Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial

Edoxaban versus warfarin in vitamin K antagonist experienced and naïve patients from the edoxaban versus warfarin in subjects undergoing cardioversion of atrial fibrillation (ENSURE-AF) randomised trial

Background

In ENSURE-AF study, edoxaban had similar efficacy and safety profile versus enoxaparin–warfarin (enox–warf) in patients undergoing electrical cardioversion of non-valvular atrial fibrillation.

Objectives

To evaluate the efficacy and safety of edoxaban versus enox–warf in patients who were vitamin K antagonists (VKA) naïve or experienced at time of randomisation into ENSURE-AF trial.

Methods

The primary efficacy endpoint was a composite of stroke, systemic embolic event, myocardial infarction, and cardiovascular death during the overall study period, 28 days on study drug after cardioversion and 30 days follow-up. The primary safety endpoint was the composite of major and clinically relevant nonmajor bleeding during the on-medication period from time of first dose to last dose of study drug taken + 3 days.

Results

Of 2199 patients enrolled in ENSURE-AF, 1095 were randomised to edoxaban and 1104 to enox–warf. There were numerically fewer primary efficacy endpoint events with edoxaban than enox–warf irrespective of whether VKA experienced or naïve (0.5% vs. 0.9%, 0.3% vs. 1.4%, respectively). There were no significant differences in the primary safety endpoint [odds ratio (OR) 2.09, 95% confidence interval (CI) 0.72–6.81 in anticoagulant experienced patients, OR 0.77, 95% CI 0.15–3.60 in anticoagulant naïve patients] and in major bleeding rates regardless of treatment or VKA experience (OR 0.69, 95%CI 0.06–6.04, OR 0.48, 95% CI 0.01–9.25, respectively).

Conclusions

Edoxaban had comparable efficacy and safety to optimized anticoagulation with enox–warf. The primary efficacy and safety endpoint outcomes were broadly similar between VKA experienced or naïve patients.

Is anticoagulant therapy always indicated in "medium-risk" patients with first diagnosed atrial fibrillation? Insights from a real world, 10-year observational study

BACKGROUND

The choice of antithrombotic prophylaxis in the so-called "medium-risk" patients (i.e., CHA₂DS₂-VASc score = 1 in males or 2 in females) is one of the major enigmatic issues in clinical management of atrial fibrillation (AF).

METHODS

We retrospectively evaluated 30-day and 1-year thromboembolic events in all consecutive medium-risk patients visited for first diagnosed AF in the local Emergency Department during a 10-year period. The main aim was to establish whether anticoagulant or antiplatelet therapy was effective to lower the thromboembolic risk in patients receiving these drugs. Bleeding events, related to anticoagulant or antiplatelet therapy, was defined as secondary end point.

RESULTS

The final study population consisted of 6389 (3640 males and 2749 females) patients for whom a complete dataset regarding targeted follow-up was available. Patients were then subdivided into two subgroups, according to performance of cardioversion and spontaneous sinus rhythm restoring. In both genders, no significant difference in thromboembolic or bleeding events was noted between patients who underwent cardioversion and were discharged with oral anticoagulant therapy or antiplatelet treatment versus those who were not treated with antithrombotic drugs. Moreover, no difference was also observed in thromboembolic or hemorrhagic event rate between low risk and "medium-risk" patients.

CONCLUSIONS

The results of this study suggest that anticoagulant or antiplatelet therapy would not produce clinical benefits in "medium-risk" AF patients.

Effectiveness and safety of electrical cardioversion for acute-onset atrial fibrillation in the emergency department: a real-world 10-year single center experience

OBJECTIVE

Despite limited evidence, electrical cardioversion of acute-onset atrial fibrillation (AAF) is widely performed in the emergency department (ED). The aim of this study was to describe the effectiveness and safety of electrical cardioversion of AAF performed by emergency physicians in the ED.

METHODS

All episodes of AAF electrically cardioverted in the ED were retrieved from the database for a 10-year period. Most patients not already receiving anticoagulants were given enoxaparin before the procedure (259/419). Procedural complications were recorded, and the patients were followed-up for 30 days for cardiovascular and hemorrhagic complications.

RESULTS

Four hundred nineteen eligible cases were identified; men represented 69%, and mean age was 61±13 years. The procedure was effective in 403 cases (96.2%; 95.4% in women, 96.5% in men), with considerable differences with respect to the age of the patients, the procedure being effective in 100% of patients aged 18 to 39 and only 68.8% in those >80 years. New ED visits (33/419) were identified within 30 days (31 due to atrial fibrillation/atrial flutter recurrence, 1 due to iatrogenic hypokalemia, 1 due to hypertensive emergency). No strokes, major bleeding, life-threatening arrhythmias or peripheral thromboembolism were recorded. Nine small and mild skin burns were observed.

CONCLUSION

Electrical cardioversion is an effective and safe procedure in the vast majority of patients, albeit less effective in patients aged >80 years. It appears reasonable to avoid anticoagulation in low-risk patients with AAF and administer peri-procedural heparin to all remaining patients. Long-term anticoagulation should be planned on an individual basis, after assessment of thromboembolic and hemorrhagic risk.

2018 Korean Guideline of Atrial Fibrillation Management

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.

Cardiac tachyarrhythmias and anaesthesia: General principles and focus on atrial fibrillation

Cardiac tachyarrhythmias are encountered commonly during the perioperative period and need to be promptly identified and appropriately managed by the anaesthesiologist. This review intends to highlight important aspects of these tachyarrhythmias and explore a temporal relationship between common medications employed in the perioperative period and their causation. Mechanisms of initiation of tachyarrhythmias, drugs that can trigger those, as well as their diagnosis and management, are also parts of the current review. Cardiac tachyarrhythmias may not always require treatment, and sometimes, aggressive management can trigger more serious types of arrhythmias. A thorough understanding of these tachyarrhythmias and their pathogenesis enables adopting a more objective approach, eschewing risks of inappropriate or unnecessary management strategies. We performed a MEDLINE search using combinations of MeSH terms such as ‘cardiac’, ‘arrhythmias’, ‘anaesthesia’, ‘perioperative’, ‘tachyarrhythmias’ and ‘anaesthetic implications’. We reviewed the relevant publications with regard to cardiac tachyarrhythmias occurring in the perioperative period.

Anticoagulation in patients with pulmonary arterial hypertension: An update on current knowledge

Pulmonary hypertension is a severe clinical condition characterized by molecular and anatomic changes in pulmonary circulation. It is associated with increased pulmonary vascular resistance, which leads to right-sided heart failure if left untreated and, ultimately, death. Treatment of patients with pulmonary arterial hypertension (PAH) involves a complex strategy that takes into consideration disease severity, general and supportive measures, and combination drug regimens. Abnormalities of blood coagulation factors, anti-thrombotic factors, and the fibrinolytic system may contribute to a prothrombotic state in patients with idiopathic PAH. These physiologic changes, in concert with the presence of non-specific risk factors for venous thromboembolism such as heart failure and immobility, are thought to be the basis for oral anticoagulation in PAH. Several observational studies provide helpful information in favor of anticoagulation use in idiopathic PAH but not in other pulmonary hypertension etiologies. Guideline recommendations are based on the lack of prospective comparative trials in this regard. For that reason, large differences exist in the use of anticoagulants in different countries and centers. More studies should be carried out to clarify the risks and the potential benefits of anticoagulant use in a heterogeneous population of patients who are already at considerable life risk.

Translatability scoring in drug development: eight case studies

Translational medicine describes the transfer of basic in vitro and in vivo data into human applications. In the light of low rates of market approvals for new medical entities, better strategies to predict the risk of drug development should be used to increase output and reduce costs. Recently, a scoring system to assess the translatability of early drug projects has been proposed. Here eight drugs from different therapeutic areas have been subjected to a retrospective test-run in this system fictively located at the phase II-III transition. The scores gained here underline the importance of biomarker quality which is pivotal to decrease the risk of the project in all cases. This is particularly evident for gefitinib. The EGFR mutation status is a breakthrough biomarker to predict therapeutic success which made this compound clinically acceptable, and this is plausibly reflected by a considerable increase of the translatability score. For psychiatric and Alzheimer's drugs, and for a CETP-inhibitor, the lack of suitable biomarkers and animal models is reflected by a low translatability score, well correlating with the excessive translational risk in these areas. These case studies document the apparent utility of the scoring system, at least under retrospective conditions, as the scores correlate with the outcomes at the level of market approval. Prospective validation is still missing, but these case studies are encouraging.

Low molecular weight heparin (parnaparin) for cardioembolic events prevention in patients with atrial fibrillation undergoing elective electrical cardioversion: a prospective cohort study

Systemic thromboembolism is a severe complication in patients undergoing electrical cardioversion (ECV) for atrial fibrillation (AF). Vitamin K antagonists greatly reduce the risk of thromboembolic events, but the administration scheme before ECV is troublesome as difficulties in reaching and maintaining the target therapeutic range for 3 weeks often delay the restoration and likelihood of maintaining sinus rhythm. Low molecular weight heparins (LMWHs) do not need dose adjustment, and may be preferable in this clinical setting. In this multicentre study, the LMWH parnaparin was used at a dose of 85 anti-factor Xa U/kg b.i.d. 2 weeks before and 3 weeks after ECV of AF. In an intention to treat analysis of 102 patients, there was no systemic thromboembolism or major bleeding (0%, 95% CI 0-3.6). Two clinically relevant non-major bleeds (2.5%, 95% CI 0.7-8.8) and three minor bleeds (3.8%, 95% CI 1.3-10.6) were recorded. No heparin-induced thrombocytopenia or other major adverse events were recorded. Parnaparin appears effective and safe for thromboprophylaxis of elective ECV in patients with AF.

INR deviations in hemodialyzed patients under low dose oral anticoagulant therapy

The aim of this retrospective study was to evaluate the International Normalized Ratio (INR) in hemodialyzed uremic patients under treatment with oral anticoagulation drugs. Eleven out of one hundred and forty-two uremic hemodialyzed patients in our unit were included in the study. These 11 patients aged from 70 to 85 (mean: 76 years) were under oral anticoagulation treatment for protection from thromboembolic events. They received 1 mg acenocumarol daily with the therapeutic goal of achieving an INR between 2 and 2.5 units. During the last year, the number of total INR determinations was 129. Based on the INR levels, measurements were classified into three categories of anticoagulation, termed "under-anticoagulation", "target-anticoagulation", and "over-anticoagulation". The number, the percentage, and the mean value (+/-SD) of INR measurements for each category, respectively, were under-anticoagulation: 39, 30%, 1.78 +/- 0.14; target-anticoagulation: 48, 37.5%, 2.20 +/- 0.14; and over-anticoagulation: 42, 32.5%, 3.14 +/- 0.64. The mean value +/-SD of all INR determinations (n=129) was 2.34 +/-0.65. No thromboembolic or major bleeding events occurred in our patients with these INR. In conclusion, in elderly, hemodialyzed uremic patients with indications for oral anticoagulation treatment, adequate and safe INR levels can be achieved in a high proportion without serious deviations from the therapeutic goal by using low doses of drugs. Therefore, oral anticoagulation therapy should not be considered automatically contra-indicated in this patient group.

Warfarin: what are the clinical implications of an out-of-range-therapeutic international normalized ratio?

Warfarin is a commonly used oral anticoagulant, and has well-established clinical efficacy. However, it has a narrow therapeutic window, and a mode-of-action affected by inter-individual differences and environmental factors. The effectiveness and safety of warfarin are closely related to maintenance of the international normalized ratio (INR) within therapeutic range. A supra-therapeutic INR puts patients at risk of bleeding, whereas a sub-therapeutic INR may not protect against thromboembolic complications. Research suggests a lack of anticoagulation control during warfarin therapy in different settings. Careful monitoring of the INR is essential, especially in geriatric or cancer populations who are at an increased risk of major hemorrhage. Warfarin is an effective treatment but optimization of the risk-benefit ratio is crucial in order to maximize efficacy and safety. Here, we will assess the extent to which INRs are an issue in the management of warfarin therapy, and the effect INRs may have on clinical outcomes.

AFFECT: a prospective, open-label, multicenter trial to evaluate the feasibility and safety of a short-term treatment with subcutaneous certoparin in patients with persistent non-valvular atrial fibrillation

BACKGROUND

Patients with persistent atrial fibrillation (AF) scheduled for electrical cardioversion need immediate anticoagulation. Unfractionated heparin (UFH) is often used for early anticoagulation in these patients before oral anticoagulation becomes effective. However, dose adjustment is required to achieve a two- to three-fold prolongation of the activated partial thromboplastin. Low molecular weight heparins, given in body weight-adjusted or independent fixed dosage, require less laboratory monitoring and are also effective within hours of first dosing. They seem to be an attractive alternative to UFH. Previous evidence has shown that these drugs are safe and effective in this indication.

PATIENTS AND METHODS

In this prospective, open-label, multicenter pilot study, 203 patients were enrolled with persistent non-valvular AF scheduled for electrical cardioversion. Patients received a fixed dose of 8000 U anti-Xa certoparin twice daily starting immediately after enrolment and before cardioversion was performed. Patients with AF > 48 h underwent transoesophageal echocardiography (TEE) before cardioversion to exclude intra-atrial thrombi. After cardioversion, overlapping oral anticoagulation was started. Treatment with certoparin was stopped only after two consecutive days with INR values >2.

OBJECTIVES

The objective was to document the feasibility and safety of a short-term treatment with a fixed, body weight-independent certoparin regimen (2 x 8000 U anti-Xa).

RESULTS

Out of 203 patients enrolled, 200 received at least one dose of certoparin and were included in the analysis (safety population). Median treatment duration with certoparin was 7 days. Bleedings were observed in 8 patients (4.0%) and were classified as major (1.5%) or minor (2.5%). Cerebral ischemia was reported for 1 patient (0.5%). One patient showed mild thrombocytopenia (0.5%). There were no reports of venous thromboembolism or death during the treatment period.

CONCLUSION

Certoparin administered at 8000 U anti-Xa twice daily independent of body weight was safe and appeared to be effective in patients with non-valvular AF undergoing electrical cardioversion. Its ease of use and the possibility of treatment on an outpatient basis make it an attractive option for early anticoagulation in AF.

Economic evaluation of enoxaparin for anticoagulation in early cardioversion of persisting nonvalvular atrial fibrillation: a statutory health insurance perspective from Germany

OBJECTIVE

To estimate, from the perspective of Statutory Health Insurance (SHI, third-party payer) in Germany, the economic consequences of using the subcutaneous low-molecular-weight heparin (LMWH) enoxaparin instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing transesophageal echocardiography (TEE)-guided early electrical cardioversion (ECV) of persisting nonvalvular atrial fibrillation (AF) without intracardiac clot.

DESIGN AND SETTING

The incremental cost for the enoxaparin-based regimen versus the UFH/PPC-based regimen was chosen as the target variable. A decision-analytic model considering the in- and outpatient sectors was used to quantify the target variable. Resource use during in- and outpatient treatment was taken from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial and from expert interviews with cardiologists in Germany in order to reflect the day-to-day conditions of clinical practice. Costs were given by SHI expenses for inpatient treatment and for medical services, drugs, disposables, and laboratory tests during outpatient treatment. These costs were determined by multiplying utilized resource items by the price or tariff of each item based on German healthcare regulations for the reference period of 2003/2004. According to the ACE trial, the evaluation encompassed 28 (26-30) treatment days with two consecutive phases. Phase I with 5 (3-12) days comprised diagnostics, start of anticoagulation, and ECV. Phase II with the remaining days consisted of continued anticoagulation and patient monitoring. The dosage of enoxaparin was 1 mg/kg bodyweight twice daily in treatment phase I followed by 40 mg twice daily with a bodyweight <65 kg or 60 mg twice daily with a BW > or =65 kg in treatment phase II. The daily dosages of UFH by continuous infusion and overlapping PPC were adjusted to an International Normalized Ratio of 2.0-3.0 in treatment phase I followed by 2.25mg PPC once daily in treatment phase II. Patients with any comorbidity and complication level (CCL) and those with low comorbidity and complications expected to occur in rare cases only (low-risk patients) were analyzed separately. In each base-case analysis, exclusively point estimates of all respective model parameters were applied.

MAIN OUTCOME MEASURES AND RESULTS

There were savings of 339 euro and 579 euro per patient receiving the enoxaparin-based regimen versus the UFH/PPC-based regimen in the case of patients with any CCL and of low-risk patients, respectively (1 euro approximate, equals $US1.25; first quarter 2004 values). In comprehensive sensitivity analyzes, the robustness of the model and its results was shown. First, the impact of the model parameters on the target variable for each patient group was quantified in a deterministic model. Secondly, the dependency of the target variable on random variables was described for each patient group using Monte Carlo simulation. Irrespective of the patient group, the cost weight and the base rate of hospitals for inpatient ECV in phase I turned out to have the greatest impact on the savings obtained by the enoxaparin-based regimen. In the case of patients with any CCL, this impact was about 1.4-fold of that of the probability of enoxaparin patients undergoing outpatient ECV in phase I. In the case of low-risk patients, the impact of the cost weight and the base rate of hospitals for inpatient ECV in phase I was about 4.1-fold of that of the price of enoxaparin 60 mg prefilled syringes in the outpatient sector. In 79% and 93% of 10,000 simulated comparisons each versus the UFH/PPC-based regimen, there were savings obtained by the enoxaparin-based regimen in patients with any CCL and in low-risk patients, respectively.

CONCLUSIONS

Results of this evaluation showed that an enoxaparin-based regimen for TEE-guided ECV of AF in patients without intracardiac clot offers SHI in Germany a considerable saving potential when used instead of an UFH/PPC-based regimen.