Thromboembolic Risk Scores Research Articles

Incidence of New Onset Atrial Fibrillation After Cardiovascular Surgery in Vietnam: Results From A Novel Screening Strategy.

To examine the incidence of atrial fibrillation (AF) newly developed after cardiovascular surgery in Vietnam, its associated risk factors, and postoperative complications. We also sought to evaluate the feasibility of a novel screening strategy for post-operative AF (POAF) using the combination of two portable devices. Single-centre, prospective cohort study at the Cardiovascular Centre, E Hospital, Hanoi, Vietnam. All patients aged≥18 years, undergoing cardiovascular surgery and in sinus rhythm preoperatively were eligible. The primary outcome was occurrence of new-onset POAF detected by hand-held single-lead electrocardiography (ECG) or a sphygmomanometer with AF-detection algorithm. Multivariate logistic regression was used to identify risk factors of developing post-operative AF. Feasibility was evaluated by compliance to the protocol and semi-structured interviews. 112 patients were enrolled between 2018-2019: mean age 52.9±12.2 years; 50.9% female;92.0% (n=103) valve surgery; 9.8% (n=11)coronary surgery. New-onset POAF developed in 49patients (43.8%) with median time to onset 1.27days (IQR 0.96 -2.00 days). Age≥65 years was the only significant risk factor for the development of POAF(OR 3.78, 95% CI 1.16-12.34).The median thromboembolism risk scores (CHA2DS2-VASc score) were comparable among patients with and without POAF (1.0 vs. 1.0, p=0.104). The occurrence of POAF was associated with higher rates of postoperative complications (24.5% vs. 3.2%, p<0.001). Both doctors and nurses found this screening strategy feasible to be implemented long-term with the main difficulties being the instructions on both devices were in English, and an increase in workload. In this single-centre study, new-onset POAF occurred in 43.8% of patients who underwent cardiovascular surgery. This novel POAF screening strategy was feasible in a low resource setting, and its implementation could be improved by providing continuous training and translation to local language.

Antithrombotic Management and Long-Term Outcomes of Patients with Atrial Fibrillation. Insights from CRAFT Trial.

Background: We aimed to compare long-term outcomes in Polish patients with atrial fibrillation (AF) according to oral anticoagulation (OAC) type and to evaluate the predictive value of common thromboembolic and bleeding risk scores. Methods: Data from the CRAFT trial (NCT02987062) were included. The primary study endpoint was major adverse event (MAE; all-cause death, thromboembolic and hemorrhagic event) during the mean four-year follow-up period. Results: Out of 2983 patients with available follow-up data, 1686 (56%) were prescribed with vitamin K antagonist (VKA), 891 (30%) with rivaroxaban and 406 (14%) with dabigatran. Predominance of elderly and female patients with previous history of thromboembolic and hemorrhagic events was observed within rivaroxaban (vs. other OAC) group. Higher rate of MAEs and its components was observed in patients on VKA followed by rivaroxaban as compared to patients on dabigatran (43% vs. 42% vs. 31%, p < 0.01). After group matching based on clinical characteristics, higher risk of hemorrhagic events in VKA (vs. dabigatran) and rivaroxaban (vs. dabigatran) group were observed. The available thromboembolic (CHA2DS2-VASs, ATRIA, R2CHADS2) and bleeding (HAS-BLED, ATRIA, ORBIT) risk scores showed poor prediction value. Conclusions: Despite no difference in the thromboembolic event rate, treatment with VKA and rivaroxaban was associated with a significant increase in the risk of hemorrhagic events.

Chronic thromboembolic pulmonary hypertension risk score evaluation and validation (CTEPH SOLUTION): proposal of a study protocol aimed to realize a validated risk score for early diagnosis.

Chronic thromboembolic pulmonary hypertension (CTEPH) is the most serious long-term complication of acute pulmonary embolism (PE) though it is the only potentially reversible form of pulmonary hypertension (PH). Its incidence is mainly limited to the first 2 years following the embolic event, however it is often underdiagnosed or misdiagnosed. This is a multicenter observational cross-sectional and prospective study. Patients with a prior diagnosis of PE will be enrolled and undergo baseline evaluation for prevalent PH detection through a clinical examination and an echocardiogram as first screening exam. All cases of intermediate-high echocardiographic probability of PH will be confirmed by right heart catheterization and then identified as CTEPH through appropriate imaging and functional examinations in order to exclude other causes of PH. A CTEPH Risk Score will be created using retrospective data from this prevalent cohort of patients and will be then validated on an incident cohort of patients with acute PE. One thousand retrospective and 218 prospective patients are expected to be enrolled and the study is expected to be completed by the end of 2021. Up to now 841 patients (620 retrospective and 221 prospective) have been enrolled. This study is the first large prospective study for the prediction of CTEPH development in patients with PE. It aims to create a comprehensive scoring tool that includes echocardiographic data which may allow early detection of CTEPH and the application of targeted follow-up screening programs in patients with PE.

Rate of venous thromboembolism and atrial fibrillation in a real-world case series of advanced cancer patients: the CaTEV Study.

Venous thromboembolism is the second leading cause of death in cancer patients and its incidence seems underestimated. In addition, cancer patients have an increased risk of developing atrial fibrillation, which may be the first presentation of cancer itself. The primary aim of this study was to define the incidence of venous thromboembolism (VTE) and atrial fibrillation in a real-word series of advanced cancer patients. We performed a retrospective single-institution study on patients diagnosed with stage IV solid neoplasia at the outpatient clinic of the Medical Oncology Unit (Spedali Civili Brescia, Italy), from January to December 2018. A total of 403 patients were enrolled, with a mean age at presentation of 63 years (range 18-85 years). A VTE was observed in 24% of cases, half of which occurred after diagnosis of metastatic neoplasia, with a median time of onset of 5.5 months (range 0-84). About 3% of patients developed atrial fibrillation after cancer diagnosis. In this patient series, no statistically significant differences were found when comparing Khorana and PROTECHT thromboembolic risk scores, both before and after the start of chemotherapy. Overall, about 25% of the patients received anticoagulant therapy; in most cases, the drug of choice was low-molecular-weight heparin (LMWH). This study showed for cancer patients a considerably higher incidence of VTE and a comparable incidence of atrial fibrillation than reported in literature. Validated thromboembolic risk scores appear to be poorly predictive, and LMWH remains the most widely used anticoagulant drug.

Abstract 13132: Reclassification of CHA 2 DS 2 -VASc Thromboembolic Risk by Coronary Calcifications on Cardiac Computed Tomography in Atrial Fibrillation

Background: CHA 2 DS 2 -VASc is the most widely used thromboembolism risk score in patients with atrial fibrillation (AF). Cardiac computed tomography (CCT) routinely performed before or after pulmonary vein isolation (PVI) for AF rhythm control offers the opportunity to detect coronary calcifications (CAC) and this vascular pathology. We evaluated the frequency of CAC and the extent it affects the CHA 2 DS 2 -VASc and decision for anticoagulation for AF patients undergoing PVI. Methods: In 2014, 772 consecutive patients underwent PVI at Cleveland clinic, and 621 patients who had CCT within 1-year before or after PVI were studied. Relationships between CAC recorded as a binary variable with clinical characteristics and reclassification of CHA 2 DS 2 -VASc was analyzed. Results: Mean age was 63.1±9.8 years, 163 (26.2%) were females, 322 (51.9%) had paroxysmal AF and 264 (42.5%) having prior PVI. CAC was identified on CCT in 388 (62.5%) patients. Age was the only factor independently associated with CAC, odds ratio 1.02 (95% confidence interval 1.01-1.04), P=0.004. CAC increased the CHA 2 DS 2 -VASc in 306 (49.3%) patients, and the mean from 2.0±1.5 to 2.5±1.4 (Table). Using gender-specific cutpoints from the latest guidelines, 71 (11.4%) had CHA 2 DS 2 -VASc going from 0 to 1 in men or 1 to 2 in women (where anticoagulation may be considered), and 113 (18.2%) had CHA 2 DS 2 -VASc going from 1 to 2 in men or to 3 in women (where long-term anticoagulation is indicated). Conclusion: Almost two-thirds of patients undergoing PVI have CAC detectable on CCT, and after incorporating this information, long-term anticoagulation may or would be indicated in an additional 30% of the cohort. By assessing vascular pathology, CCT can play an important screening role for thromboembolic risk in AF patients incremental to clinical risk factors.

Risk scores for occult cancer in patients with unprovoked venous thromboembolism: Results from an individual patient data meta‐analysis

BackgroundThe Registro Informatizado de Pacientes con Enfermedad TromboEmbólica (RIETE) score and the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) risk scores aim to identify patients with acute unprovoked venous thromboembolism (VTE) at high risk of occult cancer, but their predictive performance is unclear. MethodsThe scores were evaluated in an individual patient data meta‐analysis. Studies were eligible if enrolling consecutive adults with unprovoked VTE who underwent protocol‐mandated screening for cancer. The primary outcome was a cancer diagnosis between 30 days and 2 years of follow‐up. The discriminatory performance was evaluated by computing the area under the receiver (ROC) curve in random‐effects meta‐analyses. ResultsThe RIETE score could be calculated in 1753 patients, of whom 63 (3.6%) were diagnosed with cancer. The pooled area under the ROC curve was 0.59 (95% confidence interval [CI], 0.52‐0.66; I2 = 0%). Of the 427 patients (24%) classified as high risk, 25 (5.9%) were diagnosed with cancer compared with 38 of 1326 (2.9%) low‐risk patients (hazard ratio [HR], 2.0; 95% CI, 1.3‐3.4). The SOME score was calculated in 925 patients, of whom 37 (4.0%) were diagnosed with cancer. The pooled area under the ROC curve was 0.56 (95% CI, 0.46‐0.65; I2 = 46%). Of the 161 patients (17%) classified as high risk (≥2 points), eight (5.0%) were diagnosed with cancer compared with 29 of 764 (3.8%) low‐risk patients (HR, 1.2; 95% CI, 0.55‐2.7). ConclusionsThe predictive discriminatory performance of both scores is poor. When used dichotomously, the RIETE score is able to discriminate between low‐ and high‐risk patients. Because this is largely driven by advanced age, these results do not support the use of these scores in daily clinical practice.

Fibrillation atriale de novo chez les patients en choc septique

Une fibrillation atriale de novo (FAN)survient chez 4,5 à 11% des patients admis en réanimation et peut atteindre 46% chez des patients en choc septique. Si la morbidité associée à la FAN semble acquise (instabilité hémodynamique, accident vasculaire cérébral, allongement de la durée de séjour), les données de la littérature concernant l’association d’une FAN à la mortalité restent débattues. Les recommandations actuelles émanant des sociétés internationales de rythmologie sont plutôt en faveur d’un contrôle de la fréquence cardiaque en cas de retentissement hémodynamique plutôt qu’un contrôle du rythme cardiaque. Dans ce dernier cas, on pourrait proposer un bétabloquant de durée d’action courte pour bloquer l’activation sympathique présente en phase aiguë du choc septique. Il faut, quelle que soit la stratégie adoptée, identifier et contrôler les facteurs de risques de FAN, notamment les troubles hydro-électrolytiques. L'anticoagulation se discute en cas de retour en rythme sinusal et pourrait dépendre des scores de risques thrombo-emboliques (CHA2DS2VASc) et hémorragiques (HAS-BLED) mais aussi du risque individuel du patient. Le risque d’AVC à moyen et long terme de ces patients même après un retour en rythme sinusal reste présent et nécessite sans doute un suivi régulier pour traquer les FA silencieuses.

Left atrial spontaneous echo contrast occurring in patients with low CHADS2 or CHA2DS2-VASc scores

BackgroundLeft atrial spontaneous echo contrast (LASEC) is common in patients with atrial fibrillation (AF), although scarce information exists on LASEC occurring in nonvalvular AF patients who have low thromboembolic risk scores. We therefore examined prevalence and determinants of LASEC under low CHADS2 or CHA2DS2-VASc scores in these patients.MethodsAmong 713 patients who underwent transesophageal echocardiography, 349 with a CHADS2 score < 2 (CHADS2 group) (93 women, mean age 65 years) and 221 with a CHA2DS2-VASc score < 2 (CHA2DS2-VASc group) (39 women, mean age 62 years) were separately examined for clinical and echocardiographic findings.ResultsLASEC was found in 77 patients of CHADS2 group (22%) and in 41 of CHA2DS2-VASc group (19%). Multivariate logistic regression analysis, adjusted for several parameters including non-paroxysmal AF, LA enlargement (LA diameter ≥ 50 mm), left ventricular (LV) hypertrophy, and an elevated B-type natriuretic peptide (BNP) (BNP ≥200 pg/mL) revealed that for CHADS2 group, non-paroxysmal AF (Odds ratio 5.65, 95%CI 3.08–10.5, P < 0.001), BNP elevation (Odds ratio 3.42, 95%CI 1.29–9.06, P = 0.013), and LV hypertrophy (Odds ratio 2.26, 95%CI 1.19–4.28, P = 0.013) were significant independent determinants of LASEC, and that for CHA2DS2-VASc group, non-paroxysmal AF (Odds ratio 3.38, 95%CI 1.51–7.54, P = 0.003) and LV hypertrophy (Odds ratio 2.53, 95%CI 1.13–5.70, P = 0.025) were significant independent determinants of LASEC.ConclusionsLASEC was present in a considerable proportion of patients with nonvalvular AF under low thromboembolic risk scores. Information on AF chronicity, BNP, and LV hypertrophy might help identify patients at risk for thromboembolism, although large-scale studies are necessary to confirm our observations.

Characterization, Pathogenesis, and Clinical Implications of Inflammation-Related Atrial Myopathy as an Important Cause of Atrial Fibrillation.

Historically, atrial fibrillation has been observed in clinical settings of prolonged hemodynamic stress, eg, hypertension and valvular heart disease. However, recently, the most prominent precedents to atrial fibrillation are metabolic diseases that are associated with adipose tissue inflammation (ie, obesity and diabetes mellitus) and systemic inflammatory disorders (ie, rheumatoid arthritis and psoriasis). These patients typically have little evidence of left ventricular hypertrophy or dilatation; instead, imaging reveals abnormalities of the structure or function of the atria, particularly the left atrium, indicative of an atrial myopathy. The left atrium is enlarged, fibrotic and noncompliant, potentially because the predisposing disorder leads to an expansion of epicardial adipose tissue, which transmits proinflammatory mediators to the underlying left atrium. The development of an atrial myopathy not only leads to atrial fibrillation, but also contributes to pulmonary venous hypertension and systemic thromboembolism. These mechanisms explain why disorders of systemic or adipose tissue inflammation are accompanied an increased risk of atrial fibrillation, abnormalities of left atrium geometry and an enhanced risk of stroke. The risk of stroke exceeds that predicted by conventional cardiovascular risk factors or thromboembolism risk scores used to guide the use of anticoagulation, but it is strongly linked to clinical evidence and biomarkers of systemic inflammation.

External Validation of a Venous Thromboembolic Risk Score for Cancer Outpatients with Solid Tumors: The COMPASS-CAT Venous Thromboembolism Risk Assessment Model.

Current risk assessment models (RAMs) for prediction of venous thromboembolism (VTE) risk in the outpatient cancer population have shown poor predictive value in many of the most common cancers. The Comparison of Methods for Thromboembolic Risk Assessment with Clinical Perceptions and AwareneSS in Real Life Patients-Cancer Associated Thrombosis (COMPASS-CAT) RAM was derived in this patient population and predicted patients at high risk for VTE even after initiation of chemotherapy. We sought to externally validate this RAM. Patients aged ≥18 years who presented to a tertiary care center between January 1, 2014, and December 31, 2016, with invasive breast, ovarian, lung, or colorectal cancers were included. The COMPASS-CAT RAM was applied using our health system's tumor registry and variables that were identified by International Statistical Classification of Diseases and Related Health Problems-9 and -10 codes of the electronic health record and independent chart review. The primary endpoint at 6-month study follow-up was documented VTE. A total of 3,814 patients were included. Documented VTE at 6-month follow-up occurred in 5.85% of patients. Patients stratified into low/intermediate- and high-risk groups had VTE rates of 2.27% and 6.31%, respectively. The sensitivity, specificity, and negative and positive predictive value of the RAM were 95%, 12%, 97.73%, and 6.31%, respectively. Diagnostic accuracy via receiver operating characteristic curve was calculated at 0.62 of the area under the curve. In this large retrospective external validation study of the COMPASS-CAT RAM for VTE in patients with cancer undergoing active treatment, model discrimination was moderate and calibration was poor. The model had good negative predictive value. Further prospective validation studies-especially within 6 months of cancer diagnosis-are needed before the model can be implemented into routine clinical practice for primary thromboprophylaxis of high-VTE-risk patients with cancer with solid tumors. This study provides further guidance for researchers and clinicians in determining clinical and laboratory risk factors associated with development of venous thromboembolism among the ambulatory population of patients being treated for lung, breast, colorectal, or ovarian cancer. It validates the COMPASS-CAT risk model that was developed in this cancer population and suggests that further prospective validation of the model, with more focus on patients within 6 months of their index cancer diagnosis, would likely enhance the accuracy and usefulness of this model as a clinical prediction tool.

106 Mitral annulus calcification: potential indicator of vascular disease and higher thromboembolic risk

Abstract Background In CHA2DS2-VASc thromboembolic risk score, vascular diseases (V) include either prior myocardial infarction, peripheral arterial disease or aortic plaque, summarizing the patient’s atherosclerotic burden. Despite this, thromboembolic risk scores used in atrial fibrillation (AF) patients do not include mitral annular calcification (MAC) as a potential indicator of vascular disease. Purpose This case-control study retrospectively assessed the relationship between MAC and thromboembolic risk scores (CHADS2 and CHA2DS2-VASc) in non-valvular AF patients (paroxysmal and non-paroxysmal). Methods We compared thromboembolic risk scores value, clinical and transthoracic echocardiographic data in AF patients with and without MAC. The presence and severity of MAC was assessed in parasternal short axis and apical four chamber views. It was qualitatively defined as either mild, moderate or severe based on echodensity and extension in mitral annulus ring. MAC of &amp;gt; 4mm thickness was also considered severe. Results We included 103 patients: mean age 72.6 ± 9.9 years, 44.7% male, 83.5% hypertensive, 30.1% diabetic, 79.6% with heart failure, 40.8% were in atrial fibrillation and 7.8% had a history of stroke/transient ischemic stroke. We identified MAC in 50.5% patients: 15.7% severe, 50.3% moderate, 34% mild. Mean CHADS2 and CHA2DS2-VASc were 2,56 ± 1.213 and 4.57 ± 1.61, respectively. In MAC patients, both scores tended to increase with a mean of 2,88 ± 1,114, p = 0.003 and 5,211 ± 1,51, p &amp;lt; 0.001 as compared with control (2,23 ± 1,06 and 3,92 ± 1,46), respectively. The presence of MAC was a risk factor for vascular disease (OR = 2,47, χ2 = 34,32, p &amp;lt; 0,001). Moreover, the AUC for CHA2DS2-VASc, CHADS2, and MAC was 0.73 (95% CI, 0.63-0.82) and 0.65 (95% CI, 0.54-0.75), respectively. Both scores showed higher AUC in women: 0.79 (95% CI, 0.67-0.91) for CHA2DS2-VASc and 0.68 (95% CI, 0.54-0.82) for CHADS2. Left ventricular ejection fraction (LVEF) negatively correlated with the presence of MAC (r=-0.254, p = 0.01). Sinus rhythm patients with MAC showed significantly decreased LVEF as compared to those without MAC (55.73 ± 12.3% vs 46.96 ± 14.5 %, p = 0.013). The difference was not significant in AF patients (46.83 ± 10.6% vs 45.92 ± 11.59, p= 0.79). Conclusion The presence of MAC, irrespective of severity, correlates very well with both vascular disease and thromboembolic risk scores. Therefore, we consider that MAC might be a potential indicator of vascular disease and of higher thromboembolic risk. This study raises the question whether inclusion of MAC in thromboembolic risk scores as an indicator of vascular disease (V) might increase their predictive value.

Pregnancy-related thrombosis risk in patients with protein C deficiency and comparison with pregnant women with heterozygous factor V Leiden mutation.

: The risk of pregnancy-related venous thromboembolism is high in patients with inherited thrombophilia. The aim of this study was to compare the risk of pregnancy related-venous thromboembolism of women with protein C (PC) deficiency to patients with heterozygous factor V Leiden mutation. 145 consecutive pregnant women with confirmed PC deficiency or heterozygous factor V Leiden mutation were prospectively enrolled in the study. Lyon venous thromboembolism-risk score was used to individually tailor antithrombotic prophylaxis. The use of a validated clinical score presents the advantage to have a homogenous management of the venous thromboembolism risk in patients having similar risk factors. 53 pregnancies with PC deficiency were compared with 190 pregnancies in heterozygous factor V Leiden mutation carriers. 50% of the patients with PC deficiency and 64% of the heterozygous factor V Leiden mutation carriers were asymptomatic. According to the Lyon-venous thromboembolism risk score, 50% of patients with PC deficiency and 51% of heterozygous factor V Leiden carriers did not received any antepartum heparin prophylaxis. 34 and 37% of patients respectively received heparin prophylaxis during the third trimester only. No venous thromboembolism was observed in patients with PC deficiency and one postpartum venous thromboembolism occurred in a patient with heterozygous factor V Leiden. In the absence of randomized controlled clinical studies, we report here a large prospective series of pregnant women with PC deficiency. In our cohort, no difference of outcome, in terms of venous thromboembolism, was observed between pregnant women with PC deficiency and those with heterozygous factor V Leiden. Based on our results, low-molecular-weight heparin prophylaxis should not be mandatory in all pregnant women with PC deficiency. Similar prophylaxis strategies may be applied to women with factor V Leiden mutation or PC deficiency.

P2833Safety and efficacy of oral anticoagulation discontinuation in high thromboembolic risk patients at long term follow-up after successful atrial fibrillation ablation

Abstract Background Current guidelines recommend the use of oral anticoagulation (OAC) after successful ablation procedure of atrial fibrillation (AF), according to patient's thromboembolic risk score. However, several observational studies demonstrated similar thromboembolic events and lower incidence of major bleedings in patients who discontinued OAC after successful AF ablation compared with those on OAC. However, data on long-term follow-up after OAC discontinuation in high thromboembolic risk patients successfully treated with AF ablation are missing. Purpose To evaluate the incidence of stroke/TIA and bleeding events at long term follow-up after successful AF ablation in high thromboembolic risk patients who discontinued OAC therapy (Off OAC group) compared to those who continued it indefinitely (On OAC group). Methods Patients with CHA2DS2VASC score of 2 or more at time of the ablation procedure who discontinued OAC after successful catheter ablation for AF performed between 2001 and 2018 were included in this study. OAC was discontinued in patients without atrial tachyarrhytmias recurrences after intensive monitoring, left atrial dysfunction or pulmonary stenosis. Results 503 patients (pts), were enrolled in the study (On OAC group: 241 pts; Off OAC group: 262 pts). After a median follow up of 6.3 years, occurred 12 and 14 stroke/TIA events in the On OAC and Off OAC group, respectively (p: 0.854). Bleeding events occurred more frequently in the On OAC group compared to Off OAC group (18 vs 8 events, p: 0.025). At multivariate analysis OAC therapy was independently associated with an increased risk of major bleeding (OR: 2.92, CI95%: 1.11–7.70, p: 0.03) whereas no difference in the risk of stroke were found (OR 0.89, CI95%: 0.37–2.16, p: 0.799). Conclusion Discontinuation of OAC after successful AF ablation in high thromboembolic risk patients seems to be a safe and effective strategy even in a long term follow up. Prospective randomized trials are needed to confirm these results

Safety and effectiveness of reduced-dose apixaban in Japanese patients with nonvalvular atrial fibrillation in clinical practice: A sub-analysis of the STANDARD study

BackgroundThe safety and effectiveness of reduced-dose apixaban 2.5mg twice daily (BID) have not been elucidated thoroughly in Japanese patients with nonvalvular atrial fibrillation (NVAF). MethodsA post-marketing survey study included NVAF patients who newly initiated apixaban for prevention of thromboembolism, and followed them for 104 weeks. Apixaban doses were selected at the discretion of treating physicians. Hemorrhagic and thromboembolic (ischemic stroke, systemic embolism, and transient ischemic attack) events were examined. The relationship between dose reduction criteria (DRC), selected doses, and outcome events was also examined. ResultsOf 6306 patients, 3600 (57.1%) received the standard dose (5mg BID) and 2694 (42.7%) received the reduced dose. Compared with the standard-dose group, the reduced-dose group had more female patients; the patients were older, of lower body weight, with reduced creatinine clearance, higher thromboembolic and hemorrhagic risk scores, and more frequent antiplatelet use. Incidence rates of major hemorrhage and thromboembolism were higher in the reduced-dose group compared with the standard-dose group (3.00%/year vs 1.93%/year, p=0.001 and 1.40%/year vs 0.72%/year, p=0.001, respectively). In the standard-dose group, 90.0% of patients did not meet the DRC (recommended standard-dose group). In the reduced-dose group, 62.4% of patients met the DRC (recommended reduced-dose group) and 34.9% did not (non-recommended reduced-dose group). Incidence rates of major hemorrhage and thromboembolism were numerically highest in the recommended reduced-dose group (3.30%/year, p=0.007 and 1.69%/year, p<0.001, respectively), followed by the non-recommended reduced-dose group. In multivariate analysis, apixaban dose was not associated with these outcome events. ConclusionThe reduced-dose group showed higher incidence rates of thromboembolic and major hemorrhagic events than the standard-dose group due to baseline clinical characteristics. The safety and effectiveness of reduced-dose apixaban need to be carefully monitored in clinical practice.

Atrial Fibrillation in Active Cancer Patients: Expert Position Paper and Recommendations.

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

Status of treatment for atrial fibrillation in a community health service center in Shanghai Pudong New Area

Objective To analyze the status of the treatment for atrial fibrillation (AF) in a community health service center in Shanghai Pudong New Area. Methods Clinical data of all patients with AF attended in Hudong Community Health Service Center of Shanghai Pudong from August 2016 to August 2017 were retrospectively reviewed. The gender, age, smoking history, drinking history, concomitant diseases, antithrombotic therapy, rhythm control, ventricular rate control drugs, health education, needs for setting up AF clinics in the community were analyzed. Result The study included 220 patients, with average age of (59.7±10.4) years; 34.1% (75/220) patients had hypertension and the blood pressure was controlled in 41.3% (31/75) ; 20.5% (45/220) patients had diabetes mellitus and glycosylated hemoglobin (HbA1c) was controlled well in 26.7% (12/45) . Three cases of mitral stenosis were treated with warfarin anticoagulation. Among 217 patients without valvular atrial fibrillation, 157 had thromboembolic risk score≥2, 20.4% (32/157) of whom used warfarin anticoagulation, 10.8% (17/157) used new oral anticoagulant (NOAG) and 58.1% (91/157) had never used warfarin or NOAG anticoagulation. The reasons were as follows:doctors did not prescribe (41.9%, 39/91), patients did not accept (35.2%, 32/91), and so on. There were 21.8% (48/220) of patients undergoing drug cardioversion, and 5.9% (13/220) undergoing electrical cardioversion. For control of ventricular rate, 55.9% (123/220) patients used beta blockers, 13.6% (30/220) used non-dihydropyridine calcium antagonists, and 23.6% (52/220) used digitalise. Less than 55% of patients were given health education of physical exercise, weight management and medicine use. For AF clinic in community hospital, 56.8% (125/220) of patients needed, and 17.3% (38/220) very need; 50.0% (110/220) patients trusted and 12.3% (27/220) very trusted in anticoagulation management in community hospitals. Conclusion The anticoagulant rate is relatively low, treatment of concomitant diseases is less satisfactory and the health education might be incomplete in the community surveyed in this study. Key words: Atrial fibrillation; Community health services; General practitioner; Treatment

Abordaje de la fibrilación auricular en pacientes con cáncer activo. Documento de consenso de expertos y recomendaciones

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.Full English text available from:www.revespcardiol.org/en

Potent Anticoagulation Does Not Reduce Venous Thromboembolism in High-Risk Patients.

Based on current guidelines from the American Academy of Orthopaedic Surgeons (AAOS), a number of prophylactic modalities for the prevention of venous thromboembolism in total joint arthroplasty may be used. It is common practice that more potent prophylactic agents are used for patients at higher risk of venous thromboembolism. However, we are aware of no studies that have investigated the efficacy of potent anticoagulation in higher-risk individuals. Therefore, the purpose of our study was to test the hypothesis that low-molecular-weight heparin and warfarin result in a reduction in venous thromboembolism events in high-risk patients. A retrospective, multi-institutional study of 60,467 primary and revision total joint arthroplasties from 2000 to 2015 was performed. Identified medications were classified as aspirin, low-molecular-weight heparin, or warfarin. Patients with unavailable venous thromboembolism prophylaxis information or those not receiving the aforementioned prophylaxis were excluded. Information pertinent to the objective of this study was collected and a venous thromboembolism risk score was calculated based on 26 variables. Treatment outcomes assessed included 90-day rate of symptomatic venous thromboembolism and periprosthetic joint infection. Propensity score matching was performed (1:1), as well as logistic regression analysis on the total sample. Aspirin prophylaxis demonstrated a lower rate of deep vein thrombosis, pulmonary embolism, and venous thromboembolism than warfarin and low-molecular-weight heparin alone throughout all risk scores. In the matched propensity score analysis, low-molecular-weight heparin and warfarin demonstrated increased odds of venous thromboembolism for both standard-risk and high-risk patients undergoing total knee arthroplasties compared with aspirin. For primary total hip arthroplasty, warfarin demonstrated an increased risk for high-risk patients and low-molecular-weight heparin demonstrated an increased risk for standard-risk patients. The prevalence of periprosthetic joint infection was higher in patients receiving warfarin (p < 0.001 for both comparisons of warfarin with aspirin and low-molecular-weight heparin). The results of this multi-institutional study demonstrate that the use of warfarin and low-molecular-weight heparin in higher-risk patients does not necessarily result in a reduction in symptomatic venous thromboembolism. Aspirin administered to higher-risk patients seems to be as effective as potent anticoagulation and more effective than warfarin. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Agatston calcium score, CHA2DS2-VASc and HAS-BLED in patients before atrial fibrillation ablation

Clinical scores of thrombo-embolism risk (CHA2DS2-VASc) and hemorrhagic risk (HAS-BLED) have been developed to characterize the patients with non-valvular atrial fibrillation. These scores have been defined in part with clinical risk factors of atherosclerosis. Before their ablation, a coronary computed tomography angiography enables to determine the Agatston calcium score (coronary artery calcium score) which is a atherosclerosis marker. In this study,we tried to find out a link between the Agatston calcium score and the CHA2DS2-VASc, as well as between the Agatston calcium score and the HAS-BLED. In total, 344 atrial fibrillation subjects were included in our observational and retrospective study between January 1st, 2013 and January 1st, 2017, in the same institute. All of these patients had undergone a coronary computed tomography angiography. Three hundred and seventeen patients were included in this study: 233 men (73.5%) and 84 women (26.5%), with an average age of 60.4 years. Agatston calcium score was significantly higher in the subjects with CHA2DS2-VASc score ≥ 2 ( P < 0.00001); for men ( P < 0.000000001 for a CHA2DS2-VASc ≥ 2 ) and for women too ( P = 0.03 for CHA2DS2-VASc ≥ 3). This link is also found between the Agatston calcium score and the HAS-BLED score ≥ 2 ( P < 0.00000000001) (Fig 1). This study shows a strong link between the atherosclerosis marker determined by CT (coronary artery calcium score), the thrombo-embolism risk score (CHA2DS2-VASc) and the hemorrhagic risk score (HAS-BLED) determined by clinical elements in patients with non-valvular atrial fibrillation.

Differences in atrial fibrillation management strategies among physicians: A survey based study

Aim: Previous data reflected confusions about classification and management of atrial fibrillation (AF) among physicians. Although relatively clear suggestions of dedicated guidelines, poor adaptation of them to routine clinical practice may result with suboptimal prevention and treatment measures. As a main stakeholder of management, physicians' perceptions about the disease have major role. The study aimed to assess confusions and concordances of physicians about the definition and management of the disease. Methods and Results: We developed a web-based survey about AF consisting of 27 questions regarding valvular or non-valvular AF perception, using thromboembolic and bleeding risk scores, antithrombotic management and rate/rhythm control strategies. Two hundred and thirty two physicians participated and 224(97%) of them completed the survey. Although only cardiologists were invited to the survey, 27 physicians from different specialties also responded the survey. Half of the physicians reported that ≥40% of their patients had valvular AF. Dramatically, the survey responses revealed that nearly one-third of physicians classified the AF patients with mitral regurgitation as valvular AF. Most of the physicians denoted that they were using bleeding and stroke risk scores before deciding oral anticoagulation therapy and also preferring long term rhythm-control strategy in AF patients with systolic heart failure. However, results exposed evident disparities among physicians at specific aspects of the disease management. Conclusion: The survey-based study demonstrated a great heterogeneity in classification and management of AF among physicians because of guideline confusions/failures, inadequate evidence about some specific conditions and not being able to dominate the guidelines by physicians.