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van de Kar MRD, van Brakel TJ, Van't Veer M, van Steenbergen GJ, Daeter EJ, Crijns HJGM, van Veghel D, Dekker LRC, Otterspoor LC. Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis. Eur Heart J 2024:ehae267. [PMID: 38809189 DOI: 10.1093/eurheartj/ehae267] [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: 09/12/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications. METHODS A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC. RESULTS The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)]. CONCLUSIONS In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk.
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Affiliation(s)
- Mileen R D van de Kar
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Thomas J van Brakel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Marcel Van't Veer
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Gijs J van Steenbergen
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, Antonius Hospital, Utrecht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Centre Maastricht (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Dennis van Veghel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Lukas R C Dekker
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Luuk C Otterspoor
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
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Vanderkam P, Pomes C, Dzeraviashka P, Castera P, Jaafari N, Lafay-Chebassier C. Insomnia and parasomnia induced by validated smoking cessation pharmacotherapies and electronic cigarettes: a network meta-analysis. CNS Spectr 2024; 29:96-108. [PMID: 38433577 DOI: 10.1017/s1092852924000087] [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] [Indexed: 03/05/2024]
Abstract
We aim to assess the relationship between validated smoking cessation pharmacotherapies and electronic cigarettes (e-cigarettes) and insomnia and parasomnia using a systematic review and a network meta-analysis. A systematic search was performed until August 2022 in the following databases: PUBMED, COCHRANE, CLINICALTRIAL. Randomized controlled studies against placebo or validated therapeutic smoking cessation methods and e-cigarettes in adult smokers without unstable or psychiatric comorbidity were included. The primary outcome was the presence of "insomnia" and "parasomnia." A total of 1261 studies were selected. Thirty-seven studies were included in the quantitative analysis (34 for insomnia and 23 for parasomnia). The reported interventions were varenicline (23 studies), nicotine replacement therapy (NRT, 10 studies), bupropion (15 studies). No studies on e-cigarettes were included. Bayesian analyses found that insomnia and parasomnia are more frequent with smoking cessation therapies than placebo except for bupropion. Insomnia was less frequent with nicotine substitutes but more frequent with bupropion than the over pharmacotherapies. Parasomnia are less frequent with bupropion but more frequent with varenicline than the over pharmacotherapies. Validated smoking cessation pharmacotherapies can induce sleep disturbances with different degrees of frequency. Our network meta-analysis shows a more favorable profile of nicotine substitutes for insomnia and bupropion for parasomnia. It seems essential to systematize the assessment of sleep disturbances in the initiation of smoking cessation treatment. This could help professionals to personalize the choice of treatment according to sleep parameters of each patient. Considering co-addictions, broadening the populations studied and standardizing the measurement are additional avenues for future research.
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Affiliation(s)
- Paul Vanderkam
- Université de Poitiers, INSERM, U-1084, Laboratoire de Neurosciences Expérimentales et Cliniques, Poitiers, France
- Unité de Recherche Clinique Intersectorielle en Psychiatrie, Centre Hospitalier Henri Laborit, Poitiers, France
- Department of General Practice, University of Bordeaux, Bordeaux, France
| | - Charlotte Pomes
- Department of General Practice, University of Poitiers, Poitiers, France
| | | | - Philippe Castera
- Department of General Practice, University of Bordeaux, Bordeaux, France
| | - Nematollah Jaafari
- Unité de Recherche Clinique Intersectorielle en Psychiatrie, Centre Hospitalier Henri Laborit, Poitiers, France
| | - Claire Lafay-Chebassier
- Université de Poitiers, INSERM, U-1084, Laboratoire de Neurosciences Expérimentales et Cliniques, Poitiers, France
- CHU de Poitiers, Service de Pharmacologie Clinique et Vigilances, Poitiers, France
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Fadel R, Khan E, Maskoun W. The use of percutaneous left atrial appendage occluder device in a patient with prior surgical ligation with incomplete exclusion: a case report. Eur Heart J Case Rep 2024; 8:ytae058. [PMID: 38332926 PMCID: PMC10852016 DOI: 10.1093/ehjcr/ytae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
Background Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and the most common cause of cardioembolic stroke. The left atrial appendage (LAA) is the main source of thrombus formation in patients with AF. Therapies include use of percutaneous LAA closure devices, or surgical LAA occlusion (LAAO). Despite these options, complete closure of the LAA is not always achieved, and residual communication between the LAA and atrium may result in increased thrombus formation. Although studies have analysed the use of percutaneous measures such as coils, plugs, or second occluder device deployment in LAA with peri-device leak (PDL), use of percutaneous occlude devices in surgically occluded LAA is far less studied. Case summary We present a case of a 79-year-old female patient who underwent LAAO device deployment within a surgically occluded LAA with PDL. She underwent 27 mm LAAO device (WATCHMANTM) deployment and all the P.A.S.S. (Position, Anchor, Size, and Seal) criteria were satisfied. Only 1.4 mm PDL was present. She was continued on apixaban and aspirin post-operatively. Post-operative transoesophageal echocardiogram at 6 weeks demonstrated trivial PDL measuring 1.49 mm. Patient was continued on aspirin and clopidogrel, with discontinuation of apixaban. Discussion Percutaneous LAAO device deployment in previously surgically ligated LAA with incomplete exclusion is a potential therapeutic option for patients with AF and a high bleeding risk seeking a minimally invasive strategy, in an attempt to de-escalate anticoagulation therapy.
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Affiliation(s)
- Raef Fadel
- Division of Cardiovascular Medicine, Henry Ford Hospital, 2799 W Grand Boulevard, Detroit, MI 48202, USA
| | - Essaq Khan
- Division of Cardiovascular Medicine, Henry Ford Hospital, 2799 W Grand Boulevard, Detroit, MI 48202, USA
| | - Waddah Maskoun
- Division of Cardiovascular Medicine, Henry Ford Hospital, 2799 W Grand Boulevard, Detroit, MI 48202, USA
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Brouillard P, Diallo EH, Masson JB, Raymond JM, Riahi M, Potter B, Kouz R, Potvin J. Real-World Management Strategies of Anticoagulated Atrial Fibrillation Patients After a Clinically Significant Bleeding Episode. Can J Cardiol 2024:S0828-282X(23)02048-2. [PMID: 38181972 DOI: 10.1016/j.cjca.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Systemic anticoagulation for stroke prevention in patients with atrial fibrillation (AF) carries inherent bleeding risks, and determining whether and when to resume anticoagulation after significant bleeding is a common dilemma. We aimed to describe the clinical characteristics of AF patients discharged after a bleeding event, document real-life thromboembolic prevention strategy (TPS), and analyse their associated clinical outcomes. METHODS We retrospectively reviewed the charts of anticoagulated AF patients admitted for bleeding from 2017 to 2019. RESULTS A total of 140 patients were included, with a mean age of 78.6 years. Four discharge groups were defined: 75 patients (53.5%) had optimal anticoagulation (OA), 37 (26.4%) had a suboptimal antithrombotic regimen (SAR; low-dose direct oral anticoagulants without dose-reduction criteria or antiplatelet therapy), 10 (7.1%) were referred for left atrial appendage occlusion (LAAO), and 18 (12.9%) left without any TPS. All-cause mortality at 2 years was high (28.6%) but not statistically different between groups (P = 0.71). Patients discharged with a TPS (OA/SAR/LAAO referral) were more likely to be readmitted for bleeding at 2 years (34% vs 0%; P = 0.002), and those discharged without a TPS had higher rates of stroke (16.6% vs 1.4%; P = 0.003). SAR yielded readmission rates for bleeding similar to resumption of OA (27% vs 34.7%; P = 0.41) but was associated with high rates of death or readmission at 2 years. CONCLUSIONS This real-life cohort reveals that clinicians frequently downgrade or discontinue long-term thromboembolic protection after a bleeding event despite current guideline recommendations to the contrary, and downgrading resulted in bleeding risk similar to OA.
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Affiliation(s)
- Philippe Brouillard
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada.
| | - El Hadji Diallo
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Bernard Masson
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marc Raymond
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Mounir Riahi
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Brian Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
| | - Rémi Kouz
- Département de médecine, Université de Montréal, Montréal, Québec, Canada; Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Jeannot Potvin
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada
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Bangash AB, Li Y, Huang W, Zhong J, Zheng H, Zhang D, Zeng A, Wang R, Zhao W, Wang M, Zhao Y, Yu L, Liu Q, Jiang R, Jiang C, Zhang J. Left atrial appendage occlusion using the LAmbre device in atrial fibrillation patients with a history of ischemic stroke: 1-Year outcomes from a multicenter study in China. Pacing Clin Electrophysiol 2023; 46:1478-1483. [PMID: 37943004 DOI: 10.1111/pace.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/07/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patients with non-valvular atrial fibrillation (NVAF) and previous stroke have a significantly higher risk of stroke recurrence. This study aimed to examine the safety and efficacy of the LAmbre left atrial appendage occlusion device in NVAF patients with a history of stroke. METHODS We examined 103 consecutive NVAF patients in 11 Chinese medical centers who had a history of stroke or transient ischemic attacks (TIA) and underwent placement of the LAmbre device. Follow-up was conducted 1, 3, 6, and 12 months after the procedure. The primary endpoints were the incidence of new ischemic or hemorrhagic stroke, TIA, systemic embolism, or cardiac death. Secondary endpoints were serious perioperative or device-related complications and cerebral, gastrointestinal, or other bleeding events requiring transfusion of at least 2 units of packed red blood cells. RESULTS Mean patient age was 67.63 ± 7.14 years; mean CHA2DS2-VASc score was 4.72 ± 1.18 and mean HAS-BLED score was 1.90 ± 1.00. LAmbre device placement was successful in 101 patients (98.05%). Mean follow-up was 12.2 months. Five patients (4.95%) developed a new pericardial effusion after the procedure; none required treatment. Eighty-six patients (85.15%) exhibited no peri-device leak (PDL). However, 13 (12.8%) had a small (0-3 mm) PDL and two (2.3%) had a moderate PDL (3-5 mm). One recurrent stroke occurred during follow-up (1.1%). No other complications occurred. CONCLUSIONS This multicenter study shows the safety and efficacy of LAmbre left atrial appendage occlusion for NVAF patients with a history of stroke or TIA.
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Affiliation(s)
- Abdul Basit Bangash
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuechun Li
- Department of Cardiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jingquan Zhong
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Hongmei Zheng
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Dayong Zhang
- Department of Cardiology, Sichuan Mianyang 404 Hospital, Mianyang, Sichuan, China
| | - Anning Zeng
- Department of Cardiology, The People's Hospital of Qiannan, Duyun, Guizhou, China
| | - Rui Wang
- Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenbiao Zhao
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Maojing Wang
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yu Zhao
- Department of Cardiology, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Lu Yu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qiang Liu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ruhong Jiang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jinhua Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Segar MW, Zhang A, Paisley RD, Badjatiya A, Lambeth KD, Mullins K, Razavi M, Molina-Razavi JE, Rasekh A, Saeed M. Risk Stratification in Patients Who Underwent Percutaneous Left Atrial Appendage Occlusion. Am J Cardiol 2023; 200:50-56. [PMID: 37295180 DOI: 10.1016/j.amjcard.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/04/2023] [Accepted: 05/13/2023] [Indexed: 06/12/2023]
Abstract
Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas.
| | - Allan Zhang
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Anish Badjatiya
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Kaleb D Lambeth
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Karen Mullins
- Quality CV Service Line, Baylor St. Luke's Medical Center, Houston, Texas
| | - Mehdi Razavi
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | | | - Abdi Rasekh
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Mohammad Saeed
- Department of Cardiology, Texas Heart Institute, Houston, Texas
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Ding WY, Lip GYH, Gupta D. Left Atrial Appendage Occlusion-A Choice or a Last Resort? How to Approach the Patient. Card Electrophysiol Clin 2023; 15:133-140. [PMID: 37076225 DOI: 10.1016/j.ccep.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion. Overall, an individualized and multidisciplinary team approach should be adopted in patients who are being considered for LAA occlusion.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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9
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Camm AJ. Leap or lag: left atrial appendage closure and guidelines. Europace 2023; 25:euad067. [PMID: 37012659 PMCID: PMC10227666 DOI: 10.1093/europace/euad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/28/2023] [Indexed: 04/05/2023] Open
Abstract
Atrial fibrillation (AF) is associated with life-threatening thromboembolism. Most emboli stem from thrombosis in the left atrial appendage (LAA). The current treatment of choice is oral anticoagulants (OACs), but a small proportion of patients cannot take OACs predominantly because of the so-called unacceptable bleeding risks. However, many who initially accept OACs subsequently stop therapy or reduce the OAC treatment to a potentially non-effective dose leaving them exposed to thromboembolic risk. A relatively simple alternative therapy involves the catheter-based insertion of a LAA closure (LAAC) device to prevent thromboembolism from the LAA. There is a considerable evidence base for this therapy consisting of clinical trials and observational data which suggests comparable therapeutic efficacy with a possible small excess of ischaemic strokes. Although LAAC has been very closely examined by regulators and approved for market release, guidelines from most professional societies give only weak recommendations for use of this device which may be the only known effective therapy available to some at-risk AF patients. Guidance materials from the same societies more enthusiastically endorse LAAC. Clinical practice is running well ahead of the guidelines because equipoise has been lost by physicians faced with patients for whom they have no other effective therapy. Guideline writers are correct in providing recommendations which are less strong for LAAC than for OACs, for those who are able and willing to take OAC treatment, but for those who are not, a stronger recommendation is needed. But, should the guidelines lag behind or leap ahead of the available evidence?
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Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK
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Incidence and Predictors of Early Death in Patients Undergoing Percutaneous Left Atrial Appendage Closure. JACC Clin Electrophysiol 2022; 8:1093-1102. [DOI: 10.1016/j.jacep.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/25/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
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Ding WY, Lip GYH, Gupta D. Left Atrial Appendage Occlusion-A Choice or a Last Resort? How to Approach the Patient. Interv Cardiol Clin 2022; 11:135-142. [PMID: 35361458 DOI: 10.1016/j.iccl.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion. Overall, an individualized and multidisciplinary team approach should be adopted in patients who are being considered for LAA occlusion.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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12
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Long-term outcomes of left atrial appendage occlusion in high-risk atrial fibrillation patients: 4-year follow up data. J Thromb Thrombolysis 2020; 51:1090-1093. [PMID: 33165818 DOI: 10.1007/s11239-020-02333-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
Long-term follow-up data of left atrial appendage (LAA) occlusion in patients with atrial fibrillation (AF) are sparse. To address these data gaps, we analysed the 4-year outcomes of AF patients following LAA occlusion. The was a retrospective cohort study of high-risk patients with AF who underwent successful implantation of the Amulet device at our center between 2014 and 2017. Study endpoints were the rate of stroke, major bleeding and all-cause mortality. We included 71 patients (35.2% females) with a median age of 78 (IQR 73-82) years. Over a median follow-up period of 46 (IQR 19-56) months, the annual rate of ischemic stroke was 1.06 events/100 patient-years (95% CI 0-2.35), hemorrhagic stroke was 1.06 events/100 patient-years (95% CI 0-2.35) and major extracranial bleeding that required unplanned hospital admission was 1.84 events/100 patient-years (95% CI 0.25-3.43). A total of 28 (39.4%) patients died during this period with an annual mortality rate of 10.29 events/100 patient-years (95% CI 7.25-13.32). Our experience suggests that LAA occlusion using the Amulet device appears to be associated with a low risk of ischemic stroke in high-risk AF patients who are deemed unsuitable for oral anticoagulation; however, these patients have a high rate of mortality over the medium to long-term follow-up, and an ongoing significant risk of bleeding and thrombotic events.
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13
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Li X, Jin Q, Zhang X. Closure Device-Related Thrombosis After Anticoagulation With Dabigatran in Patients Undergoing Percutaneous Left Atrial Appendage Closure: Case Reports and Literature Review. Front Pharmacol 2020; 11:563920. [PMID: 33013399 PMCID: PMC7506050 DOI: 10.3389/fphar.2020.563920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/21/2020] [Indexed: 12/18/2022] Open
Abstract
Percutaneous left atrial appendage closure (LAAC) is an effective and safe operation strategy for stroke prevention in patients who are diagnosed with atrial fibrillation (AF) but cannot tolerate long term anticoagulation medication. We presented four rare cases of thrombosis formation on the occluder device. After the LAAC operation was successfully performed on patients, they followed a course of anticoagulation with dabigatran (110 mg b.i.d.), and device-related thrombosis (DRT) occurred as indicated by a transesophageal echocardiogram (TEE) during the follow-up period. Regressions were achieved after replacing dabigatran with rivaroxaban or warfarin for more than 1 month. No thrombosis or bleeding-related complications occurred in subsequent follow-ups.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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14
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Abstract
AF is associated with an increased risk of thromboembolic events, which is usually managed with oral anticoagulation therapy. However, despite a broad range of anticoagulant options and improved uptake in anticoagulation over the past decade, there are some limitations to this approach. Percutaneous left atrial appendage occlusion has been shown to be an effective alternative in this setting, and population data suggest a clear demand for this procedure. Over the past decade, several important changes to the commissioning and delivery of this service have occurred in the UK. In this article, the authors describe the use of percutaneous left atrial appendage occlusion in the UK and discuss the challenges that lie ahead.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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15
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Ding WY, Mandrola J, Gupta D. Left Atrial Appendage Occlusion: Past, Present and Future. Thromb Haemost 2020; 120:1484-1491. [DOI: 10.1055/s-0040-1714654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractThere are several situations whereby oral anticoagulation may be unsuitable for stroke prevention in patients with atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) occlusion has received much attention in this area. Various devices have already been developed and tested for this purpose. Data from registries and cohort studies have indicated favourable short- and long-term outcomes with LAA occlusion, and several international guidelines recommend its use in AF patients with contraindications to oral anticoagulation. However, prospective controlled trials in this very population are lacking. Furthermore, while modelling studies on cost analyses have suggested that LAA occlusion may be a cost-effective strategy compared with standard medical therapy, these have not been performed in high-risk patients who may have limited survival in the medium to long term. Thus, while LAA occlusion offers promise, there is a strong need for additional research to investigate its exact role, its long-term outcomes and cost efficacy.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Department of Cardiology, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - John Mandrola
- Department of Cardiology, Baptist Health Louisville, Louisville, Kentucky, United States
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Department of Cardiology, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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16
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Osman M, Busu T, Osman K, Khan SU, Daniels M, Holmes DR, Alkhouli M. Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2020; 6:494-506. [PMID: 32439033 PMCID: PMC7988890 DOI: 10.1016/j.jacep.2019.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO). BACKGROUND Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated. METHODS A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model. RESULTS A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices. CONCLUSIONS In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Tatiana Busu
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khansa Osman
- Michigan Health Specialist, Michigan State University, Flint, Michigan, USA
| | - Safi U Khan
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Matthew Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
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Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
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18
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Left Atrial Appendage Occlusion Guided Only by Transesophageal Echocardiography. Cardiol Res Pract 2019; 2019:1376515. [PMID: 30719340 PMCID: PMC6334355 DOI: 10.1155/2019/1376515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 12/16/2018] [Indexed: 11/17/2022] Open
Abstract
Aims To investigate a new method of left atrial appendage occlusion without fluoroscopy. Methods and Results We performed left atrial appendage occlusion for 14 patients with atrial fibrillation in our hospital. All of the surgeries were completed in a general surgery setting, avoiding fluoroscopy, and in each case, the entire procedure was guided by transesophageal echocardiography (TEE). All of the surgeries were performed through the femoral vein pathway. All operations went smoothly with no serious complications. Postoperative TEE indicated that each device was in a good position, and there was no residual shunt around any of the devices. Conclusions TEE-guided left atrial appendage occlusion is safe and reliable, simplifies the procedure, protects doctors and patients from radiation, and is gradually becoming the mainstream operation for left atrial appendage occlusion. This trial is registered with ChiCTR1800018387.
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19
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Phan QT, Shin SY, Cho IS, Lee WS, Won H, Sharmin S, Lee DY, Kim TH, Kim CJ, Kim SW. Impact of left atrial appendage closure on cardiac functional and structural remodeling: A difference-in-difference analysis of propensity score matched samples. Cardiol J 2018; 26:519-528. [PMID: 29718529 DOI: 10.5603/cj.a2018.0047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/25/2018] [Accepted: 03/19/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although the safety and efficacy of left atrial (LA) appendage (LAA) closure (LAAC) in nonvalvular atrial fibrillation (NVAF) patients have been well documented in randomized controlled trials and real-world experience, there are limited data in the literature about the impact of LAAC on cardiac remodeling. The aim of the study was to examine the impact of LAAC on cardiac functional and structural remodeling in NVAF patients. METHODS Between March 2014 and November 2016, 47 NVAF patients who underwent LAAC were included in this study (LAAC group). A control group (non-LAAC group) was formed from 141 NVAF patients without LAAC using propensity score matching. The difference-in-difference analysis was used to evaluate the difference in cardiac remodeling between the two groups at baseline and follow-up evaluations. RESULTS The LAAC group had a larger increase in LA dimension, volume and volume index than the non-LAAC group (+3.9 mm, p = 0.001; +9.7 mL, p = 0.006 and +5.9 mL/m2, p = 0.011, respectively). Besides, a significant increase in E and E/e' ratio was also observed in the LAAC group (+14.6 cm/s, p = 0.002 and +2.3, p = 0.028, respectively). Compared with the non-LAAC group, left ventricular (LV) ejection fraction and fractional shortening decreased in LAAC patients, but were statistically insignificant (-3.5%, p = 0.109 and -2.0%, p = 0.167, respectively). CONCLUSIONS There were significant increases in LA size and LV filling pressure among NVAF patients after LAAC. These impacts of LAAC on cardiac functional and structural remodeling may have some clinical implications that need to be addressed in future studies.
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Affiliation(s)
- Quang Tan Phan
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea. .,Intervention Center, Quang Nam Central General Hospital, Quang Nam, Vietnam.
| | - Seung-Yong Shin
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Ik-Sung Cho
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Wang-Soo Lee
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Hoyoun Won
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Saima Sharmin
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Dong-Young Lee
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Tae-Ho Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Chee-Jeong Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Sang-Wook Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
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20
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Gupta D, Masoud A, Bartoletti S. The Authors’ reply. BRITISH HEART JOURNAL 2018. [DOI: 10.1136/heartjnl-2017-312829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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21
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Khan HR, Kralj-Hans I, Haldar S, Bahrami T, Clague J, De Souza A, Francis D, Hussain W, Jarman J, Jones DG, Mediratta N, Mohiaddin R, Salukhe T, Jones S, Lord J, Murphy C, Kelly J, Markides V, Gupta D, Wong T. Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF): study protocol for a randomised controlled trial. Trials 2018; 19:117. [PMID: 29458408 PMCID: PMC5819216 DOI: 10.1186/s13063-018-2487-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 01/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Atrial fibrillation is the commonest arrhythmia which raises the risk of heart failure, thromboembolic stroke, morbidity and death. Pharmacological treatments of this condition are focused on heart rate control, rhythm control and reduction in risk of stroke. Selective ablation of cardiac tissues resulting in isolation of areas causing atrial fibrillation is another treatment strategy which can be delivered by two minimally invasive interventions: percutaneous catheter ablation and thoracoscopic surgical ablation. The main purpose of this trial is to compare the effectiveness and safety of these two interventions. METHODS/DESIGN Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF) is a prospective, multi-centre, randomised controlled trial within three NHS tertiary cardiovascular centres specialising in treatment of atrial fibrillation. Eligible adults (n = 120) with symptomatic, long-standing, persistent atrial fibrillation will be randomly allocated to either catheter ablation or thoracoscopic ablation in a 1:1 ratio. Pre-determined lesion sets will be delivered in each treatment arm with confirmation of appropriate conduction block. All patients will have an implantable loop recorder (ILR) inserted subcutaneously immediately following ablation to enable continuous heart rhythm monitoring for at least 12 months. The devices will be programmed to detect episodes of atrial fibrillation and atrial tachycardia ≥ 30 s in duration. The patients will be followed for 12 months, completing appropriate clinical assessments and questionnaires every 3 months. The ILR data will be wirelessly transmitted daily and evaluated every month for the duration of the follow-up. The primary endpoint in the study is freedom from atrial fibrillation and atrial tachycardia at the end of the follow-up period. DISCUSSION The CASA-AF Trial is a National Institute for Health Research-funded study that will provide first-class evidence on the comparative efficacy, safety and cost-effectiveness of thoracoscopic surgical ablation and conventional percutaneous catheter ablation for long-standing persistent atrial fibrillation. In addition, the results of the trial will provide information on the effects on patients' quality of life. TRIAL REGISTRATION ISRCTN Registry, ISRCTN18250790 . Registered on 24 April 2015.
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Affiliation(s)
- Habib Rehman Khan
- Royal Brompton and Harefield NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- Institute of Cardiovascular Medicine and Science, London, UK
| | | | - Shouvik Haldar
- Royal Brompton and Harefield NHS Trust, London, UK
- Institute of Cardiovascular Medicine and Science, London, UK
| | | | | | | | - Darrel Francis
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - David Gareth Jones
- Royal Brompton and Harefield NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | | | - Simon Jones
- New York University School of Medicine, New York, NY USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Caroline Murphy
- King’s Clinical Trials Unit, Institute of Psychiatry, King’s College London, London, UK
| | - Joanna Kelly
- King’s Clinical Trials Unit, Institute of Psychiatry, King’s College London, London, UK
| | | | - Dhiraj Gupta
- National Heart and Lung Institute, Imperial College London, London, UK
- Institute of Cardiovascular Medicine and Science, London, UK
- Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Tom Wong
- Royal Brompton and Harefield NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- Institute of Cardiovascular Medicine and Science, London, UK
- Royal Brompton Hospital, Sydney Street, London, UK
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22
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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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23
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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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de J Ramos Ramirez M, Young B, Harjai K, Mascarenhas V, Vijayaraman P. Left atrial appendage occlusion: 2016 in review. J Interv Cardiol 2017; 30:448-456. [PMID: 28799239 DOI: 10.1111/joic.12410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 01/14/2023] Open
Abstract
A significant body of data has emerged in the area of Percutaneous Left Atrial Appendage Occlusion (LAAO). In this article, we present an overview of the most notable publications along with a review of the most important publications on LAAO in 2016. We also present important historical data such as landmark clinical studies, review of most utilized occlusion devices, and important clinical studies that are underway.
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Affiliation(s)
| | - Bonnie Young
- Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania
| | - Kishore Harjai
- Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania
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25
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Left Atrial Appendage Closure Device With Delivery System: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2017; 17:1-106. [PMID: 28744335 PMCID: PMC5515321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Atrial fibrillation is a common cardiac arrhythmia, and 15% to 20% of those who have experienced stroke have atrial fibrillation. Treatment options to prevent stroke in people with atrial fibrillation include pharmacological agents such as novel oral anticoagulants or nonpharmacological devices such as the left atrial appendage closure device with delivery system (LAAC device). The objectives of this health technology assessment were to assess the clinical effectiveness and cost-effectiveness of the LAAC device versus novel oral anticoagulants in patients without contraindications to oral anticoagulants and versus antiplatelet agents in patients with contraindications to oral anticoagulants. METHODS We performed a systematic review and network meta-analysis. We also conducted an economic literature review, economic evaluation, and budget impact analysis to assess the cost-effectiveness and budget impact of the LAAC device compared with novel oral anticoagulants and oral antiplatelet agents (e.g., aspirin). We also spoke with patients to better understand their preferences, perspectives, and values. RESULTS Seven randomized controlled studies met the inclusion criteria for indirect comparison. Five studies assessed the effectiveness of novel oral anticoagulants versus warfarin, and two studies compared the LAAC device with warfarin. No studies were identified that compared the LAAC device with aspirin in patients in whom oral anticoagulants were contraindicated. Using the random effects model, we found that the LAAC device was comparable to novel oral anticoagulants in reducing stroke (odds ratio [OR] 0.85; credible interval [Cr.I] 0.63-1.05). Similarly, the reduction in the risk of all-cause mortality was comparable between the LAAC device and novel oral anticoagulants (OR 0.71; Cr.I 0.49-1.22). The LAAC device was found to be superior to novel oral anticoagulants in preventing hemorrhagic stroke (OR 0.45; Cr.I 0.29-0.79), whereas novel oral anticoagulants were found to be superior to the LAAC device in preventing ischemic stroke (OR 0.67; Cr.I 0.24-1.64). The body of clinical evidence was found to be of moderate quality as assed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. Results from the economic evaluation indicate that the LAAC device is cost-effective compared with aspirin in patients with contraindications to oral anticoagulants. In patients without contraindications to oral anticoagulants, we found that the LAAC device is not cost-effective compared with novel oral anticoagulants. Publicly funding the LAAC device in patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulants could result in additional funding of $1.1 million to $7.7 million over the first five years. Patients interviewed reported on the impact of living with nonvalvular atrial fibrillation and were supportive of the LAAC device as a treatment option. CONCLUSIONS Moderate-quality evidence suggests that the LAAC device is as effective as novel oral anticoagulants in preventing stroke in people with nonvalvular atrial fibrillation. However, our results indicate that the LAAC device is cost-effective only in patients with contraindications to oral anticoagulants. People with nonvalvular atrial fibrillation with whom we spoke reported positive support for the LAAC device.
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Nicolosi GL. Potential uselessness and futility of left atrial appendage occlusion and patent foramen ovale closure in cardioembolic stroke. J Cardiovasc Med (Hagerstown) 2017; 18:393-397. [DOI: 10.2459/jcm.0000000000000512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Akin I, Nienaber CA. Left atrial appendage occlusion: A better alternative to anticoagulation? World J Cardiol 2017; 9:139-146. [PMID: 28289527 PMCID: PMC5329740 DOI: 10.4330/wjc.v9.i2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023] Open
Abstract
Non-valvular atrial fibrillation is associated with a significantly increased risk of embolic stroke due to blood clot forming predominantly in the left atrial appendage (LAA). Preventive measures to avoid embolic events are permanent administration of anticoagulants or surgical closure of the LAA. Various clinical trials provide evidence about safety, effectiveness and therapeutic success of LAA occlusion using various cardiac occluder devices. The use of such implants for interventional closure of the LAA is likely to become a valuable alternative for stroke prevention, especially in patients with contraindication for oral anticoagulation as safety, clinical benefit and cost-effectiveness of LAA occlusion has recently been demonstrated.
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Affiliation(s)
- Ibrahim Akin
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
| | - Christoph A Nienaber
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
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Sharma M, Khalighi K. Non-Pharmacologic Approach to Prevent Embolization in Patients with Atrial Fibrillation in Whom Anticoagulation is Contraindicated. Clin Pract 2017; 7:898. [PMID: 28243428 PMCID: PMC5264548 DOI: 10.4081/cp.2017.898] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/09/2016] [Accepted: 12/28/2016] [Indexed: 12/26/2022] Open
Abstract
Ischemic stroke is the most common complication of atrial fibrillation (AF). Anticoagulation therapy reduces the risk of systemic embolization in almost all patients with AF irrespective of the type of AF (paroxysmal, persistent or permanent). But, all patients are not suitable candidates for systemic anticoagulation mainly due to the risk of bleeding. Left atrial appendage closure (LAAC) devices have been found to be very effective non-pharmacologic alternative therapy for such patients. There are various types of LAAC devices but United States Food and Drug Administration (US-FDA) have approved only Watchman device. Initially, bigger medical centers in the US had started the insertion of Watchman device but with improving procedural techniques and exciting outcomes, even the community-based hospitals have started to embrace this therapy. We have presented the first three cases of Watchman device placement performed in our hospital and discussed about the indications for placement of LAAC devices. We have also reviewed their efficacy individually.
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Affiliation(s)
- Munish Sharma
- Department of Internal Medicine, Easton Hospital , Easton, PA
| | - Koroush Khalighi
- Department of Cardiology, Easton Hospital and Clinical Medicine, Drexel University College of Medicine , Easton, PA, USA
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Shahid F, Shantsila E, Lip GYH. Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention. F1000Res 2016; 5:2887. [PMID: 28105320 PMCID: PMC5224684 DOI: 10.12688/f1000research.10176.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/29/2022] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14-17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA 2DS 2VASc (congestive heart failure, hypertension, age 65-74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.
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Affiliation(s)
- Farhan Shahid
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Eduard Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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Abstract
Whereas the left atrial appendage plays a rather minor role under physiological circumstances, it gains an importance in patients with atrial fibrillation. Compelling evidence has revealed that the left atrial appendage is implicated as the source of thrombus in the vast majority of strokes in atrial fibrillation. Oral anticoagulation remains the standard of care for stroke prevention in atrial fibrillation; nevertheless, this treatment has several limitations and is often contraindicated, particularly in the elderly population in whom the risk of stroke is high. Therefore, occluding the left atrial appendage is a logical approach to prevent thrombus formation and subsequent cardioembolic events in these patients. We present a review of clinical outcomes of patients with atrial fibrillation undergoing left atrial appendage closure and the challenges faced in this field.
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Lüscher TF. Catheter-based and surgical interventions in cardiac and aortic conditions. Eur Heart J 2016; 37:3421-3424. [PMID: 28039217 DOI: 10.1093/eurheartj/ehw624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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Athanassopoulos GD. 3D Printing for Left Atrial Appendage (LAA) Modeling Based on Transesophageal Echocardiography: A Step Forward in Closure with LAA Devices. Cardiology 2016; 135:249-254. [PMID: 27537688 DOI: 10.1159/000448024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022]
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Tereshchenko LG, Henrikson CA, Cigarroa J, Steinberg JS. Comparative Effectiveness of Interventions for Stroke Prevention in Atrial Fibrillation: A Network Meta-Analysis. J Am Heart Assoc 2016; 5:e003206. [PMID: 27207998 PMCID: PMC4889191 DOI: 10.1161/jaha.116.003206] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/18/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND The goal of this study was to compare the safety and effectiveness of individual antiembolic interventions in nonvalvular atrial fibrillation (AF): novel oral anticoagulants (NOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban); vitamin K antagonists (VKA); aspirin; and the Watchman device. METHODS AND RESULTS A network meta-analysis of randomized, clinical trials (RCTs) was performed. RCTs that included patients with prosthetic cardiac valves or mitral stenosis, mean or median follow-up <6 months, <200 participants, without published report in English language, and NOAC phase II studies were excluded. The placebo/control arm received either placebo or no treatment. The primary efficacy outcome was the combination of stroke (of any type) and systemic embolism. All-cause mortality served as a secondary efficacy outcome. The primary safety outcome was the combination of major extracranial bleeding and intracranial hemorrhage. A total of 21 RCTs (96 017 nonvalvular AF patients; median age, 72 years; 65% males; median follow-up, 1.7 years) were included. In comparison to placebo/control, use of aspirin (odds ratio [OR], 0.75 [95% CI, 0.60-0.95]), VKA (0.38 [0.29-0.49]), apixaban (0.31 [0.22-0.45]), dabigatran (0.29 [0.20-0.43]), edoxaban (0.38 [0.26-0.54]), rivaroxaban (0.27 [0.18-0.42]), and the Watchman device (0.36 [0.16-0.80]) significantly reduced the risk of any stroke or systemic embolism in nonvalvular AF patients, as well as all-cause mortality (aspirin: OR, 0.82 [0.68-0.99]; VKA: 0.69 [0.57-0.85]; apixaban: 0.62 [0.50-0.78]; dabigatran: 0.62 [0.50-0.78]; edoxaban: 0.62 [0.50-0.77]; rivaroxaban: 0.58 [0.44-0.77]; and the Watchman device: 0.47 [0.25-0.88]). Apixaban (0.89 [0.80-0.99]), dabigatran (0.90 [0.82-0.99]), and edoxaban (0.89 [0.82-0.96]) reduced risk of all-cause death as compared to VKA. CONCLUSIONS The entire spectrum of therapy to prevent thromboembolism in nonvalvular AF significantly reduced stroke/systemic embolism events and mortality.
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Affiliation(s)
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Joaquin Cigarroa
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Jonathan S Steinberg
- University of Rochester School of Medicine & Dentistry and The Arrhythmia Institute of The Valley Health System, New York, NY University of Rochester School of Medicine & Dentistry and The Arrhythmia Institute of The Valley Health System, Ridgewood, NJ
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