral region, after adjustment for demographic, clinical, and provider characteristics and type of insurance. Finally, we computed the correlation between 2 probabilities. Higher in the Midwest (0.54) and Northeast (0.54) and lowest in the South (0.47), the mean adjusted probability of initiating oral anticoagulation was 0.51, ranging from 0.32 to 0.72. The mean adjusted probability of being prescribed an NOAC among those on oral anticoagulation was 0.42 and was highest in the South (0.50) and lowest in the Midwest (0.36) and Northeast (0.39). In areas with the lower use of oral anticoagulation, patients on any oral anticoagulation therapy had a higher likelihood of being prescribed an NOAC (correlation coefficient, -0.16; P=0.006). Large geographic variation exists in oral anticoagulation use in atrial fibrillation. The use of oral anticoagulation is lower in the South, where the rates of stroke are unusually high. In the future, it will be important to analyze whether the high rates of stroke in the South can be partially attributed to the underuse of oral anticoagulation in this region.

LEFT ATRIAL APPENDAGE LIGATION WITH LARIAT DEVICE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: The LARIAT device is a percutaneous endo-epicardial left atrial appendage (LAA) exclusion system that is currently performed in high risk atrial fibrillation (AF) patients intolerant to oral anticoagulation for stroke prevention and maybe reduction of AF burden. Methods: A comprehensive

Stroke risk reduction outweighed bleeding risk increase from vitamin K antagonist treatment among nonvalvular atrial fibrillation patients with high stroke risk and low bleeding risk

Objective: Warfarin is widely used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We compared the rates of stroke and major bleeding in NVAF patients with a high stroke risk and low bleeding risk profile during warfarin treated (W+) and warfarin untreated (W−) periods.Method: Insurance claims from six commercial, Medicaid or Medicare databases were analyzed from 2000 to 2014. NVAF patients treated with warfarin, with a CHADS2/CHA2DS2-VASc score ≥2, and an ATRIA score ≤3 at baseline were identified. Incidence rate ratios (IRRs) of stroke and major bleeding were calculated for W + versus W− episodes of person-time, as well as for first 30 days versus beyond 30 days of W + episodes.Results: Among 316,145 patients, anticoagulant prophylaxis with warfarin significantly reduced stroke risk, with IRRs ranging from 0.48 (95% CI: 0.46–0.51) to 0.80 (95% CI: 0.70–0.91), and increased major bleeding risk, with IRRs ranging from 1.13 (95% CI: 1.10–1.15) to 1.95 (95% CI: 1.10–3.45). Stroke and major bleeding rates were higher during the first 30 days of W + than beyond.Conclusion: In NVAF patients at high risk for stroke and low risk for bleeding, our data confirm the effectiveness of anticoagulation for stroke prevention. The decrease in stroke risk of anticoagulation may outweigh the risk of major bleeding events, particularly among elderly patients. Potential risks of warfarin during initiation warrant attention, especially among patients who stop and start therapy repeatedly.

Ischemic stroke risk in East Asian patients with CHA2DS2-VASc score of 1: systematic review and meta-analysis

ABSTRACTBackground: The use of anticoagulation for stroke prevention in patients with atrial fibrillation (AF) and CHA2DS2-VASc score of 1 has been debated, partially due to limited data on ischemic stroke risk and specific clinical trials in these patients. East Asian patients have a different stroke risk profile compared to non-East Asians. We performed a systematic review and meta-analysis of ischemic stroke risk in AF patients with a CHA2DS2-VASc score of 1 in East Asian countries.Methods: A comprehensive literature search for studies evaluating ischemic stroke risk related with AF with CHA2DS2-VASc score of 1 was conducted by two reviewers. We used a fixed-effect model first, then a random-effect model if heterogeneity was assessed with I2.Results: After pooling 6 studies, the annual rate of ischemic stroke in East Asian patients with AF and a CHA2DS2-VASc score of 1 was 1.66% (95% CI: 0.71%-2.61%, I2 = 98.4%). There was a wide range in reported pooled rates between countries, from 0.59% to 3.13%. Significant difference existed not only in the community-based studies (Chinese: 2.10% vs. Japanese: 0.60%), but also from the hospital-based studies (Chinese: 3.55% vs. Japanese: 0.42%). Confining the analysis to those on no antithrombotic treatment had limited effect on the summary estimate (eg. Chinese: 4.28% vs. Japanese: 0.6%). In Chinese studies, ischemic stroke rate was lower in females than males (female: 1.40% vs. male: 1.79%). However, the low event rate in Japanese studies may reflect unrecorded anticoagulation status at follow-up.Conclusions: Some regional differences between East Asian countries were observed for ischemic stroke risk in patients with a CHA2DS2-VASc score of 1. This may reflect methodological differences in studies and unrecorded anticoagulation use at followup, but further prospective studies are required to ascertain ischemic stroke risks, as well as the differences and reasons for this between East Asians and non-East Asians.

Health Literacy and Atrial Fibrillation: Relevance and Future Directions for Patient-centred Care.

Atrial fibrillation (AF) is a common cardiac arrhythmia with significant clinical outcomes, and is associated with high medical and social costs. AF is complicated for patients because of its specialised terminology, long-term adherence, symptom monitoring, referral to specialty care, array of potential interventions and potential for adversity. Health literacy is a frequently under-recognised, yet fundamental, component towards successful care in AF. Health literacy is defined as the capacity to obtain, process and understand health information, and has had markedly limited study in AF. However, health literacy could contribute to how patients interpret symptoms, navigate care, and participate in treatment evaluation and decision-making. This review aims to summarise the clinical importance and essential relevance of health literacy in AF. We focus here on central aspects of AF care that are most related to self-care, including understanding the symptoms of AF, shared decision-making, adherence and anticoagulation for stroke prevention. We discuss opportunities to enhance AF care based on findings from the literature on health literacy, and identify important gaps. Our overall objective is to articulate the importance and relevance of integrating health literacy in the care of individuals with AF.

Anticoagulation for stroke prevention in elderly patients with non-valvular atrial fibrillation: what are the obstacles?

The elderly with atrial fibrillation are more prone to stroke. Oral anticoagulants such as warfarin are effective in the prevention of atrial fibrillation-associated stroke and systemic embolism. The CHADS2 or CHA2D2-VASc score and HAS-BLED score were developed to stratify stroke risk associated with atrial fibrillation and bleeding risk in a patient with atrial fibrillation, respectively, to facilitate the decision for and safe use of oral anticoagulant. Nonetheless, the decision for anticoagulation is not straightforward and the elderly with non-valvular atrial fibrillation are often precluded from anticoagulant prescription. Advanced age and disadvantages associated with the elderly such as fall, comorbidities, cognitive impairment, and polypharmacy contribute to the over-concern of physicians about bleeding risk. Various treatment options such as low-intensity warfarin and aspirin plus clopidogrel have been suggested but are inferior to dose-adjusted warfarin. Novel oral anticoagulants with promising efficacy and convenience hold great appeal. Optimal management of underlying medical conditions and modifiable stroke risk factors, together with intervention to improve the safe use of oral anticoagulants, are useful.

Prevalence, Risk Factors and Pharmacological Treatment of Atrial Fibrillation in Older Hospitalized Patients in Vietnam

<p>Background. The evidence about prevalence of atrial fibrillation (AF) in Vietnam is very limited. This study aims to investigate the prevalence of AF, its associated factors and pharmacological treatment in older patients in Vietnam.The secondary aim is to investigate the impact of frailty on the pharmacological treatment of AF.</p><p>Methods. We used data from a study of the prevalence of frailty in older hospitalised patients at the National Geriatric Hospital in Hanoi, Vietnam. Consecutive patients aged ≥60 years were recruited from 4/2015 to 10/2015.</p><p>Results. A total of 461 patients was recruited (56.8% female, mean age 76.2±8.9). The prevalence of AF was 3.9% (18 patients). Amongst patients with AF, the most common medical conditions were hypertension (72.2%), followed by stroke (55.6%), heart failure (50.0%), type2 diabetes (44.4%). Living alone (OR=10.2, 95%CI 1.5–70.1), having a habit of using vitamins at home (OR=3.8, 95%CI 1.1–13.4), having heart failure (OR=31.3, 95%CI 9.6–101.8), and having type 2 diabetes (OR=3.5, 95%CI 1.2–10.7) were associated with the presence of AF on admission. All patients with AF had a high risk of stroke (CHA2DS2-VASc score≥2) and 72.2% of them had a high risk of bleeding with anticoagulant medications (HAS-BLED score≥3). Only 22.2% were anticoagulated on admission and 22.2% upon discharge, with no difference between frail and non-frail patients.</p>Conclusions. The prevalence of AF among older hospitalised patients in Vietnam is similar to that reported in other countries. Anticoagulation for stroke prevention was underused, without any significant difference between frail and non-frail patients.

Burden of atrial fibrillation: a retrospective review of patients presenting to acute medical services.

Atrial fibrillation (AF) is a major risk factor for stroke and is associated with increased stroke severity and greater morbidity and mortality. Anticoagulation is highly effective for preventing episodes of thromboembolism but remains under-utilised. The aim of this review was to estimate the short-term risk of thromboembolic events in patients presenting with an acute medical illness, to assess rates of anticoagulation in eligible patients with AF and to describe physician decisions when prescribing anticoagulation in a hospital setting. A retrospective cohort analysis of patients with AF presenting to acute medical services at Wellington Regional Hospital between 1 January 2012 and 31 December 2012 was performed. A total of 751 patient presentations with AF was identified; 613 unique patient encounters were eligible for analysis, and 38.8% of patients with a CHA2 DS2 -VASc score ≥2 were discharged after anticoagulation. The mean CHA2 DS2 -VASc score was 4.03 (SD = 1.94). The CHA2 DS2 -VASc score was not associated with being started on anticoagulation, odds ratio 1.16 (95% confidence interval = 0.83-1.61), P = 0.38, but age by decade older was associated with a reduced likelihood of being started on anticoagulation, odds ratio 0.61 (95% confidence interval = 0.41-0.89), P = 0.01. In untreated patients with a CHA2 DS2 -VASc score ≥2, the most frequently documented reasons not to initiate anticoagulation were decision deferred to the primary care physician, 15.6%; fall risk or frailty, 7.2%; and high bleeding risk, 6.6%. However, no reason was documented in 56.9%. The thromboembolic rate in patients discharged without anticoagulation within 3 months of presentation to acute medical services was 7/330 (2.1%). Anticoagulation for stroke prevention in AF remains under-utilised in eligible patients presenting to acute medical services at a tertiary-level hospital.

Clinicians’ attitudes and perceptions regarding stroke prevention in atrial fibrillation

Introduction: While appropriate oral anticoagulation in atrial fibrillation (AF) can significantly reduce the risk of stroke and is supported by evidenced-based guidelines, evidence suggests that it remains underused, or is used inappropriately. There is currently little data regarding clinicians’ perspectives on stroke prophylaxis in AF since the introduction of the non-vitamin K antagonist oral anticoagulants (NOACs). Aims: To evaluate Australian clinicians’ attitudes in their prescribing of anticoagulants for stroke prevention in AF, including their perceptions of the safety and effectiveness of the NOACs and preferred agents. Methods: A vignette-based survey was distributed to a random sample of Australian cardiologists and general practitioners (GPs) (n=500 each), and an online version of the survey was distributed via email to all clinicians affiliated with the three major Tasmanian public hospitals. Clinicians were asked to indicate their preferred anticoagulant treatment for seven fictional patients with AF. Prescribing choices were compared against expert consensus. Additional multiple-choice and Likert-item questions addressed their use of guidelines and risk stratification tools, attitudes and perceptions. Results: Of 174 respondents (39 GPs, 40 cardiologists and 95 other hospital-based clinicians), 88% reported routinely using an AF stroke risk stratification tool but only 44.5% routinely used a bleeding risk score. Fifty-three per cent of cardiologists, 49% of GPs and 32% of other hospital-based clinicians agreed with the expert panel’s prescribing choices for four or more vignettes; this was unrelated to use of scoring tools and guidelines (p>0.05). Cardiologists were significantly (p = 0.005) more likely to favour a NOAC, with apixaban being the preferred agent. Choice of anticoagulant was also influenced by clinicians’ knowledge and confidence. Discussion: This study demonstrated that prescribing patterns varied between cardiologists, GPs and other hospitalbased clinicians. Concerns over the safety of NOACs were identified as potential barriers to their utilisation by GPs and other hospital-based clinicians. Results from the vignettes demonstrated sub-optimal prescribing choices amongst all clinicians. Further education is required to ensure all clinicians are educated and confident prescribing stroke prophylaxis in AF.

Clinical trials with direct oral anticoagulants for stroke prevention in atrial fibrillation: how representative are they for real life patients?

To identify the proportion of real-life patients with atrial fibrillation (AF) eligible for direct oral anticoagulant (DOAC) therapy, based on the inclusion and exclusion criteria used in the clinical studies and based on the officially approved indications as mentioned in the Summary of Product Characteristics (SmPC). Data for this retrospective cross-sectional study was extracted from the UZ Brussel Stroke Registry, containing anonymized data of 2205 patients with a suspected stroke. Characteristics of patients with documented AF were compared with the patient characteristics in clinical trials and the approved indications in the SmPC. Data of 468 patients with AF was analyzed. Based on the selection criteria of the clinical trials, significantly less patients were eligible for treatment with rivaroxaban compared to dabigatran etexilate (39.3 versus 47.6%; p=0.010), but not compared to apixaban (45.5%; p=0.055). Based on the indications and contraindications in the SmPC, significantly fewer patients were eligible for apixaban compared to dabigatran etexilate and rivaroxaban (62.0% for apixaban, 72.9% for dabigatran etexilate, and 75.6% for rivaroxaban; p<0.001 and p<0.001, respectively). Significantly, more patients were eligible for DOAC therapy based on the indications and contraindications in the SmPC compared to the inclusion and exclusion criteria of the clinical trials (72.9 versus 47.6%; p<0.001 for dabigatran; 75.6 versus 39.3%; p<0.001 for rivaroxaban and 62.0 versus 45.5%; p<0.001 for apixaban). When taking into account the selection criteria from the pivotal clinical trials with DOACs for stroke prevention in AF, less than half of real-life patients are eligible for therapy with one of the DOACs. However, the indications mentioned in the SmPCs of these drugs are less strict.

Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants.

Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients. This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke. The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke. Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.

Positioning the New oral Anticoagulants for prevention of stroke in patients with non-valvular atrial fibrilation

Positioning the New oral Anticoagulants for prevention of stroke in patients with non-valvular atrial fibrilation

Atrial fibrillation ablation and left appendage closure in heart failure patients.

Patients with atrial fibrillation and heart failure experience an increased morbidity and mortality from the hemodynamic consequences of atrial fibrillation and an increased stroke risk. Consequently, there has been increased attention to procedural alternatives to pharmacologic rhythm control and anticoagulation for stroke prevention. This review aims to evaluate the evidence for atrial fibrillation ablation and left atrial appendage closure in heart failure patients. Several randomized control trials and systematic reviews demonstrate the safety and efficacy of atrial fibrillation ablation in patients with heart failure and left ventricular systolic dysfunction. In multiple trials, these patients have shown clinical benefit from atrial fibrillation ablation including improved left ventricular systolic function, quality of life, and clinical heart failure symptoms. The evidence of clinical benefit of atrial fibrillation ablation in heart failure patients with preserved ejection fraction remains limited. Only a handful of randomized controlled trials have been performed evaluating left atrial appendage closure, and there is insufficient data regarding the safety and efficacy of these procedures in heart failure patients. Atrial fibrillation ablation in heart failure patients remains well tolerated with an overall efficacy comparable to atrial fibrillation ablation in patients without heart failure. There is consistent evidence for the clinical benefit of atrial fibrillation ablation in heart failure patients with left ventricular systolic dysfunction and limited evidence for atrial fibrillation ablation in heart failure patients with preserved ejection fraction. Currently, there is insufficient data regarding the safety and efficacy of left atrial appendage closure devices in heart failure patients.

Anticoagulants for stroke prevention in patients with atrial fibrillation

Atrial fibrillation (AF) is one of the most important and modifiable risk factors for ischaemic stroke. Patients who suffer an AF-associated stroke have a high mortality and morbidity. There are now alternative agents available that reduce ischaemic stroke in patients who suffer with non-valvular atrial fibrillation (NVAF) and have been shown to all have significantly fewer safety concerns with regard to intracerebral haemorrhage. Despite this, there are still many patients who are not receiving effective treatment. National Institute for Health and Care Excellence guidance, updated in 2014, recommends that all patients with NVAF require a personalised package of care. This aims to support the patient in making an informed choice regarding their treatment regimen through the provision of individualised information and intervention regarding their AF diagnosis and treatment plan. Providing a holistic approach to AF management is crucial in stroke prevention. This article discusses how to balance established clinical requirements with developing practice related to newer treatment interventions, while maintaining the needs of the individual patient.

Abstract MP07: Rising Incidence and Prevalence of Atrial Fibrillation from 2004 to 2013: A Community-Based Study Using Electronic Medical Records

Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia observed in clinical practice and is associated with an elevated risk of stroke and mortality. Evaluating community-level temporal trends in AF incidence and prevalence serve to describe the evolving public health and clinical burden of AF, however recent studies describing AF trends in community-based settings have been inconsistent, with no recent data evaluating trends among individuals under 65 years of age. Accordingly, this study sought to describe community-level trends in AF incidence and prevalence from 2004 to 2013 using the electronic medical records (EMR) of a single, large health care system. Methods: This study includes 329,634 patients receiving primary care and other health care services through the Geisinger Health System (Geisinger) over at least a two-year period. Geisinger consists of over 40 outpatient and seven inpatient facilities spread throughout central and northeastern Pennsylvania. Geisinger’s extensive EMR data repository contains information on demographics, vital signs, social history, diagnoses, medical history, problem lists, medications, procedures, laboratory results, and billing information from all Geisinger encounters since 2001. Incident and prevalent AF were identified by ICD-9 codes observed within any EMR domain. For incident AF, cases had no AF ICD-9 code in the EMR for at least two years prior to the diagnosis. Incidence and prevalence rates were age- and sex-adjusted to the 2010 US census and reported per 1000 person-years (persons). Stratified rates are reported across age groups (&lt;45, 45-54, ¼, &gt;85) and sex. Results: Age- and sex-adjusted AF incidence rates remained relatively stable from 2004 to 2008, but increased sharply thereafter. Incidence rates were 5.0, 5.2, and 8.4 cases per 1000 person-years in 2004, 2008, and 2013, respectively. The overall annual increase was 5.5% per year (95% CI: 4.8, 6.3%). Incidence rates increased significantly in all age and gender groups, with the largest relative increase observed among patients &lt;45 years of age (annual increase in males: 10.8%, females: 11.6%). Prevalence rates increased consistently throughout the entire 10-year period from 23.5 to 39.2 AF cases per 1000 persons from 2004 to 2013 (6.0% annual increase; 95% CI: 5.7, 6.4%). Conclusions: AF incidence and prevalence have been increasing in the community over the last 10 years. Increases were observed in all age and gender groups, with notable increases in the very young. Prevailing trends may be attributable to increased application of AF diagnostics in an aging population and/or an increased clinical recognition of AF due to the recent availability of novel oral anticoagulants for stroke prevention. A mature EMR system functioning within a large health care system can be a powerful tool for performing epidemiologic studies and disease surveillance.

Anticoagulation for stroke prevention in new atrial fibrillation after coronary artery bypass graft surgery

BackgroundThe benefit of early anticoagulation for stroke prophylaxis in atrial fibrillation after coronary artery bypass graft (CABG) surgery is uncertain. We therefore studied what proportion of ischemic strokes in patients with atrial fibrillation early after CABG surgery were potentially preventable by anticoagulation with warfarin. MethodsWe reviewed medical records from 2264 patients with isolated CABG performed during a period when our institution had no policy on anticoagulation for postoperative atrial fibrillation. The outcome was ischemic stroke within 30days postoperatively and verified with computed tomography (CT) in patients with new postoperative atrial fibrillation for more than 48h. ResultsNew, postoperative atrial fibrillation occurred in 403 (17.8%) of the patients and 191 of those (47.4%) were not started on warfarin at 48hours. Eight patients developed CT-verified ischemic stroke, which occurred on postoperative day 1–3 in 4 patients and in 3 patients was of the lacunar type. In two patients (stroke day 25 and day 30) warfarin could have been preventive. In another patient with onset of neurological symptoms on postoperative day 8 (4days from onset of the arrhythmia), systemic anticoagulation might have limited the severity of the stroke but warfarin therapy would not likely have reached therapeutic levels within 2days. ConclusionThe preventive effect of warfarin on early stroke associated with new atrial fibrillation after CABG seems limited. Treatment with warfarin during the hospitalization has to take the risk of bleeding, particularly into the pericardium, as reported in the literature, into account.

Left atrial appendage occlusion for prevention of stroke in nonvalvular atrial fibrillation: a meta-analysis.

When anticoagulation for stroke prevention is contraindicated, left atrial appendage occlusion (LAAO) may be performed. Studies of LAAO have been limited by their small size, disparate patient populations, and lack of control group. Our purpose was to perform a meta-analysis of the safety and efficacy of LAAO in comparison with standard therapy for stroke prevention in nonvalvular AF. Due to the lack of a control group in studies of LAAO, data on stroke prevention from multiple large outcomes studies were used to produce a hypothetical control group based on clinical variables in the individual studies. Results were stratified according to LAAO device type. We identified 16 studies with a total of 1759 patients receiving LAAO. Summary estimates demonstrate LAAO reduced risk of stroke in comparison with no therapy or aspirin therapy [relative risk (RR), 0.34; 95% CI, 0.25-0.46] and in comparison with warfarin therapy (RR, 0.65; 95% CI, 0.46-0.91). Summary estimates differed based on the study used to derive the hypothetical control group. Device deployment was unsuccessful in 6.1% of patients, and overall complication rate was 7.1%. Efficacy and safety were similar across LAAO device type although a majority of patients in the meta-analysis received a Watchman device. Our data suggest that LAAO is a reasonable option for stroke prophylaxis in AF when anticoagulation is not an option, and the risk for stroke outweighs the risk of procedural complications. Data were limited with the use of most available devices. To better establish the risk and benefit of LAAO in comparison with standard therapy, more randomized controlled trials are necessary.