VASc Score Research Articles

Is there a Concordance between CHA2DS2 VASc and HAS-BLED Scores in Middle Eastern Patients with Nonvalvular AF? Analysis of the Jordan Atrial Fibrillation (JoFib) Study

Background: Nonvalvular Atrial Fibrillation (NVAF) is a common arrhythmia that potentially contributes to stroke and systemic embolization. Anticoagulants may contribute to the risk of bleeding in these patients. Reports of NVAF on Middle Eastern populations are scarce and outdated. This study investigated the concordance between congestive heart failure, hypertension, ≥75 years of age, diabetes mellitus, stroke or transient ischemic attack, vascular disease, 65 to 74 years of age group, sex category (CHA2DS2 VASc), and Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) scores, and the risks of stroke and bleeding in Jordanian NVAF patients. Methods: Results were extracted from the Jordan Atrial Fibrillation (JoFib) multicenter registry (NCT03917992). To assess the risk of stroke, a CHA2DS2 VASc score was used. The HAS-BLED score was used to assess the risk of bleeding. Subgroup analysis for males and females was carried out. Results: We included 1823 NVAF patients, almost equally distributed among males and females. The overall mean age was 68.2 years. Most patients had a body mass index (BMI) ≥ 25 (71.5%). Almost half of the patients were smokers, 45.5% had diabetes, and 76.3% had hypertension. Paroxysmal AF was the most common subtype (38%), followed by the permanent (28.6%), long-standing (17.3%), and persistent types (16.1%). Females had a significantly higher CHA2DS2 VASc score than males (p=0.012). For the risk of bleeding, 48.9% of patients had a low risk, 31.5% had intermediate risk, and 19.6% had a high risk. A correlation was found between the two scoring systems. Out of the 357 patients who had a high HAS-BLED score, 354 (99.2%) patients also had a high CHA2DS2 VASc score. Conclusion: In almost all NVAF patients with a high risk of bleeding (high HAS-BLED score), the use of anticoagulants is highly recommended and strongly indicated according to the CHA2DS2 VASc score stratification. Therefore, strict strategies of well-controlled administration of anticoagulants should always be considered and followed in Middle Eastern patients with NVAF and a high risk of bleeding.

Sleep apnea is associated with stroke in young patients with or without atrial fibrillation:A population study of >2 million individuals

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH, R01 HL149134, R01HL83359 Background Both Sleep Apnea (SA) and Atrial Fibrillation/flutter (AF) are known risk factors for stroke, and both are increasing in prevalence. They are both under-diagnosed in young adults <60 Y. There is an urgent need to define stroke risk portended by SA and AF yet there a paucity of data in adults aged 20-60 years. Purpose To define the relationship between stroke, SA, and AF in a very large cohort of 2 million young-middle aged adults aged 20-60 Y in Northern California. Methods We probed the Stanford Research Repository of electronic health data from 01/01/2008 to 11/30/2021 for the diagnoses of stroke, transient ischemic attacks, AF and SA using relevant codes (stroke: 433.X, 434.X, 436.X, I63.X, I65.X, I66.X, G45.X, G46.X; AF: I48.X; SA: G47.X, 327.27). Results We identified 2267485 patients aged 20-60Y (55% F; 32% White, 12% Asian, 3% Black), of whom SA was diagnosed in 52730 (2.3%), AF in 10230 (0.4%) and incident stroke in 10385 (0.4%) (Figure 1A) In patients with SA, 1.5% developed incident stroke. Stroke was more common in patients with SA than those without, regardless of co-existing diagnosis of AF; OR with AF: 1.5 [1.3-1.7, p<0.001] and OR without AF: 3.0 [2.8-3.3 p<0.0001]. Risk of stroke with SA than without was noted to be higher in the younger age subgroups (Figure 1B) regardless of AF. Although AF was more common in patients with SA than without (odds ratio, OR: 10.1 [9.6-10.6, p<0.0001]), the majority of SA patients (63% with CHADS2VASC ≥2) with stroke did not have a diagnosis of AF (75%), of whom 96% were not anticoagulated (Fig 1, left panel). Of the remaining patients with SA and incident stroke, who did have AF (25%), only 26% were taking OACs at the time of stroke despite median CHADS2 VASC score=3 (Fig 1A, left panel). Finally, 7% of AF patients developed incident stroke. Of these, 73% had CHADS2VASC ≥2, yet 44% were not anticoagulated. Patients with SA comprised a third of all AF patients with stroke and, compared to AF patients with stroke and without SA, had higher CHADS2VASC (median 3 vs 2, p<0.001) and a similarly low use of anticoagulation (56% vs 54% on OAC) (Fig 1A, right panel). Conclusions In >2 million young individuals, we uncover a novel association between SA and incident stroke, regardless of the diagnosis of AF. Surprisingly, three quarters of patients with SA developed incident stroke in the absence of AF, and were not anticoagulated. These results underscore the need to screen for AF and sleep apnea in young adults.

P17 DOACS EFFECTIVENESS AND SAFETY: FURTHER CONFIRMATIONS FROM REAL WORLD EXPERIENCE

Abstract The present analysis is aimed to evaluate the use and results of direct oral anticoagulants (DOACs) in the past years, in a group of patients presenting with multiple comorbidies and at medium–high thromboembolic risk. In the past years, our outpatient Center followed 929 patients (mean age at admission 76.5 + 9.2 years, range: 29–99 years, 501 men), 848 with non–valvular atrial fibrillation/flutter, and 81 with recent phlebopulmonar thromboembolism (PPTE). An anamnesis of previous cardiovascular events were present in 302 patients (32.5%): coronary artery disease (146), carotid or peripheral atherosclerosis (109), cerebral stroke or ischemia (116). Initial CHA2DS2–VASc and HASBLED score were respectively 3.9 and 2.3 points. Patients were initially treated with Apixaban (A) (301, 89 with reduced dose, according to clinical–prescriptive characteristics), Dabigatran (D) (332, 256 with low dose), Edoxaban (E) (161, 83 with reduced dose), Rivaroxaban (R) (135, 53 with reduced dose). All patients were followed–up periodically (every 6 months) with both clinical and instrumental controls (electrocardiogram, blood tests, etc.), re–evaluating risk factors, in order also to check indication and dosage appropriateness. After a mean follow–up of 3.8 years (range: 6 montsh–9 years), for a total of 3530.2 years*patient, 57 patients (6.1%) had stopped DOAC therapy, because of: severe renal failure (12), repeated bleeding (6), clinical criteria (19), mechanical valve insertion (7), detection of thrombophilia (5), left atrial appendage occlusion (3), frailty (5). In the remaining 872 patients, 33 strokes (7 relapses), 11 PPTE, 17 major bleedings, 24 clinically relevant bleedings, and 71 minor bleedings, occurred. DOAC dose reduction occurred in 101 patients (11.6%: 31on A, 25 on D, 16 on E, 29 on R), because of clinical criteria (28), renal failure (56), bleedings (17). A replacement with other DOACS occurred in 104 patients (11.9%: 7 on A, 71 on D, 5 on E, 21 on R), because of renal failure (29), digestive disorders (27), bleedings (32), thrombotic events (6), lactose intolerance (3), allergic reactions (7). Clinical–and instrumental periodical control of patients treated with DOACs confirmed their effectiveness and safety, even in a population at medium–high thromboembolic risk. Additionally, such a management may allow also a greater prescribing appropriateness, as well as a safer and reliable follow–up over time of these patients.

P94 LOWER RATE OF MAJOR BLEEDING IN HIGH–RISK PATIENTS UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION: A PROPENSITY MATCHED COMPARISON WITH DIRECT ORAL ANTICOAGULATION

Abstract Background Stroke prophylaxis in very high risk (CHA2DS2–VASc ≥ 5) patients with atrial fibrillation (AF) is one of the major challenges faced by physicians. Specifically, initiating direct oral anticoagulants (DOACs) in these patients poses a therapeutic conundrum due to the concomitant high risk of bleeding. Left atrial appendage occlusion (LAAO) might be a potential alternative for thromboembolic (TE) prevention; however, there are no studies comparing these two strategies in very high–risk patients. Objective To evaluate the efficacy of LAAO versus DOACs in AF patients at very high TE risk. Methods Data were extracted from two prospective databases including 1053 Watchman and 1328 DOAC patients. Watchman patients with a CHA2DS2–VASc ≥ 5 accounted for 26.3% (n = 277). In order to attenuate the imbalance in covariates, a 1:1 propensity score matching technique was used (co–variates: age, sex, CHA2DS2–VASc and HAS–BLED scores). This method resulted in 554 matched patients (277 patients per group; mean age: 79±7y; 57.4% F; CHA2DS2–VASc: 5.8±0.9). The primary endpoint was a composite of cardiovascular (CV) death, TE events (Stroke/TIA/peripheral embolism) and clinically significant bleeding. The annual TE and major bleeding risks were estimated based on the CHA2DS2–VASc score and compared with the annualized observed risk. Results After a mean follow–up of 26±7 months, total events were 55 (9.4 event rates per 100 patient–years) in LAAO group vs. 78 (14.9 event rates per 100 patient–years) in DOAC group. DOACs had a significantly higher risk of the primary endpoint (hazard ratio [HR]: 1.30; 95% confidence interval [CI]: 1.08 to 1.56; p = 0.03). TE events (HR: 1.15; 95% CI: 0.84 to 1.57; p = 0.63) and CV death (HR: 1.13; 95% CI: 0.84 to 1.54; p = 0.63) did not differ between groups. Major bleeding events were significantly lower in LAAO patients (HR: 0.75; 95% CI: 0.51 to 0.82; p = 0.04). The unadjusted estimated risk of TE events was 12.3% with LAAO and 12.4% with DOACs. The annualized incidence of TE was 3.2% with LAAO and 4.1% with DOACs, which led to a risk reduction of 74% and 67%, respectively. Conclusion In a large cohort of AF patients at very high TE risk (CHA2DS2–VASc ≥ 5), LAAO showed similar stroke prevention but a significantly lower risk of major bleeding than DOACs during a > 2year follow–up.

P375 RECURRENT CEREBRAL ISCHEMIC ATTACKS IN PATIENT ON DIRECT ACTING ORAL ANTICOAGULANTS FOR ATRIAL FIBRILLATION

Abstract We present the case of an 81 year old man suffering from hypertensive heart disease with dilated evolution, dyslipidemia and previous TIAs; on one occasion documentation of cardioembolic origin of the event: AF paroxysm. CHA2DS2–VASc Score = 6. In therapy with DOAC: Dabigatran 110 mg x 2. Placed in therapy with Mysoline for inconstant tremors of the limbs and doubt of absences. Three days after the start of this therapy, the patient was hospitalized for dysarthria (2 h); NIHSS: 0 and ABCD2 score: 4; Brain CT: not acute lesions; centralization to Hub stroke not indicated and DOAC dosage not performed in the PS; at the verification of the DOAC concentration at the peak, during the infra–hospital intake, values of 123 ng / ml; no changes in blood pressure at onset, unchanged CHA2DS2 Vasc Score and HAS–BLED, unchanged blood tests, verified correct intake (CP count), kept the original packaging of the drug, there were no changes in body weight and there was no associated GE pathology; however, primidone was found to be a drug able to decreasing the plasma levels of Dabigatran as an inducer of P–gp glycoprotein. Tp confirmed with Dabigatran and Mysoline replaced with Clonazepam. Subsequent new hospitalization for dysarthria (2 h); centralized in Hub stroke; NIHSS: 1 (slight deviation of the buccal rim–outcome); pressure rise upon access to the PS; peak DOAC concentration 53 ng / ml; CT angiography of the neck and intracranial vessels with evidence of significant underlying vascular lesion load already in itself a contraindication to reperfusion tp which has been excluded; no brain CT lesions; hypothesized in the acute phase switch to another DOAC that has been performed; switch to Apixaban 5 mg 1 tablet x 2 and potentiation of antihypertensive treatment. NMR program of brain in sedation for claustrophobia. Subsequent new hospitalization for septic state and profound drowsiness; severe alteration of blood tests; subacute ischemic hypodensity in the peripheral territory of the left posterior brain; exitus of the patient. Many patients with AF remain at high residual risk of stroke despite an apparent appropriate dosage of oral anticoagulant drugs. However, a multidisciplinary and integrated investigation strategy of all known risk factors does not always give an effective answer, as in the case presented, and there is a lack of information in the literature regarding management options in such circumstances.

A frozen decade: Ten years outcome of atrial fibrillation ablation using a single shot device for pulmonary vein isolation.

Cryoballoon-guided pulmonary vein isolation (CB-PVI) for symptomatic atrial fibrillation (AF) has become an established treatment option with encouraging results in terms of safety and efficacy. Data reporting on long-term data beyond a follow-up (FU) period of 5 years is scarce. This prospective study aimed to evaluate very long-term outcome after CB-PVI for AF. Data from consecutive patients treated with CB-PVI for symptomatic and drug refractory AF between 2005 and 2012 were analyzed. Patients with a FU of ≥9 years after index CB-PVI were included. All patients were continuously followed-up in our outpatient clinic. Arrhythmia recurrence was defined as AF or atrial tachycardia (AT) lasting >30 s beyond a 3-month blanking period. A total of 385 patients (71% male) were included. Mean age was 58 ± 10 years and paroxysmal AF was present in 93% of patients. Mean FU duration was 124 ± 24 months. At the end of the observational period, 73% of all patients were in stable sinus rhythm after a mean of 2 ± 0.8 ablation procedures. Patients with AF/AT recurrence were older (60 ± 8 vs. 57 ± 10 years; p = .019), had a higher CHA2 DS2 -Vasc Score (2.47 ± 1.46 vs. 1.98 ± 1.50; p = .01) and presented with a larger left atrium (LA)-diameter (43 ± 5.6 vs. 40 ± 5.1 mm; p = .002). The LA-diameter was also a significant predictor for AF/AT recurrence after CB-PVI (odds ratio: 0.939, 95% confidence interval: [0.886, 0.992], p = .03). CB-PVI as index procedure for AF ablation resulted in favorable long-term outcome in symptomatic AF. CB-PVI might be recommended as interventional therapy in patients with lower LA remodeling.

Analgesic Effects and Safety of Dexmedetomidine Added to Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia for Children After Tonsillectomy Adenoidectomy.

Tonsillectomy is a frequently performed surgical procedure in children, requiring post-operative analgesia. This study evaluated the efficacy and safety of nalbuphine or sufentanil combined with dexmedetomidine for patient-controlled intravenous analgesia (PCIA) after pediatric tonsillectomy adenoidectomy. A total of 400 patients undergoing tonsillectomy with and without adenoidectomy were included in the study. Patients received a PCIA pump (0.5 mg/kg nalbuphine, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group ND (n = 200). Patients received a PCIA pump (2 μg/kg sufentanil, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group SD (n = 200). More stable hemodynamic changes were noted in Group ND than Group SD from 1 h to 48 h after operation. At 6, 12, 24, and 48 h after operation, the children in Group ND had higher Ramsay sedation scores than those in Group SD. The times to push the PCIA button in Group ND and Group SD were 2.44 ± 0.74 and 2.62 ± 1.00, showing significant differences (p = 0.041). The VASR scores of children in Group ND were significantly lower within 6, 12, and 24 h than those in Group SD (p < 0.05). The VASC scores of children in Group ND were significantly lower within four time points (2, 6, 12, and 24 h) than those in Group SD (p < 0.05). At 1st day after surgery, the children in Group ND had lower levels of serum ACTH, IL-6, and COR levels than those in Group SD (p < 0.001). The incidence rates of nausea and vomiting, and pruritus were significantly higher in Group SD than Group ND (5.00% vs. 11.00%, p = 0.028; 1.00% vs. 4.50%, p = 0.032). The total incidence rate of adverse reactions was significantly higher in Group SD than Group ND (15.00% vs. 31.00%, p = 0.0001). The study demonstrated that dexmedetomidine added to nalbuphine PCIA enhanced the analgesic effects, attenuated the postoperative pain, and reduced the stress response after pediatric tonsillectomy adenoidectomy.

Prognostic implications of traditional and non‐traditional cardiovascular risk factor profiles in patients with non‐valvular atrial fibrillation

Atrial fibrillation (AF) is a prevalent disease with associated mortality risk, mediated in large part through its associated cardiovascular risk factors. Standard modifiable cardiovascular risk factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) are established drivers of cardiovascular disease; however, the importance of non-traditional mediators of cardiovascular risk (NTRFs) such as chronic renal impairment, obstructive sleep apnoea and obesity is emerging. The differential impact of these risk factors on outcomes in patients with AF is not well studied. Consecutive patients admitted to our service between January 2013 and January 2018 with a primary diagnosis of non-valvular AF were assessed. Assessment of demographic, anthropometric, risk factor profile and pharmacotherapeutics was performed. The clinical course of these patients was followed for up to five years for the composite outcome of all-cause death and major adverse cardiovascular events. Of the 1010 patients (62.29±16.81years, 51% men) included, 154 (15%) had no risk factors, 478 (47%) had only SMuRFs, 59 (6%) had only NTRFs and 319 (32%) had both SMuRFs and NTRFs. Over a mean follow-up period of 33.18 ± 21.27months, a total of 288 patients met the composite outcome. On Cox regression, the coexistence of SMuRFs and NTRFs was an independent predictor of the composite outcome (HR 1.40; 95%CI 1.09-1.82, p=.01). Other independent predictors included age, heart failure, CHA2 DS2 VASc score, persistent AF and anaemia. The presence of both SMuRFs and NTRFs has prognostic implications in patients with non-valvular AF.

MO182: Safety Analysis of Anticoagulant Therapy in Stage 4 CKD in Combination with AF

Abstract BACKGROUND AND AIMS A renocardial comorbid condition with a combination of chronic kidney disease (CKD) and atrial fibrillation (AF) increases the risk of thromboembolic complications (TEC) and hemorrhagic events. As kidney function worsens, this risk only increases. Anticoagulant therapy is the standard for prevention of acute cerebrovascular accident (ACVA) in AF. Clinical data on the use of new oral anticoagulants (NOACs) in patients with advanced CKD and AF are very limited, which indicates the relevance of research. Analysis of safety and efficacy indicators of rivaroxaban in patients with stage 4 CKD in combination with AF. METHOD The study included 106 patients with a glomerular filtration rate (GFR) of 15–29 mL/min/1.73 m2 and AF. A total of 73 patients took rivaroxaban at a dose of 15 mg/day and 33 patients took warfarin, the dose of which was individually adjusted according to INR values. The average follow-up period was 18 months. Thromboembolic complications were the primary endpoint. The secondary endpoint is the development of haemorrhagic events (major and minor bleeding). RESULTS In the rivaroxaban group, the mean CHA2DS2 VASc score was 4.9, the HAS BLED score was 3.2, and in the warfarin group, 4.5 and 3.1, respectively. The incidence of stroke in the rivaroxaban group was observed in one patient (1.37%), and in the warfarin group in two patients (6.06%). The results of the study on the primary endpoint indicate that the indicators in both groups did not differ significantly (P = .24). The incidence of haemorrhagic events such as minor bleeding in the rivaroxaban group on the BARC scale was n = 31 (42.5%), and n = 24 (72.7%) in the warfarin group (P &amp;lt; .01). This indicator on the ISTH scale is n = 27 (36.9%) and n = 21 (63.6%), respectively. Major bleeding was observed in the rivaroxaban group n = 2 (2.74%), and in the warfarin group n = 2 (6.06%) on the BARC and ISTH scales (P = .31). Heamorrhagic events were significantly more frequent in the warfarin group compared with the rivaroxaban group. CONCLUSION The data obtained from this study indicate a favourable safety profile of NOAC (rivaroxaban) compared with a vitamin K antagonist in patients with stage 4 CKD in combination with AF.

Adverse events and stroke prevention by interventional left atrial appendage occlusion in patients with low CHA2 DS2 -VASc score-results from the multicenter German LAARGE registry.

Interventional left atrial appendage occlusion (LAAO) is routinely performed in patients with nonvalvular atrial fibrillation and contraindications to standard anticoagulation. We investigated its role in patients at low stroke risk, and compared the effectiveness and safety in patients with low versus high risk. LAARGE is a prospective registry depicting the clinical reality of LAAO. LAAO was conducted with different standard commercial devices, and follow-up period was 1 year. Patients with started procedure and documented CHA2 DS2 -VASc score were selected from the whole database. A total of 638 patients from 38 centers were divided into CHA2 DS2 -VASc score ≤2, i.e., low-risk group (10.2%), and >2, i.e., high-risk group (89.8%). The latter had a pronounced cardiovascular risk profile and preceding strokes (0% vs. 23.9%; p < 0.001). Implantation success was consistently high (97.6%), frequencies of intrahospital major adverse cardiac and cerebrovascular events (0% vs. 0.5%) and other major complications (4.6% vs. 4.0%) were low (each p = not significant [NS]). Numerous moderate complications were also observed in the low-risk patients (12.3% vs. 9.4%; p = NS). Frequencies of nonfatal strokes (0% vs. 0.7%) and severe bleedings (0% vs. 0.7%) were low (each p = NS). In a specific analysis, patients at very high risk of stroke (i.e., CHA2 DS2 -VASc score >4) did not have increased rates of complications or nonfatal strokes in the first year after the procedure. Low-risk patients had no nonfatal strokes and major bleedings within 1 year after hospital discharge but had unexpectedly high rates of moderate procedural complications. The indication in these patients should be strictly defined based on an individual benefit-risk assessment.

Screening For Arrhythmias In Transthyretin Cardiac Amyloidosis With Long Term Monitoring: Surprising What You Find

<h3>Background</h3> Atrial fibrillation is common in patients with transthyretin cardiac amyloidosis (ATTR-CA) and is associated with a high rate of intracardiac thrombosis and embolism. Anticoagulation is recommended irrespective of the CHA₂DS₂-VASc score and some patients initial presentation is an embolic event. We hypothesized that a significant percentage of patients would have atrial fibrillation on long-term monitoring. <h3>Methods</h3> : This is a retrospective study of patients with ATTR-CA, who underwent long-term monitoring for cardiac arrhythmias between June 2018 and April 2021. Baseline demographics, cardiac biomarkers, New York Heart Association (NYHA) functional class assessment and arrhythmia monitor results were obtained. Gillmore stage was calculated for each patient (1 point for each of NT-proBNP >3000 pg/ml and eGFR < 45 ml/min/m2) for a range of 0 to 2 points corresponding to stages 1 to 3. <h3>Results</h3> Thirty-one patients with ATTR-CA who underwent long-term cardiac monitoring were included (18 with ATTRwt and 13 with ATTRv). Mean age was 77±11 years, 84% male with average NYHA class 2.2±0.7, NT-proBNP of 2,312±1977 pg/ml, hs Troponin T of 50±29 ng/L and eGFR of 53±20 ml/min/m2. Their mean Gillmore stage was 1.6±0.6. Subjects wore the monitor for an average of 13.3±2.4 days (range 2 to 14 days). Seven patients (23%) had atrial fibrillation or flutter of whom 2 (6%) were newly diagnosed. Two patients (6%) had high degree atrioventricular blockade and 1 had prolonged sinus pauses, all of whom underwent placement of a permanent pacemaker (at 2-, 29- and 119-days following results, respectively). Twenty-five patients (81%) had documented non-sustained ventricular tachycardia with an average of 37.2 episodes (range of 1 to 713). No patients had an implantable cardioverter defibrillator placed. <h3>Conclusions</h3> In patients with ATTR-CA there is an equal prevalence of new atrial arrhythmias and significant conduction disease requiring permanent pacing. The burden of ventricular arrhythmias was significantly higher than atrial arrhythmias in this population. This is contrary to other cardiomyopathies in which atrial arrhythmias often precede ventricular arrhythmias.

Antithrombotic therapy in patients with non-valvular atrial fibrillation and high risk of stroke after successful endovascular left atrial appendage occlusion

Aim. To assess the antithrombotic therapy after left atrial appendage occlusion (LAAO) with the Watchman device (WD) and Amplarzer Cardiac Plug (ACP) for stroke prevention in patients with nonvalvular atrial fibrillation (AF) with contraindications for long anticoagulation therapy.Methods. 200 consecutive patients with nonvalvular AF and contraindications to oral anticoagulation therapy with contraindications for long anticoagulation who undergone LAAO implantation using WD (n=108; WD group) and ACP (n=92; ACP group) were enrolled into this study. Antithrombotic therapies were prescribed after successful LAAO implantation according to indications. Patients were followed at 45 days, 3, 6 and 12 months after enrollment. At each follow-up visit the data regarding clinical events and healthcare utilization were collected. Transesophageal echo (TEE) was perfomed at 45 days and 6 months after successful LAAO implantation. The efficacy end point was the composite of transit ischemic attack (TIA)/stroke, device thrombosis and procedure-related death.Results. During the follow-up TIA/stroke has occurred in 4.8% of patients in the WD group with no such events in ACP group (4.8% vs 0%, p=0.062). These patients had 4 or more points on the CHA2 DS2 -VASc, and they were prescribed various combinations of antithrombotic therapy, except warfarin, while patients from the WD group with 4 or more points on the CHA2 DS2 -VASc score taking warfarin had no thromboembolic events. Device thrombosis during TEE at 45 days after successful LAAO implantation was confirmed in 3 patients (2,9%) with WD with no such events in ACP group (2.9% vs 0%, p=0.251). The efficacy end point events in all groups were 4.6%: 8 events in WD group (7.6%) and 1 case in ACP group (1.1%). One patient in the ACP group died in 6 weeks after LAAO implantation. No autopsy was performed; therefore, the exact cause of death was not determined (p=0.038). Survival rate showed significantly higher rate events in WD group versus ACP group (p=0.027).Conclusion. Any combinations of antithrombotic therapy could be prescribed to patients with contraindications for anticoagulant therapy and high risk of stroke who undergone successful (LAAO) implantation with Amplatzer Cardiac Plug. It’s possible to cancel oral anticoagulants in this patient. Patients aged 70 and older with a CHA2 DS2 -VASc &gt;4 and a history of stroke are recommended to take warfarin after successful Watchman Device implantation.

Knowledge about atrial fibrillation and anticoagulation affects the risk of clinical outcomes

BackgroundKnowledge about atrial fibrillation (AF) and oral anticoagulation (OAC) is insufficient among AF patients. ObjectiveWe examined the association between this knowledge and event rate. MethodsWe studied 174 anticoagulated patients with AF aged 69±10.7 years (median CHA2DS2 -VASc 4). Knowledge was assessed at baseline using the Jessa AF Knowledge Questionnaire (JAKQ). The primary endpoint was a composite of ischemic cerebrovascular events, major or non-major clinically relevant bleeding, and death, recorded during a median follow-up of 42 months. ResultsThe primary endpoint occurred in 48 (27.5%) patients (10.5 per 100 patient-years) including 12 ischemic cerebrovascular events (2.2 per 100 patient-years) and 29 bleeding episodes (5.8 per 100 patient- years). Lower baseline JAKQ scores were associated with the primary outcome (p=0.007), solely when patients who bled during follow-up were compared with the remainder (p=0.007). Patients who were aware of the importance of a regular anticoagulant intake despite the absence of AF symptoms, had, however, a lower risk of cerebrovascular events (p<0.0001). The subjects who experienced bleeding or the primary endpoint were less likely to understand the essence of AF (p=0.03), to know safe painkillers used in combination with OAC (p<0.001), and what to do when the anticoagulant was forgotten (p=0.02). Worse knowledge about AF and OAC, longer OAC therapy, and higher CHA2DS2 -VASc score were independent predictors for the primary endpoint. ConclusionsOur study shows a prognostic value of low knowledge about AF and OAC supporting the need for improved education of AF patients.

Prognostic significance of CHADS2 and CHA2DS2-VASc scores to predict unfavorable outcomes in hospitalized patients with COVID-19.

Introduction: Owing to the imposed burden of the coronavirus disease 2019 (COVID-19),the need for stratifying the prognosis of patients has never been timelier. Hence, we aimed to ascertain the value of CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (one point for male instead of female) scores to predict unfavorable outcomes in COVID-19 patients. Methods: We enrolled consecutive patients above 18 years of age with confirmed COVID-19,who were admitted between February 16 and November 1, 2020. The primary endpoint of this study was three-month all-cause mortality. The secondary endpoints were considered four major in-hospital clinical features, including acute respiratory distress syndrome, cardiac injury,acute kidney injury, and mechanical ventilation. Results: A total of 1,406 hospitalized COVID-19 patients were studied, among which 301(21.40%) patients died during the follow-up period. Regarding the risk scores, CHADS 2≥1,CHA2DS2-VASc≥2, and CHA2DS2-VASc-M≥2 were significantly associated with mortality. The performance of all risk scores for predicting mortality was satisfactory (area under the curve:0.668, 0.668, and 0.681, respectively). Appraising secondary endpoints, we found that all three risk scores were associated with increased risk of acute respiratory distress syndrome, cardiac injury, acute kidney injury, and mechanical ventilation. Lastly, we revealed that all risk scores were significantly correlated with serum levels of laboratory biomarkers. Conclusion: Our analysis illustrated that the CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-Mscores could aid prognostication of unfavorable outcomes in COVID-19 patients. Therefore,these easily calculable methods could be integrated into the overall therapeutic strategy to guide the COVID-19 management more accurately.

Utility of CHA2DS2-VASc Score to Predict Mid-Term Clinical Outcomes in Hemodialysis Patients

Background: The CHA₂DS₂-VASc score has been widely used to predict stroke in patients with atrial fibrillation (AF). Recently, it was reported that the CHA₂DS₂-VASc score helps predict cardiovascular disease (CVD) or all-cause mortality in patients with or without AF. However, few reports have examined the association between this score and mortality in hemodialysis (HD) patients. Methods: We analyzed 557 consecutive patients who initiated HD at our facilities between February 2005 and October 2017. The CHA₂DS₂-VASc score was calculated at the time of initiation of HD. Patients were then categorized into three groups according to their CHA₂DS₂-VASc scores: 0–1 (low), 2–3 (intermediate), and 4–9 (high). Multivariate Cox proportional hazards analysis was used to assess independent risk factors for 3-year all-cause mortality. Results: During the 3-year follow-up period, 153 (27.5%) patients died (cardiovascular death: n = 88). According to multivariate analysis, serum albumin (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.43–0.85, p = 0.003), creatinine (HR 0.91, 95% CI 0.84–0.99, p = 0.049), and CHA₂DS₂-VASc score (HR 1.33, 95% CI 1.20–1.46, p < 0.001) were associated with 3-year all-cause mortality. Compared with patients in the low CHA₂DS₂-VASc score group, those in the intermediate- and high-score groups had a higher risk for all-cause and CVD mortality (all-cause mortality: HR 1.77, 95% CI 1.23–2.55, p = 0.002 and HR 2.94, 95% CI 1.90–4.53, p < 0.001, respectively; CVD mortality: HR 1.82, 95% CI 1.27–2.59, p = 0.001 and HR 2.85, 95% CI 1.88–4.31, p < 0.001, respectively). Conclusion: The CHA₂DS₂-VASc score is a valuable predictor of 3-year all-cause and CVD mortality in incident HD patients.

Atrial fibrillation as a new independent risk factor for thromboembolic events: hemodynamics and vascular consequence of long ventricular pauses.

Atrial fibrillation (AF) is a leading risk factor of arterial thromboembolic events. Aim is to study the main arteries hemodynamics and kinetics in AF and to propose the functional classification of AF. We included 188 patients (80 as the control). We performed 24-hours ECG monitoring, blood lipids analysis, echocardiography, stress echocardiography, coronary angiography, renal arteries angiography, ultrasound Doppler of brachiocephalic arteries, abdominal aorta branches, renal arteries, lower extremities arteries, sphygmography. Patients were divided into 3 groups up to the duration of maximum pauses between ventricular complexes in AF: 1) with a pause <1 second (64); 2) with a pause of ≥1, but <2 seconds (62); 3) ≥2 seconds (62). We analyzed the thromboembolic events within 1 year. We observed the increase of linear blood flow velocity and volume flow in patients with AF during the spreading of the wave after a long pause between ventricles' contractions. The longer the pause between the ventricles' contractions, the more increase of arteries kinetics parameters is observed. The most frequent incidence of thromboembolic events within 1 year was in group 3. We propose a functional classification of AF: 1) AF with the pauses of less than 1 second; 2) more 1, but less than 2 seconds; and 3) 2 or more seconds. The most unfavorable is AF with pauses of 2 seconds or more. We supplemented the CHA<inf>2</inf>DS<inf>2</inf>-VASc Score with the new independent risk factor - type of AF - in accordance with the maximum duration of pauses between cardiac cycles.

CHA2DS2 VASc score and brachial artery flow-mediated dilation as predictors for no-reflow phenomenon in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BackgroundFollowing primary percutaneous coronary intervention (PCI), no-reflow is associated with a high rate of long-term unfavorable clinical outcomes. Despite the importance of early no-reflow prediction in cardiovascular medicine, noninvasive assessment is lacking. This study aimed to evaluate the preprocedural CHA2DS2 VASc score and the brachial artery flow-mediated dilation percentage (FMD%) as predictors of the no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI.ResultsThis study included 150 patients who presented with acute STEMI, underwent primary PCI, and were divided into two groups according to the flow result, reflow group and a no-reflow group. The CHA2DS2 VASc score was calculated and evaluation of endothelial function by measuring the brachial artery FDM% was done for each patient before the procedure. There were 39 (26%) patients in the no-reflow group and 111 (74%) in the reflow group. The no-reflow patients were older and had significantly higher body mass index (BMI), higher frequency of diabetes mellitus, hypertension, history of heart failure, dyslipidemia, Killip class IV on admission, thrombus grade V, multiple affected vessels, conventional stenting, and multiple stents placement, longer ischemic times, higher CHA2DS VASc score, and lower brachial artery FMD% (p-values of < 0.05 for all). Moreover, there was a significant negative correlation between CHA2DS VAS score and preprocedural FMD%, with the higher the score indicating lower FMD among cases (p-value = 0.000).ConclusionsPreprocedural CHA2DS2 VASc score and the brachial artery FMD can be used as predictors for the no-reflow phenomenon in patients with STEMI, undergoing primary PCI.

Warfarin Use, Stroke, and Bleeding Risk among Pre-Existing Atrial Fibrillation US Veterans Transitioning to Dialysis

Introduction: Anticoagulation is commonly used for stroke prevention among patients with atrial fibrillation (AF); however, end-stage renal disease (ESRD) patients on hemodialysis are at higher risk of bleeding and stroke, even without anticoagulation. It is unclear if patients should be continued on anticoagulation at the time of transition to ESRD. In this study, we validated risk scores for stroke and bleeding in this population and assessed risk of stroke and bleeding among warfarin users compared to nonusers. Methods: We utilized a cohort of 28,620 pre-dialysis US veterans transitioning to hemodialysis between October 2007 and March 2015. Incident rates for the risks of stroke and bleeding were ascertained based upon CHA₂DS₂-VASc or HAS-BLED scores, respectively. A propensity score-based competing risk analysis was used to assess risk of stroke and bleeding. Findings: The mean age of our cohort was 77 ± 9 years, and the median CHA₂DS₂-VASc and HAS-BLED scores were 7 (5, 8) and 3 (3, 4), respectively. Increasing CHA₂DS₂-VASc and HAS-BLED scores were predictive of increasing stroke and bleeding rates, respectively. However, warfarin use did not appear to affect the risk of stroke and bleeding (p-interaction = 0.84 for stroke and 0.24 for bleeding). Warfarin use was associated with a higher risk of stroke (adjusted SHR 1.44, 95% CI: 1.23–1.69) and a higher risk of bleeding (adjusted SHR 1.38, 95% CI: 1.25–1.52) when accounting for the competing risk of death. Discussion: There was no difference in incidence rates of stroke or bleeding among warfarin users versus nonusers. Warfarin was associated with a higher risk of stroke and bleeding after considering mortality risk.

CHA2 DS2 -VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism.

BackgroundAccurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA2DS2‐VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation.HypothesisThis study aims to evaluate the association between CHA2DS2‐VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA).MethodsOne hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA2DS2‐VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA.ResultsPESI and CHA2DS2‐VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA2DS2‐VASc score and PESI score had a positive correlation. The area under the curve value for the CHA2DS2‐VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity.ConclusionThis study showed that not only CHA2DS2‐VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA2DS2‐VASc and PESI scores are able to predict RV dysfunction.

Comparison of Safety and Efficacy Between Dabigatran and Rivaroxaban in Nonvalvular Atrial Fibrillation in Tertiary Level Hospital

Background: Thromboembolism is a major complication of atrial fibrillation. Vitamin K antagonist is the main oral anticoagulant which was used for prevention of thromboembolism in atrial fibrillation for many years. New oral anticoagulant drugs are emerging as alternatives to warfarin for the prevention of stroke in patients with non-valvular atrial fibrillation.&#x0D; Objective: The aim of the study was to compare safety and efficacy of dabigatran and rivaroxaban for prevention of thromboembolism in tertiary level hospital.&#x0D; Methodology: This Randomized controlled trial study was conducted in the Department of Cardiology in Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka. Patients were divided into two groups, in group A 37 patients were given dabigatran 110 mg twice daily and in group B 37 patients were given rivaroxaban 20 mg daily for 6 months duration. Data was collected according to the pre designed semistructured data collection sheet. Statistical analyses were carried out by using the Statistical Package for Social Sciences (SPSS) version 23.0 for Windows Software.&#x0D; Results: The mean CHADS2- VASC score (Risk of stroke) in rivaroxaban group and in dabigatran group was 3.95±1.37 and 3.74±1.42 respectively. There was no significant difference of CHADS2- VASC score between the two groups. Regarding outcome of 6th month follow up 2(5.4%) patients were lost to follow up in dabigatran group and 3(8.1%) in rivaroxaban group. Comparaing effectiveness and safety study we found that ischemic stroke rate with rivaroxaban group was higher than dabigatran group although statistically not significant. We also found higher bleeding rate in rivaroxaban group than dabigatran group although statistically not significant.&#x0D; Conclusion: Dabigatran is a safe and effective anticoagulant same as rivaroxaban for prevention of thromboembolism in the treatment of non valvular atrial fibrillation.&#x0D; University Heart Journal 2022; 18(1): 10-13