Stroke prevention strategies in high-risk patients with atrial fibrillation

Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery

The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-analysis

Aortic stenosis is a common and significant valve condition requiring bioprosthetic heart valves with transcatheter aortic valve replacement (TAVR) being strongly recommended for high-risk patients or patients over 75 years. This meta-analysis aimed to pool existing data on postprocedural clinical as well as echocardiographic outcomes comparing valve-in-valve (ViV)-TAVR to redo-surgical aortic valve replacement to assess the short-term and medium-term outcomes for both treatment methods. A systematic literature search on Cochrane Central, Scopus, and Medline (PubMed interface) electronic databases from inception to August 2023. We used odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Twenty-four studies (25,216 patients) were pooled with a mean follow-up of 16.4 months. The analysis revealed that ViV-TAVR group showed a significant reduction in 30-day mortality (OR 0.50, 95% confidence interval [CI] 0.43 to 0.58, p <0.00001), new-onset atrial fibrillation (OR 0.34, 95% CI 0.17 to 0.67, p = 0.002), major bleeding event (OR 0.28, 95% CI 0.17 to 0.45, p <0.00001) and lower rate of device success (OR 0.25, 95% CI 0.12 to 0.53, p = 0.0003). There were no significant differences between either group when assessing 1-year mortality, stroke, myocardial infarction, postoperative left ventricular ejection fraction, and effective orifice area. ViV-TAVR cohort showed a significantly increased incidence of paravalvular leaks, aortic regurgitation, and increased mean aortic valve gradient. ViV-TAVR is a viable short-term option for older patients with high co-morbidities and operative risks, reducing perioperative complications and improving 30-day mortality with no significant cardiovascular adverse events. However, both treatment methods present similar results on short-term to medium-term complications assessment.

Stroke Related Brain-Heart Crosstalk: Pathophysiology, Clinical Implications, and Underlying Mechanisms

The emergence of acute ischemic stroke (AIS) induced cardiovascular dysfunctions as a bidirectional interaction has gained paramount importance in understanding the intricate relationship between the brain and heart. Post AIS, the ensuing cardiovascular dysfunctions encompass a spectrum of complications, including heart attack, congestive heart failure, systolic or diastolic dysfunction, arrhythmias, electrocardiographic anomalies, hemodynamic instability, cardiac arrest, among others, all of which are correlated with adverse outcomes and mortality. Mounting evidence underscores the intimate crosstalk between the heart and the brain, facilitated by intricate physiological and neurohumoral complex networks. The primary pathophysiological mechanisms contributing to these severe cardiac complications involve the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic and parasympathetic hyperactivity, immune and inflammatory responses, and gut dysbiosis, collectively shaping the stroke-related brain-heart axis. Ongoing research endeavors are concentrated on devising strategies to prevent AIS-induced cardiovascular dysfunctions. Notably, labetalol, nicardipine, and nitroprusside are recommended for hypertension control, while β-blockers are employed to avert chronic remodeling and address arrhythmias. However, despite these therapeutic interventions, therapeutic targets remain elusive, necessitating further investigations into this complex challenge. This review aims to delineate the state-of-the-art pathophysiological mechanisms in AIS through preclinical and clinical research, unraveling their intricate interplay within the brain-heart axis, and offering pragmatic suggestions for managing AIS-induced cardiovascular dysfunctions.

Safety and efficacy of Cox-Maze procedure for atrial fibrillation during mitral valve surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Cox-Maze procedure is currently the gold standard treatment for atrial fibrillation (AF). However, data on the effectiveness of the Cox-Maze procedure after concomitant mitral valve surgery (MVS) are not well established. The aim of this study was to assess the safety and efficacy of Cox-Maze procedure versus no-maze procedure n in AF patients undergoing mitral valve surgery through a systematic review of the literature and meta-analysis.

METHODS

A systematic search on PubMed/MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials (Cochrane Library, Issue 02, 2017) databases were performed using three databases from their inception to March 2023, identifying all relevant randomized controlled trials (RCTs) comparing Cox-Maze procedure versus no procedure in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Nine RCTs meeting the inclusion criteria were included in this systematic review with 663 patients in total (341 concomitant Cox-Maze with MVS and 322 MVS alone). Across all studies with included AF patients undergoing MV surgery, the concomitant Cox-Maze procedure was associated with significantly higher sinus rhythm rate at discharge, 6 months, and 12 months follow-up when compared with the no-Maze group. Results indicated that there was no significant difference between the Cox-Maze and no-Maze groups in terms of 1 year all-cause mortality, pacemaker implantation, stroke, and thromboembolism.

CONCLUSIONS

Our systematic review suggested that RCTs have demonstrated the addition of the Cox-Maze procedure for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke, and thromboembolism.

Altered Callosal Morphology and Connectivity in Asymptomatic Carotid Stenosis

BACKGROUND

Carotid stenosis, even in the clinically asymptomatic stage, causes cognitive impairment, silent lesions, and hemispheric changes. The corpus callosum (CC) is crucial for hemispheric cortical integration and specialization.

PURPOSE

To examine if CC morphology and connectivity relate to cognitive decline and lesion burden in asymptomatic carotid stenosis (ACS).

STUDY TYPE

Retrospective, cross-sectional.

POPULATION

33 patients with unilaterally severe (70%) ACS and 28 demographically and comorbidity-matched controls. A publicly available healthy adult lifespan (ages between 18 and 80; n = 483) MRI dataset was also included.

FIELD STRENGTH/SEQUENCE

A 3.0 T; T1 MPRAGE and diffusion weighted gradient echo-planar imaging sequences.

ASSESSMENT

Structural MRI and multidomain cognitive data were obtained. Midsagittal CC area, circularity, thickness, integrity, and probabilistic tractography were calculated and correlated with cognitive tests and white matter hyperintensity. Fractional anisotropy, mean diffusivity (MD), and radial diffusivity were determined from DTI.

STATISTICAL TESTS

Independent two-sample t-tests, χ2 tests, Mann-Whitney U, locally weighted scatterplot smoothing (LOWESS) curve fit, and Pearson correlation. A P value < 0.05 was considered statistically significant.

RESULTS

Patients with ACS demonstrated significant reductions in callosal area, circularity, and thickness compared to controls. The callosal atrophy was significantly correlated with white matter hyperintensity size (r = -0.629, P < 0.001). Voxel-wise analysis of diffusion measures in the volumetric CC showed that ACS patients exhibited significantly lower fractional anisotropy and higher MD and radial diffusivity in the genu and splenium of the CC than controls. Further lifespan trajectory analysis showed that although the midsagittal callosal area, circularity, and thickness exhibited age-related decreases, the values in the ACS patients were significantly lower in all age groups.

DATA CONCLUSION

Midsagittal callosal atrophy and connectivity reflect the load of silent lesions and the severity of cognitive decline, respectively, suggesting that CC degeneration has potential to serve as an early marker in ACS.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

The relationship between atrial fibrillation and coronary artery disease: Understanding common denominators

Atrial fibrillation (AF) and coronary artery disease (CAD) are highly prevalent cardiovascular conditions. The coexistence of both diseases is common as they share similar risk factors and common pathophysiological characteristics. Systemic inflammatory conditions are associated with an increased incidence of both AF and CAD. The presence of both entities increases the incidence of complications and adverse outcomes. Furthermore, their coexistence poses challenges for the management of patients, particularly with respect to anticoagulation and rhythm management. In this review, we aim to better understand the relationship between AF and CAD by detailing basic molecular pathophysiology, assessing therapeutic guidelines, and describing interactions between the two conditions.

Implications of Clinical Risk Phenotypes on the Management and Natural History of Atrial Fibrillation: A Report From the GLORIA-AF

Background Clinical risk factors are common among patients with atrial fibrillation (AF), but there are still limited data on their association with oral anticoagulant (OAC) treatment patterns and major outcomes. We aim to analyze the association between clinical risk phenotypes on AF treatment patterns and the risk of major outcomes. Methods and Results The GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation) phase 2 and 3 registries enrolled patients with a recent diagnosis of AF between 2011 and 2016. We defined 4 features of clinical risk among patients with CHA2DS2-VASc ≥2: elderly individuals (aged ≥80 years), chronic kidney disease (estimated glomerular filtration rate <45 mL/min), history of stroke, and history of bleeding. We analyzed the odds of receiving OAC and the risk of OAC discontinuation and adverse events at follow-up according to specific combinations and cumulative burden of these features. Primary outcome was the composite of all-cause death, thromboembolism, and major bleeding. Among 28 891 (mean±SD age, 70.1±10.5 years; 45.5% women) patients included, 10 797 (37.3%) had at least 1 clinical risk feature. OAC use was lower among patients in the elderly group (odds ratio [OR], 0.85 [95% CI, 0.75-0.96]), those with history of both stroke and bleeding (OR, 0.45 [95% CI, 0.35-0.56]), and those with multiple features (OR, 0.71 [95% CI, 0.62-0.82]). Increasing burden of clinical risk features was associated with OAC discontinuation, with highest magnitude in those with ≥3 features (hazard ratio [HR], 1.68 [95% CI, 1.31-2.15]). Groups with increasingly complex clinical risk phenotypes were associated with the occurrence of the primary composite outcome, with the highest figures observed for groups with a history of both stroke and bleeding (adjusted HR, 2.36 [95% CI, 1.83-3.04]) and multiple features (adjusted HR, 2.86 [95% CI, 2.52-3.25]). Conclusions In patients with AF, clinical risk phenotypes are multifaceted and heterogenous, and they are associated with differences in stroke prevention and worse prognosis.

Adverse Clinical Outcomes and Associated Predictors in Rivaroxaban-Treated Atrial Fibrillation Patients With Renal Impairment

Renal impairment confers worse prognosis in patients with atrial fibrillation (AF) but there is scarce evidence about the influence of direct-acting oral anticoagulants in routine clinical practice. Herein, we compared clinical outcomes between patients with AF with and without renal impairment on rivaroxaban and investigated predictors for clinical outcomes in patients with AF with renal impairment. This was a multicenter study including patients with AF on rivaroxaban for at least 6 months. During 2.5 years follow-up, ischemic strokes (IS)/transient ischemic attacks (TIA)/systemic embolisms (SE)/myocardial infarctions (MI), major bleeding, and major adverse cardiovascular events (MACE) were recorded. Creatinine clearance (CrCl) was estimated using the Cockroft-Gault equation, renal impairment was defined as a CrCl <60 ml/min, and 1,433 patients (34.8% with CrCl <60 ml/min) were included. Patients with CrCl <60 ml/min showed higher event rates for major bleeding (1.87%/year vs 0.62%/year; p = 0.003) and MACE (1.97%/year vs 0.62%/year; p = 0.002) but similar event rates for IS/TIA/SE/MI (0.66%/year vs 0.67%/year; p = 0.955). In patients with renal impairment, CHA2DS2-VASc was associated with higher risk of IS/TIA/SE/MI; HAS-BLED and any dependency level were associated with higher risk of major bleeding; and male gender and heart failure were associated with higher risk of MACE. Antiplatelets were independently associated with increased risk of IS/TIA/SE/MI and MACE. In conclusion, in patients with AF on rivaroxaban, the incidence of IS/TIA/SE/MI did not increase in those with renal impairment, suggesting that rivaroxaban may be an effective option in this subgroup. In patients with AF, male gender, heart failure, dependency, antiplatelets, CHA2DS2-VASc, and HAS-BLED were associated with increased risk of adverse outcomes.

Anticoagulation for Stroke Prevention in Atrial Fibrillation

Cardioembolic stroke from atrial fibrillation causes substantial death and disability in the United States. Treatment with oral anticoagulants provides safe and effective stroke prevention for high-risk patients. This article reviews strategies for the use of anticoagulation and highlights the nurse's role in patient education.

XGBoost-based machine learning test improves the accuracy of hemorrhage prediction among geriatric patients with long-term administration of rivaroxaban

BACKGROUND

Hemorrhage is a potential and serious adverse drug reaction, especially for geriatric patients with long-term administration of rivaroxaban. It is essential to establish an effective model for predicting bleeding events, which could improve the safety of rivaroxaban use in clinical practice.

METHODS

The hemorrhage information of 798 geriatric patients (over the age of 70 years) who needed long-term administration of rivaroxaban for anticoagulation therapy was constantly tracked and recorded through a well-established clinical follow-up system. Relying on the 27 collected clinical indicators of these patients, conventional logistic regression analysis, random forest and XGBoost-based machine learning approaches were applied to analyze the hemorrhagic risk factors and establish the corresponding prediction models. Furthermore, the performance of the models was tested and compared by the area under curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

A total of 112 patients (14.0%) had bleeding adverse events after treatment with rivaroxaban for more than 3 months. Among them, 96 patients had gastrointestinal and intracranial hemorrhage during treatment, which accounted for 83.18% of the total hemorrhagic events. The logistic regression, random forest and XGBoost models were established with AUCs of 0.679, 0.672 and 0.776, respectively. The XGBoost model showed the best predictive performance in terms of discrimination, accuracy and calibration among all the models.

CONCLUSION

An XGBoost-based model with good discrimination and accuracy was built to predict the hemorrhage risk of rivaroxaban, which will facilitate individualized treatment for geriatric patients.

Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre

Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be 'tailored' in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004-2011 and beyond (years 2012-2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients' sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004-2011 and 2012-2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012-2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.

Heart-brain axis: Association of congenital heart abnormality and brain diseases

Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.

Non-embolic outcomes in patients with cardiovascular disease and atrial fibrillation treated with rivaroxaban

Aim: It is not well known how comorbidities may change the prognosis of atrial fibrillation (AF) patients. This study was aimed to analyze the impact of cardiovascular disease on this population. Materials & methods: EMIR was a multicenter, prospective study, including 1433 AF patients taking rivaroxaban for ≥6 months. Data were analyzed according to the presence of vascular disease. Results: Coronary artery disease was detected in 16.4%, peripheral artery disease/aortic plaque in 6.7%, vascular disease in 28.3%. Patients with coronary artery disease had higher rates (per 100 patient-years) of major adverse cardiovascular events (2.98 vs 0.71; p < 0.001) and cardiovascular death (1.79 vs 0.41; p = 0.004). Those with vascular disease had higher rates of thromboembolic events (1.47 vs 0.44; p = 0.007), major adverse cardiovascular events (2.03 vs 0.70; p = 0.004), and cardiovascular death (1.24 vs 0.39; p = 0.025). Patients with peripheral artery disease/aortic plaque had similar rates. Conclusion: AF patients with vascular disease have a higher risk of non-embolic outcomes.

Adherence to the Atrial Fibrillation Better Care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: A post-hoc analysis from the prospective GLORIA-AF Registry

BACKGROUND

The 'Atrial fibrillation Better Care' (ABC) pathway has been proposed to streamline a more holistic or integrated care approach to atrial fibrillation (AF) management. We aimed to analyse the impact of adherence to the ABC pathway on the risk of major adverse outcomes in a contemporary prospective global cohort of patients with AF.

METHODS

Patients enrolled Phase II and III of the GLORIA-AF Registry with complete data on ABC pathway adherence and follow-up were included in this post-hoc analysis between November 2011 and December 2014 for Phase II, and between January 2014 and December 2016 for Phase III. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Multivariable Cox-regression and delay of event (DoE) analyses were used to evaluate the association between adherence to the ABC pathway and the risk of outcomes.

FINDINGS

We included 24,608 patients in this analysis (mean age: 70.2 (10.3) years, 10,938 (44.4%) females). Adherence to the ABC pathway was associated with a significant risk reduction for the primary outcome, with greatest magnitude observed for full ABC pathway adherence (adjusted Hazard Ratio [aHR] 0.54, 95% Confidence Interval [CI]: 0.44-0.67, p < 0.0001). ABC pathway adherence was also associated with reduced risk of mortality (aHR: 0.89, 95% CI: 0.79-1.00, p = 0.048), thromboembolism (aHR: 0.78, 95% CI: 0.65-0.94, p = 0.0078), and MACE (aHR: 0.82, 95% CI: 0.71-0.95, p = 0.0071). An increasing number of ABC criteria attained was associated with longer event-free survival in the DoE analysis.

INTERPRETATION

Adherence to the ABC pathway in patients with AF was associated with a reduced risk of major adverse events, including mortality, thromboembolism and MACE. This underlines the importance of using the ABC pathway in the clinical care of patients with AF.

FUNDING

This study was funded by Boehringer Ingelheim.

The "obesity paradox" in patients with atrial fibrillation: Insights from the Gulf SAFE registry

BACKGROUND

The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial.

METHODS

Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted.

RESULTS

A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients.

CONCLUSION

Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.

Safety and efficacy of direct oral anticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study

AIMS

The aim of this study was to evaluate the risk of stroke and bleeding among patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) despite anaemia at treatment initiation time.

METHODS AND RESULTS

All Danish patients (N = 41 321) diagnosed with incident AF, having a baseline haemoglobin (Hb), and subsequently initiated DOAC therapy between 2012 and 2019 were identified through administrative registry databases. Patients with anaemia were subdivided according to the World Health Organization classification of anaemia and evaluated regarding risk of stroke and composite bleeding endpoint [hospitalization due to urogenital, gastrointestinal (GI), or intracranial bleeding or epistaxis]. Standardized absolute 1-year risks of stroke and composite bleeding endpoint were calculated using multivariable Cox regression analyses. The standardized absolute 1-year risk difference for composite bleeding increased by 0.96% [95% confidence interval (CI) 0.38-1.54] for patients with moderate/severe anaemia compared with patients with no anaemia. This risk was mainly driven by an increase in standardized absolute 1-year risk for serious GI bleeding, which increased by 0.41% (95% CI 0.19-0.63). No significant difference in standardized absolute 1-year bleeding risk was observed among patients with mild anaemia compared with patients with no anaemia 0.36% (95% CI -0.10 to 0.82). No significant difference in standardized absolute 1-year risk of stroke was observed among patients with mild anaemia, -0.16% (95% CI -0.13 to 0.15), and moderate/severe anaemia, -0.47% (95% CI -0.16 to 0.19), compared with patients with no anaemia.

CONCLUSION

For AF patients receiving DOACs, moderate/severe anaemia is a risk factor for serious GI bleeding, while stroke risk is the same regardless of whether anaemia was present at baseline or not.

Mobile health technology integrated care in older atrial fibrillation patients: a subgroup analysis of the mAFA-II randomised clinical trial

BACKGROUND

The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) randomised trial demonstrated the efficacy of a mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in reducing the risk of adverse events in patients with atrial fibrillation (AF). Whether these benefits also apply to older patients is unclear. In this ancillary analysis, we evaluated the effect of mAFA intervention among older AF patients.

METHODS

The mAFA-II trial enrolled adult AF patients across 40 centres in China. For this analysis, we defined older patients as those aged ≥75 years. Primary outcome was the composite of ischemic stroke or thromboembolism, all-cause death and rehospitalisation. The effect of mAFA intervention was assessed through multivariable Cox-regression models. We also evaluated the interaction between age and effect of the mAFA intervention in the main trial population.

RESULTS

In this analysis, we included 1,163 AF patients ≥75 years (mean age: 82.6 ± 5.3 years, 43.1% females); 520 were allocated to mAFA intervention, 643 to usual care. mAFA intervention was associated with a significant reduction of the primary composite outcome (adjusted hazard ratio [aHR]: 0.58, 95% confidence interval [CI]: 0.35-0.97) and rehospitalisations alone (aHR: 0.47, 95%CI: 0.24-0.91). Significant interaction between age and mAFA intervention effect was observed for both the composite outcome (P = 0.002) and rehospitalisation alone (P = 0.015), with the effect decreasing as age increased, particularly among patients ≥80 years old.

CONCLUSIONS

A mHealth technology-implemented ABC pathway is effective in reducing adverse clinical outcomes in older AF patients. The benefits obtained with mAFA intervention were attenuated at extreme ages.

A Novel Puncturable Atrial Septal Defect Occluder: The Results of Preclinical Experiment and First-in-Human Study

ReAces is a novel puncturable transcatheter atrial septal defect occluder. The device success rate was 100% (n = 14 of 14) in the animal experiment. Four swine successfully received puncture of the device 60 days after implantation of the device. The acute procedure success rate in the 10 patients was 100%. Transthoracic echocardiography examination showed that the devices were well positioned with no residual shunt, and the area of central portion of occluder was substantially thin. It is safe and effective to use ReAces for closure of secundum atrial septal defect, and puncture the atrial septum at the portion of the device is feasible.

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

BACKGROUND

 Clinical complexity is common in atrial fibrillation (AF) patients. We assessed the impact of clinical complexity on oral anticoagulant (OAC) treatment patterns and major adverse outcomes in a contemporary cohort of AF patients.

METHODS

 The GLORIA-AF Phase II and III Registry enrolled newly diagnosed AF patients with at least one stroke risk factor. Among patients with CHA₂DS₂-VASc score ≥2, we defined four domains of perceived clinical complexity: frail elderly (age ≥75 years and body mass index <23 kg/m²), chronic kidney disease (CKD, creatinine clearance <60 mL/min), history of bleeding, and those with ≥2 of the above conditions. We evaluated the associations between clinical complexity domains and antithrombotic treatment prescription, risk of OAC discontinuation, and major adverse outcomes.

RESULTS

 Among the 29,625 patients included (mean age 69.6 ± 10.7 years, 44.2% females), 9,504 (32.1%) presented with at least one complexity criterion. Clinical complexity was associated with lower OAC prescription, with stronger associations in frail elderly (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.36-0.62) and those with ≥2 complexity domains (OR: 0.50, 95% CI: 0.44-0.57). Risk of OAC discontinuation was higher among frail elderly (hazard ratio [HR]: 1.30, 95% CI: 1.00-1.69), CKD (HR: 1.10, 95% CI: 1.02-1.20), and those with ≥2 complexity domains (HR: 1.39, 95% CI: 1.23-1.57). Clinical complexity was associated with higher risk of the primary outcome of all-cause death, thromboembolism, and major bleeding, with the highest magnitude in those with ≥2 criteria (HR: 1.63, 95% CI: 1.43-1.86).

CONCLUSION

 In AF patients, clinical complexity influences OAC treatment management, and increases the risk of poor clinical outcomes. These patients require additional efforts, such as integrated care approach, to improve their management and prognosis.

Atrial Fibrillation Better Care Pathway Adherent Care Improves Outcomes in Chinese Patients With Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is a complex disease associated with comorbidities and adverse outcomes. The Atrial fibrillation Better Care (ABC) pathway has been proposed to streamline the integrated and holistic approach to AF care.

OBJECTIVES

This study sought to evaluate patients' characteristics, incidence of adverse events, and impact on outcomes with ABC pathway-adherent management.

METHODS

The study included consecutive AF patients enrolled in the nationwide, ChioTEAF registry (44 centers, 20 Chinese provinces from October 2014 to December 2018), with available data to evaluate the ABC criteria and on the 1-year follow-up.

RESULTS

A total of 3,520 patients (mean age 73.1 ± 10.4 years, 43% female) were included, of which 1,448 (41.1%) were managed as ABC pathway adherent. The latter were younger and had comparable CHA₂DS₂-VASc and lower HAS-BLED (mean 71.7 ± 10.3 years of age vs 74.1 ± 10.4 years of age; P < 0.01; 3.54 ± 1.60 vs 3.44 ± 1.70; P = 0.10; and 1.95 ± 1.10 vs 2.12 ± 1.20; P < 0.01, respectively) scores compared with ABC-nonadherent patients. At 1-year follow-up, patients managed adherent to the ABC pathway had a lower incidence of the primary composite outcome of all-cause death or any thromboembolic event (1.5% vs 3.6%; P < 0.01) as compared with ABC-nonadherent patients. On multivariate analysis, ABC pathway-adherent care was independently associated with a lower risk of the composite endpoint (OR: 0.51; 95% CI: 0.31-0.84).

CONCLUSIONS

Adherence to the ABC pathway for integrated care in a contemporary nationwide cohort of Chinese AF patients was suboptimal. Clinical management adherent to the ABC pathway was associated with better outcomes.

Effect of current smoking on ischemic events in patients with atrial fibrillation taking vitamin K antagonist

Purpose

We investigated the association between current smoking and clinical outcomes in patients with atrial fibrillation (AF) prescribed vitamin K antagonist (VKA).

Methods

We conducted a retrospective study at 71 centers in Japan. The inclusion criterion was taking a VKA for AF. Exclusion criteria were mechanical heart valves or history of pulmonary thrombosis or deep vein thrombosis. Consecutive patients were registered in February 2013 and followed until February 2017. The primary outcomes included ischemic events and major bleedings. The secondary outcomes were ischemic stroke, hemorrhagic stroke, and all-cause mortality.

Results

A total of 7826 patients were included, with a mean age of 73 years; 5274 (67%) were men. The adjusted hazard ratios (HRs; 95% confidence intervals [CIs]) of current smokers relative to non-current smokers for ischemic events and major bleedings were 1.64 (1.05-2.57) and 1.09 (0.72-1.65), respectively. The adjusted HRs (95% CIs) of current smokers relative to non-current smokers for ischemic stroke, hemorrhagic stroke, and all-cause mortality were 1.65 (1.03-2.64), 0.52 (0.12-2.15), and 1.26 (0.83-1.92), respectively.

Conclusions

There were significant associations between current smoking and ischemic events or ischemic stroke in patients with AF on VKA.

Nerve growth factor and post-infarction cardiac remodeling

The prevalence of sudden death from chronic heart failure and cardiac arrhythmias caused by myocardial infarction is a complex problem in cardiology. Post-infarction cardiac remodeling occurs after myocardial infarction. This compensatory-adaptive reaction, regulated by mechanical, neurohumoral and genetic factors, includes the structural and functional changes of cardiomyocytes, stromal elements and extracellular matrix, geometry and architectonics of the left ventricular cavity. Adverse left ventricular remodeling is associated with heart failure and increased mortality. The concept of post-infarction cardiac remodeling is an urgent problem, since the mechanisms of development and progression of adverse post-infarction changes in the myocardium are completely unexplored. In recent years, the scientist attention has been focused on neurotrophic factors involved in the sympathetic nervous system and the vascular system remodeling after myocardial infarction. Nerve growth factor (NGF) is a protein from the neurotrophin family that is essential for the survival and development of sympathetic and sensory neurons, which also plays an important role in vasculogenesis. Acute myocardial infarction and heart failure are characterized by changes in the expression and activity of neurotrophic factors and their receptors, affecting the innervation of the heart muscle, as well as having a direct effect on cardiomyocytes, endothelial and smooth muscle vascular cells. The identification of the molecular mechanisms involved in the interactions between cardiomyocytes and neurons, as well as the study of the effects of NGF in the cardiovascular system, will improve understanding of the cardiac remodeling mechanism. This review summarizes the available scientific information (2019–2021) about mechanisms of the link between post-infarction cardiac remodeling and NGF functions.

Effects of the Atrial Fibrillation Better Care Pathway on Outcomes Among Clinically Complex Chinese Patients With Atrial Fibrillation With Multimorbidity and Polypharmacy: A Report From the ChiOTEAF Registry

Background Patients with atrial fibrillation commonly have complex clinical backgrounds of multimorbidity and polypharmacy. The Atrial Fibrillation Better Care (ABC) pathway has been developed to help deliver integrated and holistic care for patients with atrial fibrillation. In this ancillary analysis, we assessed the adherence to and the effectiveness of the ABC pathway at reducing adverse outcomes in Chinese patients with atrial fibrillation with a complex clinical background of multimorbidity or polypharmacy. Methods and Results The ChiOTEAF (Optimal Thromboprophylaxis in Elderly Chinese Patients With Atrial Fibrillation) registry is a prospective, multicenter, nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite end point of all-cause death and thromboembolic events, as well as individual end points of all-cause death, thromboembolic events, and major bleeding. Multimorbidity was defined as the presence of ≥2 comorbidities, and polypharmacy was defined as the concomitant use of ≥5 medications. The eligible cohort included 4644 patients with multimorbidity, of whom 2610 (56.2%) had available data to assess the ABC pathway usage (mean age, 74.4±10.2; 42.8% women). Among patients with polypharmacy (n=2262; mean age, 74.6±10.1; 43.3% women), 1328 (58.7%) had available data to assess the use of the ABC pathway. Adherence to the ABC pathway was associated with a lower risk of the primary composite outcome among patients with multimorbidity (odds ratio, 0.48; 95% CI, 0.29-0.79) and in the polypharmacy group (odds ratio, 0.39; 95% CI, 0.19-0.78). Health-related quality of life was lower in the non-ABC-adherent group compared with the ABC-treated patients. Conclusions This nationwide real-world registry shows that adherence to the ABC pathway is associated with improved clinical outcomes and health-related quality of life in clinically complex Chinese patients with atrial fibrillation with multimorbidity or polypharmacy.

Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry

BACKGROUND

Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry.

METHODS

The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up.

RESULTS

729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA₂ DS₂ -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates.

CONCLUSIONS

In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.

Epidemiology of cerebral microbleeds and risk of adverse outcomes in atrial fibrillation: a systematic review and meta-analysis

AIMS

The aim of this study is to perform a systematic review and meta-analysis on the epidemiology of cerebral microbleeds (CMBs) and the risk of intracranial haemorrhage (ICH) and ischaemic stroke (IS) in patients with atrial fibrillation (AF).

METHODS AND RESULTS

PubMed and EMBASE databases were systematically searched from inception to 6 March 2021. All studies reporting the prevalence of CMBs and incidence of ICH and IS in AF patients with and without CMBs were included. Meta-analysis was conducted using random-effect models; odds ratios (ORs), 95% confidence intervals (CIs), and prediction intervals (PIs) were calculated for each outcome. Subgroup analyses were performed according to the number and localization of CMBs. A total of 562 studies were retrieved, with 17 studies finally included in the meta-analysis. Prevalence of CMBs in AF population was estimated at 28.3% (95% CI: 23.8-33.4%). Individuals with CMBs showed a higher risk of ICH (OR: 3.04, 95% CI: 1.83-5.06, 95% PI 1.23-7.49) and IS (OR: 1.78, 95% CI: 1.26-2.49, 95% PI 1.10-2.87). Patients with ≥5 CMBs showed a higher risk of ICH. Metaregression showed how higher of prevalence of diabetes mellitus in AF cohort is associated with higher prevalence of CMBs.

CONCLUSIONS

Cerebral microbleeds are common in patients with AF, found in almost one out of four subjects. Cerebral microbleeds were associated with both haemorrhagic and thromboembolic events in AF patients. Moreover, the risk of ICH increased consistently with the burden of CMBs. Cerebral microbleeds may represent an important overlooked risk factor for both ICH and IS in adults with AF.

Impact of Multimorbidity and Polypharmacy on Clinical Outcomes of Elderly Chinese Patients with Atrial Fibrillation

Background: The co-incidence of multiple morbidities and polypharmacy is common amongst patients with atrial fibrillation (AF); however, data on their impact on clinical outcomes are scarce in Asian cohorts. Objective: To evaluate the impact of multimorbidity and polypharmacy on clinical outcomes and AF management among elderly Chinese patients. Methods: The ChiOTEAF registry is a prospective, multicenter nationwide study conducted from October 2014 to December 2018. Endpoints of interest were the composite outcome of all-cause death/any thromboembolism (TE), all-cause death, cardiovascular death, TE events, major bleeding, as well as AF management. Results: The eligible cohort included 6341 individuals (mean age 74.7 ± 10.7; 39.1% female), of whom 4644 (73.2%) had multimorbidity (defined as two or more chronic diseases), and 2262 (35.7%) were treated with five or more medications. There were 2775 (43.8%) patients on anticoagulant (OAC) use. On multivariate analysis, (i) multimorbidity was associated with a higher odds ratio of the composite outcome (OR: 2.04; 95% CI: 1.49–2.79), all-cause death (OR: 1.82; 95% CI: 1.31–2.54), cardiovascular death (OR: 2.05; 95% CI: 1.13–3.69), any TE (OR: 2.69; 95% CI: 1.29–5.62), and major bleeding (OR: 2.61; 95% CI: 1.25–5.45); (ii) polypharmacy was associated with a lower odds ratio of all-cause death (OR: 0.78; 95% CI: 0.63–0.96). The use of OAC was safe and was associated with a lower odds ratio of the composite outcome and all-cause death in all subgroups of patients. Conclusions: Multimorbidity and polypharmacy were common among elderly AF Chinese patients. Multimorbidity was an independent predictor of adverse clinical outcomes. The use of OAC was safe and significantly improved survival amongst AF patients with multimorbidity and polypharmacy.

Effects of direct oral anticoagulants dabigatran and rivaroxaban on the blood coagulation function in rabbits

The aim of this study was to explore the effects of dabigatran and rivaroxaban on the activities of various coagulation factors. To achieve that, 60 rabbits were randomly divided into experimental groups that received different doses of dabigatran or rivaroxaban. The effects of dabigatran and rivaroxaban on the activities of FII, FV, FVIII, FX, and activated protein C (APC) were analyzed. In the dabigatran groups, activated partial thromboplastin time and thromboplastin time (TT) were prolonged after drug administration, and the activities of FII, FV, FVIII, and FX were inhibited as the drug concentration increased. Low doses of dabigatran inhibited APC activity. In the rivaroxaban groups, APTT and TT were not significantly prolonged after drug administration. In contrast, the high-dose rivaroxaban group exhibited prolonged PT, and the degree of inhibition of the activities of FII, FV, FVIII, and FX increased as the drug concentration increased. Rivaroxaban had no significant effect on APC activity regardless of dosage. As the drug concentration increased, both NOACs had more significant inhibitory effects on the activities of FII, FV, FVIII, and FX. Low concentrations of dabigatran generated an inhibitory effect on APC activity, while high concentrations of dabigatran had no significant effect. Rivaroxaban had no significant effect on APC activity.

Improvement of Retinal Microcirculation after Pulmonary Vein Isolation in Patients with Atrial Fibrillation—An Optical Coherence Tomography Angiography Study

Purpose: To evaluate retinal and optic nerve head (ONH) perfusion in patients with atrial fibrillation (AF) before and after catheter ablation of AF with pulmonary vein isolation (PVI). Methods: 34 eyes of 34 patients with AF and 35 eyes of 35 healthy subjects were included in this study. Flow density data were obtained using spectral-domain OCT-A (RTVue XR Avanti with AngioVue, Optovue, Inc, Fremont, California, USA). The data of the superficial and deep vascular layers of the macula and the ONH (radial peripapillary capillary network, RPC) before and after PVI were extracted and analysed. Results: The flow density in the superficial OCT-angiogram (whole en face) and the ONH (RPC) in patients with AF was significantly lower compared to healthy controls (OCT-A superficial: study group: 48.77 (45.19; 52.12)%; control group: 53.01 (50.00; 54.25)%; p < 0.001; ONH: study group: 51.82 (48.41; 54.03)%; control group: 56.00 (54.35; 57.70)%; p < 0.001;). The flow density in the ONH (RPC) improved significantly in the study group following PVI (before: 51.82 (48.41; 54.03)%; after: 52.49 (50.34; 55.62)%; p = 0.007). Conclusions: Patients with AF showed altered ocular perfusion as measured using OCTA when compared with healthy controls. Rhythm control using PVI significantly improved ocular perfusion as measured using OCT-A. Non-contact imaging using OCTA provides novel information about the central global microperfusion of patients with AF.

Are low doses of non-vitamin K antagonists effective in Chinese patients with atrial fibrillation? A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

BACKGROUND

Suboptimal low dosages of non-vitamin K antagonist oral anticoagulants (NOACs) are often inappropriately used due to a fear of bleeding, particularly among elderly patients. Such practice is common in Asia, and we aimed to evaluate the use of low-dose NOACs and their impact on clinical outcomes among Chinese patients with atrial fibrillation.

METHODS

The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry was a prospective, multicenter study conducted in China from October 2014 to December 2018. For this report, we included NOAC-treated patients with available data on NOAC dosage and one-year follow-up. Logistic regression analysis assessed the association (adjusted for age, sex, prior ischemic stroke, prior major bleeding, heart failure, coronary artery disease, hypertension, diabetes mellitus, chronic kidney disease, liver disease, current anemia) between the low doses and study outcomes among NOAC-treated patients, as well as comparisons with non-anticoagulated patients.

RESULTS

The eligible cohort included 1310 NOAC-treated patients (mean age of 72.1 ± 10.9; 38.9% female), of whom 341 (26.0%) received a low "off-label" dose. The use of low-dose NOACs was independently associated with higher odds of the composite outcome (OR: 2.51; 95% CI: 1.11-5.71) and thromboembolism (OR: 4.73; 95% CI: 1.11-20.01). Compared with non-anticoagulated patients, lower rates of the composite outcome (7.3% vs. 11.3%; p = 0.025) and all-cause death (5.3% vs. 9.7%; p = 0.007) were seen in the low-dose group (ORs 0.50; 95% CI: 0.32-0.78, and 0.42; 95% CI: 0.26-0.70, respectively).

CONCLUSIONS

Low doses of NOACs should not be recommended as a part of standard therapy among Chinese patients with atrial fibrillation as their use was associated with a higher odds ratio of the composite outcome and thromboembolic events compared with standard dose NOAC regimens. Compared to non-treatment, the use of low-dose NOAC may result in a survival benefit (but not thromboembolic reduction) among high-risk patients.

One-year Follow-up Results of the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

BACKGROUND

The high prevalence of atrial fibrillation (AF) in the very elderly population (aged >80 years) might be underestimated. The elderly are at increased risk of both fatal stroke and bleeding. The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry provides contemporary management strategies among the elderly Chinese patients in the new era of non-vitamin K antagonists.

OBJECTIVE

To present the 1-year follow-up data from the ChiOTEAF registry, focusing on the use of antithrombotic therapy, rate vs. rhythm control strategies, and determinants of mortality and stroke.

METHODS

The ChiOTEAF registry analyzed consecutive AF patients presenting in 44 centers from 20 Chinese provinces from October 2014 to December 2018. Endpoints of interest were mortality, thromboembolism, major bleedings, cardiovascular comorbidities, and hospital re-admissions.

RESULTS

Of the 7077 patients enrolled at baseline, 657 patients (9.3%) were lost to the follow-up and 435 deaths (6.8%) occurred. The overall use of anticoagulants remains low, approximately 38% of the entire cohort at follow-up, with similar proportions of vitamin K antagonists (VKA) and non-vitamin K antagonists (NOACs). Antiplatelet therapy was used in 38% of the entire cohort at follow-up, and more commonly among high-risk patients (41%). Among those on a NOAC at baseline, 22.4% switched to antiplatelet therapy alone after one year.Independent predictors of stroke/transient ischemic attack/peripheral embolism and/or mortality were age, heart failure, chronic kidney disease, prior ischemic stroke, dementia, and chronic obstructive pulmonary disease.

CONCLUSIONS

The ChiOTEAF registry provides contemporary data on AF management, including stroke prevention. The poor adherence of NOACs and common use of antiplatelet in these high-risk elderly population calls for multiple comorbidities management.

Oral anticoagulation improves survival in very elderly Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

BACKGROUND

Advancing age is a major risk factor for ischemic stroke in atrial fibrillation. We aimed to evaluate the predictors of all-cause death/any thromboembolism and the impact of oral anticoagulant on clinical outcomes in very elderly (≥85 years) Chinese atrial fibrillation patients.

METHODS

The ChiOTEAF is a prospective registry proceeded in 44 sites from 20 provinces in China between October 2014 and December 2018. Outcomes of interest were all-cause mortality, any thromboembolism, major bleeding, and new onset/worsening heart failure.

RESULTS

The eligible cohort for this analysis included 6416 patients and 1215 (18.9%) patients were aged ≥85 years. Only 320 (26.4%) very elderly patients were treated with oral anticoagulant, of whom 205 (64.1%) received non-vitamin K antagonist oral anticoagulants, while antiplatelet therapy was used among 642 (53.1%) very elderly patients. On multivariate analysis, the use of oral anticoagulant was an independent predictor of a lower risk of the composite outcome (OR: 0.46; 95% CI: 0.32-0.66) and all-cause death (OR: 0.47; 95% CI: 0.32-0.69) among these very elderly atrial fibrillation patients.

CONCLUSIONS

Advanced age should not be a reason to withhold oral anticoagulant, since the use of oral anticoagulants is safe and improves survival.

The 2020 ESC Guidelines on the Diagnosis and Management of Atrial Fibrillation

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Characterization of atrial fibrillation in real-world patients: testing the 4S-AF scheme in the Spanish and French cohorts of the EORP-AF Long-Term General Registry

AIMS

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] has recently been described as a novel approach to in-depth characterization of AF. We aim to determine if the 4S-AF scheme would be useful for AF characterization and provides prognostic information in real-world AF patients.

METHODS AND RESULTS

The Spanish and French cohorts of the EORP-AF Long-Term General Registry were included. The baseline 4S-AF scheme was calculated and related to the primary management strategy (rhythm or rate control). Follow-up was performed at 1-year with all-cause mortality and the composite of ischaemic stroke/transient ischaemic attack/systemic embolism, major bleeding, and all-cause death, as primary endpoints. A total of 1479 patients [36.9% females, median age 72 interquartile range (IQR 64-80) years] were included. The median 4S-AF scheme score was 5 (IQR 4-7). The 4S-AF scheme, as continuous and as categorical, was associated with the management strategy decided for the patient (both P < 0.001). The predictive performances of the 4S-AF scheme for the actual management strategy were appropriate in its continuous [c-index 0.77, 95% confidence interval (CI) 0.75-0.80] and categorical (c-index 0.75, 95% CI 0.72-0.78) forms. Cox regression analyses showed that 'red category' classified patients in the 4S-AF scheme had a higher risk of all-cause death (aHR 1.75, 95% CI 1.02-2.99) and composite outcomes (aHR 1.60, 95% CI 1.05-2.44).

CONCLUSION

Characterization of AF by using the 4S-AF scheme may aid in identifying AF patients that would be managed by rhythm or rate control and could also help in identifying high-risk AF patients for worse clinical outcomes in a 'real-world' setting.

Poor adherence to guideline-directed anticoagulation in elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

AIMS

Adherence to guideline-directed oral anticoagulation (OAC) in patients with atrial fibrillation (AF) improves outcomes, but limited data are available from China. We evaluated the adherence to guideline-directed anticoagulation and its impact on clinical outcomes in a high-risk cohort of elderly Chinese patients.

METHODS AND RESULTS

The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre study conducted from October 2014 to December 2018. Endpoints of interest were all-cause death, thromboembolic (TE) events and major bleedings in patients with a guideline-directed indication for OACs (CHA2DS2-VASc ≥1 if male or ≥2 if female). The eligible cohort consisted of 5742 patients, of whom 2567 (44.7%) patients were treated with an OAC. Seven independent predictors of OAC undertreatment were identified: age [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.03-1.05; P < 0.001], first diagnosed AF (OR: 1.71; 95%CI: 1.44-2.03; P < 0.001), chronic kidney disease (OR: 1.67; 95%CI: 1.36-2.06; P < 0.001), liver disease (OR: 1.69; 95%CI: 1.19-2.41; P = 0.003), dementia (OR: 1.67; 95%CI: 1.06-2.64; P = 0.026), prior extracranial bleeding (OR: 1.89; 95%CI: 1.35-2.64; P < 0.001), and the use of antiplatelet drug (OR: 6.97; 95%CI: 5.89-8.23; P < 0.001). On multivariate analysis, OAC undertreatment was significantly associated with a higher risk all-cause death (OR: 3.79; 95%CI: 2.61-5.53; P < 0.001) and TE events (OR: 2.28; 95%CI: 1.39-3.72; P = 0.001), and a similar risk of major bleeding as compared with guideline-directed OAC therapy.

CONCLUSION

Only 44.7% of all eligible patients were prescribed OAC in accordance with guideline recommendations. The independent predictors for OAC undertreatment were age, first diagnosed AF, chronic kidney disease, chronic obstructive pulmonary disease, prior extracranial bleeding, and the use of the antiplatelet drugs. Guideline-adherent thromboprophylaxis was safe and may be associated with improved survival and less TE among elderly Chinese patients with AF.

Atrial Fibrillation in Patients with Chronic Kidney Disease

There is a bidirectional relationship between atrial fibrillation (AF) and chronic kidney disease (CKD), with multiple shared risk factors. This article discusses an integrated care approach toward the management of patients with AF, including those with CKD. There is an increasing risk of both ischemic stroke and bleeding with progressive deterioration of renal function, complicating the decision of optimal stroke prevention strategies among patients with AF and CKD. The optimal stroke prevention strategy in patients with AF and severe CKD remains uncertain. An individualized approach incorporating stroke and bleeding risk stratification is needed, especially in those with end-stage renal disease.

Aspirin versus P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation

OBJECTIVE

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelet and anticoagulant therapies; however, this has the potential to increase bleeding risk. Here, we aimed to evaluate the efficacy and safety of P2Y₁₂ inhibitors and aspirin in patients also receiving anticoagulant therapy.

METHODS

We evaluated patients from the Atrial Fibrillation and Ischaemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received rivaroxaban plus an antiplatelet agent; the choice of antiplatelet agent was left to the physician's discretion. The primary efficacy and safety end points, consistent with those of the AFIRE trial, were compared between P2Y₁₂ inhibitors and aspirin groups. The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularisation or death from any cause. The primary safety end point was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

RESULTS

A total of 1075 patients were included (P2Y₁₂ inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs) and there was no significant difference in PPI use in the groups. There were no significant differences in the primary end points between the groups (efficacy: HR 1.31; 95% CI 0.88 to 1.94; p=0.178; safety: HR 0.79; 95% CI 0.43 to 1.47; p=0.456).

CONCLUSIONS

There were no significant differences in cardiovascular and bleeding events in patients with AF and stable CAD taking rivaroxaban with P2Y₁₂ inhibitors or aspirin in the chronic phase.

TRIAL REGISTRATION NUMBER

UMIN000016612; NCT02642419.

Current trends in the use of anticoagulant pharmacotherapy in the United Kingdom are changes on the horizon?

INTRODUCTION

Effective stroke prevention with oral anticoagulation (OAC) reduces the risk of stroke and death among patients with atrial fibrillation (AF). For most patients with AF, treatment options include vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOACs). NOACs have been introduced as an alternative to VKAs, and their use has been steadily increasing in the United Kingdom and Europe over a decade. In randomized clinical trials, NOACs had a favorable risk-benefit profile as compared to warfarin. However, there is a concern about their long-term safety in clinical practice, especially in high-risk patients. There have been a number of registries and surveys based on the real-world patients with AF which has been conducted and published, providing data on contemporary AF management.

AREAS COVERED

In this narrative review, the authors discuss current trends in the use of OAC in the United Kingdom and Europe, considering the potential directions for future anticoagulant therapy in patients with AF.

EXPERT OPINION

The increasing prevalence of AF and AF-related comorbidities proves the need for comprehensive prevention and management strategies. The challenge is the optimization of therapy for each patient. However, there are still gaps in optimal stroke prevention, and the mortality rates remain high in patients with AF.