Anticoagulation In Atrial Fibrillation Research Articles

Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications.

Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.

AF-React study: Prevalence of thrombotic events in patients with atrial fibrillation receiving NOACs - real-world data analysis from northern Portugal primary healthcare.

Anticoagulation is recommended for stroke prevention in patients with atrial fibrillation (AF). The guidelines suggest non-vitamin K antagonist anticoagulants (NOACs) as the primary therapy for anticoagulation in AF. Several patient-related factors increase the risk of thrombotic events: elderly individuals, a previous history of stroke, and chronic kidney disease. This study aims to determine the association between NOACs and other patient variables in AF and the occurrence of thrombotic events. The database included all adults with the code K78 (ICPC-2 code for AF) who received clinical care in Northern Portugal's Primary Health Care between January 2016 and December 2018 and were dispensed the same NOAC at the pharmacy. The results indicate that 10.2% of AF patients on NOAC anticoagulation experienced a stroke. Furthermore, patients treated with apixaban and dabigatran had higher odds of experiencing a stroke compared to those treated with rivaroxaban. Among patients with the same age, gender, and CHA2DS2Vasc Score, apixaban was significantly associated with a higher likelihood of thrombotic events than rivaroxaban. These results have not been previously reported in studies with real-world data; therefore, a more detailed analysis should be conducted to enhance the validity of these findings.

Should left atrial appendage closure be considered in resistant left atrial appendage thrombus cases? 'Former Foe, New Ally'.

The study explores left atrial appendage closure (LAAC) as a safe and effective alternative to anticoagulation for atrial fibrillation (AF) patients at high bleeding risk. Complications, such as cardioembolic events due to left atrial appendage thrombus (LAAT), highlight the need for alternative stroke prevention strategies. This research assesses LAAC's safety and efficacy in patients with LAAT, aiming to offer valuable insights into its potential as a viable option for stroke prevention in such cases. The study included 205 patients who underwent LAAC using specific devices between September 2015 and February 2023. Among them, 32 patients had persistent LAAT. Baseline characteristics, antithrombotic medications, risk scores, and LAAC indications were documented. Patients were followed to monitor significant clinical events like stroke, cardiovascular mortality, and all-cause mortality. The mean age was 71.9 and mostly female. Indications for LAAC were ischemic cerebrovascular events (CVE) despite anticoagulation (25%), bleeding complications (major/minor, 37.5% each), or both. Successful LAA closure was achieved in all cases, with minimal pericardial effusion in one. One-month follow-up showed no major events or device-related issues. Median follow-up of 16.5 months saw 21.9% non-cardiac deaths. The study underscores LAAC's efficacy for stroke prevention in patients with persistent LAAT. The LAAC in cases of LAAT, whether pursued initially or as a deferred approach, demonstrates feasibility and safety, exhibiting notable procedural success and minimal incidence of periprocedural complications.

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation.

Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics.

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by five times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc.), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for Factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a re-evaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Patterns of atrial fibrillation anticoagulation with rivaroxaban — 7-year follow-up from the Dresden NOAC registry

IntroductionData on long-term effectiveness and safety of rivaroxaban for stroke prevention in atrial fibrillation (SPAF) are scarce and not available from randomized clinical trials. MethodsWe used data from the prospective, non-interventional DRESDEN NOAC REGISTRY to evaluate rates of stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and ISTH major bleeding, in general and changes of event patterns over time. ResultsBetween 1st October 2011 and 31st December 2022, 1204 SPAF patients receiving rivaroxaban were followed for 6.7 ± 3.4 years with a mean rivaroxaban exposure of 4.9 ± 3.5 years. During follow up, intention-to treat rates of stroke/TIA/SE were 3.5/100 pt. years (95 % CI 2.5–4.7) in the first year and fell to 1.6/100 pt. years (95 % CI 1.2–2.0) in years 2–5 and 2.1/100 pt. years (95 % CI 1.6–2.7) after 5 years. Similarly, on-treatment event rates fell from 2.4/100 pt. years (95 % CI 1.5–3.5) to 1.1 (95 % CI 0.7–1.5) and 1.6 (95 % CI 1.0–2.3), respectively.Major bleeding rates on treatment were 3.5/100 pt. years in the first treatment year (95 % CI 2.5–4.8) and 2.7 (95 % CI 2.2–3.4) and 3.5 (95 % CI 2.7–4.6) in the periods 2–5 and > 5 years, respectively. Of note, rates of fatal bleeding were low throughout follow-up (0.2 vs. 0.2 vs. 0.1/100 pt. years). ConclusionsOur results demonstrate the long-term effectiveness and safety of rivaroxaban therapy in unselected SPAF patients in daily care. Our data indicate that patterns of cardiovascular events remain constant over many years. In contrast, bleeding patterns change over time, possibly due to effects of co-morbidities in an ageing population.

Fibrillatory wave amplitude and thromboembolic risk in non-anticoagulated patients with atrial fibrillation

Background The benefit of oral anticoagulation in atrial fibrillation (AF) is well established for patients at elevated stroke risk, but less clear for those at intermediate risk. We investigated whether analysis of electrocardiogram (ECG) derived fibrillatory waves (F-waves) could help identify patients at risk for stroke and systemic embolism (SSE). Methods The Finnish Cardioversion (FinCV) study included patients not on permanent anticoagulation therapy who underwent cardioversion for an acute AF episode. We identified 739 individuals with a valid ECG and complete follow-up data. The maximum amplitudes of the F-waves in leads II and V1 were manually measured from the pre-procedure ECG. Patients were categorized into fine and coarse F-wave groups. The optimal lead and amplitude threshold for grouping were found in an events per person-years analysis. SSE were identified from the patient medical records until either anticoagulation was prescribed, AF was deemed chronic, the patient had deceased, or the end of follow-up. Results Overall 37 (5.0%) patients suffered SSE during the median follow-up time of 5.4 years (1.9–10.8). Measured from lead V1 the SSE rates per 100 person-years were 1.5 and 0.7 in fine and coarse F-wave groups, respectively. Fine F-waves were observed in 112 (15.2%). Baseline characteristics were similar between the groups. Fine F-wave predicted SSE in a competing risk analysis (SHR 2.34, 95%CI 1.12–4.87, p = .023). Analyses from lead II did not provide significant results. Conclusion Electrocardiographic F-wave amplitude may provide additional information on stroke risk in patients with paroxysmal AF and borderline indications or contraindications for anticoagulation.

Patient perspectives on oral anticoagulation for atrial fibrillation: can more specific communication on bleeding risk help?

Patient perspectives on oral anticoagulation for atrial fibrillation: can more specific communication on bleeding risk help?

Anticoagulants for atrial fibrillation: from warfarin and DOACs to the promise of factor XI inhibitors.

Anticoagulation is the mainstay of stroke prevention in appropriate patients with atrial fibrillation. Due to advances in pharmacotherapy the anticoagulants used for this purpose have evolved significantly over the past decades with the aim of optimizing effectiveness while minimizing bleeding risks. Though significant improvements have been made toward this goal, bleeding risk remains the major concern with these therapies. An investigational class of agents which inhibit Factor XI have shown promise in pre-clinical and early clinical trials to significantly minimize bleeding while maintaining efficacy against stroke and systemic embolism. This mini-review will discuss anticoagulants currently used for stroke prevention in patients with atrial fibrillation including warfarin and direct oral anticoagulants. We will also review the mechanism of action and data from early clinical trials for Factor XI inhibitors and discuss their potential advantages and shortcomings.

Facility-Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: The REACH-AF Study.

Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. Retrospective cohort study. Black and White patients enrolled in the VA with incident AF from 2020 through 2021. The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from - 29.9 (95% CI, - 54.9 to - 4.8) to 14.2 (95% CI, - 9.1 to 25.0) across facilities for any anticoagulant therapy and from - 28.8 (95% CI, - 58.3 to 0.8) to 15.0 (95% CI, - 8.0 to 38.1) for DOAC therapy.For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.

Oral anticoagulation for atrial fibrillation and high risk of bleeding in daily practice: What clinical considerations?

Oral anticoagulation for atrial fibrillation and high risk of bleeding in daily practice: What clinical considerations?

Weighing the risks and benefits of anticoagulation in atrial fibrillation: a case report of left atrial appendage absence in a patient referred for procedural occlusion

Abstract Background The absence of the left atrial appendage is an exceedingly rare structural variant that could have important implications for anticoagulation regimens in patients with atrial fibrillation. Case summary We report the case of a 63-year-old Puerto Rican female with a history of hypertension, cerebral artery aneurysms, and type 2 diabetes mellitus who suffered multiple haemorrhagic strokes. The patient had never received anticoagulation therapy. During the indicated stroke work-up, the patient was found to have paroxysmal atrial fibrillation. Given the patients high risk for thromboembolism and contraindications to anticoagulation therapy, the patient was referred for left atrial appendage occlusion. Pre-procedural transoesophageal echocardiography failed to identify the left atrial appendage. Evaluation by way of cardiac computed tomography confirmed absence of the left atrial appendage. Left atrial appendage occlusion could not be carried out. The patient had been deemed being at high risk of bleeding, was not anticoagulated, and was instead closely followed. The patient has not had thrombo-embolic events nor has she experienced a haemorrhagic stroke recurrence at follow-up appointments. Discussion To our knowledge, this is the first such case report that reports left atrial appendage absence in the setting of multiple haemorrhagic strokes. Given the rarity of the condition and lack of available guidelines, the most viable way to currently manage this patient population is on a case-to-case basis. However, we propose that absence of the left atrial appendage could confer a decreased risk of thrombo-embolic phenomena in patients with atrial fibrillation.

Cardiovascular Events and Mortality in Patients on Hemodialysis: The Prognostic Value of the CHA2DS2-VASc Score.

Background and Objectives: Cardiovascular events are the major cause of morbidity and mortality in patients on hemodialysis (HD). Identifying risk factors can help in the effort to reduce cardiovascular risk and improve life expectancy. The objective of this study was to evaluate the ability of the CHA2DS2-VASc score-the risk index of stroke in atrial fibrillation (AF)-to predict strokes, major cardiovascular events, and mortality in patients with end-stage kidney disease. Materials and Methods: The CHA2DS2-VASc and HAS-BLED scores (the bleeding risk from the use of anticoagulation in AF) were calculated in 237 HD patients, 99 women with a median age of 76 (15) years, at the time they commenced HD. The scores' ability to predict long term cardiovascular morbidity and mortality was estimated, both in those with and without AF. Among the exclusion criteria were the change of dialysis method or loss of follow-up, HD due to acute renal failure, and incompliance with medical instructions, thus the sample is not representative of a broader population. Results: The CHA2DS2-VASc score was higher in AF (n = 69) compared to non-AF (n = 168) patients, 5 (2.5) vs. 4 (2), p < 0.0001, respectively. An increased CHA2DS2-VASc score was correlated with cardiovascular events, namely, heart failure (p = 0.007, p = 0.024), stroke (p < 0.0001, p < 0.0001), and risk of all-cause mortality (p < 0.0001, p < 0.0001) in AF and non-AF groups, respectively. The C statistics indicated that the referred score showed modest discrimination in AF and non-AF patients on HD for heart failure, stroke, and all-cause mortality, however for cardiovascular mortality this was found only in the AF group. Conclusions: An increased CHA2DS2-VASc score at the time of HD initiation can predict strokes, heart failure, and all-cause mortality in HD patients independent of the presence of AF. The risk of cardiovascular mortality could only be predicted in patients with AF.

Anticoagulation in atrial fibrillation and end-stage kidney disease on hemodialysis: a meta-analysis of randomized trials comparing direct oral anticoagulants with vitamin K antagonists

BackgroundOnly small randomized trials have investigated the efficacy and safety of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients with non–valvular atrial fibrillation (NVAF) and end-stage kidney disease. ObjectivesTo perform a systematic review and meta-analysis comparing anticoagulation with DOACs to VKAs in patients with NVAF undergoing chronic hemodialysis. MethodsA systematic search using Medline, Web of Science, and Embase was performed. All randomized trials comparing DOACs with VKAs in patients with NVAF undergoing chronic hemodialysis were included. As primary endpoint, we analyzed all-cause mortality. As secondary endpoints, we investigated total bleeding events, life-threatening or major bleeding events, and thromboembolic events or stroke. We used the odds ratio as outcome measure and fitted a random-effects model due to the expected heterogeneity. ResultsThree studies fulfilled the inclusion criteria comprising 383 patients (218 on apixaban or rivaroxaban, 165 on VKA). No significant difference between DOACs and VKAs regarding death (OR, 0.94; 95% CI, 0.55-1.63; p = .84), total bleedings (OR, 0.99; 95% CI, 0.63-1.54; p = .96) and life-threatening or major bleeding (OR, 0.65; 95% CI, 0.32-1.33, p = .24) was detected. There was a trend toward a reduction of thromboembolic events or stroke in patients receiving DOACs (OR, 0.39; 95% CI, 0.14-1.05; p = .06). ConclusionOrally administered activated factor X inhibitors carried a similar risk of bleeding and death when compared with VKAs in patients with NVAF undergoing chronic hemodialysis. Moreover, there was a trend towards a reduction of thromboembolic events or stroke in patients receiving DOACs.

Review of the use of anticoagulation with Direct Oral Anticoagulants (DOACs) for prevention of stroke in patients with Atrial Fibrillation and initiating in Primary care

Anticoagulation with direct oral anticoagulants (DOAC) is becoming increasingly more prominent for stroke prevention in patients with Atrial Fibrillation (AF). Whereas a vitamin k analogue like warfarin would traditionally be used for this; DOACs offer several advantages over warfarin. This review article will provide an overview of the current evidence supporting the use of DOACs for anticoagulation in AF and how a primary care clinician would go about choosing which DOACs to choose and considerations that need to be taken before initiation of the drug. Keywords: Direct Oral Anticoagulants, atrial fibrillation, stroke, primary care, anticoagulation, warfarin

Chronic Anticoagulation in Patients with Atrial Fibrillation and COVID-19: A Systematic Review and Meta-Analysis.

Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability. It remains uncertain whether ongoing anticoagulation for atrial fibrillation (AF) in patients who later contract COVID-19 improves clinical outcomes. To compare chronic oral anticoagulation with no previous anticoagulation in patients with AF who contracted a COVID-19 infection concerning the outcomes of all-cause mortality, COVID-19 mortality, intensive care unit (ICU) admission, and hospitalization. We systematically searched PubMed, Embase, and Cochrane Library for eligible studies from inception to December 2022. We included studies comparing COVID-19 outcomes in patients with versus without prior chronic anticoagulation for AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. The level of significance was set at p < 0.05. Quality assessment and risk of bias were performed according to Cochrane recommendations. Ten studies comprising 1,177,858 patients with COVID-19 and AF were identified, of whom 893,772 (75.9%) were on prior chronic anticoagulation for AF. In patients with COVID-19, being on chronic anticoagulation for AF significantly reduced all-cause mortality (RR 0.75; 95% CI 0.57 to 0.99; p = 0.048; I2 = 89%) and COVID-19-related mortality (RR 0.76; 95% CI 0.72 to 0.79; p < 0.001; I2 = 0%) when compared with no prior anticoagulation. In contrast, there was no difference between groups regarding hospitalization (RR 1.08; 95% CI 0.82 to 1.41; p = 0.587; I2 = 95%) or ICU admission (RR 0.86; 95% CI 0.68 to 1.09; p = 0.216; I2 = 69%). In this meta-analysis, chronic anticoagulation for patients with AF who contracted COVID-19 was associated with significantly lower rates of all-cause mortality and COVID-19-related mortality as compared with no previous anticoagulation.

Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010–2020

BackgroundThere is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD).Setting and methodsWe used the UK Clinical...

Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation

Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation

Oral Anticoagulation for Atrial Fibrillation in Octogenarians Across the Renal Function Spectrum

Oral Anticoagulation for Atrial Fibrillation in Octogenarians Across the Renal Function Spectrum

Comparison of the Efficacy and Safety of Left Atrial Appendage Closure and Direct Oral Anticoagulants for Atrial Fibrillation: A Meta-Analysis of Randomized Control Trials and Observational Studies.

The aim of this study was to compare the efficacy and safety of left atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). This meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Two investigators performed an online database search on PubMed, Web of Science, and Scopus databases from inception to October 31, 2023, without any language or time restrictions. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, stroke, and major bleeding events. Eight studies were included in this meta-analysis, enrolling 7,629 participants with AF (4,287 in the DOAC group and 3,342 in the LAAC group). The pooled analysis showed that the risk of all-cause mortality was significantly higher in patients in the DOAC group compared to LAAC (relative risk (RR): 1.87, 95% confidence interval (CI): 1.50 to 2.34). The risk of cardiovascular mortality was 1.60 times higher in patients receiving DOACs compared to those receiving LAAC (RR: 1.60, 95% CI: 1.12 to 2.28). The risk of stroke was not significantly different between the two groups (RR: 1.15, 95% CI: 0.95 to 1.41). In conclusion, LAAC for AF patients proves to be safe and effective for stroke prevention, exhibiting a superior profile in terms of all-cause mortality, cardiovascular events, and major bleeding compared to oral anticoagulation (OAC). These findings prompt consideration of LAAC as a preferred treatment for cardiovascular event prevention in high-bleeding-risk patients.