Valvular Atrial Fibrillation Patients Research Articles

Predictive value of nutritional indices for left atrial thrombus in patients with valvular atrial fibrillation

BackgroundThe prognostic nutritional index (PNI) and geriatric nutritional risk index (GNRI) are well known indicators for adverse outcomes in various diseases, but there is no evidence on their association with the risk of left atrial thrombus (LAT) in patients with valvular atrial fibrillation (VAF).MethodsA comparative cross-sectional analytical study was conducted on 433 VAF patients. Demographics, clinical characteristics and echocardiographic data were collected and analyzed. Patients were grouped by the presence of LAT detected by transesophageal echocardiography.ResultsLAT were identified in 142 patients (32.79%). The restricted cubic splines showed an L-shaped relationship between PNI and LAT. The dose-response curve flattened out near the horizontal line with OR = 1 at the level of 49.63, indicating the risk of LAT did not decrease if PNI was greater than 49.63. GNRI was negative with the risk of LAT and tended to be protective when greater than 106.78. The best cut-off values of PNI and GNRI calculated by receiver operating characteristics curve to predict LAT were 46.4 (area under these curve [AUC]: 0.600, 95% confidence interval [CI]:0.541–0.658, P = 0.001) and 105.7 (AUC: 0.629, 95% CI:0.574–0.684, P<0.001), respectively. Multivariable logistic regression analysis showed that PNI ≤ 46.4 (odds ratio: 2.457, 95% CI:1.333–4.526, P = 0.004) and GNRI ≤ 105.7 (odds ratio: 2.113, 95% CI:1.076–4.149, P = 0.030) were independent predictors of LAT, respectively.ConclusionsLower nutritional indices (GNRI and PNI) were associated with increased risk for LAT in patients with VAF.

Outcomes and Safety of Direct Oral Anticoagulants (DOACs) versus Vitamin K Antagonists (VKAs) amongst Patients with Valvular Heart Disease (VHD): A Systematic Review and Meta-Analysis

Background: Both valvular heart disease (VHD) and atrial fibrillation (AF) frequently coexist. AF is an important cause of arrhythmias with a definitive cardiovascular morbidity. The use of either vitamin K antagonists (VKAs/warfarin) or direct oral anticoagulants (DOACs) (also known as new oral anticoagulants (NOACs)) has been the mainstay for preventing stroke and systemic embolism in patients with VHD and/or AF, and this has been broadly discussed. However, there are limited studies on anticoagulation therapy for patients with valvular atrial fibrillation (VAF). The main aim of this meta-analysis was to evaluate the outcomes (stroke–vascular events and intracranial bleeding) following DOAC and VKA treatment amongst patients with VAF. Methods: We identified clinical trials and observational studies published in the last 10 years. A systematic review and a meta-analysis were performed to evaluate the outcomes of patients with valvular atrial fibrillation following DOAC vs. VKA treatment. Data evaluation was performed using Review Manager 5.4; the endpoints were stroke–vascular events and intracranial bleeding following DOAC and VKA treatment amongst VAF patients. Risk ratios (RR) were evaluated with 95% confidence intervals. Using random effects models, forest plots were obtained. Heterogeneity was assessed by using the I2 statistic. Results: Eight studies were included in this metanalysis, and a total of fifteen thousand two hundred and fifteen patients (DOAC (8732) and VKA (6483)) were pooled. We found a significant risk reduction in stroke–vascular events when using DOACs in comparison with using VKAs (pooled RR: 0.76; 95% CI: 0.64–0.90, p = 0.002). A total of 14862 patients (DOAC (8561) and VKA (6301)) were pooled from a total of six studies for intracranial bleeding. We found a significant risk reduction in terms of intracranial bleeding when using DOACs in comparison with using VKAs (pooled RR: 0.43; 95% CI: 0.24–0.77, p ≤ 0.05). Conclusions: When compared to VKAs, DOAC agents were found to have less risk of stroke–vascular events and intracranial bleeding. Further prospective studies are essential to establish the efficacy and safety of DOAC agents in patients with various subtypes of VAF.

Abstract P2137: Comparative Effectiveness And Safety Of Rivaroxaban Versus Warfarin In Valvular Atrial Fibrillation: A Systematic Review And Meta-Analysis

Introduction: Patients with valvular atrial fibrillation (AF), which refers to moderate to severe mitral stenosis or mechanical prosthetic heart valves, have an increased risk of ischemic stroke and systemic embolism, which mandates the need for long-term anticoagulation. Still, there are no clear consensus guidelines on the indications of anticoagulation therapy in valvular AF. We aimed to compare the effectiveness of rivaroxaban, a common direct-acting oral anticoagulant (DOAC), to warfarin for preventing thromboembolism in valvular AF patients. Methods: We performed a systematic search of the following databases; PubMed, Cochrane Library, Google Scholar, and EMBASE from inception until February 06, 2023. Results: After screening 389 studies, 8 studies with 68,847 patients have been included in the final analysis. Our meta-analysis did not reveal a significant difference in the occurrence of all-cause mortality between patients who received rivaroxaban and those who received warfarin [RR, 0.97 (95% CI: 0.53-1.76]), p =0.91]. On analysis of the individual studies, rivaroxaban was non-inferior to warfarin with a lower risk of bleeding events [RR, 0. 80 (95% CI: 0.62-1.04), p =0.72], myocardial infarction [RR, 0.56 (95% CI: 0.13-2.47), p =0.44], and stroke/systemic embolism [RR, 0.54 (95% CI: 0. 11-2.55), p = 0.43]. But there was no statistically significant difference between the two groups. Conclusions: With a decreased risk for major adverse events, rivaroxaban appears to have a favorable safety profile, making them a promising alternative to warfarin in treating patients with valvular AF. However, more randomized clinical trials are imperative.

Differences in Clinical Characteristics of Patients with Valvular and Non-Valvular Atrial Fibrillation

Background: There is an increasing global prevalence of atrial fibrillation (AF), including in Indonesia. Based on the presence of mitral stenosis and/or prosthetic valve, AF is divided into two groups, namely valvular AF and non-valvular AF. The differences in clinical characteristics between valvular and non-valvular AF in Indonesia, especially in Semarang, have not been described. This study aimed to determine the differences in clinical characteristics between valvular and non-valvular AF in Semarang.&#x0D; Methods: This study was an observational analytic study with a cross-sectional design and was performed in July-August 2020. The subjects were 54 AF patients, which were divided into two categories, namely valvular (n=28) and non-valvular (n=26) AF. The data were collected from medical records. The differences between the two groups were analyzed with bivariate analysis.&#x0D; Results: The patients with valvular AF were predominantly female (82.1% vs 69.2%; p &lt;0.001), of a younger age (46.54 ± 12.20 vs 61.04 ± 8.68; p &lt;0.001), more likely to have rheumatic heart disease (46.4% vs 3.8%; p &lt;0.001), and have had heart surgery (57.1% vs 0%; p &lt;0.001). The patients with non-valvular AF were more likely to have hypertension (17.9% vs 80.8%; p &lt;0.001), myocardial infarction (0% vs 19.2%; p = 0.021), dyslipidemia (7.1% vs. 42.3%; p = 0.003), and higher BMI (21.03 ± 4.16 vs 25.48 ± 4.20; p &lt;0.001). The INR values in most of the AF patients have not reached the target. The valvular AF patients were more likely to be taking warfarin (100% vs 80,8%, p=0,021) and diuretic therapy (96,4% vs 57,7%, p=0,001).&#x0D; Conclusion: There are significant demographic and clinical characteristics differences between valvular and non-valvular AF.

TARGETING TUMOR NECROSIS FACTOR (TNF) IN ATRIAL STRETCH-DEPENDENT ADVERSE ATRIAL REMODELING AND VALVULAR ATRIAL FIBRILLATION IN A MOUSE MODEL OF AORTIC REGURGITATION

TARGETING TUMOR NECROSIS FACTOR (TNF) IN ATRIAL STRETCH-DEPENDENT ADVERSE ATRIAL REMODELING AND VALVULAR ATRIAL FIBRILLATION IN A MOUSE MODEL OF AORTIC REGURGITATION

Prediction of herbal medicines based on immune cell infiltration and immune- and ferroptosis-related gene expression levels to treat valvular atrial fibrillation.

Inflammatory immune response is apparently one of the determinants of progressive exacerbation of valvular atrial fibrillation(VAF). Ferroptosis, an iron-dependent modality of regulated cell death, is involved in the immune regulation of cardiovascular disease. However, the relevant regulatory mechanisms of immune infiltration and ferroptosis in VAF have been less studied. In the current study, a highly efficient system for screening immunity- and ferroptosis-related biomarkers and immunomodulatory ability of herbal ingredients has been developed with the integration of intelligent data acquisition, data mining, network pharmacology, and computer-assisted target fishing. VAF patients showed higher infiltration of neutrophils and resting stage dendritic cells, while VSR patients showed higher infiltration of follicular helper T cells. In addition, six (e.g., PCSK2) and 47 (e.g., TGFBR1) ImmDEGs and one (SLC38A1) and four (TGFBR1, HMGB1, CAV1, and CD44) FerDEGs were highly expressed in patients with valvular sinus rhythm (VSR) and VAF, respectively. We further identified a core subnetwork containing 34 hub genes, which were intersected with ImmDEGs and FerDEGs to obtain the key gene TGFBR1. Based on TGFBR1, 14 herbs (e.g., Fructus zizyphi jujubae, Semen Juglandis, and Polygonum cuspidatum) and six herbal ingredients (curcumin, curcumine, D-glucose, hexose, oleovitamin A, and resveratrol) were predicted. Finally, TGFBR1 was found to dock well with curcumin and resveratrol, and it was further verified that curcumin and resveratrol could significantly reduce myocardial fibrosis. We believe that herbs rich in curcumin and resveratrol such as Rhizoma curcumae longae and Curcuma kwangsiensis, mitigate myocardial fibrosis to improve VAF by modulating the TGFβ/Smad signaling pathway. This strategy provides a prospective approach systemically characterizing phenotype-target-herbs relationships based on the tissue-specific biological functions in VAF and brings us new insights into the searching lead compounds from Chinese herbs.

Left Atrial Appendage Circular RNAs Are New Predictors of Atrial Fibrillation Recurrence After Surgical Ablation in Valvular Atrial Fibrillation Patients

Atrial fibrillation (AF) recurrence after ablation will increase mortality and morbidity during follow up. We attempted to evaluate the relationship between circular RNAs (circRNA) and AF recurrence to establish a predictive model for early intervention. Patients who received surgical ablation retrospectively were analyzed. The expression of circRNAs were detected in the left atrial appendage. The independent risk factors of late recurrence were analyzed by multivariate analysis. The predictive model was visualized by Nomogram and tested by receiver operating characteristic curve and calibration plot. Kaplan-Meier plot was used to compare the rate of freedom from AF recurrence after surgery. The relationships between circRNAs and clinical characteristics were detected by Spearman's correlation analysis. A total of 136 patients were enrolled from September 2018 to June 2019, 55 patients experienced late recurrence during one-year follow up. Increased age, longer AF duration and increased circ 81906-RYR2, circ 44782-LAMA2, circ 418-KCNN2 and circ 35880-ANO5 were detected in recurrent patients. Multivariate analysis revealed that increased age (odds ratio (OR)=1.072, P = 0.006), longer AF duration (OR=1.007, P = 0.036) and increased circ 81906-RYR2 (OR=2.210, P < 0.001) were independent risk factors for late recurrence. Area under the curve was 0.77, and the cut-off value was 70 points of the predictive model. Kaplan-Meier plots showed that patients over 70 points tended to experience AF recurrence. Circ 81906-RYR2 could be a new predictor of late recurrence after surgical ablation. A predictive model consists of age, atrial fibrillation duration, and circ 81906-RYR2 was alternative for early intervention of AF recurrence.

B-PO04-115 HYPERTENSION AND ABNORMAL RENAL FUNCTION INCREASED THE RISK OF ISCHEMIC STROKE IN ANTICOAGULATED EHRA TYPE-1 VALVULAR ATRIAL FIBRILLATION

Atrial fibrillation (AF) increases the risk of stroke substantially, therefore many scores have been developed to risk stratify these patients. However, most of the previous studies have focused on non-valvular AF. The most widely used risk stratification score is the CHA2DS2-VASC score. Unfortunately, the validation of this score in valvular AF is poor. This study aimed to evaluate the clinical factors and echocardiographic parameters related to the incidence of ischemic stroke in anticoagulated EHRA (Evaluated Heartvalves, Rheumatic or Artificial) type-1 valvular AF patients. We conducted a retrospective cohort study based on data from the Indonesian Registry on Atrial Fibrillation (OneAF). Patients with type-1 EHRA valvular AF between January 2015 and December 2019 were analysed. The clinical outcome was an ischemic stroke that occurred during the monitoring period of January 2015 - December 2019. Among 329 AF patients with mitral stenosis or prosthetic mechanical valves, we found the incidence of ischemic stroke was 17 (5.2%). Multivariate logistic regression analysis showed that two clinical factors, i.e., history of hypertension (OR 5.59; 95% CI: 1.93-16.15; p = 0.001) and estimated Glomerular Filtration Rate (eGFR) ≤ 59 mL/min/m2 (OR 3.62; 95% CI: 1.30-10.02; p = 0.013) were independently associated with the incidence of ischemic stroke. No echocardiographic parameters were associated with the incidence of ischemic stroke in this population. We observed that two clinical factors i.e., history of hypertension and abnormal renal function, were markedly associated with stroke incidence in anticoagulated EHRA type-1 valvular AF patients.

Indonesian registry on atrial fibrillation (OneAF).

Background:Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF.Methods/design:The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events.Results:Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events.Trial registration:Registered at clinicaltrials.gov (NCT04222868).

Association between Red Cell Distribution Width and Left Atrial Thrombus in Patients with Valvular Atrial Fibrillation

Background: Red cell distribution width (RDW) is a quantitative measure of variability in the size of circulating erythrocytes and previously shown to provide information concerning the prothrombotic status or adverse outcome of cardiovascular disease. Left atrial thrombus (LAT) is commonly detected in patients with valvular atrial fibrillation (VAF) due to rheumatic mitral valve stenosis (RMVS) but there is very limited data regarding the predictive value of RDW for the development of LAT in these patients.&#x0D; Aim: To determine the association between RDW and LAT in VAF patients.&#x0D; Methods: A total of 58 patients were included in a retrospective observational study between January 2016 to December 2016 in patients who admitted to Dr. Moewardi General Hospital, due to symptomatic VAF. Blood examination and transthoracic echocardiography were performed to all patients. LAT was defined as a fixed or mobile echogenic mass within left atrium (LA) and left atrial appendage (LAA). The RDW was compared between a patient with LAT or without LAT.&#x0D; Results: There were 28 patients (mean age: 46.2±13.3 years) in LAT(+) group and 30 patients (mean age: 45.6±11.5 years) in LAT(-) group. RDW was significantly higher in LAT(+) group (14.4±1.8% vs. 13.3±1.5%, p=0.010). The RDW was independent predictor of LAT by multivariate analysis (OR 1.619; p=0.020; 95% CI: 1.079-2.429). The cut-off RDW value for LAT was &gt;13.5% with a sensitivity of 73.3% and a specificity of 64.3% (area under curve=0.700; 95% CI: 0.562-0.838; p=0.009). The prevalence of LAT was significantly higher in patient with an RDW &gt;13.5% than in those with an RDW &lt;13.5 % (64.3% and 35.7%, p=0.002), with prevalence ratio 5.91.&#x0D; Conclusion: This study shows that a higher level of RDW has an association with the presence of LAT and an independent risk factor of LAT formation in patients with VAF.

Preoperative monocyte-to-HDL-cholesterol ratio predicts early recurrence after radiofrequency maze procedure of valvular atrial fibrillation.

BackgroundMonocyte‐to‐high‐density lipoprotein (M/H) ratio has emerged as a novel cardiovascular prognostic biomarker. We aimed to evaluate the prognostic values of M/H with early recurrence in persistent valvular atrial fibrillation (AF) patients after radiofrequency (RF) maze procedure.MethodsWe retrospectively analyzed 131 consecutive persistent AF patients with valvular heart diseases who were followed up 3 months after RF maze procedure. Their clinical data were recorded. Logistic regression analyses were performed for significant predictors. Receiver operating characteristic analysis was used for validation with corresponding area under the curve.Results70 (53.4%) patients experienced early recurrence after procedure. Patients with early recurrence were older, have longer AF duration history, larger left atria diameter (LAD), higher plasma C‐reactive protein (CRP), lower triglycerides (TG), lower cholesterol (TC), increased monocyte counts, lower HDL cholesterol, and increased M/H ratio. In multivariate analysis, age (OR 1.1 95% CI 1.0‐1.1 P = .003), LAD (OR 2.1, 95%CI 1.2‐3.5, P = .006), TG (OR 0.35, 95% CI 0.15‐0.84, P = .019), M/H (OR 6.1, 95% CI 2.9‐13.0, P < .001) were significantly independent predictors of AF early recurrence. M/H ratio demonstrated a significant predictive value (AUC = 0.77, sensitivity 89.0%, specificity 54%). Further, there was a positive correlation of M/H ratio with CRP and white blood cell.ConclusionPreoperative M/H ratio was an independent risk factor of AF early recurrence following RF maze operation. M/H ratio should be considered in prediction of early recurrence for valvular AF patients.

P3780Clinical characteristics and outcomes in Japanese atrial fibrillation patients with valvular heart disease: the Fushimi AF registry

Abstract Background Previous studies have suggested that valvular atrial fibrillation (VAF), defined as atrial fibrillation (AF) patients with prosthetic valve or rheumatic mitral stenosis, increased the risks of thromboembolism. However, clinical characteristics and outcomes of VAF and non-valvular AF (NVAF) patients with other valvular heart disease (VHD) has not been fully described. Method The Fushimi AF Registry was designed to enroll all of the AF patients. In the entire cohort (4,454 patients), follow-up data including echocardiography data were available for 3,566 patients. We compared clinical characteristics and outcomes between 131 VAF patients (3.7%), 583 NVAF with VHD (NVAF-VHD: 16.3%) and 2,852 without VHD (Non-VHD: 80.0%). Result Compared with Non-VHD, patients in VAF and NVAF-VHD were older (VAF vs. NVAF-VHD vs. Non-VHD: 74.3 vs. 76.9 vs. 72.9 years, respectively; p≤0.0001), more often female (56.5% vs. 51.1% vs. 36.9%, p≤0.0001), less in body weight (54.3 vs. 54.7 vs. 60.6 kg, p≤0.0001), more persistent/permanent type (64.1% vs. 65.4% vs. 45.8%, p≤0.0001), more likely to have heart failure (61.8% vs. 53.2% vs. 23.3%, p≤0.0001), had higher CHADS2 score (2.18 vs. 2.49 vs. 1.96, p≤0.0001) and CHA2DS2-VASc score (3.71 vs. 4.02 vs. 3.26, p≤0.0001), and received oral anticoagulant prescription more frequently (78.6% vs. 63.0% vs. 55.6%, p0.0001). NVAF-VHD was more likely to have previous stroke/systemic embolism (SE) than VHD or Non-VHD (14.5% vs. 23.5% vs. 19.6%, p=0.03). VAF or NVAF-VHD had larger left atrium than Non-VHD (50.5 vs. 47.2 vs. 42.4 mm, p&lt;0.0001). Heart rate, diabetes mellitus and previous bleeding were comparable between the groups. During the median follow-up of 1,471 days, the incidence rate of stroke/SE was not significantly different between three groups, however, NVAF-VHD showed modestly higher rate than Non-VHD (1.67 vs. 1.96 vs. 1.28 per 100 person-years, respectively, log rank p=0.054) (Figure). The incidence rates of all-cause death (4.62 vs. 5.74 vs. 3.21, p≤0.0001), cardiac death (1.07 vs. 1.01 vs. 0.44, p=0.0003), and those of hospitalization for heart failure (3.29 vs. 4.41 vs. 1.80, p≤0.0001) were higher in NVAF-VHD and VAF, than Non-VHD. After adjustment by relevant factors including the components of CHA2DS2-VASc score and oral anticoagulant use, NVAF-VHD, but not VAF, was an independent predictor for hospitalization for heart failure. Neither VAF nor NVAF-VHD was predictors for all-cause death, cardiac death or stroke/SE. Figure 1. Incidence of stroke/SE Conclusion As compared with Non-VHD, the risk of stroke/SE in VAF and NVAF-VHD was not particularly high; although NVAF-VHD had modestly higher rate than Non-VHD. VAF and NVAF-VHD were associated with higher incidence rates of all-cause death, cardiac death and hospitalization for heart failure. NVAF-VHD was an independent predictor for hospitalization for heart failure in multivariate analysis. Acknowledgement/Funding Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare and Daiichi Sankyo

Stroke Risk Status, Anticoagulation Treatment, and Quality-of-Life in Chinese Patients with Atrial Fibrillation: China Registry of Atrial Fibrillation (CRAF).

Objective. To investigate the contemporary status of stroke risk profile, antithrombotic treatment, and quality-of-life (QoL) of patients with all types of atrial fibrillation (AF) in China. Design. This is a multicenter, cross-sectional study. Setting. Tertiary (80%) and Tier 2 hospitals (20%) were identified in different economic regions (Northeast, East, West, and Middle) by using a simple random sampling. Participants. A total of 3562 (85.6%) patients with nonvalvular atrial fibrillation (NVAF) and 599 (14.4%) with rheumatic valvular atrial fibrillation (VAF) were consecutively enrolled from 111 hospitals from July 2012 to December 2012. Data Collection. Patient information was collected and QoL was assessed using Short-Form 36 Health Survey (SF-36) questionnaire. Primary and Secondary Outcome Measures. The risk of stroke was assessed using the CHADS2 and CHA2DS2-VASc. QoL was assessed using Medical Outcomes Study SF-36 questionnaire. Results. Overall, 31.7% of the patients received anticoagulant treatment and 61.2% received antiplatelet treatment. The rate of anticoagulant treatment was higher in patients with VAF than in those with NVAF. The anticoagulant use was the lowest in Northeast and the highest in Middle regions. Independent risk factors associated with underuse of anticoagulants for NVAF were age, systolic blood pressure (SBP), non-Middle regions, nontertiary hospitals, and new-onset or paroxysmal AF. For VAF patients, the independent factors were age, paroxysmal AF, treatment in Tier 2 hospitals, SBP, diastolic blood pressure, history of coronary artery disease, and nonreceipt of antiarrhythmic therapy. Patients receiving anticoagulants fared significantly better in some QoL domains than those who received no antithrombotic therapy. Conclusions. These findings suggest that antiplatelet treatment is overused and anticoagulant treatment is underused both in Chinese patients with VAF and NVAF, even though usage of anticoagulants is associated with better QoL. Risk factors with underuse of anticoagulants were not identical in patients with NVAF and VAF.

Clinical characteristics and rhythm outcome of catheter ablation of hemodynamically corrected valvular atrial fibrillation

BackgroundAlthough the hemodynamic burden and structural substrate contribute to valvular atrial fibrillation (VAF) mechanisms, the role of catheter ablation has rarely been reported. We investigated the clinical characteristics, mapping findings, and long-term rhythm outcomes after catheter ablation of hemodynamically corrected VAF. MethodsWe compared 77 patients with VAF (46.8% male, 52.7±8.8 years old, 46.8% paroxysmal AF, 24.7% with maze procedures) and 2244 patients with non-VAF (NVAF) who underwent catheter ablation. Among the VAF patients, 44 (57.1%) had mechanical valve AF (MV-AF) and 33 (42.9%) underwent a prior mitral valvuloplasty (MVP-AF). We analyzed the catheter ablation rhythm outcomes for MV-AF and MVP-AF. ResultsThe left atrial (LA) diameter was greater (p<0.001), LA voltage lower (p<0.001), and procedure-related complication rate higher (mainly sinus node dysfunction, p=0.004) for VAF than NVAF. During 70.2±1.8 months of follow-up, the rhythm outcome of VAF did not significantly differ from that of NVAF after catheter ablation (log rank p=0.399), even after excluding patients with maze procedures (log rank p=0.629). The clinical recurrence rates did not differ between the MV-AF and MVP-AF groups (log rank p=0.244), or between patients with prior maze procedures and those without (log rank p=0.651). The main conduction recovery sites of previous maze procedures were the perimitral (84.2%) and cavotricuspid isthmus (84.2%) areas, and recurrence mechanisms were macroreentry (63.2%) and focal/microreentry (26.3%) at scar border zones. ConclusionsAlthough hemodynamically corrected VAF was associated with advanced LA remodeling, the rhythm outcome did not significantly differ from that of NVAF after catheter ablation.

227Prevalence of New Stroke in Non Valvular Atrial Fibrillation Patients on DOAC in Rural Population Admitted to Acute Stroke Unit

227Prevalence of New Stroke in Non Valvular Atrial Fibrillation Patients on DOAC in Rural Population Admitted to Acute Stroke Unit

Use of Novel Oral Anticoagulants (NOACs) in Patients with Risk of Stroke in Non Valvular Atrial Fibrillation (AF)

Background: Warfarin was used for decades to prevent stroke in high risk AF patients, recent guidelines and published data is recommending use of NOACs like Rivaroxaban as an alternative to Warfarin, Its use is increasing world over because of its predictable action, less food and drug interaction and no need of monitoring for dose adjustments, considering these facts we planned to conduct a study to see the frequency of use of Rivaroxaban in our local population of AF patients with risk of stroke calculated by CHA2DS2-VASc score. Method: This cross-sectional study was done at National Institute of Cardiovascular disease (NICVD) from May 2017 to September 2017 included 137 non-valvular AF patients with high risk of stroke calculated by applying CHA2DS2-VASc score more than or equal to 2. Clinical details and information about anticoagulant medications prescribed to them was also obtained. SPSS 19 was used for the analysis, descriptive statistics such as mean ±SD, frequency and percentages were calculated. Z-test, t-test, and chi-square test were used for the assessment and comparison of data. Two sided p-value of 0.05 was considered for statistical significance. Results: Total 137 patient were included 50.4% (69) were male, 104 (75.91%) out of 137 were on Anticoagulant therapy, with 86 (62.77%) were on Warfarin and only 18 (13.14%) were taking Rivaroxaban. Conclusion: Our study showed very small percentage of non valvular AF patients with risk of stroke were prescribed Rivaroxaban. It’s important to update our treating Physicians about this novel agent which is shown to be equally effective and safe in comparison to warfarin, and easy to prescribe without monitoring to reduce stroke risk.

CHA2DS2-VASc-HSF score – New predictor of severity of coronary artery disease in 2976 patients

BackgroundCHADS2 and CHA2DS2-VASc scores have been used for assessing prognostic risk of thromboembolism in non valvular atrial fibrillation patients. They include similar risk factors for the development of CAD To increase the likelihood of determining CAD severity, the CHA2DS2-VASc-HS and CHA2DS2-VASc-HSF score comprising of hyperlipidemia, smoking and family history respectively in addition to the components of the CHA2DS2-VASc score and male instead of female gender. The aim was to investigate whether these risk scores can be used to predict CAD severity. Methods and resultsA total of 2976 consecutive patients who underwent coronary angiography were enrolled in the study. Presence of >50% stenosis in a coronary artery was assessed as significant CAD. Of the patients,804 had normal coronary angiograms and served as group 1. The remaining 2172 patients with coronary stenosis were further classified into 2 groups according to CAD with stenosis of <50% or >50%: 834 patients with mild CAD as group 2 and 1338 patients with severe CAD as group 3. The scores were significantly different among the 3 groups. All the four scores correlated significantly with the number of diseased and the Gensini score. ConclusionCHADS2, CHA2DS2-VASc, and especially CHA2DS2-VASc-HS and CHA2DS2-VASc-HSF scores could be considered predictive of the risk of severe CAD with CHA2DS2-VASc-HSF the best scoring scheme to predict CAD severity. The risk scoring systems may play an important role as predictive models because they are simple and can be easily applied by physicians without any additional costs in routine practice.

Abstract 19679: Is Major Bleeding Risk for Oral Anticoagulants Similar Among Newly Initiated Non Valvular Atrial Fibrillation Patients?

Aim: The purpose of this study was to compare the risk of first major inpatient/outpatient bleeding event among non valvular atrial fibrillation (NVAF) patients newly initiated with warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs) including apixaban, dabigatran, or rivaroxaban. Methods: Retrospective cohort study was conducted using MarketScan® database from 01/2012 to 12/2013. NVAF patients 18+ years with ≥1 year baseline period were included if they were newly prescribed an oral anticoagulant from 01/01/ 2013 to 12/31/2013. Major bleeding on anticoagulant was defined as inpatients and/or outpatient bleeding on the index drug during the supply duration or within 30 days after the last supply day of the last prescription. A Cox proportional hazards model was used to estimate the hazard ratios (HR) of major bleeding adjusted for age, sex, baseline comorbidities, and comedications. Results: Among 29,338 NVAF patients newly initiated on an oral anticoagulant, 2,402 (8.19%) were on apixaban, 4,173 (14.22%) on dabigatran, 10,050 (34.26%) on rivaroxaban and 12,713 (43.33%) on warfarin. Patients initiating warfarin (72.5±11.9 yrs) and apixaban (69.3±12.3 yrs) were older as compared to rivaroxaban (67.3±12.2 yrs) and dabigatran (66.8±12.1 yrs). Patients initiating warfarin were higher risk as compared to those initiating NOACs in terms of CHA 2 DS 2- VASc score (3.22±1.65) and higher Charlson comorbidity index (CCI) score of 2.37±2.33 (p &lt;0.0001 across all treatments). After adjusting for baseline characteristics, as compared to patients newly initiated on warfarin, patients newly initiated on apixaban or dabigatran had significantly lower risk of major bleeding (Table). Conclusion: Among newly anticoagulated NVAF patients in the real world setting, initiation with apixaban or dabigatran was associated with significantly lower risk of major bleeding compared to initiation on warfarin.

Abstract 18465: Real World Comparison of Major Bleeding Risk Among Non-valvular Atrial Fibrillation Patients Newly Initiated on Warfarin versus Apixaban 5mg BID, Dabigatran 150 mg BID, or Rivaroxaban 20 mg QD

Aim: Limited data are available on the real-world safety of non-vitamin K antagonist oral anticoagulants (NOACs). The study purpose was to compare the first major bleeding event risk among non valvular atrial fibrillation patients (NVAF) patients newly initiated on dose-adjusted warfarin versus apixaban 5mg BID, dabigatran 150mg BID, or rivaroxaban 20 mg QD. Methods: Retrospective cohort study was conducted using MarketScan® commercial &amp; Medicare supplemental database from 01/2012 to 12/2013. NVAF patients 18+ years with ≥1 year baseline and newly prescribed oral anticoagulant from 01/01/2013 to 12/31/2013 were included. Major bleeding was defined as bleeding requiring hospitalization on the index drug during the supply duration or within 30 days after the last supply day of the last prescription. A Cox proportional hazards model was used to estimate the hazard ratios (HR) of major bleeding adjusted for age, sex, baseline comorbidities and comedications. Results: Among 26,604 patients, 2,057 (7.73%) were newly initiated on apixaban 5mg, 3,768 (14.16%) on dabigatran 150mg, 8,066 (30.32%) on rivaroxaban 20mg and 12,713 (47.79%) on warfarin. Patients initiating warfarin (72.5±11.9 yrs) and apixaban 5mg (67.0±11.4 yrs) were older as compared to rivaroxaban 20mg (65.2±11.4 yrs) and dabigatran 150mg (65.4±11.5 yrs). Patients initiating warfarin had higher CHA 2 DS 2- VASc score (3.22±1.65) and Charlson comorbidity index score (2.37±2.33) (P &lt;0.0001 across all treatments) as compared to those initiating NOACs. After adjusting for baseline characteristics, patients newly initiated on apixaban 5mg BID had significantly lower risk of major bleeding (HR: 0.53, 95% CI: 0.29-0.97, P=0.0399) as compared to those initiated on warfarin (Table). Conclusion: Among newly anticoagulated NVAF patients in the real world setting, as compared to dose adjusted warfarin, only patients initiating on apixaban 5mg BID were associated with significantly lower risk of major bleeding.

Medication prescription and adherence disparities in non valvular atrial fibrillation patients: an Italian portrait from the ARAPACIS study.

Non-valvular atrial fibrillation (NVAF) represents a major health-care problem, needing an extensive and strict thrombosis prevention for stroke and cardiovascular (CV) disease risks. NVAF management guidelines recommend adequate antithrombotic and anti-atherosclerotic therapies. Medication adherence has been recognized as a pivotal element in health quality promotion and in the achievement of better clinical outcomes. We conducted a post-hoc analysis of the "Atrial fibrillation Registry for Ankle-brachial index Prevalence Assessment-Collaborative Italian Study (ARAPACIS)" with the aim of discerning differences in pharmacological management and medication adherence among NVAF Italian patients. Furthermore, data were analysed according to Italian geographical macro-regions (North, Center, South) to evaluate whether socioeconomic conditions might also influence medication adherence. Thus, we selected 1,366 NVAF patients that fulfilled the Morisky Medication Adherence Scale-4 items. Regional disparities in drug prescriptions were observed. In particular, in high-risk patients (CHA2DS2-VASc ≥2) oral anticoagulants were more prescribed in Northern and Center patients (61 and 60%, respectively) compared to 53% of high-risk Southern patients. Also, medication adherence showed a progressive decrease from North to South (78 vs. 60%, p<0.001). This disparity was independent of the number of drugs consumed for any reason, since prevalence of poly-therapy among the three macro-regions was similar. Our results show regional differences in NVAF patients' antithrombotic management and medication adherence, potentially reflecting well-known disparities in socioeconomic status among Italian regions. Future interventions promoting campaigns to global health-care education may be desirable to improve clinical outcomes in NVAF patients.