Permanent Non-valvular Atrial Fibrillation Research Articles

Thromboembolic and hemorrhagic risk level in patients with permanent nonvalvular atrial fibrillation

Thromboembolic and hemorrhagic risk level in patients with permanent nonvalvular atrial fibrillation

Decision of Anticoagulation in Nonvalvular Atrial Fibrillation in the Real World in the Non-Antivitamin K Anticoagulants Era.

Background. Patients with nonvalvular atrial fibrillation (NVAF) have five times higher risk of stroke than the general population. Anticoagulation (ACO) in NVAF is a class I indication after assessing the CHA2DS2-VASc and HAS-BLED scores. However, in the real world, NVAF patients receive less ACO than needed due to patients’ comorbidities that can be assessed by the Charlson comorbidity index (CCI). The use of non-antivitamin K anticoagulants (NOAC) has improved the decision to anticoagulate. Objective. We analyzed the factors influencing the ACO prescribing decision in NVAF patients in the real world and the changes induced by the introduction of NOAC. Method. We carried out an observational retrospective cross-sectional study that included consecutive patients with permanent NVAF and CHA2DS2-VASc ≥ 2, admitted to a community hospital between 2010–2011 (group 1, 286 patients), when only vitamin K antagonists (VKA) were used, and 2018–2019 (group 2, 433 patients), respectively. We calculated CHA2DS2-VASc, HAS-BLED, and CCI and recorded the ACO decision and the use of VKA or NOAC in group 2. We compared the calculated scores between ACO and non-anticoagulated (nonACO) patients in both groups and between groups. Results. A 31.5% share of patients in group 1 and 12.9% in group 2 did not receive ACO despite a CHA2DS2-VASc score ≥ 2. In group 1, nonACO patients had higher HAS-BLED and CCI scores than the ACO patients, but their CHA2DS2-VASc scores were not significantly different. Old age, dementia, severe chronic kidney disease, neoplasia, and anemia were the most frequent reasons not to prescribe anticoagulants. In group 2, more nonACO patients had dementia, diabetes mellitus, and higher HAS-BLED than ACO patients. Moderate-severe CKD, neoplasia with metastasis, liver disease, anemia, and diabetes mellitus were statistically significantly more frequent in nonACO patients from group 1 than those from group 2. In group 2, 55.7% of ACO patients received NOAC. Conclusions. In real-world clinical practice, the decision for anticoagulation in NVAF is influenced by patient age, comorbidities, and risk of bleeding, and many patients do not receive anticoagulants despite a high CHA2DS2-VASc score. The use of NOAC in the past few years has improved treatment decisions. At the same time, the correct diagnosis, treatment, and surveillance of comorbidities have cut down the risk of bleeding and allowed anticoagulant use according to guidelines.

Demographic, clinical, and functional determinants of antithrombotic treatment in patients with nonvalvular atrial fibrillation

BackgroundThis study assessed the sociodemographic, functional, and clinical determinants of antithrombotic treatment in patients with nonvalvular atrial fibrillation (NVAF) attended in the internal medicine setting.MethodsA multicenter, cross-sectional study was conducted in NVAF patients who attended internal medicine departments for either a routine visit (outpatients) or hospitalization (inpatients).ResultsA total of 961 patients were evaluated. Their antithrombotic management included: no treatment (4.7%), vitamin K antagonists (VKAs) (59.6%), direct oral anticoagulants (DOACs) (21.6%), antiplatelets (6.6%), and antiplatelets plus anticoagulants (7.5%). Permanent NVAF and congestive heart failure were associated with preferential use of oral anticoagulation over antiplatelets, while intermediate-to high-mortality risk according to the PROFUND index was associated with a higher likelihood of using antiplatelet therapy instead of oral anticoagulation. Longer disease duration and institutionalization were identified as determinants of VKA use over DOACs. Female gender, higher education, and having suffered a stroke determined a preferential use of DOACs.ConclusionsThis real-world study showed that most elderly NVAF patients received oral anticoagulation, mainly VKAs, while DOACs remained underused. Antiplatelets were still offered to a proportion of patients. Longer duration of NVAF and institutionalization were identified as determinants of VKA use over DOACs. A poor prognosis according to the PROFUND index was identified as a factor preventing the use of oral anticoagulation.

Association Between Permanent Non-Valvular Atrial Fibrillation with Microalbuminuria and C-Reactive Protein

Background: An understanding of atrial fibrillation (AF) mechanisms, as the most common cardiac arrhythmia, is essential for primary and secondary prevention. Some studies indicated an association between microalbuminuria and C-reactive protein (CRP) protein, with the incidence and prevalence of AF. This study aimed to investigate the relationship between permanent non-valvular AF with microalbuminuria and reactive protein C. Materials and Methods: In this case-control study, 40 permanent non-valvular AF patients and 40 non-AF patients (control group) were studied. Demographic data and measurements of albumin, urine creatinine, CRP, and microalbuminuria were recorded and compared between the two groups. Results: In patients with permanent non-valvular atrial fibrillation, CRP level (P<0.001) and microalbuminuria (P=0.012) were significantly higher than the control group. Also, in patients with permanent non-valvular AF, the CRP positive (P = 0.014) and microalbuminuria (P = 0.003) were significantly higher than controls. The results showed that elevated chance of permanent non-valvular AF with abnormal CRP was 4.25 (odds ratio [OR]= 4.25, 95% confidence interval [CI]: 1.18-1.28; P= 0.026), and with microalbuminuria was 6.54 (OR= 6.54, 95% CI: 1.65-25.89; P=0.007). Conclusion: An elevated CRP level and microalbuminuria were significantly associated with permanent non-valvular atrial fibrillation. A longitudinal study is necessary. [GMJ.2021;10:e2106]

Association Between Permanent Non-Valvular Atrial Fibrillation with Microalbuminuria and C-Reactive Protein

Background: An understanding of atrial fibrillation (AF) mechanisms, as the most common cardiac arrhythmia, is essential for primary and secondary prevention. Some studies indicated an association between microalbuminuria and C-reactive protein (CRP) protein, with the incidence and prevalence of AF. This study aimed to investigate the relationship between permanent non-valvular AF with microalbuminuria and reactive protein C. Materials and Methods: In this case-control study, 40 permanent non-valvular AF patients and 40 non-AF patients (control group) were studied. Demographic data and measurements of albumin, urine creatinine, CRP, and microalbuminuria were recorded and compared between the two groups. Results: In patients with permanent non-valvular atrial fibrillation, CRP level (P<0.001) and microalbuminuria (P=0.012) were significantly higher than the control group. Also, in patients with permanent non-valvular AF, the CRP positive (P = 0.014) and microalbuminuria (P = 0.003) were significantly higher than controls. The results showed that elevated chance of permanent non-valvular AF with abnormal CRP was 4.25 (odds ratio [OR]= 4.25, 95% confidence interval [CI]: 1.18-1.28; P= 0.026), and with microalbuminuria was 6.54 (OR= 6.54, 95% CI: 1.65-25.89; P=0.007). Conclusion: An elevated CRP level and microalbuminuria were significantly associated with permanent non-valvular atrial fibrillation. A longitudinal study is necessary. [GMJ.2021;10:e2106]

Why are antithrombotic drugs not prescribed to octogenarian patients with atrial fibrillation at risk of stroke?

ObjectiveIn non-valvular atrial fibrillation (NVAF) patients at risk of stroke, anticoagulant drugs are less likely to be received by older patients than younger patients. In this study, an attempt is made to discover whether the reasons reported by physicians for denying anticoagulant drugs prescription differ between older and younger atrial fibrillation patients. Materials and methodsA retrospective, cross-sectional, multicentre study was conducted from October 2014 to July 2015. The study comprised patients aged ≥18 years diagnosed with NVAF, with a moderate to high stroke risk (CHADS2 score ≥2). Patients were stratified according to age (<80 and ≥80 years). ResultsA total of 1309 NVAF patients were evaluated, of whom 40.1% were ≥80 years old. Older patients were predominantly women with higher mean time since diagnosis of AF, with a higher rate of permanent NVAF, and with higher thromboembolic risk. In patients for whom physicians decided not to prescribe any anticoagulant agents, the following reasons were significantly more frequent in patients aged ≥80 years compared to younger patients: cognitive impairment, perceived high bleeding risk, falls, difficult access to monitoring, non-neoplastic terminal illness, and perceived low thromboembolic risk. Uncontrolled hypertension was a significantly more frequent reason for non-prescription of anticoagulant agents in patients aged <80 year. ConclusionsOctogenarian patients with NVAF and a moderate to high risk of stroke had a different as regards reasons for not being prescribed anticoagulant agents, which should be taken into account in order to improve.

Percutaneous left atrial appendage closure, a safe alternative to anticoagulation for patients with nonvalvular atrial fibrillation and end-stage renal disease on hemodialysis: A single center experience.

The evidence about the effectiveness and safety of oral anticoagulation in patients on hemodialysis is conflicting and scarce. Percutaneous left atrial appendage occlusion (LAAO) has demonstrated to be a valid alternative therapeutic option for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study is to present the outcomes of percutaneous LAAO in patients with end-stage renal disease (ESRD) on hemodialysis and NVAF in our center. We conducteda retrospective review of clinical records, demographics, LAAO procedure, complications, and outcomes of patients with NVAF and ESRD on hemodialysis who underwent a percutaneous LAAO in our center between January 2017 and January 2019. In the period of the study, eight patients with ESRD on hemodialysis underwent a percutaneous LAAO in our center. The overall mean age was 67.5years (range 56-81; SD±7.2). All patients had permanent NVAF. The total mean dialysis duration was 8.49years (range 0.83-14.8; SD±6.2). The mean CHA2DS2-VASc and HAS-BLED scores were high (4.75 [SD±1.16] and 4.62 [SD±0.91], respectively). All patients had history of a major hemorrhagic event (BARC Score ≥3). Most patients (n=6) showed left ventricular hypertrophy, and the average LVEF was 54% (SD±6.5). All devices were implanted successfully. Postprocedural antithrombotic regimen prescribed was based on antiplatelet therapy. No deaths, cardioembolic events, or major bleeding (according to the BARC scale) were reported during a mean follow-up of 14.24months (SD±9.44). Percutaneous LAAO could be of particular interest in patients with NVAF and CKD in hemodialysis. Further studies will be necessary to confirm this hypothesis.

Interactions between Atrial Fibrillation, Cardiovascular Risk Factors, and ApoE Genotype in Promoting Cognitive Decline in Patients with Alzheimer's Disease: A Prospective Cohort Study.

An association between non-valvular atrial fibrillation (NVAF) and cognitive impairment has been hypothesized. We sought to evaluate whether and how permanent NVAF (pNVAF) is associated with progression of cognitive impairment in patients with Alzheimer's disease (AD) in the presence of vascular or genetic risk factors. 310 consecutive patients affected by mild-moderate AD were included and followed for a 24-month period. At the end of the follow-up, based on the results of the neuropsychological evaluation patients were classified as stable or deteriorated to severe AD. Clinical history, therapy, time in therapeutic range for anticoagulation, Framingham cardiovascular risk profile (FCRP), CHA2DS2-VASc score, Mini-Mental State Examination (MMSE), ApoE genotype, brain CT-scan, carotid ultrasound, and ECG were collected. Binary logistic and path analysis were adopted to assess relationships between pNVAF, ApoE, and cognitive outcome. Despite anticoagulant therapy, pNVAF was associated with lower entry MMSE, higher mean intima-media thickness (mIMT) and higher FCRP. Among patients carrying ApoE ɛ4 allele and affected by pNVAF, the lowest MMSE (14.90±7.62) and the highest mIMT (1.16±0.17 mm) and FCRP (26.24±3.96) values were detected. In this group, the risk of cognitive deterioration reached the highest probability. pNVAF was associated with an increased cognitive deterioration in subjects with high FCRP, CHA2DS2-VASc, or mIMT. pNVAF seems to identify AD patients with a significant atherosclerotic burden and reduced cognitive performances. The interaction between pNVAF and ApoE ɛ4 genotype, especially with aggregated risk factors and an advanced stage of vascular damage is associated with higher risk of fast cognitive deterioration.

Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the Watchman TM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation. Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA 2 DS 2 -Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization. Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.

The Grade of Left Ventricular Diastolic Dysfunction as a Predictive Factor for Permanent Atrial Fibrillation

Abstract The objective of this study was to find a link between the grade of left ventricular diastolic dysfunction (LVDD) and the progression to permanent non-valvular atrial fibrillation (AF), in a group of patients with left ventricular diastolic dysfunction and paroxysmal or persistent atrial fibrillation. Methods: A bidirectional study on 57 patients meeting the inclusion criteria was conducted; each patient was admitted in a university-based hospital between January 1st - June, 30, 2013, with a follow up 3 and 6 months later. Permanent atrial fibrillation development was followed. Results: Out of the 57 patients, 23 had paroxysmal AF and 34 were with persistent AF. After six months, 21 patients progressed to permanent AF, representing 36.84% of the total patients. Female patients with age over 65 had more often atrial fibrillation, but more men progressed to a sustained form of AF. No statistically significant difference regarding the grade of diastolic dysfunction, the left atrial size or volume, or the left ventricular ejection fraction was observed between the patients with progression, compared to those without progression. Conclusions: The grade of left ventricular diastolic dysfunction did not prove to be a predictive factor for permanent atrial fibrillation, neither the left atrial size or volume, or the left ventricular ejection fraction.

Rationale and design of the RT-AF study: Combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention

ObjectiveOptimal antithrombotic strategy for patients with concomitant coronary artery disease and atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is still controversial, and the role of novel antithrombotic agents has nerve been tested. Therefore, the aim of this study is to evaluate and overall safety and efficacy profile of the combination of rivaroxaban and ticagrelor in this particular population. DesignThe RT-AF study is an open-label, randomized, active-controlled, multicenter clinical trial with up to 420 subjects enrolled in 5 centers. Eligible patients, who have a history or new onset paroxysmal, persistent, or permanent non-valvular AF, referred to the study centers with indications for PCI will be randomly assigned to receive triple therapy (including warfarin, clopidogrel and aspirin) or dual therapy (rivaroxaban and ticagrelor). All subjects will have clinical follow-up at discharge, at 30days, 6months and 12months. The primary end point is major or clinically relevant non-major bleeding events at 12months. The major secondary end point is the composite efficacy outcome of death, myocardial infarction, stent thrombosis and ischemic stroke. ConclusionThe study will be sufficiently powered to provide data primarily regarding the safety of dual therapy with rivaroxaban and ticagrelor over the traditional triple therapy in patients with AF undergoing PCI at 12months. It will also provide important information regarding the efficacy of the two different antithrombotic regimens. (ClinicalTrials.gov identifier: NCT02334254).

An open-label, randomized, controlled, multicenter study exploring two treatment strategies of rivaroxaban and a dose-adjusted oral vitamin k antagonist treatment strategy in subjects with atrial fibrillation who undergo percutaneous coronary intervention (PIONEER AF-PCI)

Guidelines recommendations regarding anticoagulant therapy after percutaneous coronary intervention (PCI) among patients with atrial fibrillation (AF) rely on retrospective, nonrandomized observational data. Currently, patients are treated with triple-therapy (dual antiplatelet therapy [DAPT] + oral anticoagulation therapy), but neither the duration of DAPT nor the level of anticoagulation has been studied in a randomized fashion. Recent studies also suggest dual pathway therapy with clopidogrel plus oral anticoagulation therapy may be superior, and other studies suggest that novel oral anticoagulants such as rivaroxaban may further improve patient outcomes. PIONEER AF-PCI (ClinicalTrials.gov NCT01830543) is an exploratory, open-label, randomized, multicenter clinical study assessing the safety of 2 rivaroxaban treatment strategies and 1 vitamin K antagonist (VKA) treatment strategy in subjects who have paroxysmal, persistent, or permanent nonvalvular AF and have undergone PCI with stent placement. Approximately 2,100 subjects will be randomized in a 1:1:1 ratio to receive either rivaroxaban 15 mg once daily plus clopidogrel 75 mg daily for 12 months (a WOEST trial-like strategy), or rivaroxaban 2.5 mg twice daily (with stratification to a prespecified duration of DAPT 1, 6, or 12 months, an ATLAS trial-like strategy), or dose-adjusted VKA once daily (with stratification to a prespecified duration of DAPT 1, 6, or 12 months, traditional triple therapy). All patients will be followed up for 12 months for the primary composite end point of Thrombolysis in Myocardial Infarction major bleeding, bleeding requiring medical attention, and minor bleeding (collectively, clinically significant bleeding). The PIONEER AF-PCI study is the first randomized comparison of VKA vs novel oral anticoagulant therapy in patients with NVAF receiving antiplatelet therapy after PCI to assess the relative risks of bleeding complications.

Left atrial appendage occlusion: What is its role today?

In many patients with paroxysmal or permanent nonvalvular atrial fibrillation and a CHA2DS2-VASc score of 2 or more, warfarin or other newer oral anti-coagulant therapies are contra-indicated, or are not prescribed, for a variety of reasons. These patients are therefore at risk of serious life threatening thrombo-embolic events particularly large stroke. Percutaneous occlusion of the left atrial appendage, the source of the majority of these emboli, is a therapy which should be considered in these patients. There is growing evidence that this procedure is as good as, if not superior in the long term, to chronic warfarin therapy.

Pattern of atrial fibrillation and risk of outcomes: The Loire Valley Atrial Fibrillation Project

BackgroundRisk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) is categorised in stroke risk stratification scores. The role of pattern of NVAF in risk prediction is unclear in contemporary ‘real world’ cohorts. Methods and resultsPatients with NVAF in a four-hospital-institution between 2000 and 2010 were included. Stroke/TE event rates were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent. Risk factors were investigated by Cox regression.Among 7156 NVAF patients, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent patterns of NVAF were included. In non-anticoagulated patients, overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13–1.47). Compared with paroxysmal NVAF, rates of stroke/TE, bleeding and all-cause mortality (p<0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients.In multivariate analyses, previous stroke (hazard ratio, HR 2.58, 95% CI 2.08–3.21), vascular disease (HR 1.34, 1.12–1.61), heart failure (HR 1.20, 1.00–1.44), age≥75years (HR 2.75, 2.16–3.50) and age 65–74years (HR 1.60, 1.22–2.09) independently increased stroke/TE risk, but not persistent (HR 1.13, 0.76–1.70) and permanent (HR 1.44, 0.96–2.16) NVAF patterns. ConclusionIn this large ‘real world’ NVAF cohort, rates of stroke, TE, death and bleeding differed significantly by patterns of NVAF. However, only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased risk of adverse outcomes in multivariate analyses. Thus, stroke risk is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors, not on arrhythmia pattern.

Abstract P285: Pattern of Atrial Fibrillation and Risk of Outcomes: The Loire Valley Atrial Fibrillation Project

Background: The risk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) can be classified in commonly-used stroke risk stratification scores. The role of the pattern of atrial fibrillation in risk prediction is unclear in contemporary ‘real world’ cohorts. Methods: Patients diagnosed with NVAF in a four-hospital-institution between 2000 and 2010 were identified and included. Event rates of stroke/TE were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent, defined by consensus guidelines. Independent risk factors of stroke/TE were investigated by Cox regression. Results: Among 7156 patients with NVAF, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent NVAF patterns were included. In non-anticoagulated patients, the overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13–1.47). Paroxysmal NVAF patients were more likely to be female (p&lt;0.001). Persistent NVAF patients were less likely to have prior history of stroke (p–0.002) and vascular disease (p&lt;0.001), and more likely to have hypertension (p&lt;0.001) and vitamin K antagonist therapy (p&lt;0.001). Permanent NVAF patients were more likely to have diabetes (p&lt;0.001), heart failure therapy (p&lt;0.001) and less likely to have dyslipidaemia (p&lt;0.001). Compared with paroxysmal NVAF, rates of stroke/TE (p=0.001), bleeding (p&lt;0.001) and all-cause mortality (p&lt;0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients. In multivariate analyses, only previous stroke (hazard ratio, HR 2.58, 95% CI 2.08–3.21), vascular disease (HR 1.34,1.12–1.61), heart failure (HR 1.20,1.00–1.44), age≥75 years (HR 2.75, 2.16–3.50) and age 65–74 years (HR 1.60,1.22–2.09) increased stroke/TE risk, but persistent (HR1.13, 0.76–1.70) and permanent (HR 1.44,0.96–2.16) patterns of NVAF did not. Conclusion: In this large ‘real world’ cohort of NVAF patients, there were significant differences in rates of stroke, TE, death and bleeding between patterns of NVAF, however only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased the risk of stroke/TE, death and bleeding in multivariate analyses. Therefore, the risk of stroke is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors not NVAF pattern.

Upper Digestive Bleeding in Atrial Fibrillation: Evaluation of Gastroscopy Prior to Oral Anticoagulant Therapy (GOAT), Prospective, Randomized, Double Blind Study on a Community Population.

BackgroundThe aim of this study was to investigate the incidence of digestive hemorrhages in patients with non-valvular atrial fibrillation (NVAF), scheduled for oral anticoagulant therapy.MethodsWe conducted, over 24 months, a prospective, randomized, population-based observational study on consecutive patients with recurrent paroxysmal, persistent, or permanent NVAF, scheduled for oral anticoagulant therapy. The study initially included 268 patients with NVAF (162 males and 106 females) with a mean age of 74 years (range 42-86 years). Patients were split into two groups: those undergoing preventive Esophago-Gastro-Duodenoscopy (EGD) (Group A) and those who did not (Group B). All patients positive by EGD underwent medical treatment and subsequent 30-day endoscopic controls showed complete healing. The primary outcome of the study was to determine if previous EGD in patients with NVAF resulted in a low risk of bleeding during oral anticoagulant therapy. The two groups were comparable for most variables.ResultsSignificant differences were found between groups for the incidence of antiarrhythmic drugs and for early hemorrhage (P <0.001). The incidences of early hemorrhages were significantly different between the two groups with 12 in group B (12%) and 2 in group A (1.7%).ConclusionsPreventive EGD can identify hidden digestive diseases, which may increase the incidence of early hemorrhages.

Successful anticoagulation for treatment of a giant left atrial thrombus

We report the discovery at transthoracic echocardiography of a very large, sessile formation in the left atrium in a 77-year-old woman with permanent non-valvular atrial fibrillation who did not receive anticoagulant therapy. After six weeks of anticoagulation by subcutaneous low-molecular-weight heparin, a control echocardiogram demonstrated an almost complete resolution of the mass without systemic embolisation. This case highlights the success, without complications, of a medical anticoagulant therapy for giant left atrial thrombus.

Oral Anticoagulation in Nonvalvular Atrial Fibrillation in Clinical Practice: Impact of CHADS2 Score on Outcome

Objectives: CHADS₂ score predicts embolic risk in patients with nonvalvular atrial fibrillation (NVAF), but also bleeding risk in patients receiving oral anticoagulation (OAC). Our objective is to analyze the effectiveness and safety of OAC in patients with NVAF in daily clinical practice, according to embolic risk evaluated by means of CHADS₂ score. Methods: All consecutive outpatients with permanent NVAF seen at 2 cardiology clinics were prospectively followed for embolic events (transient ischemic attack, ischemic stroke, peripheral embolism) and severe bleedings. OAC was prescribed according to the recommendations of scientific associations. CHADS₂ score was obtained for each patient. Results: From February 1, 2000 to July 31, 2003, 796 outpatients fulfilled the inclusion criteria. OAC was prescribed to 564 (71%) patients. After 2.4 ± 1.9 years of follow-up, the embolic event rates (per 100 patient-years) for each stratum of the CHADS₂score for patients with/without OAC were: 1/4.1, p = 0.23 (CHADS₂ = 0); 0.6/7.1, p = 0.0018 (CHADS₂ = 1); 0.5/5.1, p = 0.0014 (CHADS₂ = 2); 2.4/12.5, p = 0.0017 (CHADS₂ = 3) and 2.9/20, p = 0.013 (CHADS₂ ≧4). The severe bleeding rates for the same CHADS₂ score strata were 3/0.8, 0.8/0.7, 1.3/0.7, 0.4/0, and 2.9/5 in patients with/without OAC (n.s.). Conclusion: OAC is effective and safe in daily clinical practice in patients with NVAF and CHADS₂ score ≧1.

Predicting Embolic Events in Patients With Nonvalvular Atrial Fibrillation: Evaluation of the CHADS 2 Score in a Mediterranean Population

A new index for predicting embolic risk in nonvalvular atrial fibrillation has been proposed, the CHADS2 score, which is calculated by adding 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes, and by adding 2 points for a history of stroke or transient ischemic attack (TIA). Our objective was to evaluate the use of this score in a Mediterranean population. Between February 1st, 2000 and December 20th, 2006, all patients with permanent nonvalvular atrial fibrillation being treated at two outpatient cardiology clinics in a university hospital in the south of Spain were offered antithrombotic therapy in accordance with scientific society recommendations and were prospectively monitored for embolic events (i.e., stroke, TIA or peripheral embolism). A CHADS2 score was derived for each of the 296 patients who did not receive anticoagulation. The CHADS2 score was 0 in 69 (23.3%) patients, 1 in 81 (27.4%), 2 in 99 (33.4%), 3 in 30 (10.1%), and 4 or more in 17 (5.7%). After 21 (17) months of follow-up, the embolic event rates for CHADS2 scores of 0, 1, 2, 3, and > or =4 were 2.88, 5.80, 5.16, 14.78 and 22.02 per 100 patient-years, respectively (P=.0016). Patients with a CHADS2 score from 0-2 had an embolic rate of 4.63 per 100 patient-years, compared with 17.31 per 100 patient-years in those with a score > or =3 (P=.00087). The CHADS2 score proved useful for quantifying the risk of an embolic event in Mediterranean patients with nonvalvular atrial fibrillation. In our series, the risk of embolism in patients with a low score was not negligible.

Potential applicability and utilization of left atrial appendage occlusion devices in patients with atrial fibrillation

The WATCHMAN left atrial appendage occluder device (Atritech, Inc, Minneapolis, MN) is currently being tested in a Food and Drug Administration-approved clinical trial, the PROTECT AF trial, for patients who are diagnosed with paroxysmal, persistent, or permanent nonvalvular atrial fibrillation. However, rigorous screening and the study design have resulted in the exclusion of a large number of patients. Hence, the purpose of this study was to assess the potential utility of this device among those who were eligible but excluded for trial criteria and the reasons for exclusion. Screening logs from the respective sites participating in the PROTECT AF trial were collected and analyzed for potential utilization outside of a research trial. Only 31 patients were enrolled into the research trail from the screening of 1798 total patients. Information from the excluded patients was examined and it was determined that 79% of these patients would be eligible for the device outside the research trial. Twenty-one percent of patients were not able to receive the device because of long-term warfarin need, contraindications to warfarin, unsuitable anatomy as determined by echocardiography, or the inability to take short-term aspirin and clopidogrel for protocol requirements. Should a device like the WATCHMAN left atrial appendage occluder be approved, approximately 79% of all patients with atrial fibrillation would be eligible for device placement.