Use Of Oral Anticoagulants In Patients Research Articles

Factors Associated With Oral Anticoagulant Use in Patients With Atrial Fibrillation and Mental Disorders.

Factors Associated With Oral Anticoagulant Use in Patients With Atrial Fibrillation and Mental Disorders.

The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting.

Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia. Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management. The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management. According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.

Risk of Bleeding Following Non–Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase

Current guidelines advise against intravenous alteplase therapy for treatment of acute ischemic stroke in patients previously treated with non-vitamin K antagonist oral anticoagulants (NOACs). To evaluate the risk of bleeding and mortality after alteplase treatment for acute ischemic stroke among patients treated with NOACs compared to those not treated with NOACs. This nationwide, population-based cohort study was conducted in Taiwan using data from Taiwan's National Health Insurance Research Database from January 2011 through November 2020 and included 7483 patients treated with alteplase for acute ischemic stroke. A meta-analysis incorporating the results of the study with those of previous studies was performed, and the review protocol was prospectively registered with PROSPERO. NOAC treatment within 2 days prior to stroke, compared to either no anticoagulant treatment or warfarin treatment. The primary outcome was intracranial hemorrhage after intravenous alteplase during the index hospitalization (the hospitalization subsequent to alteplase administration). Secondary outcomes were major bleeding events and mortality during the index hospitalization. Propensity score matching was used to control potential confounders. Logistic regression was used to estimate the odds ratio (OR) of outcome events. Meta-analysis was performed using a random-effects model. Of the 7483 included patients (mean [SD] age, 67.4 [12.7] years; 2908 [38.9%] female individuals and 4575 [61.1%] male individuals), 91 (1.2%), 182 (2.4%), and 7210 (96.4%) received NOACs, warfarin, and no anticoagulants prior to their stroke, respectively. Compared to patients who were not treated with anticoagulants, those treated with NOACs did not have significantly higher risks of intracranial hemorrhage (risk difference [RD], 2.47% [95% CI, -4.23% to 9.17%]; OR, 1.37 [95% CI, 0.62-3.03]), major bleeding (RD, 4.95% [95% CI, -2.56% to 12.45%]; OR, 1.69 [95% CI, 0.83-3.45]), or in-hospital mortality (RD, -4.95% [95% CI, -10.11% to 0.22%]; OR, 0.45 [95% CI, 0.15-1.29]) in the propensity score-matched analyses. Furthermore, the risks of bleeding and mortality were not significantly different between patients treated with NOACs and those treated with warfarin. Similar results were obtained in the meta-analysis. In this cohort study with meta-analysis, compared to no treatment with anticoagulants, treatment with NOACs prior to stroke was not associated with a higher risk of intracranial hemorrhage, major bleeding, or mortality in patients receiving intravenous alteplase for acute ischemic stroke.

Trends in newly diagnosed atrial fibrillation and oral anticoagulant use after cardiac surgery: a population-based analysis from Ontario, Canada

Abstract Background Post-operative atrial fibrillation after cardiac surgery is associated with an increased risk of death and ischemic cardiovascular outcomes. In the non-surgical setting, oral anticoagulation (OAC) is beneficial among patients with AF in reducing their risk of thromboembolism. The use of OAC for patients with post-operative AF after cardiac surgery is not well-defined in contemporary clinical practice - at a time when direct oral anticoagulants (DOAC) are commonly prescribed in the non-surgical setting. Purpose To examine trends in OAC use among patients with post-operative atrial fibrillation after cardiac surgery at a time when DOAC is commonly prescribed in clinical practice. Methods The study cohort consisted of consecutive patients (>65 years) who experienced post-operative AF within 90 days after coronary artery bypass grafting (CABG), isolated left-sided non-mechanical heart valve surgery (iValve), and combined CABG + valve surgery between 2008 and 2021, identified by a mandatory provincial registry of all patients undergoing cardiac surgery in Ontario, Canada. Key exclusion criteria included: patients with pre-existing AF, end-stage renal disease requiring dialysis, mechanical heart valves, left atrial appendage ligation, and those who required anticoagulation for non-AF indications. Prescription of OAC (warfarin or DOAC) within 90 days after discharge from surgery was collected via linkage with the Ontario Drug Benefits Plan. Results The overall cohort consisted of 45,571 patients, in whom 14,572 (32.0%) developed POAF after cardiac surgery. Rates of POAF were highest among patients who underwent combined CABG + valve surgery (44.3% in 2008 to 34.2% in 2021), followed by iValve (42.6% in 2008 to 37.3% in 2021), then followed by isolated CABG (27.6% in 2008 to 24.2% in 2021). Over the study period, there was a decrease in the rates of POAF among patients who underwent all three types of cardiac surgery (P[trend] <0.01). In 2021, rates of oral anticoagulation were highest among patients who underwent combined CABG + valve surgery (61.1%), followed by iValve (59.2%) and isolated CABG (42.0%). Among patients who underwent isolated CABG, there was a 9% increase in the rates of OAC use during the study period (P[trend] <0.001). On the other hand, rates of OAC use remained largely unchanged (Figure A) among patients who underwent iValve and combined CABG + valve surgery (P[trend] 0.24 and 0.26, respectively). Since 2018, DOAC accounted for 60-70% of all OAC prescriptions (Figure B). Conclusions Despite advances in surgical techniques and post-operative care, the rates of post-operative atrial fibrillation after cardiac surgery remain substantial. Prescription rates for OAC remain modest over the past decade, but DOAC is increasingly more commonly prescribed in this patient population. Randomized trials are needed to assess the risks and benefits of OAC, specifically DOAC, in this high-risk patient population.Figure AFigure B

Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation.

To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018. The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy. We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women. This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.

Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications.

The use of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and low stroke risk might cause more harm than benefit. Little attention has been given to address its prevalence and associated consequences. This study aimed to investigate the prescription rate of OACs, identify associated factors, and describe incident bleeding events in low-risk patients. We included patients with a new diagnosis of AF between 1 January 2011 and 31 December 2018 having a low risk of stroke (CHA2DS2-VASc score of 0 for males and 1 for females) from Australian general practice data (MedicineInsight). Patients were classified as OAC users if there was a recorded prescription of an OAC within 60 days of AF diagnosis, and factors associated with the prescription of an OAC were assessed using logistic regression. Recorded incident bleeding events were identified within 6 months after AF diagnosis or after OAC initiation for OAC non-users and users, respectively. The risk of bleeding was compared between the two groups by adjusting their baseline differences using propensity score matching. The study included 2810 low-risk patients (62.3% male) with a mean age of 49.3 ± 10.8 years. Of the total, 705 (25.1%) patients had a record of OAC prescription within 60 days of diagnosis of AF. Older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.03-1.04) and diagnosis periods (2015-2016 [OR 1.46; 95% CI 1.10-1.94] and 2017-2018 [OR 1.65; 95% CI 1.17-2.23] vs. 2011-2012) were associated with higher odds of OAC initiation. Female sex (OR 0.71; 95% CI 0.59-0.85), higher bleeding risk (ORBIT score; OR 0.80; 95% CI 0.68-0.94), and higher socioeconomic index for areas (SEIFA) quintiles (SEIFA quintiles; 2 [OR 0.65; 95% CI 0.48-0.88], 3 [OR 0.74; 95% CI 0.56-0.98], 4 [OR 0.70; 95% CI 0.52-0.94], 5 [OR 0.69; 95% CI 0.52-0.91] compared with quintile 1) were associated with lower odds of OAC prescription. A total of 52 (in 1.8% of patients) incident bleeds were identified, with 18 (2.6%) among OAC users. The rate of bleeding was not significantly different between users and non-users after matching. However, within OAC users, commencement of OAC was associated with an increased risk of bleeding compared to the period before OAC initiation (p = 0.006). One in four patients at low risk of stroke received an OAC within 60 days of AF diagnosis. Older age and the period following the widespread availability of direct-acting OACs were associated with an increased likelihood of OAC prescription. Positively, using OACs was not associated with an increased rate of bleeding compared to non-users.

Safety of direct oral anticoagulant use in patients taking verapamil or diltiazem

Safety of direct oral anticoagulant use in patients taking verapamil or diltiazem

Effect of clinic-based single-lead electrocardiogram rhythm assessment on oral anticoagulation prescriptions in patients with previously diagnosed atrial fibrillation.

Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.

Abstract TP162: Age, Weight, And Prior Stroke Predicts Ischemic Stroke Despite Direct Acting Oral Anticoagulant Use In Patients With Atrial Fibrillation

Introduction: Direct-acting oral anticoagulants (DOACs) and warfarin are standard of care for secondary prevention of ischemic stroke (IS) in persons with atrial fibrillation (AF). However, despite adequate anticoagulation (AC), patients may still experience recurrent IS. We aimed to study the characteristics of patients who developed IS despite therapeutic AC, specifically with DOACs. Methods: Between 2012 and 2021, patients admitted at our hospital with IS despite adequate AC for AF were enrolled. Clinical variables collected included National Institute of Health Stroke Scale (NIHSS), CHA 2 DS 2 -VASc and modified Rankin Score (mRS) at admission. Baseline characteristics were compared between patients taking DOACs and warfarin. Logistic regression analyses were performed to identify predictors of IS in patients using DOACs. Results: A total of 595 patients were included. Of these, 291 patients (48.9%) were on DOACs with a mean age of 75.21 and 43.9% were female. The median CHA 2 DS 2 -VASc and NIHSS score in the DOAC group was 4 and 6, respectively. Compared to those on Warfarin, patients on DOACs were younger (75.21 vs. 78.99 p < 0.001), more likely to be men (55.3% vs. 45.2% p = 0.01) and had higher rates of prior TIA/IS (37.5% vs. 29.3% p = 0.04). Both groups had similar rates of hemorrhagic transformation, but more patients in the DOAC group were on antiplatelet agents concomitantly (21% vs. 6.9% p < 0.001). The most prescribed DOAC was apixaban (66.3%) and cardioembolism was the most common stroke etiology (63.6%), followed by cryptogenic, which was significantly higher in the DOAC group (18.2% vs. 8.3% p = 0.02). Notably, DOAC failure in preventing IS was associated with younger age, overweight/obesity, and prior TIA/IS (Table) . Conclusions: IS despite the use of DOACs is more likely to occur in younger people with prior TIA/IS and obesity. Focusing on preventative strategies and risk factor control for competing mechanisms in this subgroup may help prevent IS recurrence.

Antiplatelet Agents and Oral Anticoagulant Use in Patients with Atrial Fibrillation and Carotid Artery Disease After First-Time Ischaemic Stroke.

People with atrial fibrillation (AF) frequently have competing mechanisms for ischaemic stroke, including extracranial carotid atherosclerosis. The objective of this study was to determine associations between use of oral anticoagulants (OACs) plus antiplatelet agents (APA) after ischaemic stroke and outcomes for patients with AF and carotid artery disease. A retrospective cohort study was conducted. Participants receiving OACs with or without APA were propensity score-matched for age, sex, ethnicity, co-morbidities and presence of cardiac and vascular implants and grafts. Outcomes were 1-year mortality, recurrent stroke and major bleeding. Of 5708 patients, 24.1% (n=1628) received non-vitamin K antagonist OACs (NOACs) with no APA, 26.0% (n=1401) received NOACs plus APA, 20.7% (n=1243) received warfarin without APA and 29.2% (n=1436) received warfarin plus APA. There was no significant difference in risk of recurrent stroke between the groups. Compared to receiving NOACs without APA, receiving warfarin plus APA was associated with a higher risk of mortality (hazard ratio (HR) 1.51 (95% confidence interval (CI) 1.20, 1.89)) and major bleeding (HR 1.66 (95% CI 1.40, 1.96)). Receiving NOACs plus APA was also associated with a higher risk of major bleeding compared to NOACs without APA (HR 1.27 (95% CI 1.07, 1.51), respectively). The results suggest for patients with AF and carotid artery disease after ischaemic stroke, receiving NOACs without APA is associated with a lower risk of major bleeding with no negative impact on recurrent stroke or mortality. Evidence from randomised trials is needed to confirm this finding.

Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice.

Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.

Trends in oral anticoagulant use in patients with atrial fibrillation in Belgium from 2013 to 2019: A nationwide cohort study.

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly preferred over vitamin K antagonists (VKAs) in atrial fibrillation (AF) management. However, differences in oral anticoagulant (OAC) prescribing according to patient's age, sex and physician's specialty may be present. Therefore, incident and prevalent use of OACs, NOACs and VKAs, stratified by age, sex and prescriber, and factors associated with the choice of OAC were investigated. Using two Belgian nationwide healthcare databases, AF patients ≥45 years old with ≥1 OAC prescription claim between 2013 and 2019 were identified. OAC use was investigated per half-year. Factors influencing NOAC vs. VKA initiation were identified by multivariable logistic regression. Among 448 661 included OAC-treated AF patients, 297 818 were newly treated. Incident OAC use ranged from 45-49 to 42-44 users/10 000 persons between 2013 and 2019, whereas prevalent OAC use increased from 337 to 435 users/10 000 persons. Incident and prevalent NOAC use exceeded VKA use since 2013 and 2015, respectively, and NOACs represented 92% of incident and 81% of prevalent OAC users in 2019. Apixaban was the most frequently used NOAC since 2016. NOACs were significantly more prescribed by cardiologists and to older patients, whereas VKAs were more initiated in patients with cardiovascular, renal and hepatic comorbidities. Prevalent OAC use increased less in women than men (25.3% vs. 33.0% between 2013 and 2019) and female subjects had 5% significantly lower odds of NOAC vs. VKA initiation than men. Since 2013, prevalent anticoagulant use increased almost one third in Belgium, while incident use was stable. Potential (N)OAC underuse in women requires further exploration.

Trends in oral anticoagulant use in patients with atrial fibrillation in Belgium from 2013 to 2019: a nationwide cohort study

Abstract Background Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly preferred over vitamin K antagonists (VKAs) in atrial fibrillation (AF) management. However, differences in oral anticoagulant (OAC) prescribing according to patient's age, patient's sex and physician's specialty may be present. Purpose To investigate the incident and prevalent use of OACs, NOACs and VKAs, stratified by age, sex and prescriber, and factors associated with the choice of OAC on a full-population scale. Methods Using two Belgian nationwide healthcare databases, AF patients ≥45 years old with ≥1 OAC prescription claim between January 1st, 2013 and December 31st, 2019 were identified. OAC use was investigated per half-year with a repeated cross-sectional design, based on medication prescription claims on a day-to-day basis. Incident use was defined as the first OAC use during the study period in OAC-naïve AF patients, whereas prevalent OAC use was defined as at least 1 OAC dispensing during a specific half-year. Factors influencing NOAC versus VKA initiation were identified by multivariable logistic regression models. Results Among 448,661 included OAC-treated AF patients (260,184 prevalent NOAC and 188,477 prevalent VKA users), 297,818 were newly-treated (232,739 incident NOAC and 65,079 incident VKA users). The mean age of incident NOAC and VKA users was 76±10 and 71±12 years, and 48% and 47% were female, respectively. Incident OAC use ranged from 45–49 to 42–44 users/10,000 persons between 2013–2019, whereas prevalent OAC use increased from 337 to 435 users/10,000 persons. Incident and prevalent NOAC use exceeded VKA use since 2013 and 2015 respectively, and NOACs represented 92% of incident and 81% of prevalent OAC users in 2019. Apixaban was the most frequently used NOAC since 2016. NOACs were significantly more prescribed by cardiologists and to older patients, whereas VKAs were more initiated in patients with cardiovascular, renal and hepatic comorbidities. Prevalent OAC use increased less in women than men (+25% versus +33% between 2013–2019) and female subjects had a 5% significantly lower odds of NOAC versus VKA initiation than men after multivariable adjustment. Conclusions Prevalent anticoagulant use increased with 29% in Belgium between 2013 and 2019. However, potential (N)OAC underuse among female AF patients was observed. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders (FWO)

Trends in direct oral anticoagulant use in patients presenting with acute stroke.

Acute ischaemic strokes occur despite the use of direct oral anticoagulants (DOACs). A retrospective review was conducted at a high‐volume primary stroke centre over a 3‐year period to assess the acute management of stroke presentations in patients prescribed DOACs. During the time period of the study, 103 of 195 anticoagulated stroke patients presented within the timeframe for thrombolysis and only 15 patients had DOAC plasma level assays performed. Of these 103, 5 received thrombolysis; however, DOAC level was not a factor in these cases.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Effect of Mailing Educational Material to Patients With Atrial Fibrillation and Their Clinicians on Use of Oral Anticoagulants

Only about half of patients with atrial fibrillation (AF) who are at increased risk for stroke are treated with an oral anticoagulant (OAC), despite guideline recommendations for their use. Educating patients with AF about prevention of stroke with OACs may enable them as agents of change to initiate OAC treatment. To determine whether an educational intervention directed to patients and their clinicians stimulates the use of OACs in patients with AF who are not receiving OACs. The Implementation of a Randomized Controlled Trial to Improve Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation (IMPACT-AFib) trial was a prospective, multicenter, open-label, pragmatic randomized clinical trial conducted from September 25, 2017, to May 1, 2019, embedded in health plans that participate in the US Food and Drug Administration's Sentinel System. It used the distributed database comprising health plan members to identify eligible patients, their clinicians, and outcomes. IMPACT-AFib enrolled patients with AF, a CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score of 2 or more, no evidence of OAC prescription dispensing in the preceding 12 months, and no hospitalization-related bleeding event within the prior 6 months. Randomization to a single mailing of patient and/or clinician educational materials vs control. Analysis was performed on a modified intention-to-treat basis. The primary end point was the proportion of patients with at least 1 OAC prescription dispensed or at least 4 international normalized ratio test results within 1 year of the intervention. Among 47 333 patients, there were 24 909 men (52.6%), the mean (SD) age was 77.9 (9.7) years, mean (SD) CHA2DS2-VASc score was 4.5 (1.7), 22 404 patients (47.3%) had an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more, and 8890 patients (18.8%) had a history of hospitalization for bleeding. There were 2328 of 23 546 patients (9.9%) in the intervention group with initiation of OAC at 1 year compared with 2330 of 23 787 patients (9.8%) in the control group (adjusted OR, 1.01 [95% CI, 0.95-1.07]; P = .79). Among a large population with AF with a guideline indication for OACs for stroke prevention who were randomized to a mailed educational intervention or to usual care, there was no clinically meaningful, numerical, or statistically significant difference in rates of OAC initiation. More-intensive interventions are needed to try and address the public health issue of underuse of anticoagulation for stroke prevention among patients with AF. ClinicalTrials.gov Identifier: NCT03259373.

MO514: Cardiorenal Outcomes Associated With Oral Anticoagulant Use in Patients With Atrial Fibrillation

Abstract BACKGROUND AND AIMS Novel oral anticoagulants (NOAC) are currently the first-line choice for stroke prevention in patients with atrial fibrillation (AF), as they have a better risk/benefit profile compared with vitamin K antagonists (VKA). Secondary analyses of trials suggest that NOAC also reduces kidney outcomes, but this has been less explored. METHOD Observational study from the SCREAM project comparing clinical outcomes of all persons with AF and eGFR ≥15 mL/min/1.73 m2 that initiated NOAC or VKA in Stockholm, Sweden, during 2011–18. The primary outcomes were acute kidney injury (AKI, by diagnosis or sudden creatinine elevation) and the composite of kidney failure and >30% eGFR decline. Secondary outcomes were major bleeding and the composite of hospital admission with stroke or systemic embolism. Inverse probability of treatment weighting (IPTW) was used to balance 51 baseline confounders. Sensitivity analyses included falsification endpoints (pneumonia and cataract surgery), subgroups and evaluation of per-protocol effects. RESULTS A total of 32 699 patients initiated oral anticoagulants (median age, 75 years, 45% women, median eGFR 73 mL/min/1.73 m2), of which 18 323 (56%) used NOAC. Compared with VKA, initiation of NOAC was associated with a 13% lower relative risk of experiencing the composite kidney outcome (HR: 0.87; 95% CI 0.78–0.98) and a 12% relative risk reduction on AKI occurrence (HR: 0.88; 95% CI 0.80–0.97). Compared with VKA, NOAC use was associated with a lower risk of major bleeding (HR 0.77; 95% CI 0.67–0.89), but a similar risk of stroke/systemic embolism (HR: 0.93; 95% CI 0.78–1.11). Results were similar across subgroups, including patients with chronic kidney disease (eGFR <60 mL/min/1.73 m2) and when censoring patients at treatment discontinuation or switch. CONCLUSION Compared with VKA, and regardless of baseline kidney function, initiation of NOAC was associated with a lower risk of CKD progression, AKI and major bleeding, but a similar risk of the composite of stroke and systemic embolism.

PO-701-04 OUTCOMES OF LEFT ATRIAL APPENDAGE CLOSURE IN PATIENTS WITH ATRIAL FIBRILLATION AND END-STAGE RENAL DISEASE ON DIALYSIS

Oral anticoagulation (OAC) therapy is the mainstay of treatment for stroke-risk reduction in patients with atrial fibrillation (AF). However, OAC use in patients with end-stage renal disease (ESRD) on dialysis is associated with a significantly increased risk of bleeding and an uncertain benefit in stroke reduction. In these patients, left atrial appendage closure (LAAC) could be alternative. To describe procedural efficacy, safety, and clinical outcomes of patients with AF and ESRD on dialysis undergoing LAAC for stroke prevention. Consecutive patients with AF and ESRD who underwent LAAC for stroke prevention were included. LAAC was performed with Watchman (Boston Scientific) under continuous echocardiographic guidance. Baseline clinical and procedural characteristics, post procedural anticoagulation and clinical outcomes during follow-up were collected. The primary endpoint was the risk of stroke, which was compared to historical cohorts. The secondary endpoints were procedure related complications and all-cause mortality. Between October 2017 and October 2021, a total of 27 patients (mean age 70 years, +/- 9.1; 29.6% female, mean CHA2DS2Vasc score 4.6, +/-2.1) were included. Sixteen patients (59%) had prior history of bleeding on OAC. Procedural success was achieved in 26 (96%) patients. Postprocedural treatment included time limited OAC (48%), single or dual antiplatelet therapy (22% and 26% respectively), or no antithrombotic treatment (3%). No stroke or embolic events were reported at a mean follow up of 482 days. Compared with a historical cohort that reported a risk of hospitalization for stroke of 7.7% with OAC, a significant reduction in the risk of stroke was observed. Two patients had procedure related complications. Six patients died (22%), none of them due to stroke or procedure related complications. Mortality was lower than 41% reported in a similar cohort on OAC. Patients with ESRD and AF undergoing LAAC have a significant reduction in the risk of stroke during follow-up. Although all-cause mortality is high in this group of patients, LAAC should be considered in this group of patients as a treatment option taking into consideration the lack of proven net clinical benefit with OAC therapy and the favorable reduction in stroke risk.

Global Oral Anticoagulation Use Varies by Region in Patients With Recent Diagnosis of Atrial Fibrillation: The GLORIA-AF Phase III Registry.

BackgroundEffective stroke prevention with oral anticoagulants (OAC) is recommended for some patients with atrial fibrillation (AF). We aimed to describe OAC use by geographical region and type of site in patients with recent‐onset AF enrolled in a large global registry.Methods and ResultsEligible participants were recruited into GLORIA‐AF (Global Registry on Long‐Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation), a prospective observational cohort study from 2014 to 2016 in 4 international regions: North America, Europe, Asia, and Latin America. Cumulative incidence functions were generated for direct OACs (DOAC), vitamin K antagonists, and antiplatelet drugs considering competing risks, stratified by region and type of site. Time‐to‐treatment initiation after AF diagnosis was analyzed with Fine‐Gray subdistribution hazard models. A total of 21 237 patients eligible for analysis were identified. By 30 days after AF diagnosis, 40%, 16%, and 8.6% of patients had DOAC, vitamin K antagonists, and antiplatelet drugs initiated, respectively. Earlier initiation of DOACs was observed in Europe, with Asia and Latin America having lower hazard rates of DOAC time‐to‐treatment initiation than Europe (hazard ratio [HR], 0.66; 95% CI, 0.62–0.70 and HR, 0.79; 95% CI, 0.73–0.85, respectively). DOAC initiation was highest in community hospitals, vitamin K antagonists in outpatient health care centers/anticoagulation clinics, and antiplatelet drugs in primary care clinics.ConclusionsImportant geographic variability exists with the use of OACs for patients with AF. Differences in the time‐to‐treatment initiation of OAC by type of site suggests suboptimal implementation of guideline recommendations and could result in less benefit and more harm. Optimizing OAC use for patients with AF may improve outcomes and reduce health care costs.RegistrationURL: http://www.clinicaltrials.gov; Unique identifiers: NCT01468701, NCT01671007.

Antithrombotic Therapy after Transcatheter Aortic Valve Replacement.

ABSTRACTTranscatheter aortic valve replacement (TAVR) is a treatment option for patients with asymptomatic severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. TAVR carries a risk for thrombotic and bleeding events, focusing on the importance of defining the optimal antithrombotic regimen. Patients undergoing TAVR are mostly elderly and have many comorbidities such as atrial fibrillation (AF) requiring oral anticoagulants (OACs) or coronary artery disease requiring antiplatelet agents. After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy is associated with an increased risk for bleeding events, particularly early postprocedure compared with single-antiplatelet therapy with aspirin. The risk of leaflet thrombosis in patients undergoing TAVR raised concern about the use of OAC in patients without an initial indication for anticoagulation therapy. Although it showed effectiveness in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with AF, adding antiplatelet therapy increases bleeding events. A favorable effect of new OAC agents over Vitamin K antagonists is debatable. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation, respectively. This article aims to review the available published studies and recommendations in the literature regarding the use of antithrombotic therapy post-TAVR.