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Lapetina Arroyo R, Barrios BM, Rivera HF, Gotay AO, Marrero Gonzalez A. Weighing the risks and benefits of anticoagulation in atrial fibrillation: a case report of left atrial appendage absence in a patient referred for procedural occlusion. Eur Heart J Case Rep 2024; 8:ytae063. [PMID: 38332925 PMCID: PMC10852102 DOI: 10.1093/ehjcr/ytae063] [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: 06/10/2023] [Revised: 01/20/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024]
Abstract
Background The absence of the left atrial appendage is an exceedingly rare structural variant that could have important implications for anticoagulation regimens in patients with atrial fibrillation. Case summary We report the case of a 63-year-old Puerto Rican female with a history of hypertension, cerebral artery aneurysms, and type 2 diabetes mellitus who suffered multiple haemorrhagic strokes. The patient had never received anticoagulation therapy. During the indicated stroke work-up, the patient was found to have paroxysmal atrial fibrillation. Given the patients high risk for thromboembolism and contraindications to anticoagulation therapy, the patient was referred for left atrial appendage occlusion. Pre-procedural transoesophageal echocardiography failed to identify the left atrial appendage. Evaluation by way of cardiac computed tomography confirmed absence of the left atrial appendage. Left atrial appendage occlusion could not be carried out. The patient had been deemed being at high risk of bleeding, was not anticoagulated, and was instead closely followed. The patient has not had thrombo-embolic events nor has she experienced a haemorrhagic stroke recurrence at follow-up appointments. Discussion To our knowledge, this is the first such case report that reports left atrial appendage absence in the setting of multiple haemorrhagic strokes. Given the rarity of the condition and lack of available guidelines, the most viable way to currently manage this patient population is on a case-to-case basis. However, we propose that absence of the left atrial appendage could confer a decreased risk of thrombo-embolic phenomena in patients with atrial fibrillation.
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Affiliation(s)
- Roberto Lapetina Arroyo
- Department of Medicine, Cardiovascular Disease Division, University of Puerto Rico School of Medicine, P.º Dr. José Celso Barbosa, 00921 San Juan, Puerto Rico
| | - Brian Monge Barrios
- Department of Medicine, Cardiovascular Disease Division, University of Puerto Rico School of Medicine, P.º Dr. José Celso Barbosa, 00921 San Juan, Puerto Rico
| | - Hilton Franqui Rivera
- Department of Medicine, Cardiovascular Disease Division, University of Puerto Rico School of Medicine, P.º Dr. José Celso Barbosa, 00921 San Juan, Puerto Rico
| | - Antonio Orraca Gotay
- Department of Medicine, Cardiovascular Disease Division, Pavia Santurce Hospital, San Juan, Puerto Rico
| | - Amanda Marrero Gonzalez
- Department of Medicine, Cardiovascular Disease Division, Pavia Santurce Hospital, San Juan, Puerto Rico
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2
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Cai H, Chen G, Hu W, Jiang C. Anticoagulant in atrial fibrillation patients with prior intracranial haemorrhage: a meta-analysis. Heart 2023; 109:1594-1600. [PMID: 37321829 DOI: 10.1136/heartjnl-2023-322492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The benefit of resuming anticoagulation in atrial fibrillation (AF) patients with prior intracranial haemorrhage (ICH) and which anticoagulant to choose are controversial. SUMMARY OF REVIEW PubMed, Embase, Web of Science and the Cochrane Library were searched from their inception until 13 February 2022. Thirteen eligible articles (17 600 participants) were collected, including 11 real-world studies (n=17 296) and 2 randomised controlled trials (RCTs) (n=304). Compared with no anticoagulants, oral anticoagulation (OAC) was not associated with an increased risk of ICH recurrence (HR 0.85 (95% CI 0.57 to 1.25), p=0.41), but with a significantly increased risk of major bleeding (HR 1.66 (95% CI 1.20 to 2.30), p<0.01). Meanwhile, OAC was associated with a reduced risk of ischaemic stroke/systemic thromboembolism (IS/SE) (HR 0.54 (95% CI 0.42 to 0.70), p<0.01) and all-cause death (HR 0.38 (95% CI 0.28 to 0.52), p<0.01) compared with no anticoagulants. Furthermore, compared with warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with a significant reduction of ICH recurrence (HR 0.64 (95% CI 0.49 to 0.85), p<0.01), while the risk of IS/SE and all-cause mortality were comparable between warfarin and NOACs. CONCLUSIONS For patients with AF with prior ICH, OAC is associated with a significant reduction in IS/SE and all-cause mortality without increasing ICH recurrence, but may increase major bleeding risk. Compared with warfarin, NOACs had a better safety profile and comparable efficacy. Further larger RCTs are warranted to validate these findings.
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Affiliation(s)
- Huiya Cai
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guoquan Chen
- Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Wei Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chunjiao Jiang
- Department of Pharmacy, The Second Hospital of Zhangzhou, Zhangzhou, Fujian, China
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3
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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4
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Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
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Caso V, Mosconi MG. Lessons to be learned in intracerebral haemorrhage research. Lancet Neurol 2021; 20:779-780. [PMID: 34487723 DOI: 10.1016/s1474-4422(21)00296-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia 06156, Italy.
| | - Maria Giulia Mosconi
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia 06156, Italy
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6
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 452] [Impact Index Per Article: 150.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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7
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Low-dose antiplatelet therapy survey after intracerebral hemorrhage in China: a retrospective hospital-based study. Neurosurg Rev 2021; 44:2923-2931. [PMID: 33502641 DOI: 10.1007/s10143-021-01483-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/10/2020] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
Restarting of antiplatelet therapy (AT) for patients with a history of intracerebral hemorrhage (ICH) is still a clinical dilemma in China. We aimed to investigate the association between low-dose AT and the long-term clinical outcome in Chinese ICH patients. A total of 312 patients with a history of ICH were retrospectively enrolled and followed. The ischemic vascular events, recurrent ICH, and all-cause death were reviewed retrospectively. We explored the predictors of ischemic vascular events and recurrent ICH from all patients using Cox proportional hazard regression model. One hundred fifty-one (48.4%) patients were treated with low-dose AT, and the median duration of follow-up was 4.0 years (interquartile range, 2.5-5 years). Compared to 30 (19.8%) of 151 participants who restarted low-dose AT had ischemic vascular events, 51 (31.7%) of 161 participants who did not receive AT showed ischemic vascular events (p=0.025). Eighteen (11.9%) of 151 participants treated with low-dose AT had recurrent ICH and 21 (13.0%) of 161 in non-AT participants (p=0.830). Cox regression analysis also showed that diabetes mellitus was an independent risk factor for ischemic vascular events (p=0.029). Uncontrolled blood pressure (BP) was independently associated with the risk for both ischemic vascular events (p=0.025) and recurrent ICH (p=0.001). Atrial fibrillation (AF) was an independent risk factor for recurrent ICH among patients with a history of ICH (p=0.018). In a Chinese population of patients with predominantly deep, mild to moderate severity ICH, restarting of low-dose AT at a median of 6.2 months was associated with a lower risk of ischemic vascular events without increased risk of recurrent ICH.
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Pani A, Pastori D, Senatore M, Romandini A, Colombo G, Agnelli F, Scaglione F, Colombo F. Clinical and pharmacological characteristics of elderly patients admitted for bleeding: impact on in-hospital mortality. Ann Med 2020; 52:413-422. [PMID: 32795156 PMCID: PMC7877962 DOI: 10.1080/07853890.2020.1808238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Clinical and pharmacological characteristics of elderly patients hospitalized for bleeding and in-hospital mortality according to bleeding type are barely described. METHODS Retrospective cohort study of 13,496 consecutive patients admitted to internal medicine wards. Clinical characteristics, comorbidities and pharmacological treatments were collected for each patient. Predictors of in-hospital mortality were investigated. RESULTS Overall, 531 (3.9%) patients were admitted for bleeding: 189 clinically relevant non-major bleeding, 106 cerebral and 236 major non-cerebral (95.8% gastrointestinal (GI)). Among 106 cerebral bleedings, 28.3% and 24.5% were typical and atypical intracranial, respectively, and 47.2% were subdural haemorrhages. Most of patients with GI bleeding presented with anaemia (90.7%). A similar rate of GI bleeding was found in aspirin-treated patients taking or not proton pump inhibitors (PPI). In-hospital mortality was 9.98%. Age ≥80 years (odds ratio (OR) 2.513, p=.005), cerebral bleeding (OR 5.373, p<.001), eGFR <30 ml/min/m2 (OR 2.388, p=.035) and COPD (OR 2.362, p=.024) were positively associated with mortality, while ACE inhibitors/ARBs use was negatively associated (OR 0.383, p=.028). CONCLUSIONS The most frequent type of major haemorrhage was GI bleeding, which was not modified by the use of PPI in patients taking aspirin. Cerebral bleeding increased all-cause death, which was lower in ACE inhibitors/ARBs users. KEY MESSAGE Gastrointestinal (GI) bleeding was the most common reason for hospital admission. The rate of GI bleeding was similar in patients on aspirin using or not PPI. Cerebral bleeding increased in-hospital mortality, which was lower in patients taking ACE inhibitors/ARBs.
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Affiliation(s)
- Arianna Pani
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy.,Clinical Pharmacology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Atherothrombosis Center, Sapienza University of Rome, Rome, Italy
| | - Michele Senatore
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy.,Clinical Pharmacology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandra Romandini
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy.,Clinical Pharmacology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giulia Colombo
- Internal Medicine Department, Policlinico Maggiore Ca' Granda, Milan, Italy
| | - Francesca Agnelli
- Internal Medicine Department, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy.,Clinical Pharmacology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Colombo
- Internal Medicine Department, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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9
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Effectiveness and Safety of Restarting Oral Anticoagulation in Patients with Atrial Fibrillation after an Intracranial Hemorrhage: Analysis of Medicare Part D Claims Data from 2010-2016. Am J Cardiovasc Drugs 2020; 20:471-479. [PMID: 31808136 DOI: 10.1007/s40256-019-00388-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) who survive an anticoagulant-related intracranial hemorrhage (ICH), the benefits of restarting oral anticoagulation (OAC) remain unclear. OBJECTIVE In this study, we sought to determine the effectiveness and safety associated with resumption of OAC in atrial fibrillation patients who survive an ICH. METHODS Using 2010-2016 Medicare claims data, we identified patients with non-valvular AF who experienced an OAC-related ICH and survived at least 6 weeks after the ICH (n = 1502). The primary outcomes included the composite of ischemic stroke and transient ischemic attack (TIA), thromboembolism (TE), a composite of ischemic stroke/TIA and TE, recurrent ICH, and all-cause mortality. We constructed Cox proportional hazard models to evaluate the association between post-ICH OAC resumption, which was measured in a time-dependent manner, and the risk of primary outcomes, while controlling for a comprehensive list of covariates. RESULTS Among patients who survived an ICH, 69% reinitiated OAC within 6 weeks of the event, and among those who resumed OAC, 83% restarted warfarin. There was no significant difference in the risk of ischemic stroke/TIA (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.62-1.21), TE (HR 0.85, 95% CI 0.55-1.32), and ischemic stroke/TIA/TE (HR 0.81, 95% CI 0.61-1.07) between post-ICH OAC use and non-use. Post-ICH OAC use was associated with a lower risk of recurrent ICH (HR 0.62, 95% CI 0.41-0.95) and all-cause mortality (HR 0.48, 95% CI 0.37-0.62) compared with non-OAC use. CONCLUSIONS In AF patients who survived an ICH, restarting OAC was not associated with a greater risk of recurrent ICH. Evidence from randomized controlled studies is needed to further clarify the clinical benefit of restarting OAC in this high-risk population. Further evaluation of which individuals benefit from restarting OAC is also needed to provide more clinical guidance.
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10
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Ward R, Ponamgi S, DeSimone CV, English S, Hodge DO, Slusser JP, Graff-Radford J, Rabinstein AA, Asirvatham SJ, Holmes D. Utility of HAS-BLED and CHA 2DS 2-VASc Scores Among Patients With Atrial Fibrillation and Imaging Evidence of Cerebral Amyloid Angiopathy. Mayo Clin Proc 2020; 95:2090-2098. [PMID: 32829908 PMCID: PMC8635034 DOI: 10.1016/j.mayocp.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/18/2020] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the utility of the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly) and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age, Diabetes, previous Stroke/transient ischemic attack-VAScular disease) scores among patients on anticoagulation (AC) therapy for atrial fibrillation (AF) who have evidence of cerebral amyloid angiopathy (CAA). PATIENTS AND METHODS Patients older than 55 years with a diagnosis of AF who had a nontraumatic intracerebral hemorrhage (ICH) while on AC therapy between 1995 and 2016 were identified using the Rochester Epidemiology Project Database. Medical records were reviewed, including imaging of the brain, to identify baseline characteristics, AC use, and outcomes. RESULTS A total of 65 patients were identified (mean age, 81.3 years); 35 (53.8%) had evidence of possible/probable CAA. Mean HAS-BLED score in the CAA group was significantly lower (2.1) than that of the non-CAA group (2.9; P<.001). Mortality after ICH, adjusted for HAS-BLED scores, was not significantly different among patients with and without CAA. Sixteen patients restarted on AC therapy after ICH; CHA2DS2-VASc scores were no different between this group and those who were not restarted. Among patients with CAA, the overall rate of ICH recurrence was 8.6% over 93.5 person-years of follow-up. Among patients with CAA, the rate of ICH recurrence was 3.2 per 100 patient-years, higher than their HAS-BLED scores would predict (1.9 bleeds/100 patient-years). CONCLUSION HAS-BLED scores were lower in patients who had evidence of CAA compared with those without, suggesting underestimation of ICH risk in patients with CAA. CHA2DS2-VASc scores did not affect resumption of AC therapy. ICH recurrence was higher in patients with CAA than their HAS-BLED scores predicted. Current risk assessment scoring systems do not accurately account for CAA in patients with AF on AC.
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Affiliation(s)
- Robert Ward
- Division of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Shiva Ponamgi
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | | | | | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Joshua P Slusser
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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11
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Rivera-Caravaca JM, Esteve-Pastor MA, Camelo-Castillo A, Ramírez-Macías I, Lip GYH, Roldán V, Marín F. Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy. Expert Opin Pharmacother 2020; 21:1867-1881. [PMID: 32658596 DOI: 10.1080/14656566.2020.1789099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Oral anticoagulants (OAC) reduce stroke/systemic embolism and mortality risks in atrial fibrillation (AF). However, there is an inherent bleeding risk with OAC, where intracranial hemorrhage (ICH) is the most feared, disabling, and lethal complication of this therapy. Therefore, the optimal management of OAC-associated ICH is not well defined despite multiple suggested strategies. AREAS COVERED In this review, the authors describe the severity and risk factors for OAC-associated ICH and the associated implications for using DOACs in AF patients. We also provide an overview of the management of OAC-associated ICH and treatment reversal strategies, including specific and nonspecific reversal agents as well as a comprehensive summary of the evidence about the resumption of DOAC and the optimal timing. EXPERT OPINION In the setting of an ICH, supportive care/measures are needed, and reversal of anticoagulation with specific agents (including administration of vitamin K, prothrombin complex concentrates, idarucizumab and andexanet alfa) should be considered. Most patients will likely benefit from restarting anticoagulation after an ICH and permanently withdrawn of OAC is associated with worse clinical outcomes. Although the timing of OAC resumption is still under debate, reintroduction after 4-8 weeks of the bleeding event may be possible, after a multidisciplinary approach to decision-making.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Universidad De Murcia, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca) , Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
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12
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Wang CL, Wu VCC, Huang YT, Chen YL, Chu PH, Kuo CF, Wen MS, Chang SH. Incidence and consequences of resuming oral anticoagulant therapy following hematuria and risks of ischemic stroke and major bleeding in patients with atrial fibrillation. J Thromb Thrombolysis 2020; 51:58-66. [PMID: 32409936 DOI: 10.1007/s11239-020-02135-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Following hematuria, it is uncertain to what extent a vitamin K antagonist (VKA) or non-VKA oral anticoagulant (NOAC) is resumed, and the risks of ischemic stroke/systemic embolism and major bleeding associated with NOAC and VKA resumption are unknown. A cohort study was conducted using electronic medical records collected from 2009 to 2017 at a multicenter healthcare provider in Taiwan. The cohort included 4155 atrial fibrillation patients receiving anticoagulant therapy with hematuria (age: 71.4 ± 11.2 years; 48.8% female). Within 90 days following hematuria, 3287 patients (79.1%) resumed oral anticoagulants including VKA (n = 1554, 37.4%) and NOACs (n = 1733, 41.7%), whereas 868 patients did not resume anticoagulant. Follow-up was initiated 90 days after the occurrence of hematuria, and time-varying multiple Cox regression analyses were used for comparisons between the resumption of NOAC and VKA. The event rates per 100 person-years in the VKA resumption and NOAC resumption groups were 3.04 and 3.28 for ischemic stroke/systemic embolism, and 2.63 and 2.92 for major bleeding, respectively. Patients resuming NOAC had similar risks of ischemic stroke/systemic embolism (hazard ratio 1.14, 95% CI 0.75-1.74) and major bleeding (hazard ratio 1.12, 95% CI 0.72-1.74) compared with those resuming VKA. Since 2011, the proportion of NOAC resumption has increased, whereas the proportions of VKA resumption and non-resumption have decreased. In conclusion, more and more patients who suffer a hematuria while on oral anticoagulant therapy resume NOAC. Patients resuming NOAC have similar risks of ischemic stroke/systemic embolism and major bleeding compared with those resuming VKA.
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Affiliation(s)
- Chun-Li Wang
- Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Victor Chien-Chia Wu
- Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
| | - Yu-Ling Chen
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ming-Shien Wen
- Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan City, Taiwan. .,Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan. .,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.
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13
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Zhou Y, Guo Y, Liu D, Feng H, Liu J. Restarting of anticoagulation in patients with atrial fibrillation after major bleeding: A meta-analysis. J Clin Pharm Ther 2020; 45:591-601. [PMID: 32181518 DOI: 10.1111/jcpt.13130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/18/2020] [Indexed: 12/31/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Benefits and risks of restarting oral anticoagulants (OACs) in patients with atrial fibrillation after major bleeding remain unknown. A meta-analysis was performed to systematically evaluate the effects of restarting OACs on thromboembolism and bleeding events in these patients. METHODS Relevant studies were obtained via systematically search of PubMed, Cochrane's Library and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses according to the types of OACs and sites of reoccurred bleeding were performed. RESULTS AND DISCUSSION Seven retrospective cohort studies with 12 197 patients were included. Restarting OACs was associated with reduced risk of thromboembolism (risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.42-0.87; P = .007). Subgroup analyses showed that restarting warfarin reduced risk of thromboembolism (RR = 0.59, P = .05), but not for the new oral anticoagulants (NOACs; RR = 1.37, P = .18). Moreover, restarting OACs did not affect the risk of reoccurred bleeding (RR = 0.98, 95% CI: 0.74-1.30, P = .89). Similar results were found for warfarin and NOACs, as well as for reoccurred intracranial haemorrhage or gastrointestinal bleeding. In addition, restarting OACs was associated with significantly reduced risk of all-cause mortality (RR = 0.42, 95% CI: 0.33-0.52, P < .001). Consistent results were found for warfarin and NOACs. WHAT IS NEW AND CONCLUSION Restarting of OACs after major bleeding in AF patients may be associated with reduced risks of thromboembolism and mortality without increasing reoccurrence of bleeding.
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Affiliation(s)
- Ying Zhou
- Department of Healthcare Medicine, Liuzhou People's Hospital, Liuzhou, China
| | - Yujie Guo
- Department of Healthcare Medicine, Liuzhou People's Hospital, Liuzhou, China
| | - Daihua Liu
- Department of Pharmacy, Liuzhou People's Hospital, Liuzhou, China
| | - Haiyan Feng
- Department of Otorhinolaryngology, Liuzhou People's Hospital, Liuzhou, China
| | - Jie Liu
- Department of Healthcare Medicine, Liuzhou People's Hospital, Liuzhou, China
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14
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Sadighi A, Wasko L, DiCristina H, Wagner T, Wright K, Capone K, Monczewski M, Kester M, Bourdages G, Griessenauer C, Zand R. Long-term outcome of resuming anticoagulation after anticoagulation-associated intracerebral hemorrhage. eNeurologicalSci 2020; 18:100222. [PMID: 32123759 PMCID: PMC7037578 DOI: 10.1016/j.ensci.2020.100222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The risk and benefit of restarting oral anticoagulation (OAC) therapy among patients with atrial fibrillation or flutter (AF) and an episode of anticoagulation-associated intracerebral hemorrhage (ICH) remain unclear. Whether or not to resume OAC after an OAC-associated ICH will remain an unanswered clinical question until we have sufficient data through randomized clinical trials. Here, we analyzed the long-term outcome of patients with AF who did or did not resume OAC after an OAC-associated ICH. Patients and methods We studied consecutive patients with AF who were discharged from our institution after an OAC-associated ICH event between 2010 and 2017. Baseline characteristics of patients, past medical history, and history or OAC use were recorded. Outcome measures in our study included recurrent ICH, ischemic stroke or systemic emboli, and death. Results Out of 115 patients with AF and OAC-associated ICH, 93 patients (mean age 76.2 ± 10.3 years [44–91 years old], 54.3% men) were included in this study. Thirty-eight (40.9%) patients resumed OAC after the episode of OAC-associated ICH. More than 70% of patients had resumed OAC within two months of ICH (mean delay 56.0 ± 52.5 days). There was no significant difference between the group who resumed OAC and the group who did not in terms of mean follow-up duration (1.9 vs. 2.4 years), the type of initial ICH, as well as history of hypertension, diabetes, previous ischemic stroke, congestive heart failure, coronary artery disease, and tobacco use. There was no significant difference between the two groups considering the incidence rate of recurrent ICH (relative risk 2.9; 95% CI, 0.3–30.8). There was also no significant difference between the two groups regarding the incidence rate of ischemic stroke or systemic emboli (relative risk 0.9; 95% CI, 0.3–2.7). There was no significate difference between patients who did and did not resume OAC was 96 and 121 per 1000 patient-years, respectively (relative risk 0.8; 95% CI, 0.3–1.9). Conclusions We did not observe any significant difference between the group of patients who resumed OAC and the patients who did not in terms of recurrent ICH, ischemic stroke or systemic emboli, and death. However, there was a tendency toward a higher long-term risk of recurrent ICH among patients who resumed OAC. Outcome of AF patients who did/did not resume OAC after an OAC-ICH was studied. No significant difference between two groups in terms of recurrent ICH and death. Tendency toward a higher long-term risk of recurrent ICH in patients who resumed OAC.
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Affiliation(s)
- Alireza Sadighi
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Lisa Wasko
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Thomas Wagner
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Kathryn Wright
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Kellie Capone
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Margaret Kester
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - George Bourdages
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | | | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
- Corresponding author at: Department of Neurology, Division of Cerebrovascular Diseases, Geisinger Medical Center, 100 N Academy Ave, Danville, PA 17822, USA.
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15
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[Oral anticoagulation in atrial fibrillation: differential therapy with non vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists (VKA)]. MMW Fortschr Med 2019; 161:15-23. [PMID: 31587168 DOI: 10.1007/s15006-019-0920-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Non-vitamin K-dependent oral anticoagulants (NOAC) have changed the management of patients with oral anticoagulation. This raises the question of which patients should preferably be anticoagulated with NOAC and which preferably with vitamin K antagonists (VKA). This discussion has so far been insufficiently conducted and often decided on a flat-rate basis in favor of the NOAC. METHOD To clarify the question owhich form of anticoagulation - NOAC or VKA - is the best choice for patients with atrial fibrillation, an interdisciplinary team of experts met. RESULTS AND CONCLUSIONS The experts discussed essential practical aspects of NOAC and VKA therapy. Based on typical clinical scenarios, they developed assistance, comments and tips on the differentiated use of oral anticoagulants in patients with atrial fibrillation. A criteria served amongst others practicability in daily medical practice, contraindications, side effects and interactions, but also the patient's desire. The advantages and disadvantages of therapy with VKA and NOAC were summarized in a table.
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16
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Black-Maier E, Piccini JP, Granger CB. Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:2968-2976. [PMID: 31520437 DOI: 10.1111/jce.14182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short-term warfarin therapy is noninferior to long-term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life-threatening bleeding compared to OAC. Although direct-acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end-stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device-related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.
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Affiliation(s)
- Eric Black-Maier
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christopher B Granger
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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17
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Perreault S, Côté R, White-Guay B, Dorais M, Oussaïd E, Schnitzer ME. Anticoagulants in Older Patients with Nonvalvular Atrial Fibrillation after Intracranial Hemorrhage. J Stroke 2019; 21:195-206. [PMID: 31161763 PMCID: PMC6549060 DOI: 10.5853/jos.2018.02243] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 01/07/2019] [Indexed: 01/02/2023] Open
Abstract
Background and Purpose Patients with nonvalvular atrial fibrillation (NVAF) who survive an intracranial hemorrhage (ICH) have an increased risk of ischemic stroke and systemic embolism (IS/ SE). We investigated whether starting oral anticoagulants (OACs) among older NVAF patients after an ICH was associated with a lower risk of IS/SE and mortality but offset by an increase in major bleeding.
Methods We assembled a patient cohort from the Quebec Régie de l’Assurance Maladie du Québec (RAMQ) and Med-Echo administrative databases. We identified older adults with NVAF from 1995 to 2015. All patients with incident ICH and discharged in community were included. Patients were categorized according to OAC exposure. Outcomes included IS/SE, all-cause mortality, recurrent ICH and major bleeding after a quarantine period of 6 weeks. Crude event rates were calculated at 1-year of follow-up, and Cox proportional hazard models with a time-dependent binary exposure were used to assess adjusted hazard ratios (AHRs).
Results The cohort of 683 NVAF patients with ICH aged 83 years on average. The rates (per 100 person-years) for IS/SE, death, ICH and major bleeding were 3.3, 40.6, 11.4, and 2.7 for the no OAC group; and 2.6, 16.3, 5.2, and 5.2 for OAC group, respectively. The AHR for IS/SE and death was 0.10 (95% confidence interval [CI], 0.05 to 0.21), 0.43 (95% CI, 0.19 to 0.97) for recurrent ICH and 1.73 (95% CI, 0.71 to 4.20) for major extracranial bleeding comparing OAC exposure to non-exposed.
Conclusions Initiating OAC after ICH in older individuals with NVAF is associated with a reduction of IS/SE and mortality and a trend in recurrent ICH supporting its use after ICH.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Brian White-Guay
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Marc Dorais
- StatScience Inc., Notre-Dame-de-l'Île-Perrot, QC, Canada
| | - Essaïd Oussaïd
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
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