Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, including compliance with current guidelines-data from the POLish Atrial Fibrillation (POL-AF) Registry

Impact of Underdosing of Direct Oral Anticoagulants on Clinical Outcomes in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

BACKGROUND

Underdoses of direct oral anticoagulants (DOAC) are sometimes prescribed due to bleeding risk concerns in patients with atrial fibrillation (AF). We investigated the prevalence of DOAC underdosing and its impact on clinical outcomes in AF patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This multicenter observational cohort study enrolled patients with AF on DOAC undergoing PCI between January 2015 and March 2021 at 15 institutions across Japan. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE), all-cause mortality, ischemic stroke, and major bleeding events, were evaluated. Of 623 patients enrolled, 167 (26.8%) received underdoses, 224 (36.0%) received appropriate low doses, 210 (33.7%) received appropriate standard doses, and 22 (3.5%) received overdoses. Clinical outcomes were compared between patients with underdoses (n=167) and appropriate doses (n=434). Although the incidence of MACE, all-cause mortality, and major bleeding events did not differ significantly between the 2 groups (log-rank P=0.850, P=0.163, and P=0.711, respectively), ischemic stroke occurred more frequently in the underdose than appropriate-dose group (log-rank P=0.011). After propensity score matching, the same result was observed for the frequency of ischemic stroke (log-rank P=0.026).

CONCLUSIONS

Compared with appropriate doses of DOAC, DOAC underdosing was associated with a higher incidence of ischemic stroke, despite no significant difference in MACE, all-cause mortality, and major bleeding events in AF patients undergoing PCI.

Association of Serum Gamma-Glutamyltransferase with In-hospital Heart Failure in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background

To explore the association between gamma-glutamyltransferase (GGT) and in-hospital heart failure (HF) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 412 patients diagnosed with STEMI and treated with primary PCI were included in our study. Univariate and multivariate logistic regression models were used to evaluate the association between GGT and the risk of in-hospital HF in STEMI patients. The receiver operating characteristic (ROC) curve was used to assess the accuracy of GGT in predicting in-hospital HF.

Results

The incidence of HF after STEMI increased significantly with increasing GGT tertiles (the first, second, and third tertile groups were 7.97%, 14.49%, and 18.38%, respectively; p = 0.039). Multivariate logistic regression analysis revealed that the risk of HF in the second and third GGT tertile groups was 2.51 times greater (95% CI, 1.06-5.96) and 2.77 times greater (95% CI, 1.13-6.81), respectively, than that in the first GGT tertile group. Each 1-unit increase in the lnGGT level was related to a 1.88-fold increased risk of HF (odds ratio, OR, 1.88; 95% CI, 1.19-2.96; p = 0.007). Restricted cubic splines suggested a linear relationship between GGT and in-hospital HF (p for nonlinearity = 0.158). The area under the curve was 0.607 (95% CI, 0.558-0.654; p = 0.007) when GGT was used to predict in-hospital HF, with a sensitivity of 57.14% and a specificity of 64.04%. Moreover, the incidence of HF significantly increased in-hospital death risk (OR, 7.75; 95% CI, 1.87-32.12; p = 0.005).

Conclusions

GGT is positively associated with in-hospital HF and is an independent risk factor for in-hospital HF in STEMI patients.

High long-term mortality in ischaemic heart disease accentuated among ethnic minorities in Eastern Europe: findings from a prospective all-comers percutaneous coronary intervention registry in Romania

BACKGROUND

Long-term outcomes in cardiovascular diseases are historically under-reported in Eastern Europe. Our aim was to report long-term survival and to identify survival predictors in a prospective Romanian percutaneous coronary intervention (PCI) registry, with an emphasis on important under-resourced minorities, such as Hungarian and Roma ethnicities.

METHODS

An all-comers patient population treated by PCI in a tertiary cardiovascular centre that has been included prospectively in the local registry since January 2016 was analysed. Cardiovascular cause and all-cause mortality data were available as of December 2023.

RESULTS

A total of 6867 patients with 8442 PCI procedures were included. Romanian group consisted of 5095 (74.2%) patients, the Hungarian group consisted of 1417 (20.6%) patients and the Roma group consisted of 355 (5.1%) patients. During a median follow-up of 3.60 (1.35-5.75) years, a total of 1064 cardiovascular-cause and 1374 all-cause events occurred. Romanian, Hungarian and Roma patients suffered 5.12, 5.89 and 7.71 all-cause deaths per 100 patient-years, respectively. Romanian, Hungarian and Roma patients suffered 3.94, 4.63 and 6.22 cardiovascular-cause deaths per 100 patient-years, respectively. Both Hungarian and Roma patients presented significantly higher all-cause mortality than Romanian patients (adjusted HR (aHR)=1.20 (1.05-1.36), p=0.005 and aHR=1.51 (1.21-1.88), p=0.0001). Similarly, Hungarian and Roma patients presented significantly higher cardiovascular cause mortality than Romanian patients (aHR=1.22 (1.05-1.41), p=0.006 and aHR=1.51 (1.18-1.92), p=0.0008).

CONCLUSIONS

High long-term cardiovascular and all-cause mortality was observed for the entire included population. Long-term survival was significantly lower in ethnic minorities, such as the Hungarian and Roma minority than in the Romanian population.

An observational study of therapeutic procedures and in-hospital outcomes among patients admitted for acute myocardial infarction in Spain, 2016-2022: the role of diabetes mellitus

BACKGROUND

We used the Spanish national hospital discharge data from 2016 to 2022 to analyze procedures and hospital outcomes among patients aged ≥ 18 years admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) according to diabetes mellitus (DM) status (non-diabetic, type 1-DM or type 2-DM).

METHODS

We built logistic regression models for STEMI/NSTEMI stratified by DM status to identify variables associated with in-hospital mortality (IHM). We analyzed the effect of DM on IHM.

RESULTS

Spanish hospitals reported 201,950 STEMIs (72.7% non-diabetic, 0.5% type 1-DM, and 26.8% type 2-DM; 26.3% female) and 167,285 NSTEMIs (61.6% non-diabetic, 0.6% type 1-DM, and 37.8% type 2-DM; 30.9% female). In STEMI, the frequency of percutaneous coronary intervention (PCI) increased among non-diabetic people (60.4% vs. 68.6%; p < 0.001) and people with type 2-DM (53.6% vs. 66.1%; p < 0.001). In NSTEMI, the frequency of PCI increased among non-diabetic people (43.7% vs. 45.7%; p < 0.001) and people with type 2-DM (39.1% vs. 42.8%; p < 0.001). In NSTEMI, the frequency of coronary artery by-pass grafting (CABG) increased among non-diabetic people (2.8% vs. 3.5%; p < 0.001) and people with type 2-DM (3.7% vs. 5.0%; p < 0.001). In the entire population, lower IHM was associated with undergoing PCI (odds ratio [OR] [95% confidence interval] = 0.34 [0.32-0.35] in STEMI; 0.24 [0.23-0.26] in NSTEMI) or CABG (0.33 [0.27-0.40] in STEMI; 0.45 [0.38-0.53] in NSTEMI). IHM decreased over time in STEMI (OR = 0.86 [0.80-0.93]). Type 2-DM was associated with higher IHM in STEMI (OR = 1.06 [1.01-1.11]).

CONCLUSIONS

PCI and CABG were associated with lower IHM in people admitted for STEMI/NSTEMI. Type 2-DM was associated with IHM in STEMI.

Association of Body Mass Index with Outcomes in Patients with Atrial Fibrillation: Analysis from the (JoFib) Registry

Background

Atrial fibrillation (AF) accounts for the majority of arrhythmias affecting adults. It is associated with an increased mortality and various complications. Obesity being a major risk factor of cardiovascular and metabolic diseases including AF has always been connected to the overall burden of AF, but its role in the development of AF complications remains unclear. Our study aims to evaluate the impact of obesity on the complications of AF in Jordanian patients to establish a proper prognosis since studies regarding this topic in the Middle East are scant.

Methods

This study analyzed data from the Jordanian AF study (JoFib), which enrolled Jordanians with AF. Clinical characteristics were compared among patients who developed complications and those who did not. A binary logistic regression analysis was conducted to identify factors associated with AF complications development.

Results

1857 patients were enrolled. There was no significant difference in BMI value between patients who developed complications and those who did not. Male sex, old age, hypertension, diabetes mellitus, and higher risk scores were associated with increased odds of developing complications. The oral anticoagulant use was found to be protective. Smoking had no significant effect on odds of complications.

Conclusion

The study concludes that increased BMI is not significantly associated with a reduced risk of developing AF complications. Further research with longer follow-up and larger sample sizes is needed to confirm these results.

Worsening Renal Function and Adverse Outcomes in Patients with HFpEF with or without Atrial Fibrillation

Since worsening renal function (WRF) and atrial fibrillation (AF) often coexist in preserved ejection fraction (HFpEF), we aimed to investigate the effect of WRF on the prognosis of HFpEF patients with and without AF. The study population of this study (n = 1763) was based on the subset of the Americas in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT). We found that the cumulative probabilities of the primary composite outcome and cardiovascular death were significantly higher in AF patients post-WRF when compared to non-AF patients. In the time-dependent Cox proportional hazard model, WRF was significantly associated with higher risks of adverse outcomes (primary composite outcome: HR = 1.58 (95% CI, 1.19-2.11); all-cause death: HR = 1.50 (95% CI, 1.10-2.06); cardiovascular death: HR, 2.00 (95% CI, 1.34-3.00)) after adjustments for confounding factors at baseline in HFpEF patients with AF, whereas in HFpEF patients without AF, WRF was not significantly associated with any adverse outcome. p for interactions for the primary composite outcome, cardiovascular death, and AF were significant. In conclusion, these findings highlight that WRF was associated with a greater risk of the primary composite outcome, all-cause death, and cardiovascular death in HFpEF patients with AF.

The Value of Rivaroxaban Combined with Ticagrelor in Antithrombotic Therapy after PCI in Patients with Nonvalvular Atrial Fibrillation with Acute Coronary Syndrome

Objective

Based on a retrospective cohort study, to investigate the value of rivaroxaban combined with ticagrelor in antithrombotic therapy after PCI in patients with nonvalvular atrial fibrillation with acute coronary syndrome.

Methods

A total of 60 patients from January 2019 to May 2021 accepted therapy with antithrombotic therapy after PCI. The patients treated with ticagrelor were set as the control group, and those given rivaroxaban combined with ticagrelor were set as the research group. The curative effect, myocardial level, TIMI blood flow grade, platelet aggregation rate, and the incidence of cardiovascular events were taken from the comparisons.

Results

The research group's therapeutic impact was superior to the control group's therapeutic impact, and the value was higher. After treatment, the myocardial levels of the two groups decreased, and the levels of troponin I, creatine kinase isoenzyme, and hypersensitive C-reactive protein in the research group were greatly less than those in the control group, and the difference was statistically significant (P < 0.05). After operation, the TIMI blood flow classification in the experimental group was better than that in the control group, and the difference was statistically significant (P < 0.05). The experimental group's platelet aggregation incidence was considerably lower than the control group's platelet aggregation incidence at 0.5 and 2 hours following surgery, and the difference was statistically significant (P < 0.05). The incidence of acute myocardial infarction, cardiogenic death, and intractable angina pectoris in the research group was significantly lower than that in the control group.

Conclusion

Rivaroxaban combined with ticagrelor in the treatment of nonvalvular atrial fibrillation with acute coronary syndrome after percutaneous coronary intervention; the TIMI blood flow grade is better than ticagrelor, which is of great significance to reduce mortality and has high safety in clinical application.

Do Patients with Atrial Fibrillation and a History of Ischemic Stroke Overuse Reduced Doses of NOACs?-Results of the Polish Atrial Fibrillation (POL-AF) Registry

BACKGROUND

The aim of our study was to assess if patients with AF (atrial fibrillation) and a history of ischemic stroke (IS) excessively receive reduced doses of NOACs (non-vitamin K antagonist oral anticoagulants).

METHODS

The Polish AF (POL-AF) registry is a prospective, observational, multicenter study, including patients with AF from 10 cardiology hospital centers. In this study we focused on patients with IS in their past.

RESULTS

Among 3999 patients enrolled in the POL-AF registry, 479 (12%) had a previous history of IS. Compared to patients without IS history, post-stroke subjects had a higher CHA₂DS₂-VASc score (median score 7 vs. 4, p < 0.05). Of these subjects, 439 (92%) had anticoagulation therapy, 83 (18.9%) were treated with a vitamin K antagonist (VKA), 135 (30.8%) with rivaroxaban, 112 (25.5%) with dabigatran, and 109 (24.8%) with apixaban. There were a significant number of patients after IS with reduced doses of NOACs (48.9% for rivaroxaban, 45.5% for dabigatran, and 36.7% for apixaban). In many cases, patients were prescribed reduced doses of NOACs without any indication for reduction (28.8% of rivaroxaban use, 56.9% of dabigatran use, and 60.0% of apixaban use-out of reduced dosage groups, p = 0.06).

CONCLUSIONS

A significant proportion of AF patients received reduced doses of NOAC after ischemic stroke in a sizeable number of cases, without indication for dose reduction.

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

Thromboembolic events are a common risk in adults with atrial fibrillation, those with previous cerebrovascular accidents and undergoing emergency or elective surgeries. The widespread availability of antithrombotic agents and differing guidelines contribute to practice variations and increased risk of complications and deaths. The objective of this review was to investigate the extent of overuse and underuse of antithrombotics for primary or secondary prevention as measured by deviation from prescribing guideline recommendations. We conducted a systematic review of Medline and EMBASE for quantitative articles published between 2000 and 2021 and used a modified version of the Hoy’s risk of bias assessment tool. Here we report evidence from the past decade about wide practice variations in hospitals and primary care, and discuss clinician and patient-driven determinants of non-adherence to guidelines. Finally, we summarise implications for practice, identify enhanced ways of measuring overuse and underuse, and propose potential solutions to the measurement challenges.

The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention

Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y₁₂ inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y₁₂ inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y₁₂ inhibitor) for 6 to 12 months.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF). Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019–2020. Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non–HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%—at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non–HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non–HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them. Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.

Symptomatic and Asymptomatic Patients in the Polish Atrial Fibrillation (POL-AF) Registry

BACKGROUND

Atrial fibrillation (AF) can cause severe symptoms, but it is frequently asymptomatic. We aimed to compare the clinical features of patients with asymptomatic and symptomatic AF.

METHODS

A prospective, observational, multicenter study was performed (the Polish Atrial Fibrillation (POL-AF) registry). Consecutive hospitalized AF patients over 18 years of age were enrolled at ten centers. The data were collected for two weeks during each month of 2019.

RESULTS

A total of 2785 patients were analyzed, of whom 1360 were asymptomatic (48.8%). Asymptomatic patients were more frequently observed to have coronary artery disease (57.5% vs. 49.1%, p < 0.0001), heart failure with preserved ejection fraction (39.8% vs. 26.5%, p < 0.0001), a previous thromboembolic event (18.2% vs. 13.1%, p = 0.0002), and paroxysmal AF (52.3% vs. 45.2%, p = 0.0002). In multivariate analysis, history of electrical cardioversion, paroxysmal AF, heart failure, coronary artery disease, previous thromboembolic event, and higher left ventricular ejection fraction were predictors of a lack of AF symptoms. First-diagnosed AF was a predictor of AF symptoms.

CONCLUSIONS

In comparison to symptomatic patients, more of those hospitalized with asymptomatic AF had been previously diagnosed with this arrhythmia and other cardiovascular diseases. However, they presented with better left ventricular function and were more frequently treated with cardiovascular medicines.