Non-warfarin Oral Anticoagulants Research Articles

Severity of Ischemic Stroke After Left Atrial Appendage Closure vs Nonwarfarin Oral Anticoagulants

BackgroundStrokes after left atrial appendage closure (LAAC) prophylaxis are generally less severe than those after warfarin prophylaxis—thought to be secondary to more hemorrhagic strokes with warfarin. Hemorrhagic strokes are similarly infrequent with direct oral anticoagulant (DOAC) prophylaxis, so the primary subtype after either LAAC or DOAC prophylaxis is ischemic stroke (IS). ObjectivesThe purpose of this study was to compare the severity of IS using the modified Rankin Scale in atrial fibrillation patients receiving prophylaxis with DOACs vs LAAC. MethodsA retrospective analysis was performed of consecutive patients undergoing LAAC at 8 centers who developed an IS (ISLAAC) compared with contemporaneous consecutive patients who developed IS during treatment with DOACs (ISDOAC). The primary outcome was disabling/fatal stroke (modified Rankin Scale 3-5) at discharge and 3 months later. ResultsCompared with ISDOAC patients (n = 322), ISLAAC patients (n = 125) were older (age 77.2 ± 13.4 years vs 73.1 ± 11.9 years; P = 0.002), with higher HAS-BLED scores (3.0 vs 2.0; P = 0.004) and more frequent prior bleeding events (54.4% vs 23.6%; P < 0.001), but similar CHA2DS2-VASc scores (5.0 vs 5.0; P = 0.28). Strokes were less frequently disabling/fatal with ISLAAC than ISDOAC at both hospital discharge (38.3% vs 70.3%; P < 0.001) and 3 months later (33.3% vs 56.2%; P < 0.001). Differences in stroke severity persisted after propensity score matching. By multivariate regression analysis, ISLAAC was independently associated with fewer disabling/fatal strokes at discharge (OR: 0.22; 95% CI: 0.13-0.39; P < 0.001) and 3 months (OR: 0.25; 95% CI: 0.12-0.50; P < 0.001), and fewer deaths at 3 months (OR: 0.28; 95% CI: 0.12-0.64; P < 0.001). ConclusionsIschemic strokes in patients with atrial fibrillation are less often disabling or fatal with LAAC than DOAC prophylaxis.

PO-713-05 ISCHEMIC STROKE AFTER PROPHYLAXIS WITH LEFT ATRIAL APPENDAGE CLOSURE VS NON-WARFARIN ORAL ANTICOAGULANTS: A “REAL-WORLD” MULTICENTER COMPARISON OF STROKE SEVERITY

In randomized trials, strokes occurring in patients who have received left atrial appendage closure (LAAC) devices have been less severe than in patients receiving warfarin prophylaxis - an observation thought related to warfarin’s higher rate of hemorrhagic stroke (which are known to have worse outcomes). Similar stroke rates have been described with LAAC vs NOACs (non-warfarin oral anticoagulants), but the low hemorrhagic stroke rate of NOACs raises the question of stroke severity between these two therapies. To compare stroke severity in AF patients sustaining ischemic strokes while receiving either LAAC or NOAC prophylaxis. In a retrospective analysis from 6 centers, we evaluated all consecutive AF patients who developed non-procedural (>7 days) ischemic strokes while receiving either LAAC (Watchman or Amulet) or NOAC prophylaxis. The primary outcome was a comparison of stroke severity between groups, based on the Modified Rankin Scale (mRS) at baseline and 3 months post-stroke. Non-disabling stroke was defined as mRS = 0-2; disabling was ≥3 (6=fatal). Compared to NOAC pts (n=89; apixaban 46%, rivaroxaban 40%, dabigatran 14%) LAAC pts (n=98; Watchman 97%, Amulet 3%) were older (77±14 vs 73±11 yrs, p=0.03) with higher CHA2DS2-VASc [5 (4-6) vs 4 (3-5), p=0.001] and HAS-BLED scores [3 (2-4) vs 2 (2-3), p<0.001], and more prior hemorrhagic strokes (18.4% vs 3.4%, p=0.001) - but similar prior ischemic stroke rates (33.7% vs 39.3%, p=0.4). (Table 1) Stroke severity during hospital admission, discharge and at 3 months follow up was lower in the LAAC vs NOAC group (Table 2). Logistic regression revealed both LAAC and concomitant intracerebral hemorrhage (ICH) to independently predict mRS at admission, discharge and 3 mo. LAAC also predicted disabling/fatal stroke (mRS≥3) at discharge [OR 0.22, (95% CI 0.10-0.45), p<0.001] and 3 months [OR 0.20, 95% CI (0.09-0.45), p<0.001]. Despite a higher baseline risk profile of the LAAC cohort, ischemic strokes were of less severity after LAAC than while receiving NOACs. Future studies should confirm these findings in larger cohorts, and address the mechanism(s) of differential severity - less embolic burden, less secondary hemorrhage and expansion of brain infarcts, or something else?View Large Image Figure ViewerDownload Hi-res image Download (PPT)

B-PO02-117 PERICARDIAL EFFUSIONS DURING LEFT ATRIAL ABLATION PROCEDURES IN PATIENTS RECEIVING NON-WARFARIN ORAL ANTICOAGULANTS: MANAGEMENT AND OUTCOMES

An increasing number of left atrial ablation procedures are being performed on patients receiving non-warfarin oral anticoagulants (NOACs), often uninterrupted. Little has been reported on the management and outcomes of pericardial effusion in the setting of NOAC use. To evaluate the characteristics and outcomes of procedure-related pericardial effusion while taking NOACs. We performed a single-center retrospective review of all left atrial catheter ablation procedures between 2017 and 2020. Data collection included patient demographics, procedure type, pre-procedural anticoagulation strategies, peri-procedural management, and outcomes. Of the 2192 ablation procedures performed, 22 pericardial effusions occurred (1.0%), of which 21 occurred in patients taking NOACs (Apixaban in 15, Rivaroxaban in 6) - uninterrupted in 15 (71.4%; see Table). Pericardiocentesis was performed in 20 of 21 patients (95.2%), either intraoperatively (n=16) or for delayed effusion (n=5); repeat pericardiocentesis was required in 3 patients (14.3%). Reversal agents were frequently used: protamine (n=12) and prothrombin concentrate complex (n=7). Additional management strategies included covered stent implant for CS perforation (n=2) and Amplatzer plug implant for LA wall perforation (n=1). Surgery was not required, and there were 0 strokes and deaths. Median length of hospital stay was 3 days (range 1-12). Left atrial ablation procedure-related pericardial effusion on NOACs can be managed without surgical intervention. Novel NOAC-specific reversal agents may further streamline management.

Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study

In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.

Prevention of gastrointestinal bleeding in patients receiving oral anticoagulants: focus on proton pump inhibitors

The review addresses the issue of the gastrointestinal bleeding (GIB) development in patients receiving oral anticoagulants, and the proton pump inhibitors (PPIs) efficiency in reducing of such complications. Epidemiological data on the prevalence of GIB in the presence of nonwarfarin oral anticoagulants (NOACs) and warfarin intake are presented. The factors that increase the risk of bleeding associated with the use of anticoagulants are discussed, including the potential drug-drug interactions and patients’ dietary habits. A description of the scales that assess the bleeding risks during anticoagulant therapy is given. In the second part of the article the principles of prevention and minimization of the GIB risks in the presence of oral anticoagulants treatment are presented. In the context of evidence-based medicine, the PPIs’ role in reducing the risk of GIB is fully discussed. The results of recent large-scale randomized clinical trials and meta-analyses are described in detail, suggesting the benefits of PPIs in the decreasing the risk of the upper gastrointestinal tract bleeding when NOACs and warfarin are prescribed, especially with concomitant therapy with acetylsalicylic acid. So, PPIs can be considered as one of the effective drug prevention “tools” of these complications.

Cost‐Effectiveness of Left Atrial Appendage Closure for Stroke Reduction in Atrial Fibrillation: Analysis of Pooled, 5‐Year, Long‐Term Data

BackgroundRecent publications reached conflicting conclusions about the cost‐effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost‐effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long‐term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long‐Term Warfarin) trials.Methods and ResultsA Markov model was constructed from a US payer perspective with a lifetime (20‐year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5‐year data. Warfarin and NOAC inputs were derived from published meta‐analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost‐effective relative to warfarin by year 7 ($48 674/quality‐adjusted life‐year) and dominant (more effective and less costly) by year 10. LAAC became cost‐effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality‐adjusted life‐years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost‐effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively.ConclusionsUsing pooled, 5‐year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost‐effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.

Outpatient Treatment of Pulmonary Embolism: a Practical Guide

Pulmonary embolism (PE) is an ever increasing diagnosis in the emergency department. Traditionally, all patients with PE were admitted to the hospital; however, with the advent of higher resolution CT scanners, more PEs of questionable clinical significance are being diagnosed. This phenomenon coupled with the emerging evidence of the safety of non-warfarin oral anticoagulants for outpatient management suggests that an alternative approach is both timely and appropriate. This paper reviews the growing body of literature supporting outpatient treatment of select patients with low risk pulmonary embolism. We believe that with an established protocol, institutional support to include assurance of reliable and timely outpatient follow-up that select low risk PE patients can be safely discharged home.

Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device

In the stroke prevention trials of left atrial appendage closure with the Watchman device (Boston Scientific), a postimplantation antithrombotic regimen of 6 weeks of warfarin was used. Given the clinical complexity of warfarin use, the purpose of this study was to study the relative feasibility and safety of using non-warfarin oral anticoagulants (NOACs) instead of warfarin during the peri- and initial postimplantation periods after Watchman implantation. This was a retrospective multicenter study of consecutive patients undergoing Watchman implantation and receiving peri- and postprocedural NOACs or warfarin. Transesophageal echocardiography or chest computed tomography was performed between 6 weeks and 4 months postimplant to assess for device-related thrombosis. Bleeding and thromboembolic events also were evaluated at the time of follow-up. In 5 centers, 214 patients received NOACs (46% apixaban, 46% rivaroxaban, 7% dabigatran, and 1% edoxaban) in either an uninterrupted (82%) or a single-held-dose (16%) fashion. Compared to a control group receiving uninterrupted warfarin (n = 212), the rates of periprocedural complications, including bleeding events, were similar (2.8% vs 2.4%, P = 1). At follow-up, the rates of device-related thrombosis (0.9% vs 0.5%, P = 1), composite of thromboembolism or device-related thrombosis (1.4% vs 0.9%, P = 1), and postprocedure bleeding events (0.5% vs 0.9%, P = .6) also were comparable between the NOAC and warfarin groups. NOACs proved to be a feasible peri- and postprocedural alternative regimen to warfarin for preventing device-related thrombosis and thromboembolic complications expected early after appendage closure with the Watchman device, without increasing the risk of bleeding.

Anticoagulation for prosthetic heart valves: unresolved questions requiring answers.

The efficacy of anticoagulation for valvular prostheses is the result of a delicate balance between the risk of thromboembolic (TE) events and bleeding. Here, we review data on anticoagulation for valve prostheses with a focus on clinical trials that address key unanswered questions. There are several unanswered questions in the field of prosthetic valve anticoagulation, including: optimal TE prophylaxis in the short term for bioprostheses, optimal TE prophylaxis following transcatheter aortic valve implantation, the safety and efficacy of lower levels of anticoagulation with the bileaflet mechanical prosthesis, the role of aspirin for patients with mechanical prostheses, and the management of anticoagulation for mechanical valves in pregnancy. Other areas of study include the role, if any, of nonwarfarin oral anticoagulants for prosthetic TE prophylaxis as well as self-INR monitoring. Finally, we briefly mention studies of newer anticoagulants, such as novel vitamin K antagonists and antisense oligonucleotides, that are on the horizon. Optimal antithrombotic management is a key issue for patients with valvular prostheses, and the publication of recent trials has provided much-needed guidance. We highlight areas of progress, in addition to the major unanswered questions for which well-designed, prospective clinical trials are forthcoming.

Non-Warfarin Oral Anticoagulants in Anti-Phospholipid Syndrome

Introduction: Anti-Phospholipid Syndrome (APS) is a serious and deadly disorder leading to a significant risk of thrombi, requiring lifelong therapeutic anticoagulation. Traditionally, the vitamin K antagonist (VKA) warfarin has been considered standard of care in this patient population. However, the VKAs require frequent laboratory monitoring, have a narrow therapeutic window, numerous drug interactions and dietary restrictions. Due to these factors, many patients suffer recurrent thrombi and/or major bleeding, warranting therapy modification or switching to parenteral anticoagulants. The non-warfarin oral anticoagulants (NOACs), specifically the direct Xa inhibitors apixaban and rivaroxaban, have been approved for the treatment of venous thromboembolism and represent attractive options for these patients.Methods: We designed a retrospective analysis of all patients at the University of Virginia with APS that were treated with either apixaban or rivaroxaban since September 2011. All patients were required to have a definitive diagnosis of APS [defined by the Sydney criteria as an arterial or venous thrombosis and IgM and/or IgG anti-cardiolipin antibody >40GLP, IgG and/or IgM beta-2 glycoprotein >99th percentile, and/or positive lupus anticoagulant (e.g. prolonged silica clot time or dilute Russell viper venom time)]. Patients were reviewed for recurrent thrombi, severe bleeding or other complications that led to changes in their management.Results: Sixty-six patients were identified with suspected APS, with 18 being treated with a NOAC. Of these, 10 had definitive APS per the Sydney criteria and were analyzed. 6/10 (60%) were treated with apixaban and 4/10 (40%) were treated with rivaroxaban. No patients developed severe bleeding or thrombotic complications and none required changes of their therapy. 30% started a NOAC as the first line outpatient regimen with the remaining 70% being previously treated with other anticoagulants. 7/10 (70%) were treated with warfarin and 3 patients were treated with fondaparinux before changing to a NOAC. Reasons for stopping warfarin were difficulty managing INRs (33%) or thrombi while on warfarin (66%). Of those previously on fondaparinux, reasons for changing therapy were transient ischemic attack (33%), difficulty with injections (33%) and cost (33%). Of these 10 patients, safe and effective anticoagulation with a NOAC was noted for up to 36 months without adverse effects.Conclusion: Apixaban and rivaroxaban showed to be a safe and effective first line outpatient regimen for patients with APS or patients with APS who develop recurrent thrombi on warfarin or parenteral anticoagulation. Further prospective studies are needed before their use should be considered standard of care.Table 1Patients with Anti-Phospholipid Syndrome Treated with Non-Warfarin Oral AnticoagulantPatientFirst Positive TestSecond Positive TestSerum Testing Performed off WarfarinAnticoagulantLength of Treatment (in months)Bleeding ComplicationsThrombotic ComplicationsPrior Anticoagulant UseReason Therapy was Changed1Cardiolipin IgG 52, β2 IgG >112Cardiolipin IgG 76, β2 IgG >112; RVVT prolongedNoApixaban8NoneNoneYes (warfarin)Difficult to control INR2Cardiolipin IgG >15;RVVT prolongedCardiolipin IgG >15;RVVT prolongedYesApixaban6NoneNoneYes (warfarin)Difficult to control INR3Cardiolipin & β2 >112Cardiolipin & β2 >112YesApixaban2NoneNoneYes (warfarin)Stroke while on warfarin4Cardiolipin IgM 66, β2 IgM 68Cardiolipin IgM 98, β2 IgM 87YesApixaban8NoneNoneNoN/A5β2 IgG 122;+ LACardiolipin & β2 >112NoApixaban7NoneNoneYes (warfarin)Multiple strokes while on warfarin6β2 IgM 29;+ LACardiolipin IgM 50, β2 IgM 74RVVT prolongedYesApixaban4NoneNoneYes (Fondaparinux)Difficulty with injections7Cardiolipin IgG 73Cardiolipin IgG & β2 IgG>112;RVVT prolongedYesRivaroxaban36NoneNoneYes (warfarin & fondaparinux)Thrombi on warfarin & fondaparinux8Cardiolipin IgG>112;RVVT prolongedCardiolipin IgG>112Yes*Rivaroxaban2NoneNoneYes (warfarin)Difficult to control INR9Cardiolipin IgM & β2 IgM>112Cardiolipin IgM & β2 IgM>112Yes*Rivaroxaban15NoneNoneNoN/A10β2 IgG>100RVVT prolongedβ2 IgG>100;RVVT prolongedNoRivaroxaban31NoneNoneYes (warfarin & fondaparinux)Thrombi on warfarin & fondaparinux*Second serum testing drawn while on rivaroxaban DisclosuresOff Label Use: Apixaban and rivaroxaban use in patients with Anti-phospholipid Syndrome.

Non-Warfarin Oral Anticoagulants in Heparin-Induced Thrombocytopenia

Introduction: Heparin-Induced Thrombocytopenia (HIT) is an antibody-mediated reaction where exposure to heparin products (unfractionated and, less commonly, low molecular weight heparins) leads to a paradoxical prothrombotic state. Current treatment guidelines recommend immediate cessation of all heparin products and initiation of a non-heparin anticoagulant. This is typically accomplished with argatroban and then transitioning to a vitamin K antagonist once platelets have recovered. An attractive alternative is the use of the non-warfarin oral anticoagulants (NOACs) in the treatment of HIT, namely the direct Xa inhibitors apixaban and rivaroxaban which have already proven safe and effective for the treatment of venous thromboembolism.Methods: We designed a retrospective analysis of all patients at the University of Virginia with a positive serotonin release assay (for a definitive diagnosis of HIT) that were treated with either apixaban or rivaroxaban since September 2011. Results from heparin induced platelet antibody testing were also recorded. Patients were reviewed for recurrent thrombi, severe bleeding or other complications that led to changes in their management.Results: Eleven patients were identified based on the inclusion criteria. All patients had a positive serotonin release assay despite 4/11 (36%) testing negative for heparin induced platelet antibody. All patients received intravenous argatroban or bivalirudin at the time of diagnosis and were transitioned to an oral anticoagulant at time of hospital discharge. 9/11 (81%) were treated with apixaban and 2/11 (19%) were treated with rivaroxaban. Zero patients developed recurrent thrombi (summarized in Table 1). One patient in each group developed major bleeding leading to discontinuation of anticoagulation. Of these, both had additional risk factors for bleeding prior to initiation of anticoagulation (one with concurrent clopidogrel use after coronary artery bypass grafting and prior bleeding from gastric varices; the other with previously diagnosed metastatic squamous cell lung cancer). Of the remaining 9 patients, safe and effective anticoagulation with a NOAC was noted for up to18 months without adverse effects.Conclusion: Apixaban and rivaroxaban, along with all forms of anticoagulation, should be used with caution in patients with risk factors for severe bleeding. These medications, however, showed to be a safe and effective first line outpatient regimen for patients with HIT. Further prospective studies are needed before their use should be accepted as standard of care.Table 1Patients with Heparin-Induced Thrombocytopenia Treated with Non-Warfarin Oral AnticoagulantPatientHeparin Induced Platelet Antibody (%)Serotonin Release Assay (%)AnticoagulantLength of Therapy (in months)Bleeding ComplicationsThrombotic ComplicationsCurrent Plan1-+ (93)Apixaban8NoNoContinue2+ (110)+ (100)Apixaban2*NoNoContinue3+ (81)+ (53)Apixaban13NoNoContinue4-+ (91)Apixaban9NoNoContinue5+ (108)+ (100)Apixaban16NoNoContinue6-+ (92)Apixaban6NoNoContinue7+ (126)+ (100)Apixaban2†GastrointestinalNoOff since bleed8-+ (30)Rivaroxaban1‡HemoptysisNoOff since bleed9+ (107)+ ( 77)Apixaban10NoNoContinue10+ (89)+ (44)Apixaban6NoNoContinue11+ (106)+ (67)Rivaroxaban18NoNoContinue*No evidence of thrombosis at diagnosis, only thrombocytopenia†severe bleeding from known gastric varices; also on clopidogrel for CAD‡moderate hemoptysis secondary to known squamous cell lung cancer DisclosuresOff Label Use: Apixaban and rivaroxaban use in patients with heparin-induced thrombocytopenia.

Time to Cost-Effectiveness Following Stroke Reduction Strategies in AF: Warfarin Versus NOACs Versus LAA Closure

BackgroundLeft atrial appendage closure (LAAC) and nonwarfarin oral anticoagulants (NOACs) have emerged as safe and effective alternatives to warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation (AF). ObjectivesThis analysis assessed the cost-effectiveness of warfarin, NOACs, and LAAC with the Watchman device (Boston Scientific, Marlborough, Massachusetts) for stroke risk reduction in patients with nonvalvular AF at multiple time points over a lifetime horizon. MethodsA Markov model was developed to assess the cost-effectiveness of LAAC, NOACs, and warfarin from the perspective of the Centers for Medicare & Medicaid Services over a lifetime (20-year) horizon. Patients were 70 years of age and at moderate risk for stroke and bleeding. Clinical event rates, stroke outcomes, and quality of life information were drawn predominantly from PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) 4-year data and meta-analyses of warfarin and NOACs. Costs for stroke risk reduction therapies, treatment of associated acute events, and long-term care following disabling stroke were presented in 2015 U.S. dollars. ResultsRelative to warfarin, LAAC was cost-effective at 7 years ($42,994/quality-adjusted life-years [QALY]), and NOACs were cost-effective at 16 years ($48,446/QALY). LAAC was dominant over NOACs by year 5 and warfarin by year 10. At 10 years, LAAC provided more QALYs than warfarin and NOACs (5.855 vs. 5.601 vs. 5.751, respectively). In sensitivity analyses, LAAC remained cost-effective relative to warfarin ($41,470/QALY at 11 years) and NOACs ($21,964/QALY at 10 years), even if procedure costs were doubled. ConclusionsBoth NOACs and LAAC with the Watchman device were cost-effective relative to warfarin, but LAAC was also found to be cost-effective and to offer better value relative to NOACs. The results of this analysis should be considered when formulating policy and practice guidelines for stroke prevention in AF.

OACs in Complex Settings: Cardioversion, CAD, and PCI

The safety and efficacy of oral anticoagulation with warfarin or the nonwarfarin oral anticoagulants have not been well established in settings such as cardioversion or ablation for atrial fibrillation, coronary artery disease, percutaneous coronary intervention, and stent placement. Recent meta-analyses and randomized trials provide new data to consider regarding the positioning of oral anticoagulation in these settings.