Anticoagulation In Atrial Fibrillation Research Articles

The Need for Randomized Trials to Define the Optimal Dose of Anticoagulants for Atrial Fibrillation in Chronic Kidney Disease

The Need for Randomized Trials to Define the Optimal Dose of Anticoagulants for Atrial Fibrillation in Chronic Kidney Disease

Abstract 15688: Association of Cytochrome P450 2C19 Polymorphism With Ischemic and Bleeding Risk in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Introduction: CYP2C19 isoenzymes of cytochrome P450 impact the effect of clopidogrel. Guidelines recommend clopidogrel in addition to oral anticoagulation (OAC) in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). This study aimed to evaluate the association of CYP2C19 polymorphism with ischemic and bleeding risk in patients with AF undergoing PCI. Methods: Patients with AF and an indication for OAC were included in this two-center prospective cohort study up to 3 days after PCI. Carriers of ≥1 loss of function (LOF) allele CYP2C19*2 were classified as poor metabolisers (PM). Carriers of ≥1 gain of function allele (GOF) were defined as rapid metabolisers (RM). Normal metabolisers (NM) were defined as absence of LOF and GOF alleles. Primary outcome was defined as death, myocardial infarction, or stroke (MACE) at 6 months ±2 weeks. Secondary outcome was defined as non-major clinically relevant (NMCR) or major bleedings. Results: 283 patients were included in the study. Median age was 78 (interquartile range, IQR 72-82) years old and 204 (72%) were males. All patients received treatment with clopidogrel and OAC. 73 (26%) were PM, 108 (38%) were NM and 102 (36%) RM. The primary ischemic outcome occurred in 22 (8%) and the secondary outcome in 38 (13%) patients. PM status did not significantly associate with primary ischemic outcome (PM: 6 [8.2%] vs. NM+RM: 16 [7.6%]; odds ratio, OR 1.09 [95% confidence interval 0.41-2.89], p=0.805). RM status did not significantly associate with bleeding (RM: 14 [13.7%] vs. PM+NM: 24 [13.3%]; OR 1.04 [0.51-2.12], p=1.00). Bleeding rates tended to be lower for patients with PM status (major, NMCR, or minor bleeding: PM 12 [28.7%] vs. NM+RM 84 [40.0%]; 0.61 [0.34-1.07], p=0.09). Conclusions: This pilot study of patients with oral anticoagulation for atrial fibrillation and clopidogrel after PCI ruled out, with 95% confidence, a ≥3-fold increase of ischemic risk for carriers of ≥1 loss of function allele CYP2C19*2 compared with non-carriers. This study was underpowered to detect less pronounced associations. LOF-carrier status might protect from bleeding.

Temporal Relation Between Myocardial Infarction and New-Onset Atrial Fibrillation: Results from a Nationwide Registry Study

Myocardial infarction (MI) and atrial fibrillation (AF) are commonly seen in the same patient. In this study, we evaluated the temporal relations and prognosis of MI and AF. This is a substudy of the nationwide registry-based Finnish Anticoagulation in Atrial Fibrillation (FinACAF) study, comprising all Finnish patients with new-onset AF from 2010 to 2017. Patients with MI and AF were divided into groups depending on the temporal relation between the disease onsets: (1) MI before AF (MI<AF), (2) MI ± 30days before or after AF (MI=AF), (3) MI after AF (MI>AF), and (4) no MI. The 1-year mortality in the groups were studied with the Cox proportional hazards model. Of the 153,207 patients with new-onset AF (mean age 72.7 years, 50.0% women), 16,265 (10.6%) were diagnosed with MI. Altogether, 8,889 (54.7%) of the patients with MI were in the MI<AF group, 4,278 (26.3%) were in the MI=AF group, and 3,098 (19.1%) were in the MI>AF group. Of all MIs, 42.2% were diagnosed within 1year from new-onset AF. The MI>AF group had the worst survival, with an adjusted hazard ratio for death of 3.08 (confidence interval [CI] 2.89 to 3.27) compared with patients without MI. For the MI<AF and MI=AF groups, the hazard ratios were 1.34 (CI 1.27 to 1.41) and 1.69 (CI 1.59 to 1.81). In conclusion, the diagnoses of MI and AF accumulated close to one another, and the survival of patients with concomitant AF and MI varied, with the worst outcome found in patients with MI diagnosed after the new-onset AF.

The Role of Extracellular Matrix and Inflammation in the Stratification of Bleeding and Thrombotic Risk of Atrial Fibrillation on Oral Anticoagulant Therapy: Insights from Strat-Af Study.

In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. We hypothesize that both circulating and neuroimaging-based markers might improve the prediction of bleeding and thrombotic risk in anticoagulated AF patients. The Strat-AF study is an observational, prospective, single-center study enrolling 170 patients with AF; recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral magnetic resonance imaging and circulating biomarkers assessment. The main outcome is the evaluation of cerebral microangiopathy related to the levels of circulating biomarkers of inflammation and extracellular matrix (ECM) remodeling. At multivariate logistic regression analysis adjusted for age, sex, CHA2DS2-VASc, HAS-BLED and type of anticoagulant, matrix metalloproteinases (MMP)-2 levels were significantly and positively associated with the presence of cerebral microbleeds (CMBs). A significant association between MMP-2, tissue inhibitor of metalloproteinases (TIMP)-1,-2,-4 levels and white matter hyperintensity was also found. Concerning the small vessel disease (SVD) score, MMP-2 and TIMP-1,-2 levels were associated with the presence of two and three or more signs of SVD, whereas TIMP-4 levels were associated with the presence of three signs of SVD with respect to patients with no instrumental signs of SVD. As regarding the presence of enlarged perivascular spaces (EPVS), a significant association was found for high levels of interleukin (IL)-8 and TIMP 1-2-3. These results demonstrate that patients with AF have evidence of impaired ECM degradation, which is an independent risk factor for thrombotic complications of AF patients on oral anticoagulant therapy. The incorporation of these markers in the prognostic schemes might improve their clinical capability in predicting stroke risk and thrombotic complications.

Anticoagulation in atrial fibrillation. A large real-world update

IntroductionIn a large nationwide administrative database including ∼35 % of Italian population, we analyzed the impact of oral anticoagulant treatment (OAT) in patients with a hospital diagnosis of non-valvular atrial fibrillation (NVAF). Methods and resultsOf 170404 OAT-naïve patients (mean age 78.7 years; 49.4 % women), only 61.1 % were prescribed direct oral anticoagulants, DOACs, or vitamin-K antagonists, VKAs; 14.2 % were given aspirin (ASA), and 24.8 % no anti-thrombotic drugs (No Tx). We compared ischemic stroke (IS), IS and systemic embolism (IS/SE), intracranial hemorrhage (ICH), major bleeding (MB), major gastro-intestinal bleeding, all-cause deaths and the composite outcome, across four propensity-score matched treatment cohorts with >15400 patients each.Over 2.9±1.5 years, the incidence of IS and IS/SE was slightly less with VKAs than with DOACs (1.62 and 1.84 vs 1.81 and 1.99 events.100 person-years; HR=0.85, 95%CI=0.76-0.95 and HR=0.87, 95%CI=0.78-0.97). This difference disappeared in a sensitivity analysis which excluded those patients treated with low-dose of apixaban, edoxaban, or rivaroxaban (41.7% of DOACs cohort). Compared with DOACs, VKAs were associated with greater incidence of ICH (1.09 vs 0.81; HR=1.38, 95%CI=1.17-1.62), MB (3.78 vs 3.31; HR=1.14, 95%CI=1.02-1.28), all-cause mortality (9.66 vs 10.10; HR=1.07, 95%CI=1.02-1.11), and composite outcome (13.72 vs 13.32; HR=1.04, 95%CI=1.01-1.08). IS, IS/SE, and mortality were more frequent with ASA or No Tx than with VKAs or DOACs (p<0.001 for all comparisons). ConclusionsBeyond confirming the association with a better net clinical benefit of DOACs over VKAs, our findings substantiate the large proportion of NVAF patients still inappropriately anticoagulated, thereby reinforcing the need for educational programs.

Trends in Drug Spending of Oral Anticoagulants for Atrial Fibrillation, 2014–2021

INTRODUCTIONThis study documents cost trends in oral anticoagulants (OAC) in patients with newly diagnosed atrial fibrillation (AF). METHODSUsing MarketScan databases, the mean annual patients’ out-of-pocket costs, insurance payments, and the proportion of patients initiating OAC within 90 days from AF diagnosis were calculated from July 2014 to June 2021. Costs of OACs (apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin) and the payments by three insurance types (commercial payers, Medicare, and Medicaid) were calculated. Patients’ out-of-pocket costs and insurance payments were adjusted to 2021 prices. Joinpoint regression models were used to test trends of outcomes and average annual percent changes (AAPC) were reported. Data analyses were performed in 2022-2023. RESULTSFrom July 2014 to June 2021, the mean annual out-of-pocket costs of any OAC increased for commercial insurance (AAPC 3.0%) and Medicare (AAPC 5.1%) but decreased for Medicaid (AAPC -3.3%). The mean annual insurance payments for any OAC significantly increased for all insurance groups (AAPC 13.1% [95% CI 11.3 to 15.0] for Medicare; AAPC 11.8% [95% CI 8.0 to 15.6] for commercial insurance; and AAPC 16.3% [95% CI 11.3 to 21.4] for Medicaid). The initiation of any OAC increased (AAPC 7.3% for commercial insurance; AAPC 10.2% for Medicare; AAPC 5.3% for Medicaid). CONCLUSIONSThere was a substantial increase in the overall cost burden of OACs and OAC initiation rates in patients with newly diagnosed AF in 2014-2021; these findings provide insights into the current and anticipated impact of rising drug prices on patients’ and payers’ financial burden.

Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation.

To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018. The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy. We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women. This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.

Efficacy and Safety of Novel Oral Anticoagulants in Atrial Fibrillation: A Systematic Review.

In recent times, novel oral anticoagulants (NOACs)/direct oral anticoagulants (DOACs) have emerged as an alternative to the traditionally used VitaminK oral antagonists (VKA)like warfarin for the treatment of atrial fibrillation (AF). This systematic review and meta-analysis aims toevaluate the efficacy and safety of NOACs in patients with AF and, thus, the related thromboembolic risks and sequelae. Of the 131 published articles we examined, 11 were included in an in-depth systematic review. The articles we reviewed were from the past ten years, from 2013 onward. The analysis derived the efficacy and safety of NOACs in patients with AF and also included different patients' baseline characteristics and subgroups. This systematic review reiterates previous research findings of superior efficacy and safety of the use of NOACs in the AF population and also illuminates certain head-to-head comparisons of individual NOACs with warfarin.It digressed into subgroups of patients with different baseline characteristics to provide evidence and support the existing guidelines for the use of NOACs in the treatment of AF. Overall, there is marked efficacy and safety of NOACs in patients with AF, be they elderly or Asian, with decreased renal function, or with other comorbidities. Adherence to NOACs was also satisfactory. Despite such a review, there needs to be more research on vast subgroups and also on reversal antidotes like andexanet alfa and idarucizumab, as well as more head-to-head analysis between NOACs over a long duration of study, which would provide more answers and pinpoint reasons as to the differences that exist between demographics and subgroups in the usage of NOACs.

Future Perspectives to Improve CHA2DS2VASc Score: The Role of Left Atrium Remodelling, Inflammation and Genetics in Anticoagulation of Atrial Fibrillation.

In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients.

Impact of left atrial appendage closure in patients on anticoagulation for atrial fibrillation and recurrent or chronic gastrointestinal bleeding

Impact of left atrial appendage closure in patients on anticoagulation for atrial fibrillation and recurrent or chronic gastrointestinal bleeding

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies.

Two recent randomized controlled trials (RCTs), the PROTECT-AF and the PREVAIL, showed that in atrial fibrillation (AF) patients, left atrial appendage closure (LAAC) is comparable to oral anticoagulants (OAC) in the prevention of stroke and could also possibly reduce mortality. Nevertheless, this net clinical benefit was not confirmed in the most recent RCT comparing LAAC vs. OAC, the PRAGUE-17 trial. aim of the present study was to evaluate the efficacy and safety of LAAC compared with OAC among available high-quality studies. A systematic search of electronic databases (Medline, Scopus, Embase and the Cochrane Library) was performed to identify eligible RCTs and observational studies with propensity score matching (PSM) analysis. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Outcomes of interest were the occurrence of cardiovascular death (CVD), all-cause death, all-type stroke, and major bleedings. A total of 3 RCTs and 7 PMS studies involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy. After a median follow-up of 2.6 years (IQR 2-4.4), patients who received LAAC had lower risk of CVD (RR = 0.62; 95%CI, 0.51-0.74, I2 = 0%), all-cause death (RR = 0.67; 95% CI, 0.57-0.78, I2 68%) and major bleedings (RR = 0.68; 95%CI, 0.48-0.95 I2 = 87%) compared with patients on OAC. No difference was found between the two groups regarding strokes incidence (RR = 0.94; 95% CI, 0.77-1.15, I2 = 0%). According to this meta-analysis, LAAC has comparable efficacy in the prevention of stroke compared with OAC and a reduced risk of major bleedings, all-cause death and CVD that may be even larger with longer follow-up. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269768, identifier CRD42021269768.

Clinical profile of atrial fibrillation in hospitalized patients: experience from two tertiary centers of Bangladesh

Background: Chronic rheumatic heart disease (RHD), particularly mitral stenosis, is traditionally thought to be the dominating cause of atrial fibrillation (AF) in Bangladesh. But over the past decades, parallel to the changes in dominating disease pattern, rheumatic fever and possibly RHD has declined in the country. Also, the current practice of anticoagulation in AF here is not known. The study was carried out to explore the current aetiology and clinical profile of AF in hospitalized patients. Methods: This cross-sectional study included 302 consecutive adult patients with AF admitted in 2 hospitals in Dhaka, Bangladesh. History, clinical examination and investigations including transthoracic echocardiography were done to find out the aetiology, type of AF, selected complications and the pharmacotherapy including anticoagulation practice in hospitalized AF patients. Results: The mean age of the patients was 54.00 ± 12.46 years (range 14 to 85 years). The most common etiology was rheumatic valvular heart disease (47.7%), followed by ischaemic heart disease (IHD) (29.5%) and hypertensin (5.0%). Majority (249, 82%) had coarse AF and only 18% had fine AF. Thirteen (4.3%) patients presented with stroke and 7 (2.3%) had left atrial thrombus. The most common drugs used were beta blocker (32.78%), digoxin (32.45%) and combination of beta blocker and digoxin (23.84%). Anticoagulant was used in 56.95% cases. Among the anticoagulants, warfarin was most commonly prescribed (69.18%), followed by rivaroxaban and apixaban in 15.69% and 13.95% cases, respectively. Conclusion: RHD is still the dominating cause of AF in hospitalized patients in Bangladesh. Despite high prevalence of rheumatic valvular AF, anticoagulants are underused. Warfarin is far more commonly used than the direct oral anticoagulants (DOACs). BIRDEM Med J 2023; 13(3): 143-148

Patients' Perspectives on Commencing Oral Anticoagulants in Atrial Fibrillation: An Exploratory Qualitative Descriptive Study.

Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

57 A review of the utilisation of the SHARE frailty instruments (SHARE-FI and SHARE-Fi75+) in the literature

Abstract Background The Survey of Health, Ageing and Retirement in Europe (SHARE) frailty instruments SHARE-FI and SHARE-FI75+ were developed as non-commercial, open access frailty phenotype-based identification tools for rapid use in the primary care setting. This literature review examined their utilisation since their publication. Methods We used the Google Scholar ‘cited by’ function (accessed on February 20th, 2023) to identify all citations of the original SHARE-FI and SHARE-FI75+ studies. Included articles were categorised into four themes: epidemiological studies (prevalence and associated factors); associations with geriatric syndromes, diseases and health outcomes; randomised clinical trials (RCTs); and expert consensus and practice guidelines. Results Of 529 articles screened (446 citing SHARE-FI and 83 citing SHARE-FI75+), 64 (12.1%) were included in the narrative review. Sixteen (25.0%) were epidemiological; 35 (54.7%) described associations; 10 (15.6%) were RCTs; and 3 (4.7%) were expert consensus or practice guidelines. Frailty was associated with older age; female sex; higher morbidity; lower education; social isolation; worse nutrition and mobility; rheumatological, cardiovascular, and endocrine diseases; and greater healthcare utilisation and mortality. SHARE-FI was used in RCTs as entry criterion, controlling variable and intervention outcome. The most commonly studied interventions were exercise, nutrition and social support. SHARE-FI and SHARE-FI75+ have been recommended to aid the management of atrial fibrillation anticoagulation (2015 European Heart Rhythm Association (EHRA) Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation) and hypertension (2016 Expert Opinion From the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects), respectively. Conclusion SHARE-FI and SHARE-FI75+, two open access phenotypical frailty measurement tools, have been utilised for diverse purposes, and mostly in epidemiological/associational studies. The relative paucity of RCTs and guidelines vis-à-vis epidemiological and associational studies highlights scope for their future utilisation in studies that will be able to generate higher-level evidence.

Anticoagulants in atrial fibrillation

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Kidney Function and the Use of Vitamin K Antagonists or Direct Oral Anticoagulants in Atrial Fibrillation

Abstract Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with a five-fold increase in the risk for ischemic stroke. Therefore, lifelong use of anticoagulants is crucial to reduce the morbidity and mortality burden of AF. The incidence of AF in chronic kidney disease (CKD) is two to three times greater than in the general population, and there is a mutual aggravation of the two conditions as well as the presence of both an increased thromboembolic risk in CKD and an increased bleeding risk in severe CKD. The preservation of kidney function in patients with cardiovascular diseases is important, as the latter is the leading cause of death in patients with eGFR &lt;60 mL/min/1.73 m2. Similarly, kidney dysfunction is a serious limitation to the use of many cardiovascular drugs, including anticoagulants. Evidence is present for the faster progression of kidney disease with vitamin K antagonists, likely due to the vitamin K-related process of vascular calcification. Conversely, direct oral anticoagulants (DOACs) have been shown to reduce the progression of CKD and have a beneficial effect as far as the modulation of inflammation and oxidative stress are concerned in experimental models. Another less-discussed problem is the use of DOACs in advanced CKD.

Anticoagulation in atrial fibrillation: Special scenarios

Atrial fibrillation is the most common cardiac arrhythmia in the world, with an estimated prevalence of 2 to 4%, and represents a high burden of disease worldwide. It is defined as a supraventricular tachyarrhythmia with loss of atrial activity, diagnosed by specific electrocardiographic findings. Its classification is clearly defined, based on the form of presentation, duration and the resolution of the episodes. One of the pillars in the treatment of this pathology is anticoagulant therapy, which represents a challenge due to the heterogeneity of the patients, however there are specific situations such as chronic kidney disease, oncological diseases and liver disease, where the situation becomes even more complex, however different studies have been carried out in which the best strategies based on scientific evidence have been proposed for the approach of these patients in special situations.

Meta-Analysis Assessing Efficacy and Safety of Vitamin K Antagonists Versus Direct Oral Anticoagulants for Atrial Fibrillation After Transcatheter Aortic Valve Implantation

Patients who underwent transcatheter aortic valve implantation (TAVI) with concomitant atrial fibrillation (AF) are at a higher risk for thromboembolic and bleeding events. The optimal antithrombotic strategy for patients with AF after TAVI remains unclear. We sought to determine the comparative efficacy and safety of direct oral anticoagulants (DOAC) versus oral vitamin K antagonists (VKAs) in these patients. Electronic databases such as PubMed, Cochrane, and Embase databases were searched till January 31, 2023, for relevant studies evaluating clinical outcomes of VKA versus DOAC in patients with AF after TAVI. Outcomes assessed were (1) all-cause mortality, (2) stroke, (3) major/life-threatening bleeding, and (4) any bleeding. Hazard ratios (HRs) were pooled in meta-analysis using random effect model. Nine studies (2 randomized and 7 observational) were included in systematic review, and 8 studies with 25,769 patients were eligible to be included in the meta-analysis. The mean age of the patients was 82.1years, and 48.3% were male. Pooled analysis using random-effects model showed no statistically significant difference in all-cause mortality (HR 0.91, 95% confidence interval [CI] 0.76 to 1.10, p=0.33), stroke (HR 0.96, 95% CI 0.80 to 1.16, p=0.70), and major/life-threatening bleeding (HR 1.05, 95% CI 0.82 to 1.35, p=0.70) in patients that received DOAC compared with oral VKA. Risk of any bleeding was lower in the DOAC group compared with oral VKA (HR 0.83, 95% CI 0.76 to 0.91, p=0.0001). In patients with AF, DOACs appear to be a safe alternative oral anticoagulation strategy to oral VKA after TAVI. Further randomized studies are required to confirm the role of DOACs in those patients.

Oral anticoagulation for atrial fibrillation in rheumatic heart disease.

Oral anticoagulation for atrial fibrillation in rheumatic heart disease.

Aspirin deprescribing in patients on oral anticoagulation for atrial fibrillation or venous thromboembolism: A national survey of clinician practices

AbstractIntroductionConcomitant use of oral anticoagulation (OAC) and aspirin increases bleeding risk without decreasing thromboembolic events compared with OAC monotherapy. Weak guideline recommendations and limited data exist for deprescribing aspirin for primary prevention or stable coronary artery disease in patients already on OAC for atrial fibrillation (AF) or venous thromboembolism (VTE).ObjectivesThe objective of this study was to identify aspirin deprescribing practices among clinicians for patients on OAC for AF or VTE and concomitant aspirin for non‐compelling reasons.MethodsA cross‐sectional, national survey was electronically distributed to pharmacists and non‐pharmacists (physicians, nurse practitioners, physician assistants). Co‐primary end points were composite aspirin discontinuation rates in patients on OAC for AF or VTE in primary prevention and stable coronary artery disease (CAD) cases. Key secondary end points were clinician comfort level with deprescribing aspirin and availability of institutional protocols.ResultsThree hundred four responses were included: 212 (69.7%) pharmacists and 92 (30.3%) non‐pharmacists. Mean age of respondents was 35.4 years, and 37.4% male. In the primary prevention cases, pharmacists were more likely to discontinue aspirin than non‐pharmacists (76.7% vs. 54.6%, p &lt; 0.001). In the stable CAD cases, composite rates of aspirin discontinuation by pharmacists and non‐pharmacists were similar (41.7% vs. 40.1%, p = 0.140). More pharmacists than non‐pharmacists stated that their aspirin deprescribing decisions were independent of the type of OAC that was used (60.4% vs. 35.9%, p &lt; 0.001). Pharmacists were more likely to discontinue aspirin after discussing with patients compared with non‐pharmacists (62.7% vs. 47.8%, p = 0.017). 27.3% of clinicians reported having a protocol to deprescribe aspirin at their institution/clinic.ConclusionThere are variations in aspirin deprescribing practices among clinicians in patients on OAC for AF or VTE and without compelling indications for aspirin. Further studies and stronger recommendations are warranted to guide clinicians regarding optimal antithrombotic therapy in these scenarios. Lack of institutional protocols for aspirin deprescribing creates opportunities for future quality improvement initiatives.