Management Of Oral Anticoagulants Research Articles

Coronary Artery Ectasia in Acute Coronary Syndrome: The Role of Non-vitamin K Antagonist Oral Anticoagulants in Management

Coronary artery ectasia (CAE) is an abnormal dilatation of coronary artery segments, often linked with atherosclerosis. This report discusses two cases of CAE presenting as acute coronary syndrome. A 36-year-old man had proximal blockage in the left circumflex artery (LCx) and ectasia in the obtuse marginal artery and left anterior descending artery (LAD), while a 53-year-old male smoker had an ectatic LAD with a substantial thrombus. Both were treated with dual antiplatelet therapy (aspirin and clopidogrel) and non-vitamin K antagonist oral anticoagulants (NOACs), specifically apixaban, along with atorvastatin. The first patient had complete resolution of LCx occlusion after 1 year, and the second patient had complete thrombus dissolution in the LAD in 2 months. These cases highlight the potential benefits of NOACs in managing CAE in acute coronary syndrome, suggesting that triple therapy can significantly improve clinical outcomes.

Perioperative direct oral anticoagulant management during cardiac implantable electronic device surgery: an updated systematic review and meta-analysis.

Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC). However, the evidence on whether to continue or temporarily discontinue DOAC therapy during the perioperative period in these patients is unclear. We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through July 2024. We included studies comparing uninterrupted versus interrupted perioperative DOAC therapy in patients undergoing CIED procedure- primary implants, pulse generator replacement, and device upgrades. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding. A total of 1,607 patients from 8 studies were included. The mean age was 73.2years, with atrial fibrillation as the indication for DOAC therapy in most patients. The mean CHA2DS2-VASc was 3.4. Among the included studies, 2 were randomized control trials (RCTs), while the others were observational cohort studies, including one that was propensity score matched. Our meta-analysis found both strategies to be similar in terms of clinically significant pocket hematoma (RR 1.70; 95%CI 0.84-3.45; p = 0.14; I2 = 0%), thromboembolic complications (RR 0.35; 95%CI 0.04-3.32; p = 0.36; I2 = 19%), any pocket hematoma, all-cause mortality and any bleeding with a higher risk of major bleeding with uninterrupted anticoagulation. This meta-analysis shows that uninterrupted DOAC therapy is comparable to interrupted therapy for CIED procedures, with a potential increase in major bleeding risk but low overall complication rates. Further research is needed to confirm the best approach of periprocedural anticoagulation in these patients.

Current Real-World Status of Oral Anticoagulant Management in Japanese Patients

Current Real-World Status of Oral Anticoagulant Management in Japanese Patients

System-Wide, Electronic Health Record-Based Medication Alerts for Appropriate Prescribing of Direct Oral Anticoagulants: Pilot Randomized Controlled Trial.

While direct oral anticoagulants (DOACs) have improved oral anticoagulation management, inappropriate prescribing remains prevalent and leads to adverse drug events. Antithrombotic stewardship programs seek to enhance DOAC prescribing but require scalable and sustainable strategies. We present a pilot, prescriber-level randomized controlled trial to assess the effectiveness of electronic health record (EHR)-based medication alerts in a large health system. The pilot assessed prescriber responses to alerts for initial DOAC prescription errors (apixaban and rivaroxaban). A user-centered, multistage design process informed alert development, emphasizing clear indication, appropriate dosing based on renal function, and drug-drug interactions. Alerts appeared whenever a DOAC was being prescribed in a way that did not follow package label instructions. Clinician responses measured acceptability, accuracy, feasibility, and utilization of the alerts. The study ran from August 1, 2022, through April 30, 2023. Only 1 prescriber requested trial exclusion, demonstrating acceptability. The error rate for false alerts due to incomplete data was 6.6% (16/243). Two scenarios with alert design and/or execution errors occurred but were quickly identified and resolved, underlining the importance of a responsive quality assurance process in EHR-based interventions. Trial feasibility issues related to alert-data capture were identified and resolved. Trial feasibility was also assessed with balanced randomization of prescribers and the inclusion of various alerts across both medications. Assessing utilization, 34.2% (83/243) of the encounters (with 134 prescribers) led to a prescription change. The pilot implementation study demonstrated the acceptability, accuracy, feasibility, and estimates of the utilization of EHR-based medication alerts for DOAC prescriptions and successfully established just-in-time randomization of prescribing clinicians. This pilot study sets the stage for large-scale, randomized implementation evaluations of EHR-based alerts to improve medication safety. ClinicalTrials.gov NCT05351749; https://clinicaltrials.gov/study/NCT05351749.

Delphi consensus on oral anticoagulation management in special clinical situations in the cardiology setting.

Background: Management of oral anticoagulation (OAC) can be challenging, such as in complex cases of nonvalvular atrial fibrillation (NVAF).Materials & methods: A Delphi study comprising two rounds was used for gathering expert opinion through an online questionnaire (83 items grouped in 8 dimensions) on OAC management in specific clinical settings.Results: Consensus was reached for 79 items (95%) in round 1. Experts recommended direct-acting oral anticoagulants (DOACs) for pericardioversion, uninterrupted OAC for catheter ablation, and dual therapy with a DOAC and clopidogrel after percutaneous coronary intervention. They also recommended restarting OAC with a DOAC after an intracranial haemorrhage.Conclusion: The expert-based recommendations obtained may contribute to standardizing and guiding the management of OAC in complex clinical situations in cardiology.

Application of Alfalfa App in the management of oral anticoagulation in patients with atrial fibrillation: a multicenter randomized controlled trial

BackgroundIn recent years, mobile medical technology has made great progress in chronic disease management, but its application in patients with atrial fibrillation (AF) still needs to be clarified.ObjectiveThis study aims to determine whether the newly developed smartphone app for patients with AF (Alfalfa App) can improve anticoagulation knowledge, drug treatment compliance, and satisfaction of AF patients.MethodsAlfalfa App integrates the functions of patient education, remote consultation, and medication reminder through a simple user interface. From June 2020 to December 2020, patients with AF were recruited in five large tertiary hospitals in China. Patients were randomly divided into the Alfalfa App or routine nursing groups. Patients’ knowledge, medication adherence, and satisfaction with anticoagulation were assessed using validated questionnaires at baseline, 1 month, and 3 months.ResultsIn this randomized controlled trial, 113 patients with AF were included, 57 patients were randomly assigned to the Alfalfa App group, and 56 patients were randomly assigned to the routine nursing group. Forty-eight patients in the Alfalfa App group completed a three-month follow-up, and 48 patients in the routine nursing group completed a three-month follow-up. Basic demographic data were comparable between the two groups. The average age of AF patients was 61.65 ± 11.01 years old, and 61.5% of them were male. With time (baseline to 3 months), the knowledge scores of the Alfalfa App group (P<.001) and the routine nursing group (P = .002) were significantly improved, the compliance scores of the routine nursing group(P<.001) and Alfalfa App group(P<.001) significantly improved. Compared with the routine nursing group, patients’ knowledge level and medication compliance using the Alfalfa App at 1 month and 3 months were significantly higher (all P < .05). There were significant differences in knowledge and compliance scores between the two groups with time (all P < .05). The satisfaction degree of drug treatment in the Alfalfa App group was significantly better than that in the routine nursing group (all P < .05).ConclusionsAlfalfa App significantly improved the anticoagulation knowledge, drug treatment compliance, and satisfaction of AF patients. In oral anticoagulation management for AF patients, mobile medical technology that integrates the functions of patient education, remote consultation, and medication reminder may be helpful.Trial registrationRegistration number, ChiCTR1900024455. Registered on July 12, 2019.

A review of the perioperative management of direct oral anticoagulants for pediatric anesthesiologists.

Although direct oral anticoagulants (DOACs) have been used in the adult population for over a decade, DOACs use has begun to rise in pediatric populations since FDA approval of rivaroxaban and dabigatran, DOACs offer several advantages for pediatric patients, to other anticoagulants, including a similar safety profile, minimal lab monitoring, and ease of administration. The rise in DOAC use has led to an increasing number of pediatric patients managed on DOACs presenting for elective and urgent procedures. Perioperative management of anticoagulation is often challenging for providers due to the lack of expert consensus guidelines and the difficulty in balancing a patient's thrombotic risk with bleeding risk for a given procedure. Using the most up to date literature, we provide a focused review on the perioperative management of DOACs in pediatric patients. This work presents a focused review for pediatric anesthesiologists on clinically available DOACs, perioperative monitoring and management of DOACs, as well as options and indications for reversal. While consensus expert practice guidelines are still needed, we hope this work will familiarize perioperative physicians with these agents, recommended uses, and potential perioperative management.

Perioperative Elective Management in Patients Treated with Direct Oral Anticoagulants - Practical Guide.

&lt;b&gt;Introduction:&lt;/b&gt; Despite clear, relatively easy-to-use guidance, many clinicians find the perioperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate antithrombotic management can delay procedures and lead to bleeding or thromboembolic complications.&lt;b&gt;Aim:&lt;/b&gt; We aimed to describe perioperative management practices related to planned procedures regarding DOACs in accordance with the applicable guidelines of cardiological and surgical societies.&lt;b&gt;Results:&lt;/b&gt; Perioperative management of DOAC therapy depends on many factors, and recommendations in the guidelines are not consistent.&lt;b&gt;Conclusions:&lt;/b&gt; The best approach to managing these patients is therefore to strike a balance between the risks of bleeding and thromboembolism.

Open Issues in the Choice and Management of Direct Oral Anticoagulants in Patients with Cancer-Related Venous Thromboembolism.

Open Issues in the Choice and Management of Direct Oral Anticoagulants in Patients with Cancer-Related Venous Thromboembolism.

Chinese expert consensus on home management of oral anticoagulants(2024 edition)

Oral anticoagulants are widely used in the home care of patients who require prevention and treatment of thromboembolic diseases. The irrational use of anticoagulants may cause thrombosis and hemorrhage. Currently, there are no national or international guidelines or consensus providing recommendations for home management of oral anticoagulants. Therefore, the Hospital Pharmacy Professional Committee of the Chinese Pharmaceutical Association organized domestic experts in the fields of clinical pharmacy, cardiovascular surgery, cardiovascular medicine, vascular surgery, respiratory medicine and laboratory science to sort out the relevant issues and compile the expert consensus on the home management of oral anticoagulants. The main contents of this consensus include pharmacological monitoring of oral anticoagulants, the process and precautions of carrying out home management of oral anticoagulants, and treatment of some special conditions during home management, with the aim of enhancing the safety and effectiveness of oral anticoagulants' usage and reducing the adverse events.

Perioperative Management of Traditional and Direct Oral Anticoagulants in Hip Fracture Patients.

Hip fractures are an increasingly common injury in the senior population and almost always require surgical fixation or prosthetic replacement. These surgeries, according to the American Academy of Orthopaedic Surgeons, are considered high-risk for bleeding, especially in a population fraught with comorbidities and often presenting on anticoagulation medications. Direct oral anticoagulants represent a class of drugs that have been becoming more popular in use in this population, with many benefits over the historically used Warfarin. There are recommendations for preoperative discontinuation and postoperative resumption of these medications, which can be more readily managed for elective surgeries. However, there is a paucity of literature detailing best practice guidelines for the perioperative management of direct oral anticoagulants when a patient presents with a hip fracture. This review article summary of the periprocedural management of DOACs for hip surgery was developed by examining the American College of Chest Physicians evidence-based clinical practice guidelines, Perioperative Guidelines on Antiplatelet and Anticoagulant Agents written by anesthesiologists, various retrospective studies, and drug labels for pharmacokinetic data. These recommendations should be used as a guideline, along with the collaboration of multidisciplinary hospital teams during inpatient admission, to manage these complex patients.

Direct Oral Anticoagulation in Lung Transplant Recipients.

Presently, the management of direct oral anticoagulants lacks specific guidelines for patients before and after transplant, particularly for lung transplant recipients. We aimed to consolidate the existing literature on direct oral anticoagulants and explore their implications in lung transplant recipients. We conducted a comprehensive search in PubMed and Google Scholar databases for studies published between January 2000 and December 2022, using specific search terms. We only included studies involving lung transplant recipients and focusing on direct oral anticoagulants. Five relevant publications were identified, providing varied insights. None of the studies specifically addressed bleeding complications associated with direct oral anticoagulants in lung transplant recipients. Limited details were available on the type of solid-organ transplant or the specific direct oral anticoagulant used in these studies. Varied bleeding complications associated with direct oral anticoagulants in lung transplant recipients were reported, but studies lacked specificity on transplant type and direct oral anticoagulant variations. Notably, the incidence of venous thrombotic embolism in lung transplant recipients was comparatively higher than in other solid-organ transplant recipients, potentially linked to factors such as corticosteroid therapy, calcineurin inhibitors, and cytomegalovirus infections. Our synthesis on findings of use of direct oral anticoagulant in lung transplant recipients emphasized challenges of managing these medications in urgent transplant situations. Recommendations from experts suggested caution in initiation of direct oral anticoagulants posttransplant until stability in renal and hepatic function is achieved. The limited evidence on safety of direct oral anticoagulants in lung transplant recipients underscores the need for further research and guidance in this specific patient population.

European expert consensus recommendations on the primary care use of direct oral anticoagulants in patients with venous thromboembolism

BackgroundDirect oral anticoagulants for the treatment of venous thromboembolism are supported by robust clinical trial evidence. Despite published guidance, general practitioners are faced with increasingly complex decisions and implementation remains sub-optimal in certain real-world scenarios.MethodsA two stage formal consensus exercise was performed to formulate consensus statements and a summary guide, facilitating optimal management of direct oral anticoagulants in venous thromboembolism patients by generalist physicians across Europe. An online questionnaire distributed to a broad panel (Phase 1), followed by a virtual panel discussion by an expert group (Phase 2) were conducted. Phase 1 statements covered nine management domains, and were developed via a literature review and expert steering committee. Participants rated statements by their level of agreement. Phase 1 responses were collated and analysed prior to discussion and iterative refinement in Phase 2.ResultsIn total 56 participants from across Europe responded to Phase 1. The majority had experience working as general practitioners. Consensus indicated that direct oral anticoagulants are the treatment of choice for managing patients with venous thromboembolism, at initiation and for extended treatment, with a review at three to six months to re-assess treatment effect and risk profile. Direct oral anticoagulant choice should be based on individual patient factors and include shared treatment choice between clinicians and patients; the only sub-group of patients requiring specific guidance are those with cancer.ConclusionResults demonstrate an appreciation of best practices, but highlight challenges in clinical practice. The patient pathway and consensus recommendations provided, aim to highlight key considerations for general practice decision making, and aid optimal venous thromboembolism treatment.

Assessment of Population-Based Approach to Direct Oral Anticoagulant Management.

Background: As preferences for oral anticoagulation shift from warfarin to direct oral anticoagulants (DOACs), a new care management model is needed. A population approach leveraging a DOAC Dashboard was implemented to track all patients on a DOAC followed by a physician at an academic medical center. The DOAC Dashboard is a real-time report within the electronic health record (EHR) that identifies patients who require evaluation for DOAC dose/therapy adjustment due to changing renal function, age, weight, indication, and/or significant drug-drug interaction (DDI). Objective: This study aims to describe the initial phase of DOAC Dashboard implementation, to evaluate the effectiveness of interventions, and to assess a multidisciplinary approach to management. Method: Retrospective descriptive study of the DOAC Dashboard from August 22, 2019, to January 20, 2022. Primary outcomes include total number of alerts addressed and interventions needed. Secondary outcome is the proportion of interventions implemented by the prescribing clinician. Result: A total of 10 912 patients were identified by the DOAC Dashboard at baseline. A total of 5038 alerts were identified, with 668 critical alerts, 3337 possible critical alerts, and 1033 other alerts. Pharmacists addressed 1796 alerts during the study period (762 critical alerts and 1034 possible critical). Critical alerts included 62 significant DDI, 379 inappropriate dosing, and 321 others. Of the critical alerts, intervention was needed in 291 cases (38%), with 255 (88%) of proposed interventions implemented. Critical alerts and possible critical alerts not requiring intervention were resolved by data entry. Conclusion: The DOAC Dashboard provides an efficient method of identifying patients on DOACs that require dose adjustments or therapeutic modifications.

Central American and Caribbean Consensus Document for the Optimal Management of Oral Anticoagulation in Patients with Non-Valvular Atrial Fibrillation Endorsed by the Central American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention.

Atrial fibrillation (AF) is the most common arrhythmia in adults. Prevention of the ischaemic risk with oral anticoagulants (OACs) is widely recommended, and current clinical guidelines recommend direct oral anticoagulants (DOACs) as preference therapy for stroke prevention. However, there are currently no clinical practice guidelines or recommendation documents on the optimal management of OACs in patients with AF that specifically address and adapt to the Central American and Caribbean context. The aim of this Delphi-like study is to respond to doubts that may arise in the management of OACs in patients with non-valvular AF in this geographical area. A consensus project was performed on the basis of a systematic review of the literature, a recommended ADOLOPMENT-like approach, and the application of a two-round Delphi survey. In the first round, 31 recommendations were evaluated and 30 reached consensus, of which, 10 unanimously agreed. The study assessed expert opinions in a wide variety of contextualized recommendations for the optimal management of DOACs in patients with non-valvular atrial fibrillation (NVAF). There is a broad consensus on the clinical practice guideline (CPG) statements used related to anticoagulation indication, patient follow-up, anticoagulation therapy complications, COVID-19 management and prevention, and cardiac interventions.

Effectiveness and Safety of the Coadministration of Rifampin and Warfarin versus Direct Oral Anticoagulants: A Cohort Study.

Pharmacokinetic studies have shown that rifampin reduces the levels of oral anticoagulants during the initiation of coadministration, raising concerns about an increased thrombotic risk, but there are limited comparative clinical outcomes between rifampin and warfarin compared with direct oral anticoagulants (DOACs). This study aimed to evaluate the effectiveness and safety of concurrent use of rifampin and warfarin versus DOACs, with assessments of outcome-associated factors and oral anticoagulant (OAC) management quality. A total of 142 patients given rifampin plus warfarin (n = 56) or DOACs (n = 86) for over 7 days were included, and their clinical data and outcomes were compared. The median Charlson Comorbidity Index and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly) score of the two groups were 2 and 3, respectively. The incidence rate of composite ischemic or thromboembolic events was 2.16 and 1.44 per 10,000 patient-days in the warfarin and DOAC groups, respectively, with an adjusted hazard ratio (HR) of 0.41 (95% confidence interval [CI] 0.02-7.34). The incidence rate of composite major bleeding or clinically relevant nonmajor bleeding events was 1.58 and 1.52 per 10,000 patient-days in the warfarin and DOAC groups, respectively, with an adjusted HR of 1.12 (95% CI 0.32-4.45). The risk of composite bleeding events increased with a higher HAS-BLED score (HR: 1.62, 95% CI: 1.02-2.63). Moreover, 34.3% of warfarin users maintained a percent time in therapeutic range of above 50%. Furthermore, 77.9% of DOAC users received appropriate dosing. No significant differences were observed in terms of the incidence of thrombotic or bleeding events between the two groups during coadministration. In addition, a higher HAS-BLED score was associated with a greater risk of bleeding events regardless of the class of OACs used. Finally, close monitoring of bleeding events should be considered.

Knowledge, attitude and practice toward oral anticoagulants among patients with atrial fibrillation.

Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke and other cardiovascular complications. Oral anticoagulants (OACs) are effective in reducing this risk. To investigate the knowledge, attitude and practice (KAP) toward OACs among patients with AF. This web-based cross-sectional study was conducted at local Hospital between April 2023 and May 2023, and enrolled AF patients. A total of 491 valid questionnaires were collected, with 293 (59.67%) male and 73.93% resided in urban areas. The KAP scores were 4.64 ± 3.28, 21.09 ± 2.33 and 26.18 ± 2.15, respectively. Multivariate logistic regression analysis showed that junior high school [odd ratio (OR) = 0.346, 95% confidence interval (CI) = 0.145-0.825, P = 0.017], junior college/bachelor and above (OR = 6.545, 95% CI = 2.863-14.963, P < 0.001), monthly income ≥5,000 (OR = 2.343, 95% CI = 1.074-5.111, P = 0.032), never taken OACs (OR = 0.015, 95% CI = 0.004-0.059, P < 0.001), and having been diagnosed AF (6-10 months, OR = 4.003, 95% CI = 1.653-9.692, P = 0.002;over 20 months, OR = 4.046, 95% CI = 1.753-9.340, P = 0.001) were independently associated with knowledge. Knowledge (OR = 1.376, 95% CI = 1.162-1.629, P < 0.001), junior high school (OR = 0.258, 95% CI = 0.084-0.792, P = 0.018), monthly income ≥5,000 (OR = 5.486, 95% CI = 1.834-16.412, P = 0.002), and never undergone AF ablation (OR = 0.214, 95% CI = 0.097-0.471, P < 0.001) were independently associated with attitude. Knowledge (OR = 1.128, 95% CI = 1.030-1.235, P = 0.009), 70-79 years (OR = 2.193, 95% CI = 1.166-4.124, P = 0.015) and ≥80 years (OR = 4.375, 95% CI = 2.034-9.411, P < 0.001) were independently associated with proactive practice. Patients with AF had inadequate knowledge, suboptimal attitude and inactive practice towards AF and OACs. Improving patient education, especially among those with lower education levels, enhances understanding and management of AF and OACs.

Management of edoxaban therapy and clinical outcomes in patients undergoing major or nonmajor surgery: a subanalysis of the EMIT-AF/VTE study

BackgroundOptimising periprocedural management of direct oral anticoagulation in patients with atrial fibrillation on chronic treatment undergoing major surgeries is an important aspect of balancing the risk of surgery-related bleeding with the risk of thromboembolic events, which may vary by surgery type.MethodsThis subanalysis of the prospective EMIT-AF/VTE programme assessed periprocedural-edoxaban management, according to physicians’ decisions, and bleeding and thromboembolic event rates in patients who underwent major vs. nonmajor surgeries. Edoxaban interruption and clinical outcomes were compared between major vs. nonmajor surgeries and between renal function subgroups (creatinine clearance [CrCL] ≤ 50 mL/min vs. > 50 mL/min).ResultsWe included 276 major and 512 nonmajor surgeries. The median pre- and postprocedural duration of edoxaban interruption in major vs. nonmajor surgeries was 4 vs. 1 days, whereas median duration of interruption for those with preprocedural-only and postprocedural-only interruption was 2 vs. 1 days and 2 vs. 0 days, respectively (P < 0.0001). Rates of all bleeding and clinically relevant nonmajor bleeding were numerically higher in major vs. nonmajor surgeries. Event rates (number of events per 100 surgeries) were low overall (< 6 events per 100 surgeries), independent of renal function subgroups.ConclusionIn this subanalysis of the EMIT-AF/VTE programme, periprocedural-edoxaban interruption was significantly longer in patients undergoing major vs. nonmajor surgery. This clinician-driven approach was associated with low rates of bleeding and thromboembolic events following both major and nonmajor surgeries.Trial registrationNCT02950168, registered October 31, 2016; NCT02951039, registered November 1, 2016.

Directions for optimizing the organization of long-term anticoagulant treatment

Background: In this study the organization of long-term anticoagulant treatment has been evaluated to estimate whether clinical practice is in accordance with current recommendations for optimal use and effective control of oral anticoagulant (OAC) treatment. Material and methods: Mixed (quantitative and qualitative), transversal, descriptive, selective study. Samples: quantitative study – 394 adult patients, eligible for anticoagulant treatment; qualitative study – 39 family doctors. Results: The rate of use of OAC treatment is 68%. The period from the diagnosis of the disease to the initiation of OAC treatment lasted one month or more in 59.1% of patients. 60.6% of patients do not have sufficient knowledge regarding the treatment of OAC. The high price is the most important barrier to direct oral anticoagulant administration (91.1%). Patients’ satisfaction with OAC treatment control is low, mainly for vitamin K antagonists (59.8%). 75.5% of respondents claim that OAC treatment control and management is poor. 40.3% do not perform safe therapeutic International Normalized Ratio control, and 54.7% are not in the optimal therapeutic range. Conclusions: The main barriers to adherence to OAC treatment: the burden of regular monitoring of blood parameters, perceived concern about complications, limited access to laboratory tests and specialist doctors, insufficient information about anticoagulation, and deficiencies in communication with medical staff. There is limited conviction, and uncertainty persists in the initiation and monitoring of OAC treatment by family doctors.

Impact of bleeding events on mortality in patients with atrial fibrillation and silent left atrial thrombi: insight from the LAT trial

Abstract Background Thrombolytic therapy is important to prevent thromboembolism in patients with atrial fibrillation (AF) and left atrial (LA) thrombi. However, bleeding complications are a major concern. Purpose To investigate the incidence and prognosis of bleeding complications in patients with AF and silent LA thrombi. Methods An analysis was performed from the LAT trial, a multicenter observational study investigating outcomes of silent LA thrombi detected by trans-esophageal echocardiography (TEE) in AF patients. Of 17,436 patients who underwent TEE, 297 (median age, 70 years; 31% female, median CHA2DS2-VASc score of 4) were eligible for inclusion. Management of oral anticoagulants was at the physician’s discretion, and the follow-up period was set as 1-year. Major bleeding was defined as intracranial hemorrhage, bleeding requiring surgery or transfusion, or ≥4 g/dl decrease in hemoglobin level. Results Prescription rates of oral-anticoagulants at baseline and the final follow-up were 81.8% and 89.9%, respectively (p = 0.002). During a median follow-up of 385 (interquartile range, 365-411) days after the thrombi detection, the incidence of thromboembolism, major bleeding, and all-cause death was 5.7% (n = 17), 11.4% (n = 34) and 8.4 % (n = 25), respectively. Patients with thromboembolism were more likely experience subsequent death than those without thromboembolism (17.7% vs. 7.9%, log-rank p = 0.063). Similarly, patients with major bleeding more frequently experienced subsequent death than those without bleeding (20.6% vs. 6.8%, log-rank p = 0.002). Time-adjusted Cox regression analysis revealed a temporal association between major bleeding and subsequent death (hazard ratio, 3.72; 95% confidence interval 1.55–8.93; p = 0.003) as well as between thromboembolism and subsequent death (hazard ratio, 2.98; 95% confidence interval 0.89–9.99; p = 0.077). Conclusions In the LAT trial, about 10% of patients with AF and silent LA thrombi experienced major bleeding during 1-year follow-up. Not only thromboembolism but also major bleeding was strongly associated with subsequent death.