Oral Anticoagulant Group Research Articles

Pre-injury use of antiplatelet and anticoagulations therapy are associated with increased mortality in a cohort of 1038 hip fracture patients.

Hip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common. This study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients. Mortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p=0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007). Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences. A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant. Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score. We believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs.

Analysis of pre-ablation oral anticoagulation in patients with non-valvular atrial fibrillation in real clinical practice

Objective:To investigate the incidence of left atrial appendage (LAA) thrombosis and to assess the oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF) before catheter ablation.Material and Methods.We studied 638 patients with AF who underwent transesophageal echocardiography before AF ablation from 2014 to 2017. The analysis included the baseline characteristics of patients.Results.There was no statistical difference in the risk of thromboembolic complications (TEC) in patients with and without OAC. All patients were divided into four groups: 167 patients (26.2%) received warfarin (group 1); 128 patients (20.1%) received dabigatran (group 2); 145 patients (22.7%) received rivaroxaban or apixaban (group 3); and 198 patients (31%) were not administered with OAC (group 4). Among patients without OAC, only 26 individuals (13.1%) had a low TEC risk, whereas 172 patients had a moderate or high TEC risk. Half of group 4 received antiplatelet drugs, but a third of them had a high TEC risk and were recommended to take OAC. Patients in the pre-ablation period received different types of OAC with the same frequency. LAA thrombosis was detected in 44 patients (6.9%). Significant differences in the incidence of LAA thrombosis in patients receiving different OAC were not detected. LAA thrombosis was detected in one patient receiving dabigatran with a low risk of TEC. There was also a trend for more frequent therapeutic levels of INR in patients taking warfarin with LAA thrombosis and there were no patients with INR > 3.0. About half of patients without thrombosis were treated with subtherapeutic warfarin therapy, and only a third of them had the therapeutic range of INR.Conclusion.Not all patients with non-valvular AF take OAC at the pre-ablation period. All types of OAC are prescribed with the same frequency. Differences in the incidence of LAA thrombosis, depending on the received OAC, were not detected. There was no association between the detection of thrombosis and the therapeutic range of INR in group 1. There were no significant differences in the incidence rates of LAA thrombosis between warfarin, dabigatran, rivaroxaban, or apixaban.

Anticoagulation With or Without Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement for Patients With Atrial Fibrillation: A Meta-Analysis

BackgroundAlthough current guidelines recommend oral anticoagulants (OAC) with or without antiplatelet therapy (APT) following transcatheter aortic valve replacement (TVAR) in patients with an indication for long-term anticoagulation therapy, the optimal antithrombotic strategy remains unknown in these population. Herein, we conducted a meta-analysis comparing the outcome of OAC alone versus OAC with APT following TAVR in patients with atrial fibrillation (AF). MethodsMEDLINE and EMBASE were searched through May 2020 to identify clinical trials that investigated OAC alone versus OAC with APT following TAVR in patients with AF. From each study, we extracted the hazard ratios (HRs) or risk ratios of major or life threatening bleeding, stroke, all-cause mortality and cardiovascular mortality. Results1 randomized controlled trial and 3 observational studies were identified, which enrolled a total of 2032 patients with AF who underwent TAVR assigned to the OAC group (n = 722) or OAC with APT group (n = 1310). Pooled analyses demonstrated the rate of major or life threatening bleeding was significantly lower in the OAC group compared to the OAC with APT group (HR [95% Confidence Interval [CI] = 0.54 [0.38–0.77], P = .0006]). However, the rate of stroke was similar in both groups (HR [95% CI] = 1.22 [0.80–1.87], P = .36). All-cause and cardiovascular mortalities were also similar in both groups. ConclusionsWe observed that OAC with APT following TAVR in patients with AF increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke.

A CLINICAL CASE OF LYSIS OF THROMBUS IN THE LEFT ATRIAL APPENDAGE IN A PATIENT WITH ATRIAL FIBRILLATION PREVIOUSLY TREATED WITH WARFARIN

The article describes the clinical observation of LAA thrombosis in a 46-year-old patient with atrial fibrillation that first occurred during taking warfarin; discusses further management of the patient. Due to inefficacy of medical cardioversion (CV) and the need to restore sinus rhythm, electric CV was planned. Before the planned restoration of the rhythm, transesophageal echocardiography was performed and a thrombus in the LAA was detected. Given that the patient had been on adequate warfarin therapy for a long time, it was decided to prescribe a drug from the direct oral anticoagulants group dabigatran etexilate at a dose of 150 mg BID for 8 weeks. The control transesophageal echocardiographic examination showed evidence of complete lysis of thrombus.

Long-term effect of anticoagulation following left atrial appendage occlusion with the LARIAT device in patients with nonvalvular atrial fibrillation: impact on thromboembolism, bleeding and mortality. Real life data.

IntroductionIndications for left atrial appendage occlusion (LAAO) are varied and patients require individual management strategies. However, currently no guidelines exist for postprocedure oral anticoagulation (OAC) after an LAAO procedure.AimTo evaluate the effect of OAC on thromboembolism, bleeding and mortality following the LAAO procedure for patients with AF.Material and methodsOne hundred and thirty-nine consecutive patients with nonvalvular atrial fibrillation (NVAF) who underwent LAAO with the LARIAT device were followed for at least 40 months. Decisions about OAC and its modifications were individualized based on clinical presentation, patient and physician preferences.ResultsFollowing LAAO, 52 (41%) patients did not receive OAC (No-OAC group) and 75 (59%) patients received OAC (OAC group), without any intergroup differences in CHADS2, CHA2DS2-VASc score or other thromboembolic risk factors. The median HAS-BLED score was higher in the OAC-group (median 3 (3–4) vs. 3 (2–4), p = 0.014). During a median follow-up time of 51 (43–57) vs. 55 (48–59) months in the No-OAC group and in the OAC group (p = 0.19) there were no significant differences between groups in ischemic stroke/TIA, 0 (0%) vs. 2 (2.7%), other thromboembolic events, 0 (0%) vs. 1 (1.3%), life-threatening, disabling or major events, 2 (3.7%) vs. 2 (2.7%), or annual mortality rate, 1.9% vs. 0.9%, respectively.ConclusionsThere is no need for OAC after the LAAO procedure. Omitting OAC after an LAAO procedure in AF patients: (1) has similar stroke prevention rates as patients on OAC, (2) has similar bleeding prevention rates as patients on OAC, (3) has similar safety endpoints and long-term efficacy as patients on OAC.

The Beneficial Effect of Anticoagulation in Aortic Bioprosthesis is Associated with its Size.

ObjectiveTo evaluate the clinical and echocardiographic outcomes in aortic valve replacement (AVR) patients with aortic bioprosthesis under oral anticoagulation (OA).MethodsPatients who underwent AVR with bioprosthesiswere prospectively enrolled. They were classified based on postoperative use of OA. Clinical and operative variables were collected. Echocardiographic and clinical follow-ups were performed two years after surgery. The primary outcome evaluated was change in transprosthetic gradient. Secondary outcomes analyzed were change in New York Heart Association (NYHA) class, major bleeding episodes, hospitalization, stroke, and transient ischemic attack.ResultsWe included 103 patients (61 without OA and 42 with OA). Clinical characteristics were similar among groups, except for younger age (76±6.3 vs. 72.4±8.1 years, P=0.016) and higher prevalence of atrial fibrillation (0% vs. 23.8%, P<0.001) in the OA group. Mean (21.4±10 mmHg vs. 16.8±7.7 mmHg, P=0.037) and maximum (33.4±13.7 mmHg vs. 28.4±10.2 mmHg, P=0.05) transprosthetic gradients were higher in patients without OA. Improvement in NYHA class was more frequent in patients with OA (73% vs. 45.3%, P=0.032). Major bleeding, stroke, and hospitalization were similar among groups. OA was the only independent predictor for improvement of NYHA class after multivariate logistic regression analysis (odds ratio [OR]: 5.9, 95% confidence interval [CI]: 1.2-29.4; P=0.028). Stratification by prosthesis size showed that patients with ≤ 21 mm prosthesis benefited from OA.ConclusionEarly anticoagulation after AVR with bioprosthesis was associated with significant decrease of transprosthesis gradient and improvement in NYHA class. These associations were seen mainly in patients with ≤ 21 mm prosthesis.

ANTICOAGULATION IN CHRONIC KIDNEY DISEASE PATIENTS WITH ATRIAL FIBRILLATION: OLD VS NEW DRUGS

In the last two decades a group of novel oral anticoagulants (NOACs) has been developed that directly block the activity of thrombin or activated factor X. No randomized controlled trials have been conducted to verify their efficacy and safety in patients with advanced chronic kidney disease (CKD) and atrial fibrillation. Few studies compared NOACs (dabigatran, rivaroxaban, apixaban, edoxaban) with classic anticoagulants in this unique group, and the results of these analyses remain controversial and inconclusive. Simple extrapolation of recommendations from the general population may be erroneous and lead to an increased risk of complications. Several controlled randomized trials with oral direct anticoagulants in hemodialysis patients are currently underway.

P2833Safety and efficacy of oral anticoagulation discontinuation in high thromboembolic risk patients at long term follow-up after successful atrial fibrillation ablation

Abstract Background Current guidelines recommend the use of oral anticoagulation (OAC) after successful ablation procedure of atrial fibrillation (AF), according to patient's thromboembolic risk score. However, several observational studies demonstrated similar thromboembolic events and lower incidence of major bleedings in patients who discontinued OAC after successful AF ablation compared with those on OAC. However, data on long-term follow-up after OAC discontinuation in high thromboembolic risk patients successfully treated with AF ablation are missing. Purpose To evaluate the incidence of stroke/TIA and bleeding events at long term follow-up after successful AF ablation in high thromboembolic risk patients who discontinued OAC therapy (Off OAC group) compared to those who continued it indefinitely (On OAC group). Methods Patients with CHA2DS2VASC score of 2 or more at time of the ablation procedure who discontinued OAC after successful catheter ablation for AF performed between 2001 and 2018 were included in this study. OAC was discontinued in patients without atrial tachyarrhytmias recurrences after intensive monitoring, left atrial dysfunction or pulmonary stenosis. Results 503 patients (pts), were enrolled in the study (On OAC group: 241 pts; Off OAC group: 262 pts). After a median follow up of 6.3 years, occurred 12 and 14 stroke/TIA events in the On OAC and Off OAC group, respectively (p: 0.854). Bleeding events occurred more frequently in the On OAC group compared to Off OAC group (18 vs 8 events, p: 0.025). At multivariate analysis OAC therapy was independently associated with an increased risk of major bleeding (OR: 2.92, CI95%: 1.11–7.70, p: 0.03) whereas no difference in the risk of stroke were found (OR 0.89, CI95%: 0.37–2.16, p: 0.799). Conclusion Discontinuation of OAC after successful AF ablation in high thromboembolic risk patients seems to be a safe and effective strategy even in a long term follow up. Prospective randomized trials are needed to confirm these results

How minimally interrupted direct oral anticoagulants affect intraprocedural anticoagulation during atrial fibrillation ablation? Insights from a Japanese single-center retrospective study.

BackgroundData are still lacking regarding the effects of minimally interrupted direct oral anticoagulants (MID) on the intensity of intraprocedural anticoagulation of atrial fibrillation (AF) ablation.MethodsA total of consecutive 269 patients who undergone AF ablation were eligible for the study. All oral anticoagulants (OACs) were discontinued just one dose before the procedure except warfarin. We assessed the total required dose of UFH and time‐to‐target ACT > 300 seconds (TTA) for each of direct oral anticoagulant (DOAC) groups compared with the uninterrupted warfarin group.ResultsDOACs were used in 86% of the patients in the present study (dabigatran group (DG)‐17%, rivaroxaban group (RG)‐30%, apixaban group (AG)‐29%, and edoxaban group (EG)‐10%). DG and EG used comparable dose of total UFH to WG (WG vs DG; 206 ± 53 U/kg vs 231 ± 63 U/kg; P = .664, vs EG; 239 ± 67 U/kg; P = .335), while RG and AG required higher total UFH (WG vs RG; 206 ± 53 U/kg vs 270 ± 63 U/kg; P < .001, vs AG; 263 ± 62 U/kg; P < .001). TTA was significantly longer in RG (RG:73 ± 28 minutes vs WG:51 ± 25 minutes; P = .001), AG (AG:64 ± 26 minutes vs WG:51 ± 25 minutes; P = .02), and EG (EG:67 ± 34 minutes vs WG:51 ± 25 minutes; P = .02) than WG, whereas DG was comparable to WG (DG:51 ± 29 minutes vs WG:51 ± 25 minutes; P = NS). Especially, only RG demonstrated significantly slower increase in ACT than WG (P = .013). In the multivariate analysis, warfarin or dabigatran use, age > 75 years, and body weight < 60 kg are clinical predictors for achieving TTA within 60 minutes (TTA‐60).ConclusionMID‐dabigatran was comparable to uninterrupted warfarin, whereas MID‐factor Xa inhibitors were not. MID is a feasible protocol; however, we should be aware of its effect on the intraprocedural anticoagulation and differences among DOACs in the responsiveness to heparin.

PB1850 DENTAL MANAGEMENT OF PATIENTS TAKING NOVEL ORAL ANTICOAGULANTS (NOAS): DABIGATRAN.

Background:A new group of oral anticoagulants with clear advantages over classic dicoumarin oral anticoagulants (warfarin and acenocoumarol) has been developed in recent years.Aims:Patients being treated with oral anticoagulants are at higher risk for bleeding when undergoing dental treatments.Methods:A literature search was conducted through April 2015 for publications in the ISI Web of Knowledge, PubMed and Cochrane Library using the keywords “dabigatran”, “new oral anticoagulants”, “bleeding” and “dental treatment”.Results:There is no need for regular coagulation monitoring of patients on dabigatran therapy. Whether or not to temporarily discontinue dabigatran must be assessed according to the bleeding risk involved in the dental procedure to be performed.Summary/Conclusion:The number of patients under treatment with new oral anticoagulants will increase in the coming years. It is essential to know about the pharmacokinetics and pharmacodynamics of new oral anticoagulants and about their interactions with other drugs. It is necessary to develop clinical guidelines for the perioperative and postoperative management of these new oral anticoagulants in oral surgical procedures and to carefully evaluate the bleeding risk of dental treatment, as well as the thrombotic risk of suppressing the new oral anticoagulant.

Anticoagulants in Older Patients with Nonvalvular Atrial Fibrillation after Intracranial Hemorrhage

Background and PurposePatients with nonvalvular atrial fibrillation (NVAF) who survive an intracranial hemorrhage (ICH) have an increased risk of ischemic stroke and systemic embolism (IS/ SE). We investigated whether starting oral anticoagulants (OACs) among older NVAF patients after an ICH was associated with a lower risk of IS/SE and mortality but offset by an increase in major bleeding. MethodsWe assembled a patient cohort from the Quebec Régie de l’Assurance Maladie du Québec (RAMQ) and Med-Echo administrative databases. We identified older adults with NVAF from 1995 to 2015. All patients with incident ICH and discharged in community were included. Patients were categorized according to OAC exposure. Outcomes included IS/SE, all-cause mortality, recurrent ICH and major bleeding after a quarantine period of 6 weeks. Crude event rates were calculated at 1-year of follow-up, and Cox proportional hazard models with a time-dependent binary exposure were used to assess adjusted hazard ratios (AHRs). ResultsThe cohort of 683 NVAF patients with ICH aged 83 years on average. The rates (per 100 person-years) for IS/SE, death, ICH and major bleeding were 3.3, 40.6, 11.4, and 2.7 for the no OAC group; and 2.6, 16.3, 5.2, and 5.2 for OAC group, respectively. The AHR for IS/SE and death was 0.10 (95% confidence interval [CI], 0.05 to 0.21), 0.43 (95% CI, 0.19 to 0.97) for recurrent ICH and 1.73 (95% CI, 0.71 to 4.20) for major extracranial bleeding comparing OAC exposure to non-exposed. ConclusionsInitiating OAC after ICH in older individuals with NVAF is associated with a reduction of IS/SE and mortality and a trend in recurrent ICH supporting its use after ICH.

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis

PurposeWe sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy.BackgroundDirect oral anticoagulants have become a popular choice...

DIRECT ORAL ANTICOAGULANTS: A COMPARISON OF EFFICACY AND SAFETY, ERRORS IN THEIR APPLICATION, AND THE USAGE OF REVERSAL AGENTS

This review is devoted to updating the existing knowledge about pharmacology of the drugs from the group of direct oral anticoagulants (DOACs). Special attention is paid to comparison of the anticoagulant properties of DOACs with traditional (indirect) anticoagulants at various dosage regimens and to study drug interactions of DOACs with drugs from different pharmacological groups. Widely analyzed the side effects associated with errors in the application of DOACs and provided recommendations for their correction, including the using of reversal agents therapy. Based on this, the presented article will be useful to clinicians to familiarize themselves with modern medical strategies based on the use of drugs from the DOACs group for the prevention and treatment of diseases associated with increased blood clotting ability and using of DOACs specific antagonists for treatment overdose of DOACs.

Significance of CYP4F2 polymorphism on oral anticoagulation therapy with acenocoumarol in South Indian patients with mechanical heart valves

BackgroundThe coumarin group of oral anticoagulants has a narrow therapeutic range and wide inter-individual variability. Polymorphism of VKORC1 and CYP2C9 genes are the major genetic determinants of the drug-dose response. Our study aimed to investigate the role of CYP4F2 (1347 G > A) polymorphism on the acenocoumarol daily dose requirement, and its interaction with VKORC1 and CYP2C9 polymorphism. Methods301 Rheumatic Heart Disease (RHD) patients with mechanical cardiac valves were recruited. Genotyping for CYP4F2, VKORC1 and CYP2C9 was done by PCR-RFLP. CYP4F2 genotype distribution GG, GA and AA was 23.5%, 51.5% and 25% respectively. The mean daily dose requirement for variant homozygous patients (AA) was 0.46 folds more when compared to wild type (GG) (Adjusted OR 0.46; 0.21–0.99, p = .048). However, on combined genotype analysis of CYP4F2, VKORC1 and CYP2C9 there was no significant difference in mean dose requirement. ConclusionThe homozygous genotype (AA) of CYP4F2 gene was more prevalent in our study cohort. No significant association was found between CYP4F2 gene polymorphism and acenocoumarol mean dose requirement, both when analyzed individually and in combination with VKORC1 and CYP2C9 polymorphisms.

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.

Influence of Polypharmacy on the Effectiveness and Safety of Rivaroxaban Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation.

Patients with nonvalvular atrial fibrillation (NVAF) often have multiple comorbidities requiring concomitant medications in addition to their oral anticoagulant (OAC). The objective of this study was to evaluate the impact of polypharmacy on the effectiveness and safety of rivaroxaban versus warfarin in patients with NVAF managed in routine clinical practice. Retrospective claims analysis. United States Truven MarketScan database (November 2012-March 2017). Adults who were OAC naïve during the 12months before the day of the first qualifying rivaroxaban or warfarin dispensing (index date); had at least two International Classification of Diseases, Ninth or Tenth Revision diagnosis codes for atrial fibrillation without codes suggesting valvular heart disease; had at least 12months of continuous insurance coverage prior to the qualifying OAC dispensing; and were experiencing polypharmacy (concomitant prescription claims for five or more unique chronic medication claims) were included. Patients who had concomitant prescription claims for ≥10 unique chronic medication claims constituted the substantial polypharmacy cohort used in the secondary analysis. Patients receiving rivaroxaban were propensity-score matched in a 1:1 ratio to patients receiving warfarin (13,981 patients in each polypharmacy OAC group, and 1765 patients in each substantial polypharmacy OAC group). Patients were followed until occurrence of an event (stroke or systemic embolism [SSE] combined [primary effectiveness outcome] or major bleeding [primary safety outcome]), OAC discontinuation or switch (30-day permissible gap), insurance disenrollment, or end of follow-up period. Rates of SSE, ischemic stroke, and major bleeding were compared by using Cox regression, reported as hazard ratios (HRs) and 95% confidence intervals (CIs). In patients with NVAF taking five or more chronic medications, rivaroxaban was associated with a 34% (95% CI 12-50) and 40% (95% CI 16-57) hazard reduction of SSE and ischemic stroke, respectively. Occurrence of major bleeding was similar between OAC cohorts (HR 1.08, 95% CI 0.92-1.28). A secondary analysis in patients with NVAF with substantial polypharmacy (taking ≥10 chronic medications) was also performed. Similar trends in SSE (HR 0.44), ischemic stroke alone (HR 0.62), and major bleeding (HR 1.07) were observed in patients with NVAF who had substantial polypharmacy, although 95% CIs crossed 1.0 for each outcome in this smaller study cohort. This real-world study suggests that in the setting of polypharmacy and NVAF, rivaroxaban is an effective and safe alternative to warfarin.

Clinical Impact of Oral Anticoagulation in Patients with Atrial High-rate Episodes

Background: Atrial high-rate episodes (AHREs) are common in pacemaker patients. Our aims were to compare patients with AHREs to those without them and to assess if, in those with AHREs, the initiation of oral anticoagulation (OAC) has any clinical impact on the occurrence of ischemic and hemorrhagic events. Methods: From 2014-2017 we selected patients with pacemaker in whom AHREs were detected. AHREs were defined as episodes lasting more than 6 minutes if the electrogram was available or more than 6 hours if not. We used an age- and gender-matched population with pacemaker but no AHRE as a control group (observational study). Those with AHRE were referred to their assistant physician to decide OAC initiation, based on individual circumstances (interventional study). In interventional study, the primary outcome was a composite of systemic thromboembolism or major bleeding. Secondary outcomes were clinical relevant nonmajor bleeding, major and nonmajor bleeding, CV death, and death from all causes. Results: AHREs were detected in 86 patients: 69 patients initiated OAC and the remaining 17 patients did not. When comparing patients with and without AHRE, baseline characteristics were not different between the groups, except for indexed left atrium volume—40 mL (IQR: 34-50) in AHRE group versus 35 mL (IQR: 34-40) in control group (P = .014). AHREs were associated with future development of atrial fibrillation (AF) and the risk was higher if AHRE duration was superior to 6 hours. Death and cardiovascular (CV) death were not significantly different between the groups with and without AHRE. Primary outcome occurred in 4.9 per 100 person-year in OAC group versus 3.4 per 100 person-year in non-OAC group (HR 1.4, 95% CI .2-11.3, P = .78). Secondary outcomes were not significantly different in the groups. Conclusions: In this group of patients with pacemakers, the presence of AHREs was useful for predicting the future development of AF and the risk of AF was higher in those with a longer duration of AHRE. In the AHRE group, OAC therapy was not associated with a significant difference in the risk of thromboembolism or major bleeding.

Cognitive functions in patients with atrial fibrillation at baseline and at different stages after pacemaker implantation depending on the received anticoagulant therapy

Aim. Comparative assessment of cognitive functions (memory, attention, cognition and neurodynamics) in patients with atrial fibrillation before and at different stages after implantation of permanent pacemaker depending on the received anticoagulant therapy. Methods. We examined 44 patients (average age 65.5 ± 2.5 years) with ischemic heart disease (IHD) complicated by persistent or paroxysmal atrial fibrillation, which required implantation of a permanent pacemaker (PM). The patients were divided into 2 groups: receiving warfarin (28 patients - 63.6 %, average age 65.5 ± 1.6 years) and those who received oral anticoagulants (OAC) (16 patients - 36.4 %, average age 66.3 ± 1.4 years, p = 0.614). To assess the cognitive functions, psycho-physiological complex «Status PF» was used. Results. Before PM implantation, the patients of both groups had decreased indices of visual memory. On days 5-7 after PM implantation, each group showed its increase (p = 0.001 and p = 0.013, respectively). On days 30-40, patients receiving warfarin developed a dramatic decrease of visual memory compared to the previous data and they became reliably lower than in the control group (p = 0.001). In the group receiving OAC, visual memory stayed unchanged (p = 0.076). Similar changes in warfarin group occurred at the assessment of auditory memory and attention volume (p = 0.001). Cognition indices (difficult analogues) were worse at baseline in warfarin group than in the group of OAC (7.0 ± 0.5 и 9.6 ± 0.6, р1 = 0.003) and this interrelation persisted on two following examinations (9.5 ± 0.4 and 10.8 ± 0.4, р1 = 0.041; 8.5 ± 0.4 and 9.8 ± 0.4, р1 = 0.048). Before PM implantation, the patients of both groups required more time of average exposure for neurodynamics test than in the control group (р = 0.001 and р = 0.002 respectively). On days 5-7 after PM implantation, the average exposure time decreased in both groups and they had no differences between each other and with the control (р1 = 0.132, р = 0.934 and р = 0.058). At the second testing only warfarin group had increased the mentioned time, and it exceeded the same parameter in the OAC group (p = 0.007). Conclusion. A comparative assessment of cognitive functions in patients with IHD and atrial fibrillation demonstrated that in the warfarin group and the group receiving OAC patients had cognitive deficit more profound in the patients receiving warfarin. Those differences persisted at different stages after permanent PM implantation.

Antikoagulační léčba u seniorů

Elderly and fragile patients have a higher risk of atrial fibrillation, a higher risk of systemic embolism. They are therefore often candidates for long-term anticoagulation medication. At the same time, they have an increased risk of bleeding due to age and co-morbidities, which anticoagulation therapy necessarily potentiates. New Oral Direct Anticoagulants (NOAC) registered in the Czech Republic - dabigatran, rivaroxaban, apixaban or edoxaban - are a good alternative to the currently dominant warfarin in many of these indications. Their great advantage is that they do not need to be regularly monitored on a laboratory basis and are considered to be safer, especially to significant reduction of the risk of intracranial haemorrhage. Each drug in the group of direct oral anticoagulants has some specificity resulting from pharmacological properties or the results of registration studies, so it is possible to individually determine an optimal anticoagulation strategy. Older, respectively fragile patients are characterized by reduced body weight, limited renal function, and multiple comorbidities (associated with many co-medications). For a number of seniors, it is advantageous to use a reduced dose of these drugs. Consideration of benefit and risk is often complicated in elderly patients, but this should be repeatedly done during the therapy. Key words: anticoagulation therapy - apixaban - dabigatran - edoxaban - fragile patient - geriatrics - rivaroxaban.

PCV31 - ANTICOAGULANTS IN OLDER PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATION AFTER INTRACRANIAL HEMORRHAGE

Patients with non-valvular atrial fibrillation (NVAF) who survive an intracranial hemorrhage (ICH) have an increased risk of ischemic stroke and systemic emboli (IS/SE). We investigated whether starting oral anticoagulants (OAC) among older NVAF patients after an ICH was associated with a lower risk of IS/SE and mortality, but offset by an increase in major bleeding. Cohort study assembled from administrative data from the Quebec RAMQ and Med-Echo databases. We identified older adults (> 65 years) with NVAF from 1995 to 2015 who were discharged in the community. All patients with incident ICH were included. Patients were categorized as no or OAC exposure. Outcomes included IS/SE, all-cause mortality, recurrent ICH and other major bleeding after a quarantine period of 6 weeks. Crude event rates were calculated at 1-year of follow-up, and Cox proportional Hazard models and a time-dependent binary exposure were used to calculate adjusted HRs (AHR). Cohort of 681 NVAF patients with ICH aged 83 years on average. The rate (per 100 person-years) for IS/SE, death, ICH and major bleeding were 3.3, 40.6, 11.4 and 2.7 for the no OAC group; and 2.6, 16.3, 5.2 and 5.2 for OAC group, respectively. The AHR for IS/SE and death was 0.23 (0.14-0.39) (95% confidence interval), 0.40 (0.18-0.89) for recurrent ICH and 2.26 (0.96-5.36) for major bleeding comparing OAC exposure to non-exposed. Initiating OAC after ICH in older individuals with NVAF is associated with a reduction of IS/SE and mortality as well as recurrent ICH supporting it’s use after ICH.