Systemic Embolism In Patients Research Articles

Predictive Value of D-dimer Levels for Detection of Left Atrial Thrombus in Patients with Rheumatic Severe Mitral Stenosis

Background: Systemic embolism is one of the most common complications of mitral stenosis (MS). Systemic embolism in patients with MS is caused by left atrial (LA) thrombus. Trans Esophageal Echocardiography (TEE) is considered the most reliable in ruling out LA thrombus, however, it is semi-invasive, operator-dependent, and not widely available. On the other hand, D-dimer is an indirect marker of fibrin formation. It reflects the activation of coagulation system. Objective: To measure D-dimer levels in patients with and without LA thrombus and find out predictive value of D-dimer levels to detect LA thrombus. Methods: In this cross-sectional observational study 50 patients with rheumatic severe mitral stenosis have been assessed. Patients underwent Trans Thoracic Echocardiography (TTE) and TEE to rule out LA thrombus. If TTE showed LA thrombus, TEE was not done. Patients were divided into two groups based on presence of LA thrombus; group I- patients with LA thrombus, and group II- patients without LA thrombus. D-dimer level was measured in two groups and comparison was done. Results: D-dimer was significantly elevated in group I compared to group II (2.8±1.9 µg/ml vs. 0.43±0.13µg/ml, p<0.001). Receiver Operator Characteristic (ROC) Curve showed D-dimer level > 0.6 µg/ml can predict LA thrombus with sensitivity of 84% & specificity of 88%. Conclusion: A higher level of D-dimer can predict LA thrombus in patients with rheumatic severe MS, and can be used as a noninvasive marker to rule out LA thrombus in patients with rheumatic severe MS. Bangladesh Medical Res Counc Bull 2022; 48(3): 231-235

Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2DS2-VASc score of 0

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA2DS2-VASc score of 0. Purpose This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke. Methods Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA2DS2-VASc score of 0 followed up for at least 6 months were enrolled. Patients whose only risk factor was female were included as a CHA2DS2-VASc score of 0 in this study. The primary outcome was stroke or systemic embolism. Results The mean age at AF diagnosis was 49.9 years, and 398 (73.4%) were men. During the mean follow-up of 4.7 years, the primary outcome rate was 0.78%/year (stroke, 0.70%/year; systemic embolism, 0.08%/year), and major bleeding and all-cause death occurred in 0.31%/year and 1.02%/year, respectively. The proportions of age ≥50 years at diagnosis, left ventricular end-diastolic dimension (LVEDD) of ≥46 mm, and non-paroxysmal AF in patients with stroke or systemic embolism were significantly higher than in those without. Cox proportional hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811–24.860, P-value=0.004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038–19.626, P-value=0.045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621–19.175, P-value=0.006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have stroke or systemic embolism. Conclusion The annual stroke or systemic embolism rate in NVAF patients with CHA2DS2-VASc score of 0 was 0.78%/year. Age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to be at very low risk of stroke.

Transcatheter Left Atrial Appendage Closure.

Atrial fibrillation is the most common arrhythmia worldwide, placing a large population at risk for potentially disabling ischemic strokes, yet an estimated 50% of eligible patients cannot tolerate or are contraindicated to receive oral anticoagulation. Within the last 15 years, transcatheter options for left atrial appendage closure (LAAC) have provided a valuable alternative to chronic oral anticoagulation for reducing risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. With newer generation devices such as Watchman FLX and Amulet gaining approval from the US Food and Drug Administration in recent years, several large clinical trials have demonstrated the safety and efficacy of transcatheter LAAC in a population intolerant to systemic anticoagulation. In this contemporary review, we discuss the indications for transcatheter LAAC and the evidence evaluating the use of various device therapies currently available or in development. We also examine current unmet challenges in intraprocedural imaging and controversies in postimplantation antithrombotic regimens. Several ongoing seminal trials are hoping to clarify the role of transcatheter LAAC as a safe, first-line option for all patients with nonvalvular atrial fibrillation.

Association of Left Atrial Size With Stroke or Systemic Embolism in Patients With Atrial Fibrillation Having Undergone Bioprosthetic Valve Replacement From the BPV-AF Registry.

Background: The left atrial volume index (LAVI) is important for predicting thromboembolism in patients with non-valvular atrial fibrillation (AF), but the utility of LAVI for predicting thromboembolism in patients with both bioprosthetic valve replacement and AF remains unclear. Methods and Results: Of 894 patients from a previous multicenter prospective observational registry (BPV-AF Registry), 533 whose LAVI data had been obtained by transthoracic echocardiography were included in this subanalysis. Patients were divided into tertiles (T1-T3) according to LAVI as follows: T1 (n=177), LAVI=21.5-55.3 mL/m2; T2 (n=178), LAVI=55.6-82.1 mL/m2; T3 (n=178), LAVI=82.5-408.0 mL/m2. The primary outcome was defined as either stroke or systemic embolism for a mean (±SD) follow-up period of 15.3±4.2 months. Kaplan-Meier curves indicated that the primary outcome tended to occur more frequently in the group with the larger LAVI (log-rank P=0.098). Comparison of T1 with T2 plus T3 using Kaplan-Meier curves indicated that patients in T1 experienced significantly fewer primary outcomes (log-rank P=0.028). Furthermore, univariate Cox proportional hazard regression showed that 1.3- and 3.3-fold more primary outcomes occurred in T2 and T3, respectively, than in T1. Conclusions: Larger LAVI was associated with stroke or systemic embolism in patients who had undergone bioprosthetic valve replacement and with a definitive diagnosis of AF.

Analysis of factors related to systemic embolism in patients≥75 years old with non-valvular atrial fibrillation

Objective: To explore the related risk factors for systemic embolism (SE) in patients aged≥75 years with non-valvular atrial fibrillation (NVAF). Methods: A case-control study. NVAF patients aged≥75 years who were hospitalized at the First Affiliated Hospital of Xinjiang Medical University from October 2018 to October 2020 were divided into no SE (n=1 127) and SE (n=433) groups according to the occurrence of SE after NVAF. Multivariate logistic regression was used to analyze SE-related factors in patients with NVAF without anticoagulation treatment. Results: In the multivariate model, the following factors were associated with an increased risk of SE in patients with NVAF: history of AF≥5 years [odds ratio (OR)=2.75, 95% confidence interval (CI) 1.98-3.82, P<0.01], lipoprotein(a)>300 g/L (OR=2.07, 95%CI 1.50-2.84, P<0.01), apolipoprotein (Apo)B>1.2 g/L (OR=1.91, 95%CI 1.25-2.93, P=0.003), left ventricular ejection fraction (LVEF) of 30%-49% (OR=2.45, 95%CI 1.63-3.69, P<0.01), left atrial diameter>40 mm (OR=1.54, 95%CI 1.16-2.07, P=0.003), and CHA2DS2-VASc score≥3 (OR=15.14, 95%CI 2.05-112.13, P=0.01). ApoAI>1.6 g/L was negatively correlated with the occurrence of SE (OR=0.28, 95%CI 0.15-0.51, P<0.01). Conclusions: History of AF≥5 years, lipoprotein(a)>300 g/L, elevated ApoB, left atrial diameter>40 mm, LVEF of 30%-49%, and CHA2DS2-VASC score≥3 are independent risk factors for SE whereas ApoAI>1.6 g/L is a protective factor against SE in patients with NVAF.

Elevated thrombin generation levels in the left atrial appendage in patients with atrial fibrillation

BackgroundAtrial Fibrillation (AF) is the most common sustained tachi-arrhythmia. Thrombus formation in the left atrial appendage (LAA) increases the risk of stroke and systemic embolism in patients with AF. ObjectivesThe aim of this study was to compare thrombin generation in the LAA to the LA among patients with AF. MethodsA cross-sectional study of consecutive patients with AF undergoing pulmonary veins catheter ablation. Blood samples from the femoral vein (FV), right atrium (RA), left atrium (LA), and LAA were collected during the catheter ablation procedures. Thrombin generation was assessed by a Calibrated Automated Thrombogram. The LAA-calibrated automated thrombogram parameters were compared with the RA, LA, and FV. ResultsA total of 47 consecutive patients were enrolled in the study. The endogenous thrombin potential and peak height were significantly higher in the LAA compared with the LA, the mean differences and 95% CI between the LA and LAA were -378.9 (-680.5, -77.2) (nM∗min) and -66.7 (-119.6, -13.8) (nM) in the endogenous thrombin potential and peak height respectively. ConclusionIn patients with AF undergoing catheter ablation, the LAA demonstrated increased thrombin generation compared with the LA. This finding might contribute to the understanding of why the LAA is more predisposed to thrombus formation than the LA. Clinical Trials RegistrationNCT03795883

Efficacy and Safety of Renal Function on Edoxaban Versus Warfarin for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Background: Edoxaban is a novel oral anticoagulant which may decrease the risk of stroke and systemic embolism in patients suffering from atrial fibrillation (AF). However, the decreased efficacy of edoxaban versus warfarin for the avoidance of stroke and systemic embolism in AF with creatinine clearance (CrCl) > 95 mL/min has been reported. The purpose of this meta-analysis is to further clarify the safety (major bleeding) and efficacy (stroke or systemic embolism) of edoxaban for AF patients with various CrCl. Methods: A systematic search of studies on edoxaban and warfarin in AF patients related to renal function was conducted in PubMed, Medline, Web of Science databases, EBSCO, Embase, and the Cochrane Central Register of Controlled Trials. In this meta-analysis (protocol number: PROSPERO CRD 42021245512), we included studies that provide specific data on three outcomes: ischemic stroke or systemic embolism (S/SE), bleeding, and all-cause mortality. Results: This meta-analysis enrolled two randomized controlled trials (RCTs) studies and two retrospective studies that enrolled 28,065 patients. According to CrCl, subjects are divided into three groups (CrCl 30−50 mL/min, CrCl 50−95 mL/min, CrCl > 95 mL/min). In AF patients with CrCl 30−50 mL/min, edoxaban 30 mg daily is similar to warfarin in the prevention of ischemic S/SE and all-cause mortality, resulting in lower bleeding rate and better net clinical outcome (ischemic S/SE: hazard ratio (HR), 0.85, 95% confidence interval (CI), 0.19−1.87; all-cause mortality: HR, 0.65, 95% CI, 0.35−1.19; bleeding: HR, 0.75, 95% CI, 0.60−0.93; net clinical outcome: HR, 0.75, 95% CI, 0.63−0.90). In the group of CrCl 50−95 mL/min, the net clinical outcome was more favorable with edoxaban 60 mg daily than warfarin (HR, 0.81, 95% CI: 0.68−0.96), and there was no significant difference between edoxaban 60 mg daily and warfarin in terms of prevention of bleeding, ischemic S/SE, and all-cause mortality. For AF patients with CrCl > 95 mL/min, there was a statistically significant difference in lower bleeding rate between edoxaban 60 mg daily and warfarin (bleeding: HR: 0.70, 95% CI: 0.58−0.84). There was no differential safety in ischemic S/SE, all-cause mortality, and net clinical outcome. Conclusion: Overall, edoxaban was superior to warfarin in terms of net clinical outcome in various groups of CrCl with AF patients. Although there was no significant difference in net clinical outcome between edoxaban and warfarin for AF patients with CrCl > 95 mL/min, edoxaban is not inferior to warfarin in safety and effectiveness in the various levels of CrCl. Edoxaban may be a more effective and safe treatment than warfarin for patients with chronic kidney disease (CKD) who require anticoagulation. More high-quality and long-term clinical research are needed to further estimate the effects of edoxaban.

Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2 DS2 -VASc score of 0.

Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA2 DS2 -VASc score of 0. This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke. Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA2 DS2 -VASc score of 0 followed up for at least 6 months were enrolled. Patients with only being woman as a risk factor were included as a CHA2 DS2 -VASc score of 0 in this study. The primary outcome was stroke or systemic embolism. The primary outcome rate was 0.78%/year. In Cox hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811-24.860, p=.004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038-19.626, p=.045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621-19.175, p=.006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have a stroke or systemic embolism. The annual stroke or systemic embolism rate in NVAF patients with CHA2 DS2 -VASc score of 0 was 0.78%/year, and age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to have a very low risk of stroke.

Tailored Direct Oral Anticoagulation in Patients with Atrial Fibrillation: The Future of Oral Anticoagulation?

Direct oral anticoagulants (DOAC) are currently the drug of choice for drug prevention of stroke or systemic embolism in patients with atrial fibrillation (AF). However, repeated ischemic stroke or systemic embolism and bleeding while on DOAC is still a challenging clinical phenomenon in the management of future long-term anticoagulation. It is not known whether tailoring the DOAC therapy to achieve optimal therapeutic drug levels could improve the clinical course of DOAC therapy. To be able to tailor the therapy, it is necessary to have a valid laboratory method for DOAC level assessment, to be aware of factors influencing DOAC levels and to have clinical options to tailor the treatment. Furthermore, the data regarding clinical efficacy/safety of tailored DOAC regimes are still lacking. This article reviews the current data on tailored direct oral anticoagulation in patients with AF.

Anticoagulant therapy with direct oral anticoagulants in the context of polypragmasy: a course to safety

Cardiovascular disease is the most common cause of death in the world. For almost 60 years vitamin K antagonists (VKAs) have been the mainstay of anticoagulant therapy, but in recent years direct oral anticoagulants (DAACs) have become the anticoagulant of choice, as they have many well-known advantages: more predictable anticoagulant effect, no need for dose selection (there is a need for dose adjustment only for renal dysfunction), routine laboratory monitoring of pharmacodynamic effect (except in special clinical situations), less frequency of clinically significant drug interactions compared with warfarin, and less dependence on patient genetic characteristics. The main indications for POAC are: prevention of venous thromboembolism in patients who have undergone endoprosthesis of lower limbs, prevention of stroke and systemic embolism in patients with atrial fibrillation, treatment and prevention of recurrent deep vein thrombosis (DVT) and pulmonary embolism. The administration of direct oral anticoagulants (DOACs) has long been considered a major therapeutic advance, mainly because they do not require therapeutic monitoring. Despite this, POACs, like vitamin K antagonists, can still cause major and clinically significant minor bleeding, even when used correctly. Considering that POAC patients are often older and have multiple comorbidities, polypragmasy is widespread. Drug interactions involving POACs are important contributors to the increased risk of bleeding. Awareness of these drug interactions and how to address them is critical to optimizing treatment while reducing the risk of bleeding. This review provides an overview of POAC metabolism, the most common drugs that may interact with POACs, and ways to eliminate these interactions.

Risk of stroke or systemic embolism in patients with degenerative mitral stenosis with or without atrial fibrillation: A cohort study.

BackgroundAtrial fibrillation (AF) is associated with an increased risk of stroke and the combination of AF and mitral stenosis (MS) is associated with a higher risk. In developed nations, degenerative mitral stenosis (DMS) constitutes a sizeable proportion of patients with MS. Current international guidelines do not offer recommendations regarding anticoagulation in these patients. The objective of this study was to describe the incidence of stroke or systemic embolism in patients with DMS with or without prevalent AF.MethodsA cohort study of DMS patients from 1997 to 2018, using data from the Danish health registries. The cohort was stratified based on AF prevalence and prior ischemic stroke. The primary outcome was a diagnosis of ischemic stroke or systemic embolism after 1 year of follow-up from time of DMS diagnosis.ResultsThe study included 1162 patients with DMS, of which 421 had prevalent AF. The incidence rate of stroke or systemic embolism after 1 year of follow-up was highest in the DMS without AF group (7.58 vs. 6.63 per 100 person-years). In both groups, DMS without AF and DMS with AF, the incidence rate was highest in patients with prior thromboembolic events (29.61 vs. 5.15 and 19.53 vs. 5.15, respectively).ConclusionsThe incidence rate of stroke or systemic embolism was highest in DMS patients without AF. Current Danish guidelines recommend DMS patients should be treated with anticoagulation only with concurrent AF, yet our results call for additional research to establish if DMS patients without AF could benefit from stroke prevention therapy.

Comparison of Direct Oral Anticoagulants and Warfarin in the Prevention of Stroke in Patients With Valvular Heart Disease: A Meta-Analysis

Warfarin is the standard of care, and direct oral anticoagulants (DOACs) are a group of newer drugs to prevent stroke in patients with valvular heart disease. The aim of this meta-analysis is to compare the efficacy and safety of DOACs and warfarin in the prevention of stroke in patients with valvular heart disease (VHD). The current meta-analysis was conducted using the standards developed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation. The databases from the Cochrane library, PubMed, and Excerpta Medica database (EMBASE) were used to search for relevant articles without placing restrictions on the year of publication. Outcomes assessed in the current meta-analysis included a number of patients with stroke or systemic embolism, patients having myocardial infarction during the study period, patients with major bleeding events, and patients who died due to any reason. Overall, five studies were included in the current meta-analysis. Direct oral anticoagulants were associated with a lower risk of stroke or systemic embolism in patients with VHD (relative risk (RR): 0.75, 95% confidence interval (C)I: 0.60 to 0.94). The risk of major bleeding events is 31% lower in patients receiving DOAC compared to patients receiving warfarin (RR: 0.69, 95% CI: 0.58 to 0.83). No significant difference was found between the two groups in terms of all-cause mortality and myocardial infarction. The current meta-analysis shows that DOACs were associated with a lower risk of stroke or systemic embolism as compared to warfarin in patients with VHD. Besides this, the risk of major bleeding events was also lower in patients receiving DOACs compared to patients receiving warfarin. No significant differences were reported in terms of myocardial infarction and all-cause mortality between the two groups.

Controlled Level and Variability of Systolic Blood Pressure on the Risk of Thromboembolic Events in Atrial Fibrillation and Hypertension

Hypertension is an independent risk factor for thromboembolic events in patients with atrial fibrillation (AF). However, the association between blood pressure (BP) control and thromboembolic events remains under-evaluated in patients with AF. We aimed to identify the relation between BP control and the risk of ischemic stroke and systemic embolism in hypertensive patients with AF. Data on 13,712 consecutive patients with AF (9,505 with and 4,207 without hypertension) were retrospectively analyzed. The hypertensive group was divided into quartiles according to the initial BP, linearly interpolated mean BP, variability independent of the mean of the BP, and time in therapeutic range (&lt;130 mm Hg for systolic BP [SBP] and &lt;80 mm Hg for diastolic BP) during follow-up. The primary outcome was ischemic stroke and systemic embolism. The mean follow-up duration of the study population was median 2.7 years (interquartile range 1.1 to 4.9 years), and the median number of BP measurements was 14 (interquartile range 6 to 25) times. Strictly controlled initial and interpolated mean BP and low variability in controlled BP (variability independent of the mean) were associated with a lower risk of ischemic stroke and systemic embolism for both SBP and diastolic BP. A similar risk was observed in patients with strictly controlled SBP (time in therapeutic range under 130 mm Hg &gt;94%) and those without hypertension. In conclusion, continuous and strict maintenance of SBP under 130 mm Hg with low variability at outpatient clinic follow-up reduces the risk of ischemic stroke and systemic embolism in patients with hypertension and AF.

Clinical case of an ischemic stroke of the patient with non-bacterial thrombotic endocarditis

Ischemic stroke in oncological diseases occurs as a result of the prothrombotic effect caused by cancer. Besides that, it is associated with antitumor therapy. In the first instance, cardioembolism should be ruled out for recurrent systemic embolism in patients with a tumor history. In most cases, the cause of cerebral embolism in oncological diseases is non-bacterial thrombotic endocarditis. Its diagnosis preferably based on transesophageal echocardiography. This article presents a clinical case of ischemic stroke developed by marantic endocarditis, methods of its verification and treatment.

Increased Risk of Stroke Due to Non-adherence and Non-persistence with Direct Oral Anticoagulants (DOACs): Real-World Analyses Using a Nested Case-Control Study from The Netherlands, Italy and Germany.

A high degree of adherence to direct oral anticoagulants is essential for reducing the risk of ischaemic stroke and systemic embolism in patients with atrial fibrillation, owing to the rapid decline in anticoagulation activity when doses are omitted (i.e. rebound effect). We aimed to assess the relationship between non-adherence and non-persistence with direct oral anticoagulants and the incidence of ischaemic stroke in patients with atrial fibrillation. A nested case-control study was conducted in the Netherlands, Italy and Germany among patients with atrial fibrillation starting direct oral anticoagulants between the drug approval date and the end of database availability. Patients with an ischaemic stroke during the follow-up were selected as cases and compared with matched controls (matched on age ±5 years, sex, year of cohort entry date and CHA2DS2-VASc-score at cohort entry date). The cohort entry date was the first dispensing date. Study patients were those aged ≥45 years, with ≥1 year database history, ≥1 year follow-up and at least two direct oral anticoagulant dispensings after the cohort entry date. Adherence and persistence to direct oral anticoagulant treatment were defined as the proportion of days covered ≥80% or direct oral anticoagulant continuous use between the cohort entry date and the index date (i.e. date of ischaemic stroke), respectively. In The Netherlands, Italy and Germany, 105 cases and 395 controls, 1580 cases and 6248 controls, and 900 cases and 3570 controls were included, respectively. Odds ratios (ORs) for stroke among current users who were non-adherent compared to adherent users were 0.43 (95% confidence interval [CI] 0.09-1.96) in The Netherlands, 1.11 (95% CI 0.98-1.26) in Italy and 1.21 (95% CI 1.01-1.45) in Germany. The risk of stroke was significantly higher among non-persistent users compared with persistent users in all three databases [OR 1.56 (95% CI 1.00-2.44), OR 1.48 (1.32-1.65) and OR 1.91 (95% CI 1.64-2.22), respectively]. In The Netherlands and Germany, the risk of stroke was higher the longer a patient had stopped using direct oral anticoagulants. Both non-adherence (in Germany) and non-persistence increased the risk of stroke, either using a once-daily or twice-daily regime.

Clinical outcomes of gastrointestinal bleeding management during anticoagulation therapy.

Acute gastrointestinal (GI) bleeding is not an uncommon complication of oral anticoagulation (OAC) therapy that requires medication cessation. However, drug cessation may cause fatal stroke or systemic embolization in patients at high thromboembolic risk. Here we sought to find an appropriate anticoagulation cessation strategy in cases of GI bleeding during OAC therapy. This single-center retrospective cohort analysis was performed between 2010 and 2018. Patients were enrolled if the following three consecutive conditions were met: 1) electrocardiography electrocardiography-proven atrial fibrillation; 2) OAC therapy; and 3) GI bleeding. We divided the drug cessation strategy into the continuation and discontinuation groups. During 1-year follow-up, the rates of major thromboembolic and rebleeding events were calculated. One hundred and forty-six patients (continuation [n = 54] vs. discontinuation [n = 92] group) were enrolled. Patients in the discontinuation group were more likely to be older (69.8 ± 9.0 yrs vs. 74.9 ± 8.9 yrs, p = 0.001), while patients in the continuation group were more likely to have undergone cardiac valve surgery (51.9% vs. 20.7%, p<0.001). The presence of a mechanical mitral valve was a determinant of continuation strategy (38.9% vs. 7.5%, p<0.001). However, the mean CHA₂DS₂-VASc (3.4±1.3 vs. 4.1±1.6, p = 0.010) and Glasgow-Blatchford (8.0±2.4 vs. 8.9±2.5, p = 0.037) scores were higher in the discontinuation group. Two major embolic strokes occurred in each group (3.7% vs. 2.2%, p = 0.585). Four of 54 (7.4%) and five of 92 (5.4%) patients had rebleeding events during follow-up (p = 0.632). One embolic event in the continuation group and one rebleeding event in the discontinuation group were fatal. The Glasgow-Blatchford score was a predictor of 1-year rebleeding events (odds ratio [OR], 1.36; 95% confidence interval [CI], 0.68-2.20; p = 0.028). The high CHA₂DS₂-VASc score showed a strong trend (OR, 1.71; 95% CI, 0.92-3.20; p = 0.089) in 1-year thromboembolic events. No single risk factor or drug cessation strategy was attributed to adverse clinical events after GI bleeding. The risk of future thrombotic or rebleeding events should be individualized and controlled for based on a pre-existing stratification system.

Impaired heart rate variability triangular index predicts stroke and systemic embolism in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation Introduction Despite the broad use of oral anticoagulants, stroke remains one of the most serious complications in atrial fibrillation (AF) patients. Stroke has been linked to disturbances of the autonomic nervous system as both share similar risk factors. Therefore, impaired cardiac autonomic function may indicate an enhanced stroke risk. Purpose We hypothesized that impaired cardiac autonomic function, quantified by means of heart rate variability (HRV), might be useful in predicting stroke in patients with AF. Methods We enrolled 1,933 patients with a documented history of AF from the multicenter Swiss-AF cohort study who were either in sinus rhythm (SR-group, n=1130) or AF (AF-group, n=803) on a 5-minute resting ECG recording. HRV triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-min total power and power in the high frequency, low frequency and very low frequency range were calculated. We constructed cox regression models to analyze the predictive power of HRV parameters for the composite endpoint stroke or systemic embolism. Results Mean age was 71±8 years in the SR group and 75±8 in the AF group, 28% of the total study cohort were female. 36 patients in the SR group (3.2%) and 58 patients in the AF group (6.5%) experienced a stroke or systemic embolism during a follow-up time of 4.0±1.3 years. In patients with sinus rhythm, HRVI &amp;lt;15 was the only HRV parameter independently associated with stroke or systemic embolism (hazard ratio 2.94; 95% confidence interval 1.3-6.8; p=0.011) after adjustment for multiple clinical confounders (age, sex, AF type, history of hypertension, history of diabetes, history of chronic kidney disease, prior stroke or transient ischemic attack, intake of oral anticoagulation, antiarrhythmics or betablockers). In the AF group, no HRV parameter was associated with the composite endpoint. Conclusions HRVI measured during SR on a single 5-minute ECG recording is an independent predictor of stroke or systemic embolism in AF patients. HRV analysis may help to improve risk stratification in AF patients.

Dabigatran Reversal: A Practical Approach

Dabigatran is a direct oral anticoagulant used to prevent stroke and systemic embolism in patients with atrial fibrillation. In situations that require the urgent reversal of its anticoagulant activity, such as in the case of severe bleeding that is life-threatening; urgent/ emergent surgery or invasive procedures with significant bleeding risk; and the need for thrombolysis in a patient with ischemic stroke, several measures can be taken, including the use of its specific reversal agent, idarucizumab. Based on the guidelines for the use of reversal agents for oral anticoagulants, and on the clinical experience of reversal of dabigatran, a practical guide is presented for use in clinical situations where reversal of dabigatran anticoagulation is required, including the use of idarucizumab. The adoption of this type of guideline contributes to therapeutic optimization and, consequently, greater reversal efficiency and a better resource management.

Concomitant Surgical Left Atrial Appendage Occlusion: a Review.

In this review, we discuss some of the observational studies that examined the impact of left atrial appendage occlusion on stroke, the Left Atrial Appendage Occlusion Study (LAAOS) III research program that provided definitive evidence for the benefit of surgical left atrial appendage occlusion on ischemic stroke, and high priority studies in the field that should be pursued by the surgical community. Atrial fibrillation is common in patients undergoing cardiac surgery. Oral anticoagulants are effective at preventing strokes related to atrial fibrillation; they have been the standard of care for stroke prevention in patients with atrial fibrillation for decades. Most strokes in patients with atrial fibrillation originate from the left atrial appendage. LAAOS III, a large randomized controlled trial, has recently demonstrated that concomitant left atrial appendage occlusion in patients undergoing cardiac surgery for another indication reduces the risk of stroke or systemic embolism on top of oral anticoagulation. Surgical left atrial appendage occlusion reduces the risk of ischemic stroke and systemic embolism in patients with atrial fibrillation and a CHA2DS2-VASc score ≥ 2 undergoing cardiac surgery for another indication. The role of surgical left atrial appendage occlusion with patients without atrial fibrillation, as a substitute to anticoagulation and as a standalone procedure, remains unclear.

Outcomes of Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Valvular Heart Disease.

Direct oral anticoagulants (DOACs) are increasingly used for the treatment and prevention of thromboembolic events in patients with non-valvular atrial fibrillation (AF). Evidence regarding their role in patients with AF and concurrent valvular heart disease (VHD) continues to evolve. Post hoc analyses of randomized clinical trials suggest that DOACs are non-inferior to warfarin for the prevention of stroke or systemic embolism in patients with AF and VHD. Emerging evidence from observational data showed a favorable benefit-risk profile for DOACs compared to warfarin in patients with AF and VHD. DOACs are an attractive option for the treatment of patients with AF and VHD who cannot tolerate or have contraindications to warfarin therapy. Future studies are needed to evaluate their effectiveness, safety, and examine variability in the direction and magnitude of treatment effects in selected VHD subgroups.