Navigating the choice of oral anticoagulation therapy for atrial fibrillation in the NOAC era

Factors Influencing the Selection of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients With Non-Valvular Atrial Fibrillation

BACKGROUND

Major atrial fibrillation (AF) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, except in rare clinical circumstances based on 4 randomized controlled trials comparing each NOAC with warfarin. We aimed to investigate the current NOAC prescription behaviors in alignment with the recent clinical evidence available.

METHOD

We conducted a cross-sectional analysis of NOAC-using patients with non-valvular atrial fibrillation (NVAF) who were aged ≥65 years on the index date (July 1, 2018) based on nationwide claims data. The types of NOACs being taken were analyzed using chi-squared tests, and factors influencing NOAC selection were identified using multinomial logistic regression analysis.

RESULTS

A total of 6,061 patients were included. Among the 4 NOACs, rivaroxaban was the most used NOAC. Patients aged ≥75 years (odds ratio [OR] = 1.270, confidence interval [CI] = 1.089-1.450) and women (OR = 1.148, CI = 1.011-1.284) were more likely to use apixaban relative to rivaroxaban. Patients with prior stroke/transient ischemic attack/thromboembolism had higher odds of using dabigatran (OR = 1.508, CI = 1.312-1.704) and apixaban (OR = 1.186, CI = 1.026-1.346). Patients with renal disease had higher odds of using apixaban (OR = 1.466, 95% CI = 1.238-1.693). These findings are consistent with the efficacy and safety profiles reported in pivotal trials and observational studies comparing individual NOACs.

CONCLUSION

Among the 4 NOACs, rivaroxaban was the most commonly used NOAC. Apixaban was preferred for patients aged ≥75 years, females, and patients with renal disease.

The impact of antiplatelet and antithrombotic regimen after TAVI: Data from the VIenna CardioThOracic Aortic Valve RegistrY (VICTORY)

BACKGROUND

We compared the outcomes and adverse events of TAVI patients based on the discharge and long-term antiplatelet or anticoagulant treatment regimens (single antiplatelet [SAPT] vs. dual antiplatelet [DAPT] vs. anticoagulation [OAC] vs. no treatment [NT]).

METHODS

The outcome of 532 consecutive patients treated with TAVI was evaluated. As the main study endpoint, the 1-year all-cause mortality was chosen to compare the different discharge treatment regimens and the 3-year all-cause mortality to compare the different long-term treatment regimens. The secondary endpoints were adverse events as defined by the Valve Academic Research Consortium-II.

RESULTS

One-year survival after TAVI was highest amongst patients treated with DAPT compared to SAPT (P < .001) and OAC (P = .003), and patients under OAC demonstrated improved 1-year survival over patients treated with SAPT (P = .006). Furthermore, there was a strong trend towards improved 3-year survival for patients in the OAC cohort treated with non-vitamin K antagonists compared to vitamin K antagonists (N-VKAs vs. VKA; log-rank P = .056).

CONCLUSION

The lower all-cause mortality for DAPT within the first year and N-VKAs over VKA within the first 3 years warrant considerable attention in further recommendations of antithrombotic and anticoagulation regimens after TAVI.

Safety and Effectiveness of Edoxaban in Atrial Fibrillation Patients in Routine Clinical Practice: One-Year Follow-Up from the Global Noninterventional ETNA-AF Program

Non-vitamin K antagonist oral anticoagulants such as edoxaban are the standard of care for stroke prevention in patients with atrial fibrillation (AF). The Global Edoxaban Treatment in routiNe clinical prActice (ETNA)-AF program integrates prospective, observational, noninterventional regional studies from Europe, Japan, and other Asian countries, collecting data on patient characteristics and clinical outcomes in unselected patients treated with edoxaban for stroke prevention in AF. Overall, 26,823 patients completed a 1-year follow-up and were treated with edoxaban; either 60 or 30 mg once daily. The majority (82.6%) of patients received the recommended doses according to the local label. At baseline, the median (interquartile range) age was 75 (68, 80) years, the CHA₂DS₂-VASc score was 3.0 (2.0, 4.0), and the hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs, or alcohol (HAS-BLED) score was 2.0 (2.0, 3.0). At one year, there were 273 (1.12%/year) major bleeding events, including 75 (0.31%/year) intracranial hemorrhages and 140 (0.57%/year) major gastrointestinal (GI) bleeds. There were 214 ischemic strokes (0.87%/year). Mortality was 3.03%/year (745 deaths), and cardiovascular mortality accounted for 40% of all deaths (1.22%/year, 299 cardiovascular deaths). In conclusion, stroke, intracranial hemorrhage, and other major bleeding events were low in patients with AF treated with edoxaban in routine care. Even on anticoagulation, cardiovascular death remained common.

A comprehensive appraisal of dabigatran etexilate clinical evidence and applications: a 10-year-long story

During the last decade, non-vitamin K antagonist oral anticoagulants (NOACs) revolutionized the thromboprophylaxis management of several medical conditions, including atrial fibrillation and venous thromboembolism. Dabigatran etexilate was the first NOAC widely available worldwide, and it is currently the only one that directly inhibits thrombin. More recently, the availability of idarucizumab, a specific reversal agent, has increased the safety of dabigatran use in clinical practice, especially for those patients with severe and life-threatening bleeding. This review aims to summarize current evidence on dabigatran, starting from its pharmacological characteristics, and providing an updated overview of pivotal randomized controlled trials and real-world data on its efficacy and safety.

Fixed-dose three-factor prothrombin complex concentrates is safe and effective in warfarin reversal

BACKGROUND

Reversal of warfarin with prothrombin complex concentrates (PCC) is required in cases of significant bleeding or need for urgent surgery. A weight-based regimen is commonly, but a fixed-dose approach is also feasible with clinically equivalent outcomes. The purpose of this audit is to review the clinical and laboratory outcomes of patients treated in our centre where fixed-dose PCC is used for warfarin reversal.

OBJECTIVES

The primary objective was to evaluate the post-reversal INR. Secondary objectives were the proportion of patients requiring repeat PCC and 30-day complication rates (death, haemorrhage and thrombosis). A subgroup analysis was also performed to compare the outcomes of those who received a dose of ≤15 IU/kg (reduced dose) to those who received >15 IU/kg (standard dose).

METHODS

Patients who received three-factor PCC for warfarin reversal between 1st January and 31st December 2016 were identified and analysed. Clinical data and PCC dosages were extracted from electronic patient records.

RESULTS

Total of 144 patients were analysed. The median INR pre-reversal was 3.25 (range 1.4-10), which reduced to 1.5 (0.9-3.0) post-reversal. 87% of patients achieved a post-reversal INR of less than 2 and 55% less than 1.5. Sixteen patients required a repeat dose. Complications occurred in 22 patients (15.3%), which consisted of 15 deaths, 7 thrombosis and 2 haemorrhage. No statistically significant differences in the primary and secondary outcomes were noted between reduced-dose and standard-dose subgroups.

CONCLUSION

Our results support the use of fixed-dose PCC for warfarin reversal in a day-to-day clinical practice in a hospital setting. This article is protected by copyright. All rights reserved.

Paroxysmal atrial fibrillation is associated with early coagulation activity regardless of risk factors for embolism

BACKGROUND

Paroxysmal atrial fibrillation (PAF) is associated with an increased incidence of embolic events, even in patients with no embologenic risk factors. This fact raises the question for the hypercoagulability in PAF as a state closely related to the arrhythmia itself, independent of other well established embologenic risk factors. The scarce data on that topic predisposed our aim that was to study coagulation activity in the early hours (up to the twenty-fourth hour) of the disease.

METHODS

Fifty-one non-anticoagulated patients (26 men, 25 women; mean age 59.84±1.60 years) and 52 controls (26 men, 26 women; mean age 59.50±1.46 years) were consequently selected for the study. Plasma coagulation activity of factor II (FII), factor V (FV) and factor X (FX) was examined.

RESULTS

In the PAF group, there was a higher activity of FII (167.81±9.12% vs. 100.43±5.77%, P<0.001), FV (198.47±10.88% vs. 121.53±4.79%, P<0.001) and FX (193.20±11.85 vs. 116.20±5.86, P<0.001). The deviations were independent of age, sex, body mass index, presence of hypertension and CHA<inf>2</inf>DS<inf>2</inf>-VASc risk score (P>0.05). PAF duration was a significant predictor of FII activity (r=0.83, P<0.001) but no correlation was established between FV and FX activity and the arrhythmia duration (r=0.10, P>0.05; r=0.11, P>0.05, respectively).

CONCLUSIONS

We established high coagulation activity during the first twenty-four hours of PAF. The observed deviations in the studied parameters give us reason to consider PAF a procoagulant state independent of the well-established prothrombotic risk factors, even in its early clinical manifestation.

The Left Atrial Appendage, Including LAA Occlusion Devices Line Watchman, Amulet, and Lariat

Atrial fibrillation is a very common arrhythmia whose prevalence is expected to increase significantly as the population ages. The associated stroke risk is a major cause of morbidity and mortality. Stroke prevention by anticoagulation carries its own risks, leading to the search for alternative strategies. Multiple techniques have been developed to exclude the left atrial appendage (the main source of thromboembolism in atrial fibrillation) from the circulation. Such techniques offer the hope of stroke prevention without the risks of anticoagulation. This article describes the percutaneous approaches being currently performed in the United States. Particular emphasis is placed on the use of transesophageal echocardiography to guide these procedures.