Thromboprophylaxis In Atrial Fibrillation Research Articles

Deep Vein Thrombosis While Still on NOAC

Novel oral anticoagulation treatment has been extensively used for thromboprophylaxis in atrial fibrillation and other clinical conditions because of predicable pharmacokinetic profile and safety. However, rarely plasma drug level variation can occur that can lead to thrombotic and bleeding events. We describe a case of deep vein thrombosis in a compliant patient still on apixaban. Anticoagulation failure with NOAC is concerning and obviously there is growing need of assay in these subsets showing the activity of NOAC. Till the availability of such methods, switching back to conventional therapy with Vitamin K antagonist with accurate monitoring could be appropriate strategy.

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Abstract Aims Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anti-coagulation compared with those who stop transiently, permanently, or never start. Methods and results This retrospective cohort study utilized linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorized based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing risk regression was utilized to compare SSE and bleeding risks between cohorts during 5-year follow-up. Of an overall cohort of 47 427 people, 26 277 (55.41%) were never anti-coagulated, 7934 (16.72%) received continuous anti-coagulation, 9107 (19.2%) temporarily discontinued, and 4109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥ 75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. Stroke/systemic embolism risk was significantly greater in those with discontinuous anti-coagulation, compared with continuous [subhazard ratio (SHR): 2.65; 2.39–2.94]. In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42–2.14). Conclusion Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centred and must recognize that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

Haemorrhagic stroke among patients with atrial fibrillation: preceding oral anticoagulation use and 30-day case fatality over 10 years

Abstract Background and purpose Oral anticoagulation (OAC) is the cornerstone of thromboprophylaxis in atrial fibrillation (AF) yet complicated by elevated bleeding risk. We examined the temporal evolution of OAC treatment on 30-day fatality in patients with AF and first-ever hemorrhagic stroke (HS). Methods We identified the study population from the nationwide registry-linking Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study. Patients were eligible if the incident AF was diagnosed between January 2009 and November 2017, with a subsequent first-ever HS (ICD-10 I60* or I61*) recorded in hospital or death registries before December 2018. OAC purchases in the previous 90 days were registered. Results Over the ten-year period, 1,890 patients experienced their first-ever HS (53% women, median age 79.5 [IQR 72.5-85.5]). Of these, 1,039 (55%) had a recent OAC purchase. The 30-day case fatality was 45.4% (n=858, 57% women) and did not vary by prior OAC purchase (warfarin 47%, Non-Vitamin K Antagonist Oral Anticoagulants 41%, none 45%). The proportion of patients without OAC decreased from 67% to 34%, while case fatality increased between 2009 and 2011 from 42% to 54% and then decreased from 54% to 43%. Conclusions Despite the near-doubled proportion of patients with AF exposed to OAC prior to their first-ever HS, their 30-day case fatality rate decreased slightly over 10 years. These results suggest that the recent evolution of OAC treatment is associated with improved outcomes in the AF population.

Silent cerebral embolism after left atrial appendage occlusion

Abstract Background Left atrial appendage (LAA) intervention is an alternative to oral anticoagulation therapy for thromboprophylaxis in atrial fibrillation (AF). There is limited data on procedure-related silent cerebral embolisms (SCE) during LAA intervention. The aim of our study is to assess the incidence and risk factors of the new SCE after percutaneous LAA occlusion (LAAO)in AF patients and compare the rate of SCE after LAAO with LAA excision (LAAE). Methods Consecutive AF patients from 2 independent cohorts (LAAO cohort and LAAE cohort) between September 2018 and December 2020 were included. All patients underwent cerebral magnetic resonance imaging (MRI) before and within 7 days after the procedure. The incidence, size and location of SCE, as well as risk factors were analyzed. Results Forty-two patients from LAAO cohort and 32 patients from LAAE cohort were enrolled. In the LAAO cohort, patients developing SCE had significantly higher CHA2DS2-VASc scores (OR 2.172; 95% CI 1.149–4.104; p=0.017), longer LAAO placement time (OR 1.067; 95% CI 1.018–1.118; p=0.006), and lower peak activated clotting time (ACT) level (OR 0.976; 95% CI 0.954–0.998; p=0.035). Furthermore, a significantly higher incidence of new SCE was seen in LAAO cohort compared to LAAE (54.8% vs. 6.3%, p<0.001). 71.4% of SCE located in the cortex. Conclusions The incidence of procedure-related SCE was strikingly high in patients with percutaneous LAAO. More cardiovascular co-morbidities, longer LAAO placement time and lower ACT level were significantly associated with the development of SCE during LAAO procedure.

Thromboprophylaxis in atrial fibrillation: correct interpretation and effective use of CHA2DS2-VASc and HAS-BLED scores

Thromboprophylaxis is one of the most important aspects of atrial fibrillation (AF) management as irregular atrial contractions foster formation of blood clots that may result in ischemic stroke. Strokes caused by AF are relatively large and often lead to death or sever disability, but they may be avoided with appropriate anticoagulation therapy. Unfortunately, the risk factors for stroke overlap with risk factors for bleeding, creating a genuine challenge for clinicians seeking to strike a balance in preventing these two types of complications. This is why risk assessment scores CHA2DS2-VASc and HAS-BLED have been developed. While their role to optimize the anticoagulation therapy was confirmed in multiple studies, the misinterpretation of the criteria within these scores and their inappropriate application can result in suboptimal treatment and needlessly expose patients to the risk of stroke, hemorrhage, or both. This review aims to present appropriate interpretation of CHA2DS2-VASc and HAS-BLED scores and discuss how anticoagulation therapy of AF patients should be guided by those two scores.

In-Hospital and readmission outcomes of patients with myeloproliferative neoplasms and atrial fibrillation: insights from the National Readmissions Database.

Patients with myeloproliferative neoplasms (MPNs) and atrial fibrillation (AF) are at increased risk of thrombosis and bleeding. However, the risk of thrombosis and bleeding in patients with AF and MPN compared with the general population with AF is unclear. Additionally, traditional risk scores (CHA2DS2-VASC and HAS-BLED) for risk/benefit estimation of thromboprophylaxis in AF do not account for MPN status. Therefore, we aimed to investigate bleeding and thrombosis risk in patients with MPN hospitalized for AF. We utilized the National Readmission Database (NRD) to identify patients with AF with and without MPN. Primary bleeding and thrombosis outcomes were in-hospital or 30-day readmission for bleeding or thrombosis, respectively. We propensity score (PS) matched patients with and without MPN. Risk of primary outcomes in MPN was assessed in PS matched cohort using logistic regression. Receiver operating characteristic (ROC) curve used to evaluate predictive ability of CHA2DS2-VASC and HAS-BLED of primary thrombosis and bleeding outcomes, respectively. 24,185 patients without MPN were matched with 1,617 patients with MPN and variables were balanced between groups. Patients with MPN were at increased risk of meeting the thrombosis (OR 1.98, 95% CI 1.23-3.21) but not bleeding (OR 0.87, 95% CI 0.63-1.19) primary outcomes. In MPN, CHA2DS2-VASC predicted thrombosis (C-statistic 0.66, 95% CI 0.54-0.78) but HAS-BLED was a poor predictor of bleeding (C-statistic 0.55, 95% CI 0.46-0.64). In patients with AF, MPN was associated with increased risk of bleeding and thrombosis. HAS-BLED scores did not accurately predict bleeding in MPN. Further investigation is needed to refine risk scores in MPN.

Real-world evidence that among atrial fibrillation patients warfarin is associated with reduced nonelective admissions compared with those on DOACs.

Randomized trials show inconsistent estimates on risks of direct-acting oral anticoagulants (DOACs) versus warfarin in bleeding and mortality for atrial fibrillation (AF) patients. Trials are confounded by additional DOAC adherence support, while warfarin has a low time in therapeutic range. Few real-world studies compared emergency hospitalization risk between DOAC and warfarin users in AF. This study aimed to determine emergency hospitalization risk for AF patients on DOACs or warfarin in real-world settings. A tapered-matched real-world cohort extracted data from 412 English general practices' primary care records linked with emergency department (ED) and hospitalization data from the ECLIPSE database. AF patients with new DOAC or warfarin prescriptions were included. The primary outcome was all-cause ED attendance; the secondary outcomes were ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months. Weighted Cox regression estimated relative risk difference. 39 201 DOAC patients were matched with 13 145 warfarin patients. DOAC patients had a 25% higher likelihood of attending ED (odds ratio 1.25; 95% confidence interval [CI] 1.01-1.55). DOAC use also associated with higher ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months: 1.41 (95% CI 1.00-1.98), 1.26 (1.00-1.57), and 1.54 (1.01-2.34), respectively, with p-values < .05. DOACs for AF thromboprophylaxis are associated with the increased risk of ED attendance, recurrent hospitalization, and numerical rise in ED re-attendance and first nonelective hospitalization compared to warfarin. However, these real-world data cannot establish if this difference results from medication adherence, lack of regular warfarin clinic monitoring, unmeasured confounders, or fundamental agent efficacy disparities.

Percutaneous left atrial appendage occlusion: impact on left atrial deformation indices

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is an accepted alternative to thromboprophylaxis in atrial fibrillation (AF) patients who are: i) intolerant to oral anticoagulation (OAC) (e.g. life-threatening haemorrhage), ii) non-adherent to OAC, or iii) at a high bleeding risk with OAC. Improvement in LA mechanics was shown post-LAAO in the LAFIT-LARIAT study, using the Lariat device (SentreHEART, Redwood City, CA, USA). No significant change was seen in LA mechanics after LAAO with the Watchman device (Boston Scientific, St. Paul, MN, USA) in the LAFIT-Watchman study. The impact of LAAO with the Amplatz or Amulet device (Abbot Vascular, St. Paul, MN, USA) on LA deformation mechanics, has not been investigated. Purpose To evaluate the impact of LAAO with the Amplatz or Amulet device on echocardiographic LA deformation indices. Methods All patients undergoing percutaneous LAAO from 2013 to 2021 at a single centre were included from an ongoing clinical registry. LA reservoir, conduit and contractile strain and strain rate were assessed with two-dimensional speckle tracking echocardiography from an apical four-chamber view. Conduit and contractile strain and strain rates were only recorded for patients without AF at the time of echocardiography. Changes in LA deformation indices over time were compared with a linear mixed model. Results 32 LAAO recipients (mean age 72±12 years, 63% male) were analysed. 5 (16%) patients had AF pre- or post-procedure. After a mean follow-up of 17 months, the mean LA reservoir strain increased from 11.8±7.7% to 12.9±9.1% (P=0.49), the mean LA conduit strain increased from 6.8±6.0% to 8.0±7.4% (P=0.42) and the mean LA contractile strain decreased from 5.7±5.2% to 5.3±5.4% (P=0.77). During the same time interval, the mean LA reservoir strain rate decreased from 0.68±0.44/s to 0.64±0.47/s (P=0.70), the mean LA conduit strain rate increased from −0.52±0.43/s to −0.44±0.32/s (P=0.42) and the mean LA contractile strain rate decreased from −0.77±0.55/s to −0.83±0.53/s (P=0.66). Conclusions No statistically significant improvement in LA mechanical function was seen after LAAO with the Amplatz or Amulet device, although a trend towards improved strain was observed for reservoir and conduit strain, with a worsening in contractile strain. Different LAAO devices therefore appear to have divergent effects on LA deformation, the clinical implications of which require further study. Funding Acknowledgement Type of funding sources: None.

Convenience and satisfaction in direct oral anticoagulant–treated patients with atrial fibrillation

BackgroundDirect oral anticoagulants (DOACs) are the preferred anticoagulants for thromboprophylaxis in atrial fibrillation. We aimed to identify determinants of quality of life related to DOAC treatment to optimize DOAC treatment convenience and satisfaction. MethodsWe conducted a cross‐sectional study in DOAC users. DOAC treatment–related convenience and satisfaction were measured by Perception of Anticoagulant Treatment Questionnaire. Higher scores are more favorable (range, 0‐100). Patient‐reported outcome measures and drug‐ and organization‐related factors were collected. Multiple regression analyses were used to evaluate the association between these factors (ie, exposure variables) and DOAC treatment–related convenience and treatment satisfaction (ie, outcome variables). ResultsOf 1598 patients invited, 1035 responded, and 962 were included. The median convenience score was 98.1 (94.2‐100.0), mean satisfaction score 66.5± 14.9. Twenty‐four percent felt not well informed at the start of DOAC; 6.9% did not know who to turn to with questions. Multiple regression analyses showed that lacking sense of security, the predefined composite of receiving insufficient information at start of DOAC and/or not knowing who to turn to with questions was associated with lower convenience (regression coefficient, −1.29; 95% confidence interval [CI], −2.16 to −0.41). Bleeding, gastrointestinal complaints, and lower medication adherence were also associated with lower convenience. Missing sense of security (regression coefficient −6.59; 95% CI, −8.94 to −4.24) and bleeding without consultation were associated with lower treatment satisfaction. ConclusionsAccessible interventions to improve DOAC care could be providing more instruction at treatment initiation and ensuring that patients know who to contact in case of problems.

Clinical Outcomes Associated With LeftAtrial Appendage Occlusion VersusDirect Oral Anticoagulation in Atrial Fibrillation.

This study sought to investigate clinical outcomes associated with left atrial appendage occlusion (LAAO) versus direct oral anticoagulants (DOACs) in patients with high-risk atrial fibrillation (AF). LAAO has been shown to be noninferior to warfarin for stroke prevention in AF. However, anticoagulation with DOACs is now preferred over warfarin as thromboprophylaxis in AF. Patients with AF enrolled in the Amulet Observational Registry (n=1,088) who had successful LAAO with the Amplatzer Amulet device (n=1,078) were compared with a propensity score-matched control cohort of incident AF patients (n=1,184) treated by DOACs identified from Danish national patient registries. Propensity score matching was based on the covariates of the CHA2DS2-VASc (congestive heart failure, hypertension, age≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) and HAS-BLED (hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores for predicting stroke and bleeding. The primary outcome was a composite of ischemic stroke, major bleeding (Bleeding Academic Research Consortium≥3), or all-cause mortality, and follow-up was 2 years. AF patients treated with LAAO had a significantly lower risk of the primary composite outcome as compared with patients treated with DOACs (hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.49 to 0.67). Total events and event rates per 100 patient-years were (LAAO vs. DOACs) 256 vs. 461 and 14.5 vs. 25.7, respectively. The risk of ischemic stroke was comparable between groups (HR: 1.11; 95%CI: 0.71 to 1.75), while risk of major bleeding (HR: 0.62; 95%CI: 0.49 to 0.79) and all-cause mortality (HR: 0.53; 95%CI: 0.43 to 0.64) were significantly lower in patients treated with LAAO. Among high-risk AF patients, LAAO in comparison with DOACs may have similar stroke prevention efficacy but lower risk of major bleeding and mortality.

Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management.

In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty. We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians. A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively. This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.

Anatomic Considerations for Epicardial and Endocardial Left Atrial Appendage Closure

Left atrial appendage closure is an increasingly used means of achieving thromboprophylaxis in atrial fibrillation, particularly in patients with contraindications to anticoagulation. Left atrial appendage anatomy is highly variable, and preprocedural imaging is critical to choosing the correct device and approach for left atrial appendage closure. This article reviews the common endocardial and epicardial closure systems, including anatomic considerations, advantages and disadvantages, as well as complications to be avoided.

Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General Long-Term Registry.

In recent years, stroke prevention in patients with atrial fibrillation (AF) has radically changed, with increasing use of non-vitamin K antagonist oral anticoagulants (NOACs). Contemporary European data on AF thromboprophylaxis are needed. We report 1-year follow-up data from the EURObservational Research Programme in Atrial Fibrillation (EORP-AF) General Long-Term Registry. Outcomes were assessed according to antithrombotic therapy. At 1-year follow-up, 9663 (88.0%) patients had available data for analysis: 586 (6.1%) were not treated with any antithrombotic; 681 (7.0%) with antiplatelets only; 4066 (42.1%) with vitamin K antagonist (VKA) only; 3167 (32.8%) with NOACs only; and 1163 (12.0%) with antiplatelet and oral anticoagulant. At 1-year follow-up, there was a low rate of stroke (0.7%) and any thromboembolic event (TE) (1.2%), while haemorrhagic events occurred in 222 patients (2.3%). Cardiovascular (CV) death and all-cause death occurred in 3.9% and 5.2% of patients, respectively. Cumulative survival for all the three main outcomes considered was highest amongst patients treated only with NOACs (P < 0.0001). Multivariable-adjusted Cox regression analysis found that VKA or NOACs use was independently associated with a lower risk for any TE/acute coronary syndrome/CV death, while all treatments were independently associated with a lower risk for CV death and all-cause death. The 1-year follow-up of EORP-AF General Long-Term Registry reported a low occurrence of thromboembolic and haemorrhagic events, although mortality was high. Both VKA and NOACs were associated with a lower risk of all main adverse outcomes. All treatments were associated with a lower risk for CV death and all-cause death.

The changing landscape of thromboprophylaxis for atrial fibrillation: insights from the ISPAF-2 survey.

The changing landscape of thromboprophylaxis for atrial fibrillation: insights from the ISPAF-2 survey.

Shared decision-making tool for thromboprophylaxis in atrial fibrillation – A feasibility study

BackgroundAppropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. MethodsWe hypothesized that a shared decision-making interaction facilitated by an Atrial Fibrillation Shared Decision Making Tool (AFSDM) would improve patient knowledge about atrial fibrillation, and the risks and benefits of various treatment options for stroke prevention; increase satisfaction with the decision-making process; improve the therapeutic alliance between patient and the clinical care team; and increase medication adherence. Using a pre- and post-visit study design, we enrolled 76 patients and completed 2 office visits and 1-month telephone follow-up for 65 patients being seen in our Arrhythmia Clinic over the 1-year period (July 2016 through June 2017). Our primary outcome measure was change in decisional conflict between the first and second clinical visit. ResultsDecisional conflict decreased from an average of 31 to 9. Mean change was 22.3 (95% CI, 25.7 - 37.1), corresponding to an effect size of 0.94 standard deviations. Satisfaction with decision increased from 4.0 to 4.5, measures of therapeutic alliance with the care team (Kim Alliance scale) increased from 100.1 to 103.1, and satisfaction with provider increased from 4.2 to 4.5 (P < .0001 for all measures). AF knowledge assessment scores increased from 8.4 to 9.1, and knowledge about personal stroke and bleeding risk increased from 1 to 1.5 (P < .0001). Finally, medication adherence improved as reflected by an increase in the Morisky Medication Adherence scale from 5.9 to 6.4 (P < .0001). ConclusionsA shared decision-making interaction, facilitated by an AFSDM can significantly improve multiple measures of decision-making quality, leading to improved medication adherence and patient satisfaction.

The relationship between knowledge, health literacy, and adherence among patients taking oral anticoagulants for stroke thromboprophylaxis in atrial fibrillation.

Patients' knowledge regarding their oral anticoagulant (OAC) treatment for stroke prevention in atrial fibrillation (AF), their level of medication adherence, and health literacy are known to affect treatment outcomes. However, contemporary data regarding the relationships between these variables are lacking. To investigate the relationships between anticoagulant knowledge, health literacy, and self-reported adherence in patients taking warfarin and the directly acting oral anticoagulants. A cross-sectional survey was conducted in 48 patients with AF identified from general practices. The Anticoagulation Knowledge Tool (AKT) was used to assess anticoagulation knowledge; the Short Test of Functional Health Literacy in Adults (s-TOFHLA) for health literacy; and the 8-item Morisky Medication Adherence Scale (MMAS) for medication adherence. Participants had mean scores of 61.6±15.8, 7.2±1.1, and 24.7±9.5 for the AKT, MMAS-8 and s-TOFHLA, respectively. Significant correlations were observed between anticoagulation knowledge and health literacy with medication adherence (0.37, P<.01 and .30, P<.05, respectively). Participants with inadequate health literacy had a significantly lower mean knowledge score than those with adequate health literacy (55.8±15.9 vs 66.1±14.4, P<.05). Participants who self-reported adherence to their OAC had significantly higher knowledge scores than those who did not (67.5±13.3 vs 56.1±16.2, P<.05). Significant correlations between health literacy, OAC knowledge, and adherence were observed, and these relationships should to be considered by health professionals responsible for monitoring patients who are prescribed anticoagulants. We also observed serious gaps in OAC knowledge. Interventions designed to optimize the outcomes of anticoagulant treatment need to address these factors.

Dabigatran reversal with idarucizumab in a patient undergoing heart transplantation: first European report

BackgroundDabigatran is a direct thrombin inhibitor with a favorable effectiveness and safety profile when compared to vitamin K antagonists, both in randomized trials and real world registries of atrial fibrillation patients. Yet, physicians’ fear of high bleeding risk scenarios in daily clinical practice still precludes a more widespread use of oral anticoagulation. We hereby report a successful case of dabigatran reversal with the novel monoclonal antibody fragment idarucizumab in a patient undergoing heart transplantation.Case presentationA 45-year old male patient on dabigatran for atrial fibrillation thromboprophylaxis was enlisted for heart transplantation due to end-stage ischemic heart failure. Upon donor availability and suitability and following the last intake of the drug 12 h previously, activated partial thromboplastin time was measured and found to be elevated. After general anesthesia and before extracorporeal circulation, idarucizumab was administered as two boluses of 2.5 g. Orthotopic heart transplantation ensued under full heparinization and cardiopulmonary bypass. Total chest tube output was 1125 mL after 3 days and 4 units of fresh frozen plasma and one platelet pool were administered in the operating room without further need for blood products. The post-operative period was uneventful.ConclusionsIdarucizumab was associated with an effective hemostasis in the setting of heart transplantation. Dabigatran may be considered as an alternative to vitamin K antagonists in heart transplant candidates with an indication for oral anticoagulation.

Real-practice thromboprophylaxis in atrial fibrillation.

This retrospective observational study was based on databases of the Local Health Authority of Treviso, Italy. It evaluated the prevalence and the effectiveness of oral anticoagulation treatment (OAT) for the management of nonvalvular atrial fibrillation (NVAF) in everyday clinical practice. Out of 6,138 NVAF patients, only 3,024 received vitamin K antagonist (VKA). Potential barriers decreasing the probability of being treated with VKA were female sex, older age, antiplatelet treatment and history of bleeding. In addition, VKA-treatment was not in line with current ESC and AIAC guidelines, since the patients at high or low risk of stroke were under- or over-treated, resp. Among VKAtreated patients, 73 % of subjects were not at target with anticoagulation. OAT resulted to be effective in reducing stroke risk. However, stroke events were significantly influenced also by previous stroke or transient ischemic attack (hazard ratio, HR = 2.99, p < 0.001) and by previous bleeding events (HR = 1.60, p < 0.001).

Surgical Management of Thromboembolic Complications Associated with Mitral Valve Stenosis

Major systemic thromboembolism accounts for 40% of deaths in individuals with mitral valve stenosis (MS). Furthermore, atrial fibrillation (AF) occurs in approximately 45% of patients with MS, adding to the burden of disease. Contraindications to the use of oral anticoagulation such as recent intracranial haemorrhage, places patients at high risk of thromboembolic events. We present the case of a 70-year-old female who presented with symptoms of acute bilateral lower limb and spinal cord ischaemia, within 24 hours of discharge from a stroke rehabilitation unit. Her initial admission was following an atraumatic intracranial haemorrhage after the administration of warfarin as thrombo-prophylaxis for AF. Following surgery for haematoma evacuation, her anticoagulation had been completely ceased. A computed tomography angiogram of her chest demonstrated a saddle embolism of her descending aorta at the bifurcation of the common iliac arteries, and a filling defect in the left atrial appendage. She underwent emergent bilateral aorto-iliac thrombectomy and postoperative anticoagulation with intravenous heparin. Transoesophageal echocardiography showed a 4.5 × 2.2 cm mobile left atrial thrombus and moderate rheumatic MS and she underwent left atrial thrombectomy and mitral valvotomy with full heparinisation and cardiopulmonary bypass. Her postoperative recovery was unremarkable and she was re-commenced on warfarin. This case demonstrates the potentially devastating thromboembolic complications of AF and MS, and the difficulties in decision-making in regards to anticoagulation for patients with previous bleeding complications. Warfarin remains the only oral anticoagulant suitable for these patients given its potential reversibility and titratable dosing regime.

The Trends in Utilizing Nonvitamin K Antagonist Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation: A Real-Life Experience.

Dabigatran and rivaroxaban are novel nonvitamin K antagonist oral anticoagulants (NOACs) approved for thromboprophylaxis in atrial fibrillation (AF). In Turkey, like other countries, the efficacy of translation of the clinical trial results and current guideline recommendations into daily clinical practice is yet to be discovered. Using data from medical records of three tertiary care cardiology centers, we identified patients with nonvalvular AF on dabigatran or rivaroxaban treatment. Baseline characteristics and utilization trends were compared between dabigatran and rivaroxaban groups. Secondarily, clinical events including ischemic stroke and/or transient ischemic attack, systemic embolism, and bleeding were evaluated. Among 294 patients with AF included, dabigatran was utilized in 177 (60.2%) and rivaroxaban in 117 (39.8%). Overall, 76% of patients had received long-term warfarin therapy. The use of 110 mg twice a day (55.4%) was the prevailing strategy in dabigatran group, whereas in rivaroxaban group 20 mg every day (67.5%) was the preferred option. Of the patients, 37.3% had severe valvular disease in which mitral regurgitation was the predominant valve abnormality. Scores of CHADS2, CHA2DS2VASc, and HAS-BLED were similar in both the groups. Of the patients, 24% in dabigatran group and 13.7% in rivaroxaban group were prescribed the lower dose inappropriately. The two NOACs did not differ significantly in terms of clinical events. The results of this study indicate that in daily practice, the physicians' behavior in utilizing the NOACs is shaped by the clinical trials and the guideline recommendations. On the other hand, in dose selection, this adherence is not of high quality.