Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding

Stroke prevention strategies in high-risk patients with atrial fibrillation

Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.

Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulants: a single hospital cohort study

BACKGROUND

Central nervous system (CNS) hemorrhage is a serious complication related to direct oral anticoagulant (DOAC) therapy. Current recommendations about re-initiation of anticoagulation treatment are limited to expert opinions. For this purpose, we analyzed the data of all consecutive DOAC patients with CNS hemorrhage, in whom DOACs were reinitiated.

METHODS

Over a 6-year period (2012-2018), all consecutive patients with CNS hemorrhage (subdural, subarachnoid, intracerebral, spinal), while receiving DOACs, were included in this observational single-center cohort study. DOAC therapy was reinitiated only in patients with well-controlled arterial hypertension and diabetes, as well as exclusion of vascular malformations and cerebral amyloid angiopathy. The composite primary endpoint comprised of recurrent CNS hemorrhage, ischemic stroke, and mortality; secondary endpoints were separate aforementioned outcomes.

RESULTS

Of the 54 patients included, 18 died within a month of CNS hemorrhage. The average observational time was 590 days. DOACs were reinitiated in 13/36 patients (36%); of these patients, three died: none due to ischemic stroke or recurrent CNS bleeding. In 23 patients, anticoagulation was not reinitiated; of these patients, 10 died: three from recurrent CNS hemorrhage, one due to ischemic stroke, and six from causes unrelated to stroke.

CONCLUSIONS

In carefully selected patients, re-initiation of DOAC therapy did not increase the rate of both endpoints. Recommendations for DOAC re-initiation, which include hypertension and diabetes control, as well as treated vascular malformations, and excluded cerebral amyloid angiopathy, appear to be valid in clinical practice.

Restarting of anticoagulation in patients with atrial fibrillation after major bleeding: A meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Benefits and risks of restarting oral anticoagulants (OACs) in patients with atrial fibrillation after major bleeding remain unknown. A meta-analysis was performed to systematically evaluate the effects of restarting OACs on thromboembolism and bleeding events in these patients.

METHODS

Relevant studies were obtained via systematically search of PubMed, Cochrane's Library and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses according to the types of OACs and sites of reoccurred bleeding were performed.

RESULTS AND DISCUSSION

Seven retrospective cohort studies with 12 197 patients were included. Restarting OACs was associated with reduced risk of thromboembolism (risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.42-0.87; P = .007). Subgroup analyses showed that restarting warfarin reduced risk of thromboembolism (RR = 0.59, P = .05), but not for the new oral anticoagulants (NOACs; RR = 1.37, P = .18). Moreover, restarting OACs did not affect the risk of reoccurred bleeding (RR = 0.98, 95% CI: 0.74-1.30, P = .89). Similar results were found for warfarin and NOACs, as well as for reoccurred intracranial haemorrhage or gastrointestinal bleeding. In addition, restarting OACs was associated with significantly reduced risk of all-cause mortality (RR = 0.42, 95% CI: 0.33-0.52, P < .001). Consistent results were found for warfarin and NOACs.

WHAT IS NEW AND CONCLUSION

Restarting of OACs after major bleeding in AF patients may be associated with reduced risks of thromboembolism and mortality without increasing reoccurrence of bleeding.

Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting

Patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) are at high risk of stroke, recurrent coronary ischemic events, and cardiovascular mortality. The composition of antithrombotic therapy including an oral anticoagulant and antiplatelet drug(s) should be tailored according to the individual patient's risk profile, to reduce the bleeding risk and maintain antithrombotic effect. There is no single antithrombotic treatment regimen that would fit to all patients with AF and ACS. However, available data promote the use of full-dose direct oral anticoagulants (DOACs) (dabigatran 150 mg twice daily or apixaban 5 mg twice daily) or rivaroxaban 15 mg once daily in patients with AF and ACS or percutaneous coronary intervention (PCI). For many patients, a DOAC plus P2Y12 inhibitor early after ACS and/or PCI would be optimal, whereas a longer course of triple therapy should be used in patients at high thrombotic risk.