Efficacy Of Oral Anticoagulants Research Articles

Temporal trends in initiation of oral anticoagulants and stroke-free survival among elderly and very elderly patients with new onset atrial fibrillation - a 20-year perspective.

Abstract Background Oral anticoagulants (OACs) significantly reduce the risk of ischemic stroke in patients with atrial fibrillation (AF). However, evidence regarding efficacy of OACs are lacking in the very elderly patients. Aim To examine temporal trends in initiation of OACs and five-year stroke-free survival in the very elderly patients with new onset AF over a time span of 20 years. Methods From the Danish nationwide registries, we identified patients ≥ 65 years of age with new onset AF from 1999 to 2018. The index date was defined as the day of AF diagnosis for outpatients and as the day of discharge for inpatients. Patients with a prescription of OAC, history of bleeding events, or history of stroke/transient ischemic attack prior to index were excluded. Patients were divided into two age groups based on their age at index: 1) 65-84 years (elderly); and 2) ≥ 85 years (very elderly). Patients were further divided into four calendar year groups from 1999-2018, based on the year of inclusion. We investigated the initiation of OACs and calculated the absolute five-year probability of stroke-free survival in both age groups. Results We included 167,122 patients with new-onset AF between January 1st, 1999, and December 31st, 2018. Among the patients, 23.1 % were aged 85 years or older, 48 % were male and 80.5 % had a CHA2DS2-VASc score equivalent to 2 or higher for men and 3 or higher for women. Initiation of OACs increased in both age groups after the guideline implementation of DOACs in 2010 (Figure 1). In the elderly age group, the proportion of patients receiving OACs increased from 50% in 2010 to almost 90% in 2018. In the very elderly age group, the proportion increased from 25% in 2010 to almost 90% in 2018. The probability of the five-year stroke-free survival improved by approximately 15% from 1999 to 2018 in the elderly age group, with no significant changes in the very elderly age group. Conclusion The proportion of elderly AF patients receiving OAC has increased markedly in the last 20 years. Even so, stroke-free survival remains the same among the very elderly patients.Five-year stroke-free survival

Efficacy of oral anticoagulants in chronic kidney disease and hemodialysis patients with atrial fibrillation: a systematic review and meta-analysis.

This meta-analysis seeks to evaluate the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKA) in individuals with chronic kidney disease (CKD), end-stage renal disease (ESRD), and undergoing hemodialysis (HD) who also have atrial fibrillation (AF). A comprehensive search of MEDLINE, clinicaltrials.gov, EMBASE, and Cochrane Database for relevant studies reporting the usefulness of OAC therapy for CKD, ESRD, and HD patients with AF was conducted from its inception until 1st May 2023. The studies that reported OR, RR, or HR for adult AF patients to investigate the efficacy of OAC in CKD, ESRD, and HD were included. Statistical analysis was completed using a generic inverse variance and random-effects model to calculate the combined HR and their corresponding 95% CIs for all outcomes. The meta-analysis included 33 studies with 178,956 patients. The analysis revealed that the DOACs, when compared to VKA, significantly lowered the risk of stroke or systemic embolism (HR: 0.81 [95% CI: 0.70, 0.93]; P=0.002; I2=62%), bleeding (HR: 0.77, [95% CI: 0.67, 0.89]; P=0.0003; I2=83%), and intracranial hemorrhage (HR: 0.56, [95% CI 0.47, 0.66]; P<0.00001; I2=0%). Similarly, the risks of cardiovascular death (HR: 0.88, [95% CI 0.78, 1.00]; P=0.05; I2=0%), all-cause mortality (HR: 0.88, [95% CI 0.70, 1.10]; P=0.25; I2=96%), and myocardial infarction (HR: 0.80, [95% CI 0.54, 1.17]; P= 0.25; I2= 0%) were lowered by DOAC, but the result was insignificant. No significant difference was seen in the risk of gastrointestinal bleeding between DOAC and VKA as well (HR: 0.95, [95% CI 0.75, 1.20]; P=0.65; I2=83%). Our meta-analysis confirms that DOACs are effective for managing AF in patients with kidney disease, with potential clinical implications for AF and CKD management. Further research should explore DOACs' reno-protective effects.

Cerebral Venous Thrombosis Among Bangladeshi Population: A Systematic Review.

Cerebral venous thrombosis (CVT) is a rare cause of stroke which remains unsung among Bangladeshi physicians and the general population. Our objective was to provide a comprehensive review of published data on Bangladeshi CVT patients. We searched all-electronic databases for Bangladeshi studies on CVT until November 2023, including literature in all languages. This study reviews the age of onset, gender distribution, radiological characteristics, and outcomes of Bangladeshi CVT patients.We included 13 studies (two observational and 11 case reports) that evaluated102 CVT patients and found that women suffered CVT significantly higher than men (59.8% vs 40.2%; P =0.04), respectively. The overall age of the study population was 36.6±6.8, and men were significantly older than women (45.4±12.3 vs. 32.4±8.3; P<0.001). The most commonly affected sites were the superior sagittal sinus and transverse sinus thrombosis. Rivaroxaban was primarily used for long-term anticoagulation after initial low molecular weight heparin therapy. Furthermore, most studies observed an excellent clinical outcome with completed recanalisation on early follow-up angiography in three studies. In Bangladesh, women 1.5 times more commonly suffer from CVT and 13 years earlier than men. Although this review found that prompt diagnosis and anticoagulation therapy provides good clinical outcome, we recommended further studies to evaluate the long-term outcome, especially the safety and efficacy of oral anticoagulants, with recanalisation and recurrence rate.

Relationships, Current Issues, Safety and Efficacy of Oral Anticoagulation in Cancer Patients with Atrial Fibrillation.

A relationship between malignancy and impaired hemostasis has been proven, and balancing clotting and bleeding risks can be challenging. Half of cancer patients with atrial fibrillation (AF) do not receive any oral anticoagulation (OAC). Using PubMed on the relationship between cancer and AF and their association with hemostasis, targeting studies comparing vitamin K antagonists (VKAs) and direct OAC (DOAC) strategies in AF cancer patients, three RCTs (>3000 patients) and eight observational studies (>250,000 patients) comparing different OACs were retrieved. The VKA prescribed was always warfarin. Dabigatran was the only DOAC not analyzed in the RCTs but the most used in non-randomized studies, whereas edoxaban-treated patients were the majority in the RCTs. Overall, the DOAC patients showed similar or lower rates of efficacy (thromboembolic) and safety (bleeding) outcomes compared to the VKA patients. DOACs are subject to fewer interactions with antineoplastic agents. DOACs may be preferable to VKAs as a thromboembolic prophylaxis in cancer patients with non-valvular AF.

Safety and efficacy of oral anticoagulants in extreme weights

BackgroundThe 2021 International Society on Thrombosis and Haemostasis' (ISTH) recommends standard doses of apixaban and rivaroxaban regardless of high body mass index (BMI) and weight, but had not compare DOACs head-to-head in obesity or address underweight patients. MethodsOur aim is to evaluate the safety and efficacy of DOACs in underweight and obese patients compared to warfarin. The primary endpoints include incidence of thromboembolic and bleeding events. Descriptive statistics was used for continuous variables. The Kruskal-Wallis test was used to compare the four-groups for continuous measures and the chi-square test or Fisher's exact test was used to analyze categorical data. The chi-square test or Fisher's exact test, was used for categorical variables, and the Mann-Whitney test (the non-parametric counterpart to the two-sample t-test) for continuous data. ResultsOf 2940 patients receiving anticoagulation for venous thromboembolism (VTE) treatment or atrial fibrillation (AF), 492 met eligibility criteria. Within each group, 248 patients received warfarin, 101 received apixaban, 100 received rivaroxaban and 43 received dabigatran. Patients were characterized in 4 body mass index (BMI) categories, in which 80 were underweight and 412 were obese. ConclusionsWhen each DOAC was compared to warfarin in rates of VTE, apixaban showed statistically significant lower rate of VTE (p = 0.0149). However, no statistical significance was identified in the rate of VTE between DOACs combined vs. warfarin (p = 0.1529). When each DOAC was compared to warfarin, apixaban showed the lowest rate of overall bleeding (p = 0.0194). However, no statistical difference in the rate of bleeding was observed between DOACs combined vs. warfarin (p = 0.3284). Patients with extreme body weights requiring anticoagulation for VTE and AF may safety benefit from DOAC therapy. This evaluation showed apixaban with the lowest rate of VTE and bleeding compared to warfarin, rivaroxaban, and dabigatran. These results provide experience for the clinician to use DOACs, particularly apixaban, in underweight and obese populations.

Safety and efficacy comparison between OACs plus single antiplatelet and dual antiplatelet therapy in patients with cerebral venous sinus stenosis poststenting

Background and purposeThe present strategies regarding poststent management for cerebral venous sinus stenosis (CVSS) are inconsistent. Herein, we compared the safety and efficacy of oral anticoagulants (OACs) plus single antiplatelet therapy and dual antiplatelet therapy for CVSS poststenting.MethodsA real-world observational study conducted from January 2009 through October 2019 enrolled patients who were diagnosed with CVSS and received stenting. Patients were divided into two groups according to the management they received poststenting. Group 1: OACs plus a single antiplatelet agent (clopidogrel 75 mg or aspirin 100 mg) and Group 2: dual antiplatelet therapy (clopidogrel 75 mg plus aspirin 100 mg). The safety (such as major or minor bleeding or venous thrombosis) and efficacy (the incidences of cerebral venous sinus restenosis, intrastent thrombosis, or stent displacement) of the two groups were compared.ResultsThere were a total of 110 eligible patients in the final analysis, including 79 females and 31 males with a mean age of 43.42 ± 13.23 years. No major bleeding or venous thrombosis occurred in either of the two groups. Two minor bleeding events occurred in group 2 (one with subcutaneous bleeding points in both lower limbs, another with submucosal bleeding in the mouth), whereas no bleeding events occurred in Group 1. In addition, at the 1-year follow-up, one case of intraluminal restenosis and two cases of in-stent thrombi occurred in Group 2, while none occurred in Group 1. Neither stenosis at stent-adjacent segments nor stent migration was detected in either group during the 1-year following stent placement.ConclusionOACs plus single antiplatelet therapy and dual antiplatelet therapy alone are both safe and efficacious management strategies after CVSS stent placement. The former may have more advantages than the latter for inhibiting intrastent thrombosis. However, further research by larger, multicenter clinical trials is needed.

Atrial fibrillation: focus on monitoring strategies after cryptogenic stroke.

Atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes, with stroke potentially being the first manifestation of a previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic events, searching for unknown AF after stroke requires a comprehensive diagnostic workup. Prospective data have demonstrated the benefits of long-term cardiac monitoring to identify AF in association with cryptogenic stroke, as most strokes are presumed to result from AF. However, strategies of empirical anticoagulation using oral anticoagulants following cryptogenic stroke failed to improve outcomes. We herein summarize contemporary evidence and knowledge gaps on searching for AF after a stroke and the potential secondary prevention strategies to prevent further recurrences.

Efficacy and Safety of Oral Anticoagulants in the Treatment of COVID-19

Coagulopathy and associated thrombotic complications are common conditions seen in COVID-19. Therefore, anticoagulants are an integral part of the treatment of patients with COVID-19.The aim of the study was to compare the efficacy of oral anticoagulants and low molecular weight heparins in the prevention of pulmonary embolism and their safety in terms of major bleeding incidence, as well as to evaluate the cost-effectiveness of using oral anticoagulants in the treatment of COVID-19.Materials and methods. Two stages of patient management were compared: before and after the start of a widespread use of oral anticoagulants (OAC). The incidence of pulmonary embolism and gastrointestinal bleeding during the compared time periods was analyzed to assess the efficacy and safety of anticoagulants. To assess the cost-effectiveness, we compared the cost of anticoagulants per day of treatment and per patient.Results. The incidence of pulmonary embolism and gastrointestinal bleeding did not differ during the compared time periods. Despite the increased frequency of anticoagulant use, the costs per day of treatment and per patient decreased after the start of a widespread use of OACs.Conclusion. According to the results of the study, inclusion of OACs in COVID-19 management protocols allows to reduce treatment costs without compromising its efficacy and safety. However, the short period of comparison does not allow drawing any firm conclusions. Additional large-scale comparative studies are needed.

Can clinical pharmacists utilize telehealth to double the safety and efficacy of oral anticoagulation while reducing health care costs and improving patient satisfaction in patients with atrial fibrillation?

AbstractBackgroundPublished reports from the United States and New Zealand have described excellent control of the international normalized ratio (INR) and improved patient satisfaction in warfarin‐treated patients whose therapy was managed by clinically trained pharmacists using point of care (POC, or “fingerstick”) blood testing and online technology. This report examines the projected impact of such management on clinical outcomes and health care costs by using previously published information which quantified the relationships between anticoagulation control and rates of thromboembolism, major hemorrhage, and death.MethodsAnticoagulation control was defined as the percent of time that the INR was within the target range (TTR). Published regression equations and adjusted relative risks were used to calculate the rate of thromboembolism, major bleeding, and death associated with various TTR values. The rates of ischemic stroke, myocardial infarction, intracranial hemorrhage, gastrointestinal bleed, and death, and the cost for each type of event, were used to determine a key composite end point rate and associated costs at various TTR values and as reported in the four direct‐acting oral anticoagulant (DOAC) studies.ResultsBoth the US and New Zealand online systems achieved comparable TTR values of approximately 75% (or better). Cost avoidance per 1000 patients per year based on projected key composite end point rates at a TTR of 75% ranged from $10.4 million compared with a TTR of 30% to $2.2 million compared with a TTR of 65%,. Cost avoidance compared with the rates reported in the DOAC trials ranged from $1.4 to $4.5 million. Patient satisfaction scores exceeded 90% with both systems as reported previously.ConclusionClinically‐trained pharmacists using POC INR testing and online management may reduce major clinical events by more than 50%, substantially reduce health care costs, and improve patient satisfaction. Data from Europe confirm that these low projected event rates are achievable.

Comparison of the Use and Efficacy of Oral Anticoagulation in Patients Undergoing Transesophageal Echocardiography and Possible Electrical Cardioversion for Atrial Fibrillation: An Initial Report

Comparison of the Use and Efficacy of Oral Anticoagulation in Patients Undergoing Transesophageal Echocardiography and Possible Electrical Cardioversion for Atrial Fibrillation: An Initial Report

Thromboembolic and Hemorrhagic Outcomes in the Direct Oral Anticoagulant Trials Across the Spectrum of Kidney Function.

Chronic kidney disease is a common comorbidity among patients taking direct-acting oral anticoagulants (DOACs). Herein, we evaluate the influence of kidney function on stroke or systemic embolism (SEE), hemorrhage, and composite end points (stroke/SEE/hemorrhage/death and stroke/SEE/death) among patients on DOACs and warfarin. Baseline kidney function was categorized as glomerular filtration rate (GFR)≥60 (reference), 45-59, and <45mL/min/1.73m2 for participants in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) (n=18,049), Apixaban for Reduction in Stroke and Other Thromboembolic Events (ARISTOTLE) (n=18,187), and The Effective Anticoagulation with Factor Xa Next Generation in AF (ENGAGE AF) (n=20,798) trials. Incidence of events was compared across GFR categories. Hazard ratios for events were estimated using Cox regression using intention-to-treat analysis adjusting for known predictors. A large proportion of participants had GFR<60 (25-29% had 45 ≤ GFR < 60 and 9.5-12.6% with GFR<45). Compared with patients with GFR≥60, warfarin users across the trials with GFR≥45-59 and GFR<45 had a higher incidence of hemorrhage (P values<0.0001) and warfarin users in the ARISTOTLE and ENGAGE trials had higher incidence of stroke/SEE (P values≤0.05). Compared with patients with GFR≥60, dabigatran users with GFR≥45-59 and GFR<45 had a higher incidence of stroke/SEE (P≤0.02), hemorrhage (P<0.001), and both composite end points (P<0.0001). Compared with patients with GFR≥60, apixaban and edoxaban users with GFR≥45-59 and GFR<45 had a higher incidence of hemorrhage (P values≤0.05) and composite end points (P values≤0.05). After adjustment, compared with patients with GFR≥60, warfarin users with GFR<60 in the ARISTOTLE and RE-LY trials had a higher risk of hemorrhage (P<0.05), as did dabigatran (P<0.001) and edoxaban (P≤0.005) users, while apixaban users did not exhibit an increased risk (P=0.08 GFR≥45-59; P=0.71 GFR<45). Kidney function significantly influences the safety and efficacy of oral anticoagulants.

Atrial Fibrillation and Diabetes Mellitus: the Control of Thromboembolic Risk

Atrial fibrillation is one of the most common concomitant diseases in patients with diabetes mellitus (DM). Meta-analyses of multiple studies have shown that the risk of AF is higher for diabetic patients with impaired glucose homeostasis than for patients without DM. Patients with AF and DM were younger, more frequently had arterial hypertension, chronic kidney disease, heart failure, and ischemic heart disease, and stroke and were characterized with a more severe course of AF. The article discusses possible mechanisms of the mutually aggravating effects of DM and AF, scales for evaluating the risk of bleeding (CHADS2, CHA2DS2‑VASc, HAS-BLED), and the role of anticoagulants. A meta-analysis of 16 randomized clinical studies, including 9 874 patients, has demonstrated the efficacy of oral anticoagulants in prevention of stroke with an overall decrease in the relative risk by 62 % compared to placebo (95% confidence interval, from 48 to 72 ). For prevention of complications in patients with AF and DM, current antithrombotic therapies can be used, specifically the oral factor Xa inhibitor, rivaroxaban, which is the best studied in patients with AF and DM and represents a possible alternative to warfarin in such patients.

Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration.

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Differences in safety and efficacy of oral anticoagulants in patients with non-valvular atrial fibrillation: A Bayesian analysis.

Novel oral anticoagulants are the cornerstone of therapy for non-valvular atrial fibrillation patients to lower the risk of ischaemic stroke. Given the lack of head-to-head comparisons among oral anticoagulants, a Bayesian analysis was used to evaluate their safety and efficacy based on studies from real-world practice. The PubMed, Embase, Cochrane and Web of Science databases were searched for relevant studies. Bayesian analyses were conducted to estimate hazard ratios (HR) and 95% credible intervals (CrI) for the safety and efficacy of oral anticoagulants. In the 22 studies included in our analysis, novel oral anticoagulants exhibited a clear advantage over warfarin in preventing ischaemic stroke, haemorrhagic stroke and, especially, intracranial haemorrhage. Incidence of major bleeding was lowest for apixaban, followed by dabigatran, warfarin and rivaroxaban. Gastrointestinal bleeding risk was lowest for apixaban, followed by warfarin, and was slightly lower for dabigatran than for rivaroxaban with no statistical difference (HR 1.05, 95% CrI 0.99-1.11). Ischaemic stroke risk was lowest for rivaroxaban, followed by apixaban, dabigatran and warfarin (HR 1.13, 95% CrI 1.07-1.20). In real-world practice, apixaban may represent the optimal treatment in terms of safety and efficacy for patients with non-valvular atrial fibrillation. For patients with high risk of ischaemic events but low bleeding risk, rivaroxaban may be preferable.

Meta-analysis of safety and efficacy of oral anticoagulants in patients requiring catheter ablation for atrial fibrillation.

The ideal oral anticoagulant agent during catheter ablation (CA) for atrial fibrillation (AF) remained unclear. Novel oral anticoagulants (NOACs) are safer and effective compared to uninterrupted vitamin K antagonists (U-VKA) among patients requiring CA for AF. Four randomized controlled trials (RCTs) and 9 observational studies (OS) were selected using PubMed/Medline, EMBASE and the CENTRAL data bases (Inception-December-2017). Estimates were reported as random effects risk ratio (RR) with 95% confidence interval (CI). The primary safety outcome was major bleeding and main efficacy endpoint was thromboembolism. In RCTs restricted analysis, NOACs significantly reduced the relative risk of major bleeding by 72% compared to U-VKA (RR, 0.28, 95% CI, 0.14-0.58, P < 0.001). This significant effect was not achieved in OS based analysis (RR, 0.86, 95% CI, 0.42-1.78, P = 0.68). In terms of thromboembolism, both anticoagulation strategies were equally effective in analysis of RCTs (RR, 0.28, 95% CI, 0.05-1.70, P = 0.17) or OS (RR, 1.43, 95% CI, 0.46-4.39, P = 0.54). In sensitivity analysis, there was no difference among uninterrupted NOACs (U-NOACs) and U-VKA in terms of major bleeding [(RCTs: RR, 0.33, 95% CI, 0.10-1.06, P = 0.06); (OS: RR, 0.70, 95% CI, 0.28-1.78, P = 0.46)] or thromboembolism [(RCTs: RR, 0.25, 95% CI, 0.03-2.29, P = 0.22); (OS: RR, 0.68, 95% CI, 0.08-5.53, P = 0.72)]. NOACs, either interrupted or un-interrupted, are safer and equally effective drugs compared to U-VKA in AF patients requiring CA.

Left atrial appendage occlusion: rationale, evidence, devices, and patient selection.

Atrial fibrillation (AF) is a worldwide epidemic associated with significant morbidity and mortality, often due to disabling or fatal thromboembolic stroke. Oral anticoagulation is highly effective at preventing ischaemic stroke and improving all-cause survival in patients with non-valvular AF. Despite the efficacy of oral anticoagulation, many patients are not treated due to either absolute or perceived contraindications to therapy, including bleeding. Left atrial appendage (LAA) closure has emerged as a mechanical alternative to pharmacologic stroke prevention. Initial and mid-term clinical trial data suggest that LAA closure is safe, with less intracranial bleeding, and a net clinical benefit that appears to be non-inferior to oral anticoagulation. However, concern remains over the possible increased risk of ischaemic stroke in long-term follow-up. Careful patient selection for LAA closure is paramount. Patients with prior intracranial bleeding or recurrent serious bleeding who are not eligible for long-term oral anticoagulation are typical candidates for LAA closure; however, other populations may benefit as well, such as patients with end-stage renal disease. Clinical investigation and randomized trials are needed to clarify the best methods of LAA occlusion, optimal pharmacologic strategies in the short-term after LAA closure, and to identify patient populations who will derive the most benefit from LAA occlusion. In this article, we review the rationale for LAA closure, the currently available devices and their evidence base, patient selection, challenges in management, and future directions for LAA closure science.

Use of Direct-Acting Oral Anticoagulants in Nonagenarians: A Call for More Data.

The prevalence and embolic risk of atrial fibrillation (AF) increase with age. Vitamin K antagonists (VKAs) or direct-acting oral anticoagulants (DOACs) reduce the risk of stroke or embolism. The aim of this review was to summarize the paucity of information regarding the safety and efficacy of DOACs in AF patients aged 90years or older. The maximum age of included patients is not listed in any of the available DOAC investigating trials and registries, thus it is unclear if nonagenarians were included. Additionally, we could not find any subgroup analysis addressing this issue. There is an urgent need to collect more information on the safety and efficacy of oral anticoagulants in nonagenarians, especially regarding the role of DOACs, which are increasingly prescribed to this group of patients despite the lack of data. The best solution to this problem would be a prospective, randomized trial in this group of patients, however that would require a large investment of time, effort, and funds. In the meantime, we suggest subgroup analyses addressing the effects and safety of VKAs versus DOACs in nonagenarians, in case they have been included in previously completed or ongoing trials or registries. This could be feasible and would be desirable in view of the large amount of data already accumulated. Irrespective of age, anemia in patients receiving DOACs should be carefully investigated to rule out occult blood loss. With their known interaction profile and the possibility of monitoring these drugs, VKAs should be favored over DOACs in nonagenarians until more data are available regarding the safety of DOACs.

EFFICACY OF ANTICOAGULATION IN PREVENTING THROMBOEMBOLISM AFTER BIO PROSTHETIC AORTIC VALVE REPLACEMENT: A META-ANALYSIS

The efficacy of oral anticoagulation (AC) after bio prosthetic aortic valve replacement (BPAVR) remains unclear. Current guidelines recommend AC for first three months after BPAVR, but there is significant variation in clinical practice. We performed a meta-analysis of studies comparing AC to

Abstract 14126: Safety and Efficacy of Anti-thrombotic Therapy After PCI in Octogenarians With Atrial Fibrillation: A Multi-center Study

The purpose of the present study was to clarify the safety and efficacy of oral anticoagulation (OAC) in addition to dual antiplatelet therapy (DAPT) in octogenarians with atrial fibrillation (AF) undergoing PCI. Method and Result: We examined consecutive 360 AF patients registered at 8 medical centers who took DAPT or OAC + DAPT at the time of PCI. Octogenarians (n=77) were compared with those of younger patients (n=283). In octogenarians, acute coronary syndrome (octogenarians vs. younger patients = 54.6% vs. 37.4%) was more common and diabetes (32.5% vs. 45.6%) and usage of drug-eluting stent (58.4% vs. 73.1%) were less common (P&lt;0.01, respectively). There was a significant difference in CHADS2 score (2.9±1.0 vs. 2.2±1.3, P&lt;0.01) and no statistical difference HAS-BLED score (2.4±0.7 vs. 2.2±0.8). At 1-year, major adverse cerebro-cardiovascular events (MACCE) was significantly higher in octogenarians than in younger patients (16.9% vs. 3.9% P&lt;0.01) and bleeding complications (defined as TIMI minor plus major) were similar (7.8% vs. 5.6% P=0.48). In octogenarians, there was a trend in lower cumulative incidence of MACCE in OAC+DAPT patients (n=44) compared to DAPT patients (n=33; 13.6% vs. 21.2% p=0.06), however, there was an excess risk of bleeding complications (13.6% vs. 0%, p=0.008). Conclusion: Octogenarians with AF undergoing PCI showed poor prognosis and were at high risk of bleeding, especially in patients who took OAC + DAPT. “Tailor-made” treatment strategies should be considered in this high-risk subset.

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.