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Reddy VY, Zhong Y, McGovern AM, Amorosi SL, Gavaghan MB, Hertz DS, Low K, Freeman S, Holmes Jr DR. Comparative Costs to Medicare and Medicare Beneficiaries of Alternative AF Stroke Risk Reduction Strategies. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:81-96. [PMID: 38374959 PMCID: PMC10875168 DOI: 10.2147/ceor.s440556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/28/2023] [Indexed: 02/21/2024] Open
Abstract
Background As healthcare costs are increasingly being shifted from payers to patients, it is important to understand the economic consequences of therapeutic strategies to both payers and patients. Objective To determine the relative costs to Medicare and Medicare beneficiaries (patients) of warfarin, non-vitamin K oral anticoagulants (NOACs), and left atrial appendage closure (LAAC) for stroke risk reduction in nonvalvular atrial fibrillation. Methods An economic model was developed to assess costs at 5 and 10 years. For warfarin and NOACs, inputs were derived from published meta-analyses; for LAAC with the Watchman device, inputs were derived from pooled 5-year PROTECT AF and PREVAIL trial results. The model captured therapy costs vs clinical event costs, including procedural complications and follow-up clinical outcomes. Costs were based on 2023 Medicare reimbursement and copayment rates. Results At 10 years, overall LAAC costs ($48,337) were lower than those of NOACs ($81,198) and warfarin ($52,359). Overall LAAC costs were lower than those of NOACs by year 5 and warfarin by year 9. At 5 years, patient LAAC costs were lowest at $4,764, compared to $7,146 and $6,453 for NOACs and warfarin, respectively. LAAC patient costs were lower than those of NOACs by year 3 and warfarin by year 4. Clinical events comprised 96% of overall warfarin costs vs 48% for LAAC and 40% for NOACs. Conclusion LAAC yielded the lowest overall and patient costs. Warfarin costs were largely driven by clinical events, which may represent an unplanned financial burden for patients. These considerations should be incorporated into shared decision-making discussions about stroke prophylaxis strategies.
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Affiliation(s)
- Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yue Zhong
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Stacey L Amorosi
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
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Amalathasan T, Nagaratnam PA, El Dirani M, Nagaratnam JM, Kholoki S. Should the Left Atrial Appendage Closure (LAAC) Technique Be the Main Form of Stroke Prevention in Patients With Long-Standing Persistent or Permanent Atrial Fibrillation? Cureus 2024; 16:e54256. [PMID: 38496111 PMCID: PMC10944332 DOI: 10.7759/cureus.54256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Currently, oral anticoagulants are considered the gold standard for stroke prevention in patients with atrial fibrillation. Despite the efficacy of oral anticoagulants in reducing stroke incidence, patients are at risk of developing adverse reactions such as excessive bleeding and bruising, and can also have drug-drug interactions. In the early 2000s, a minimally invasive technique called the left atrial appendage closure emerged as an alternative for stroke prevention in atrial fibrillation patients who could not tolerate oral anticoagulants. Despite the success of the left atrial appendage closure, practitioners still opt for medication therapy and are reluctant to advocate for this procedure. Given the adverse effects of oral anticoagulants, physicians should question if this is the appropriate method of stroke prevention in long-standing persistent or permanent atrial fibrillation patients. This case report investigates an 82-year-old Middle Eastern male in the United States with long-standing persistent atrial fibrillation who underwent a left atrial appendage closure due to recurrent bleeding on oral anticoagulants. In addition, there will be further discussion on the appropriate method of stroke prevention in similar patients.
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Affiliation(s)
| | | | - Mirna El Dirani
- Internal Medicine, Saint James School of Medicine, Chicago, USA
| | | | - Samer Kholoki
- Internal Medicine, La Grange Memorial Hospital, Chicago, USA
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3
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Hewage SA, Noviyani R, Brain D, Sharma P, Parsonage W, McPhail SM, Barnett A, Kularatna S. Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:76. [PMID: 37872572 PMCID: PMC10591401 DOI: 10.1186/s12962-023-00486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations. METHODS We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively. RESULTS In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common. CONCLUSIONS While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.
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Affiliation(s)
- Sumudu A Hewage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia.
| | - Rini Noviyani
- Department of Pharmacy, Udayana University, Bali, Indonesia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Cardiology department, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, QLD, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
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Kamae I, Zhong Y, Hara H, Inoue K, Yasaka M, Reddy VY, Holmes DR, Sakurai M, Gavaghan MB, Amorosi SL, McGovern AM, Priest V, Inoue S, Shibahara H, Akehurst RL. Cost-effectiveness of left atrial appendage closure with Watchman for non-valvular atrial fibrillation patients in Japan. J Med Econ 2023; 26:1357-1367. [PMID: 37819734 DOI: 10.1080/13696998.2023.2266275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
AIMS Left atrial appendage closure (LAAC) has been demonstrated to be cost-saving relative to oral anticoagulants for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF) in the United States and Europe. This study assessed the cost-effectiveness of LAAC with the Watchman device relative to warfarin and direct oral anticoagulants (DOACs) for stroke risk reduction in NVAF from a Japanese public healthcare payer perspective. METHODS A Markov model was developed with 70-year-old patients using a lifetime time horizon. LAAC clinical inputs were from pooled, 5-year PROTECT AF and PREVAIL trials; warfarin and DOAC inputs were from published meta-analyses. Baseline stroke and bleeding risks were from the SALUTE trial on LAAC. Cost inputs were from the Japanese Medical Data Vision database. Probabilistic and one-way sensitivity analyses were performed. RESULTS Over the lifetime time horizon, LAAC was less costly than warfarin (savings of JPY 1,878,335, equivalent to US $17,600) and DOACs (savings of JPY 1,198,096, equivalent to US $11,226). LAAC also provided 1.500 more incremental quality-adjusted life years (QALYs) than warfarin and 0.996 more than DOACs. In probabilistic sensitivity analysis, LAAC was cost-effective relative to warfarin and DOACs in 99.98% and 99.73% of simulations, respectively. LAAC dominated (had higher cumulative QALYs and was less costly than) warfarin and DOACs in 89.94% and 83.35% of simulations, respectively. CONCLUSIONS Over a lifetime time horizon, LAAC is cost-saving relative to warfarin and DOACs for stroke risk reduction in NVAF patients in Japan and is associated with improved quality-of-life.
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Affiliation(s)
- Isao Kamae
- Graduate School of Public Policy, University of Tokyo, Tokyo, Japan
| | - Yue Zhong
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Hidehiko Hara
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koichi Inoue
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Vivek Y Reddy
- Icahn School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Stacey L Amorosi
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Virginia Priest
- Health Economics and Market Access, Boston Scientific Asia Pacific, Singapore
| | | | | | - Ronald L Akehurst
- BresMed Health Solutions, Sheffield, UK
- University of Sheffield, Sheffield, UK
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Left atrial appendage occlusion should be offered only to select atrial fibrillation patients. Heart Rhythm O2 2022; 3:448-454. [PMID: 36097461 PMCID: PMC9463703 DOI: 10.1016/j.hroo.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022] Open
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Son MK, Song DS, Lee K, Park HY. Lower number of modifiable risk factors was associated with reduced atrial fibrillation incidence in an 18-year prospective cohort study. Sci Rep 2022; 12:9207. [PMID: 35654825 PMCID: PMC9163060 DOI: 10.1038/s41598-022-13434-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 05/06/2022] [Indexed: 11/09/2022] Open
Abstract
Prevention strategies for atrial fibrillation (AF) are lacking. This study aimed to identify modifiable risk factors (MRFs) and estimate their impact on AF in the midlife general population. We assessed 9049 participants who were free of prevalent AF at baseline from the Korean Genome and Epidemiology Study. Cox models with time-varying assessment of risk factors were used to identify significant MRFs for incident AF. The MRF burden was defined as the proportion of visits with MRFs during follow-up. Over a median follow-up of 13.1 years, 182 (2.01%) participants developed AF. Three MRFs, including systolic blood pressure (SBP) ≥ 140 mmHg, obesity with central obesity, and an inactive lifestyle were significantly associated with incident AF. Among participants with 3, 2, 1, and 0 MRFs at baseline, 16 (3.9%), 51 (2.5%), 90 (1.8%) and 25 (1.5%) had incident AF, respectively. Compared to participants with three MRFs, those with one or no MRFs had a decreased risk of AF (hazard ratio [95% CI] for one MRF, 0.483 [0.256-0.914]; and for no MRF, 0.291 [0.145-0.583]). A decreasing MRF burden was associated with reduced AF risk (hazard ratio [95% CI] per 10% decrease in burden for SBP ≥ 140 mmHg, 0.937 [0.880-0.997]; for obesity with central obesity, 0.942 [0.907-0.978]; for inactivity, 0.926 [0.882-0.973]). Maintaining or achieving MRF ≤ 1 was associated with decreased AF risk, suggesting that minimizing the burden of MRF might help prevent AF.
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Affiliation(s)
- Mi Kyoung Son
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, 200 OsongSaengmyeong 2-Ro, Osong-Eup, Cheongju, Chungcheongbuk-do, 28160, Republic of Korea
| | - Dae Sub Song
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, 200 OsongSaengmyeong 2-Ro, Osong-Eup, Cheongju, Chungcheongbuk-do, 28160, Republic of Korea
| | - Kyoungho Lee
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, 200 OsongSaengmyeong 2-Ro, Osong-Eup, Cheongju, Chungcheongbuk-do, 28160, Republic of Korea
| | - Hyun-Young Park
- Department of Precision Medicine, Korea National Institute of Health, 187 OsongSaengmyeong 2-Ro, Osong-Eup, Cheongju, Chungcheongbuk-do, 28159, Republic of Korea.
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AMANO ATSUSHI. Refinement of Coronary Artery Bypass Grafting at Juntendo University Hospital. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2022; 68:101-114. [PMID: 38912283 PMCID: PMC11189799 DOI: 10.14789/jmj.jmj21-0012-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/25/2021] [Indexed: 06/25/2024]
Abstract
Surgical treatment of ischemic heart disease began in 1945. After 1970, coronary artery bypass grafting (CABG) with cardiopulmonary bypass was developed along with coronary angiography. Juntendo University has been treating ischemic heart disease since 1980, and is actively performing off-pump CABG (OPCAB) since 2002. Besides the age of patients undergoing surgery, complications such as chronic hemodialysis, cerebrovascular disease, and malignancies make it challenging to reduce postoperative complications using OPCAB as graft preservation. OPCAB is technically challenging, and the CORONARY trial did not reveal its superiority over conventional CABG. Furthermore, high revascularization rates and technical differences among surgeons are important concerns. While not widely accepted in Europe and the United States, OPCAB comprises 65% of all stand-alone CABG in Japan. Japan reported a 2.5% hospital mortality rate in 2018, while the US reported 2.2% (according to the American Association of Thoracic Surgeons). In contrast, Juntendo University Hospital has maintained a 1% hospital mortality rate since 1984. To reduce the incidence of remote stroke in CABG patients, Juntendo has been using stroke-free management since 2010. Postoperative atrial fibrillation is 4-5 times more likely to recur than normal sinus rhythm after a 5-year course. In our study, 20% of patients suffered from chronic atrial fibrillation after ten years. Furthermore, left atrial appendage closure or amputation significantly reduces stroke in patients who undergo CABG and develop postoperative atrial fibrillation. Thus, OPCAB is a minimally invasive procedure with fewer complications; prevention of cardiogenic cerebral infarction can help improve remote outcomes.
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Affiliation(s)
- ATSUSHI AMANO
- Corresponding author: Atsushi Amano, Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan, TEL&FAX: +81-3-3813-3210 E-mail:
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8
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Mazzone P, Bella PD, Baratto F. Percutaneous left atrial appendage closure vs oral anticoagulation: The scariest might be the cheepest. Int J Cardiol 2022; 353:51-52. [DOI: 10.1016/j.ijcard.2022.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 01/25/2022] [Indexed: 11/26/2022]
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Chao TF, Joung B, Takahashi Y, Lim TW, Choi EK, Chan YH, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary. Thromb Haemost 2022; 122:20-47. [PMID: 34773920 PMCID: PMC8763451 DOI: 10.1055/s-0041-1739411] [Citation(s) in RCA: 228] [Impact Index Per Article: 114.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022]
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yi-Hsin Chan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic Disease, Chinese PLA General Hospital, Beijing, China
| | | | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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D'Ancona G, Arslan F, Safak E, Weber D, Al Ammareen R, Ince H. Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation. Int J Cardiol 2021; 351:61-64. [PMID: 34929249 DOI: 10.1016/j.ijcard.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
AIMS Comparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only. METHODS AND RESULTS Patients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records. Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1. Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281-8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607-2735) in OAC patients and € 1013 (IQR: € 0-4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = -0.8; CI: -1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7). CONCLUSION Percutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.
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Affiliation(s)
- Giuseppe D'Ancona
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany.
| | - Fatih Arslan
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany; Department of Cardiology, Leiden University Medical Center, Leiden, NL, the Netherlands
| | - Erdal Safak
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Denise Weber
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Raid Al Ammareen
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Hüseyin Ince
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
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11
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D'Ancona G, Ince H. Rehospitalization and actual management costs after percutaneous left atrial appendage closure: Facing the conundrum. Int J Cardiol 2021; 344:84-85. [PMID: 34600976 DOI: 10.1016/j.ijcard.2021.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Affiliation(s)
- G D'Ancona
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany.
| | - H Ince
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany; Rostock University, Rostock, Germany
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12
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Dong XJ, Wang BB, Hou FF, Chen KP, Zhou HD, Guo JW, Sun X, Liu XL, Chen LJ. Homocysteine (HCY) levels in patients with atrial fibrillation (AF): A meta-analysis. Int J Clin Pract 2021; 75:e14738. [PMID: 34399017 DOI: 10.1111/ijcp.14738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Atrial fibrillation (AF) is one of the most common persistent arrhythmia, and its complications include cerebral embolism, arterial embolism and heart failure. Some studies have found that elevated Homocysteine (HCY) levels is a new risk factor for AF. Currently, there is no meta-analysis to explore whether the HCY levels is related to AF. Therefore, a meta-analysis was conducted to evaluate the relationship between the HCY levels and AF, in order to draw the attention of clinicians to the HCY levels. METHODS A meta-analysis was performed in the study to evaluated the association between the HCY levels and AF. In order to identify eligible original articles, The EMBASE, PubMed, and web of science were systematically searched until November 2020. All data were analyzed with Review Manager 5.3. The meta-analysis results were evaluated depending on standardized mean differences (SMD) with 95% confidence intervals (CI). Moreover, the subgroup analysis and sensitivity analysis were also analyzed. RESULTS The HCY levels was significantly associated with AF (WMD = 0.81, 95% CI: 0.58 to 1.03; P < .00001). In the analysis, there was a medium degree of heterogeneity (I2 = 73%). Subgroup analysis showed that female < 60, BMI≥25, BMI <25, age ≥60 and publication year ≥2010 were identified as possible sources of heterogeneity. Sensitivity analysis showed that the main results remained unchanged after omitting any single study or converting the random effects model (REM) to fixed effects model (FEM). CONCLUSIONS The meta-analysis showed that there is a significant correlation between the HCY levels and AF, and the role of HCY in AF patients should not be ignored in clinical.
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Affiliation(s)
- Xin-Jiang Dong
- Department of intensive care unit, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Bei-Bei Wang
- Department of Cardiology, The First People's Hospital of Jinzhong, Jinzhong, China
| | - Fei-Fei Hou
- Department of intensive care unit, Affiliated of Inner Mongolia Medical University, Huhehaote, China
| | - Kai-Peng Chen
- Department of Emergency, Yun Cheng Central Hospital, Yuncheng, China
| | - Hui-Dong Zhou
- Department of Neurosurgery, Yun Cheng Central Hospital, Yuncheng, China
| | - Jing-Wei Guo
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Xun Sun
- Department of intensive care unit, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Xiao-Li Liu
- Department of Cardiology, Yun Cheng Central Hospital, Yuncheng, China
| | - Li-Juan Chen
- Department of Cardiology, Yun Cheng Central Hospital, Yuncheng, China
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Collado FMS, Lama von Buchwald CM, Anderson CK, Madan N, Suradi HS, Huang HD, Jneid H, Kavinsky CJ. Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022274. [PMID: 34668395 PMCID: PMC8751840 DOI: 10.1161/jaha.121.022274] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.
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Left atrial appendage closure with the watchman device reduces atrial fibrillation management costs. Clin Res Cardiol 2021; 111:105-113. [PMID: 34652527 DOI: 10.1007/s00392-021-01943-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
AIMS To report hospitalization costs of patients with non-valvular atrial fibrillation (AF) submitted to percutaneous left atrial appendage closure (LAAC) with the Watchman device. METHODS Pre- and post-procedural hospitalization AF-related costs were calculated using the DRG system (diagnosis-related groups) and compared. RESULTS Between 2012 and 2016, 677 non-valvular AF patients underwent LAAC. Median time from first cardiac hospitalization to LAAC was 5.9 years (IQR 1.6-9.1) and median follow-up after LAAC was 4.8 years (IQR 3.6-5.6). LAAC mortality was 1.3% and follow-up mortality 16.9%. Median pre-LAAC hospitalization cost was € 17,867 (IQR € 7512-35,08) and post-LAAC € 8772 (IQR € 1183-25,159) (p < 0.0001). Annualized cost pre-LAAC was 3773 € (IQR € 1644-8,493) and post-LAAC 2,001 € (IQR € 260-6913) (p < 0.0001). Follow-up survivors had significantly lower post-LAAC costs (p < 0.0001) and after a survival cut-off time of 4.6 years LAAC procedural and post-procedural hospitalization costs achieved parity with pre-LACC costs (AUC 0.64; p = 0.02). CHA2DS2-VASc score (B = 0.04; p = 0.02; 95% CI 0.006-0.08), and HAS-BLED score (B = 0.08; p = 0.004; 95% CI 0.02-0.14) were independent determinants for annualized hospitalization costs post-LAAC. At Cox-regression analysis the DRG mean clinical complexity level (CCL) was the only independent determinant for follow-up mortality (OR = 2.2; p < 0.0001; 95% CI 1.6-2.8) with a cut-off value of 2.25 to predict follow-up mortality (AUC 0.72; p < 0.0001; Spec. 70%; Sens. 70%). CONCLUSION Hospitalization costs pre-LAAC are consistent, and after LAAC, they are significantly reduced. Costs seem related to the patient's risk profile at the time of the procedure. With the increase in post-LAAC survival time, the procedure becomes economically more profitable.
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Yamamoto T, Endo D, Matsushita S, Shimada A, Nakanishi K, Asai T, Amano A. Evidence and Challenges in Left Atrial Appendage Management. Ann Thorac Cardiovasc Surg 2021; 28:1-17. [PMID: 34334504 PMCID: PMC8915931 DOI: 10.5761/atcs.ra.21-00040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This review aimed to discuss the anatomical properties of the left atrial appendage (LAA), its relationship with atrial fibrillation (AF), effectiveness of LAA occlusion (LAAO), techniques, and new devices used to perform this procedure. An electronic search was performed to identify studies, in the English language, on LAA management. Searches were performed on PubMed Central, Scopus, and Medline from the dates of database inception to February 2020. For the assessed papers, data were extracted from the reviewed text, tables, and figures, by two independent authors. Anticoagulant therapy for patients with AF has proven beneficial and is highly recommended, but it is challenging for many patients to maintain optimal treatment. Surgery is the most cost-effective option; surgical methods include simple LAA resection, thoracoscopic surgery, and catheter treatment. Each procedure has its advantages and disadvantages, and many prospective studies have been conducted to evaluate various treatment methods. In managing the LAA, dissection of the LAA, such as changes in its shape and size due to remodeling during AF, changes in autonomic nerve function, and thrombosis, must be understood anatomically and physiologically. We believe that early treatment intervention for the LAA should be considered particularly in cases of recurrent AF. Conclusion: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.
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Affiliation(s)
- Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | | | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Keisuke Nakanishi
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
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Cruz Neto J, Barros LDO, Morais SSFD, Silva MGCD. Review of cost-effectiveness of antithrombotic alternatives in patients with atrial fibrillation. Rev Assoc Med Bras (1992) 2021; 67:1050-1055. [DOI: 10.1590/1806-9282.20210332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/06/2021] [Indexed: 11/22/2022] Open
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18
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Demonstration of proof-of-concept of StrokeShield system for complete closure and occlusion of the left atrial appendage for non-valvular atrial fibrillation therapy. PLoS One 2021; 16:e0253299. [PMID: 34157041 PMCID: PMC8219146 DOI: 10.1371/journal.pone.0253299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
In the US, the most significant morbidity and mortality associated with non-valvular atrial fibrillation (NVAF) is embolic stroke, with 90% of thrombus originating from the left atrial appendage (LAA). Anticoagulation is the preferred treatment for the prevention of stroke in NVAF patients, but clinical studies have demonstrated high levels of non-compliance and increased risk of bleeding or ineligibility for anticoagulation therapy, especially in the elderly population where the incidence of NVAF is highest. Alternatively, stroke may be preventing using clinically approved surgical and catheter-based devices to exclude or occlude the LAA, but these devices continue to be plagued by peri-device leaks and thrombus formation because of residual volume. To overcome these limitations, Cor Habere (Louisville, KY) and the University of Louisville are developing a LAA closure device (StrokeShield) that completely occludes and collapses the LAA to minimize the risk of stroke. The StrokeShield device is a collapsible occluder (nitinol reinforced membrane) that completely covers the LAA orifice with an expandable conical coil anchor that attaches to the myocardium. The device is designed for catheter-based delivery and expands to completely occlude the LAA orifice and collapse the LAA. The primary advantages of the StrokeShield system are a completely sealed LAA (no peri-device flow or residual space) and smooth endothelialized connection to the left atrial wall with minimal risk of cardiac bleeding and tamponade. We tested proof-of-concept of a prototype StrokeShield device in acute (n = 2) and chronic 60-day (n = 2) healthy canine models. Acute results demonstrated that the conical coil securely attached to the myocardium (5N pull-out force) and the Nitinol umbrella fully deployed and covered the LAA ostium. Results from the chronic implants demonstrated long-term feasibility of device placement with no procedural or device-related intra- or post-operative complications, secure placement and correct positioning of the device with no device migration. The device successfully occluded the LAA ostium and collapsed the LAA with no interference with the mitral valve, circumflex coronary artery, or pulmonary veins. Necropsy demonstrated no gross signs of thrombus or end-organ damage and the device was encapsulated in the LAA. Histology demonstrated mature neointima covering the device with expected foreign body inflammatory response. These early positive results will help to guide the iterative design process for the continued development of the StrokeShield system.
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19
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Jackson LR, Jackson KP, Thomas KL. Percutaneous left atrial appendage occlusion: A review of current devices, clinical evidence, patient selection, and post procedural antithrombotic management. Prog Cardiovasc Dis 2021; 66:92-100. [PMID: 34332665 PMCID: PMC9899495 DOI: 10.1016/j.pcad.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.
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Affiliation(s)
- Larry R Jackson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America; Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America.
| | - Kevin P Jackson
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America
| | - Kevin L Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America; Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America
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20
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Murtaza G, Boda U, Turagam MK, Della Rocca DG, Akella K, Gopinathannair R, Lakkireddy D. Risks and Benefits of Removal of the Left Atrial Appendage. Curr Cardiol Rep 2020; 22:129. [PMID: 32910248 DOI: 10.1007/s11886-020-01387-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW In patients with atrial fibrillation who are unable to take novel oral anticoagulants for stroke prophylaxis due to bleeding risk or other contraindications, left atrial appendage (LAA) occlusion and exclusion devices have shown benefit. In this review, we highlight the risks and benefits associated with LAA removal. RECENT FINDINGS LAA, once considered a vestigial organ, has been shown to have physiological, anatomical, and arrhythmogenic properties. Device-related complications such as pericardial effusion, device embolization, device-related thrombus, while uncommon, are still present. With increased operator experience related to appendage occlusion, overall procedural complications have declined. Further refinements in device technology will help decrease complications. While benefits of appendage removal are plenty, procedural complications need to be weighed into the equation when making decisions regarding LAA occlusion.
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Affiliation(s)
- Ghulam Murtaza
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Urooge Boda
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Mohit K Turagam
- Department of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Krishna Akella
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA.
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21
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Ong E, Meseguer E, Guidoux C, Lavallée PC, Hobeanu C, Charles H, Labreuche J, Cabrejo L, Martin-Bechet A, Rigual R, Nighoghossian N, Amarenco P. Prevalence and Outcome of Potential Candidates for Left Atrial Appendage Closure After Stroke With Atrial Fibrillation: WATCH-AF Registry. Stroke 2020; 51:2355-2363. [PMID: 32640939 DOI: 10.1161/strokeaha.120.029267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE As a result of contraindications (eg, frailty, cognitive impairment, comorbidities) or patient refusal, many patients with stroke and atrial fibrillation cannot be discharged on oral anticoagulant. Among them, the proportion of potential candidates for left atrial appendage closure (LAAC) and their 12-month outcome is not well known. METHODS The prospective WATCH-AF registry (Warfarin Aspirin Ten-A Inhibitors and Cerebral Infarction and Hemorrhage and Atrial Fibrillation) enrolled consecutive patients admitted within 72 hours of an acute stroke associated with atrial fibrillation in 2 stroke centers. Scales to evaluate stroke severity, disability, functional independence, risk of fall, cognition, ischemic and hemorrhagic risk-stratification, and comorbidities were systematically collected at admission, discharge, 3, 12 months poststroke. The 2 main end points were death or dependency (modified Rankin Scale score >3) and recurrent stroke (brain infarction and brain hemorrhage). RESULTS Among 400 enrolled patients (370 with brain infarction, 30 with brain hemorrhage), 31 died before discharge and 57 (14.3%) were possible European Heart Rhythm Association/European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Rhythm Society candidates for LAAC. At 12 months, the rate of death or dependency was 17.9%, and the rate of stroke recurrence was 9.8% in the 274/400 (68.5%) patients discharged on a long-term oral anticoagulant strategy, as compared with 17.5% and 24.7%, respectively, in 57 patients candidate for LAAC. As compared with patients on a long-term oral anticoagulant strategy, there was a 2-fold increase in the risk of stroke recurrence in the group with an indication for LAAC (adjusted hazard ratio, 2.58 [95% CI, 1.40-4.76]; P=0.002). CONCLUSIONS Fourteen percent of patients with stroke associated with atrial fibrillation were potential candidates for LAAC. The 12-month stroke risk of these candidates was 3-fold the risk of anticoagulated patients.
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Affiliation(s)
- Elodie Ong
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.).,Hospices Civils de Lyon, Department of Neurology and Stroke center, Lyon University, France (E.O., N.N.)
| | - Elena Meseguer
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Celine Guidoux
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Philippa C Lavallée
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Cristina Hobeanu
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Hugo Charles
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Julien Labreuche
- Université Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France (J.L.)
| | - Lucie Cabrejo
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Anna Martin-Bechet
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Ricardo Rigual
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
| | - Norbert Nighoghossian
- Hospices Civils de Lyon, Department of Neurology and Stroke center, Lyon University, France (E.O., N.N.)
| | - Pierre Amarenco
- APHP, Department of Neurology and Stroke center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France (E.O., E.M., C.G., C.H., P.C.L., H.C., L.C., A.M.-B., R.R., P.A.)
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Lu S, Du X, Yang X, Jia Z, Li J, Xia S, Chang S, Zuo S, Guo X, Tang R, Sang C, Bai R, Zhou Y, Dong J, Ma C. Physical activity and atrial tachyarrhythmia recurrence in atrial fibrillation patients after catheter ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:922-929. [PMID: 32638394 DOI: 10.1111/pace.14006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/08/2020] [Accepted: 07/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The association between physical activity (PA) and atrial tachyarrhythmia (AT) recurrence after ablation for atrial fibrillation (AF) remains unclear. METHODS We consecutively enrolled 496 patients treated with AF ablation therapy in Beijing Anzhen Hospital. After excluding six patients with valvular heart disease, seven patients with congenital heart disease, 33 patients lost to follow-up, and 14 patients who did not provide PA level during follow-ups, 436 patients had their PA level assessed by the International Physical Activity Questionnaire-Short Form before ablation and each time of follow-up. The association between PA level (measured at the time closest to AT recurrence, or the end of 12-month follow-up if no AT recurrence), as well as active PA during follow-up, and postablation AT recurrence was tested by multivariate logistic regression. RESULTS Of the enrolled patients, 134 (30.7%) patients experienced AT recurrence in the first 12 months postablation. Compared to patients with low PA, patients with moderate or high PA had a lower risk of AT recurrence (odds ratio [OR] = .44; 95% confidence interval [CI], .25-.80; P = .01 for patients with moderate PA; and OR = .43 [95% CI, .21-.85], P = .02 for patients with high PA). Compared to patients without active PA, patients with active PA had a lower risk of AT recurrence (OR = .44 [95% CI, .27-.70], P < .01). CONCLUSIONS Moderate and high PA are associated with a lower risk of AT recurrence after AF ablation. Active PA during follow-up is also associated with a significantly lower risk of AT recurrence in the postablation AF population.
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Affiliation(s)
- Shangxin Lu
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China.,Heart Health Research Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Xiaoyi Yang
- KLATASDS-MOE, School of Statistics, East China Normal University, Shanghai, China
| | - Zhaoxu Jia
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Jingye Li
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Shijun Xia
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Sanshuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Song Zuo
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Yingchun Zhou
- KLATASDS-MOE, School of Statistics, East China Normal University, Shanghai, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
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Structural heart intervention for prevention of embolic and hemorrhagic stroke: The new field of neurocardiology. J Cardiol 2020; 76:227-235. [PMID: 32482326 DOI: 10.1016/j.jjcc.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022]
Abstract
Cardiogenic stroke (CS), characteristic causes of which include atrial fibrillation (AF) and right-to-left shunting due to a patent foramen ovale (PFO), has a well-known tendency to be associated with a more extensive ischemic area. This may result in severe neurological damage, and require strict life-long antithrombotic therapy. However, the fact that some patients have problems complying with the requirement for extended oral antithrombotic treatment has motivated the development of alternative approaches for stroke prevention. Heart structures such as the left atrial appendage (LAA) and PFO are potential targets for stroke prevention by way of device implantation. Several large prospective randomized clinical trials have demonstrated efficacy and safety of devices dedicated to this purpose. Percutaneous LAA occlusion for patients with non-valvular AF resulted in similar embolic event rates but significantly reduced bleeding events than did therapy with warfarin. Furthermore, PFO closure significantly reduced the frequency of recurrent embolic stroke relative to oral antithrombotic treatment. Current unsolved problems remaining in the application of these two strategies can be identified as the lack of standardized regimens for post-procedural antithrombotic therapy, ambiguity of determining the indications therefore, and the problem of device-related thrombus, which need to be investigated in depth in future. Cost-benefit analysis in comparison with standard medication is also required for each instance. A heart-brain multidisciplinary team approach, mandated to start such structural heart interventions, will become the future standard unit of personnel for stroke management, which promises to usher in the new field of neurocardiology.
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Rodwin BA, Desai NR. The Reply. Am J Med 2019; 132:e723. [PMID: 31307679 DOI: 10.1016/j.amjmed.2019.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Benjamin A Rodwin
- Department of Medicine, West Haven Veterans Affairs Medical Center, West Haven, Conn; Yale School of Medicine, New Haven, Conn
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital; Section of Cardiovascular Medicine, Yale University, New Haven, Conn.
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Reddy VY, Akehurst RL, Gavaghan MB, Amorosi SL, Holmes DR. Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Reduction in Atrial Fibrillation: Analysis of Pooled, 5-Year, Long-Term Data. J Am Heart Assoc 2019; 8:e011577. [PMID: 31230500 PMCID: PMC6662368 DOI: 10.1161/jaha.118.011577] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/11/2019] [Indexed: 01/20/2023]
Abstract
Background Recent publications reached conflicting conclusions about the cost-effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost-effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long-term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long-Term Warfarin) trials. Methods and Results A Markov model was constructed from a US payer perspective with a lifetime (20-year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5-year data. Warfarin and NOAC inputs were derived from published meta-analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost-effective relative to warfarin by year 7 ($48 674/quality-adjusted life-year) and dominant (more effective and less costly) by year 10. LAAC became cost-effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality-adjusted life-years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost-effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively. Conclusions Using pooled, 5-year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost-effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.
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Holmes DR, Alkhouli M, Reddy V. Left Atrial Appendage Occlusion for The Unmet Clinical Needs of Stroke Prevention in Nonvalvular Atrial Fibrillation. Mayo Clin Proc 2019; 94:864-874. [PMID: 30962008 DOI: 10.1016/j.mayocp.2018.09.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/29/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
Oral anticoagulation is the dominant strategy for stroke prevention in patients with nonvalvular atrial fibrillation. However, lifelong oral anticoagulation is associated with major issues including inappropriate dosing, nonadherence, and adverse effects. Therefore, efforts have been made to develop site-specific therapy aimed to occlude the left atrial appendage, the anatomical site accountable for more than 90% of nonvalvular atrial fibrillation-related ischemic strokes. This review focuses on the growing literature to put into perspective the risk-balance ratio of left atrial appendage occlusion.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Mohamad Alkhouli
- Division of Cardiology, West Virginia University School of Medicine, Morgantown
| | - Vivek Reddy
- Department of Medicine, Division of Cardiology, Helmsley Electrophysiology Center, Mount Sinai Medical Center, New York, NY
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Yu J, Liu X, Zhou J, Xue X, Muenzel M, Schulze PC, Moebius-Winkler S, Keil T, Meng Z, Tang S. Long-term safety and efficacy of combined percutaneous LAA and PFO/ASD closure: a single-center experience (LAAC combined PFO/ASD closure). Expert Rev Med Devices 2019; 16:429-435. [PMID: 30999776 DOI: 10.1080/17434440.2019.1604216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To report long-term safety and efficacy of combined percutaneous LAA and PFO/ASD closure. METHODS A retrospective study of 370 consecutive patients undergoing LAAC procedures using the Watchman (WM) device. Data were compared between 330 cases only with LAAC procedure (Group I) and 25/5 (PFO/ASD) cases with sequential procedures of LAAC and PFO/ASD closure (Group II). RESULTS Compared to Group I, Group II had more males (86.7% vs. 65.8%, p < 0.05) and a higher rate of stroke (33.3% vs. 10.6%, p < 0.01), but there were no statistical differences in the remaining patient characteristics. During the follow-up period, there were no significant differences between the two groups in embolism events (6.1% vs. 0%, p = 0.39), device related thrombus (5.8% vs 3.3%, p = 1.0), major bleeding (9.4% vs. 6.7%, p = 1.0) and cardiac death (3.6% vs. 0%, p = 0.61). The observed rate of all thromboembolic events by Kaplan-Meier analysis was decreased by 39.9% and 100% and the observed annual rate of bleeding was reduced by 32.9% and 57.6% in Group I and Group II, respectively. CONCLUSIONS LAAC combined with PFO/ASD closure might be an ideal choice to prevent stroke and other thrombotic complications in patients with both NVAF and PFO/ASD.
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Affiliation(s)
- Jiangtao Yu
- a Clinic for General Internal Medicine and Cardiology , Marienhof Katholisches Klinikum Koblenz·Montabaur , Koblenz , Germany.,b Department of Cardiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany
| | - Xiaoxia Liu
- c Department of Cardiology , the 4th Hospital of Harbin Medical University , Harbin , PR China
| | - Junling Zhou
- b Department of Cardiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany.,d Department of Cardiology , the Provincial Hospital Anhui , Hefei , PR China
| | - Xin Xue
- b Department of Cardiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany.,e Department of Cardiology , The Second Hospital, Jilin University , Changchun , PR China
| | - Manuela Muenzel
- b Department of Cardiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany
| | - P Christian Schulze
- f Department of Internal Medicine I, Division of Cardiology , University Hospital Jena, Friedrich-Schiller-University , Jena , Germany
| | - Sven Moebius-Winkler
- f Department of Internal Medicine I, Division of Cardiology , University Hospital Jena, Friedrich-Schiller-University , Jena , Germany
| | - Thorsten Keil
- g Department of Anesthesiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany
| | - Zhaohui Meng
- b Department of Cardiology , Helmut-G.-Walther-Klinikum , Lichtenfels , Germany.,h Department of Cardiology , The 1st Hospital of Kunming Medical University , Kun-ming , PR China
| | - Shaoyong Tang
- i Department of Cardiology , Wuhan N0.4 Hospital , Wuhan , PR China
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Kupsky DF, Wang DD, Eng M, Gheewala N, Nakhle A, Georgie F, Shah R, Wyman J, Mahan M, Greenbaum A, O’Neill WW. Socioeconomic Disparities in Access for Watchman Device Insertion in Patients with Atrial Fibrillation and at Elevated Risk of Bleeding. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1569795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Daniel F. Kupsky
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Dee Dee Wang
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Marvin Eng
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Neil Gheewala
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Asaad Nakhle
- Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Fawaz Georgie
- Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Rajan Shah
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Janet Wyman
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Meredith Mahan
- Department of Biostatistics, Henry Ford Health System, Detroit, Michigan, USA
| | - Adam Greenbaum
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - William W. O’Neill
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
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Rocca DGD, Prete AD, Biase LD, Horton RP, Al-Ahmad A, Bassiouny M, Mohanty S, Trivedi C, Romero J, Gianni C, Burkhardt JD, Gallinghouse GJ, Sanchez JE, Versaci F, Natale A. Current Endocardial Approaches for Left Atrial Appendage Closure. ACTA ACUST UNITED AC 2019. [DOI: 10.17925/ejae.2019.5.1.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Romero J, Avendano R, Diaz JC, Taveras J, Lupercio F, Di Biase L. Is it safe to stop oral anticoagulation after catheter ablation for atrial fibrillation? Expert Rev Cardiovasc Ther 2018; 17:31-41. [DOI: 10.1080/14779072.2019.1550718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Jorge Romero
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ricardo Avendano
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jose Taveras
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Florentino Lupercio
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
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Nédellec E, Pineau J, Prognon P, Martelli N. Level of Evidence in Economic Evaluations of Left Atrial Appendage Closure Devices: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:793-802. [PMID: 30171480 DOI: 10.1007/s40258-018-0429-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The objective of the present work was to assess the level of evidence in economic evaluations of percutaneous left atrial appendage closure devices, and to test the complementarity of three different tools for assessing the quality of economic evaluations. METHODS We conducted a systematic review of articles in English or French listed in MEDLINE, Embase, Cochrane, the Cost-Effectiveness Analysis registry and the National Health Service Economic Evaluation Database. We included only economic evaluations concerning left atrial appendage closure devices. Data were extracted from articles by two authors working independently and using three analysis grids to measure the quality of economic evaluations [the British Medical Journal (BMJ) checklist, the hierarchy scale developed by Cooper et al. (J Health Serv Res Policy 10:245-50, 2005) and the Quality of Health Economic Studies (QHES) instrument]. RESULTS Seven economic evaluations met our inclusion criteria. All were published between 2013 and 2016. All were cost-utility analyses, and fully complied with the BMJ checklist. According to the hierarchy scale developed by Cooper et al., the quality of data used was heterogeneous. Finally, the mean score for the seven economic studies was 90/100 with the QHES instrument. CONCLUSIONS Despite the recent development of left atrial appendage closure devices, most economic evaluations conducted here were well-designed studies. Furthermore, different tools used to assess the quality of these studies were complementary, but none gave a global vision of the quality of economic studies.
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Affiliation(s)
- Etienne Nédellec
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Judith Pineau
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Patrice Prognon
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Nicolas Martelli
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France.
- Université Paris-Sud, Université Paris-Saclay, EA7358 GRADES, 5 rue Jean-Baptiste Clément, 92290, Châtenay-Malabry, France.
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Salcedo J, Hay JW, Lam J. Cost-effectiveness of rivaroxaban versus warfarin for treatment of nonvalvular atrial fibrillation in patients with worsening renal function. Int J Cardiol 2018; 282:53-58. [PMID: 30518479 DOI: 10.1016/j.ijcard.2018.11.087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/27/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Nonvalvular atrial fibrillation (NVAF) is highly prevalent and increases the risks of cardiovascular events. In a recent subgroup analysis, treatment response was shown to vary for patients exhibiting worsening renal function (WRF) on-treatment. It is important to understand the cost-effectiveness of novel oral anticoagulant (NOAC) use in this population. METHODS A cost-effectiveness analysis (CEA) was conducted using a Markov model to determine whether NOAC rivaroxaban treatment is cost-effective relative to warfarin in NVAF patients with on-treatment WRF. Input parameters were sourced from clinical literature including a multicenter clinical trial and subgroup analysis. We studied elderly US male patients at increased risk for stroke (CHADS2 score ≥ 2) undergoing treatment for NVAF and exhibiting WRF. Main outcome measures included total healthcare costs in 2017 US dollars (societal perspective), total quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and incremental net monetary benefits (INMB) per-patient. RESULTS The remaining lifetime use of rivaroxaban is associated with 5.69 QALYs at a cost of $66,075 per patient, while warfarin produced 5.22 QALYs with costs of $78,504 per patient. At a willingness-to-pay (WTP) of $150,000 per QALY, incremental net monetary benefits (INMB) per patient are $83,590. In our population, treatment with warfarin was dominated by rivaroxaban in 99.4% of 10,000 simulations. CONCLUSIONS Rivaroxaban is likely a dominant treatment over warfarin in elderly US male NVAF patients exhibiting WRF, providing increased QALYs at a decreased overall cost. Application of these findings may require healthcare providers to predict which patients are likely to exhibit WRF.
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Affiliation(s)
- Jonathan Salcedo
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, United States of America; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, United States of America.
| | - Joel W Hay
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, United States of America; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, United States of America
| | - Jenny Lam
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, United States of America; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, United States of America
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Sharma SP, Park P, Lakkireddy D. Left Atrial Appendages Occlusion: Current Status and Prospective. Korean Circ J 2018; 48:692-704. [PMID: 30073807 PMCID: PMC6072669 DOI: 10.4070/kcj.2018.0231] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
Stroke continues to be a major cause of morbidity and mortality in atrial fibrillation (AF) patients. Oral anticoagulation (OAC) provides protection against stroke and peripheral embolization in AF but significant proportion of patients could not be started on anticoagulation because of bleeding complications. Left atrial appendage harbors clot in about 90% of nonvalvular AF. The advent of left atrial appendage occlusion (LAAO) techniques has provided these patients with alternative to OAC for stroke prophylaxis. Multiple LAAO devices are currently available with Watchman and Amulet being the most commonly used in clinical practice. Randomized studies are available for Watchman device only. Data on Amplatzer Cardiac Plug, Amulet and Lariat devices are limited by the paucity of randomized data. Long-term data on different LAAO techniques are showing promising results. Device related thrombosis continues to be a serious complication associated with LAAO. Future studies should look into comparative effectiveness between different LAAO techniques, optimal patient selection, risk of complications, and anticoagulant treatment after LAAO. This article aims to provide current available evidence on efficacy and safety of different LAAO devices and future prospective.
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Affiliation(s)
| | - Peter Park
- Kansas City Heart Rhythm Institute, Overland Park, KS, USA
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Alkhouli M, Noseworthy PA, Rihal CS, Holmes DR. Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2018; 71:2790-2801. [DOI: 10.1016/j.jacc.2018.04.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/16/2018] [Accepted: 04/09/2018] [Indexed: 12/18/2022]
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Reddy VY, Akehurst RL, Amorosi SL, Gavaghan MB, Hertz DS, Holmes DR. Cost-Effectiveness of Left Atrial Appendage Closure With the WATCHMAN Device Compared With Warfarin or Non-Vitamin K Antagonist Oral Anticoagulants for Secondary Prevention in Nonvalvular Atrial Fibrillation. Stroke 2018; 49:1464-1470. [PMID: 29739915 PMCID: PMC5976225 DOI: 10.1161/strokeaha.117.018825] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 02/01/2018] [Accepted: 02/15/2018] [Indexed: 12/13/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non–vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack. Methods— A Markov model was constructed using data from the secondary prevention subgroup analyses of the non–vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHA2DS2-VASc score of 7 (annual stroke risk=9.60%) and HAS-BLED score of 3 (annual bleeding risk=3.74%). Results— LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis. Conclusions— Upfront procedure costs initially make LAAC higher cost than warfarin and the non–vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.
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Affiliation(s)
- Vivek Y Reddy
- From the Icahn School of Medicine at Mount Sinai Medical Center, New York, NY (V.Y.R.)
| | - Ronald L Akehurst
- BresMed, Sheffield, United Kingdom (R.L.A.).,School of Health and Related Research, University of Sheffield, United Kingdom (R.L.A.)
| | - Stacey L Amorosi
- Health Economics Center of Excellence, Boston Scientific, Marlborough, MA (S.L.A.)
| | | | | | - David R Holmes
- Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.R.H.)
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Xue X, Jiang L, Duenninger E, Muenzel M, Guan S, Fazakas A, Cheng F, Illnitzky J, Keil T, Yu J. Impact of chronic kidney disease on Watchman implantation: experience with 300 consecutive left atrial appendage closures at a single center. Heart Vessels 2018; 33:1068-1075. [PMID: 29564543 PMCID: PMC6096728 DOI: 10.1007/s00380-018-1157-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/16/2018] [Indexed: 12/11/2022]
Abstract
The prevalence of chronic kidney disease (CKD) is high in patients with atrial fibrillation (AF). Left atrial appendage closure (LAAC) has been recognized as an efficient alternative to oral anticoagulation for the prevention of thromboembolic events in patients with non-valvular AF (NVAF); however, the long-term safety and efficacy of LAAC in patients with CKD remain unclear. This study was designed to provide data regarding the safety and efficacy of LAAC in NVAF patients with CKD. A real-world analysis of the safety and efficacy of LAAC was performed on a cohort of 300 NVAF patients with or without CKD who underwent LAAC using the Watchman (WM) device at our center. The patients with CKD (n = 151) were significantly older (77.0 ± 7.2 vs. 73.2 ± 7.8 years, respectively, P < 0.0001) and had a higher CHA2DS2-VASc score (4.3 ± 1.5 vs. 3.4 ± 1.4, respectively, P < 0.0001) and HAS-BLED score (4.0 ± 1.0 vs. 3.0 ± 1.0, respectively, P < 0.0001) than the patients without CKD (n = 149). However, there were no differences between groups with respect to the device implant success rate (98.7 vs. 97.3%, respectively, P = 0.446) or severe periprocedural complications within 7 days. The patients were followed up for 637 ± 398 days, and all patients received repeat transesophageal echocardiography (TEE). Thirteen (4.3%) device-related thrombi, 3 (1.0%) ischemic strokes, and 19 (6.3%) non-procedural major bleeding cases were documented, and there were no differences in these complications between groups. The observed rate of all thromboembolic events by Kaplan–Meier analysis decreased by 68.8% (CKD) and 48.6% (non-CKD); moreover, the observed annual rate of bleeding was reduced by 57.5% (CKD) and 11.4% (non-CKD). Our results indicate that LAAC with the WM device is safe and effective in preventing stroke in NVAF patients with and without CKD.
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Affiliation(s)
- Xin Xue
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany.,Department of Cardiology, The Second Hospital, Jilin University, Changchun, People's Republic of China
| | - Lisheng Jiang
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany.,Department of Cardiology, Chest Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Erich Duenninger
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany
| | - Manuela Muenzel
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany
| | - Shaofeng Guan
- Department of Cardiology, Chest Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Adam Fazakas
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany
| | - Fanzhou Cheng
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany.,Department of Cardiology, Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Juergen Illnitzky
- Department of Nephrology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | - Thorsten Keil
- Department of Anesthesiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | - Jiangtao Yu
- Department of Cardiology, Helmut-G.-Walther-Klinikum, 96215, Lichtenfels, Germany.
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Dar T, Turagam MK, Yarlagadda B, Tantary M, Sheldon SH, Lakkireddy D. Indication, Patient Selection, and Referral Pathways for Left Atrial Appendage Closure. Interv Cardiol Clin 2018. [PMID: 29526286 DOI: 10.1016/j.iccl.2017.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Left atrial appendage closure (LAAC) has emerged as a viable option for stroke prevention, especially in those intolerant of or not suitable for long-term oral anticoagulation therapy. This article describes the clinical characteristics, indications, and a proposed referral system for potential LAAC patients. Patient selection remains a challenge because of the paradox between the available randomized data on this intervention and the actual patient population who may gain maximum benefit. Further investigations comparing different LAAC devices with each other and with novel oral anticoagulants are needed. Also, the optimal antithrombotic regimen post-procedure has yet to be determined.
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Affiliation(s)
- Tawseef Dar
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital and Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mohit K Turagam
- Division of Cardiology, Helmsey Center for Electrophysiology, Icahn School of Medicine at Mount Sinai, 1190 5th Avenue, 1 South, New York, NY 10029, USA
| | - Bharath Yarlagadda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital and Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mohmad Tantary
- Department of Internal Medicine, Clinch Valley Medical Center, 6801 Governor G C Peery Highway, Richlands, VA 24641, USA
| | - Seth H Sheldon
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital and Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital and Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Pérez de Prado A, Serrador A, Jiménez-Quevedo P, Benito González T, Fernández Vázquez F, Pan M. Selección de lo mejor del año 2017 en cierre percutáneo de la orejuela izquierda: completando la evidencia científica. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pérez de Prado A, Serrador A, Jiménez-Quevedo P, Benito González T, Fernández Vázquez F, Pan M. Selection of the Best of 2017 in Left Atrial Appendage Occlusion: Filling the Gap in Knowledge. ACTA ACUST UNITED AC 2018; 71:225-227. [PMID: 29352720 DOI: 10.1016/j.rec.2017.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/11/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Ana Serrador
- Servicio de Cardiología, Hospital Clínico Universitario, CIBERCV, Valladolid, Spain
| | - Pilar Jiménez-Quevedo
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | | | | | - Manuel Pan
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
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Sanchez JM, Al-Dosari G, Chu S, Beygui R, Deuse T, Badhwar N, Lee RJ. Hybrid and surgical procedures for the treatment of persistent and longstanding persistent atrial fibrillation. Expert Rev Cardiovasc Ther 2018; 16:91-97. [PMID: 29327638 DOI: 10.1080/14779072.2018.1425140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common cardiac arrhythmia. The incidence of AF increases with age and is associated with increased stroke, heart failure and mortality. Persistent and long standing persistent AF is difficult to treat and often refractory to medical therapy and catheter ablation. Areas covered: This article reviews the historical development of the surgical Cox-MAZE procedure and current hybrid and minimally invasive surgical approaches for the treatment of persistent and long standing persistent AF. The role of concomitant pulmonary vein isolation and left atrial appendage (LAA) exclusion will also be reviewed. Expert commentary: An ablation pattern emulating the Cox-Maze surgical procedure is commonly needed to obtain maintenance of sinus rhythm in patients with persistent and long standing persistent atrial fibrillation. Minimally invasive bilateral thorascopic surgical procedures can achieve a similar Cox-Maze lesion set, but are associated with increased adverse events compared to catheter ablation. Future prospective randomized studies are required to confirm whether the recently developed hybrid subxyphoid epicardial/endocardial procedure and percutaneous LAA ligation and catheter ablation are indeed as effective as surgical options with less adverse events.
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Affiliation(s)
- Jose M Sanchez
- a Division of Cardiology, Section of Cardiac Electrophysiology, Department of Medicine , University of California , San Francisco , CA , USA
| | - Ghannam Al-Dosari
- b Cardiovascular Surgery Division, Department of Surgery , University of Texas , Galvaston , TX , USA
| | - Sherman Chu
- a Division of Cardiology, Section of Cardiac Electrophysiology, Department of Medicine , University of California , San Francisco , CA , USA
| | - Ramin Beygui
- c Cardiovascular Surgery Division, Department of Surgery , University of California , San Francisco , CA , USA
| | - Tobias Deuse
- c Cardiovascular Surgery Division, Department of Surgery , University of California , San Francisco , CA , USA
| | - Nitish Badhwar
- a Division of Cardiology, Section of Cardiac Electrophysiology, Department of Medicine , University of California , San Francisco , CA , USA
| | - Randall J Lee
- a Division of Cardiology, Section of Cardiac Electrophysiology, Department of Medicine , University of California , San Francisco , CA , USA
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Joo H, Wang G, George MG. Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke. Am J Prev Med 2017; 53:S205-S212. [PMID: 29153122 PMCID: PMC5819005 DOI: 10.1016/j.amepre.2017.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/09/2017] [Accepted: 06/05/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA. METHODS A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017. RESULTS Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY. CONCLUSIONS IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.
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Affiliation(s)
- Heesoo Joo
- IHRC Inc., Atlanta, Georgia; Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Gloekler S, Saw J, Koskinas KC, Kleinecke C, Jung W, Nietlispach F, Meier B. Left atrial appendage closure for prevention of death, stroke, and bleeding in patients with nonvalvular atrial fibrillation. Int J Cardiol 2017; 249:234-246. [DOI: 10.1016/j.ijcard.2017.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023]
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Affiliation(s)
- Lluis Asmarats
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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Yao Y, Shang MS, Dong JZ, Ma CS. Homocysteine in non-valvular atrial fibrillation: Role and clinical implications. Clin Chim Acta 2017; 475:85-90. [PMID: 29050786 DOI: 10.1016/j.cca.2017.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/15/2017] [Accepted: 10/15/2017] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia, is associated with a series of adverse complications that cause so-called AF socioeconomic burden. Apart from the classical risk factors, it seems to be novel factors that increase the risk of AF and AF-related stroke. Recently, more and more evidence has well documented the close relationships between homocysteine (Hcy) and AF. As a well-known marker for pro-oxidation and pro-inflammation, Hcy plays an important role in a number of vascular diseases having strong association with AF. This review will discuss the expression of Hcy and its association with ischemic stroke in AF patients especially for elderly patients, and the role and clinical implications of Hcy in the thromboembolic events and rhythm outcome in AF patients. The possible mechanisms linking elevated Hcy and cardiovascular events in AF patients will also be addressed, including oxidative stress, inflammatory response, atrial remodeling, etc.
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Affiliation(s)
- Yan Yao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China.
| | - Mei-Sheng Shang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
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Reddy VY. Left atrial appendage closure devices: A reasonable therapeutic alternative. Heart Rhythm 2017; 15:302-305. [PMID: 29030234 DOI: 10.1016/j.hrthm.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York.
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47
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Fastner C, Behnes M, Ansari U, El-Battrawy I, Borggrefe M. Interventional Left Atrial Appendage Closure: Focus on Practical Implications. Interv Cardiol 2017. [DOI: 10.5772/67773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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49
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Freeman JV, Hutton DW, Barnes GD, Zhu RP, Owens DK, Garber AM, Go AS, Hlatky MA, Heidenreich PA, Wang PJ, Al-Ahmad A, Turakhia MP. Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.115.003407. [PMID: 27307517 DOI: 10.1161/circep.115.003407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/31/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data. METHODS AND RESULTS We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation. CONCLUSIONS Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice.
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Affiliation(s)
- James V Freeman
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.).
| | - David W Hutton
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Geoffrey D Barnes
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Ruo P Zhu
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Douglas K Owens
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Alan M Garber
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Alan S Go
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Mark A Hlatky
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Paul A Heidenreich
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Paul J Wang
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Amin Al-Ahmad
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Mintu P Turakhia
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
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Bergmann MW. LAA occluder device for stroke prevention: Data on WATCHMAN and other LAA occluders. Trends Cardiovasc Med 2017; 27:435-446. [PMID: 28461140 DOI: 10.1016/j.tcm.2017.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/10/2017] [Accepted: 03/20/2017] [Indexed: 01/01/2023]
Abstract
NOAC therapy has become the standard for stroke prevention in patients with atrial fibrillation. Yet some patients suffer extracranial bleeding events or have other reasons to seek non-pharmacologic stroke protection. LAA occlusion with the WATCHMAN device has been proven safe and effective for such patients and is now recommended in current guidelines for this patient group; other devices also seek approval.
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