Oral Anticoagulants In Atrial Fibrillation Research Articles

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation.

Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics.

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by five times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc.), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for Factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a re-evaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Fibrillatory wave amplitude and thromboembolic risk in non-anticoagulated patients with atrial fibrillation

Background The benefit of oral anticoagulation in atrial fibrillation (AF) is well established for patients at elevated stroke risk, but less clear for those at intermediate risk. We investigated whether analysis of electrocardiogram (ECG) derived fibrillatory waves (F-waves) could help identify patients at risk for stroke and systemic embolism (SSE). Methods The Finnish Cardioversion (FinCV) study included patients not on permanent anticoagulation therapy who underwent cardioversion for an acute AF episode. We identified 739 individuals with a valid ECG and complete follow-up data. The maximum amplitudes of the F-waves in leads II and V1 were manually measured from the pre-procedure ECG. Patients were categorized into fine and coarse F-wave groups. The optimal lead and amplitude threshold for grouping were found in an events per person-years analysis. SSE were identified from the patient medical records until either anticoagulation was prescribed, AF was deemed chronic, the patient had deceased, or the end of follow-up. Results Overall 37 (5.0%) patients suffered SSE during the median follow-up time of 5.4 years (1.9–10.8). Measured from lead V1 the SSE rates per 100 person-years were 1.5 and 0.7 in fine and coarse F-wave groups, respectively. Fine F-waves were observed in 112 (15.2%). Baseline characteristics were similar between the groups. Fine F-wave predicted SSE in a competing risk analysis (SHR 2.34, 95%CI 1.12–4.87, p = .023). Analyses from lead II did not provide significant results. Conclusion Electrocardiographic F-wave amplitude may provide additional information on stroke risk in patients with paroxysmal AF and borderline indications or contraindications for anticoagulation.

Patient perspectives on oral anticoagulation for atrial fibrillation: can more specific communication on bleeding risk help?

Patient perspectives on oral anticoagulation for atrial fibrillation: can more specific communication on bleeding risk help?

Oral anticoagulation for atrial fibrillation and high risk of bleeding in daily practice: What clinical considerations?

Oral anticoagulation for atrial fibrillation and high risk of bleeding in daily practice: What clinical considerations?

Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation

Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation

Oral Anticoagulation for Atrial Fibrillation in Octogenarians Across the Renal Function Spectrum

Oral Anticoagulation for Atrial Fibrillation in Octogenarians Across the Renal Function Spectrum

Comparison of the Efficacy and Safety of Left Atrial Appendage Closure and Direct Oral Anticoagulants for Atrial Fibrillation: A Meta-Analysis of Randomized Control Trials and Observational Studies.

The aim of this study was to compare the efficacy and safety of left atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). This meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Two investigators performed an online database search on PubMed, Web of Science, and Scopus databases from inception to October 31, 2023, without any language or time restrictions. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, stroke, and major bleeding events. Eight studies were included in this meta-analysis, enrolling 7,629 participants with AF (4,287 in the DOAC group and 3,342 in the LAAC group). The pooled analysis showed that the risk of all-cause mortality was significantly higher in patients in the DOAC group compared to LAAC (relative risk (RR): 1.87, 95% confidence interval (CI): 1.50 to 2.34). The risk of cardiovascular mortality was 1.60 times higher in patients receiving DOACs compared to those receiving LAAC (RR: 1.60, 95% CI: 1.12 to 2.28). The risk of stroke was not significantly different between the two groups (RR: 1.15, 95% CI: 0.95 to 1.41). In conclusion, LAAC for AF patients proves to be safe and effective for stroke prevention, exhibiting a superior profile in terms of all-cause mortality, cardiovascular events, and major bleeding compared to oral anticoagulation (OAC). These findings prompt consideration of LAAC as a preferred treatment for cardiovascular event prevention in high-bleeding-risk patients.

A Comparison of Bleeding Events Among Patients on Apixaban, Rivaroxaban, and Warfarin for Atrial Fibrillation and/or Venous Thromboembolism

Introduction Apixaban and rivaroxaban are the most commonly used direct oral anticoagulants (DOACs) for atrial fibrillation (AF) and venous thromboembolism (VTE). Both have been compared to warfarin in landmark clinical trials. However, there are limited comparative efficacy data between these drugs in a real-world setting. We sought to assess patient characteristics and outcomes of apixaban, rivaroxaban, and warfarin in a non-trial based study cohort. Methods Retrospective registry-based cohort of adults starting apixaban, rivaroxaban, or warfarin therapy or switching between these anticoagulants for the indications of VTE and/or non-valvular AF. Through the Michigan Anticoagulation Quality Improvement Initiative (MAQI 2) collaborative of six anticoagulation clinics, warfarin treated patients were followed from January 2009 to June 2023. Four of these clinics contributed DOAC patient data from June 2011 to June 2023. Patients treated with other anticoagulants, with valvular AF, or with less than 3 months of follow-up were excluded. Propensity matched cohorts (apixaban versus warfarin [1:1], rivaroxaban versus warfarin [1:3], and apixaban versus rivaroxaban [1:1]) of patients were analyzed based on DOAC use at study enrollment, using 1:1-3:1 matching ratios. Patients were matched based on demographics, social history, comorbidities, medications, bleeding/thrombotic history, indication for anticoagulation, and follow-up. The primary outcome was any new bleeding event. Secondary outcomes included new episodes of thrombosis, bleeding event type (major, fatal, life threatening, central nervous system, and non-major bleeding), emergency room (ER) visits, hospitalizations, and death. Random chart audits were done to confirm the accuracy of the abstracted data. Event rates were compared using Poisson regression. Results Of 13,435 patients on OAC who met the study inclusion criteria (3,536 on apixaban, 1,395 on rivaroxaban, and 8,504 on warfarin), the average age was 66.7 years (standard deviation [SD] 14.9 years), 51.1% identified as male, most (58.0%) were on anticoagulation for AF, and the average follow-up was 28.2 months (SD 30.7 months). After propensity matching, 3,527 patients on apixaban were compared to 3,527 patients on warfarin. Any bleeding was similar between groups, but major bleeding was higher with warfarin (3.4 versus 4.7 events/100 patient years, p<0.001). Thrombotic event rates were higher with apixaban (2.6 versus 2.1 events/100 patient years, p=0.026), including the thrombotic subtype of other thrombosis (1.0 versus 0.5 events/100 patient years, p<0.001). Rates of ER visits and hospitalizations for bleeding were higher with warfarin. Mortality was higher with warfarin (3.7 versus 4.4 deaths/100 patient years, p=0.027). After propensity matching, 1,395 patients on rivaroxaban were compared to 4,185 patients on warfarin. Any bleeding and major bleeding were higher with rivaroxaban (37.9 versus 24.9 events/100 patient years, p<0.001; 4.7 versus 3.6 events/100 patient years, p=0.041 respectively). Thrombotic event rates were similar, aside from a higher rate of the thrombotic subtype of other thrombosis with rivaroxaban (1.0 versus 0.3 events/100 patient years, p=0.002). ER visits, hospitalizations, and mortality were similar between rivaroxaban and warfarin. After propensity matching, 1,395 patients on apixaban were compared to 1,395 patients on rivaroxaban. Any bleeding and major bleeding were higher with rivaroxaban (37.9 versus 25.7 events/100 patient years, p<0.001; 4.7 versus 2.6 events/100 patient years, p<0.001). Thrombotic event rates were similar. ER visits occurred more frequently on rivaroxaban (12.8 versus 10.1 events/100 patient years, p=0.003) as did patient mortality (3.5 versus 2.6 deaths/100 patient years, p=0.047). Conclusions For patients on oral anticoagulation for AF and/or VTE we observed that bleeding was highest with rivaroxaban, followed by warfarin, and then apixaban. Rates of thrombosis were higher with apixaban compared to warfarin, seemingly largely driven by “other” thrombotic events. Thrombotic event rates were otherwise similar between apixaban, rivaroxaban, and warfarin. We observed apixaban to be associated with lower mortality than rivaroxaban and warfarin. While these findings should be confirmed with randomized studies, they may have implications for anticoagulant selection.

Time-in-therapeutic-range defined warfarin and standard dose direct oral anticoagulants in atrial fibrillation: Ischemic stroke, intracranial hemorrhage and death in a nationwide registry study

Abstract Background and aims Direct oral anticoagulants (DOACs) have almost replaced warfarin in stroke prevention of patients with atrial fibrillation (AF). However, little is known whether DOACs are more efficacious or safer than warfarin having information on time-in-therapeutic-range (TTR) in the warfarin-treated patients. Methods The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide study of AF patients combining data from several Finnish health care registers. We analyzed all new-onset AF patients from 2011 to 2018 with available laboratory data. The rates of ischemic stroke (IS), intracranial hemorrhage (ICH) and mortality during oral anticoagulation (OAC) use were analyzed until maximum follow-up of 730 days. Confounding factors by baseline characteristics as well as medications were taken into account by an inverse probability of treatment weighted analysis. For warfarin users, TTR was calculated and patient quartiles by TTR were assigned. The rates of IS, ICH and mortality in TTR quartiles for warfarin users were compared to standard dose dabigatran (150 mg bd.), apixaban (5mg bd.) and rivaroxaban (20mg od.). Results Altogether, 73 469 new-onset AF patients with OAC therapy (50.4 % male, mean age 73.0 years, 43 548 on warfarin, with mean TTR 66% and median TTR 72%) were followed for 76 546 patient years (py). The rate of IS among patients with standard dose DOACs was 0.73/100 py for dabigatran (n=4 545)[HJK1] , 1.05/100 py for apixaban (n=12 426) and 0.83/100 py for rivaroxaban (n=12 950). In the TTR quartiles of patients on warfarin, rates of IS were 3.5, 1.8, 1.2 and 0.74/100 py from the lowest (mean TTR 32%) to the highest quartile (mean TTR 90%), respectively. The weighted rates of IS were 1.3, 1.1 and 0.87/100 py for dabigatran, apixaban and rivaroxaban, and for warfarin from the lowest to the highest quartile: 3.2, 1.7, 1.2 and 0.7/100 py. The respective rates of ICH were 0.47, 0.62 and 0.67/100 py for dabigatran, apixaban and rivaroxaban, and for warfarin from the lowest to the highest quartile: 3.6, 0.99, 0.51 and 0.32/100 py. The weighted rates of ICH were 0.70, 0.65 and 0.73/100 py for dabigatran, apixaban and rivaroxaban, and for warfarin from the lowest to the highest quartile: 3.4, 0.96, 0.51 and 0.30/100 py. For mortality, the raw incidence rates were 1.2, 2.8 and 2.1/100 py for for dabigatran, apixaban and rivaroxaban, and for warfarin from the lowest to the highest quartile: 16.5, 5.3, 2.3, and 1.5/100 py. The weighted rates were 1.6, 2.9, and 2.6, for dabigatran, apixaban and rivaroxaban, and for warfarin from the lowest to the highest quartile: 14.6, 4.8, 2.0, and 1.3/100 py. The Figures provide cumulative incidence of IS and total mortality (crude rates) of the analyzed OAC groups. Conclusions The rates of IS, ICH and mortality were highest among patients on warfarin in the two lowest TTR quartiles, whereas the differences between high TTR groups and standard dose DOACs were only modest.Cumulative incidence of ischemic strokeCumulative mortality rate

Abstract 15688: Association of Cytochrome P450 2C19 Polymorphism With Ischemic and Bleeding Risk in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Introduction: CYP2C19 isoenzymes of cytochrome P450 impact the effect of clopidogrel. Guidelines recommend clopidogrel in addition to oral anticoagulation (OAC) in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). This study aimed to evaluate the association of CYP2C19 polymorphism with ischemic and bleeding risk in patients with AF undergoing PCI. Methods: Patients with AF and an indication for OAC were included in this two-center prospective cohort study up to 3 days after PCI. Carriers of ≥1 loss of function (LOF) allele CYP2C19*2 were classified as poor metabolisers (PM). Carriers of ≥1 gain of function allele (GOF) were defined as rapid metabolisers (RM). Normal metabolisers (NM) were defined as absence of LOF and GOF alleles. Primary outcome was defined as death, myocardial infarction, or stroke (MACE) at 6 months ±2 weeks. Secondary outcome was defined as non-major clinically relevant (NMCR) or major bleedings. Results: 283 patients were included in the study. Median age was 78 (interquartile range, IQR 72-82) years old and 204 (72%) were males. All patients received treatment with clopidogrel and OAC. 73 (26%) were PM, 108 (38%) were NM and 102 (36%) RM. The primary ischemic outcome occurred in 22 (8%) and the secondary outcome in 38 (13%) patients. PM status did not significantly associate with primary ischemic outcome (PM: 6 [8.2%] vs. NM+RM: 16 [7.6%]; odds ratio, OR 1.09 [95% confidence interval 0.41-2.89], p=0.805). RM status did not significantly associate with bleeding (RM: 14 [13.7%] vs. PM+NM: 24 [13.3%]; OR 1.04 [0.51-2.12], p=1.00). Bleeding rates tended to be lower for patients with PM status (major, NMCR, or minor bleeding: PM 12 [28.7%] vs. NM+RM 84 [40.0%]; 0.61 [0.34-1.07], p=0.09). Conclusions: This pilot study of patients with oral anticoagulation for atrial fibrillation and clopidogrel after PCI ruled out, with 95% confidence, a ≥3-fold increase of ischemic risk for carriers of ≥1 loss of function allele CYP2C19*2 compared with non-carriers. This study was underpowered to detect less pronounced associations. LOF-carrier status might protect from bleeding.

Trends in Drug Spending of Oral Anticoagulants for Atrial Fibrillation, 2014–2021

INTRODUCTIONThis study documents cost trends in oral anticoagulants (OAC) in patients with newly diagnosed atrial fibrillation (AF). METHODSUsing MarketScan databases, the mean annual patients’ out-of-pocket costs, insurance payments, and the proportion of patients initiating OAC within 90 days from AF diagnosis were calculated from July 2014 to June 2021. Costs of OACs (apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin) and the payments by three insurance types (commercial payers, Medicare, and Medicaid) were calculated. Patients’ out-of-pocket costs and insurance payments were adjusted to 2021 prices. Joinpoint regression models were used to test trends of outcomes and average annual percent changes (AAPC) were reported. Data analyses were performed in 2022-2023. RESULTSFrom July 2014 to June 2021, the mean annual out-of-pocket costs of any OAC increased for commercial insurance (AAPC 3.0%) and Medicare (AAPC 5.1%) but decreased for Medicaid (AAPC -3.3%). The mean annual insurance payments for any OAC significantly increased for all insurance groups (AAPC 13.1% [95% CI 11.3 to 15.0] for Medicare; AAPC 11.8% [95% CI 8.0 to 15.6] for commercial insurance; and AAPC 16.3% [95% CI 11.3 to 21.4] for Medicaid). The initiation of any OAC increased (AAPC 7.3% for commercial insurance; AAPC 10.2% for Medicare; AAPC 5.3% for Medicaid). CONCLUSIONSThere was a substantial increase in the overall cost burden of OACs and OAC initiation rates in patients with newly diagnosed AF in 2014-2021; these findings provide insights into the current and anticipated impact of rising drug prices on patients’ and payers’ financial burden.

Efficacy and Safety of Novel Oral Anticoagulants in Atrial Fibrillation: A Systematic Review.

In recent times, novel oral anticoagulants (NOACs)/direct oral anticoagulants (DOACs) have emerged as an alternative to the traditionally used VitaminK oral antagonists (VKA)like warfarin for the treatment of atrial fibrillation (AF). This systematic review and meta-analysis aims toevaluate the efficacy and safety of NOACs in patients with AF and, thus, the related thromboembolic risks and sequelae. Of the 131 published articles we examined, 11 were included in an in-depth systematic review. The articles we reviewed were from the past ten years, from 2013 onward. The analysis derived the efficacy and safety of NOACs in patients with AF and also included different patients' baseline characteristics and subgroups. This systematic review reiterates previous research findings of superior efficacy and safety of the use of NOACs in the AF population and also illuminates certain head-to-head comparisons of individual NOACs with warfarin.It digressed into subgroups of patients with different baseline characteristics to provide evidence and support the existing guidelines for the use of NOACs in the treatment of AF. Overall, there is marked efficacy and safety of NOACs in patients with AF, be they elderly or Asian, with decreased renal function, or with other comorbidities. Adherence to NOACs was also satisfactory. Despite such a review, there needs to be more research on vast subgroups and also on reversal antidotes like andexanet alfa and idarucizumab, as well as more head-to-head analysis between NOACs over a long duration of study, which would provide more answers and pinpoint reasons as to the differences that exist between demographics and subgroups in the usage of NOACs.

Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies.

Two recent randomized controlled trials (RCTs), the PROTECT-AF and the PREVAIL, showed that in atrial fibrillation (AF) patients, left atrial appendage closure (LAAC) is comparable to oral anticoagulants (OAC) in the prevention of stroke and could also possibly reduce mortality. Nevertheless, this net clinical benefit was not confirmed in the most recent RCT comparing LAAC vs. OAC, the PRAGUE-17 trial. aim of the present study was to evaluate the efficacy and safety of LAAC compared with OAC among available high-quality studies. A systematic search of electronic databases (Medline, Scopus, Embase and the Cochrane Library) was performed to identify eligible RCTs and observational studies with propensity score matching (PSM) analysis. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Outcomes of interest were the occurrence of cardiovascular death (CVD), all-cause death, all-type stroke, and major bleedings. A total of 3 RCTs and 7 PMS studies involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy. After a median follow-up of 2.6 years (IQR 2-4.4), patients who received LAAC had lower risk of CVD (RR = 0.62; 95%CI, 0.51-0.74, I2 = 0%), all-cause death (RR = 0.67; 95% CI, 0.57-0.78, I2 68%) and major bleedings (RR = 0.68; 95%CI, 0.48-0.95 I2 = 87%) compared with patients on OAC. No difference was found between the two groups regarding strokes incidence (RR = 0.94; 95% CI, 0.77-1.15, I2 = 0%). According to this meta-analysis, LAAC has comparable efficacy in the prevention of stroke compared with OAC and a reduced risk of major bleedings, all-cause death and CVD that may be even larger with longer follow-up. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269768, identifier CRD42021269768.

Patients' Perspectives on Commencing Oral Anticoagulants in Atrial Fibrillation: An Exploratory Qualitative Descriptive Study.

Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

Kidney Function and the Use of Vitamin K Antagonists or Direct Oral Anticoagulants in Atrial Fibrillation

Abstract Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with a five-fold increase in the risk for ischemic stroke. Therefore, lifelong use of anticoagulants is crucial to reduce the morbidity and mortality burden of AF. The incidence of AF in chronic kidney disease (CKD) is two to three times greater than in the general population, and there is a mutual aggravation of the two conditions as well as the presence of both an increased thromboembolic risk in CKD and an increased bleeding risk in severe CKD. The preservation of kidney function in patients with cardiovascular diseases is important, as the latter is the leading cause of death in patients with eGFR <60 mL/min/1.73 m2. Similarly, kidney dysfunction is a serious limitation to the use of many cardiovascular drugs, including anticoagulants. Evidence is present for the faster progression of kidney disease with vitamin K antagonists, likely due to the vitamin K-related process of vascular calcification. Conversely, direct oral anticoagulants (DOACs) have been shown to reduce the progression of CKD and have a beneficial effect as far as the modulation of inflammation and oxidative stress are concerned in experimental models. Another less-discussed problem is the use of DOACs in advanced CKD.

Meta-Analysis Assessing Efficacy and Safety of Vitamin K Antagonists Versus Direct Oral Anticoagulants for Atrial Fibrillation After Transcatheter Aortic Valve Implantation

Patients who underwent transcatheter aortic valve implantation (TAVI) with concomitant atrial fibrillation (AF) are at a higher risk for thromboembolic and bleeding events. The optimal antithrombotic strategy for patients with AF after TAVI remains unclear. We sought to determine the comparative efficacy and safety of direct oral anticoagulants (DOAC) versus oral vitamin K antagonists (VKAs) in these patients. Electronic databases such as PubMed, Cochrane, and Embase databases were searched till January 31, 2023, for relevant studies evaluating clinical outcomes of VKA versus DOAC in patients with AF after TAVI. Outcomes assessed were (1) all-cause mortality, (2) stroke, (3) major/life-threatening bleeding, and (4) any bleeding. Hazard ratios (HRs) were pooled in meta-analysis using random effect model. Nine studies (2 randomized and 7 observational) were included in systematic review, and 8 studies with 25,769 patients were eligible to be included in the meta-analysis. The mean age of the patients was 82.1years, and 48.3% were male. Pooled analysis using random-effects model showed no statistically significant difference in all-cause mortality (HR 0.91, 95% confidence interval [CI] 0.76 to 1.10, p=0.33), stroke (HR 0.96, 95% CI 0.80 to 1.16, p=0.70), and major/life-threatening bleeding (HR 1.05, 95% CI 0.82 to 1.35, p=0.70) in patients that received DOAC compared with oral VKA. Risk of any bleeding was lower in the DOAC group compared with oral VKA (HR 0.83, 95% CI 0.76 to 0.91, p=0.0001). In patients with AF, DOACs appear to be a safe alternative oral anticoagulation strategy to oral VKA after TAVI. Further randomized studies are required to confirm the role of DOACs in those patients.

Oral anticoagulation for atrial fibrillation in rheumatic heart disease.

Oral anticoagulation for atrial fibrillation in rheumatic heart disease.

Aspirin deprescribing in patients on oral anticoagulation for atrial fibrillation or venous thromboembolism: A national survey of clinician practices

AbstractIntroductionConcomitant use of oral anticoagulation (OAC) and aspirin increases bleeding risk without decreasing thromboembolic events compared with OAC monotherapy. Weak guideline recommendations and limited data exist for deprescribing aspirin for primary prevention or stable coronary artery disease in patients already on OAC for atrial fibrillation (AF) or venous thromboembolism (VTE).ObjectivesThe objective of this study was to identify aspirin deprescribing practices among clinicians for patients on OAC for AF or VTE and concomitant aspirin for non‐compelling reasons.MethodsA cross‐sectional, national survey was electronically distributed to pharmacists and non‐pharmacists (physicians, nurse practitioners, physician assistants). Co‐primary end points were composite aspirin discontinuation rates in patients on OAC for AF or VTE in primary prevention and stable coronary artery disease (CAD) cases. Key secondary end points were clinician comfort level with deprescribing aspirin and availability of institutional protocols.ResultsThree hundred four responses were included: 212 (69.7%) pharmacists and 92 (30.3%) non‐pharmacists. Mean age of respondents was 35.4 years, and 37.4% male. In the primary prevention cases, pharmacists were more likely to discontinue aspirin than non‐pharmacists (76.7% vs. 54.6%, p < 0.001). In the stable CAD cases, composite rates of aspirin discontinuation by pharmacists and non‐pharmacists were similar (41.7% vs. 40.1%, p = 0.140). More pharmacists than non‐pharmacists stated that their aspirin deprescribing decisions were independent of the type of OAC that was used (60.4% vs. 35.9%, p < 0.001). Pharmacists were more likely to discontinue aspirin after discussing with patients compared with non‐pharmacists (62.7% vs. 47.8%, p = 0.017). 27.3% of clinicians reported having a protocol to deprescribe aspirin at their institution/clinic.ConclusionThere are variations in aspirin deprescribing practices among clinicians in patients on OAC for AF or VTE and without compelling indications for aspirin. Further studies and stronger recommendations are warranted to guide clinicians regarding optimal antithrombotic therapy in these scenarios. Lack of institutional protocols for aspirin deprescribing creates opportunities for future quality improvement initiatives.

SA62 Prescribing Patterns and Preference Attributes of Novel Oral Anticoagulants in Atrial Fibrillation and Venous Thromboembolism in Real-World Practice in China: A Nationwide Physician Survey

Four novel oral anticoagulants (NOACs) were approved and included in the National Reimbursement Drug List in China in recent years. The prescribing patterns and preferences for NOACs in China are unclear. The study aims to describe the prescribing patterns and preference attributes affecting physicians’ choice on NOAC selection for atrial fibrillation (AF) or venous thromboembolism (VTE) in real-world clinical practice in China.