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Kikuchi T, Kono Y, Nakagawa K, Okada H, Miyamoto M, Takaya Y, Hirata S, Inoo S, Kuraoka S, Okanoue S, Matsueda K, Satomi T, Hamada K, Iwamuro M, Kawano S, Kawahara Y. Clinical significance of gastrointestinal bleeding history in patients who undergo left atrial appendage closure. JGH Open 2024; 8:e13009. [PMID: 38268955 PMCID: PMC10805487 DOI: 10.1002/jgh3.13009] [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: 06/12/2023] [Revised: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Abstract
Background and Aim Anticoagulant users with nonvalvular atrial fibrillation (NVAF) sometimes suffer from gastrointestinal bleeding (GIB) and have difficulty continuing the medication. Left atrial appendage closure (LAAC) has been developed for such situations. We aimed to clarify the clinical significance of a history of GIB in comparison to other factors in patients who had undergone LAAC. Methods From October 2019 to September 2023, patients with NVAF who underwent LAAC at our hospital were enrolled. We investigated the percentage of patients with a history of GIB who underwent LAAC and compared the incidence of post-LAAC bleeding in these patients compared to those with other factors. Results A total of 45 patients were included. There were 19 patients (42%) with a history of GIB who underwent LAAC. In a Kaplan-Meier analysis, the cumulative incidence of bleeding complications after LAAC was significantly higher in patients with a history of GIB in comparison to patients with other factors. There were eight cases of post-LAAC bleeding in total, and seven cases had GIB. Conclusions We need to recognize that GIB is a significant complication in patients who undergo LAAC. The management of GIB by gastroenterologists is essential to the success of LAAC.
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Affiliation(s)
- Tatsuya Kikuchi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoshiyasu Kono
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
- Department of Internal MedicineHimeji Red Cross HospitalHimejiJapan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shoichiro Hirata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shoko Inoo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Sakiko Kuraoka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shotaro Okanoue
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Katsunori Matsueda
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Takuya Satomi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Kenta Hamada
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoshiro Kawahara
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
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Jiang C, Li M, Hu Y, Du X, Li X, He L, Lai Y, Chen T, Li Y, Guo X, Jiang C, Tang R, Sang C, Long D, Xie G, Dong J, Ma C. Identification of atrial fibrillation phenotypes at low risk of stroke in patients with CHA2DS2-VASc ≥2: Insight from the China-AF study. Pacing Clin Electrophysiol 2023; 46:1203-1211. [PMID: 37736697 DOI: 10.1111/pace.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE Patients with atrial fibrillation (AF) are highly heterogeneous, and current risk stratification scores are only modestly good at predicting an individual's stroke risk. We aim to identify distinct AF clinical phenotypes with cluster analysis to optimize stroke prevention practices. METHODS From the prospective Chinese Atrial Fibrillation Registry cohort study, we included 4337 AF patients with CHA2 DS2 -VASc≥2 for males and 3 for females who were not treated with oral anticoagulation. We randomly split the patients into derivation and validation sets by a ratio of 7:3. In the derivation set, we used outcome-driven patient clustering with metric learning to group patients into clusters with different risk levels of ischemic stroke and systemic embolism, and identify clusters of patients with low risks. Then we tested the results in the validation set, using the clustering rules generated from the derivation set. Finally, the survival decision tree was applied as a sensitivity analysis to confirm the results. RESULTS Up to the follow-up of 1 year, 140 thromboembolic events (ischemic stroke or systemic embolism) occurred. After supervised metric learning from six variables involved in CHA2 DS2 -VASc scheme, we identified a cluster of patients (255/3035, 8.4%) at an annual thromboembolism risk of 0.8% in the derivation set. None of the patients in the low-risk cluster had prior thromboembolism, heart failure, diabetes, or age older than 70 years. After applying the regularities from metric learning on the validation set, we also identified a cluster of patients (137/1302, 10.5%) with an incident thromboembolism rate of 0.7%. Sensitivity analysis based on the survival decision tree approach selected a subgroup of patients with the same phenotypes as the metric-learning algorithm. CONCLUSIONS Cluster analysis identified a distinct clinical phenotype at low risk of stroke among high-risk [CHA2 DS2 -VASc≥2 (3 for females)] patients with AF. The use of the novel analytic approach has the potential to prevent a subset of AF patients from unnecessary anticoagulation and avoid the associated risk of major bleeding.
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Affiliation(s)
- Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Mingxiao Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yiying Hu
- Ping An Health Technology, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Heart Health Research Center, Beijing, China
| | - Xiang Li
- Ping An Health Technology, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Tiange Chen
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Yingxue Li
- Ping An Health Technology, Beijing, China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | | | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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3
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Yang L, Chung MK. Lifestyle changes in atrial fibrillation management and intervention. J Cardiovasc Electrophysiol 2023; 34:2163-2178. [PMID: 36598428 PMCID: PMC10318120 DOI: 10.1111/jce.15803] [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: 07/18/2022] [Revised: 12/13/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies.
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Affiliation(s)
- Lucy Yang
- The Departments of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, and Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mina K Chung
- The Departments of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, and Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Gonzalez-Gonzalez L, Calm A, Mañosa M, Bazán V, Borrellas A, Carrillo X, Bisbal F, Vallejo N, Cañete F, Calafat M, Domènech E. Impact of left atrial appendage closure in patients on anticoagulation for atrial fibrillation and recurrent or chronic gastrointestinal bleeding. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:621-627. [PMID: 36828118 DOI: 10.1016/j.gastrohep.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/09/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Oral anticoagulation in non-valvular atrial fibrillation is associated with an increased risk of bleeding, particularly gastrointestinal bleeding, leading to treatment withdrawal in up to 50% of patients and putting them at risk of embolic events. Left atrial appendage closure (LAAC) can be an alternative to chronic anticoagulation. We aim to describe the impact of LAAC in patients with gastrointestinal bleeding (GIB) or chronic iron deficiency anaemia (CIDA) on healthcare resources consumption. METHODS Observational retrospective study of patients who underwent LAAC for GIB or CIDA at a single centre. RESULTS Nineteen patients with a median age of 74 years and a median Charlson score of six points were included in the study. Angiodysplasias were the most frequent cause of GIB or CIDA. The procedural success rate of LAAC was 100% with a median anticoagulant and antiplatelet treatment duration of 92 days. One year after the LAAC, we found a significant improvement in the lowest haemoglobin concentration and a reduction in the number of red blood cells transfusion, hospital admissions due to GIB and CIDA and the number of endoscopic examinations. One patient died due to a pulmonary thromboembolism. No deaths related to GIB were observed. CONCLUSIONS LAAC seems to be a safe and effective alternative to anticoagulation in patients with GIB or CIDA.
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Affiliation(s)
- Laura Gonzalez-Gonzalez
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Anna Calm
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Víctor Bazán
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investivación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Andrea Borrellas
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investivación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Xavier Carrillo
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investivación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Felipe Bisbal
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investivación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Nuria Vallejo
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investivación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
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5
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Zieliński K, Pracoń R, Konka M, Kruk M, Kępka C, Trochimiuk P, Dębski M, Kaczmarska E, Przyłuski J, Kowalik I, Dzielińska Z, Kurowski A, Witkowski A, Demkow M. Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13802. [PMID: 36360682 PMCID: PMC9658798 DOI: 10.3390/ijerph192113802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC. METHODS Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014-11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure. RESULTS Among 195 patients (age 74 (68-80), 43.1% females, HAS-BLED score 2.0 (2.0-3.0)), during median follow-up of 370 (IQR, 358-392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16-60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81-210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37-84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32-25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20-17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01-11.08, p = 0.048) predicted post-LAAC CSB. CONCLUSIONS Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.
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Affiliation(s)
- Kamil Zieliński
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marek Konka
- Department of Congenital Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Kruk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Cezary Kępka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Piotr Trochimiuk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Dębski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Edyta Kaczmarska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Jakub Przyłuski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Ilona Kowalik
- Clinical Research Support Center, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Zofia Dzielińska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Andrzej Kurowski
- Department of Anesthesiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
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Kondo Y, Kobayashi Y. Antithrombotic regimes in patients with prior gastrointestinal bleeding undergoing left atrial appendage closure. Pacing Clin Electrophysiol 2022; 45:439. [PMID: 35077578 DOI: 10.1111/pace.14457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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7
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Faroux L, Rodés-Cabau J. Response to: Antithrombotic regimes in patients with prior gastrointestinal bleeding undergoing left atrial appendage closure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:440. [PMID: 34897746 DOI: 10.1111/pace.14427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/09/2021] [Accepted: 11/28/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
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