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Wang NC, Sather MD, Hussain A, Althouse AD, Adelstein EC, Jain SK, Katz WE, Shalaby AA, Voigt AH, Saba S. Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta‐analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:767-774. [DOI: 10.1111/pace.13368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/20/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Norman C. Wang
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Matthew D. Sather
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Aliza Hussain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew D. Althouse
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Evan C. Adelstein
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sandeep K. Jain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - William E. Katz
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alaa A. Shalaby
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew H. Voigt
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Samir Saba
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
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Risk of Intraatrial Thrombi After Thoracoscopic Ablation in Absence of Heparin and Appendage Closure. Ann Thorac Surg 2017; 104:790-796. [DOI: 10.1016/j.athoracsur.2017.01.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 12/27/2016] [Accepted: 01/30/2017] [Indexed: 11/24/2022]
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Lip GYH, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, van Eickels M, Cohen A. Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J 2016; 178:126-34. [PMID: 27502860 DOI: 10.1016/j.ahj.2016.05.007] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/05/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non-vitamin K antagonist (VKA) oral anticoagulant treatment are scarce. The primary objective of X-TRA was to explore the use of rivaroxaban for the resolution of LA/LAA thrombi in patients with nonvalvular atrial fibrillation (AF) or atrial flutter, with the CLOT-AF registry providing retrospective data after standard-of-care therapy in this setting. METHODS X-TRA was a prospective, single-arm, open-label, multicenter study that investigated rivaroxaban treatment for 6 weeks for LA/LAA thrombus resolution in patients with nonvalvular AF or atrial flutter and LA/LAA thrombus confirmed at baseline on a transesophageal echocardiogram (TEE). CLOT-AF retrospectively collected thrombus-related patient outcome data after standard-of-care anticoagulant treatment for 3 to 12 weeks in patients with nonvalvular AF or atrial flutter who had LA/LAA thrombi on TEE recorded in their medical file. RESULTS In X-TRA, patients were predominantly (95.0%) from Eastern European countries. The adjudicated thrombus resolution rate was 41.5% (22/53 modified intention-to-treat [mITT] patients, 95% CI 28.1%-55.9%) based on central TEE assessments. Resolved or reduced thrombus was evident in 60.4% (32/53 mITT patients, 95% CI 46.0%-73.6%) of patients. In CLOT-AF, the reported thrombus resolution rate was 62.5% (60/96 mITT patients, 95% CI 52.0%-72.2%) and appeared better in Western European countries (34/50; 68.0%) than in Eastern European countries (26/46; 56.5%). CONCLUSION X-TRA is the first prospective, multicenter study examining LA/LAA thrombus resolution with a non-VKA oral anticoagulant in VKA-naïve patients or in patients with suboptimal VKA therapy. Rivaroxaban could be a potential option for the treatment of LA/LAA thrombi.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | | | | | - Bodo Kirsch
- Global Research and Development Statistics, Bayer Pharma AG, Berlin, Germany
| | | | - Ariel Cohen
- Cardiology Department, Assistance publique-Hôpitaux de Paris and université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School, Paris, France
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Patti G, Pengo V, Marcucci R, Cirillo P, Renda G, Santilli F, Calabrò P, De Caterina AR, Cavallari I, Ricottini E, Parato VM, Zoppellaro G, Di Gioia G, Sedati P, Cicchitti V, Davì G, Golia E, Pariggiano I, Simeone P, Abbate R, Prisco D, Zimarino M, Sofi F, Andreotti F, De Caterina R. The left atrial appendage: from embryology to prevention of thromboembolism. Eur Heart J 2016; 38:877-887. [DOI: 10.1093/eurheartj/ehw159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/26/2016] [Indexed: 12/13/2022] Open
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Lip GYH, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, Morandi E, van Eickels M, Cohen A. Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J 2015; 169:464-71.e2. [PMID: 25819852 DOI: 10.1016/j.ahj.2014.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/04/2014] [Indexed: 12/24/2022]
Abstract
There are still many unresolved issues concerning patient outcomes and prognostic factors in patients with atrial fibrillation (AF) and left atrial/left atrial appendage (LA/LAA) thrombi. Rivaroxaban (Xarelto®), a potent and highly selective oral, direct factor Xa inhibitor, is a new therapeutic option in this setting. The planned study program will consist of a prospective interventional study (X-TRA) and a retrospective observational registry (CLOT-AF). The primary objective of the X-TRA study is to explore the efficacy of rivaroxaban in the treatment of LA/LAA thrombi in patients with nonvalvular AF or atrial flutter, scheduled to undergo cardioversion or AF ablation, in whom an LA/LAA thrombus has been found on transesophageal echocardiography (TEE) before the procedure. The primary end point is the complete LA/LAA thrombus resolution rate at 6 weeks of end of treatment confirmed by TEE. The secondary objectives are to describe categories of thrombus outcome in patients (resolved, reduced, unchanged, larger, or new) confirmed on TEE at the end of treatment (after 6 weeks of treatment), incidence of the composite of stroke and noncentral nervous system systemic embolism at the end of treatment and during follow-up, and incidence of all bleeding at the end of treatment and during follow-up. The objective of the CLOT-AF registry is to provide retrospective thrombus-related patient outcome data after standard-of-care anticoagulant treatment in patients with nonvalvular AF or atrial flutter, who have TEE-documented LA/LAA thrombi. The data will be used as a reference for the prospective X-TRA study. In conclusion, X-TRA and CLOT-AF will provide some answers to the many unresolved issues concerning patient outcomes and prognostic factors in patients with AF and LAA thrombi. Results from this study program would provide the first prospective interventional study (X-TRA) and a large international retrospective observational registry (CLOT-AF) on the prevalence and natural history of LA/LAA thrombi. Unique data on clot resolution with rivaroxaban in a prospective cohort would be obtained in X-TRA.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | | | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Center, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Bodo Kirsch
- Global Research and Development Statistics, Bayer HealthCare, Berlin, Germany
| | - Eolo Morandi
- Therapeutic Cardiovascular and Coagulation, Global Development, Bayer HealthCare, São Paulo, Brazil
| | | | - Ariel Cohen
- Cardiology Department, Assistance Publique-Hôpitaux de Paris and Université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School, Paris, France
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Mearns ES, White CM, Kohn CG, Hawthorne J, Song JS, Meng J, Schein JR, Raut MK, Coleman CI. Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression. Thromb J 2014; 12:14. [PMID: 25024644 PMCID: PMC4094926 DOI: 10.1186/1477-9560-12-14] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/06/2014] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) patients frequently require anticoagulation with vitamin K antagonists (VKAs) to prevent thromboembolic events, but their use increases the risk of hemorrhage. We evaluated time spent in therapeutic range (TTR), proportion of international normalized ratio (INR) measurements in range (PINRR), adverse events in relation to INR, and predictors of INR control in AF patients using VKAs. METHODS We searched MEDLINE, CENTRAL and EMBASE (1990-June 2013) for studies of AF patients receiving adjusted-dose VKAs that reported INR control measures (TTR and PINRR) and/or reported an INR measurement coinciding with thromboembolic or hemorrhagic events. Random-effects meta-analyses and meta-regression were performed. RESULTS Ninety-five articles were included. Sixty-eight VKA-treated study groups reported measures of INR control, while 43 studies reported an INR around the time of the adverse event. Patients spent 61% (95% CI, 59-62%), 25% (95% CI, 23-27%) and 14% (95% CI, 13-15%) of their time within, below or above the therapeutic range. PINRR assessments were within, below, and above range 56% (95% CI, 53-59%), 26% (95% CI, 23-29%) and 13% (95% CI, 11-17%) of the time. Patients receiving VKA management in the community spent less TTR than those managed by anticoagulation clinics or in randomized trials. Patients newly receiving VKAs spent less TTR than those with prior VKA use. Patients in Europe/United Kingdom spent more TTR than patients in North America. Fifty-seven percent (95% CI, 50-64%) of thromboembolic events and 42% (95% CI, 35 - 51%) of hemorrhagic events occurred at an INR <2.0 and >3.0, respectively; while 56% (95% CI, 48-64%) of ischemic strokes and 45% of intracranial hemorrhages (95% CI, 29-63%) occurred at INRs <2.0 and >3.0, respectively. CONCLUSIONS Patients on VKAs for AF frequently have INRs outside the therapeutic range. While, thromboembolic and hemorrhagic events do occur patients with a therapeutic INR; patients with an INR <2.0 make up many of the cases of thromboembolism, while those >3.0 make up many of the cases of hemorrhage. Managing anticoagulation outside of a clinical trial or anticoagulation clinic is associated with poorer INR control, as is, the initiation of therapy in the VKA-naïve. Patients in Europe/UK have better INR control than those in North America.
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Affiliation(s)
- Elizabeth S Mearns
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA ; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT 06102-5037, USA
| | - C Michael White
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA ; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT 06102-5037, USA
| | - Christine G Kohn
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA ; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT 06102-5037, USA
| | - Jessica Hawthorne
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA
| | - Ju-Sung Song
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA
| | - Joy Meng
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA
| | | | | | - Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 N Eagleville Road, Storrs, CT 06269-3092, USA ; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT 06102-5037, USA
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Oake N, Fergusson DA, Forster AJ, van Walraven C. Frequency of adverse events in patients with poor anticoagulation: a meta-analysis. CMAJ 2007; 176:1589-94. [PMID: 17515585 PMCID: PMC1867836 DOI: 10.1503/cmaj.061523] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients taking anticoagulants orally over the long term have international normalized ratios (INRs) outside the individual therapeutic range more than one-third of the time. Improved anticoagulation control will reduce hemorrhagic and thromboembolic event rates. To gauge the potential effect of improved anticoagulation control, we undertook to determine the proportion of anticoagulant-associated events that occur when INRs are outside the therapeutic range. METHODS We conducted a meta-analysis of all studies that assigned hemorrhagic and thromboembolic events in patients taking anticoagulants to discrete INR ranges. We identified studies using the MEDLINE (1966-2006) and EMBASE (1980-2006) databases. We included studies reported in English if the majority of patients taking oral anticoagulants had an INR range with a lower limit between 1.8 and 2 and an upper limit between 3 and 3.5, and their INR at the time of the hemorrhagic or thromboembolic event was recorded. RESULTS The final analysis included results from 45 studies (23 that reported both hemorrhages and thromboemboli; 14 that reported hemorrhages only; and 8, thromboemboli only) involving a median of 208 patients (limits of interquartile range [25th-75th percentile] 131-523 subjects; total n = 71 065). Of these studies, 64% were conducted at community practices; the remainder, at anticoagulation clinics. About 69% of the studies were classed as having moderate or high quality. Overall, 44% (95% confidence interval [CI] 39%-49%) of hemorrhages occurred when INRs were above the therapeutic range, and 48% (95% CI 41%-55%) of thromboemboli took place when below it. The mean proportion of events that occurred while the patient's INR was outside the therapeutic range was greater for studies with a short mean follow-up (< 1 yr). Between-study heterogeneity was significant (p < 0.001). INTERPRETATION Improved anticoagulation control could decrease the likelihood of almost half of all anticoagulant-associated adverse events.
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Affiliation(s)
- Natalie Oake
- Department of Medicine, University of Ottawa, Ottawa, Ont.
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Abstract
Atrial fibrillation is associated with substantial morbidity and mortality. Pooled data from trials comparing antithrombotic treatment with placebo have shown that warfarin reduces the risk of stroke by 62%, and that aspirin alone reduces the risk by 22%. Overall, in high-risk patients, warfarin is superior to aspirin in preventing strokes, with a relative risk reduction of 36%. Ximelagatran, an oral direct thrombin inhibitor, was found to be as efficient as vitamin K antagonist drugs in the prevention of embolic events, but has been recently withdrawn because of abnormal liver function tests. The ACTIVE-W (Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events) study has demonstrated that warfarin is superior to platelet therapy (clopidogrel plus aspirin) in the prevention af embolic events. Idraparinux, a Factor Xa inhibitor, is being evaluated in patients with atrial fibrillation. Angiotensin-converting enzyme inhibitors and angiotensin II receptor-blocking drugs hold promise in atrial fibrillation through cardiac remodelling. Preliminary studies suggest that statins could interfere with the risk of recurrence after electrical cardioversion. Finally, percutaneous methods for the exclusion of left atrial appendage are under investigation in high-risk patients.
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Affiliation(s)
- Stéphane Ederhy
- Assistance Publique Hôpitaux de Paris et Université Pierre et Marie Curie, Service de Cardiologie, Hôpital Saint-Antoine, 184 rue du Faubourg Saint Antoine, 75012, Paris, France
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Olshansky B, Guo H. Acute anticoagulation adjustment in patients with atrial fibrillation at risk for stroke: approaches, strategies, risks and benefits. Expert Rev Cardiovasc Ther 2006; 3:571-90. [PMID: 16076269 DOI: 10.1586/14779072.3.4.571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The acute management of anticoagulation in patients with atrial fibrillation to prevent stroke and other thromboembolic complications includes the use of individualized strategies tailored to the patient and based on the situation (cardioversion, surgeries, dental procedures, cardiac interventions, other invasive procedures and initiation of, or adjustment to, warfarin dosing). The vast range of choices can cause confusion and few randomized controlled clinical trials in this area provide adequate guidance. Chronic anticoagulation management is more straightforward since clinical evidence is ample, randomized clinical trial data provides cogent informaiton and guidelines have been established. Acute management of anticoagulation in patients with atrial fibrillation to prevent thromboembolic complications is often unrecognized but is emerging as a crucial, but challenging, and increasingly complex aspect of the care of patients with atrial fibrillation. This review addresses issues regarding such patients who may be at risk for stroke and require acute adjustments of anticoagulation (in light of, or in lieu of, chronic anticoagulation). Several promising new strategies are considered in light of established medical care. This analysis provides practical recommendations based on available data and presents results from recent investigations that may provide insight into future strategies.
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Affiliation(s)
- Brian Olshansky
- Cardiac Electrophysiology, University of Iowa Hospitals, 4426A JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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