1
|
Bernardini A, Bindini L, Antonucci E, Berteotti M, Giusti B, Testa S, Palareti G, Poli D, Frasconi P, Marcucci R. Machine learning approach for prediction of outcomes in anticoagulated patients with atrial fibrillation. Int J Cardiol 2024; 407:132088. [PMID: 38657869 DOI: 10.1016/j.ijcard.2024.132088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The accuracy of available prediction tools for clinical outcomes in patients with atrial fibrillation (AF) remains modest. Machine Learning (ML) has been used to predict outcomes in the AF population, but not in a population entirely on anticoagulant therapy. METHODS AND AIMS Different supervised ML models were applied to predict all-cause death, cardiovascular (CV) death, major bleeding and stroke in anticoagulated patients with AF, processing data from the multicenter START-2 Register. RESULTS 11078 AF patients (male n = 6029, 54.3%) were enrolled with a median follow-up period of 1.5 years [IQR 1.0-2.6]. Patients on Vitamin K Antagonists (VKA) were 5135 (46.4%) and 5943 (53.6%) were on Direct Oral Anticoagulants (DOAC). Using Multi-Gate Mixture of Experts, a cross-validated AUC of 0.779 ± 0.016 and 0.745 ± 0.022 were obtained, respectively, for the prediction of all-cause death and CV-death in the overall population. The best ML model outperformed CHA2DSVA2SC and HAS-BLED for all-cause death prediction (p < 0.001 for both). When compared to HAS-BLED, Gradient Boosting improved major bleeding prediction in DOACs patients (0.711 vs. 0.586, p < 0.001). A very low number of events during follow-up (52) resulted in a suboptimal ischemic stroke prediction (best AUC of 0.606 ± 0.117 in overall population). Body mass index, age, renal function, platelet count and hemoglobin levels resulted the most important variables for ML prediction. CONCLUSIONS In AF patients, ML models showed good discriminative ability to predict all-cause death, regardless of the type of anticoagulation strategy, and major bleeding on DOAC therapy, outperforming CHA2DS2VASC and the HAS-BLED scores for risk prediction in these populations.
Collapse
Affiliation(s)
- Andrea Bernardini
- Cardiology and Electrophysiology Unit, Santa Maria Nuova Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Italy.
| | - Luca Bindini
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | | | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, Azienda Socio-Sanitaria Territoriale, Cremona, Italy
| | | | - Daniela Poli
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Paolo Frasconi
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| |
Collapse
|
2
|
Soler-Espejo E, Rivera-Caravaca JM, Bru-Cánovas JD, Esteve-Pastor MA, Lip GYH, Marín F, Roldán V. Patients with atrial fibrillation and common exclusion criteria from clinical trials are at high risk of clinical events: the Murcia AF Project II (MAFP-II) cohort study. Intern Emerg Med 2024:10.1007/s11739-024-03701-9. [PMID: 38965203 DOI: 10.1007/s11739-024-03701-9] [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: 04/17/2024] [Accepted: 06/29/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Some clinical characteristics and comorbidities in atrial fibrillation (AF) patients are exclusion criteria in randomized clinical trials (RCTs) investigating oral anticoagulants (OAC). However, these conditions are present also in everyday clinical practice patients. We compared the risk of adverse clinical outcomes between patients with and without RCT exclusion criteria. METHODS The Murcia AF Project II was an observational cohort study including AF outpatients starting vitamin K antagonists (VKAs) from July 2016 to June 2018. For the selection of the exclusion criteria, the four pivotal RCTs of direct-acting OAC (DOACs) were used as reference. During 2 years, all ischemic strokes/transient ischemic attacks, major adverse cardiovascular events (MACEs), major bleeds, and all-cause deaths were recorded. RESULTS 1050 patients (51.5% female, median age 77 years) were included, of whom 368 (35%) met at least one exclusion criterion for RCTs. During follow-up, the incidence rate ratios for major bleeding, MACE and all-cause mortality were higher among patients with exclusion criteria (all p < 0.001). Patients fulfilling at least one exclusion criterion had increased risks of major bleeding (aHR 1.48; 95% CI 1.22-1.81; p < 0.001), MACE (aHR 1.51, 95% CI 1.10-2.09, p = 0.012), and mortality (aHR 3.22, 95% CI 2.32-4.48, p < 0.001), as well as a lower event-free survival (all log-rank p < 0.001). CONCLUSIONS In this AF cohort taking VKAs, more than one-third had at least one RCT exclusion criteria, which translates into higher risk of major bleeding, MACE, and death. These observations should be considered when translating RCTs results to AF patients for a proper and a more patient-centered management.
Collapse
Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Murcia, Spain.
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
| | | | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Yoke Hong Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| |
Collapse
|
3
|
Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [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: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
Collapse
Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
| |
Collapse
|
4
|
Truong B, Hornsby L, Fox B, Chou C, Zheng J, Qian J. Benefit and risk of oral anticoagulant initiation strategies in patients with atrial fibrillation and cancer: a target trial emulation using the SEER-Medicare database. J Thromb Thrombolysis 2024; 57:638-649. [PMID: 38504063 PMCID: PMC11026243 DOI: 10.1007/s11239-024-02958-3] [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] [Accepted: 02/06/2024] [Indexed: 03/21/2024]
Abstract
Oral anticoagulants (OACs) are recommended for patients with atrial fibrillation (AFib) having CHA2DS2-VASc score ≥ 2. However, the benefits of OAC initiation in patients with AFib and cancer at different levels of CHA2DS2-VASc is unknown. We included patients with new AFib diagnosis and a record of cancer (breast, prostate, or lung) from the 2012-2019 Surveillance, Epidemiology, and End Results (SEER)-Medicare database (n = 39,915). Risks of stroke and bleeding were compared between 5 treatment strategies: (1) initiated OAC when CHA2DS2-VASc ≥ 1 (n = 6008), (2) CHA2DS2-VASc ≥ 2 (n = 8694), (3) CHA2DS2-VASc ≥ 4 (n = 20,286), (4) CHA2DS2-VASc ≥ 6 (n = 30,944), and (5) never initiated OAC (reference group, n = 33,907). Confounders were adjusted using inverse probability weighting through cloning-censoring-weighting approach. Weighted pooled logistic regressions were used to estimate treatment effect [hazard ratios (HRs) and 95% confidence interval (95% CIs)]. We found that only patients who initiated OACs at CHA2DS2-VASc ≥ 6 had lower risk of stroke compared without OAC initiation (HR 0.64, 95% CI 0.54-0.75). All 4 active treatment strategies had reduced risk of bleeding compared to non-initiators, with OAC initiation at CHA2DS2-VASc ≥ 6 being the most beneficial strategy (HR = 0.49, 95% CI 0.44-0.55). In patients with lung cancer or regional/metastatic cancer, OAC initiation at any CHA2DS2-VASc level increased risk of stroke and did not reduce risk of bleeding (except for Regimen 4). In conclusion, among cancer patients with new AFib diagnosis, OAC initiation at higher risk of stroke (CHA2DS2-VASc score ≥ 6) is more beneficial in preventing ischemic stroke and bleeding. Patients with advanced cancer or low life-expectancy may initiate OACs when CHA2DS2-VASc score ≥ 6.
Collapse
Affiliation(s)
- Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Lori Hornsby
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Brent Fox
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA
| | - Jingyi Zheng
- Department of Mathematics and Statistics, Auburn University College of Sciences and Mathematics, Auburn, AL, USA
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306d Walker Building, Auburn, AL, 36849, USA.
| |
Collapse
|
5
|
Rafaqat S, Gluscevic S, Patoulias D, Sharif S, Klisic A. The Association between Coagulation and Atrial Fibrillation. Biomedicines 2024; 12:274. [PMID: 38397876 PMCID: PMC10887311 DOI: 10.3390/biomedicines12020274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
The existing literature highlights the presence of numerous coagulation factors and markers. Elevated levels of coagulation factors are associated with both existing and newly diagnosed cases of atrial fibrillation (AF). However, this article summarizes the role of coagulation in the pathogenesis of AF, which includes fibrinogen and fibrin, prothrombin, thrombomodulin, soluble urokinase plasminogen activator receptor, von Willebrand factor, P-selectin, D-dimer, plasminogen activator inhibitor-1, and platelet activation. Coagulation irregularities play a significant role in the pathogenesis of AF.
Collapse
Affiliation(s)
- Saira Rafaqat
- Department of Zoology (Molecular Physiology), Lahore College for Women University, Lahore 54600, Punjab, Pakistan
| | - Sanja Gluscevic
- Department of Neurology, Clinical Center of Montenegro, 81000 Podgorica, Montenegro
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital “Hippokration”, 54642 Thessaloniki, Greece
| | - Saima Sharif
- Department of Zoology (Molecular Physiology), Lahore College for Women University, Lahore 54600, Punjab, Pakistan
| | - Aleksandra Klisic
- Faculty of Medicine, University of Montenegro, 81000 Podgorica, Montenegro
- Center for Laboratory Diagnostics, Primary Health Care Center, 81000 Podgorica, Montenegro
| |
Collapse
|
6
|
Iyengar V, Patell R, Ren S, Ma S, Pinson A, Barnett A, Elavalakanar P, Kazi DS, Neuberg D, Zwicker JI. Influence of thrombocytopenia on bleeding and vascular events in atrial fibrillation. Blood Adv 2023; 7:7516-7524. [PMID: 37756539 PMCID: PMC10761355 DOI: 10.1182/bloodadvances.2023011235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Whether thrombocytopenia substantively increases the risk of hemorrhage associated with anticoagulation in patients with atrial fibrillation (AF) is not established. The purpose of this study was to compare rates of bleeding in patients with AF and thrombocytopenia (platelet count < 100 000/μL) to patients with AF and normal platelet counts (>150 000/μL). We performed a propensity score-matched, retrospective cohort study of adults (n = 1070) with a new diagnosis of AF who received a prescription for an oral anticoagulant between 2015 and 2020. The thrombocytopenia cohort was defined as having at least 2 platelet counts <100 000/μL on separate days in the period spanning the 12 weeks preceding the initiation of anticoagulation to 6 weeks after the initiation of anticoagulation. The primary end point was the 1-year cumulative incidence of major bleeding; secondary end points included clinically relevant bleeding, arterial and venous thrombotic events, and all-cause mortality. Patients with AF and thrombocytopenia experienced a higher 1-year cumulative incidence of major bleeding (13.3% vs 5.7%; P < .0001) and clinically relevant bleeding (24.5% vs 16.7%; P = .005) than the controls. Thrombocytopenia was identified as an independent risk factor for major bleeding (hazard ratio, 2.20; confidence interval, 1.36-3.58; P = .001), with increasing risk based on the severity of thrombocytopenia. The cumulative incidence of arterial thrombosis at 1 year was 3.6% in the group with thrombocytopenia and 1.5% in controls (Gray test, P = .08). These findings suggest that baseline platelet counts are an important biomarker for hemorrhagic outcomes in AF and that the degree of thrombocytopenia is an important factor in determining the level of risk.
Collapse
Affiliation(s)
- Varun Iyengar
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rushad Patell
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Siyang Ren
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Sirui Ma
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Amanda Pinson
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Amelia Barnett
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Pavania Elavalakanar
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Dhruv S. Kazi
- Harvard Medical School, Boston, MA
- Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Jeffrey I. Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| |
Collapse
|
7
|
Kowalska W, Mitręga K, Olma A, Podolecki T, Kalarus Z, Streb W. Anticoagulants versus Left Atrial Appendage Occlusion in Patients with Atrial Fibrillation and Co-Morbid Thrombocytopenia. J Clin Med 2023; 12:7637. [PMID: 38137707 PMCID: PMC10743658 DOI: 10.3390/jcm12247637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Left atrial appendage closure (LAAC) is an alternative approach to anticoagulants. Nonetheless, data regarding the outcomes of LAAC procedures in patients with thrombocytopenia remain lacking. The primary objective was to determine the incidence of the composite endpoint comprising ischemic stroke, intracranial hemorrhage, major bleeding, and cardiac cause of death among patients with atrial fibrillation (AF) and thrombocytopenia who were either undergoing LAAC or receiving oral anticoagulants. The secondary endpoint was the determination of total mortality. Data from a prospective, single-center registry of patients undergoing LAAC procedures were analyzed. A subset of 50 consecutive patients with thrombocytopenia were selected. Thrombocytopenia was defined as a thrombocyte count below 150,000. Subsequently, from patients hospitalized with AF receiving oral anticoagulants, 50 patients were further chosen based on propensity score matching, ensuring comparability with the study group. The primary endpoint occurred in 2% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.097). Additionally, a significant difference was noted in the occurrence of the secondary endpoint, which was observed in 0% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.025). In patients with thrombocytopenia the LAAC procedure improves prognosis compared with continued anticoagulant treatment.
Collapse
Affiliation(s)
- Wiktoria Kowalska
- Doctoral School, Division of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Katarzyna Mitręga
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Anna Olma
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Tomasz Podolecki
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Zbigniew Kalarus
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Witold Streb
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| |
Collapse
|
8
|
Menichelli D, Antonucci E, Pignatelli P, Violi F, Palareti G, Pastori D. Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry. Nutr Metab Cardiovasc Dis 2023; 33:2261-2268. [PMID: 37580234 DOI: 10.1016/j.numecd.2023.07.016] [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: 11/28/2022] [Revised: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND AND AIMS Statins are mainstream drugs for cardiovascular (CV) prevention, but under-prescription is an important clinical challenge. Data on the use of single statins and on the rate of under-prescription in atrial fibrillation (AF) are lacking. We evaluated the association of statin underuse with mortality risk in a large AF cohort. METHODS AND RESULTS As many as 5477 patients from the Italian nationwide START registry were included. The prevalence of different statins was reported and the association of under prescription with all-cause and CV mortality investigated. Mean age was 80.2 years, and 46.4% were women. Among 2899 patients with a clinical indication to statin, only 1578 (54.4%) were on treatment. In a mean follow-up of 22.5 ± 17.1 months, 491 (4.7%/year) deaths occurred (106 CV deaths, 1.0%/year). Atorvastatin and Simvastatin were inversely associated with all-cause (HR 0.692, 95% CI 0.519-0.923, p = 0.012 and HR 0.598, 95% CI 0.428-0.836, p = 0.003, respectively) and CV death (HR 0.372, 95% CI 0.178-0.776, p = 0.008 and HR 0.306, 95% CI 0.123-0.758, p = 0.010, respectively). The 1321 untreated patients were older, more frequently women and with a higher prevalence of diabetes, previous cerebrovascular disease, peripheral artery disease compared to those on treatment. Statin undertreatment was associated with higher risk of all-cause (HR 1.400, 95% CI 1.078-1.819, p = 0.012) and CV death (HR 2.057, 95% CI 1.188-3.561, p = 0.010). CONCLUSIONS AF patients with an indication to statins but left untreated show a high risk of all-cause and CV mortality. Implementation of statin prescription in the AF population can help reducing the residual mortality risk.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | | | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
9
|
Iijima R, Tokue M, Nakamura M, Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Miyauchi K, Hagiwara N, Kimura K, Hirayama A, Matsui K, Ogawa H. Thrombocytopenia as a Bleeding Risk Factor in Atrial Fibrillation and Coronary Artery Disease: Insights From the AFIRE Study. J Am Heart Assoc 2023; 12:e031096. [PMID: 37815031 PMCID: PMC10757527 DOI: 10.1161/jaha.123.031096] [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: 05/20/2023] [Accepted: 09/08/2023] [Indexed: 10/11/2023]
Abstract
Background Thrombocytopenia poses a risk of bleeding in patients with chronic coronary syndrome after coronary intervention. However, whether thrombocytopenia also increases the bleeding risk in patients with atrial fibrillation and chronic coronary syndrome remains unclear. Methods and Results This study evaluated the AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial. Thrombocytopenia was defined as platelet count <100 000/mm3 level at enrollment. Primary end points included incidence of major bleeding based on the International Society on Thrombosis and Hemostasis criterion and major adverse cardiovascular ischemic events (cardiac death, myocardial infarction, and stroke). A total of 2133 patients were classified into the thrombocytopenia (n=70) and nonthrombocytopenia (n=2063) groups. Major bleeding was significantly higher in the thrombocytopenia group than in the nonthrombocytopenia group (10.0% versus 4.1%, P=0.027). The thrombocytopenia group tended to have a higher risk of major adverse cardiovascular ischemic events (11.4% versus 6.2%, P=0.08). The bleeding incidence was significantly higher in patients with thrombocytopenia receiving combination therapy with rivaroxaban and a single antiplatelet drug (thrombocytopenia group, 14.3%, versus nonthrombocytopenia group, 5.0%; hazard ratio, 3.18 [95% CI, 1.27-7.97], P=0.014). Thrombocytopenia was an independent predictor of major bleeding (hazard ratio, 2.57 [95% CI, 1.19-5.56], P=0.017). Conclusions Among patients with atrial fibrillation and chronic coronary syndrome, thrombocytopenia was significantly associated with increased risk of major bleeding. Selecting drugs for patients with thrombocytopenia continuing antithrombotic therapy should be given special consideration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02642419. https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000016612.
Collapse
Affiliation(s)
- Raisuke Iijima
- Division of Cardiovascular MedicineToho University Ohashi Medical CenterTokyoJapan
| | - Masahide Tokue
- Kawasaki Miyamaedaira Tokue Internal‐Cardiovascular Medical ClinicKawasakiJapan
| | - Masato Nakamura
- Division of Cardiovascular MedicineToho University Ohashi Medical CenterTokyoJapan
| | - Satoshi Yasuda
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of MedicineUniversity of MiyazakiMiyazakiJapan
| | - Masaharu Akao
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Junya Ako
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu UniversityFukuokaJapan
| | - Katsumi Miyauchi
- Department of Cardiovascular MedicineJuntendo Tokyo Koto Geriatric Medical CenterTokyoJapan
| | | | - Kazuo Kimura
- Department of CardiologyYokosuka City HospitalYokosukaJapan
| | | | - Kunihiko Matsui
- Department of General MedicineKumamoto University HospitalKumamotoJapan
| | | | | |
Collapse
|
10
|
Basrawala H, Finley K, Jaglal M, Mohanty BD. First description of atrial fibrillation and congenital thrombotic thrombocytopenic purpura treated by left atrial appendage occlusion. EJHAEM 2023; 4:428-431. [PMID: 37206280 PMCID: PMC10188452 DOI: 10.1002/jha2.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/15/2022] [Accepted: 01/31/2023] [Indexed: 05/21/2023]
Abstract
Given an increased risk of both thrombosis and bleeding, thrombotic thrombocytopenic purpura (TTP) presents a unique challenge when anticoagulation is required for comorbid disease, particularly in the setting of major bleeding events. We present for the first time a patient with TTP and atrial fibrillation, presenting with recurrent stroke, but unable to tolerate anticoagulation due to prior intra-cerebral hemorrhage. To address both issues concomitantly, we describe the successful application of a novel management approach to facilitate left atrial appendage occlusion, there by offering a non-pharmacologic means of stroke prevention without added bleeding risk.
Collapse
Affiliation(s)
- Hussain Basrawala
- Department of Cardiovascular Sciences, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Katherine Finley
- Department of Internal Medicine, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Michael Jaglal
- Department of Hematology and Oncology, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Bibhu D. Mohanty
- Department of Cardiovascular Sciences, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| |
Collapse
|
11
|
Dangl M, Grant JK, Vincent L, Ebner B, Maning J, Olorunfemi O, Zablah G, Sancassani R, Colombo R. The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis. J Card Surg 2022; 37:4762-4773. [PMID: 36403274 DOI: 10.1111/jocs.17183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). METHOD The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. RESULTS Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend toward increasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. CONCLUSION In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.
Collapse
Affiliation(s)
- Michael Dangl
- Department of Internal Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jelani K Grant
- Department of Medicine, Cardiovascular Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Louis Vincent
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Bertrand Ebner
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jennifer Maning
- Department of Medicine, Cardiovascular Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Odunayo Olorunfemi
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gerardo Zablah
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rhea Sancassani
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rosario Colombo
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
12
|
Tatarsky BA, Kazennova NV. Thrombocytopenia Induced by Direct Oral Anticoagulants: a Clinical Case and Literature Review. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-10-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The last decade has dramatically changed the strategy of anticoagulant therapy in patients with atrial fibrillation. Direct oral anticoagulants have replaced vitamin K antagonists: either direct thrombin blockers (dabigatran) or factor IIa blockers (apixaban, rivaroxaban, edoxaban). According to the regulatory domestic and foreign documents, the use of direct oral anticoagulants in patients with atrial fibrillation has priority in comparison with vitamin K antagonists, since they have a predictable anticoagulant effect, the possibility of taking fixed doses without the need for routine anticoagulant monitoring, rapid onset and termination of action, relatively low potential for food and drug interactions. Direct oral anticoagulants are used for the prevention of thromboembolic complications in patients with atrial fibrillation, for the prevention of deep vein thrombosis in patients who have undergone surgery on the knee or hip joints, for emergency treatment and secondary prevention of deep vein thrombosis and pulmonary embolism. Alertness to side effects tends to focus on the likelihood of bleeding, with the possibility of other side effects of direct oral anticoagulants receiving less attention or going unnoticed. These mainly include liver damage, kidney damage and a number of other rare adverse reactions. The finding of isolated thrombocytopenia in patients taking direct oral anticoagulants may be associated with a high risk of life-threatening bleeding. The article analyzes published data on the occurrence of thrombocytopenia associated with the intake of direct oral anticoagulants, and presents a clinical case of thrombocytopenia while taking apixaban.
Collapse
|
13
|
Clinical Phenotypes of Atrial Fibrillation and Mortality Risk-A Cluster Analysis from the Nationwide Italian START Registry. J Pers Med 2022; 12:jpm12050785. [PMID: 35629207 PMCID: PMC9143727 DOI: 10.3390/jpm12050785] [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: 03/20/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 01/27/2023] Open
Abstract
Patients with atrial fibrillation (AF) still experience a high mortality rate despite optimal antithrombotic treatment. We aimed to identify clinical phenotypes of patients to stratify mortality risk in AF. Cluster analysis was performed on 5171 AF patients from the nationwide START registry. The risk of all-cause mortality in each cluster was analyzed. We identified four clusters. Cluster 1 was composed of the youngest patients, with low comorbidities; Cluster 2 of patients with low cardiovascular risk factors and high prevalence of cancer; Cluster 3 of men with diabetes and coronary disease and peripheral artery disease; Cluster 4 included the oldest patients, mainly women, with previous cerebrovascular events. During 9857 person-years of observation, 386 deaths (3.92%/year) occurred. Mortality rates increased across clusters: 0.42%/year (cluster 1, reference group), 2.12%/year (cluster 2, adjusted hazard ratio (aHR) 3.306, 95% confidence interval (CI) 1.204−9.077, p = 0.020), 4.41%/year (cluster 3, aHR 6.702, 95%CI 2.433−18.461, p < 0.001), and 8.71%/year (cluster 4, aHR 8.927, 95%CI 3.238−24.605, p < 0.001). We identified four clusters of AF patients with progressive mortality risk. The use of clinical phenotypes may help identify patients at a higher risk of mortality.
Collapse
|
14
|
Pérez Cabeza AI, Rivera-Caravaca JM, Roldán-Rabadán I, García Seara J, Bertomeu-Gonzalez V, Leal M, García-Fernandez A, Tercedor Sanchez L, Ayarra M, Ciudad M, Castaño S, Maestre A, Anguita M, Garcia Bolao I, Marín F. Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry. Eur J Clin Invest 2022; 52:e13709. [PMID: 34757635 DOI: 10.1111/eci.13709] [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: 10/20/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry. METHODS The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up. RESULTS 729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA2 DS2 -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates. CONCLUSIONS In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.
Collapse
Affiliation(s)
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom
| | | | - Javier García Seara
- Department of Cardiology, Hospital Clinico Universitario Santiago de Compostela, CIBERCV, Santiago de Compostela, Spain
| | - Vicente Bertomeu-Gonzalez
- Department of Cardiology, University Hospital San Juan de Alicante, Universidad Miguel Hernandez, CIBERCV, Alicante, Spain
| | - Mariano Leal
- Primary Care Health Center of San Andrés, Murcia, Spain
| | - Amaya García-Fernandez
- Department of Cardiology, Arrhythmias Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
| | - Luis Tercedor Sanchez
- Department of Cardiology, University Hospital Virgen de las Nieves, Instituto de Investigación Biosanitaria ibs.Granada, Granada, Spain
| | | | - Marianela Ciudad
- Department of Internal Medicine, University Hospital de La Princesa, Madrid, Spain
| | - Sara Castaño
- Department of Cardiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Ana Maestre
- Department of Internal Medicine, Hospital Universitario del Vinalopó, Elche, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica (IMIBIC), Córdoba, Spain
| | - Ignacio Garcia Bolao
- Department of Cardiology, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| |
Collapse
|
15
|
Menichelli D, Poli D, Antonucci E, Biccirè FG, Palareti G, Pignatelli P, Pastori D. Bleeding and mortality risk in patients implanted with mechanical prosthetic heart valves with and without thrombocytopenia. Insights from the nationwide PLECTRUM registry. Platelets 2022; 33:1018-1023. [PMID: 35021929 DOI: 10.1080/09537104.2022.2026909] [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: 10/19/2022]
Abstract
Previous studies showed that mechanical prosthetic heart valve (MPHV) patients may develop thrombocytopenia, but its association with clinical outcomes has not been investigated. We enrolled 1,663 patients with available platelet count from the multicenter nationwide retrospective PLECTRUM registry to investigate the association of thrombocytopenia with all-cause mortality and major bleeding (MB) in patients implanted with MPHV. Thrombocytopenia was defined by platelet count <150 × 109/L. Overall, 44.9% of patients were women and the mean age was 56.7 years. At baseline, 184 (11.1%) patients had thrombocytopenia. Patients with thrombocytopenia were more frequently men and elderly. Platelet count showed an age-dependent decline in men but not in women. We found an increased risk of death in patients with age ≥ 65 years, with a low anticoagulation quality, concomitant arterial hypertension, heart failure, a higher INR range, or with thrombocytopenia (OR 1.739, 95%CI 1.048-2.886, p = .032). At multivariable logistic regression, patients with age ≥65 years, concomitant AF and thrombocytopenia (OR 1.907, 95%CI 1.219-2.983, p = .005) had an increased risk of MBs. In MPHV patients, thrombocytopenia is associated with an increased risk of death and MB. There is a growing need for a sex- and age-specific threshold to define platelet count in adult patients.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | | | - Flavio Giuseppe Biccirè
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.,Department of General and Specialized Surgery "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | | | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | |
Collapse
|
16
|
Xu J, Sun Y, Gong D, Fan Y. Impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation: A meta-analysis. Front Endocrinol (Lausanne) 2022; 13:921159. [PMID: 35979438 PMCID: PMC9376236 DOI: 10.3389/fendo.2022.921159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/01/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine the impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation (AF) by conducting a meta-analysis. METHODS PubMed and Embase databases were comprehensively searched for relevant studies publishing until May 19, 2022. Cohort studies or post-hoc analyses of clinical trials that investigated the association of diabetes mellitus with cardiovascular or all-cause mortality in AF patients were included. RESULTS A total of 21 studies with 526,136 AF patients were identified. The pooled prevalence of diabetes mellitus in patients with AF was 26%. The summary multivariable-adjusted risk ratio (RR) of all-cause mortality was 1.37 (95% confidence intervals [CIs] 1.23-1.53) for patients with diabetes versus those without diabetes. Moreover, diabetes mellitus was also associated with an increased risk of cardiovascular mortality (RR 1.46; 95% CI 1.34-1.58). Stratified analyses suggested that the impact of diabetes on all-cause and cardiovascular mortality was consistently observed in each named subgroup. CONCLUSION The presence of diabetes mellitus in patients with AF is associated with an increased risk of cardiovascular and all-cause mortality, even after adjustment for important confounding factors.
Collapse
Affiliation(s)
- Juan Xu
- Department of Oncology, Ganyu District People’s Hospital of Lianyungang City, Lianyungang, China
| | - Yimeng Sun
- Institute of Molecular Biology and Translational Medicine, The Affiliated People’s Hospital, Jiangsu University, Zhenjiang, China
| | - Dandan Gong
- Institute of Molecular Biology and Translational Medicine, The Affiliated People’s Hospital, Jiangsu University, Zhenjiang, China
- *Correspondence: Yu Fan, ; Dandan Gong,
| | - Yu Fan
- Institute of Molecular Biology and Translational Medicine, The Affiliated People’s Hospital, Jiangsu University, Zhenjiang, China
- *Correspondence: Yu Fan, ; Dandan Gong,
| |
Collapse
|
17
|
Ždraljević M, Pekmezović T, Stanarčević P, Vukašinović I, Berisavac I, Ercegovac M, Vitošević F, Nestorović D, Cvetić V, Padjen V, Budimkić MS, Medjedović TŠ, Jovanović DR. Influence of Thrombocytopenia on the Outcome of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 31:106240. [PMID: 34915307 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/08/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Mechanical thrombectomy (MT) has become leading treatment option for acute ischemic stroke (AIS) due to large vessels occlusion (LVO). Platelet counts may affect outcome in patients with AIS or transient ischemic attack. The aim of our study was to determine the influence of thrombocytopenia on the safety and efficacy of MT in patients with AIS due to anterior circulation LVO. MATERIALS AND METHODS This study included 127 consecutive adult patients with AIS due to anterior circulation LVO who underwent MT. The patients were divided into 2 groups based on initial platelet count: with thrombocytopenia (<150 × 109/L) and without thrombocytopenia (≥150 × 109/L). Primary safety outcome was symptomatic intracerebral haemorrhage (SICH), while secondary safety outcome was stroke-related mortality. Efficacy outcome was functional independence, defined as modified Rankin Scale (mRS) score 0-2. Follow- up time was 90 days. RESULTS Initial thrombocytopenia (<150 × 109/L) was detected in 19 (15%) patients. Multivariable analysis showed that initial thrombocytopenia did not increase the risk of SICH and did not affect the short-term functional outcome (p = 0.587). However, initial thrombocytopenia increased the risk for stroke-related mortality (aOR 3.639, 95% CI 1.079-12.641, p = 0.037). The main cause of mortality in the group with thrombocytopenia was malignant cerebral infarction (44.4%). CONCLUSIONS Thrombocytopenia does not affect the efficacy and the risk of SICH in patients with AIS caused by anterior circulation LVO treated with MT. However, the risk of mortality is higher in patients with thrombocytopenia, mainly due to malignant cerebral infarction.
Collapse
Affiliation(s)
- Mirjana Ždraljević
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia
| | - Tatjana Pekmezović
- Institute of Epidemiology, Faculty of Medicine, Višegradska Street 26, 11 000 Belgrade, Serbia
| | - Predrag Stanarčević
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia; Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia
| | - Ivan Vukašinović
- Center for Radiology and MRI, Clinic for Neurosurgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Ivana Berisavac
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia; Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia
| | - Marko Ercegovac
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia; Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia
| | - Filip Vitošević
- Center for Radiology and MRI, Clinic for Neurosurgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Dragoslav Nestorović
- Center for Radiology and MRI, Clinic for Neurosurgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Vladimir Cvetić
- Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Dr Koste Todorovića Street 6, 11 000 Belgrade, Serbia
| | - Višnja Padjen
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia; Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia
| | - Maja Stefanović- Budimkić
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia
| | - Tamara Švabić Medjedović
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia
| | - Dejana R Jovanović
- Neurology Clinic, University Clinical Center of Serbia, Dr Subotica Street 6, 11 000 Belgrade, Serbia; Faculty of Medicine, Dr Subotica Street 8, 11 000 Belgrade, Serbia.
| |
Collapse
|
18
|
Dognin N, Salaun E, Champagne C, Domain G, O'Hara G, Philippon F, Paradis JM, Faroux L, Beaudoin J, O'Connor K, Bernier M, Rodés-Cabau J, Champagne J. Percutaneous left atrial appendage closure in patients with primary hemostasis disorders and atrial fibrillation. J Interv Card Electrophysiol 2021; 64:497-509. [PMID: 34822043 DOI: 10.1007/s10840-021-01073-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND OR PURPOSE We report our single-center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and primary hemostasis disorders (HD). METHODS Consecutive patients with primary HD who underwent a percutaneous LAAC were included. Baseline characteristics, procedural data, and clinical outcomes were prospectively collected and compared with the overall LAAC cohort without HD. RESULTS Since 2013, among 229 LAAC, 17 patients (7%) had a primary HD: thrombocytopenia (n = 5), myelodysplastic syndrome (n = 6), von Willebrand syndrome (n = 4), type A hemophilia (n = 1), and dysfibrinogenemia (n = 1). The HD population's age ranged from 61 to 87 years, and the median CHA2DS2VASc was 5. Periprocedural plasmatic management was required in 47% of patients. The immediate LAAC implantation success rate was 100%. Patients received a direct oral anticoagulant (DOA) (n = 9), dual antiplatelet (n = 6), aspirin (n = 1), or no therapy (n = 1) during the first six postoperative weeks, followed with single antiplatelet (n = 16) or no therapy (n = 1) during lifelong. After 20 months, the technical success rate and procedural success rate were 100% and 94%. Zero device-/procedure-related complication and only one life-threatening bleeding occurred. Compared to patients without HD (n = 212), a baseline history of bleeding was less frequent (53% vs 91%, p < 0.001), and more patients received a perioperative blood transfusion (47% vs 4%, p < 0.001) in the HD group. The efficacy and safety outcomes did not differ between HD and non-HD cohorts. CONCLUSIONS Percutaneous LAAC in primary HD carriers appeared as safe and as effective as in overall LAAC population for stroke and bleeding prevention at midterm follow-up. Percutaneous left atrial appendage closure in patients with atrial fibrillation and primary hemostasis disorders. The percutaneous LAAC in primary hemostasis disorders and AF carriers requires a multidisciplinary approach. Cardiologist, anesthesiologist, and hematologist discussion is a cornerstone to assess anticoagulant contraindication, LAAC feasibility, periprocedural management, and follow-up (high). This multidisciplinary care is illustrated by the case of a 61-year-old male with hemophilia type A and recurrent hemarthrosis. Pre-LAAC assessment confirmed procedural indication and cactus LAA anatomy (left). After plasmatic management with factor VIII infusion, a WATCHMAN™ no. 21 was successfully implanted (middle). During follow-up, without antithrombotic regime, no ischemic or hemorrhagic complication occurred (right). LAA, left atrial appendage; LAAC, left atrial appendage closure; TEE, transesophageal echocardiography. Percutaneous LAAC in primary HD carriers appeared as safe and as effective as in overall LAAC population for stroke and bleeding prevention at midterm follow-up.
Collapse
Affiliation(s)
- Nicolas Dognin
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada.
| | - Erwan Salaun
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Catherine Champagne
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Guillaume Domain
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Gilles O'Hara
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - François Philippon
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jean-Michel Paradis
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Laurent Faroux
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jonathan Beaudoin
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Kim O'Connor
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Mathieu Bernier
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Josep Rodés-Cabau
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jean Champagne
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| |
Collapse
|
19
|
Menichelli D, Vicario T, Ameri P, Toma M, Violi F, Pignatelli P, Pastori D. Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment. Prog Cardiovasc Dis 2021; 66:28-36. [PMID: 33915139 DOI: 10.1016/j.pcad.2021.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/14/2022]
Abstract
Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Tommasa Vicario
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy; Emergency Department, Policlinico Tor Vergata Hospital, Rome, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine, University of Genova, Genova, Italy
| | - Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine, University of Genova, Genova, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
20
|
Zaninetti C, Thiele T. Anticoagulation in Patients with Platelet Disorders. Hamostaseologie 2021; 41:112-119. [PMID: 33860519 DOI: 10.1055/a-1344-7279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Platelet disorders comprise heterogeneous diseases featured by reduced platelet counts and/or impaired platelet function causing variable bleeding symptoms. Despite their bleeding diathesis, patients with platelet disorders can develop transient or permanent prothrombotic conditions that necessitate prophylactic or therapeutic anticoagulation. Anticoagulation in patients with platelet disorders is a matter of concern because the bleeding risk could add to the hemorrhagic risk related to the platelet defect. This review provides an overview on the evidence on anticoagulation in patients with acquired and inherited thrombocytopenia and/or platelet dysfunction. We summarize tools to evaluate and balance bleeding- and thrombotic risks and describe a practical approach on how to manage these patients if they have an indication for prophylactic or therapeutic anticoagulation.
Collapse
Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Thomas Thiele
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
21
|
Zhang X, Jin Q, Hu J, Kong D, Pan C, Chen D, Chen S, Li MI, Zhou D, Ge J. Impact of Thrombocytopenia in Patients With Atrial Fibrillation Undergoing Left Atrial Appendage Occlusion: A Propensity-Matched Comparison of 190 Consecutive Watchman Implantations. Front Cardiovasc Med 2021; 8:603501. [PMID: 33898533 PMCID: PMC8062722 DOI: 10.3389/fcvm.2021.603501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: The purpose of this study was to provide data on the long-term efficacy and safety of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) and chronic thrombocytopenia (cTCP). Methods: Between January 2016 and December 2018, a total of 32 AF patients with thrombocytopenia (platelet count <100*10∧9/L) undergoing LAAO at our center were identified and their outcomes were compared with a propensity-matched cohort (match ratio 1:5) of patients without cTCP who had also been indicated for LAAO. Results: Between the cTCP patients and the control group, no difference was found on the incidence of stroke (0 vs. 3.13%, p = 0.592), systematic thromboembolisation (0 vs. 0.63%, p > 0.9) and device-related thrombus (DRT) (3.13 vs. 2.50%, p > 0.9). Major (12.50 vs. 3.75%, p = 0.065) and minor bleeding (15.63 vs. 1.25%, p = 0.002) was more frequent in cTCP patients but no statistical difference was reached in major bleeding. Moreover, thrombocytopenia was also identified as an independent predictor of any bleeding events (OR: 8.150, 95% CI: 2.579–25.757, p < 0.001), while an inverse relationship between higher absolute platelet count and stroke events was revealed (OR: 1.015; 95% CI: 1.002~1.029, p = 0.022). However, in both groups we saw a significant reduction in observed annualized rates of non-procedural complications compared with the predicted values. In the cTCP and control groups, clinical thromboembolism was reduced by 100 and 74.32%, and major bleeding by 42.47 and 71.67%, respectively. Conclusion: Our preliminary results indicate that LAAO using the Watchman device could be a safe and effective means of preventing stroke in AF patients with or without thrombocytopenia, but bleeding complications should be monitored intensively in cTCP patients.
Collapse
Affiliation(s)
- Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Dehong Kong
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Cuizhen Pan
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Dandan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Shasha Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - MIngfei Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.,Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
22
|
Pastori D, Marang A, Bisson A, Menichelli D, Herbert J, Lip GYH, Fauchier L. Thromboembolism, mortality, and bleeding in 2,435,541 atrial fibrillation patients with and without cancer: A nationwide cohort study. Cancer 2021; 127:2122-2129. [PMID: 33631041 DOI: 10.1002/cncr.33470] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/28/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The number of patients with atrial fibrillation (AF) and cancer is rapidly increasing in clinical practice. The impact of cancer on clinical outcomes in this patient population is unclear, as is the performance of the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol) and CHA2 DS2 -VASc (Congestive Heart Failure, Hypertension, Age ≥ 75 years, Diabetes Mellitus, Stroke or Transient Ischemic Attack, Vascular Disease, Age 65 to 74 Years, Sex Category) scores. METHODS This was an observational, retrospective cohort study including 2,435,541 adults hospitalized with AF. The authors investigated the incidence rates (IRs) of all-cause and cardiovascular mortality, ischemic stroke, major bleeding, and intracranial hemorrhage (ICH) according to the presence of cancer and cancer types. RESULTS Overall, 399,344 (16.4%) had cancer, with the most common cancers being metastatic, prostatic, colorectal, lung, breast, and bladder. During a mean follow-up of 2.0 years, cancer increased all-cause mortality (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.99-2.01). The IR of ischemic stroke was higher with pancreatic cancer (2.8%/y), uterine cancer (2.6%/y), and breast cancer (2.6%/y), whereas it was lower with liver/lung cancer (1.9%/y) and leukemia/myeloma (2.0%/y), in comparison with noncancer patients (2.4%/y). Cancer increased the risk of major bleeding (HR, 1.27; 95% CI, 1.26-1.28) and ICH (HR, 1.07; 95% CI, 1.05-1.10). Leukemia, liver cancer, myeloma, and metastatic cancers showed the highest IRs for major bleeding/ICH. Major bleeding and ICH rates progressively increased with the HAS-BLED score, which showed generally good predictivity with C indexes > 0.70 for all cancer types. The CHA2 DS2 -VASc score's predictivity was slightly lower in AF patients with cancer. CONCLUSIONS Cancer increased all-cause mortality, major bleeding, and ICH risk in AF patients. The association between cancer and ischemic stroke differed among cancer types, and in some types, the risk of bleeding seemed to exceed the thromboembolic risk.
Collapse
Affiliation(s)
- Daniele Pastori
- Emergency Medicine Unit - Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Amélie Marang
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Danilo Menichelli
- Emergency Medicine Unit - Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France.,Service d'information médicale, d'épidémiologie et d'économie de la santé, Centre Hospitalier Universitaire et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| |
Collapse
|
23
|
Ito S, Taniguchi T, Shirai S, Ando K, Watanabe Y, Yamamoto M, Naganuma T, Takagi K, Yamawaki M, Tada N, Yamanaka F, Tabata M, Ueno H, Yashima F, Hayashida K. The Impact of Baseline Thrombocytopenia on Late Bleeding and Mortality After Transcatheter Aortic Valve Implantation (From the Japanese Multicenter OCEAN-TAVI Registry). Am J Cardiol 2021; 141:86-92. [PMID: 33220320 DOI: 10.1016/j.amjcard.2020.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 01/05/2023]
Abstract
Baseline thrombocytopenia was reported as a risk factor for bleeding or mortality in several medical areas, particularly in the cardiovascular field. This study aimed to assess the prognostic value of baseline thrombocytopenia in patients who had transcatheter aortic valve implantation. This study included 2,588 patients from the Optimized Catheter valvular intervention Japanese multicenter registry. Thrombocytopenia was defined as platelet count of <150 × 109/L and was classified into moderate/severe (<100 × 109/L) and mild (≧100-<150 × 109/L). At 3 years after index procedure, the moderate/severe thrombocytopenia group had a significantly higher cumulative composite late bleeding than the no thrombocytopenia group (log-rank test, p < 0.0001). Moreover, the moderate/severe thrombocytopenia group had a significantly higher cumulative all-cause, cardiovascular, and noncardiovascular mortality rates than the no thrombocytopenia group (log-rank test, p < 0.0001, p = 0.0014, p < 0.0001, respectively). After adjusting for confounders, the excess risk of moderate/severe and mild thrombocytopenia relative to no thrombocytopenia for the composite bleeding remained significant (hazard ratio 2.66: [95% confidence interval: 1.35 to 4.88], p = 0.006 and hazard ratio 2.10: [95% confidence interval: 1.36 to 3.21], p = 0.001, respectively). In conclusion, baseline thrombocytopenia was associated with an increased risk of late bleeding and poor prognosis. Baseline platelet level could be a prognostic marker for risk stratification.
Collapse
|
24
|
Fradley MG, Ellenberg K, Alomar M, Swanson J, Kharod A, Nguyen ATH, Khodor S, Mishra S, Duong LM, Shah N, Armanious M, Rhea IB, Schabath MB, Kip KE. Patterns of Anticoagulation Use in Patients With Cancer With Atrial Fibrillation and/or Atrial Flutter. JACC: CARDIOONCOLOGY 2020; 2:747-754. [PMID: 34396290 PMCID: PMC8352174 DOI: 10.1016/j.jaccao.2020.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Background Atrial fibrillation (AF) is a common cardiovascular complication affecting patients with cancer, but management strategies are not well established. Objectives The purpose of this retrospective cohort study was to evaluate cross-sectional patterns of anticoagulation (AC) use in patients with cancer with AF or atrial flutter (AFL) on the basis of their risk for stroke and bleeding. Methods Patients with cancer and electrocardiograms showing AF or AFL performed at Moffitt Cancer Center in either the inpatient or outpatient setting were included in this retrospective analysis. We described percentages of AC prescription by stroke and bleeding risk, as determined by individual CHA2DS2-VASc and HAS-BLED scores, respectively. Multivariable logistic regression evaluated clinical variables independently associated with anticoagulant prescription. Results The prevalence of electrocardiography-documented AF or AFL was 4.8% (n = 472). The mean CHA2DS2-VASc score was 2.8 ± 1.4. Among patients with CHA2DS2-VASc scores ≥2 and HAS-BLED scores <3, 44.3% did not receive AC, and of these, only 18.3% had platelet values <50,000/μl. In multivariable analysis, older age, hypertension, prior stroke, and history of venous thromboembolism were each directly associated with AC use, while current chemotherapy use, prior bleeding, renal disease, and thrombocytopenia were each inversely associated with AC use. Conclusions Nearly one-half of patients with cancer, the majority with normal platelet counts, had an elevated risk for stroke but did not receive AC. In addition to known predictors, current chemotherapy use was independently associated with a lower odds of AC use. This study highlights the need to improve the application of AF treatment algorithms to cancer populations.
Collapse
Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kerry Ellenberg
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Mohammed Alomar
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Justin Swanson
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Anant Kharod
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Anh Thy H Nguyen
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Sara Khodor
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Shreya Mishra
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Linh M Duong
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Nirav Shah
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Merna Armanious
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Isaac B Rhea
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kevin E Kip
- University of South Florida College of Public Health, Tampa, Florida, USA
| |
Collapse
|
25
|
Pastori D, Antonucci E, Violi F, Palareti G, Pignatelli P. Thrombocytopenia and Mortality Risk in Patients With Atrial Fibrillation: An Analysis From the START Registry. J Am Heart Assoc 2019; 8:e012596. [PMID: 31656119 PMCID: PMC6898797 DOI: 10.1161/jaha.119.012596] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Thrombocytopenia is associated with increased mortality in the general population, but few data exist in patients with atrial fibrillation (AF) taking oral anticoagulants. We investigated factor determinants of thrombocytopenia in a large cohort of patients affected by AF and its association with total mortality. Methods and Results Multicenter prospective cohort study, including 5215 patients with AF from the START (Survey on Anticoagulated Patients Register) registry, 3877 (74.3%) and 1338 (25.7%) on vitamin K or non–vitamin K antagonist oral anticoagulants, respectively. Thrombocytopenia was defined by a platelet count <150×109/L. Determinants of thrombocytopenia were investigated, and all‐cause mortality was the primary survival end point of the study. Thrombocytopenia was present in 592 patients (11.4%). At multivariable logistic regression analysis, chronic kidney disease (odds ratio [OR], 1.257; P=0.030), active cancer (OR, 2.065; P=0.001), liver cirrhosis (OR, 7.635; P<0.001), and the use of diuretics (OR, 1.234; P=0.046) were positively associated with thrombocytopenia, whereas female sex (OR, 0.387; P<0.001) and the use of calcium channel blockers (OR, 0.787; P=0.032) were negatively associated. During a median follow‐up of 19.2 months (9942 patient‐years), 391 deaths occurred (rate, 3.93%/year). Mortality rate increased from 3.8%/year to 9.9%/year in patients with normal platelet count and in those with moderate‐severe thrombocytopenia, respectively (log‐rank test, P=0.009). The association between moderate‐severe thrombocytopenia and mortality persisted after adjustment for CHA2DS2VASc score (hazard ratio, 2.431; 95% CI, 1.254–4.713; P=0.009), but not in the fully adjusted multivariable Cox regression analysis model. Conclusions Thrombocytopenia is common in patients with AF. Despite an increased incidence of mortality, thrombocytopenia was not associated with mortality at multivariable analysis. Thrombocytopenia may reflect the presence of comorbidities associated with poor survival in AF.
Collapse
Affiliation(s)
- Daniele Pastori
- Department of Internal Medicine and Medical Specialties I Clinica Medica Atherothrombosis Centre Sapienza University of Rome Rome Italy
| | | | - Francesco Violi
- Department of Internal Medicine and Medical Specialties I Clinica Medica Atherothrombosis Centre Sapienza University of Rome Rome Italy
| | | | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties I Clinica Medica Atherothrombosis Centre Sapienza University of Rome Rome Italy
| | | | | |
Collapse
|