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Verdecchia P, Reboldi G, Angeli F, Mazzotta G, Lip GYH, Brueckmann M, Kleine E, Wallentin L, Ezekowitz MD, Yusuf S, Connolly SJ, Di Pasquale G. Dabigatran vs. warfarin in relation to the presence of left ventricular hypertrophy in patients with atrial fibrillation- the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) study. Europace 2018; 20:253-262. [PMID: 28520924 PMCID: PMC5834147 DOI: 10.1093/europace/eux022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/01/2017] [Indexed: 11/12/2022] Open
Abstract
Aim We tested the hypothesis that left ventricular hypertrophy (LVH) interferes with the antithrombotic effects of dabigatran and warfarin in patients with atrial fibrillation (AF). Methods and results This is a post-hoc analysis of the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) Study. We defined LVH by electrocardiography (ECG) and included patients with AF on the ECG tracing at entry. Hazard ratios (HR) for each dabigatran dose vs. warfarin were calculated in relation to LVH. LVH was present in 2353 (22.7%) out of 10 372 patients. In patients without LVH, the rates of primary outcome were 1.59%/year with warfarin, 1.60% with dabigatran 110 mg (HR vs. warfarin 1.01, 95% confidence interval (CI) 0.75-1.36) and 1.08% with dabigatran 150 mg (HR vs. warfarin 0.68, 95% CI 0.49-0.95). In patients with LVH, the rates of primary outcome were 3.21%/year with warfarin, 1.69% with dabigatran 110 mg (HR vs. warfarin 0.52, 95% CI 0.32-0.84) and 1.55% with 150 mg (HR vs. warfarin 0.48, 95% CI 0.29-0.78). The interaction between LVH status and dabigatran 110 mg vs. warfarin was significant for the primary outcome (P = 0.021) and stroke (P = 0.016). LVH was associated with a higher event rate with warfarin, not with dabigatran. In the warfarin group, the time in therapeutic range was significantly lower in the presence than in the absence of LVH. Conclusions LVH was associated with a lower antithrombotic efficacy of warfarin, but not of dabigatran, in patients with AF. Consequently, the relative benefit of the lower dose of dabigatran compared to warfarin was enhanced in patients with LVH. The higher dose of dabigatran was superior to warfarin regardless of LVH status. Clinical trial registration http:www.clinicaltrials.gov. Unique identifier: NCT00262600.
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Affiliation(s)
| | | | - Fabio Angeli
- Department of Cardiology and Cardiovascular Pathophysiology, Hospital S.M. della Misericordia, Perugia, Italy
| | | | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Martina Brueckmann
- Boehringer Ingelheim GmbH & Co, Ingelheim am Rhein, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Eva Kleine
- Boehringer Ingelheim GmbH & Co, Ingelheim am Rhein, Germany
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Michael D Ezekowitz
- Sidney Kimmel Medical College at Jefferson University, Philadelphia, PA, USA.,Medical College and Lankenau Medical Center, Wynnewood, PA, USA
| | - Salim Yusuf
- McMaster University, Hamilton, Ontario, Canada
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2
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Khan AA, Lip GYH. The prothrombotic state in atrial fibrillation: pathophysiological and management implications. Cardiovasc Res 2018; 115:31-45. [DOI: 10.1093/cvr/cvy272] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023] Open
Abstract
AbstractAtrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and is associated with significant morbidity and mortality. There is plenty of evidence available to support the presence of a prothrombotic or hypercoagulable state in AF, but the contributory factors are multifactorial and cannot simply be explained by blood stasis. Abnormal changes in atrial wall (anatomical and structural, as ‘vessel wall abnormalities’), the presence of spontaneous echo contrast to signify abnormal changes in flow and stasis (‘flow abnormalities’), and abnormal changes in coagulation, platelet, and other pathophysiologic pathways (‘abnormalities of blood constituents’) are well documented in AF. The presence of these components therefore fulfils Virchow’s triad for thrombogenesis. In this review, we present an overview of the established and professed pathophysiological mechanisms for thrombogenesis in AF and its management implications.
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Affiliation(s)
- Ahsan A Khan
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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3
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Li Q, Tao H, Wang J, Zhou Q, Chen J, Qin WZ, Dong L, Fu B, Hou JL, Chen J, Zhang WH. Warfarin maintenance dose Prediction for Patients undergoing heart valve replacement- a hybrid model with genetic algorithm and Back-Propagation neural network. Sci Rep 2018; 8:9712. [PMID: 29946101 PMCID: PMC6018790 DOI: 10.1038/s41598-018-27772-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/08/2018] [Indexed: 02/05/2023] Open
Abstract
Warfarin is the most recommended anticoagulant drug for patients undergoing heart valve replacement. However, due to the narrow therapeutic window and individual dose, the use of warfarin needs more advanced technology. We used the data collected from a multi-central registered clinical system all over China about the patients who have undergone heart valve replacement, subsequently divided into three groups (training group: 10673 cases; internal validation group: 3558 cases; external validation group: 1463 cases) in order to construct a hybrid model with genetic algorithm and Back-Propagation neural network (BP-GA), For testing the model's prediction accuracy, we used Mean absolute error (MAE), Root mean squared error (RMSE) and the ideal predicted percentage of total and dose subgroups. In results, whether in internal or in external validation group, the total ideal predicted percentage was over 58% while the intermediate dose subgroup manifested the best. Moreover, it showed higher prediction accuracy, lower MAE value and lower RMSE value in the external validation group than that in the internal validation group (p < 0.05). In conclusion, BP-GA model is promising to predict warfarin maintenance dose.
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Affiliation(s)
- Qian Li
- Department of Evidence-based Medicine and clinical epidemiology, West China Medical School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Huan Tao
- Department of Evidence-based Medicine and clinical epidemiology, West China Medical School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Career development, The fourth affiliated hospital of Anhui Medical University, Hefei, China
| | - Qin Zhou
- Department of Nutrition, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Chen
- Department of Anesthesiology, China Mianyang Central Hospital, Mianyang, China
| | - Wen Zhe Qin
- Department of Social Medicine and Health Management, Shandong University, Jinnan, China
| | - Li Dong
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Fu
- Department of Cardiovascular Surgery, Tianjin central hospital, Tianjin, China
| | - Jiang Long Hou
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Chen
- Department of Evidence-based Medicine and clinical epidemiology, West China Medical School of Medicine/West China Hospital, Sichuan University, Chengdu, China.
| | - Wei-Hong Zhang
- Department of Research Laboratory for Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
- Epidemiology, Biostatistics and Clinical Research Centre, School of Public Health, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
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Wang NC, Sather MD, Hussain A, Althouse AD, Adelstein EC, Jain SK, Katz WE, Shalaby AA, Voigt AH, Saba S. Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta‐analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:767-774. [DOI: 10.1111/pace.13368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/20/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Norman C. Wang
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Matthew D. Sather
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Aliza Hussain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew D. Althouse
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Evan C. Adelstein
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sandeep K. Jain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - William E. Katz
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alaa A. Shalaby
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew H. Voigt
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Samir Saba
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
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Kubo S, Mizutani Y, Meemook K, Nakajima Y, Hussaini A, Kar S. Incidence, Characteristics, and Clinical Course of Device-Related Thrombus After Watchman Left Atrial Appendage Occlusion Device Implantation in Atrial Fibrillation Patients. JACC Clin Electrophysiol 2017; 3:1380-1386. [DOI: 10.1016/j.jacep.2017.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 05/08/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
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Watanabe T, Shinoda Y, Ikeoka K, Minamisaka T, Fukuoka H, Inui H, Hoshida S. Dabigatran Therapy Resulting in the Resolution of Rivaroxaban-resistant Left Atrial Appendage Thrombi in Patients with Atrial Fibrillation. Intern Med 2017; 56:1977-1980. [PMID: 28768967 PMCID: PMC5577073 DOI: 10.2169/internalmedicine.56.8508] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Patients with persistent atrial fibrillation (AF) and a large left atrium are at a high risk for thromboembolisms. Recently, direct oral anticoagulants (DOACs) have mainly been used for the prevention of cardiac embolisms caused by AF. Transesophageal echocardiography (TEE) is performed in order to exclude any left atrial appendage (LAA) thrombi. We herein report two cases of persistent AF, both of which were treated with rivaroxaban for more than two years. Since TEE identified mobile LAA thrombi with this treatment, we switched from rivaroxaban to the direct thrombin inhibitor dabigatran. Dabigatran resolved the LAA thrombi that had been refractory to rivaroxaban.
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Affiliation(s)
- Tetsuya Watanabe
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Yukinori Shinoda
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Tomoko Minamisaka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Hidetada Fukuoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Japan
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Santangelo G, Ielasi A, Antonio Scopelliti P, Pattarino F, Tespili M. Apixaban-Induced Resolution of A Massive Left Atrial and Appendage Thrombosis in a Very Elderly Patient. J Atr Fibrillation 2016; 9:1509. [PMID: 29250263 DOI: 10.4022/jafib.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/19/2016] [Accepted: 12/24/2016] [Indexed: 11/10/2022]
Abstract
A 86-year-old woman with first diagnosed atrial fibrillation (AF) underwent mitral valve annuloplasty 10 years before was admitted to our Unit due to congestive heart failure. Trans-thoracic echocardiogram (TTE) revealed a large fluctuant echogenic mass in the posterior wall of the left atrium. Trans-esophageal echo (TEE) showed the origin of the mass within the left atrial appendage. An adjusted dose of the novel oral anticoagulant (NOAC) apixaban, was prescribed. A complete disappearance was appreciated by examination at 12 weeks after the first drug administration. Although apixaban, resulted superior to warfarin in preventing stroke and thrombo-embolic events in patients with non valvular AF, while causing less bleeding, few data are actually available regarding the efficacy and safety of this drug in left atrium and appendage thrombosis management. Our report shows that this NOAC could be a simple and useful option to manage huge atrial thrombosis in very elderly patients.
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Affiliation(s)
- Gloria Santangelo
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Alfonso Ielasi
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Pasquale Antonio Scopelliti
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Francesco Pattarino
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Maurizio Tespili
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
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Di Minno MND, Ambrosino P, Dello Russo A, Casella M, Tremoli E, Tondo C. Prevalence of left atrial thrombus in patients with non-valvular atrial fibrillation. A systematic review and meta-analysis of the literature. Thromb Haemost 2015; 115:663-77. [PMID: 26607276 DOI: 10.1160/th15-07-0532] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/22/2015] [Indexed: 11/05/2022]
Abstract
We performed a meta-analysis about the prevalence of left atrial thrombus (LAT) in patients with atrial fibrillation (AF) undergoing trans-esophageal echocardiography (TEE). Studies reporting on LAT presence in AF patients were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases and the pooled LAT prevalence was evaluated as weighted mean prevalence (WMP). Seventy-two studies (20,516 AF patients) showed a LAT WMP of 9.8 % (95 %CI: 7.6 %-12.5 %). LAT presence was associated with a higher age (mean difference: 2.56, 95 %CI: 1.49-3.62), and higher prevalence of female gender (OR: 1.35, 95 %CI: 1.04-1.75), hypertension (OR: 1.78, 95 %CI: 1.38-2.30), diabetes mellitus (OR: 1.86, 95 %CI: 1.33-2.59) and chronic heart failure (OR: 3.67, 95 %CI: 2.40-5.60). Overall, LAT patients exhibited a higher CHADS2-score (mean difference 0.88, 95 %CI: 0.68-1.07) and a higher risk of stroke/systemic embolism (OR: 3.53, 95 %CI: 2.24-5.56) compared with those without LAT. A meta-regression showed an inverse association between LAT prevalence and the presence of anticoagulation (Z-value: -7.3, p< 0.001). Indeed, studies in which 100 % of patients received oral anticoagulation reported a 3.4 % WMP of LAT (95 %CI: 1.3 %-8.7 %), whereas studies in which 0 % of patients received anticoagulation showed a LAT WMP of 7.4 % (95 %CI: 2.3 %-21.5 %). Our data suggest that LAT is present in ≍10 % of AF patients, and is associated with a 3.5-fold increased risk of stroke/systemic embolism. Interestingly, LAT is also reported in some of patients receiving anticoagulation. The implementation of the screening of LAT in AF patients before cardioversion/ablation could be useful for the prevention of vascular events.
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Affiliation(s)
- Matteo Nicola Dario Di Minno
- Matteo Nicola Dario Di Minno, MD, PhD, Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy, Tel./Fax: +39 02 58002857, E-mail:
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Nishida T, Sonoda H, Oishi Y, Tanoue Y, Tatewaki H, Shiokawa Y, Tominaga R. Long-Term Comparison of Three Types of Aortic St. Jude Medical Mechanical Prosthesis in Japanese Patients. Circ J 2015; 79:2193-200. [PMID: 26248571 DOI: 10.1253/circj.cj-15-0268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The long-term results achieved with aortic St. Jude Medical (SJM) mechanical prostheses in various age groups of Japanese patients have not been previously compared or reported. METHODS AND RESULTS Since 1981, a total of 240 SJM valves were implanted in 79 patients using the Standard model, in 58 patients with the Hemodynamic Plus model, and in 103 patients with the Regent model for aortic valve replacement (AVR). Follow-up was completed for 2,397 patient-years in 97.5% of the patients, among whom the effect of age was compared, and the subjects were divided into younger (<65 years) and older (≥65 years) groups. Hospital mortality rate was 2.5%. No structural valve deterioration was observed during the follow-up period. In addition, no significant differences were observed in long-term survival between the 3 models. In contrast, significantly better rates of freedom from all-cause death (P<0.0001), valve-related death (P=0.0018) and valve-related morbidity (P=0.0021), including bleeding events (P=0.0007), were observed in the younger group (n=157, 50.6±1.0 years old) than in the older group (n=83, 72.5±0.7 years old). CONCLUSIONS All types of SJM valve used for single AVR achieved satisfactory early and long-term results in each age group even 25 years after surgery. When selecting this prosthesis for elderly patients, however, relatively worse performance may be expected compared with that observed in younger patients.
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Affiliation(s)
- Takahiro Nishida
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences
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10
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Fujii S. Editorial: Resolution of left atrial thrombus with novel oral anticoagulants. J Cardiol Cases 2014; 10:241-242. [PMID: 30534253 PMCID: PMC6279654 DOI: 10.1016/j.jccase.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Fan X, Zhang S. The Optimal Treatment For Atrial Fibrillation In Less Developed Countries. J Atr Fibrillation 2014; 7:1147. [PMID: 27957126 DOI: 10.4022/jafib.1147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/08/2014] [Accepted: 10/14/2014] [Indexed: 01/13/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and is a major cardiovascular challenge due to its close association with increased morbidity and mortality. Although the incidence and prevalence of AF is slightly lower in developing countries than in developed countries, the AF-associated risk of stroke is similar. Treatment of AF is far from satisfactory in developing countries, which may be due to limited health-care resources and social and racial characteristics that differ from Western populations. Chronic rate control is still the main treatment strategy of persistent AF because anti-arrhythmic drugs have only a modest long-term effect on maintenance of sinus rhythm, and no superior impact in terms of cardiovascular outcomes. With the development of ablation techniques and strategies, more AF patients received catheter ablation, although the benefit, complications, and high recurrence rate associated with AF ablation remain under investigation. Improvement in antithrombotic therapy of AF has been observed, although still fewer patients receive oral anticoagulants in developing countries than in Western countries. Novel treatment for the prevention of thromboembolism, such as new oral anticoagulants with different mechanisms of action or the percutaneous transcatheter closure of the left atrial appendage, has recently been introduced in developing countries as an alternative option for the prevention of AF-associated strokes. More data are needed regarding upstream therapy.
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Affiliation(s)
- Xiaohan Fan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
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Prediction of left atrial thrombi in patients with atrial tachyarrhythmias during warfarin administration: retrospective study in Hyogo College of Medicine. Heart Vessels 2014; 30:331-7. [DOI: 10.1007/s00380-014-0496-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
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Kawakami T, Kobayakawa H, Ohno H, Tanaka N, Ishihara H. Resolution of left atrial appendage thrombus with apixaban. Thromb J 2013; 11:26. [PMID: 24359320 PMCID: PMC3878218 DOI: 10.1186/1477-9560-11-26] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/17/2013] [Indexed: 01/28/2023] Open
Abstract
Left atrial appendage (LAA) thrombosis is an important cause of cardiogenic cerebral thromboembolism. Apixaban is a member of the class of novel oral anticoagulants (NOAC) and is superior to warfarin in preventing stroke or systemic embolism, causes less bleeding, and results in lower mortality in patients with atrial fibrillation. There are few reports of resolution of LAA thrombus with other NOAC. We present a 72-year-old male patient with persistent atrial fibrillation associated with left atrial thrombus. Sixteen days of apixaban treatment showed complete thrombus resolution. In this study, soluble fibrin and D-dimer levels decreased without prolongation of international normalized ratio (INR) and activated partial thromboplastin time (APTT).
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Affiliation(s)
- Tohru Kawakami
- From the Division of Cardiology, Ichinomiyanishi Hospital, 1 Kaimei-hira, Ichinomiya, Aichi, Japan.
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14
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Fan X, Zhang S. New Insights into Anticoagulation in Atrial Fibrillation. J Arrhythm 2011. [DOI: 10.1016/s1880-4276(11)80043-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Takeuchi F, Kashida M, Okazaki O, Tanaka Y, Fukuda S, Kashima T, Hosaka S, Hiroe M, Kimura S, Kato N. Evaluation of Pharmacogenetic Algorithm for Warfarin Dose Requirements in Japanese Patients. Circ J 2010; 74:977-82. [DOI: 10.1253/circj.cj-09-0876] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Fumihiko Takeuchi
- Department of Gene Diagnostics and Therapeutics, Research Institute, International Medical Center of Japan
| | - Mitsuo Kashida
- Division of Cardiology, International Medical Center of Japan
| | - Osamu Okazaki
- Division of Cardiology, International Medical Center of Japan
| | - Yuriko Tanaka
- Division of Cardiology, International Medical Center of Japan
| | - Shoji Fukuda
- Division of Cardiovascular Surgery, International Medical Center of Japan
| | - Toshitaka Kashima
- Division of Cardiovascular Surgery, International Medical Center of Japan
| | - Shigeru Hosaka
- Division of Cardiovascular Surgery, International Medical Center of Japan
| | - Michiaki Hiroe
- Division of Cardiology, International Medical Center of Japan
| | - Sosuke Kimura
- Division of Cardiovascular Surgery, International Medical Center of Japan
- Toyama Hospital, International Medical Center of Japan
| | - Norihiro Kato
- Department of Gene Diagnostics and Therapeutics, Research Institute, International Medical Center of Japan
- Division of Cardiology, International Medical Center of Japan
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Intraoperative detection of left atrial clot using transoesophageal echocardiography in a patient undergoing off-pump coronary artery bypass grafting. Eur J Anaesthesiol 2009; 26:531-3. [DOI: 10.1097/eja.0b013e32831c0308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Reynolds MW, Fahrbach K, Hauch O, Wygant G, Estok R, Cella C, Nalysnyk L. Warfarin Anticoagulation and Outcomes in Patients With Atrial Fibrillation. Chest 2004; 126:1938-45. [PMID: 15596696 DOI: 10.1378/chest.126.6.1938] [Citation(s) in RCA: 209] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To examine the relationship between international normalized ratio (INR) and outcomes (major bleeding events and strokes) in patients with atrial fibrillation (AF) receiving anticoagulation with warfarin. METHODS A systematic review and metaanalysis of studies published in the English language between January 1, 1985, and October 30, 2002, was performed. MEDLINE (PubMed), Current Contents, and relevant reference lists were searched. Studies enrolling patients with nonvalvular AF receiving warfarin anticoagulation were eligible for inclusion if they reported stroke and/or major bleeding events in relation to INR, or time spent in therapeutic range. The risk of bleeds in overanticoagulated patients (INR > 3) and the risk of strokes in underanticoagulated patients (INR < 2) were assessed. RESULTS Twenty-one studies (6,248 patients) met all inclusion criteria. Of the 21 studies, a target conventional INR of 2 to 3 was used in 9 studies. An INR < 2, compared with an INR > or = 2, was associated with an odds ratio (OR) for ischemic events of 5.07 (95% confidence interval [CI], 2.92 to 8.80). An INR > 3, compared with an INR < or = 3, was associated with an OR for bleeding events of 3.21 (95% CI, 1.24 to 8.28). On average, in the four studies with a target INR range of 2 to 3, patients with AF receiving warfarin spent 61% of time within, 13% of time above, and 26% below the therapeutic range. CONCLUSION Available evidence indicates that in patients with nonvalvular AF, the risk of ischemic stroke with insufficient warfarin anticoagulation (INR < 2), and the risk of bleeding events with overanticoagulation (INR > 3) are significantly higher relative to patients with AF maintained within the recommended INR of 2 to 3. However, the published data are sparse, heterogeneous, and primarily reported from clinical trials. More studies evaluating clinical outcomes in relation to INR are needed, especially in a real-world setting.
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Affiliation(s)
- Matthew W Reynolds
- MetaWorks Inc., 10 President's Landing, Third Floor, Medford, MA 02155, USA.
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Abe Y, Asakura T, Sakamoto N, Ishikawa S, Muroi S, Saitoh F, Satoh M, Suzuki S, Ono M, Sakabe A, Iwai M, Sando M, Gotou J, Watanabe Y, Nagata K, Maehara K, Maruyama Y. Embolic attack in patients with atrial fibrillation and atrial thrombus depends on the character of the thrombus. Circ J 2003; 67:203-8. [PMID: 12604867 DOI: 10.1253/circj.67.203] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is very important to prevent embolisms from left atrial thrombi (LAT). The present study was a trial for the management of patients with AT using 122 patients with atrial fibrillation and LAT who were followed for 1 year after transesophageal echocardiography. LAT were classified by their shape and mobility into the mobile ball type (MB, n=28), fixed ball type (FB, n=32) and mountain type (MO, n=42). The patients were given warfarin (INR: 1.5-2.0, n=43), aspirin 81 mg (n=74) and/or ticlopidine 200 mg/day (n=31). The embolic rate (ER) in the MB group was significantly higher than in the other groups [ie, MB 39.3% vs FB 15.6% (p<0.05), vs MO 2.4% (p<0.05)]. The ER in the FB group was significantly higher than in the MO group (p<0.05). Therapy with a combination of ticlopidine and aspirin reduced the ER in the patients with ball thrombi. The ER of the ball thrombus type group, especially the MB group, was very high in spite of therapy with anti-coagulants and/or anti-platelet agents, and such patients should be treated by early surgical intervention. However, the combination of ticlopidine and aspirin may be useful for preventing embolism.
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Affiliation(s)
- Yukihiko Abe
- Department of Cardiology, Ohara Medical Center, Fukushima, Japan
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Narumiya T, Sakamaki T, Sato Y, Kanmatsuse K. Relationship between left atrial appendage function and left atrial thrombus in patients with nonvalvular chronic atrial fibrillation and atrial flutter. Circ J 2003; 67:68-72. [PMID: 12520155 DOI: 10.1253/circj.67.68] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The relationship between the left atrial appendage (LAA) function, as assessed by transesophageal echocardiography, and the incidence of left atrial thrombus was evaluated in 62 patients with nonvalvular chronic atrial fibrillation (AF; n=50) and atrial flutter (AFL; n=12). It was hypothesized that in both AF and AFL not only the LAA flow velocity (LAAFV), but also the frequency of the LAA movement (the LAA flow time, LAAFT) is a major contributing factor to thrombus formation. LAAFT was defined as the average duration of LAA flow with emptying and filling waves. The patients with AF were divided into 2 groups: lone AF (n=14) and non-lone AF (n=36). LAA thrombus was found in 6 patients with none-lone AF. LAAFV was lower and LAAFT was shorter in patients with thrombus as compared with patients without thrombus (12.0+/-2.2 cm/s vs 24.1+/-10.6 cm/s, 68.7+/-1.5 ms vs 72.9+/-3.3 ms, p<0.01, respectively). Patients with AFL had higher LAAFV and longer LAAFT than those with chronic AF. The present data suggest that, in addition to LAAFV, LAAFT characterized LAA function and might serve as a predictor of thrombus formation in chronic AF. With respect to LAA function, patients with lone AF or AFL are at low risk for thrombus formation.
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Affiliation(s)
- Tatsuyoshi Narumiya
- Department of Cardiology, Nihon University Surugadai Hospital, Tokyo, Japan.
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Zhou X, Otsuji Y, Yoshifuku S, Yuasa T, Zhang H, Takasaki K, Matsukida K, Kisanuki A, Minagoe S, Tei C. Impact of atrial fibrillation on tricuspid and mitral annular dilatation and valvular regurgitation. Circ J 2002; 66:913-6. [PMID: 12381084 DOI: 10.1253/circj.66.913] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To investigate the effects of atrial fibrillation (AF) on the mitral and tricuspid valves, the corresponding annular dilatation and valvular regurgitation were compared with 2-dimensional and Doppler echocardiography in 31 consecutive patients with lone AF and 28 normal controls. Mid-systolic mitral and tricuspid annular areas were measured from 2 diameters in 2 orthogonal apical echocardiograms. Percent (%) mitral regurgitant (MR) or tricuspid regurgitant (TR) jet area to the left or right atrial area was evaluated and % MR or TR jet area >20% was considered moderate or significant. Both the mitral and tricuspid annular areas in patients with lone AF were significantly larger compared with the controls (mitral: 9.5 +/- 1.2 vs 6.6 +/- 0.9 cm2, lone AF vs control, p < 0.01) (tricuspid: 12.0 +/- 2.0 vs 7.5 +/- 0.9 cm2, p < 0.01). The % increase in the annular area relative to the mean normal value was significantly greater in the tricuspid valve (44 +/- 18 vs 60 +/- 28%, p < 0.01). Moderate or severe MR was not observed and the incidence of moderate or severe valve regurgitation (% jet area >20%) was significantly higher in the tricuspid valve (0/31 vs 11/31, MR vs TR, p < 0.01) in patients with lone AF. The % TR jet area showed significant correlation with tricuspid annular area (r2 = 0.65, p < 0.001). Lone AF is associated with annular dilatation of both mitral and tricuspid valves, but the annular dilatation and valvular regurgitation are significantly greater in the tricuspid valve.
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Affiliation(s)
- Xiaoyan Zhou
- First Department of Internal Medicine, Kagoshima University School of Medicine, Japan
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Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Yoshida K, Tokuda Y, Matsuo T. Anticoagulant therapy in Japanese patients with mechanical mitral valves. Circ J 2002; 66:668-70. [PMID: 12135136 DOI: 10.1253/circj.66.668] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
There are no guidelines for the optimal therapeutic range of anticoagulant therapy in Japanese patients with mechanical heart valves. A total of 214 patients were followed retrospectively after mitral mechanical valve replacement (mean duration of follow-up, 4.8 years; total duration of follow-up, 1,027 patient-years). The target range of the international normalized ratio (INR) for oral anticoagulation was between 1.5 and 2.5. For all patients 10,416 measurements of the INR were obtained during the follow-up period and approximately 76% of the intensity measurements were within the target range. Thromboembolism occurred in 8 patients (0.8 per 100 patient-years) and major bleeding in 5 patients (0.5 per 100 patient-years). There was no correlation between the distribution of the INR and the occurrence of thromboembolic or bleeding complications. In the univariate analysis of the various risk factors, patients who had a tilting valve or did not receive antiplatelet therapy had an increased risk of thromboembolism. However, there were no risk factors with respect to bleeding complications. A target range of 1.5 to 2.5 INR appears to be the optimal range and is safe for thromboembolism or bleeding complications. Thromboembolism may be reduced by additional antiplatelet therapy, and a tilting valve needs more intense anticoagulation.
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