Higher HAS-BLED Scores Research Articles

Inappropriate direct oral anticoagulant dosing in atrial fibrillation patients is associated with prescriptions for outpatients rather than inpatients: a single-center retrospective cohort study

BackgroundInappropriate dosing of direct oral anticoagulants (DOACs) has been associated with clinical safety and efficacy; however, little is known about clinical data associated with an inappropriate DOAC dosing in Japan. In addition, there is no report in which the appropriateness of DOAC dosing between prescription for inpatients and for outpatients was examined. In this study, we aimed to investigate the prevalence and factors associated in the inappropriate dosing of DOACs in patients with atrial fibrillation (AF).MethodsThe retrospective cohort study was conducted at a single Japanese university hospital. Both inpatients and outpatients, who were diagnosed with AF and for whom treatment with either dabigatran, rivaroxaban, apixaban, or edoxaban was initiated between April 1, 2014 and March 31, 2018, were enrolled in the study. Appropriateness of DOAC dosing was assessed according to the manufacturer’s labeling recommendations (dose reduction criteria) of each DOAC. Inappropriate reduced dose, namely, underdosing, was defined as prescription of a reduced dose of DOAC despite the patient not meeting the dose reduction criteria. Inappropriate standard dose, namely, overdosing, was defined as prescription of a standard dose of DOAC despite the patient meeting the dose reduction criteria. Inappropriate DOAC dosing was defined as a deviation of the recommended dose (both underdosing and overdosing).ResultsA total of 316 patients (dabigatran, 28; rivaroxaban, 107; apixaban, 116; and edoxaban, 65) were included, with a median (interquartile range) age of 75 (66–81) years and 62.3% male. DOACs were prescribed at an appropriate standard dose in 39.2% of patients, an appropriate reduced dose in 36.7%, an inappropriate standard dose in 2.5%, and an inappropriate reduced dose in 19.3%. Multivariate analysis revealed that the inappropriate dosing of DOACs was significantly associated with prescriptions for outpatients (vs. inpatients; odds ratio [OR] 2.87, 95% confidence interval [CI] 1.53–5.62, p < 0.001) and those with higher HAS-BLED scores (OR 1.87, 95% CI 1.42–2.51, p < 0.001).ConclusionsOur results demonstrated that the inappropriate dosing of DOACs occurred in approximately 20% of AF patients, and was more frequent in outpatients (vs. inpatients) and in those with a higher risk of bleeding. It is recommended that pharmacists play a greater role in assisting in the prescription process to help physicians make better decisions.

Abstract WP421: Optimization of Risk Stratification for Anticoagulation-Associated Intracerebral Hemorrhage

Introduction: With more widespread anticoagulant use, anticoagulation-associated intracerebral hemorrhage (ICH) represents an increasing proportion of all ICH. We hypothesized that c ombining ischemic and hemorrhagic stroke risk estimation can guide treatment decisions, with more precision than ischemic risk estimation alone. Methods: We enrolled consecutive patients with anticoagulation-associated ICH in 15 centers in USA, Europe and Asia from 2015-2017. Each patient was assigned annual baseline ischemic stroke and hemorrhage risk based on their CHA 2 DS 2 -VASc and HAS-BLED scores without and with index ICH taken into account. We computed a net risk by subtracting the hemorrhagic from the ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative an “Unfavorable”. We compared clinical and neuroimaging characteristics between the two groups. Results: Our cohort comprised 357 patients (59% male, median age 76 [68-82] years). 69% used vitamin-K antagonists (VKA), 31 % Non vitamin K antagonist (NOAC). 191 (53.5%) of patients had a favorable indication for anticoagulation prior to their ICH event; the rest 166 (46.5%) had an unfavorable indication. Those with an unfavorable indication were younger (72[66-80] vs 78[73-84] years, p=0.001, had a lower CHA 2 DS 2 -VASc score (3[3-4] vs 5[4-6], p&lt;0.001) and higher HAS-BLED score (3[2-4] vs 2[2-3], p=0.025). Those with favorable indication had a significantly higher prevalence of all major cardiovascular risk factors and were more likely to use NOAC (35% vs 25%, p=0.045). After including ICH into the HAS-BLED score estimation, 77 of the 191 patients with favorable profile were rendered unfavorable; leaving 114 patients (32% of the cohort) with favorable profile. Conclusions: In this anticoagulation-associated ICH cohort, baseline hemorrhage risk exceeded ischemic risk in ~50% of patients. This finding highlights the need for careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining ~ 50% suffered an ICH although their baseline risk of ischemia exceeded that of hemorrhage which stresses the need for imaging, serum or other biomarkers to allow more precise estimation of hemorrhagic complication risk.

Switching from vitamin K antagonist to dabigatran in atrial fibrillation: differences according to dose

In atrial fibrillation (AF) patients 150 mg b.i.d. dabigatran is the standard dose, yet guidelines recommend 110 mg b.i.d. when bleeding risk is high. It is unknown to which extend these recommendations are followed in patients switching from vitamin K antagonist (VKA) to dabigatran. The aim of this study was to investigate if AF patients are switched from VKA to the appropriate dose of dabigatran. Using nationwide registries (22 August 2011 to 31 December 2012), we identified VKA-experienced AF patients with available creatinine values who switched to dabigatran. European guidelines criteria 2012 on dabigatran dosing were examined: age ≥80 years, HAS-BLED ≥3, estimated glomerular filtration rate (eGFR)<50 mL/min/1.73 m2, or use of interacting drugs. We identified 1626 VKA-experienced AF patients who switched to dabigatran 110 mg (820 patients) or 150 mg (806 patients). Patients who switched to 110 mg compared with 150 mg were older [median age 82 years (Q1-Q3: 77-86) vs. 68 years (Q1-Q3: 64-74)], more often females (54% vs. 35%), had a higher comorbidity burden, higher proportion with CHA2DS2-VASc score ≥2 (98% vs. 80%), and more with a HAS-BLED score ≥3 (46% vs. 28%). Patients switched to 110 mg had a higher absolute risk of mortality compared with patients switched to 150 mg. Overall, 26% were inappropriately dosed and 14% were switched to 110 mg although the higher dose was indicated. Furthermore, 39% of patients switched to 150 mg fulfilled one or more criteria for 110 mg, this mostly driven by high HAS-BLED scores (28.2% of patients on 150 mg). Female sex, age ≥80 years, eGFR < 50 mL/min/1.73 m2, drugs interacting with dabigatran, and prior bleeding were associated with switch to 110 mg. Patients inappropriately dosed had similar risk of mortality as patients appropriately dosed. Among VKA-experienced AF patients one in four were switched to a dabigatran dose contrary to guideline recommendations.

Safety of uninterrupted direct oral anticoagulants for ambulatory common atrial flutter catheter ablation: A propensity score–matched cohort study

Same-day home discharge after common atrial flutter catheter ablation (CAFCA) is a feasible, safe, and cost-effective practice, but there are currently no data for patients treated with direct oral anticoagulants (DOAs). We evaluated the safety, efficacy, and feasibility of ambulatory CAFCA in patients treated with DOAs compared with those treated with vitamin K antagonists (VKAs). Patients scheduled for isolated and elective ambulatory CAFCA in our tertiary university center between 2009 and 2019 were included. Propensity score for anticoagulant type was calculated from age, sex, body mass index, HAS-BLED and CHA2DS2-VASc scores, chronic kidney disease, associated antiplatelet treatment, procedure duration, and number of femoral venipunctures. Propensity score matching yielded 820 patients (mean age 67 ± 11 years). Catheter ablation was performed under uninterrupted VKA (n = 410; international normalized ratio 2.5 ± 0.6) or uninterrupted DOA (n = 410). The procedural success rate was 91%, and the effective same-day discharge rate was 93%. The occurrence of the primary end point, defined as any early and clinically significant bleeding (Bleeding Academic Research Consortium classification ≥ 2) at 1 week, was similar between patients treated with DOAs and those treated with VKAs (2.9% vs 3.7%; P = .70). Female sex, high HAS-BLED score, and prolonged procedure duration were independently associated with the primary end point. Uninterrupted DOA regimens are safe for patients undergoing ambulatory CAFCA in a high-volume center with a dedicated ambulatory unit and standardized procedural and postoperative management.

P1897Prescription of guideline recommended oral anticoagulation and reasons reported for non-use of OAC in patients with atrial fibrillation: Data from the German AFNET-2 Registry

Abstract Background Oral anticoagulation (OAC) reduces thromboembolic events and mortality in patients with atrial fibrillation (AF). Anticoagulation rates have substantially increased over recent years. Still, a number of patients are not receiving guideline recommended OAC. Purpose To investigate clinical factors and reasoning associated with non-prescription of OAC in a current German registry. Methods The German AFNET 2 registry is a prospective multi-center registry on atrial fibrillation comprising a total of 3491 patients from all levels of medical care (general practitioners, cardiologists, hospitals; enrolment 5/2014 to 3/2016). The registry was conducted in collaboration with the EORP program of the ESC. Here, only patients with non-valvular AF and at least two clinical risk factors for stroke (using CHA2DS2-VASc score) were considered. Results The study population consisted of 2856 patients, 58.4% male, mean age 75.5±7.8 years, mean CHA2DS2-VASc score 4.1±1.5, mean HAS-BLED score 1.8±1.0. Overall, the rate of OAC was 94.3%. 54% of these received Vitamin K antagonists (VKA) and 46% NOAC. 2.3% received antiplatelets only. Patients newly initiated on OAC mostly received a NOAC (82.5% of patients). Anticoagulation rate was lower in elderly patients (age &lt;80 years: 95.0%, age ≥80 years 92.8%, p&lt;0.05). No difference in OAC was seen between men and women (94.1% and 94.6%, respectively). Patients with high bleeding risk (HAS-BLED ≥3) received significantly less OAC than patients at low bleeding risk (95.3 vs 90.6%, p&lt;0.001). Patients on antiplatelet therapy received OAC in only 78.0% compared to patients without antiplatelet therapy in 96.6% (p&lt;0.001). In patients without OAC (n=162 patients), reasons stated for non-prescription of OAC were patient's unwillingness to take OAC (13.6%), physician preference (12.3%), prior bleeding event (10.5%), renal dysfunction (8.6%), frequent falls (5.6%), current anaemia (5.6%), current operation/intervention (4.9%), current bridging with LMW heparin (4.9%), and other reasons (9.3%). Using logistic regression analysis, non-prescription of OAC was strongly associated with antiplatelet therapy (HR=0.082), anaemia (HR=0.41), dementia (HR=0.37), and previous extra- (HR=0.2) or intracranial haemorrhage (HR=0.35). Predictors of OAC use were prior stroke/embolism (HR=2.35), hypertension (HR=2.23), heart failure (HR=1.51), and previous stent implantation (HR=2.12). When considered as a score, a HAS-BLED score ≥3 was strongly associated with non-prescription of OAC (HR=0.51). Conclusions Within registries, the guideline recommended use of OAC is very high in Germany indicating high guideline adherence by prescribing physicians. However, use of antiplatelet therapy was associated with non-prescription of OAC. In addition, a high HAS-BLED score appears to be a relevant argument for withholding proven OAC for stroke prevention in patients with AF. Acknowledgement/Funding BMS Germany; DZHK

P6559Long-term follow-up and outcomes of patients with discontinuation of oral anticoagulant therapy after successful ablation procedures for atrial fibrillation

Abstract Background Oral anticoagulant therapy (OAT) is effective for preventing strokes in atrial fibrillation (AF) patients. Currently, there is controversy regarding the discontinuation of OATs in patients with ablation procedures to eliminate AF. Aim We investigated the incidence of major bleeding and ischemic strokes/systemic embolisms in low-risk patients that discontinued OATs after successful AF ablation procedures. Methods Of 330 consecutive patients that underwent AF ablation procedures and were prescribed one of the direct oral anticoagulants or warfarin, 207 AF patients (158 men, mean age 61±11 years) who discontinued OATs three months after the procedure were enrolled. The average CHADS2 and HAS-BLED scores were 1.0±0.9 and 1.2±1.0, respectively, which meant that most patients had a low risk for strokes. Results During follow-up, 31 patients (15%) had recurrences of AF. Those patients underwent a re-ablation procedure and then re-discontinued their OATs three months after the session. During a 60±13 months follow-up, major bleeding was observed in five patients (2.4%) and was associated with a higher HAS-BLED score (2.2±0.4 vs. 1.1±1.0, P=0.027). In contrast, none of the patients experienced ischemic strokes/systemic embolisms. Conclusions This prospective study demonstrated that in patients with successful ablation procedures and low risk scores for AF management, OATs could be discontinued three months after the procedure. Unnecessary continuation of OATs may increase the incidence of major bleeding during the follow-up.

Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA

ObjectiveWe report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients...

Determinants of Antithrombotic Treatment for Atrial Fibrillation in Octogenarians: Results of the OCTOFA Study.

Atrial fibrillation, the most frequent form of arrhythmia, affects 5-15% individuals aged > 80 years. Stroke is a major risk for atrial fibrillation patients. The benefits of anticoagulant therapy clearly outweigh the risk of hemorrhage, even in the elderly. Despite the efficacy of warfarin, many eligible patients receive no prophylactic antithrombotic therapy. New generation oral anticoagulants compare favorably with vitamin K antagonists in the prevention of thromboembolic events and hemorrhage. These new agents are likely to influence the prescribing habits of anticoagulants in atrial fibrillation. The aim of this study to investigate both the frequency and the determining factors of anticoagulant prescriptions in AF patients aged≥80years and followed upby private-practice cardiologists in France. The OCTOFA (Atrial Fibrillation in Octogenarians) Study assessed the anticoagulant prescribing habits of cardiologists in France. The volunteer cardiologistsrecruited all consecutive patients fulilling the inclusion criteria. Between June 2013 and September 2016, 89 cardiologists recruited 738 eligible patients: age ≥80 years, non-valvular atrial fibrillation, no other compelling indication for anticoagulation therapy, no recent acute coronary syndrome or stroke. Most (90.7%) patients were on oral anticoagulant therapy: vitamin K antagonist or non-vitamin K antagonist oral anticoagulants, low molecular weight heparin (1.4%), aspirin (5.7%), and no antithrombotic treatment (2.2%). Patients on vitamin K antagonists were older (p<0.001), had lower renal function (p=0.033), and had a more frequent history of myocardial infarction (p<0.001), heart failure (p=0.001), peripheral artery disease (p=0.033), major hemorrhage (p=0.025), and falls (p=0.045). Four determining factors of anticoagulant prescriptions were statistically significant: high CHA2DS2-VASc score (p<0.001), high HAS-BLED score (p<0.001), age >90 years (p=0.001), and moderate/severe cognitive impairment (p=0.002). Most private-practice cardiologists prescribe anticoagulant treatment according to current guidelines in elderly atrial fibrillation patients. Non-vitamin K antagonist oral anticoagulants represent a significant proportion of prescriptions.

Dose reduction of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: A Danish nationwide cohort study

IntroductionTo investigate the patterns of dose reduction of non-vitamin K antagonist oral anticoagulants (NOAC) in patients with atrial fibrillation (AF). Materials and methodsUsing Danish nationwide registries, we identified all non-valvular AF patients initiated on standard-dose NOAC during 2011–2017 who were followed until dose reduction. The absolute risk of dose reduction was presented as cumulative incidence both overall and according to baseline characteristics. Moreover, to assess baseline comorbidities related to dose reduction, adjusted Cox regression models were used. In subgroup analysis, we investigated dose reduction following acute myocardial infarction and/or percutaneous coronary intervention (MI/PCI), chronic kidney disease (CKD), turned 80 years, intracranial hemorrhage, peripheral bleeding, ischemic stroke, cancer, bone fracture, and antiplatelet treatment start. ResultsOf 24,489 patients included, 12.2% experienced dose reduction during the study period. Dabigatran treatment, higher age at inclusion, high CHA2DS2-VASc score, and high HAS-BLED score were related to higher risk of dose reduction. Baseline ischemic heart disease (IHD), heart failure, cancer, CKD, chronic obstructive pulmonale disease (COPD), and hypertension were independent predictors of dose reduction.In subgroup analysis with six-month follow-up, MI/PCI, CKD, intracranial hemorrhage, peripheral bleeding, and antiplatelet treatment therapy were strongly associated with dose reduction. ConclusionsDose reduction of NOACs was observed in 12.2% of AF patients during 2011–2017 and was associated with dabigatran treatment, advanced age at baseline, high CHA2DS2-VASc score, and high HAS-BLED score. Among comorbidities, IHD, heart failure, cancer, CKD, COPD, and hypertension predicted dose reduction independently. During six-month follow-up, MI/PCI showed the strongest association with dose reduction.

Abstract MP18: Trajectories of Oral Anticoagulation Adherence After First Atrial Fibrillation Diagnosis

Introduction: Regardless of the benefits of stroke prevention, only 50% of atrial fibrillation (AF) patients recommended for oral anticoagulation (OAC) actually use these medications. We identified groups of patients with similar OAC adherence patterns, and evaluated what patient characteristics affect group membership. Hypothesis: We hypothesized that patients continuously adherent to OAC would be more likely to reside in the Midwest and Northeast and have higher socioeconomic score (SES) than patients who never used OAC. Methods: Using Medicare claims data, we identified continuously enrolled beneficiaries with a first diagnosis of AF in 2014-2015 (n=36,185). We calculated the proportion of days covered with OAC in the first 12 months after first diagnosis. Using group-based trajectory models, we identified trajectories of OAC adherence. We constructed multinomial logistic regression to evaluated how a comprehensive list of demographics, system-level factors and clinical characteristics (list in figure) affected group membership. Results: We identified 4 trajectories of OAC adherence: patients who never used OAC (group 1, 43.6%), late OAC initiators (group 2, 7.6%), early OAC initiators who discontinued OAC (group 3, 8.9%), and continuously adherent patients (group 4, 39.9%). Black race, eligibility for low income subsidy, residence in segregated metropolitan areas (measured by index of dissimilarity), residence in the Southeast, Southwest or West, higher HAS-BLED score, and chronic kidney disease decreased the odds of belongings to the continuously adherent group. Conclusions: Trajectories of OAC adherence were highly variable, and were determined not only by demographics and clinical characteristics, but also system-level factors including income level, segregation measures, and region of residence. These trajectories may be useful in the implementation of targeted strategies to mitigate OAC underuse in stroke prevention.

Relationship of stroke and bleeding risk profiles to efficacy and safety of dabigatran dual therapy versus warfarin triple therapy in atrial fibrillation after percutaneous coronary intervention: An ancillary analysis from the RE-DUAL PCI trial

In the RE-DUAL PCI trial of patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI), dabigatran dual therapy (110 or 150 mg bid, plus clopidogrel or ticagrelor) reduced International Society on Thrombosis and Haemostasis bleeding events compared with warfarin triple therapy, with noninferiority in overall thromboembolic events. This analysis assessed outcomes in relation to patient bleeding and stroke risk profiles, based on the modified HAS-BLED and CHA2DS2-VASc scores. The primary endpoint, major bleeding event (MBE) or clinically relevant nonmajor bleeding event (CRNMBE), was compared across study arms in patients categorized by modified HAS-BLED score 0-2 or ≥3. The composite endpoint of death, thromboembolic event, and unplanned revascularization rates was compared in patients categorized by CHA2DS2-VASc score 0-1, 2, or ≥3. Risk of MBE or CRNMBE was lower with dabigatran dual therapy (both doses) versus warfarin triple therapy, irrespective of modified HAS-BLED category (treatment-by-subgroup interaction P-value 0.584 and 0.273 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin). Risk of the composite thromboembolic endpoint was similar across CHA2DS2-VASc categories and consistent with overall study results (interaction P-value 0.739 and 0.075 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin). Higher HAS-BLED scores were associated with higher risks of bleeding in AF patients after PCI in a treatment-independent analysis. Dabigatran dual therapy reduced bleeding events irrespective of bleeding risk category and demonstrated similar efficacy regardless of stroke risk category when compared with warfarin triple therapy.

The HAS-BLED Score is Associated With Major Bleeding in Patients After Cardiac Surgery

The Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol (HAS-BLED) score has been developed to predict the risk of potential bleeding in anticoagulated patients affected by atrial fibrillation. The aim of this study was to test the hypothesis that the HAS-BLED score is associated with major bleeding also in patients after cardiac surgery. Prospective, single-center nonrandomized study. Single hospital center. Patients. Standard cardiac operation and analysis of major bleeding events. A total of 1,173 consecutive adult patients who underwent cardiac surgery were recruited. Major bleeding was defined according to the Bleeding Academy Research Consortium classification (3, 4, 5). Bleeding events were classified as early bleeding (within 48 hours after the operation) and late bleeding (after 48 hours and within 90 days, postoperatively). Patients were followed after the discharge for 120 days, through outpatient clinic visits and by phone calls. A total of 29 (2.5%) patients experienced early bleeding events (2.5%), while 34 (2.9%) experienced late bleeding events. Univariate and multivariable analysis did not find that the HAS-BLED score was associated with early bleeding, but it was associated significantly with late bleeding (odds ratio [OR], 1.86; 95% confidence intervals [CI] 1.32-2.62, and OR 1.67; 95% CI 1.19-2.35, respectively). The HAS-BLED score is associated with increased risk of major bleeding events after cardiac surgery procedures. This may help to plan the standard anticoagulation/antiplatelet therapy in cardiac surgical patients with a higher HAS-BLED score.

Bleeding and New-Onset Cancers in Patients With Atrial Fibrillation Receiving Nonvitamin K Antagonist Oral Anticoagulants

Whether bleeding should be considered a sufficient sign to justify thorough cancer surveillance in atrial fibrillation (AF) patients receiving nonvitamin K antagonist oral anticoagulants (NOACs) remains unclear. We investigated the relationships between bleeding events and new-onset cancers in AF patients receiving NOACs in a prospective cohort (n = 395, mean follow-up duration of 2.8 years). There were 18 patients who were diagnosed with new-onset cancers 584 ± 372 days after the initiation of NOACs. The patients with new-onset cancers had higher HAS-BLED scores (no, preexisting and new-onset cancer: 1.51 ± 0.81, 1.69 ± 0.87, and 2.11 ± 0.96, respectively; p = 0.006) and a higher incidence of bleeding events (22%, 33%, 67%, respectively; p<0.001) than did patients without new-onset cancers. Bleeding events that preceded the diagnosis of new-onset cancers were independently correlated with new-onset cancers (odds ratio: 7.89, p = 0.001) in the multivariate logistic regression. More than half of the patients (61%) with new-onset cancers had either a significant period of drug interruption for at least 2 months or discontinued NOACs. In conclusions, bleeding in AF patients receiving NOACs could be an alerting sign of new-onset cancers and should prompt the initiation of thorough surveillance to detect early cancers.

Usefulness of the CHA2DS2-VASc and HAS-BLED Scores in Predicting the Risk of Stroke Versus Intracranial Bleeding in Patients With Atrial Fibrillation (from the FibStroke Study)

CHA2DS2-VASc and HAS-BLED scores stratify the risk of thromboembolic and bleeding events respectively in patients with atrial fibrillation. There is only little information on how they differentiate which of the 2 clinically most important complications (ischemic stroke [IS] or an intracranial bleeding [IB]) the patient is more prone to suffer. We evaluated both scores in patients with either of these major complications. The FibStroke Study collected data on all patients with atrial fibrillation with either an IS or an IB event between 2003 and 2012 in 4 Finnish hospital districts. Individual electronic patient records were manually reviewed to collect the study data. To assess the relative risk of IS and IB, an IS/IB-ratio was calculated by dividing the absolute number of ISs with the absolute number of IBs within each score category. A total of 3,816 (82.7%) ISs and 798 (17.3%) IBs were detected in 3,909 patients. In general, ISs occurred more often than IBs in patients on oral anticoagulation in each score category (ratio 1.6 to 5.1). The ratio decreased below 1, however, only with very high HAS-BLED scores (>4). Moreover, 221 ISs and 53 IBs occurred in patients with HAS-BLED > CHA2DS2-VASc, of whom only 19.7% were on anticoagulation. In conclusion, IS was the predominant intracranial event irrespective of CHA2DS2-VASc score, HAS-BLED score ≤4, or use of oral anticoagulation, also in patients with low estimated thromboembolic risk (CHA2DS2-VASc 0 to 1). Furthermore, the HAS-BLED score predicted the excess of IBs over ISs only at very high-risk levels.

Identifying Warfarin Control With Stroke and Bleed Risk Scores

Warfarin decreases stroke risk in atrial fibrillation patients, with efficacy and safety impacted by the quality of warfarin control, as measured by time in therapeutic range (TTR). Stroke and bleed risk scores are calculated prior to commencing warfarin, so it would be beneficial if these scores also identified likely warfarin control. Some studies have investigated CHADS2, CHA2DS2VASc, and HASBLED individually for this purpose, but application of all scores to diverse ethnic populations and at sites with differing overall control has not been investigated. The aim of this study was to determine if these commonly used risk scores could identify poor warfarin control. Retrospective data was collected for non-valvular AF patients receiving warfarin between January and June 2014 in Australia and Singapore. Patient data was used to calculate TTR and risk scores. Mean TTR was used for analysis and comparison to categorised scores. There were 3199 patients in Australia and 1171 in Singapore. At both sites, mean TTR decreased according to HASBLED category, and there was a statistically higher percentage of patients achieving a TTR>65% in the low HASBLED category. The association between HASBLED scores and TTR was independent of lower dosing in higher risk patients, particularly in Australia. No significant differences were found in mean TTR according to CHADS2 at either site. Time in therapeutic range significantly decreased according to high CHA2DS2VASc category in Singapore, but no differences were found in Australia. Of the bleed and stroke risk models, HASBLED is most suitable to identify a patient's potential TTR and ability to achieve TTR>65%. A high HASBLED score may assist prescribers in determining potential suitability to warfarin, and assist prescribers in deciding on the most suitable anticoagulant for patients.

Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry

Background and objectivesThe prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. Patients and methodsObservational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. ResultsWe evaluated 804 patients with a mean age of 85 years (range 75–101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favored the use of anticoagulants. ConclusionsHospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.

Características y tratamiento antitrombótico de los pacientes ancianos con fibrilación auricular no valvular hospitalizados en Medicina Interna. Registro NONAVASC

Background and objetivesThe prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. Patients and methodsObservational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. ResultsWe evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. ConclusionsHospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.

Abstract 13053: HAS-BLED Score and Atrial Fibrillation Type as Risk Factors for Bleeding Complications Associated With Catheter Ablation of Atrial Fibrillation among Patients Receiving Direct Oral Anticoagulants

Purpose: This study aimed to identify predictors of thromboembolic and hemorrhagic events associated with catheter ablation of atrial fibrillation (AF) among patients receiving periprocedural direct oral anticoagulants (DOACs). Methods: We retrospectively studied 1034 consecutive AF patients (64±11 years; 777 males) receiving dabigatran (n=208), rivaroxaban (n=465), apixaban (n=292), or edoxaban (n=69) before AF ablation. The DOACs were continued in 61 (5.9%) patients and discontinued in 973 (94.1%) on the day of the procedure. No heparin bridging was performed before the ablation. During the procedure, heparin was given to maintain an activated clotting time (ACT) of 300-350 seconds. Major bleeding was defined as cardiac tamponade or pericardial effusions requiring drainage, intracranial and gastrointestinal hemorrhages, retroperitoneal bleeding, and bleeding requiring a blood transfusion, and vascular access site complications requiring intervention. Minor bleeding was defined as bleeding other than major bleeding. Results: No symptomatic thromboembolisms occurred. The incidence of major and minor bleeding was 0.6% and 8.8%, respectively, and did not significantly differ among the DOACs (P=0.351 and 0.177; Figure 1). In the multivariate logistic regression analysis, the HAS-BLED score and LSP-AF were significant positive predictors of bleeding complications (odds ratios, 1.358 and 1.956; 95% CIs, 1.108-1.665 and 1.196-3.198; P=0.003 and 0.007), but the DOAC type and dose (standard/reduced), periprocedural continuation of the DOACs, total heparin dosage, and intraprocedural ACT were not significant predictors. The periprocedural bleeding risk increased with higher HAS-BLED scores (Figure 2). Conclusions: Periprocedural DOAC treatment with adequate intraprocedural anticoagulation was effective in preventing symptomatic thromboembolisms. A higher HAS-BLED score and LSP-AF can be high risk factors for bleeding complications.

Assessment of the Modified-HAS-BLED and Nutrition Score in Predicting Death in Patients with Heart Failure with and without Atrial Fibrillation

Background: The HAS-BLED score is used clinically for bleeding risk stratification in atrial fibrillation (AF). Its usefulness in a population of patients with heart failure (HF) is unclear. Purpose: To investigate whether HAS-BLED and nutrition factors predicts death in a cohort of patients with HF with and without AF. Method: We enrolled 147 patients who were diagnosed as having incident HF during 2010–2012. End of follow-up was March 31, 2016. Levels of the HAS-BLED score (based on 9 possible points, with higher scores indicating higher risk), stratified by concomitant AF at baseline. Analyses took into account the competing risk of death. Main Outcomes and Measures: Death within 5 year after HF diagnosis. Results: In patients with HF, the risks of death were 32.7% (n = 48). At high HAS-BLED scores (more than 4), the absolute risk of death was high (for a score of 4, 35.7% vs 19.1% for patients without and with concomitant AF, respectively; P < .05). C-statistics indicate that the HAS-BLED score performed modestly in this HF population with and without AF (for death, 5-year C-statistics 0.60, respectively). Conclusions: Among patients with incident HF with or without AF, the HAS-BLED score was associated with risk of death. Predictive accuracy was modest, and the clinical utility of the HAS-BLED score in patients with HF remains to be determined.

Risk factors associated with bleeding after multi antithrombotic therapy during implantation of cardiac implantable electronic devices

Previous studies showed that continuous anticoagulation or single antiplatelet therapy during implantations of cardiac implantable electronic devices (CIED) was relatively safe. However, the safety of continuous multi antithrombotic therapy (AT) in patients undergoing CIED interventions has not been clearly defined. We sought to evaluate the safety of this therapy during CIED implantations. A total of 300 consecutive patients (mean 69 years old, 171 males) with CIED implantations were enrolled in this study. The patients were divided into 6 groups [No-AT, oral anticoagulant therapy (OAT), single antiplatelet therapy (SAPT), OAT and SAPT, dual antiplatelet therapy (DAPT), triple AT (TAT)], and the perioperative complications were evaluated. Clinically significant pocket hematomas (PH) were defined as PH needing surgical intervention, prolonged hospitalizations, interruption of AT, or blood product transfusions. There were 129, 89, 49, 20, 10, and 3 patients in No-AT, OAT, SAPT, OAT + SAPT, DAPT, and TAT groups, respectively. The occurrence of clinically significant PH and thromboembolism did not differ among 6 groups (p = 0.145 and p = 0.795, respectively). However, high HAS-BLED score and valvular heart disease (VHD) were associated with clinically significant PH (p = 0.014 and p = 0.015, respectively). Continuous multi AT may be tolerated, but patients with high HAS-BLED score or VHD would require a careful attention during CIED implantations.