Clinical outcomes of direct oral anticoagulant versus warfarin after transcatheter aortic valve replacement: From the STS/ACC TVT registry

BACKGROUND

Transcatheter aortic valve replacement (TAVR) recipients frequently have an indication for long-term oral anticoagulation, including atrial fibrillation or systemic thromboembolic disease. It remains unclear if there are differences in safety and effectiveness between direct oral anticoagulants (DOAC) and warfarin in this patient population.

METHODS

Clinical outcomes were compared between TAVR recipients receiving DOACs or warfarin using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) registry linked with Centers for Medicare & Medicaid Services claims data. The analysis included patients from the TVT registry who underwent successful TAVR and were discharged on either a DOAC or warfarin between January 2013 and May 2018. The primary outcome was any bleeding requiring hospitalization from discharge to 1 year. Secondary outcomes included all-cause mortality and stroke from discharge to 1 year. Multivariable Cox proportional hazards regression models were used to compare these outcomes between the 2 groups.

RESULTS

A total of 29,142 patients underwent TAVR and were discharged on oral anticoagulation, among whom 10,973 (37.7%) were discharged on a DOAC. The use of DOACs increased throughout the study period and exceed the use of warfarin by the final year (2018). The cumulative incidence of bleeding requiring hospitalization at 1 year (11.8% vs 15.2%, P < .001) and all-cause mortality (15.5% vs 17.5%, P < .001) was significantly lower in DOAC group while stroke (2.47% vs 2.39%, P = .64) was not statistically different between groups. In an adjusted model, the use of a DOAC as opposed to warfarin was associated with a significantly lower risk of bleeding requiring hospitalization (adjusted hazard ratio 0.49, 95% confidence interval 0.43-0.56), all-cause mortality (adjusted hazard ratio 0.61, 95% confidence interval 0.57-0.66), and stroke (adjusted hazard ratio 0.86, 95% confidence interval 0.81-0.92) (all P < .001).

CONCLUSIONS

In this analysis of TAVR recipients discharged on oral anticoagulation in a large U.S. registry, the use of a DOAC rather than warfarin was associated with a lower risk of bleeding requiring hospitalization, all-cause mortality, and stroke from discharge to 1 year. Future randomized studies will be necessary to establish the optimal choice of anticoagulant in TAVR patients.

Association between oral anticoagulant therapy and in-hospital complications and mortality

AIMS

This study aimed to identify patterns of direct oral anticoagulant (DOAC) and vitamin K antagonist (VKA) use in hospitalized patients and to examine their association with in-hospital haemorrhagic complications and mortality.

METHODS

An observational cross-sectional study was conducted among hospitalized patients ≥18 years from 2018 to 2022. Data on hospital discharges were obtained from the minimum data set and were matched with pharmacy records to identify patients treated with DOACs or VKAs. In-hospital haemorrhagic complications and mortality rates were calculated for study groups. Multivariate logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (95%CIs), adjusting for age, sex and comorbidities. Analyses were stratified by medical and surgical profiles. Statistical significance was set at .05.

RESULTS

The study included 74 190 patients, with 4774 receiving DOACs and 1768 VKAs. During the study period, DOAC use increased by 45.11%. DOAC-treated patients had lower complication rates than those treated with VKAs (1.9 vs. 2.8%, respectively; P = .032). DOAC use was linked to a lower risk of haemorrhagic complications in surgical patients (OR = 0.65; 95%CI: 0.35-0.91), while in medical patients, the reduction in risk was not statistically significant (OR = 0.59; 95%CI: 0.33-1.10). No effect on mortality risk was observed among medical and surgical patients.

CONCLUSIONS

The increased use of DOACs among hospitalized patients showed a protective effect against haemorrhagic complications in surgical patients, supporting their increasing use in hospital settings.

Concomitant Drug Interactions With Non-Vitamin K Oral Anticoagulants Are Associated With Bleeding and Mortality Risk in Patients With Nonvalvular Atrial Fibrillation

BACKGROUND

Non-vitamin K oral anticoagulants prevent stroke and systemic embolism in patients with nonvalvular atrial fibrillation. However, potential drug interactions with concomitant medications may compromise their efficacy and escalate the risk of adverse effects.

METHODS AND RESULTS

We conducted a territory-wide retrospective cohort study in Hong Kong, focusing on nonvalvular atrial fibrillation prescribed non-vitamin K oral anticoagulants. The objective was to investigate the associated risk of gastrointestinal bleeding, intracranial hemorrhage, hospitalization for major bleeding, and all-cause mortality in relation to various concomitant medications. Our analysis included 22 568 patients with nonvalvular atrial fibrillation (aged 75.7 ± 10.8 years; 51.2% men) taking non-vitamin K oral anticoagulants from January 1, 2017, to December 31, 2020, totaling 40 317 patient-years. It was found that amiodarone (hazard ratio [HR], 1.53), digoxin (HR, 1.30), diltiazem (HR, 1.18), clarithromycin (HR, 4.98), and fluconazole (HR, 2.38) were associated with increased gastrointestinal bleeding, whereas amiodarone (HR, 2.20) and digoxin (HR, 1.61) were associated with increased intracranial hemorrhage. Furthermore, amiodarone (HR, 1.64), digoxin (HR, 1.35), clarithromycin (HR, 4.18), and fluconazole (HR, 2.40) were associated with increased hospitalization for major bleeding. Additionally, amiodarone (HR, 2.65), digoxin (HR, 1.85), diltiazem (HR, 1.44), verapamil (HR, 1.80), antidepressants (HR, 1.31), and fluconazole (HR, 3.27) were associated with increased all-cause mortality. Conversely, dronedarone (HR, 0.56) and atorvastatin (HR, 0.86) were associated with a significant reduction in all-cause mortality.

CONCLUSIONS

For patients with nonvalvular atrial fibrillation taking non-vitamin K oral anticoagulants, several concurrent medications were associated with increased risks of intracranial hemorrhage, major bleeding hospitalizations, and overall mortality.

Net Benefit of Anticoagulation in Subclinical Device-Detected Atrial Fibrillation

Importance

The role of anticoagulation for stroke prevention in patients with device-detected atrial high-rate episodes, also known as subclinical atrial fibrillation (AF), is a subject of equipoise.

Objective

To assess the net benefit of nonvitamin K antagonist oral anticoagulants (NOACs) in patients with device-detected subclinical AF.

Design, Setting, and Participants

Decision analytical model run with 10 000 patients with anticoagulation and 10 000 patients without anticoagulation in a clinical scenario of deciding whether to start NOACs for stroke prevention in patients with subclinical AF. A Markov decision model was conducted on October 1, 2024, to estimate net outcomes of NOACs. The patients had stroke risk and bleeding risks similar to those of patients in randomized trials of anticoagulation in subclinical AF.

Exposure

Anticoagulation was modeled to decrease the risk of ischemic stroke by 32% and increase the risk of major bleeding by 62%. In probabilistic sensitivity analyses, the 95% CIs for treatment effect sizes were also considered.

Main Outcomes and Measures

The main outcome measure for overall net benefit was the cumulative quality-adjusted life-years (QALYs) during the simulation. The model considered the number and severity of ischemic strokes, hemorrhagic strokes, other intracranial bleeds, and extracranial bleeds, as well as the number of deaths during a 10-year simulation.

Results

When comparing the 2 cohorts of 10 000 patients (mean age, 77 years; 3700 [37%] women), those receiving NOAC therapy had 233 fewer ischemic strokes (21.7%), 55 fewer deaths (1.1%), and 453 more major bleeding events (37.3%) over a 10-year simulation period. Per patient, these differences translated to approximately 1 additional quality-adjusted week of life (0.024 QALYs) with NOAC treatment during the 10-year simulation. When the 95% CIs of treatment effect sizes were considered in probabilistic sensitivity analysis, there was a 65.8% probability that NOAC treatment leads to more QALYs than withholding treatment.

Conclusions and Relevance

In this analytical model study, initiating NOACs in patients with device-detected subclinical AF was associated with a minimal increase in QALYs. However, the benefits were uncertain, and the effect size of the overall net benefit does not appear to be clinically meaningful.

Comparative Efficacy and Safety of Low-Dose Direct Oral Anticoagulants Versus Dual Antiplatelet Therapy Following Left Atrial Appendage Occlusion in Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

Left atrial appendage occlusion (LAAO) is an alternative to chronic oral anticoagulation (OAT) for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with contraindications to OAT. Postprocedure antithrombotic therapy (ATT) is essential to reduce the risk of device-related thrombosis (DRT), but the optimal regimen remains uncertain.

AIMS

This study aims to compare the safety and efficacy of low-dose direct oral anticoagulants (DOACs) versus dual antiplatelet therapy (DAPT) following LAAO.

METHODS

A comprehensive search of PubMed, Scopus, Cochrane, and Web of Science was conducted in August 2024. Studies comparing low-dose DOACs and DAPT post-LAAO were included. The primary outcomes were a composite efficacy endpoint (DRT, strokes, and systemic embolism [SE]) and major bleeding events as the safety endpoint. Secondary outcomes included all bleeding events, all-cause mortality, and a composite of efficacy and safety endpoints.

RESULTS

Four studies with 727 patients were included. Low-dose DOACs were associated with lower rates of the primary composite efficacy endpoint compared to DAPT (OR = 0.36; 95% CI [0.16, 0.85], p = 0.01). No significant difference in major bleeding events was observed (OR = 0.36; 95% CI [0.11, 1.18]; p = 0.091; I² = 0%). Compared to DAPT, low-dose DOACs were also associated with lower rates of DRT events (OR = 0.36; 95% CI [0.16, 0.79], p = 0.011).

CONCLUSION

Low-dose DOACs effectively reduce thromboembolic events post-LAAO without increasing bleeding risk. These findings support their use as a viable ATT option, but larger trials are needed to confirm optimal regimens.

Efficacy and safety of DOACs vs vitamin K antagonists in patients with atrial fibrillation and chronic kidney disease undergoing hemodialysis: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Atrial fibrillation (AF) is a relatively prevalent arrhythmia in patients with kidney failure requiring dialysis who face a high risk of stroke and bleeding and for whom anticoagulation is a challenging decision. Although direct oral anticoagulants (DOACs) may offer advantages over vitamin K antagonists (VKAs), their use in this patient profile remains unclear.

OBJECTIVE

We conducted a systematic review and meta-analysis to compare DOACs and VKAs in patients with AF undergoing dialysis.

METHODS

PubMed, Embase, and Cochrane Central databases were analyzed. The outcomes analyzed were total stroke (a composite of ischemic and hemorrhagic stroke), ischemic stroke, all-cause death, cardiovascular death, myocardial infarction, major bleeding, clinically relevant nonmajor bleeding and gastrointestinal bleeding. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random effects model. R software version 4.3.2 R Studio for Statistical Computing, Vienna, Austria) was used for statistical analyses. Heterogeneity was assessed with I2 statistics.

RESULTS

The final analysis included 486 patients from 4 randomized controlled trial studies. The median follow-up ranged from 5.8 to 18 months. Although a reduction in total stroke was observed in the group receiving DOACs (RR 0.40; 95% CI 0.17-0.92; P = .031; I2 = 0%), no significant difference was found between the groups for ischemic stroke (RR 0.42; 95% CI 0.17-1.04; P = .062; I2 = 0%). In addition, a statistically significant reduction in major bleeding was noted in the DOAC group (RR 0.64; 95% CI 0.41-0.98; P = .044; I2 = 0%). However, no significant differences were observed among the groups for all-cause death (RR 0.88; 95% CI 0.57-1.35; P = .567; I2 = 47%), cardiovascular death (RR 1.13; 95% CI 0.60-2.10; P = .700; I2 = 0%), or clinically relevant nonmajor bleeding (RR 1.11; 95% CI 0.67-1.84; P = .669; I2 = 0%).

CONCLUSION

In this meta-analysis, DOACs were associated with a lower risk of total stroke and major bleeding. However, DOACs and VKA groups exhibited similar rates of ischemic stroke, all-cause and cardiovascular death, clinically relevant nonmajor bleeding, and gastrointestinal bleeding.

Evaluation of DOAC Dosing Among Various Renal Equations in Patients With Kidney Impairment and Elderly in Thailand

The Thai Food and Drug Administration (TFDA) has approved direct oral anticoagulant (DOAC) dosing based on estimated creatinine clearance, eCrCl (Cockcroft-Gault equation). However, other renal function equations are often used in practice for patients with kidney disease, leading to potential discrepancies in DOAC dosing recommendations. The actual DOAC dosing patterns in resource-limited countries remain underreported. This cross-sectional study included patients with renal impairment who were treated at the outpatient department of Siriraj Hospital, Mahidol University, Thailand. Patients received their first DOAC for atrial fibrillation from January 2019 to December 2022. The primary objective was to evaluate the percentage of DOAC prescriptions compliant with TFDA guidelines using eCrCl. We also examined dosing agreement when substituting estimated glomerular filtration rate, eGFR (CKD-EPI) for eCrCl. Patient factors and the incidence of stroke and bleeding over a one-year follow-up were also assessed. A total of 326 patients and 1587 DOAC prescriptions were analyzed. The mean patient age was 79.1 ± 9.2 years, with a mean eGFR of 45.6 ± 9.9 mL/min/1.73 m2. TFDA-compliant dosing was observed in 68.2% of prescriptions. Dose disagreement between eGFR and eCrCl was 45%, with a trend toward overdosing using eGFR. An eGFR of less than 45 mL/min/1.73 m2 was associated with dose discrepancies. Stroke and bleeding incidences were low, with no differences across DOAC types. While most Thai patients received appropriate DOAC dosing, one-third did not comply with TFDA guidelines. Using eGFR instead of eCrCl may result in dosing differences, particularly in moderate to severe renal impairment.

Inappropriate dosing of direct oral anticoagulants among very older inpatients with atrial fibrillation

Among very older patients with atrial fibrillation (AF), the frequency of inappropriate direct oral anticoagulant (DOAC) dosing, associated factors, and temporal trends in practice are unknown.This retrospective study included consecutive inpatients aged 80 years or older with a discharge diagnosis of atrial fibrillation who were prescribed DOACs at discharge from Beijing Hospital between January 2018 and August 2023. Patients were stratified into underdosed, overdosed, or recommended dosing groups. Logistic regression analysis was performed to identify risk factors associated with inappropriate dosing, and temporal trends were evaluated using the Cochran-Mantel-Haenszel test.Among 676 inpatients aged ≥ 80 years with AF (mean age 84.4 ± 3.5 years; 53.1% female) who were prescribed a DOAC at hospital discharge (22.9% dabigatran, 62.3% rivaroxaban, 14.8% edoxaban), recommended dosing was observed in 338 patients (50.6%), underdosing in 308 (45.6%), and overdosing in 30 (4.4%). The overall rate of inappropriate dosing was 49.4%. Factors independently associated with underdosing included advanced age (OR = 1.98, 95% CI: 1.52-2.60, p < 0.001), lower creatinine clearance (OR = 0.98, 95% CI: 0.97-0.99, p = 0.01), and discharge from non-internal medicine wards (OR = 2.15, 95% CI: 1.33-3.45, p = 0.002). Overdosing was associated with younger age (OR = 0.38, 95% CI: 0.19-0.75, p = 0.005). Although the proportion of recommended dosing increased over the study period, and inappropriate dosing showed a declining trend, these changes did not reach statistical significance.Inappropriate DOAC dosing, especially underdosing, remains common in very older AF inpatients. This issue persists despite years passing, emphasizing the need for patient-focused, collaborative AF management and thorough prognostic studies.

Direct oral anticoagulants versus warfarin for the management of left atrial appendage thrombus in patients with acute stroke

BACKGROUND

We compared the effectiveness of direct oral anticoagulants (DOACs) and warfarin for resolving left atrial appendage (LAA) thrombus in patients with acute stroke with non-valvular atrial fibrillation (NVAF).

METHODS

Among consecutive patients with acute stroke admitted to five major comprehensive stroke centers in Japan between January 2017 and December 2022, those with NVAF and LAA thrombus detected by transesophageal echocardiography (TEE) and underwent follow-up TEE were included. All patients received DOAC or warfarin treatment. We compared the clinical characteristics, changes in LAA thrombus size, resolution, recurrent stroke, and bleeding complications within 3 months of stroke onset.

RESULTS

This study included 63 patients (DOAC group, 22; warfarin group, 41). Sex, age, and National Institutes of Health Stroke Scale scores on admission did not significantly differ between the groups. The initial LAA thrombus size was 0.83 cm2 and 0.88 cm2 in the DOAC and warfarin groups, respectively. On follow-up evaluation 10 days after initial TEE, LAA thrombus was completely resolved in 59 % and 34 % of patients in the DOAC and warfarin groups, respectively (P = 0.02). Multivariable analysis revealed DOAC treatment as an independent factor for LAA thrombus resolution (odds ratio, 3.21; 95 % confidence interval: 1.07-10.23, P = 0.04). Recurrent stroke occurred in one and three patients in the DOAC and warfarin groups, respectively. No intracerebral hemorrhage cases were observed in either group within 3 months of stroke onset.

CONCLUSION

In patients with acute stroke with NVAF and LAA thrombus detected by TEE, DOACs may be more effective than warfarin in resolving LAA thrombus.

Risk factors for mild cognitive impairment in type 2 diabetes mellitus older adult: a systematic review and meta-analysis

AIMS

Numerous of evidence suggest that older adults with diabetes are more likely to experience mild cognitive impairment (MCI), therefore identifying risk factors is crucial. Thus, the purpose of this study was to investigate the risk factors for the development of MCI in older diabetics.

METHODS

The MEDLINE, Web of Science, Scopus, and Embase databases were searched for pertinent research on the risk factors for the beginning of MCI. The remaining studies were assessed using predetermined inclusion and exclusion criteria after duplicate studies were eliminated. The Comprehensive Meta-Analysis software (version 2) was used to analyze the data. The Egger test was used to examine publication bias, while the I-square statistic was used to evaluate study heterogeneity. 95 % confidence limits and odds ratios were used in the analysis.

RESULTS

Thirty studies were authorized for assessment and statistical analysis using the systematic review procedure. These studies' findings indicate that, using both univariate and multivariate analyses, the odds ratio for the occurrence of MCI in older people with diabetes is higher for factors like low educational attainment (univariate analysis: OR = 0.706, CI95 %: 0.622-0.801, P ≤ 0.001 and multivariate analysis: OR = 0.753, CI95 %: 0.637-0.831, P = 0.001), duration of diabetes (univariate analysis: OR = 1.249, CI95 %: 1.111-1.405, P ≤ 0.001 and multivariate analysis: OR = 1.174, CI95 %: 1.006-1.370, P = 0.042), abnormal Hemoglobin A1c (HbA1C) levels (univariate analysis: OR = 1.744, CI95 %: 1.277-2.383, P ≤ 0.001 and multivariate analysis: OR = 1.248, CI95 %: 1.091-1.427, P ≤ 0.001), retinopathy(OR = 2.163, CI95 %: 1.686-2.776, P ≤ 0.001), nephropathy(OR = 1.568, CI95 %: 1.151-2.135, P = 0.004), neuropathy(OR = 1.334, CI95 %: 0.686-2.591, P = 0.396), depression(univariate analysis: OR = 1.649, CI95 %: 1.016-2.841, P = 0.046, and multivariate analysis: OR = 1.957, CI95 %: 1.322-2.856, P ≤ 0.001), and stroke(univariate analysis: OR = 1.820, CI95 %: 1.172-2.827, P = 0.008. multivariate analysis: OR = 1.496, CI95 %: 1.184-1.899, P = 0.001). Furthermore, univariate data analysis revealed that age(OR = 1.067, CI95 %: 1.011-1.126, P = 0.019), high total cholesterol(OR = 0.934, CI95 %: 0.866-1.008, P = 0.076), fasting blood sugar(OR = 1.129, CI95 %: 1.017-1.254, P = 0.023), the presence of hypertension(OR = 1.572, CI95 %: 1.147-2.155, P = 0.005), and kidney disease(OR = 1.676, CI95 %: 0.972-2.89, P = 0.063), all affect the odds ratio for the development of MCI in older adults with diabetes.

CONCLUSION

factors like low education, long-term diabetes, abnormal HbA1C levels, retinopathy, nephropathy, depression, and stroke, as well as high total cholesterol, fasting blood glucose, high blood pressure, and kidney disease, increase the risk of developing MCI in older diabetics. These cases in diabetic patients require special attention.

Hemodynamics affects factor XI/XII anticoagulation efficacy in patient-derived left atrial models

BACKGROUND AND OBJECTIVE

Atrial fibrillation (AF) is a common arrhythmia that disrupts blood circulation in the left atrium (LA), causing stasis in the left atrial appendage (LAA) and increasing thromboembolic risk. In patients at sufficiently high risk, anticoagulation is indicated. This benefit may be counterbalanced by an increased risk of bleeding. Novel anticoagulants under development, such as factor XI/XII inhibitors, may be associated with a lower bleeding risk. However, their efficacy in preventing thrombosis is not fully understood. We hypothesized that patient-specific flow patterns in the LA and LAA not only influence the risk of thrombosis but also the effectiveness of anticoagulation agents.

METHODS

To test our hypothesis, we simulated blood flow and the intrinsic coagulation pathway in patient-specific LA anatomies with and without factor XI/XII inhibition. We included a heterogeneous cohort of thirteen patients, some in sinus rhythm and others in AF, four of whom had an LAA thrombus or a history of transient ischemic attacks. We used computational fluid dynamics based on 4D CT imaging and a detailed 32-coagulation factor system to run 247 simulations. We analyzed baseline LA flow patterns and evaluated various factor XI/XII inhibition levels. Implementing a novel multi-fidelity coagulation modeling approach accelerated computations by two orders of magnitude, enabling many simulations to be performed.

RESULTS

The simulations provided spatiotemporally resolved maps of thrombin concentration throughout the LA, showing that it peaks inside the LAA. Coagulation metrics based on peak LAA thrombin dynamics suggested patients could be classified as having no, moderate or high thromboembolic risk. High-risk patients had slower flows and higher residence times in the LAA than those with moderate thromboembolic risk, and they required stronger factor XI/XII inhibition to prevent thrombin growth. These data suggest that the anticoagulation effect was also related to the LAA hemodynamics.

CONCLUSION

The methodology outlined in this study has the potential to enable personalized assessments of coagulation risk and to tailor anticoagulation therapy by analyzing flow dynamics in patient-derived LA models, representing a significant step towards advancing the application of digital twins in cardiovascular medicine.

Association of Handgrip Strength with Diabetes, Hypertension, and Comorbidities in a Korean Population: A Large-Scale Cross-Sectional Study

Background: Handgrip strength (HGS) is strongly associated with hypertension (HTN), diabetes mellitus (DM), and HTN and DM comorbidity (HDC). However, no studies have simultaneously examined anthropometric and absolute/relative HGS indices among HTN, DM, and HDC patients. The objective of this study was to examine the associations of anthropometric and HGS indices with HTN, DM, and HDC. Methods: For this large-scale cross-sectional study, we used a dataset from the Korea National Health and Nutrition Examination Survey. The study population included 15,343 participants aged 50 years and older. Complex sample binary logistic regression was used to examine the associations of each disease with the anthropometric and HGS indices in crude and adjusted models. Results: The prevalence of HTN, DM, and HDC in the study population was 35.1%, 8.6%, and 14.4% in men and 34.7%, 5%, and 11.8% in women, respectively. In men, the indices with the strongest associations with HTN, DM, and HDC were body mass index, waist circumference, and waist-to-height ratio. Among women, body mass index and waist-to-height ratio had the strongest associations with HTN. Waist circumference and waist-to-height ratio had the strongest associations with DM. Waist-to-height ratio had the strongest associations with HDC. Additionally, the relative HGS indices were more strongly associated with these diseases than the absolute HGS indices. Conclusions: HGS indices were associated with HTN, DM, and HDC, but compared with the absolute HGS index and relative HGS indices, anthropometric indices were more strongly associated with these diseases in the Korean population.

Design and rationale of the multicenter randomized clinical trial (REVERSE): Efficacy and safety of rivaroxaban in the early postoperative period for patients with bioprosthetic valve replacement or valve repair

BACKGROUND

Rivaroxaban, a Non-vitamin K oral anticoagulant (NOAC), is extensively employed for patients at heightened risk of thrombosis, including those with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). However, to date, there is a lack of robust clinical data to explore the efficacy and safety of rivaroxaban in thromboprophylaxis during the early postoperative period (<6 months) in patients following surgical bioprosthetic valve (BPV).

METHODS

The REVERSE trial is a prospective, multicenter, non-inferior, randomized controlled trial enrolling a planned 250 patients in China. Patients are randomly assigned 1:1 to receive rivaroxaban (20 mg once daily) or dose-adjusted warfarin (target international normalized ratio 2.0-3.0) for 6 months. The primary outcome is defined as the composite of all-cause death, major cardiovascular events, or major bleeding. The safety outcome is all bleeding events defined by the International Society on Thrombosis and Haemostasis (ISTH).

CONCLUSIONS

The REVERSE trial stands as the inaugural multicenter study dedicated to evaluating the efficacy and safety of rivaroxaban for early postoperative anticoagulation in BPV surgery patients. Its findings are anticipated to contribute pivotal evidence regarding the clinical advantages of NOACs.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT06476301.

Dangerousness Index in Forensic Psychiatric Examination: A Tool for Aiding Medical Decision Regarding the Risk of Antisocial Acts

Background and Objectives: The assessment of dangerousness and risk of recidivism are crucial aspects of forensic psychiatric evaluations, influencing therapeutic and security measures. This study aimed to develop and validate a new tool, the Dangerousness Index in Forensic Psychiatry (IPPML), following a psychometric scale construction methodology. Materials and Methods: The sample consisted of 261 participants (157 males, 104 females) aged 19-75 years, divided into an experimental group (n = 126) with a history of forensic psychiatric examination and a control group (n = 135) diagnosed with schizophrenia. Results: Exploratory factor analysis revealed two factors, Performance and Social, explaining 45.55% of the data variance. The IPPML demonstrated adequate internal consistency (α = 0.881) for the entire sample, with Factor 1 showing strong consistency (α = 0.896) and Factor 2 exhibiting acceptable consistency (α = 0.628). Reliability ranged from 89.6% to 62.8% when administered to participants with psychoses undergoing forensic psychiatric evaluation, decreasing to 42.5% for legally evaluated patients and increasing from 58.7% to 84.3% for participants with schizophrenia without forensic psychiatric evaluation. Discriminant validity analysis indicated higher psychiatric dangerousness with forensic implications in males. Conclusions: The IPPML shows promise as a tool for assessing dangerousness in forensic psychiatry and aiding medical decision-making regarding the risk of antisocial and potentially harmful acts.

Rationale and design of the anticoagulant therapy after left atrial appendage closure (ATLAAC) trial

INTRODUCTION

Left atrial appendage closure (LAAC) has become a recommended addition to oral anticoagulation for patients with atrial fibrillation, who undergo cardiac surgery. The procedure significantly reduces the risk of stroke and systemic arterial embolism, potentially making oral anticoagulation (OAC) unnecessary or even harmful, when considering the associated increased risk of bleeding. This publication describes the rationale and design of a randomized trial, testing the hypothesis that stopping OAC is noninferior to continuing OAC after surgical LAAC in terms of the primary endpoint.

METHODS

The ATLAAC trial is a multicenter, randomized, controlled trial, aiming to enroll 1,220 patients with atrial fibrillation, who have undergone surgical LAAC and remain on OAC. A cardiac CT scan is performed to confirm success of the LAAC. Patients with successful closure are randomized to stop or continue OAC. The primary endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or major bleeding over an expected mean follow-up of 4 years. Secondary endpoints include all-cause mortality, cardiovascular mortality, any bleeding leading to hospitalization, blood transfusion, venous thromboembolism, myocardial infarction, and quality of life measures.

TRIAL STATUS

Enrollment for the ATLAAC trial began in March 2024. As of January 18th, 2025, 554 patients have been enrolled in the study and 319 patients have been randomized. Recruitment is expected to continue for approximately 12 months. Follow-up will be stopped once 128 primary endpoints have occurred.

CONCLUSIONS

The ATLAAC trial will evaluate the safety of stopping OAC after surgical LAAC.

TRIAL REGISTRATION NUMBER

EU-CT: 2022-502986-92-00, clinicaltrials.gov ID: NCT06401616.

Anticoagulation in device-detected atrial fibrillation: Challenges in stroke prevention and heart failure management

Atrial fibrillation (AF), the most common cardiac arrhythmia globally, contributes significantly to morbidity and mortality. With advancements in implantable devices like pacemakers, defibrillators, and loop recorders, incidental detection of AF as device-detected AF (DDAF) or subclinical AF (SCAF) has become common. This asymptomatic AF presents unique management challenges, particularly in anticoagulation decisions for stroke prevention. Evidence from recent trials, notably NOAH-AFNET 6 and ARTESiA, indicates a complex risk-benefit profile for anticoagulation in DDAF. In ARTESiA, anticoagulation modestly reduced stroke and systemic embolism rates, though this effect did not reach statistical significance. The NOAH-AFNET 6 trial found no significant reduction in a composite of cardiovascular death, stroke, or systemic embolism with anticoagulation compared to placebo. Both trials revealed an increased bleeding risk, underscoring the need to carefully weigh stroke prevention against bleeding risks in DDAF. The 2024 European Society of Cardiology guidelines reflect this nuanced approach by advocating a tailored, risk-based strategy. Emerging evidence also shows that AF burden impacts heart failure (HF) outcomes, with a five-fold increase in HF hospitalizations associated with higher AF burden. This highlights the importance of rhythm or rate control to reduce HF progression, particularly in patients with both AF and HF, where reducing AF burden is associated with better prognosis and fewer hospitalizations. Future research should focus on refining anticoagulation strategies, especially for patients with low AF burden, and exploring novel approaches like intermittent anticoagulation and advanced monitoring to support personalized DDAF management.

Effect of the frequently used antiepileptic drugs carbamazepine, gabapentin, and pregabalin on the pharmacokinetics of edoxaban and other oral factor xa inhibitors in healthy volunteers

Purpose

Pregabalin, gabapentin, and carbamazepine, a potent inducer of cytochrome P450 (CYP) 3A4 and P-glycoprotein, are frequently used antiepileptic drugs that are often administered together with factor Xa inhibitors (FXaI). We aimed to investigate whether potentially clinically relevant drug-drug interactions occur with these combinations.

Methods

In an open-label fixed-sequence trial in 36 healthy volunteers, we evaluated the pharmacokinetics of 60 mg edoxaban and of a microdosed FXaI cocktail (25 µg apixaban, 50 µg edoxaban, and 25 µg rivaroxaban) before and during treatment with carbamazepine (12 evaluable volunteers, individually dosed to therapeutic concentrations), gabapentin (11 volunteers, titrated to 3 × 400 mg/d), and pregabalin (12 volunteers, titrated to 2 × 300 mg/d). The antiepileptics were dosed to steady-state and the CYP3A activity was evaluated by assessing the pharmacokinetics of microdosed midazolam (30 µg).

Results

Carbamazepine reduced the area under the plasma concentration-time curve (AUC ∞ ) of 60 mg edoxaban by a factor of 0.48 (geometric mean ratio (GMR) with 90% CI (0.41-0.56); p < 0.0001) and Cmax by a factor of 0.47 (0.34-0.66) and reduced the exposure of the edoxaban metabolite M-4 to a similar extent. Carbamazepine also decreased the exposure (AUC ∞ ) of microdosed apixaban, edoxaban, and rivaroxaban by a factor of 0.66, 0.59, and 0.56, respectively. Gabapentin and pregabalin did neither affect the exposure of 60 mg edoxaban nor the exposure of any microdosed FXaI.

Conclusion

Carbamazepine decreased FXaI exposure to a clinically relevant extent and dose adjustment may be required to maintain an adequate anticoagulant effect, whereas gabapentin and pregabalin do not require dose adjustment of FXaI.

Dementia-related adverse events associated with direct oral anticoagulants use: a real-world, pharmacovigilance study based on the FAERS database

BACKGROUND

Direct oral anticoagulants (DOACs) are commonly used to prevent and treat thromboembolic diseases. This study aimed to assess and compare dementia related adverse events (AEs) associated with DOACs.

RESEARCH DESIGN AND METHODS

AEs related to DOACs from January 2014 to June 2023 were extracted from the FDA Adverse Event Reporting System (FAERS) database. Disproportionality analysis methods, including reporting odds ratio (ROR), proportional reporting ratio, Bayesian Confidence Propagation Neural Network, and Multi-Item Gamma Poisson Shrinker, were used to evaluate the association between DOACs and dementia-related AEs.

RESULTS

There were 12,692,968 AEs reported in FAERS after deduplication. Among these, 165, 206, 1574, and 12 dementia-related AEs that were attributed to dabigatran, rivaroxaban, apixaban, and edoxaban, respectively. Apixaban showed the strongest association with dementia-related AEs (ROR 7.66, 95% confidence interval (CI) 7.27-8.06), while rivaroxaban had the lowest ROR (0.95, 95%CI 0.83-1.09). Women exhibited higher RORs for all DOACs, with apixaban showing the most significant correlation. Subgroup analysis indicated a significant link between apixaban and dementia, dementia Alzheimer's type and senile dementia.

CONCLUSIONS

Apixaban appears most associated with dementia-related AEs among DOACs, whereas rivaroxaban poses a lower risk. Further research is needed to validate these findings through large-scale prospective studies.

Cardiac symptoms in patients 3-6 months after contracting COVID-19- data from the polish STOP-COVID registry

BACKGROUND

Common complaints of long COVID patients are cardiac symptoms such as fatigue, weakness, and a feeling of palpitations. The study aimed to investigate the clinical features of patients with persistent cardiological symptoms occurring within 3 to 6 months after COVID-19. Differences in ambulatory blood pressure monitoring (ABPM), Holter ECG (electrocardiogram) and Echocardiography between people with and without persistent cardiological symptoms were evaluated. We also assessed whether the symptoms of anxiety and depression may be implicated in the clinical outcomes.

MATERIALS AND METHODS

This was a retrospective study of patients affiliated with the STOP-COVID registry who attended a follow-up visit 3-6 months after undergoing COVID-19. The visit assessed the clinical symptoms present and performed tests: ABPM, Holter ECG and Echocardiography. 504 patients additionally had GAD-2 (Generalized Anxiety Disorder 2-item) and PHQ-2 (Patient Health Questionnaire-2) tests performed.

RESULTS

The analysis included 1080 patients. At least 1 of the analyzed symptoms was present in 586 patients (54.3%). The most common symptom was fatigue (38.9%). Comparing patients with or without palpitations showed that the mean value of ventricular extrasystole was higher in the former group (p = 0.011). Comparing patients with and without cardiac symptoms, there were differences in the mean values of the PHQ-2 (p = 0.022) and GAD-2 (p < 0.001) scales, as well as in the percentage of responses related to the risk of anxiety or depression.

CONCLUSION

Cardiological symptoms are common among health issues that patients must face after contracting COVID-19. People with palpitations had more excessive ventricular extrasystoles than patients without these symptoms.

TRIAL REGISTRATION

Our retrospective study was based on analysis of medical data of patients with COVID-19 treated on out-patient basis in the STOP-COVID registry of the Polish Long-Covid Cardiovascular (PoLoCOV-CVD) study (ClinicalTrials.gov identifier- NCT05018052, the registration date 29.05.2020). Consent to conduct the study was obtained from the Bioethics Committee of the District Medical Chamber in Lodz (no. KB-0115/2021).

Letter to the editor on "Is synovectomy still of benefit today in total knee arthroplasty with rheumatoid arthritis"

We study Hernigou P's paper "Is synovectomy still of benefit today in total knee arthroplasty with rheumatoid arthritis?" It highlights the need for further research and progress in this field. Future studies should address limitations like small sample sizes, inadequate patient stratification, lack of quantifiable metrics for synovectomy extent, and limited early postoperative analyses to provide stronger evidence for clinical practice.

Clinical characteristics, adherence to anticoagulation therapy and prognosis in patients with atrial fibrillation: a real-life study

BACKGROUND

Atrial fibrillation (AF) is a prevalent tachyarrhythmia, and a comprehensive understanding of its clinical features is essential for optimizing therapeutic management. However, the unregulated use of anticoagulants in AF remains a concern, as their efficacy and safety profiles are not yet fully understood.

METHODS

Data from AF patients were collected in 2013, 2018, and 2023. First, cross-sectional data on AF patients were gathered during each period to longitudinally evaluate long-term trends in AF characteristics and the progression of anticoagulation therapy. Additionally, predictors of non-regulated dosing of oral anticoagulants (OAC) were analyzed. Second, patients with non-valvular atrial fibrillation (NVAF) were prospectively followed for 24 and 60 months with different NOAC doses to assess the risk of clinical outcome events and to analyze independent risk factors for clinical outcomes.

RESULTS

This study included 2825 AF patients, with 394 patients undergoing longitudinal follow-up. Paroxysmal AF (49.70%) and non-valvular atrial fibrillation (NVAF) (86.30%) were the most prevalent forms with advanced age being a prominent characteristic. Independent predictors of unregulated NOAC use included age, renal insufficiency, BMI, diabetes, hypertension, and bleeding risk. At the 24-month follow-up, patients who received overdosed NOAC exhibited a higher mortality rate compared to those who were inappropriately underdosed (18.75 vs.10.92 events/patient-year, P = 0.017). At the 60-month follow-up, both all-cause mortality (10.00 vs. 6.49 events per patient-year, P = 0.019; 10.00 vs. 6.21 events per patient-year, P = 0.005) and the composite endpoint event rate (12.50 vs. 9.61 events per patient-year, P = 0.017; 12.50 vs. 9.32 events per patient-year, P = 0.013) were significantly higher in the overdosing group compared to standard and underdosing groups. Age and anemia were identified as risk factors for all-cause mortality, while renal insufficiency was associated with an increased risk of composite endpoint events.

CONCLUSION

AF remains a major disease burden, especially in elderly patients. For Asians, NOAC underdosing was still effective in preventing stroke, but its efficacy and safety need to be further validated through larger-scale clinical trials. Meanwhile, overdosing of NOAC should be avoided.

CLINICAL TRIAL NUMBER

Not applicable.

Geographic and Racial Variation in Oral Anticoagulant (OAC) Treatment Among Commercially Insured Patients with Non-valvular Atrial Fibrillation (NVAF) in the United States

BACKGROUND

Oral anticoagulants (OACs) are recommended for stroke reduction in non-valvular atrial fibrillation (NVAF). OAC use has been studied in Medicare populations, but data for younger, commercially insured populations are limited.

OBJECTIVE

This retrospective study aimed to describe the geographic variation of OAC use among commercially insured patients with NVAF at high risk of stroke (CHA2DS2-VASc score ≥ 2) in the USA.

METHODS

Geographic variation was assessed by 3-digit zip code and race among patients identified from the Komodo Health commercial database with a diagnosis of NVAF between January 1, 2016, and August 31, 2021. Continuous health plan enrollment for ≥ 12 months before and 12 months after the NVAF diagnosis was required.

RESULTS

A total of 619,111 patients with NVAF at high risk for stroke were identified, of whom approximately 50% were not treated with OACs. Of the half who received OACs, almost 85% received direct OACs (DOACs) and 15% received warfarin therapy. Overall, the highest untreated rates were observed in the South and West US regions, followed by the Midwest, then the Northeast. The highest DOAC treatment rates were in the Northeast for White patients and in the North and South for Black patients. The highest warfarin treatment rates were in the upper Midwest for White patients and the Midwest for Black patients.

CONCLUSIONS

This study may help guide the identification of areas to target interventions to improve treatment rates and confirm prior findings of geographic and racial variations of OAC use in NVAF.

Safety of edoxaban for delayed bleeding in gastrointestinal endoscopic procedures with a high risk of bleeding

Objectives

There are limited reports on the safety of gastrointestinal endoscopic procedures in individuals taking edoxaban, one of the direct oral anticoagulants. We clarified the incidence of delayed bleeding in patients who were on edoxaban in the perioperative period of gastrointestinal endoscopic procedures with a high risk of bleeding.

Methods

This was an investigator-initiated, single-center, open-label, prospective, single-arm study. Patients on warfarin or edoxaban undergoing endoscopy with a high risk of bleeding were enrolled from June 2018 to September 2021. Warfarin was replaced with edoxaban in patients on warfarin. Patients taking other direct oral anticoagulants, and antiplatelet drugs, were excluded. The primary endpoint was severe delayed bleeding (Common Terminology Criteria for Adverse Events [CTCAE] grades III-V) and the secondary endpoints included thromboembolism, all adverse events, any delayed bleeding (CTCAE grades I or II), and hospital stay durations.

Results

Twenty-one patients on edoxaban underwent high-risk endoscopy. Three cases (14%) experienced CTCAE grade III delayed bleeding, requiring endoscopic hemostasis. No CTCAE grade I-II delayed bleeding or thromboembolic events occurred. Cholangitis and aspiration pneumonia (conservatively treated) occurred during the hospital stay. The median length of hospital stay was 8 days (range 3-24 days). Patients with delayed bleeding had higher systolic blood pressure at admission and longer hospital stays.

Conclusions

The delayed bleeding incidence in high-risk endoscopic procedures for patients on edoxaban was acceptable. Higher blood pressure may be associated with increased risk, but further research is needed.

ECG-based machine learning model for AF identification in patients with first ischemic stroke

BACKGROUND

The recurrence rate of strokes associated with atrial fibrillation (AF) can be substantially reduced through the administration of oral anticoagulants. However, previous studies have not demonstrated a clear benefit from the universal application of oral anticoagulants in patients with embolic stroke of undetermined source. Timely detection of AF remains a challenge in patients with stroke.

AIM

This study aims to develop a convolutional neural network (CNN) model to accurately identify patients with AF using a 12-lead sinus-rhythm electrocardiogram (ECG) recorded around the time of the first ischemic stroke. In addition, this study also evaluates the model's ability to predict future occurrence of AF.

METHODS

A CNN model was trained with ECG data from patients at Taipei Veterans General Hospital. External validation was performed on ischemic stroke patients from National Taiwan University Hospital. The model's performance was assessed for detecting AF at the stroke event and predicting future AF occurrences.

RESULTS

The model demonstrated an area under curve (AUC) of 0.91 for internal validation and 0.69 for external validation in identifying AF at the stroke event, with sensitivity and negative predictive value both achieving 97%. Kaplan-Meier survival analysis of patients without a prior diagnosis of AF revealed a significant increase in future AF incidence among the high-risk group identified by the model (adjusted hazard ratio: 4.06; 95% confidence interval: 2.74-6.00).

CONCLUSIONS

The CNN model effectively identifies AF in stroke patients using 12-lead ECGs and predicts future AF events, facilitating early anticoagulation therapy and potentially reducing recurrent stroke risk. Further prospective studies are warranted to confirm these findings.

Apixaban Dose in Patients With Atrial Fibrillation and Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary Intervention: Insights From AUGUSTUS

BACKGROUND

Studies have demonstrated the safety and efficacy of reducing the dose of apixaban from 5.0 mg to 2.5 mg twice daily in patients with atrial fibrillation (AF) and ≥2 dose-reduction criteria (age ≥80 years, body weight ≤60 kg, serum creatinine ≥1.5 mg/dL). However, data on reduced dose apixaban in patients with AF and acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) are limited.

OBJECTIVES

The authors aimed to assess clinical outcomes, including bleeding and death/ischemic events, according to apixaban dose in AUGUSTUS.

METHODS

In AUGUSTUS, 4,614 patients with AF and/or recent ACS or PCI on a P2Y12 inhibitor were randomized to open-label apixaban or vitamin K antagonist (VKA) and blinded aspirin or placebo for 6 months. Apixaban dose was determined by investigators following the apixaban label. We assessed outcomes, including major/clinically relevant nonmajor bleeding and death/ischemic events, among patients who appropriately received reduced dose apixaban, inappropriately received reduced dose apixaban, and appropriately received standard dose apixaban compared with VKA.

RESULTS

Of 2,290 patients assigned apixaban, 229 (10%) received reduced dose apixaban and 98 (43%) of those met dose-reduction criteria. Among patients receiving appropriately reduced, inappropriately reduced, and standard dose apixaban, rates of major/clinically relevant nonmajor bleeding were 13.7%, 10.5%, and 11.0%; rates of death or ischemic events were 12.2%, 12.3%, and 5.7%. When comparing the risk of clinical outcomes in the 3 groups (appropriately reduced, inappropriately reduced, and standard dose apixaban) vs matched patients receiving VKA, we found that patients receiving apixaban had more favorable outcomes than those receiving VKA, without significant interaction (P > 0.20 across all 3 groups and all outcomes).

CONCLUSIONS

Of the ∼10% of patients in AUGUSTUS who received reduced dose apixaban, less than one-half met the dose-reduction criteria. In patients with AF and recent ACS or PCI, appropriately reduced dose apixaban was associated with a lower risk of bleeding and similar rates of ischemic outcomes compared with VKA, similar results were found with standard dose apixaban. (A Study of Apixaban in Patients With Atrial Fibrillation, Not Caused by a Heart Valve Problem, Who Are at Risk for Thrombosis [Blood Clots] Due to Having Had a Recent Coronary Event, Such as a Heart Attack or a Procedure to Open the Vessels of the Heart; NCT02415400).

Comparison of the Latest ESC, ACC/AHA/ACCP/HRS, and CCS Guidelines on the Management of Atrial Fibrillation

The introduction of evidence-based and structured guidelines has undoubtedly improved the care of cardiologic patients and in many cases simplified decision-making for the treatment team. The European Society of Cardiology in collaboration with the European Association for Cardio-Thoracic Surgery, the American College of Cardiology, the American Heart Association, the American College of Clinical Pharmacy, and the Heart Rhythm Society, and the Canadian Cardiovascular Society/Canadian Heart Rhythm Society have developed guidelines for the management of patients with atrial fibrillation. Because all 3 guidelines refer to almost the same scientific data, their recommendations are undoubtedly largely in agreement. Nevertheless, there are some interesting differences based on different interpretations of the same study, different publication dates, or differences in local conditions and health care resources. The following article aims at lining out these similarities and differences.

Prescriptions of CYP3A4- and P-gp inducers for patients on direct oral anticoagulants: Bridging the gap between epidemiology and patient management for optimal thromboembolic event prevention

Direct oral anticoagulants (DOACs) are frequently used for the treatment and prevention of ischaemic stroke in patients with non-valvular atrial fibrillation. Compared to vitamin K antagonists, DOACs have significant advantages, although their drug-drug interaction (DDI) profile may complicate drug efficacy and safety. This narrative review addresses the clinical challenges posed by these DDIs and the potential pharmacological alternatives and monitoring strategies available. A PubMed search was conducted (1 January 2000-31 December 2023) including human DDI studies on DOAC use and CYP3A4/P-gp inducers in adult patients, evaluating patient outcome data and recommendations for DDI management. Twenty-two studies were included. Case reports (n = 6) indicated that antiepileptic drugs such as carbamazepine, phenobarbital and phenytoin may be associated with thromboembolic events. The nested case-control studies (n = 2) and cohort studies (n = 9) found that co-administration of DOACs and CYP3A4/P-gp inducers, particularly carbamazepine and phenytoin, increased the risk of thromboembolic events. Pharmacovigilance database analyses indicated a significant association between DOAC DDIs and increased reported stroke rates. Management recommendations in systematic reviews (n = 5) highlighted monitoring when DOACs were combined with inducers. Strategies included using alternative drugs with a weaker or preferentially absent inducing profile. Limited evidence suggests that edoxaban may be an acceptable option in case of DOAC and CYP3A4/P-gp inducer interactions; however, robust clinical data confirming safety are needed. Present literature indicates a higher thromboembolic risk in patients on DOAC treatment combining CYP3A4- and/or P-gp inducers. DOAC management should be tailored to the individual patient through collaboration between expert healthcare professionals.

Characterization and anticoagulation treatment patterns of hospitalized patients with nonvalvular atrial fibrillation in Spain: The CARISMA registry

Background

This study described the clinical and demographic characteristics of hospitalized patients with nonvalvular atrial fibrillation (NVAF) and prescriptions for vitamin-K antagonists (VKA) and direct-acting oral anticoagulants (DOAC) in Spain.

Methods

This was an observational, multicentric, retrospective study of patients treated with DOAC or VKA due to NVAF at cardiology services of hospitals in Spain. A registry (CARISMA) included patients hospitalized for any reason and discharged before July 1st, 2021, with a prescription for DOAC or VKA. Data was collected on demographic and clinical characteristics and anticoagulant treatments prescribed. Analyses were descriptive.

Results

A total of 1,041 patients were included. Mean age (SD) was 77.2 (10.3) years and 57.6 % were men. The most frequent reason for hospital admission was heart failure (43.8 %) and arrhythmias (25.0 %). The mean (SD) CHA2DS2-VASc score was 4.0 (1.6). Prior to admission, 75.6 % of patients had been prescribed anticoagulant treatment for NVAF. Of these, 56.0 % had received VKA and 44.0 % DOAC. At discharge, 60 % had a DOAC prescription (of these, apixaban, 37.6 %; edoxaban, 26.4 %; rivaroxaban, 25.1 %; dabigatran, 10.9 %) and 40 % a VKA. DOAC prescriptions were off-label with respect to dosing in 19-34 % of cases. Patients with off-label dosing were older and with a higher proportion of women than those with on-label doses. During hospitalization, 12.1 % of patients changed treatment, usually VKA to DOAC.

Conclusion

Before hospitalization, a quarter of patients with NVAF were not receiving anticoagulation medication. Hospitalization increased the proportion of patients receiving DOAC, but about a quarter of patients had off-label dosing prescriptions.

Post COVID-19 infection and quality of life of healthcare workers at Sahloul University Hospital of Sousse in Tunisia

BACKGROUND

Since the COVID-19 pandemic, health care workers (HCWs) faced an enormous physical and mental burden, sometimes altering their quality of life due mainly to persistent challenges stemming from their frontline position.

AIMS

Todetermine the prevalence of post-COVID-19 syndrome, and its impact on the Health-Related Quality of Life (HRQoL) among HCWs.

METHODS

This is an exhaustive cross-sectional study with analytical scope, conducted among all HCWs of the University Hospital Sahloul of Sousse, Tunisia, who have contracted COVID-19 between September 2020 and 30 March 2021 (N=529 cases).The post-covid medical check-up was carried out three months after the acute phase of the COVID-19 infection (December 2020 to June 2021). HRQoL was assessed using the SF-12 (12-item Short Form Health Survey) questionnaire. Bivariate study and multiple linear regressions were performed to identify the different factors influencing the quality of life of HCWs.

RESULTS

During the study period, 529 HCWs were diagnosed with SARS CoV-2 infection, out of them 249 participants were included (47% participation rate). Post covid-19 syndrome was reported in 65% of cases. A low overall quality of life (QoL) score was reported in 28.6% of cases. Low physical and mental composite scores were reported in 34.3% and 29.4% of cases respectively. In the multiple linear regression analysis, gender, post COVID-19 syndrome and time off work were significantly associated with SF12 scores.

CONCLUSION

In our study, HCWs experienced a significant deterioration in HRQoL after COVID-19 with a high incidence of post-COVID-19 syndrome. The need of long-term follow-up after SARS-CoV-2 infection remains essential to support HCWs and mitigate long-term impacts.

Associations of COVID-19 vaccination with risks for post-infectious cardiovascular complications: an international cohort study in cancer patients with SARS-CoV-2 infection

Background

Whether COVID-19 vaccination is associated with risks for cardiovascular complications after SARS-CoV-2 infection in patients with cancer is unknown. The objective of this study was to investigate the associations between the two.

Methods

This registry (COVID-19 and Cancer Consortium)-based retrospective cohort study included patients with laboratory-confirmed SARS-CoV-2 infection from the United States, Canada, and Mexico between April 2021 and December 2022. Patients without COVID-19 vaccination were assigned to the unvaccinated group and patients with ≥2 doses of COVID-19 vaccination were assigned to the fully-vaccinated group. The primary outcome was a composite of post-infectious cardiac complications, including acute myocardial infarction, other ischemic heart disease, atrial fibrillation, ventricular fibrillation, other arrhythmias, cardiomyopathy, and congestive heart failure. The secondary outcome was a composite measure of post-infectious cardiovascular events, comprising of the cardiac complications along with pulmonary embolism, deep vein thrombosis, superficial vein thrombosis, other thrombosis, and cerebrovascular stroke. Multivariable logistic regression was used for data analysis.

Findings

A total of 2729 patients were included for analyses, with 1382 in the unvaccinated group and 1347 in the fully-vaccinated group. The median age of the study population was 65 (interquartile range (IQR), 55-74) years. Overall, 1534 (56.0%) were women; 1272 (47%) were never smokers; 1639 (60%) were not obese; 2043 (75%) had stable cancer, and 446 (16%) took anticoagulants at baseline. The primary and secondary analyses showed lower risks of cardiac complications and cardiovascular events in the fully-vaccinated group, with adjusted odds ratios (aOR) of 0.66 (95% confidence interval (CI), 0.48-0.89) and 0.76 (95% CI, 0.59-0.99), respectively. The protective trend with COVID-19 vaccination was observed across infections with different dominant SARS-CoV-2 strains and in patients with or without anticoagulant use.

Interpretation

COVID-19 vaccination was associated with a reduced risk of cardiac complications and cardiovascular events by 34% and 24%, respectively, after SARS-CoV-2 infection in patients with cancer.

Funding

National Institutes of Health USA; National Science and Technology Council of Taiwan.

Pericardial Effusion Associated With Direct Oral Anticoagulant Use in a Single Center Experience

BACKGROUND

Pericardial effusion (PEff) has been described to occur in association with direct oral anticoagulant (DOAC).

OBJECTIVES

The purpose of this study was to assess the incidence, characteristics, and predisposing factors of PEff associated with DOACs.

METHODS

In this retrospective single center study, multivariable logistic regression analysis was used to identify factors associated with PEff in adult patients (age ≥18 years) in the Santa Clara Health System between 2013 and 2023.

RESULTS

Of the 456 patients with at least small to moderate PEff, 50 were on DOACs (DOAC PEff), 16 on warfarin (warfarin PEff), and 390 with no anticoagulation (NA PEff), with annual incidence 0.069%, 0.047%, and 0.001% for DOAC, warfarin, and NA PEff, respectively. Twenty-five (50%) of the DOAC PEff cases had moderately large or large PEff. Twenty-one cases underwent either percutaneous or surgical drainage. The DOAC PEff patients were significantly older and with more concurrent use of amiodarone. Logistic regression identified the following factors associated with moderately large or large PEff: DOAC (OR: 2.28; 95% CI: 1.19-4.37), warfarin (OR: 5.50; 95% CI: 1.88-16.06), concurrent use of amiodarone (OR: 4.32; 95% CI: 1.46-12.78), and presence of solid tumor (OR: 2.06; 95% CI: 1.25-3.39).

CONCLUSIONS

This is the largest single center case series of DOAC PEff, with annual incidence higher than previously reported. Future research is needed to study the pharmacokinetic interactions between DOACs and commonly co-prescribed drugs as well as the cost-effectiveness of enhanced surveillance of PEff in those with solid cancer while on DOACs.

Oral Anticoagulation for Atrial Fibrillation in Octogenarians Across the Renal Function Spectrum

PURPOSE

Our study aimed to describe the efficacy and safety of oral anticoagulation (OAC) use in octogenarians with atrial fibrillation (AF) across the spectrum of renal function.

METHODS

Data for this study were sourced from AF Research Database (NCT03760874). AF patients aged ≥ 80 who received OAC treatment, both direct oral anticoagulant (DOAC) and vitamin K antagonist (VKA) were selected. Participants were categorized in 2 groups according to creatinine clearance (CrCl) ≥ 45 and < 45 ml/min/1.73 m2. The primary safety outcome was the occurrence major bleeding. The primary effectiveness outcome was the occurrence of thromboembolic events.

RESULTS

A total of 901 AF patients (median age 84 [4.9] years; 44% men) with age ≥ 80 years on treatment with DOACs (n: 629, 70%) and VKA (n: 272, 30%) were included in the study. 303 patients (34%) had CrCl < 45 ml/min/1.73m2 and 598 (66%) had CrCl ≥ 45 ml/min/1.73m2. No significant differences were shown in major bleedings, minor bleedings and thromboembolic events between patients on DOACs vs VKAs, both in the group with CrCl ≥ 45 than < 45 ml/min. In the group with CrCl < 45 ml/min/1.73 m2, a total of 72 patients (23%) died during the follow-up, with higher mortality in VKA group compared to DOACs (45% vs 15%; p < 0.001). At multivariate regression analysis, age [OR: 1.15; p = 0.001] and coronary artery disease (CAD) [OR: 1.74; p = 0.04] were independently associated with mortality; in contrast, the use of DOACs were inversely associated with mortality [OR = 0.26; p < 0.001]. In patients with CrCl ≥ 45 ml/min/1.73 m2, DOACs group experienced less intra-cranial hemorrhage (ICH) (0.2% vs 2.8%; p = 0.01) compared to VKAs. VKAs patients showed higher mortality compared to those on DOACs (29.1% vs 7.9%; p < 0.001). At multivariate regression analysis, chronic heart failure [OR = 2.14; p = 0.01] was independently associated with death, whereas male gender [OR: 0.45; p = 0.009] and the use of DOACs [OR: 0.29; p < 0.001] were associated with lower mortality.

CONCLUSION

DOACs seem to be safe and effective in octogenarians with chronic kidney disease at stage ≥ G3b. As compared with VKA administration, the use of DOACs was associated with lower mortality rates among AF octogenarians with renal dysfunction.

Long-term visit-to-visit blood pressure variability and risk of cardiovascular and bleeding events: insights from the ENGAGE AF-TIMI 48 trial

This post hoc analysis of the ENGAGE AF-TIMI 48 trial assesses differences in cardiovascular and bleeding events according to visit-to-visit blood pressure variability (BPv) in 19,680 patients with a minimum of 4 blood pressure measurements post randomization. Patients were categorized into four groups based on the standard deviation of systolic blood pressure (SBP-SD). In comparisons of the fourth vs first quartile of SBP-SD adjusted for components of the CHA2D2-VASc score and baseline SBP, there were no differences in the odds of stroke, cardiovascular mortality, or all-cause mortality. However, there were statistically significant increases in the risk of major bleeding (OR 1.9, (1.6-2.25)). myocardial infarction (OR 1.42 (1.08-1.87)) and heart failure outcomes (OR 1.49 (1.3-1.72)) in the fourth quartile of BPv. This post-hoc analysis shows that BPv is independently associated with an increased risk of bleeding, MI, and heart failure outcomes in a population with AF on oral anticoagulation.

Choosing the optimal oral anticoagulant for stroke prevention in atrial fibrillation: direct oral anticoagulants vs vitamin K antagonists

Direct oral anticoagulants (DOACs) have replaced vitamin K antagonists (VKAs) for stroke prevention in many patients with atrial fibrillation, but VKAs may still be preferred in some situations. We use a case-based approach to present the evidence for the possible use of a VKA in preference to a DOAC in patients with atrial fibrillation and rheumatic mitral stenosis, high body mass index, frailty, and breakthrough stroke despite being prescribed a DOAC.

Proinflammatory and prothrombotic conditions in JAK2V617F-positive MPN: a case of Lemierre's syndrome in essential thrombocythemia

Lemierre's syndrome (LS) represents a rare yet potentially life-threatening systemic infection, characterized by thrombophlebitis of the internal jugular vein and abscess formation in distant organs. It typically follows episodes of tonsillitis or other infections of the oropharyngeal region. Pulmonary complications, including septic pulmonary emboli, are common. Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm (MPN) sometimes associated with the JAK2V617F mutation, which predisposes patients to thrombotic events. A 66-year-old male with JAK2V617F-positive ET presented with severe pulsatile pain radiating from the right temporal region to the occipital area following a recent dental infection. Although pain management was administered, the pain continued to persist. Computed tomography of the chest revealed multiple subpleural nodules, raising suspicion for septic pulmonary emboli. Further investigation with gadolinium-enhanced magnetic resonance imaging identified a thrombus extending from the right sigmoid sinus into the internal jugular vein, consistent with cerebral venous thrombosis. The patient was diagnosed with　LS, complicated by septic thrombosis. Blood cultures yielded alpha-hemolytic streptococcus. Empirical antimicrobial therapy combined with anticoagulation was initiated, resulting in a gradual improvement of symptoms, including the resolution of fever and pain. Follow-up imaging confirmed the resolution of both the infection and thrombosis. This is the first reported case of LS in a patient with JAK2V617F-positive ET. The coexistence of LS and JAK2V617F-positive MPN highlights the potential interplay between proinflammatory and prothrombotic conditions associated with the JAK2V617F mutation.

Factors influencing the cost-effectiveness of novel oral anticoagulants compared to vitamin K antagonists in patients with atrial fibrillation: a systematic review

Background

Atrial fibrillation (AF) is a common clinical arrhythmia, primarily associated with the risk of stroke and various thromboembolic events, imposing significant clinical and economic burdens on patients and societies. This study aimed to review the relevant pharmacoeconomic evaluations of novel oral anticoagulants (NOACs) compared to vitamin K antagonists (VKAs) in patients with AF and explore the influencing factors and general trends of economic evaluations.

Methods

This review qualitatively analyzed the basic characteristics, model structure, and basic results of all included studies. Moreover, a cross-sectional and longitudinal comparative analysis of costs, health outcomes, and cost-effectiveness results of studies in the United States, China, and the United Kingdom was conducted. Additionally, this study employed multivariate binary logistic regression to explore the influencing factors and general trends of the cost-effectiveness between NOACs and VKAs across all included studies.

Results

A total of 103 studies were included, comprising 218 comparisons between NOACs and VKAs. Total costs and health outcomes measured in studies with different countries and baseline characteristics exhibited considerable variations. However, NOACs generally had higher total costs than VKAs and resulted in more health outcomes for patients. The binary logistic regression analysis revealed that the country's economic development level, study perspective, and cycle length significantly influenced cost-effectiveness results.

Conclusion

In high-income countries, NOACs are generally considered cost-effective, while VKAs may remain an attractive strategy in middle- and low-income countries. Additionally, factors such as drug prices, patient baseline characteristics, and model settings could impact the costs, health outcomes, and cost-effectiveness results of studies. Conducting relevant pharmacoeconomic research based on specific populations and study contexts is essential.

Management of Atrial Fibrillation in Elderly Patients: A Whole New Ballgame?

Atrial fibrillation (AF) is the most prevalent sustained supraventricular arrhythmia, particularly in older adults, with its incidence increasing dramatically with age. This condition is a significant contributor to morbidity and mortality, being closely linked to an elevated risk of heart failure, ischemic stroke, systemic thromboembolism, and dementia. The complexities of managing AF in the elderly arise from age-related physiological changes, comorbidities, frailty, and the challenges of polypharmacy. Therapeutic strategies must balance efficacy and safety, tailoring interventions to the individual's health status, life expectancy, and personal preferences. This review explores the latest evidence-based approaches to managing AF in elderly patients, focusing on the nuanced application of rate and rhythm control strategies, anticoagulation, and emerging insights into the relationship between AF and cognitive impairment.

Antithrombotic Therapy in People with Hemophilia-A Narrative Review

As the life expectancy of individuals with hemophilia continues to increase, the complexity of balancing bleeding risks and thrombotic management has become increasingly critical in people with hemophilia with or at a high risk of thrombosis. Advances in hemophilia therapies such as extended half-life coagulation factors, non-factor therapies, rebalancing agents, and gene therapy have expanded treatment options for a variety of people with hemophilia. The thrombotic risk of people with hemophilia in general are relatively low as compared to those without hemophilia. However, antithrombotic therapy for prevention and treatment for thrombosis should still be considered in some situations, even in hemophilia. This clinical focus highlights the use of antithrombotic therapy in the management of thrombosis in people with hemophilia. A multidisciplinary, personalized approach is essential for optimizing the safety and efficacy of antithrombotic therapy in people with hemophilia with or at a high risk of thrombosis. High performance computer based multidimensional data analysis may help in establishing the personalized antithrombotic therapy in the future.

Risk-factors and multimorbidity in oral anticoagulant-related intracerebral haemorrhage: a comparison of patients in pivotal trials and real life

BACKGROUND

We hypothesised that morbidity burden was higher in real-life patients with oral anticoagulant-related intracerebral haemorrhage (OAC-ICH) than direct oral anticoagulant (DOAC) trial-life patients (pivotal trial participants) and explored if pre-stroke morbidity was comparable (i) in real-life patients on DOAC or vitamin K antagonist (VKA) with ICH, and (ii) in trial-life patients versus real-life patients with OAC-ICH.

METHODS

The COOL-ICH cohort included 401 acute, consecutive patients with OAC-ICH (272 VKA-ICH, 129 DOAC-ICH) from the Capital Region of Denmark. Risk-factors and morbidity in trial-life patients were retrieved from publications.

RESULTS

Risk-factors, CHADS2 and Charlson Comorbidity Index were comparable in DOAC vs VKA users in real-life. Pre-stroke modified Rankin Scale (mRS) was higher in DOAC users than in VKA users (median mRS 1 vs 0, P = 0.002). More DOAC users were women (53% vs 39%, P = 0.009). Compared to trial-life patients, age and proportion of women were higher in real-life patients. CHADS2-scores were comparable.

CONCLUSION

In conclusion, burden of risk-factors and comorbidities were similar in real-life patients with DOAC-ICH and VKA-ICH, as well as in real-life patients compared to trial-life patients. However, real-life patients especially those on DOAC, were older and more frequently women than trial-life patients. It is reassuring that burden of comorbidity was similar in real-life and trial-life patients. Nevertheless, this report underlines the importance of recruiting adequate numbers of older people and women to cardio-vascular trials to ensure sufficient safety data to advice prescriptions in these very prevalent sub-groups of patients.

Efficacy, safety, and bleeding risk factor analysis of oral anticoagulants in AF patients ≥ 65 years of age: a multicenter retrospective cohort study

BACKGROUND

Stroke prevention in elderly patients with atrial fibrillation (AF) is challenging and requires a balance between thromboembolic prevention and bleeding. The comparison of novel oral anticoagulants (NOACs) and warfarin in clinical practice in elderly Asian patients has not been well studied. The purpose of this study was to evaluate the efficacy and safety of NOACs versus warfarin in elderly patients with AF in conjunction with data from real-world observational studies.

METHODS

This was a retrospective multicenter cohort study conducted in 4 centers in China, where patient information and clinical events were collected through an average of 15 months of follow-up and case queries. Clinical outcomes included major bleeding, minor bleeding, total bleeding, thrombosis, and all-cause mortality.

RESULTS

A total of 3450 elderly patients with AF were enrolled. 2656 patients were treated with at least 1 NOAC (dabigatran, rivaroxaban, apixaban, or edoxaban), and 794 patients were treated with warfarin. After correcting for confounders, NOACs significantly reduced the risk of minor bleeding [OR 0.70 (95% CL, 0.49-1.01),P = 0.049] and all-cause mortality [OR 0.57( 95% CI, 0.44-0.75),P < 0.001] compared with warfarin, however, major bleeding events [OR 1.51 (95% CL, 0.98-2.42),P = 0.075] and thrombotic events [OR 0.79 (95% CL, 0.57-1.13),P = 0.187] were not significantly different. There was no heterogeneity between clinical outcomes of NOACs and warfarin in subgroup analyses of age (65-74, 75-84, ≥ 85 years), sex (male, female), BMI (≥ 25, < 25), comorbidities (including hypertension, diabetes and no hypertension, no diabetes), except in female subgroup, where NOACs significantly reduced the risk of minor bleeding [OR 0.56 (95% CL, 0.34-0.91),P = 0.018] and increased the risk of major bleeding [OR 2.28 (95% CL, 1.12-5.14),P = 0.032] compared with warfarin.

CONCLUSION

Compared with warfarin, NOACs significantly reduced the risk of minor bleeding, all-cause mortality, and there were no statistically significant differences in major bleeding or thrombotic events. NOACs were not more effective than warfarin in thrombotic and bleeding events, regardless of the subgroup analyses on age, male, BMI and comorbid hypertension and diabetes.

Natural Infection of Omicron BA.5.2 in Patients Provides Broad Immune Responses Against SARS-CoV-2

The implementation of COVID-19 policy and the rapid development of SARS-CoV-2 vaccines in the early pandemic significantly contained numerous outbreaks and reduced the severity and mortality of COVID-19. However, the population immunity induced by existing vaccines was insufficient to prevent SARS-CoV-2 outbreaks. The host immunity induced by the wide spread of Omicron variants and its influence on emerging SARS-CoV-2 variants are attracting broad attention. In this study, a clinical data analysis of the patients indicated that pre-vaccination reduced inflammatory responses and mitigated the severity of COVID-19 cases caused by natural infection with Omicron BA.5.2. The analysis of adaptive immune responses indicated that natural infection with BA.5.2 induced robust and broad immune responses, including both humoral and T cell-mediated immune responses (IFN-γ) against highly conserved viral antigens, and provided cross-reactive neutralization against various viral variants. Collectively, we report that the natural infection with Omicron BA.5.2 induced broad cross-reactive immunity against SARS-CoV-2 variants, which suggests that the development of a live attenuated SARS-CoV-2 vaccine with desired safety, high efficacy, broad spectrum, and long-term immune persistence is feasible. Therefore, we suggest that herd immunity, achieved through vaccination with attenuated vaccines, combined with booster doses of existing vaccines and antiviral therapy for people with high viral loads, may contribute to the eradication of this virus.

Antithrombotic Therapy to Minimize Total Events After ACS or PCI in Atrial Fibrillation: Insights From AUGUSTUS

BACKGROUND

Limited data exist on the optimal antithrombotic strategy to minimize total bleeding and ischemic events for patients with recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) and atrial fibrillation (AF).

OBJECTIVES

The authors sought to identify the antithrombotic regimen that minimized total major or clinically relevant nonmajor bleeding events, ischemic events, and hospitalizations after ACS or PCI in AF.

METHODS

We conducted a secondary analysis of AUGUSTUS (Open-label, 2×2 Factorial, Randomized, Controlled Clinical Trial to Evaluate the Safety of Apixaban vs Vitamin K Antagonist and Aspirin vs Placebo in Patients with Atrial Fibrillation and Acute Coronary Syndrome and/or Percutaneous Coronary Intervention), a 2×2 factorial, randomized trial evaluating apixaban vs a vitamin K antagonist (VKA) and aspirin vs placebo in patients with AF and ACS or PCI who were on P2Y12 inhibitor therapy. We determined the incidence of total major or clinically relevant nonmajor bleeding events in patients receiving at least 1 dose of study therapy, total ischemic events, and total hospitalizations among patients randomized to each antithrombotic strategy.

RESULTS

Over 6 months of follow-up, 573 of 4,568 (12.5%) patients experienced at least 1 bleeding event while on study drug; among them, 110 (19.2%) had multiple bleeding events. Compared with those with 1 bleeding event, patients with multiple bleeding events were more likely to be on a high-potency P2Y12 inhibitor (prasugrel or ticagrelor vs clopidogrel). Of the 4,614 randomized participants, 219 (4.7%) had at least 1 ischemic event, among whom 75 (34.2%) had multiple ischemic events. At least 1 hospitalization occurred in 1,125 (24.4%) patients; among them, 384 (34.1%) had multiple hospitalizations. Apixaban, compared with VKA, significantly reduced the risk of total bleeding (rate ratio [RR]: 0.66; 95% CI: 0.55-0.80). Apixaban had similar rates of total ischemic events (RR: 0.83; 95% CI: 0.58-1.20) and total hospitalizations (RR: 0.90; 95% CI: 0.79-1.03) compared with VKA. Aspirin, compared with placebo, significantly increased the risk of total bleeding (RR: 2.14; 95% CI: 1.75-2.60). The rates of total ischemic events (RR: 0.75; 95% CI: 0.52-1.08) and total hospitalizations (RR: 1.11; 95% CI: 0.97-1.27) with aspirin and placebo were similar.

CONCLUSIONS

Among patients with AF and recent ACS or PCI, apixaban significantly reduced total bleeding risk compared with VKA. Aspirin doubled total bleeding risk compared with placebo without a significant change in total ischemic events. Based on this assessment of total events, our findings support the use of apixaban plus a low-potency P2Y12 inhibitor (ie, clopidogrel) without aspirin as the standard therapy for this high-risk patient population. (A Study of Apixaban in Patients With Atrial Fibrillation, Not Caused by a Heart Valve Problem, Who Are at Risk for Thrombosis [Blood Clots] Due to Having Had a Recent Coronary Event, Such as a Heart Attack or a Procedure to Open the Vessels of the Heart; NCT02415400).

Biomarker-Based Model for Prediction of Ischemic Stroke in Patients With Atrial Fibrillation

BACKGROUND

In patients with atrial fibrillation (AF) the risk of ischemic stroke is central to recommendations for stroke-prevention treatment.

OBJECTIVES

The authors evaluated the biomarker-based Age, Biomarkers, Clinical history (ABC)-AF-stroke risk score and developed a modified ABC-AF-istroke risk score for prediction of respectively total and ischemic stroke in patients with AF.

METHODS

In 26,452 patients with AF assigned to direct oral anticoagulants (DOACs) or warfarin, information on age, clinical history of stroke, and levels of N-terminal pro B-type natriuretic peptide and troponin were used for calculation of the ABC-AF-stroke score and the modified ABC-AF-istroke score.

RESULTS

During follow-up, there were 756 cases with stroke or systemic embolism (SEE) including 534 with ischemic stroke/SEE. The discrimination of total stroke/SEE was superior for the ABC-AF-stroke score, C-index (0.667 [95% CI: 0.648-0.687]), compared with 0.632 (95% CI: 0.612-0.652) for the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) and 0.614 (95% CI: 0.594-0.633) for the CHA2DS2-VASc score (P < 0.001 for both). The results were similar for ischemic stroke/SEE with C-index for ABC-AF-istroke 0.677 (95% CI: 0.654-0.700) compared with 0.642 (95% CI: 0.618-0.666) for the ATRIA and 0.624 (95% CI: 0.601-0.647) for the CHA2DS2-VASc score (P < 0.001 for both). The ABC-AF-stroke scores showed good calibration for total and ischemic stroke. Results were consistent in relevant subgroups. Decision curve analyses showed a net benefit concerning stroke-prevention decision thresholds.

CONCLUSIONS

The biomarker-based ABC-AF risk scores for the risk of total and ischemic stroke were well calibrated, showed better discrimination than clinical risk scores in predicting total and ischemic stroke, and provided meaningful decision support for stroke-prevention treatments in patients with AF.

Modifications of the Prothrombin Active Site S4 Subpocket Confer Resistance to Dabigatran

Direct anticoagulants inhibit coagulation serine proteases by reversibly engaging their active site with high affinity. By modifying the S4 active site subpocket of factor (F)Xa, we introduced inhibitor resistance while preserving catalytic activity. Given the homology between FXa and thrombin in active site architecture and direct anticoagulant binding, we have targeted the S4 subsite to introduce inhibitor resistance in (pro)thrombin.Recombinant prothrombin variants were generated in which I174 was substituted or sequence R92-N98 was exchanged with that of human kallikrein-3.Specific prothrombin clotting activity of the variants was 6-fold (intrinsic clotting) to 10-fold (extrinsic clotting) reduced relative to wild-type prothrombin. Further analyses revealed that modification of the S4 subsite hampers fibrinogen and thrombomodulin-mediated protein C conversion by thrombin. Consistent with this, the thrombin variants displayed a reduced catalytic efficiency toward the peptidyl substrate used in thrombin generation assessments. The variants displayed a 2-fold reduced sensitivity for dabigatran relative to wild-type prothrombin, while argatroban inhibition was unaffected. Analyses using a purified component system revealed an up to 24-fold and 4-fold reduced IC50 for inhibition of thrombin by dabigatran and argatroban, respectively. Molecular dynamics (MD) simulations of both dabigatran-bound and unbound (apo) modified thrombin variants indicated these to comprise a larger inhibitor binding pocket relative to wild-type thrombin and display reduced inhibitor binding. As a net effect, (pro)thrombin variants with S4 subsite modifications supported detectable fibrin formation at therapeutic dabigatran concentrations.Our findings provide proof-of-concept for the engineering of thrombin variants that are resistant to direct thrombin inhibitors by modulating the S4 subsite.

Variability in Arterial Stiffness and Vascular Endothelial Function After COVID-19 During 1.5 Years of Follow-Up-Systematic Review and Meta-Analysis

Increasing long-term observations suggest that coronavirus disease 2019 (COVID-19) vasculopathy may persist even 1.5 years after the acute phase, potentially accelerating the development of atherosclerotic cardiovascular diseases. This study systematically reviewed the variability of brachial flow-mediated dilation (FMD) and carotid-femoral pulse wave velocity (cfPWV) from the acute phase of COVID-19 through 16 months of follow-up (F/U). Databases including PubMed, Web of Science, MEDLINE, and Embase were screened for a meta-analysis without language or date restrictions (PROSPERO reference CRD42025642888, last search conducted on 1 February 2025). The quality of the included studies was assessed using the Newcastle-Ottawa Quality Scale. We considered all studies (interventional pre-post studies, prospective observational studies, prospective randomized, and non-randomized trials) that assessed FMD or cfPWV in adults (aged ≥ 18 years) with or after laboratory-confirmed COVID-19 compared with non-COVID-19 controls or that assessed changes in these parameters during the F/U. Twenty-one studies reported differences in FMD, and 18 studies examined cfPWV between COVID-19 patients and control groups during various stages: acute/subacute COVID-19 (≤30 days from disease onset), early (>30-90 days), mid-term (>90-180 days), late (>180-270 days), and very late (>270 days) post-COVID-19 recovery. Six studies assessed variability in FMD, while nine did so for cfPWV during the F/U. Data from 14 FMD studies (627 cases and 694 controls) and 15 cfPWV studies (578 cases and 703 controls) were included in our meta-analysis. FMD showed a significant decrease compared to controls during the acute/subacute phase (standardized mean difference [SMD]= -2.02, p < 0.001), with partial improvements noted from the acute/subacute phase to early recovery (SMD = 0.95, p < 0.001) and from early to mid-term recovery (SMD = 0.92, p = 0.006). Normalization compared to controls was observed in late recovery (SMD = 0.12, p = 0.69). In contrast, cfPWV values, which were higher than controls in the acute/subacute phase (SMD = 1.27, p < 0.001), remained elevated throughout the F/U, with no significant changes except for a decrease from mid-term to very late recovery (SMD= -0.39, p < 0.001). In the very late recovery, cfPWV values remained higher than those of controls (SMD = 0.45, p = 0.010). In the manuscript, we discuss how various factors, including the severity of acute COVID-19, the persistence of long-term COVID-19 syndrome, and the patient's initial vascular age, depending on metrics age and cardiovascular risk factors, influenced the time and degree of FMD and cfPWV improvement.

Anticoagulation therapy after reperfusion treatment for acute ischemic stroke with non-valvular atrial fibrillation: a multicenter retrospective study

To understand anticoagulation therapy in acute ischemic stroke (AIS) patients with non-valvular atrial fibrillation (NVAF) after receiving reperfusion treatments in the real world. This retrospective study collected basic clinical data, the initiation time of anticoagulation therapy, treatment plans, and prognosis of AIS patients with AF who underwent intravenous thrombolysis (IVT), and/or endovascular thrombectomy (EVT) from January 2019 to January 2022 in four tertiary hospitals in Jiangxi Province. A multivariate logistic regression analysis was used to analyze the factors influencing anticoagulation therapy in these patients. The reasons for delay or non-initiation of anticoagulation therapy were analyzed by questionnaire. A total of 410 patients met the selection criteria, including 168 (41.0%) in the IVT group, 144 (35.1%) in the EVT group, and 98 (23.9%) in the IVT + EVT group. Initiation of anticoagulation therapy within 14 days post-AIS was found in 175 patients in total (42.7%), which is significantly different in three groups (49.7% in IVT group, 30.3% in EVT group, and 20.0% in IVT + EVT groups, P < 0.01). Multivariate logistic regression analysis revealed that prior use of antiplatelet drugs was more common in patients receiving early anticoagulation therapy (OR = 0.122, 95% CI 0.065-0.228, P < 0.01). Patients receiving no anticoagulation had higher-3-days post-reperfusion NIHSS score (OR = 1.109, 95% CI 1.073-1.147, P < 0.01) and more in-hospital haemorrhagic transformation (OR = 2.572, 95% CI 1.423-4.648, P < 0.01). Of all patients, 281 had a favorable 90-day prognosis (mRS score 0-2), including 152 (86.9%) in the early anticoagulation group and 129 (54.9%) in the delay anticoagulation group (P < 0.01). Postoperative 90-day outcomes included 25 (6.1%) cases of recurrent ischemic stroke (P = 0.55) and 27 (6.6%) bleeding events (P = 0.32). Early initiation of anticoagulation therapy improves 90-day outcomes in NVAF post-related AIS patients with related AF after receiving reperfusion treatments; however, the initiation of anticoagulation in most patients might be much later than the currently recommended timing in real world.

Initiation of direct oral anticoagulation after reperfusion therapy in ischemic stroke in clinical practice: Results from Sits-International Stroke Registry

INTRODUCTION

Data is limited on the safety of early initiation of direct oral anticoagulation (DOAC) treatment after acute ischemic stroke (AIS) receiving reperfusion therapy in patients with atrial fibrillation (AF). We investigated the timing of DOAC initiation and its association with safety and outcomes.

MATERIALS AND METHODS

We included AIS patients receiving reperfusion therapy with AF diagnosis (prevalent or new) registered in the Safe Implementation of Treatments in Stroke international registry during 2013-2024. Safety outcomes were hemorrhage and death. Secondary outcomes were recurrent AIS, any embolism and functional independence (modified Rankin Scale [mRS] 0-2) at 3 months. We performed descriptive statistics and multivariable analysis for DOAC initiation time as an ordinal variable (0-3, 4-7, and 8-100 days after stroke onset) and its association with outcomes. Explorative analyses were performed to investigate factors associated with DOAC initiation time, as a continuous or ordinal variable.

RESULTS

In total, 13,389 patients had data on DOAC initiation time, and 7861 patients had new event data by 3-month follow-up. We observed 0.1% intracranial hemorrhage, 0.4% major extracranial hemorrhage, 1.1% recurrent ischemic stroke, and 0.2% systemic embolism. At 3 months, 4.8% patients had died, and functional independence was seen in 60.9%. In multivariable analyses, DOAC initiation after stroke onset was not associated with any outcomes. Higher 24 h NIHSS and lower pre-stroke mRS score were associated with delayed DOAC initiation.

CONCLUSION

DOAC initiation time was not associated with any outcomes in AIS patients who received reperfusion therapy. Severe stroke symptoms at 24 h were associated with delayed DOAC initiation. The low incidence of safety outcomes and missing data in this study should lead to cautious interpretations of these results.

Obesity Class and Severity of Metabolic Emergencies: A Single-Center Retrospective Five-Year Study

Background/Objectives: This study aims to investigate the impact of obesity severity on the prevalence and outcomes of acute metabolic emergencies in the emergency department (ED) setting, with a specific focus on obesity class stratification and associated metabolic complications. Methods: This retrospective, single-center study analyzed data from 433 patients admitted to the ED of the Timisoara Municipal Emergency Hospital between January 2019 and March 2024. Patients were classified according to WHO obesity grades (Class I: BMI 30.0-34.9 kg/m2, Class II: 35.0-39.9 kg/m2, Class III: ≥ 40.0 kg/m2). The prevalence and severity of metabolic emergencies, including hyperglycemic crises, acute kidney injury (AKI), and severe electrolyte imbalances, were compared across obesity classes. Results: Obese patients (37.2%) exhibited a significantly higher prevalence of metabolic emergencies than non-obese individuals (p < 0.001). Hyperglycemia was present in 27.9% of obese patients vs. 11.0% of non-obese patients (p < 0.001). AKI incidence nearly doubled in obese patients (12.4% vs. 5.5%, p = 0.01). Logistic regression identified Class III obesity as an independent risk factor for metabolic emergencies (adjusted OR = 3.2, 95% CI: 2.1-4.9, p < 0.001). Conclusions: The severity of metabolic emergencies increases with increasing obesity class, emphasizing the need for obesity-specific risk stratification in ED settings. Routine monitoring of metabolic markers and early intervention strategies should be prioritized for high-risk obese patients.