Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients With Active Cancer

Background

Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer.

Objectives

This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin.

Methods

A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score–matched cohorts.

Results

A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% CI: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, while consistent treatment effects were seen for all treatment comparisons across key cancer types.

Conclusions

Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types.

Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial

BACKGROUND

Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation.

METHODS

SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete.

FINDINGS

Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study.

INTERPRETATION

Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials.

FUNDING

British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.

Dual antithrombotic therapy with dabigatran in patients with atrial fibrillation after percutaneous coronary intervention for ST-segment elevation myocardial infarction: a post hoc analysis of the randomised RE-DUAL PCI trial

BACKGROUND

Little is known about the optimal antithrombotic therapy in patients with atrial fibrillation undergoing PCI for ST-elevation myocardial infarction (STEMI).

AIMS

The aim of this study was to investigate the safety and efficacy of dabigatran dual therapy (110 or 150 mg twice daily, plus clopidogrel or ticagrelor) versus warfarin triple therapy in patients with atrial fibrillation and STEMI.

METHODS

In the RE-DUAL PCI trial, 305 patients with STEMI were randomised to dabigatran 110 mg (n=113 versus 106 warfarin) or 150 mg (n=86 versus 84 warfarin). The primary endpoint was the time to first major/clinically relevant non-major bleeding event (MBE/CRNMBE). The thrombotic endpoint was a composite of death, thromboembolic events, or unplanned revascularisation.

RESULTS

In STEMI patients, dabigatran 110 mg (HR 0.39, 95% CI: 0.20-0.74) and 150 mg (0.43, 0.21-0.89) dual therapy reduced the risk of MBE/CRNMBE versus warfarin triple therapy (p for interaction vs all other patients=0.31 and 0.16). The risk of thrombotic events for dabigatran 110 mg (HR 1.61, 95% CI: 0.85-3.08) and 150 mg (0.56, 0.20-1.51) had p interactions of 0.20 and 0.33, respectively. For net clinical benefit, the HRs were 0.74 (95% CI: 0.46-1.17) and 0.49 (0.27-0.91) for dabigatran 110 and 150 mg (p for interaction=0.80 and 0.12), respectively.

CONCLUSIONS

After PCI for STEMI, patients on dabigatran dual therapy had lower risks of bleeding events versus warfarin triple therapy with similar risks of thromboembolic events, supporting dabigatran dual therapy even in patients with high thrombotic risk.

Serum antinuclear autoantibodies are associated with measures of oxidative stress and lifestyle factors: analysis of LIPIDOGRAM2015 and LIPIDOGEN2015 studies

Introduction

Oxidative stress is one of many factors suspected to promote antinuclear autoantibody (ANA) formation. Reactive oxygen species can induce changes in the antigenic structure of macromolecules, causing the immune system to treat them as "neo-antigens" and start production of autoantibodies. This study was designed to evaluate the relationship between oxidative stress markers, lifestyle factors and the detection of ANA.

Material and methods

We examined measures of oxidative stress indices of free-radical damage to lipids and proteins, such as total oxidant status (TOS), concentration of protein thiol groups (PSH), and malondialdehyde (MDA), activity of superoxide dismutase (SOD) in 1731 serum samples. The parameters of the non-enzymatic antioxidant system, such as total antioxidant status (TAS) and uric acid (UA) concentration, were also measured and the oxidative stress index (OSI-index) was calculated. All samples were tested for the presence of ANA using an indirect immunofluorescence assay (IIFA).

Results

The presence of ANA in women was associated with lower physical activity (p = 0.036), less frequent smoking (p = 0.007) and drinking of alcohol (p = 0.024) accompanied by significant changes in SOD isoenzymes activity (p < 0.001) and a higher uric acid (UA) concentration (p < 0.001). In ANA positive males we observed lower concentrations of PSH (p = 0.046) and increased concentrations of MDA (p = 0.047).

Conclusions

The results indicate that local oxidative stress may be associated with increased probability of ANA formation in a sex-specific manner.

Restart TICrH: An Adaptive Randomized Trial of Time Intervals to Restart Direct Oral Anticoagulants after Traumatic Intracranial Hemorrhage

Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the "r" distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.

Antithrombotic treatment pattern in newly diagnosed atrial fibrillation patients and 2-year follow-up results for dabigatran-treated patients in the Africa/Middle-East Region: Phase II results from the GLORIA-AF registry program

Background

Data on the epidemiology and treatment of atrial fibrillation in the Africa/Middle East region are limited, and the use of novel oral anticoagulants and their effectiveness in real-world clinical practice has not been evaluated.

Methods and Results

This study used prospectively collected data from the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation (GLORIA-AF) to describe anticoagulant use and outcomes in Africa and the Middle East. Baseline characteristics of patients newly diagnosed with nonvalvular atrial fibrillation from Lebanon (242 patients, 40.3%), Saudi Arabia (236 patients, 39.3%), United Arab Emirates (87 patients, 14.5%), and South Africa (35 patients, 5.8%) were described, and clinical outcomes were investigated for all patients in this region who received dabigatran.

In newly diagnosed patients (having a diagnosis within the last three months) with nonvalvular atrial fibrillation in Africa and the Middle East, the observed uptake of non-vitamin K oral anticoagulants was high in the first years following their availability; dabigatran was the most commonly used antithrombotic agent (314/600 patients), and only 1.5% of patients did not receive any antithrombotic therapy. Use of dabigatran was associated with a high persistence rate (>88% at 24 months) and low incidence rates of stroke, myocardial infarction, major bleeding, and all-cause mortality after 2 years of follow-up.

Conclusions

Data from GLORIA-AF reveal a change in the landscape for stroke prevention in the AME region, and the results were consistent with those observed in the global GLORIA-AF registry, as well as those of randomized clinical trials.

Clinical Trial Registration: NCT01937377 (https://clinicaltrials.gov/ct2/show/NCT01937377).

Atrial Fibrillation Increases the Risk of Early-Onset Dementia in the General Population: Data from a Population-Based Cohort

Atrial fibrillation (AF) is considered a risk factor for dementia, especially in the elderly. However, the association between the two diseases is not well identified in different age subgroups. The association of incident AF with the development of dementia was assessed from 1 January 2005, to 31 December 2013, in 428,262 participants from a longitudinal cohort (the Korea National Health Insurance Service-Health Screening cohort). In total, 10,983 participants were diagnosed with incident AF during the follow-up period. The incidence of dementia was 11.3 and 3.0 per 1000 person-years in the incident-AF and without-AF groups, respectively. After adjustment for clinical variables, the risk of dementia was significantly elevated by incident AF, with a hazard ratio (HR) of 1.98 (95% confidence interval [CI]: 1.80-2.17, p < 0.001), even after censoring for stroke (HR: 1.74, 95% CI: 1.55-1.94, p < 0.001). The HRs of incident AF for dementia onset before the age of 65 (early-onset dementia) and for onset after the age of 65 (late-onset dementia) were 2.91 (95% CI: 1.93-4.41) and 1.67 (95% CI: 1.49-1.87), respectively. Younger participants with AF were more prone to dementia development than older participants with AF (p for trend < 0.001). AF was associated with an increased risk of both early- and late-onset dementia, independent of clinical stroke.

Non-vitamin K antagonist oral anticoagulants in very elderly east Asians with atrial fibrillation: A nationwide population-based study

BACKGROUND

The evidence of effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) among elderly East Asians is limited.

OBJECTIVES

We aimed to describe the effectiveness and safety outcomes associated with NOACs and warfarin among elderly Koreans aged ≥80 years.

METHODS

Using the Korean Health Insurance Review and Assessment service database, patients with atrial fibrillation (AF) who were naïve to index oral anticoagulant between 2015 and 2017 were included in this study (20,573 for NOACs and 4086 for warfarin). Two treatment groups were balanced using the inverse probability of treatment weighting (IPTW) method. The clinical outcomes including ischemic stroke, major bleeding including intracranial hemorrhage (ICH) and gastrointestinal bleeding (GIB), and a composite of these outcomes were evaluated.

RESULTS

Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio 0.74 [95% confidence interval 0.62-0.89]), and composite outcome (0.78 [0.69-0.90]). NOACs showed nonsignificant trends towards to lower risks of GIB and major bleeding than warfarin. The risk of ICH of NOAC group was comparable with the warfarin group. Among NOACs, apixaban and edoxaban showed better composite outcomes than warfarin. Among the clinical outcomes, only ischemic stroke and the composite outcome had a significant interaction with age subgroups (80-89 years and ≥90 years, P-for-interaction = .097 and .040, respectively).

CONCLUSION

NOACs were associated with lower risks of ischemic stroke and the composite outcome (ischemic stroke and major bleeding) compared to warfarin in elderly East Asians. Physicians should be more confident in prescribing NOACs to elderly East Asians with AF.

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

What Is the Ideal Blood Pressure Threshold for the Prevention of Atrial Fibrillation in Elderly General Population?

Intensive blood pressure (BP) lowering in patients with hypertension at increased risk of cardiovascular disease has been associated with a lowered risk of incident atrial fibrillation (AF). It is uncertain whether maintaining the optimal BP levels can prevent AF in the general elderly population. We included 115,866 participants without AF in the Korea National Health Insurance Service-Senior (≥60 years) cohort from 2002 to 2013. We compared the influence of BP on the occurrence of new-onset AF between octogenarians (≥80 years) and non-octogenarians (<80 years) subjects. With up to 6.7 ± 1.7 years of follow-up, 4393 incident AF cases occurred. After multivariable adjustment for potentially confounding clinical covariates, the risk of AF in non-octogenarians was significantly higher in subjects with BP levels of <120/<80 and ≥140/90 mm Hg, with hazard ratios of 1.15 (95% confidence interval (CI), 1.03-1.28; p < 0.001) and 1.14 (95% CI, 1.04-1.26; p < 0.001), compared to the optimal BP levels (120-129/<80 mm Hg). In octogenarians, the optimal BP range was 130-139/80-89 mm Hg, higher than in non-octogenarians. A U-shaped relationship for the development of incident AF was evident in non-octogenarians, and BP levels of 120-129/<80 mm Hg were associated the lowest risk of incident AF. Compared to non-octogenarians, the lowest risk of AF was associated with higher BP levels of 130-139/80-89 mm Hg amongst octogenarians.

Differences in Thromboembolic Complications Between Paroxysmal and Persistent Atrial Fibrillation Patients Following Electrical Cardioversion (From the ENSURE-AF Study)

It is unclear if patients with paroxysmal atrial fibrillation (AF) and persistent AF have different outcomes following electrical cardioversion (ECV). ENSURE-AF-a multicenter, prospective, randomized, open-label, blinded-endpoint evaluation trial-compared once-daily edoxaban 60 mg with enoxaparin-warfarin in 2,199 subjects undergoing ECV of nonvalvular AF (NCT02072434). Patients received ≥3 weeks of proper anticoagulation or transesophageal echocardiogram before ECV paroxysmal AF was defined as AF with spontaneous conversion of duration of <7 days; persistent AF was defined as AF lasting ≥7 days without spontaneous conversion. Clinical characteristics and outcomes were compared between subjects based on type of AF present at baseline. In total, 415 subjects had paroxysmal AF; 1,777 had persistent AF. Patients with paroxysmal AF were older (65.8 ± 10.3 vs 63.9 ± 10.5, p = 0.001) with more hypertension (82.7% vs 77.2%, p = 0.01) versus persistent AF patients. Congestive heart failure was more common in persistent AF (46.7%) versus paroxysmal AF (31.3%, p <0.0001). CHA₂DS₂-VASc (score >2: 52.0% vs 49.5%, p = 0.4375) and prior myocardial infarction (6.5% vs 6.8%, p = 0.91) did not significantly differ between groups. After ECV, primary endpoint events were numerically higher in paroxysmal AF versus persistent AF (1.5% vs 0.6%, p = 0.0571), approaching statistical significance. Of note, myocardial infarction was observed in paroxysmal AF (n = 4 vs 0), whereas persistent AF was accompanied by stroke (n = 0 vs 5; p <0.05). In conclusion, patients with paroxysmal AF had more frequent major cardiovascular events than patients with persistent AF. Composite event rates were driven mainly by myocardial infarction in patients with paroxysmal AF and by stroke in those with persistent AF. Overall, the absolute number of events was low after ECV under anticoagulation.

Rivaroxaban Versus Apixaban for Stroke Prevention in Atrial Fibrillation

Background:

The comparative effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) is uncertain, as they have not been compared directly in randomized trials. Previous observational comparisons of NOACs are likely to be biased by unmeasured confounders. We sought to compare the efficacy and safety of rivaroxaban and apixaban for stroke prevention in patients with atrial fibrillation (AF), using practice variation in preference for NOAC as an instrumental variable.

Methods and Results:

Patients started on apixaban or rivaroxaban after newly diagnosed AF were identified using Danish nationwide registries. Patients were categorized according to facility preferences for type of NOAC, independent of actual treatment, measured as fraction of the prior 20 patients with AF initiated on rivaroxaban in the same facility. Facility preference for NOAC was used as an instrumental variable. The occurrence of stroke/thromboembolism, major bleeding, myocardial infarction, and all-cause mortality over 2 years of follow-up were investigated using adjusted Cox regressions. We analyzed 6264 patients with AF initiated on rivaroxaban or apixaban. NOAC preference was strongly related to actual choice of treatment but not associated with any other measured baseline characteristics. Patients treated in facilities that had preference for rivaroxaban had more major bleeding: compared with patients treated in facilities that used rivaroxaban in 0% to 20% of cases, the adjusted hazard ratio for bleeding was 1.06 when treated in a facility with 25% to 40% use; 1.41 with 45% to 60% use; 1.51 with 65% to 80% use; and 1.81 with 0% to 100% use ( P trend =0.01). Higher facility preference for rivaroxaban was not significantly associated with increased risk of stroke/thromboembolism ( P trend =0.06), myocardial infarction ( P trend =0.65), or all-cause mortality ( P trend =0.89). When we used the instrumental variable to model the causal relationship between choice of NOAC and major bleeding, relative risk with rivaroxaban was 1.89 (95% CI, 1.06–2.72) compared with apixaban.

Conclusions:

Using instrumental variable estimation in a cohort of patients with AF, rivaroxaban was associated with higher risk of major bleeding compared with apixaban. No significant associations to other outcomes were found in main analyses.

Effectiveness and Safety of Direct Oral Anticoagulants in Relation to Temporal Changes in Their Use

Background:

Since the direct oral anticoagulants (DOAC) were introduced, oral anticoagulant (OAC) prescription patterns have rapidly changed in patients with atrial fibrillation (AF). We aimed to evaluate the evolving trends of OAC use in a large nationwide cohort and specifically examine the changes in patient profiles treated with warfarin or DOAC and whether the time trends in OAC use affected clinical outcomes.

Methods and Results:

Using the Korean Health Insurance Review and Assessment database, we divided OAC naive patients with AF into 3 groups according to the enrollment period between January 2015 and December 2017 (n=35 353 in cohort 1, n=36 631 in cohort 2, and n=44 819 in cohort 3). DOAC use increased from 59% to 89%, whereas warfarin use has decreased from 41% to 11% during the study period. Patients treated with warfarin were increasingly younger from cohort 1 to cohort 3 (mean age 68–65 years, P <0.001) with lower mean CHA 2 DS 2 -VASc scores (3.3–2.9, P <0.001), whereas those with DOAC did not show a significant difference in clinical characteristics over the study period. Warfarin group had improved clinical outcomes over time, reflecting dynamic changes in patient characteristics. Compared with warfarin group, unadjusted hazard ratios of composite outcome for DOAC group have changed over time (hazard ratio 0.77 [95% CI, 0.69–0.85] in cohort 1, hazard ratio 0.84 [95% CI, 0.73–0.97] in cohort 2, and hazard ratio 1.00 [95% CI, 0.78–1.25] in cohort 3). After propensity score weighting between warfarin and DOAC groups in each cohort, DOAC showed consistently lower risks of the composite outcome by approximately 23% to 25% compared with warfarin across 3 different periods.

Conclusions:

In contemporary clinical practice, OAC prescription patterns and characteristics of patients treated warfarin or DOAC have dynamically changed. Despite these changes, DOAC showed a consistent better net clinical benefit compared with warfarin across different periods.

Comparison of the Effect of Age (< 75 Versus ≥ 75) on the Efficacy and Safety of Dual Therapy (Dabigatran + Clopidogrel or Ticagrelor) Versus Triple Therapy (Warfarin + Aspirin + Clopidogrel or Ticagrelor) in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention (from the RE-DUAL PCI Trial)

The RE-DUAL PCI trial reported that dabigatran dual therapy (110/150 mg twice daily, plus clopidogrel or ticagrelor) reduced bleeding events versus warfarin triple therapy (warfarin plus aspirin and clopidogrel or ticagrelor) in patients with atrial fibrillation who underwent percutaneous coronary intervention, with noninferiority in composite thromboembolic events. In this prespecified analysis, risks of first major or clinically relevant nonmajor bleeding event and composite end point of death, thromboembolic events, or unplanned revascularization were compared between dabigatran dual therapy and warfarin triple therapy in older (≥ 75 years) and younger (< 75 years) patients, using Cox proportional hazard regression. Of 2,725 patients randomized to treatment, 1,026 (37.7%) were categorized into older and 1,699 (62.3%) into younger age groups. Dabigatran 110 mg dual therapy lowered bleeding risk versus warfarin triple therapy in older (hazard ratio [HR] 0.67; 95% confidence interval [CI] 0.51 to 0.89) and younger patients (HR 0.40; 95% CI 0.30 to 0.54); interaction p value: 0.0125. Dabigatran 150 mg dual therapy lowered bleeding risk versus warfarin triple therapy in younger patients (HR 0.57; 95% CI 0.44 to 0.74), whereas no benefit could be observed in older patients (HR 1.21; 95% CI 0.83 to 1.77); interaction p value: 0.0013. For the thromboembolic end point, there was a trend for a higher risk with dabigatran 110 mg dual therapy in older patients, compared with warfarin triple therapy, whereas the risk was similar in younger patients. For dabigatran 150 mg dual therapy, the thromboembolic risk versus warfarin triple therapy was similar in older and younger patients. In conclusion, the benefits of dabigatran dual therapy differed in the 2 age groups, which may help dose selection when using dabigatran dual therapy.

Blood Pressure Variability and Incidence of New-Onset Atrial Fibrillation

Blood pressure variability is a well-known risk factor for cardiovascular disease, but its association with atrial fibrillation (AF) is uncertain. We aimed to evaluate the association between visit-to-visit blood pressure variability and incident AF. This population-based cohort study used database from the Health Screening Cohort, which contained a complete set of medical claims and a biannual health checkup information of the Koran population. A total of 8 063 922 individuals who had at least 3 health checkups with blood pressure measurement between 2004 and 2010 were collected after excluding subjects with preexisting AF. Blood pressure variability was defined as variability independence of the mean and was divided into 4 quartiles. During a mean follow-up of 6.8 years, 140 086 subjects were newly diagnosed with AF. The highest blood pressure variability (fourth quartile) was associated with an increased risk of AF (hazard ratio, 95% CI; systolic blood pressure: 1.06, 1.05–1.08; diastolic blood pressure: 1.07, 1.05–1.08) compared with the lowest (first quartile). Among subjects in the fourth quartile in both systolic and diastolic blood pressure variability, the risk of AF was 7.6% higher than those in the first quartile. Moreover, this result was consistent in both patients with or without prevalent hypertension. In subgroup analysis, the impact of high blood pressure variability on AF development was stronger in high-risk subjects, who were older (≥65 years), with diabetes mellitus or chronic kidney disease. Our findings demonstrated that higher blood pressure variability was associated with a modestly increased risk of AF.

Dabigatran Persistence and Outcomes Following Discontinuation in Atrial Fibrillation Patients from the GLORIA-AF Registry

Prospective studies evaluating persistence to nonvitamin K antagonist oral anticoagulants in patients with atrial fibrillation are needed to improve our understanding of drug discontinuation. The study objective was to evaluate if and when patients with newly diagnosed atrial fibrillation stop dabigatran treatment and to report outcomes following discontinuation. Patients prescribed dabigatran in diverse clinical practice settings were consecutively enrolled and followed for 2 years. Dabigatran persistence over time, reasons for discontinuation, and outcomes post discontinuation were assessed. Of 4,859 patients, aged 70.2 ± 10.4 years, 55.7% were male. Overall 2-year dabigatran persistence was 70.9% (95% confidence interval [CI] 69.6 to 72.2). Persistence probability was lower in the first 6-month period (83.7% [82.7 to 84.8]) than in subsequent periods for patients on dabigatran at the start of each period (6 to 12 months, 92.5% [91.6 to 93.3]; 12 to 18 months, 95.1% [94.3 to 95.8]; 18 to 24 months, 96.3% [95.6 to 96.9]). Of 1,305 patients (26.9%) who discontinued dabigatran, adverse events were reported as the reason for discontinuation in 457 (35.0%). Standardized stroke incidence rate post discontinuation (per 100 patient-years) in patients discontinuing without switching to another oral anticoagulant was 1.76 (95% CI 0.89 to 2.76) and 1.02 (95% CI 0.43 to 1.76) in those who switched, consistent with the expected benefit of remaining on treatment. Patients persistent with treatment at 1 year had >90% probability of remaining persistent at 2 years suggesting clinical interventions to improve persistence should be focused on the early period following treatment initiation.

Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey

•

23.6% of patients in the survey had newly-diagnosed atrial fibrillation (AF).

•

Those patients had different risk profiles than those with a history of AF.

•

The specificity of the management of first-diagnosed AF patients was presented.

Background

BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice.

Methods

Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey.

Results

Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA₂DS₂-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use.

Conclusions

In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.

Sex Differences in Presentation, Quality of Life, and Treatment in Chinese Atrial Fibrillation Patients: Insights from the China Atrial Fibrillation Registry Study

<strong>BACKGROUND</strong> There is a growing recognition of sex-related disparities in atrial fibrillation (AF). However, limited data is available in Chinese AF patients. <strong>MATERIAL AND METHODS</strong> We compared symptoms, quality of life (QoL), and treatment of AF according to sex from the China AF Registry study. <strong>RESULTS</strong> We studied 14 723 patients with non-valvular AF, of whom 5645 patients (38.3%) were female. Women were older than men (67.5±10.6 vs. 62.2±12.2). Compared to men, women had more comorbidities and a higher proportion of CHA₂DS₂-VASC score ≥2. Women with AF experienced more severe or disabling symptoms than men (33.7% vs. 22.9% in age <75 group; 40.3% vs. 28.7% in age ≥75 group; both P<0.0001). After multivariate analysis, women with AF still had lower QoL (OR 0.69; 95%CI, 0.63-0.76; P<0.0001). Women tended to have lower rates of ablation and rhythm-control drug use in those aged <75 years. Oral anticoagulant use was low and had no sex difference in AF patients with a CHA₂DS₂-VASC score ≥2. <strong>CONCLUSIONS</strong> In Chinese AF patients, women were older and more symptomatic, and had worse QoL. Despite all these differences, women tended to receive less rhythm-control treatment in those aged <75 years. Oral anticoagulant was substantially underused in high stroke risk patients, regardless of sex.

Antithrombotic Therapy in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention During 2-Year Follow-Up, from a Nationwide Population Study

Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) are recommended to receive oral anticoagulants (OAC) and concomitant antiplatelet agents followed by OAC monotherapy continued beyond a year after PCI. However, long-term prescription patterns of antithrombotic therapy in real-world clinical practice were not fully investigated. From the National Health Insurance Service database of Korea, we obtained records of patients with AF who underwent PCI between 2009 and 2013. Patients without repeated PCI or death within 2 years following the procedure were included. Prescription records of antithrombotic therapy including anticoagulants and antiplatelet agents were reviewed at 3-month intervals after discharge. We investigated 8,891 patients. At discharge, 76.1% of the patients received dual antiplatelet therapy (DAPT) and only 17.1% received OAC. Although the proportion of patients receiving DAPT gradually decreased, >70% of patients received only antiplatelet agents (DAPT or single antiplatelet therapy) a year after PCI. During the 2-year follow-up, the proportion of patients receiving OAC remained <20%, and only 1.5% of the patients received OAC monotherapy a year after PCI. Female gender, previous myocardial infarction, peripheral vascular disease, and prescription of DAPT at discharge were associated with underprescription of OAC a year after PCI. In conclusion, a significant proportion (76%) of patients with AF who underwent PCI were not prescribed OAC at discharge despite the high risk of stroke contrary to the current guidelines. Most patients continued to receive antiplatelet agents without OAC beyond the 1-year time point after PCI.