Use Of Oral Anticoagulants Research Articles

Left atrial appendage closure in patients with atrial fibrillation and acute ischaemic stroke despite anticoagulation

BackgroundThe occurrence of acute ischaemic stroke (AIS) while using oral anticoagulants (OAC) is an increasingly recognised problem among nonvalvular atrial fibrillation (NVAF) patients. We aimed to elucidate the potential role...

ACUTE VENOUS THROMBOEMBOLISM IS COMMON FOLLOWING ACUTE NECROTIZING PANCREATITIS AND IS ASSOCIATED WITH WORSE CLINICAL OUTCOMES.

While splanchnic vein thrombosis (SVT) is a well-known local complication of acute pancreatitis, extra-splanchnic VTE (ESVT) is inadequately studied. Here, we aim to explore the incidence of VTE in acute necrotizing pancreatitis (ANP) and the associated mortality. This is a retrospective cohort study utilizing an electronic health record database. Adults with a diagnosis of ANP from January 2017 to December 2022 were identified using appropriate ICD-10-CM codes. The primary outcome was development of acute ESVT within one month of ANP. Secondary outcomes were 90-day mortality, 30-day rehospitalization, and oral anticoagulant (OAC) use in patients with ESVT. Propensity score matching (1:1) was performed for baseline characteristics and common comorbidities. 17,942 (7.11%) patients were diagnosed with ANP during the study period and about 10% (1,737) of them had a diagnosis of ESVT. Of all VTE, 61% were ESVT with or without SVT, and 63% (N = 1,799) were SVT. 90-day mortality (16.3% vs. 5.7%, risk ration, RR 2.86 [95% CI 2.29-3.56]) and 30-day rehospitalization (31% Vs 19%, RR 1.63 [95% CI 1.49-1.79]) were higher in patients with ESVT compared to non-VTE patients. 60% of patients with ESVT were on OAC and OAC use was associated with lower 90-day mortality (8.9% vs. 19.4%, RR 0.46) without increased risk of adverse events, like - acute gastrointestinal bleeding, intracranial bleeding, or need for packed red cell transfusion. Systemic VTE is common in patients with ANP and may contribute to increased mortality and risk of readmissions. Prospective studies can confirm our findings and explore the role of aggressive VTE prophylaxis in patients with ANP during hospital stay, and in the immediate ambulatory period.

Subclinical leaflet thrombosis and anticoagulation strategy following trans-catheter aortic valve replacement: A systematic review.

Subclinical leaflet thrombosis (SLT) develops in 15% of patients undergoing trans-catheter aortic valve replacement (TAVR). TAVR is a procedure in which a faulty aortic valve is replaced with a mechanical one. An aortic valve replacement can be done with open-heart surgery; this is called surgical aortic valve replacement (SAVR). A significant problem is defining the best course of treatment for asymptomatic individuals with SLT post-TAVR, including the use of oral anticoagulation (OAC) in it. Systematic review. The most pertinent published research (original papers and reviews) in the scientific literature were searched for and critically assessed using the online, internationally indexed databases PubMed, Medline, and Cochrane Reviews. Keywords like "Transcatheter valve replacement" and "Subclinical leaflet thrombosis" were used to search the papers. Selected studies were critically assessed for inclusion based on predefined criteria. The review examined the prevalence and characteristics of SLT after TAVR. To note, the incidence of SLT is seen to be higher in TAVR compared SAVR. Dual antiplatelet therapy, which is utilized in antithrombotic regimens post-TAVR, can possibly hasten SLT progression which could result in the impaired mobility of leaflets and the worsening of pressure gradients. The use of dual antiplatelet drugs in routine antithrombotic therapy tends to accelerate initial subclinical leaflet thrombosis after TAVI, which results in a developing restriction of leaflet mobility and an increase in pressure differences.

Recurrent stroke despite correct anticoagulation therapy with DOACs: Analysis of the real-life therapeutic approach

Introduction and objectivesRecurrent strokes persist despite the use of guideline-recommended direct oral anticoagulants (DOACs). There is a scarcity of data concerning the current and optimal practices following a recurrent stroke while on DOACs. Consequently, our aim was to identify factors associated with this residual risk and to discern the current practice patterns among cardiologists and neurologists. MethodsAll consecutive patients with an acute cerebrovascular accident of any type and a diagnosis of atrial fibrillation (AF) were retrospectively screened at our stroke center. We gathered demographic information, clinical risk scores (CHA2DS2-VASc and HAS-BLED), echocardiographic and laboratory findings, risk factors, the modified Rankin score, and information about the treatment modality. DOAC usage was classified as either inappropriate (due to self-reported non-adherence and/or incorrect DOAC dosage) or appropriate. ResultsA total of 77 patients with stroke despite treatment with DOACs were included in the analysis. Of these, 28 (36%) had received inappropriate treatment (20 of them due to inadequate dosing). These patients tended to be older (P=.06) and had lower creatinine levels than the group receiving appropriate DOACs (0.9 vs 1; P=.01). At hospital discharge following the index stroke, various anticoagulants were administered to 75 patients (enoxaparin, n=5; warfarin, n=10; DOAC, n=60). Two patients died and 20 patients were given antiplatelet therapy in addition to anticoagulants. The preferred DOACs after stroke were apixaban (n=27), followed by rivaroxaban (n=16), dabigatran (n=14) and edoxaban (n=3). ConclusionsThere is no standardized model or consensus among physicians regarding anticoagulant management. Despite the intended use of the drugs, strokes continue to occur in some patients. The 25% of strokes are related to inadequate dosage.

Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis.

This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications. A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC. The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)]. In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk.

Burden of atrial fibrillation risk and outcomes amongst patients attending cardiology and elderly medicine services: prospective in-hospital implementation of the FIND-AF algorithm

Abstract Background Screening for silent AF is becoming increasingly important (1, 2), and the FIND-AF algorithms can use routinely-collected data to identify individuals at higher risk for undiagnosed AF (3). There may be a much higher prevalence of patients at risk for AF and its complications in a hospital environment compared with the community (4). Purpose We prospectively implemented the FIND-AF algorithm within cardiology and geriatric services to quantify the burden of AF risk amongst all-comers, and to understand their outcomes over the next 6 months. Methods We prospectively implemented the FIND-AF algorithm in the cardiology and geriatric departments of three UK hospitals for consecutive inpatient or outpatient attendances from February 1 to July 13th 2023. We assessed the number of individuals attending each service eligible for an AF screening protocol (exclusion criteria: age <30 years, history of AF, on a palliative care pathway, use of oral anticoagulation), and calculated the burden of AF risk in each service. Patients were followed up for 6 months for the primary outcome of incident AF, heart failure (HF), stroke/transient ischaemic attack (TIA)/systemic embolism, and death. Incident diagnoses were the first record of that condition in primary or secondary care records. Rate ratios (RRs) with 95% confidence intervals (CIs) for combined incident cardiovascular outcomes or death were derived through Poisson regression for predicted higher versus lower AF risk. Results Of 467 consecutive patients, 364 were eligible for AF screening. 66 were excluded due to a previous diagnosis of AF, 25 were already prescribed a long-term oral anticoagulant, 5 were on a palliative care pathway and 7 were aged <30 years. Baseline characteristics of each cohort are summarised in Table 1. Of patients eligible for AF screening, those attending geriatrics were at higher risk of incident AF than patients attending cardiology (median FIND-AF score: geriatrics, 0.015, 95% CI 0.008 - 0.024; cardiology, 0.005, 95% CI 0.001-0.015; p<0.05; distributions of risk summarised in Figure 1) and had a higher stroke risk. Absolute risk of AF was greater than 5% within the next 6 months for 11.6% and 9.1% of geriatric and cardiology patients, respectively. Of the eligible cohort, 328 had follow up at 6 months, with 46 experiencing the primary outcome (9, 7, 3, and 27 recorded cases of AF, HF, stroke/TIA, and death, respectively). The higher predicted risk cohort, compared to lower predicted risk, had a higher risk of combined incident AF, heart failure, or stroke/TIA/systemic embolism (Rate ratio: 5.59, 95% CI 1.13-101.01) and death (RR 9.68, 2.06-172.85). Conclusions The FIND-AF algorithm can be prospectively implemented in hospital records to identify cardiology and geriatric patients at risk of incident AF, heart failure, thromboembolic disease and death. There is an opportunity to conduct risk-guided screening in the context of hospital attendances.

Validation of CT in comparison to TEE in routine workflow for detection of LAA thrombus in patients under oral anticoagulation presenting for left atrial ablation

Abstract Background Left atrial (LA) thrombus in patients (pts) presenting for LA ablation is an absolute contraindication to ablation. Although thrombi can still form despite the use of oral anticoagulation (OAC) in advance of the procedure. Transesophageal echocardiography (TEE) has been considered the gold standard for LAA thrombus detection. Additional cardiac computer tomography (CT) is often performed in pts with persistent atrial fibrillation (AF) or atrial tachycardia (AT). The aim of the study was in routine workflow 1) to identify the incidence of LAA thrombi in TEE and CT, 2) to search for an association in detecting LAA thrombi in the 2 methods and 3) to find out if the LAA flow velocity/ LA volume influences the thrombus detection. Methods Between 05/2018 and 10/2023 patients with AF/AT under OAC which were scheduled for a LA ablation were included. TEE and CT searching for LAA thrombus were carried out at intervals of up to 7 days. LAA flow velocity measured in the TEE. The LA volume which included LAA and excluded the pulmonary veins were obtained from the CT at the end-systole. Results Patients characteristics: 283 pts were included, mean age of 66y (+9y), 182 male, mean CHA2DS2-VASc score 3 [0-7]. All patients, mostly on NOACs (n=265), were orally anticoagulated. Mean LA volume (LA + LAA) was 158 ml (+45ml), LAA flow velocity was reduced (< 40 cm/s) in 119 pts (42%). In the majority of cases (73%), TEE and CT were performed at the same day or with an interval of 1 day. In 16 pts a LAA thrombus was detected using TEE,42 pts had SEC/Sludge but no solid thrombus. An LAA thrombus in the CT was described in 26 pts (10%), 6% couldn't definitively diagnose thrombi due to contrast recesses/flow phenomena in 16 pts. In 8 out of 34 events (23%) TEE and CT agreed on the diagnosis of a thrombus, in 6 cases during same-day examinations. 18 pts: LAA thrombus on CT, not on TEE (mean interval: 2d). 8 pts: LAA thrombus on TEE, not on CT (mean interval: 1.5d). In 71% (200 out of 283) of cases, CT and TEE agreed in ruling out a thrombus (p=0.358). LAA flow velocity and thrombus verification by TEE showed a significant correlation (p < 0.001). No correlation was found between the presence of a thrombus on CT and LA volume (p= 0.964). Discussion In 12% of the patients, all treated with OAC, a thrombus was described in at least one of the examinations or in both. Only in one out of four pts TEE and CT agreed on the diagnosis of a thrombus. It was notable that both examinations excluded thrombi in 70%. LAA flow velocity and thrombus verification in the TEE are significant correlated. LA volume and thrombus notification in CT are not related. Conclusion Routine diagnosis of LAA thrombus remains challenging, with frequent discrepancies between TEE, the gold standard, and CT. TEE results depend on the examining physician, while CT is limited by flow phenomena and scan timing.

Stroke risk assessment in different atrial fibrillation subtypes: CHA2DS2-VASc score and beyond

Abstract Background Patients with atrial fibrillation (AF) have been known to have an inhomogeneous risk of stroke, with several well-documented risk factors including hypertension, history of stroke, and diabetes mellitus that have been incorporated into the CHA2DS2–VASc score to stratify risk levels. Accumulating evidence has suggested that AF subtype, namely persistent AF and paroxysmal AF, also have an impact on stroke development. Purpose This study focused on the impact of AF subtype on stroke risk in a large, long-term follow-up cohort as to provide insight of the impact on ischemic stroke risks. Such findings may play a role in future ischemic stroke risk stratification in selected patients. Methods A total of 7346 AF patients were followed up for 10 years from January 2010 to December 2020 (mean follow-up time 2.74 years). Among these patients, 2460 (33.5%) had persistent or permanent AF (PerAF) and 4886 (66.5%) had paroxysmal AF (PAF). The study evaluated the risk of ischemic stroke between the two groups using Cox models adjusting for all components of the CHA2DS2–VASc score. Analyses were further stratified into the usage of oral anticoagulation (OAC) or no OAC. Results Comparing AF patients based on subtype, it was found that PerAF patients were older, had a higher prevalence of previous stroke, congestive heart failure, PAD, DM, and were more often prescribed anticoagulants. Univariate analysis found patients with PerAF at a higher risk for ischemic stroke (HR 1.262, p<0.001). The results remained significant after multivariate analysis with factors of the CHA2DS2–VASc score (HR 1.234, p<0.001). After stratifying patients according to anticoagulation prescription, PerAF and PAF patients were found to have similar rates of developing ischemic stroke in patients under DOAC. Conclusions Patients with PerAF have a higher risk of stroke during follow-up independent of components of the CHA2DS2VASc score. In patients with OAC use, there was no difference in stroke risk between AF subtypes.Stroke Risk in OAC-naive patientsStroke Risk in OAC-experienced patients

Automated continuous rhythm monitoring with implantable cardiac monitor and real-time smartphone alerts during af episodes: SMART-ALERT study

Abstract Introduction The 'Pill-in-the-pocket' oral anticoagulation (OAC) strategy is based upon the concept of dynamic thromboembolic risk which increases during and shortly after an atrial fibrillation (AF) episode. Limiting OAC use in low-risk patients with infrequent AF may offer comparable stroke protection and reduce bleeding. However, this approach relies on precise continuous rhythm monitoring with real-time alerts to patients. LINQ II implantable cardiac monitor transmits regularly to Carelink via smartphone app, but lacks patient alerts. To address this limitation, we developed bespoke software that triages transmissions in Carelink and sends alerts via SMS to patients. Purpose This feasibility study evaluates the precision of the LINQ II in detecting AF and assesses the efficacy of bespoke software in delivering 'real-time' SMS alerts to participants' smartphones, and measures compliance with these alerts. Methods In this single-center feasibility study, individuals with frequent AF episodes underwent LINQII implantation. The bespoke software, operating in the cloud, systematically reviewed all Carelink transmissions at 5-min intervals. SMS alerts were triggered based on specific criteria: 1)AF >30 min; 2)only the initial AF episode >30 min within a 24h period was transmitted; and 3)AF episodes uploaded or detected after a 24h delay were disregarded. Participants confirmed receipt of the alert by responding to the SMS, and timestamps for these interactions were recorded in a database (Fig. 1). Results A total of 50 patients were prospectively enrolled, and LINQ II was implanted. The median age was 49 years, 62% male, 90% had paroxysmal AF. Over a 3-month mean follow-up, 4080 AF episodes >30 min occurred in 32 patients. Among these, 700 met the criteria for triggering an alert, with 72.14% sent to patients within 24 h. Alerts were not transmitted for 3 main reasons: smartphone failure to transmit to Carelink within a 24 h period, software issues connecting to Carelink (website maintenance), and updates in the webservers. The median time from an AF episode to the transmission of SMS alerts was 2.47 h, with 85.54% of alerts being sent within 12 hours. Once an SMS was sent, the median time for acknowledgment was 4.3 min. The median time from an AF episode to acknowledgment was 4.23 h (Fig. 2). Notably, 97.62% of episodes were acknowledged within 24 hours. Patients failed to acknowledge an SMS alert on only 3 occasions. Conclusions Safely delivering 'pill-in-the-pocket' OAC requires a closed-loop system where devices provide real-time alerts during during AF , thus minimising delays in initiating OAC. This feasibility study establishes that the integration of bespoke software with LINQ II exhibits promising efficacy with a high percentage of SMS alerts within 24 hours, exceptional patient compliance, and a median response time of only 4.3 min. Nonetheless, further efforts are needed for seamless integration with Carelink to enhance connectivity.

Baseline characteristics and risk of major bleeding in Taiwanese patients with atrial fibrillation and renal impairment receiving rivaroxaban: the prospective XARETO registry

Abstract Background Data about the use of direct oral anticoagulants (DOACs) in the prospective registry of Asian atrial fibrillation (AF) patients with renal dysfunction, especially those with a creatinine clearance (CCr) between 15 to 30 ml/min, are limited. This study aimed to investigate the safety of rivaroxaban in Taiwanese AF patients with renal impairment in the daily practice. Methods XARETO (Xarelto for the prevention of stroke and non-central nervous systemic embolism in non-valvular atrial fibrillation with REnal impairment in Taiwanese pOpulation) is a multi-center, non-interventional, single arm prospective observational cohort study performed in Taiwan. Subjects with non-valvular AF aged >=20 years with a documented CCr of 15-50 ml/min within 6 months before the enrollment were enrolled. All subjects were prescribed rivaroxaban for stroke prevention. The major bleeding was defined as a bleeding events with fall in Hgb of >=2 g/dL or a transfusion of >= 2 units of packed red blood cells or whole blood or occurrence of bleeding at a critical site or mortality. Results A total of 493 patients were enrolled. The mean age was 78.3 years old and 59.6% was male. The mean CHA2DS2-VASc and HAS-BLED scores were 4.4 and 2.9, respectively. Co-morbidities were as follows: 41.0% patients had chronic heart failure, 83.2% had hypertension, 40.8% had diabetes and 14.8% had prior stroke/transient ischemic attack/systemic embolic events. The mean CCr was 35.19 ml/min, and 159 (32.3%) of them has a CCr between 15-29 ml/min. During the follow up, there were 23 patients with 26 adjudicated major bleeding events with the incidence rate of 6.2 per 100 person-years (95% CI 3.9-9.3). Of these patients, there were 15 patients with 16 adjudicated major bleeding events considered as related to the rivaroxaban treatment with the incidence rate of 4.0 per 100 person-years (95% CI 2.2-6.6)(Figure) Conclusions In high-risk Taiwan AF patients (mean CHA2DS2-VASc score 4.4) with renal impairment (mean CCr 35.19 ml/min, 32.3% between 15-29 ml/min), the safety of rivaroxaban was confirmed in the prospective XARETO study.

Direct oral anticoagulants versus vitamin K antagonists as stroke prevention in atrial fibrillation after cardiac surgery: a systematic review and meta-analysis

Abstract Background Cardiothoracic surgery guidelines advocate the use of vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) in the first days to months after major cardiac surgery. No recommendations on choice of anticoagulant in the first months after cardiac surgery have been issued since 2008, before the use of direct oral anticoagulants (DOACs). The basis for this is a lack of data on the safety and efficacy of DOACs after cardiac surgery. Purpose To systematically assess and meta-analyze the existing evidence on the effect of DOACs compared with VKAs on efficacy and safety after cardic surgery. We hypothesized that DOACs are non-inferior to VKAs in the setting of AF after cardiac surgery. Methods We searched Ovid MEDLINE, Ovid EMBASE, the Cochrane Central Register of Controlled trials and Clinicaltrials.gov from inception till 20 June 2023 and screened references in relevant reviews as grey literature search. Observational studies and randomized controlled trials comparing DOACs with VKAs for stroke prevention in patients with (postoperative) atrial fibrillation after cardiac surgery were included, focusing on procedures through thoracoscopy or thoracotomy. Outcomes of interest included thromboembolic events, all-cause stroke, major bleeding and mortality up to 6 months after cardiac surgery and admission duration. A random effects model was used to determine pooled treatment effects. The level of evidence was rated following the GRADE recommendations. Results We identified 4,146 records of which ten were included, together reporting on > 30,000 patients. There were no significant differences in thromboembolic events (OR 0.98; 95% CI 0.61-1.58; I^2 0%; GRADE: very low), all-cause stroke (OR 1.14; 95% CI 0.51-2.54; I^2 0%; GRADE: very low), major bleeding (OR 0.91; 95% CI 0.51-1.62; I^2 53%; GRADE: very low), all-cause mortality (OR 1.00; 95% CI 0.73-1.37; I^2 0%; GRADE: low), admission duration (MD -0.33; 95% CI -1.16 – 0.49; I^2 0%; GRADE: very low) between DOACs and VKAs in the first 6 months after cardiac surgery. Conclusion Efficacy and safety of DOACs as stroke prevention in AF following cardiac surgery were similar to that of VKAs in ten studies comprising more than 30,000 patients. Based on the existing literature, there is insufficient evidence to recommend one class of oral anticoagulants over another in the first months after cardiac surgery.Forest plot of primary outcomes

Edoxaban, Rivaroxaban, or Apixaban for Cancer-Associated Venous Thromboembolism in the Real World: Insights from the COMMAND VTE Registry-2.

Real-world data on clinical characteristics and outcomes related to the use of different direct oral anticoagulants (DOACs) for cancer-associated venous thromboembolism (VTE) is lacking. The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive patients with acute symptomatic VTE from 31 centers in Japan from January 2015 to August 2020. Our study population comprised 1,197 patients with active cancer who were divided into the edoxaban (N = 643, 54%), rivaroxaban (N = 297, 25%), and apixaban (N = 257, 22%) groups. The cumulative 5-year incidence of recurrent VTE (9.3, 10.2, and 8.5%, respectively, p = 0.82) and all-cause death (67.5, 66.8, and 63.8%, respectively, p = 0.22) did not differ among the groups. Despite adjusting for confounders, the risks of recurrent VTE and all-cause death did not differ significantly among the groups. The cumulative 5-year incidence of major and clinically relevant bleeding was significantly lower in the rivaroxaban group than those in the other groups (22.6, 14.0, and 22.8%, p = 0.04; and 37.6, 26.8, and 38.3%, p = 0.01, respectively). After adjusting for confounders, in the rivaroxaban group, the risk for major bleeding was numerically lower (hazard ratio [HR]: 0.65, 95% confidence interval [CI]: 0.40-1.01) and that of clinically relevant all bleeding was significantly lower (HR: 0.67, 95% CI: 0.48-0.92) than those in the edoxaban group. The risks of recurrent VTE and all-cause death did not differ significantly among the different DOACs ; however, the risk of bleeding events could differ, with a potentially lower risk of bleeding with rivaroxaban.

Exploring the Perioperative Use of DOACs, off the Beaten Track.

A notable increase in direct oral anticoagulant (DOAC) use has been observed in the last decade. This trend has surpassed the prescription of vitamin K antagonists (VKAs) due to the absence of the need for regular laboratory monitoring and the more favorable characteristics in terms of efficacy and safety. However, it is very common that patients on DOACs need an interventional or surgical procedure, requiring a careful evaluation and a challenging approach. Therefore, perioperative anticoagulation management of patients on DOACs represents a growing concern for clinicians. Indeed, while several surgical interventions require temporary discontinuation of DOACs, other procedures that involve a lower risk of bleeding can be conducted, maintaining a minimal or uninterrupted DOAC strategy. Therefore, a comprehensive evaluation of patient characteristics, including age, susceptibility to stroke, previous bleeding complications, concurrent medications, renal and hepatic function, and other factors, in addition to surgical considerations, is mandatory to establish the optimal discontinuation and resumption timing of DOACs. A multidisciplinary approach is required for managing perioperative anticoagulation in order to establish how to face these circumstances. This narrative review aims to provide physicians with a practical guide for DOAC perioperative management, addressing the most controversial issues.

Number of Premature Ventricular Complexes Predicts Long-Term Outcomes in Patients with Persistent Atrial Fibrillation.

Premature ventricular complexes (PVCs) are common electrocardiographic abnormalities and may be a prognosticator in predicting mortality in patients with structurally normal hearts or chronic heart diseases. Whether PVC burden was associated with mortality in patients with chronic atrial fibrillation (AF) remained unknown. We investigated the prognostic value of PVC burden in patients with persistent AF. A retrospective analysis of 24 h Holter recordings of 1767 patients with persistent AF was conducted. Clinical characteristics, 24 h average heart rate (HR), and PVC measures, including 24 h PVC burden and the presence of consecutive PVCs (including any PVC couplet, triplet, or non-sustained ventricular tachycardia) were examined for the prediction of all-cause and cardiovascular mortality using the Cox proportional hazards model. After a median follow-up time of 30 months, 286 (16%) patients died and 1481 (84%) patients survived. Multivariate analysis revealed that age, heart failure, stroke, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, digoxin, oral anticoagulant use, and estimated glomerular filtration rate were significant baseline predictors of all-cause mortality and cardiovascular mortality. Twenty-four-hour PVC burden and the presence of consecutive PVCs were significantly associated with all-cause and cardiovascular mortality after adjusting for significant clinical factors. When compared to the first quartile of PVC burden (<0.003%/day), the highest quartile (>0.3%/day) was significantly associated with an increased risk of all-cause mortality (hazard ratio, 2.46; 95% CI, 1.77-3.42) and cardiovascular mortality (hazard ratio: 2.67; 95% CI, 1.76-4.06). Twenty-four-hour PVC burden is independently associated with all-cause and cardiovascular mortality in patients with persistent AF.

Pericardial Effusion After Left Atrial Appendage Closure: Timing, Predictors, and Clinical Impact

BackgroundPericardial effusion (PE) is the most common serious left atrial appendage closure (LAAC) complication, but its mechanisms, time course, and prognostic impact are poorly understood. ObjectivesThis study sought to assess the frequency, timing, predictors and clinical impact of PE after LAAC. MethodsData on consecutive patients undergoing percutaneous LAAC between 2009 and 2022 were prospectively collected including the 1-year follow-up. Both single (Watchman 2.5/FLX, Boston Scientific) and double (Amplatzer Cardiac Plug or Amulet, St. Jude Medical/Abbott) LAAC devices were used. An imaging core laboratory adjudicated the PEs and categorized them as early (≤7 days) and late (8-365 days). Logistic regression analysis was used to identify predictors of early and overall PE. ResultsOf 1,023 attempted LAAC procedures, PE was observed in 44 (4.3%) patients; PE was categorized as early in 34 (3.3%) and late in 10 (0.9%) patients. The majority of PEs occurred within 6 hours after LAAC (n = 25, 56.8%) and were clinically relevant (n = 28, 63.6%). Independent predictors of early PE were double-closure left atrial appendage devices (adjusted OR: 8.20; 95% CI: 1.09-61.69), female sex (adjusted OR: 3.41; 95% CI: 1.50-7.73), the use of oral anticoagulation (OAC) at baseline (adjusted OR: 2.60; 95% CI: 1.11-6.09), and advanced age (adjusted OR: 1.07; 95% CI: 1.01-1.23), whereas female sex and OAC at baseline remained independent predictors of overall PE. ConclusionsIn this large LAAC registry, PE was observed in <1 in 20 patients and usually occurred within 6 hours after procedure. The majority of early PEs were clinically relevant and occurred in the Amplatzer Cardiac Plug/Amulet procedures. Independent predictors included the use of double-closure devices, female sex, OAC at baseline, and advanced age. (LAAC-registry: Clinical Outcome After Echocardiography-guided LAA-closure; NCT04628078)

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Anticoagulant prophylaxis in patients with liver disease and atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults worldwide. The use of oral anticoagulants (DOACs) is an effective way to prevent ischemic stroke in patients with AF, reducing the risk of stroke by approximately 64 %. In patients with liver cirrhosis (LC), the presence of AF is associated with higher rates of in-hospital mortality, stroke and acute kidney injury compared with patients without arrhythmia. Liver disease and especially cirrhosis are associated with an increased risk of not only thrombosis but also bleeding, making the decision about anticoagulant therapy in these patients very difficult. The article reviews the current literature regarding the use of modern DOACs and traditional antithrombotic agents, such as vitamin K antagonists and heparins, in patients with cirrhosis and AF.

Consecutive or selectively included high bleeding risk patients in the MASTER DAPT screening log and trial

AimsScreening logs have the potential to appraise the actual prevalence and distribution of predefined patient subsets, avoiding selection biases, which are inevitably and potentially present in randomised trials and real-world registries, respectively. We aimed to assess the prevalence of high bleeding risk (HBR) characteristics in the real world and the external validity of the MASTER DAPT trial. Methods and resultsAll consecutive patients who underwent percutaneous coronary intervention (PCI) for at least two consecutive weeks across 65 sites participating in the trial were entered into a screening log. Of 2,847 consecutive patients, 1,098 (38.6 %) were HBR and 109 (9.9 %) consented for trial participation. PRECISE-DAPT score ≥ 25 was the most frequent HBR feature, followed by advanced age, use of oral anticoagulation (OAC) and anaemia. Compared with consecutive HBR patients, consenting patients were older (≥ 75 years: 69 % versus 62 %, absolute standardized difference [SD] 0.16), more frequently male (78 % versus 71 %, absolute SD 0.18), had higher use of OAC (38 % versus 20 %, absolute SD 0.39), treatment with steroids or nonsteroidal anti-inflammatory drugs (10 % versus 5 %, SD 0.16), and prior cerebrovascular events (10 % versus 6 %, absolute SD 0.18) but lower PRECISE DAPT score ≥ 25 (54 % versus 66 %, absolute SD 0.24). ConclusionsThe HBR criteria distribution differed between consecutive versus selectively included HBR patients, suggesting the existence of selection biases in the trial population.

Impact of left atrial appendage flow velocity on thrombus resolution and clinical outcomes in patients with atrial fibrillation and silent left atrial thrombi: insights from the LAT study.

Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear. The LAT study was a multicentre observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transoesophageal echocardiography (TEE). Among 17 436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (P < 0.001). During 1 year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34-138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8-22.0] vs. 22.2 [17.0-35.0], P = 0.003). Despite limited predictive power (area under the curve, 0.659; P = 0.001), LAAFV ≤ 20.0 cm/s (best cut-off) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22-6.09; P = 0.015). The incidence of adverse outcomes including ischaemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank P = 0.005). Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes.

Predicting clinical outcomes of SARS-CoV-2 infection during the Omicron wave using machine learning.

The Omicron SARS-CoV-2 variant continues to strain healthcare systems. Developing tools that facilitate the identification of patients at highest risk of adverse outcomes is a priority. The study objectives are to develop population-scale predictive models that: 1) identify predictors of adverse outcomes with Omicron surge SARS-CoV-2 infections, and 2) predict the impact of prioritized vaccination of high-risk groups for said outcome. We prepared a retrospective longitudinal observational study of a national cohort of 172,814 patients in the U.S. Veteran Health Administration who tested positive for SARS-CoV-2 from January 15 to August 15, 2022. We utilized sociodemographic characteristics, comorbidities, and vaccination status, at time of testing positive for SARS-CoV-2 to predict hospitalization, escalation of care (high-flow oxygen, mechanical ventilation, vasopressor use, dialysis, or extracorporeal membrane oxygenation), and death within 30 days. Machine learning models demonstrated that advanced age, high comorbidity burden, lower body mass index, unvaccinated status, and oral anticoagulant use were the important predictors of hospitalization and escalation of care. Similar factors predicted death. However, anticoagulant use did not predict mortality risk. The all-cause death model showed the highest discrimination (Area Under the Curve (AUC) = 0.903, 95% Confidence Interval (CI): 0.895, 0.911) followed by hospitalization (AUC = 0.822, CI: 0.818, 0.826), then escalation of care (AUC = 0.793, CI: 0.784, 0.805). Assuming a vaccine efficacy range of 70.8 to 78.7%, our simulations projected that targeted prevention in the highest risk group may have reduced 30-day hospitalization and death in more than 2 of 5 unvaccinated patients.