Characteristics of patients with atrial fibrillation prescribed edoxaban in Belgium and the Netherlands: insights from the ETNA-AF-Europe study

Background

Studies on the use of non-vitamin K antagonist oral anticoagulants in unselected patients with atrial fibrillation (AF) show that clinical characteristics and dosing practices differ per region, but lack data on edoxaban.

Methods

With data from Edoxaban Treatment in routiNe clinical prActice for patients with AF in Europe (ETNA-AF-Europe), a large prospective observational study, we compared clinical characteristics (including the dose reduction criteria for edoxaban: creatinine clearance 15–50 ml/min, weight ≤60 kg, and/or use of strong p‑glycoprotein inhibitors) of patients from Belgium and the Netherlands (BeNe) with those from other European countries (OEC).

Results

Of all 13,639 patients in ETNA-AF-Europe, 2579 were from BeNe. BeNe patients were younger than OEC patients (mean age: 72.3 vs 73.9 years), and had lower CHA₂DS₂-VASc (mean: 2.8 vs 3.2) and HAS-BLED scores (mean: 2.4 vs 2.6). Patients from BeNe less often had hypertension (61.6% vs 80.4%), and/or diabetes mellitus (17.3% vs 23.1%) than patients from OEC. Moreover, relatively fewer patients in BeNe were prescribed the reduced dose of 30 mg edoxaban (14.8%) than in OEC (25.4%). Overall, edoxaban was dosed according to label in 83.1% of patients. Yet, 30 mg edoxaban was prescribed in the absence of any dose reduction criteria in 36.9% of 30 mg users (5.5% of all patients) in BeNe compared with 35.5% (9.0% of all patients) in OEC.

Conclusion

There were several notable differences between BeNe and OEC regarding clinical characteristics and dosing practices in patients prescribed edoxaban, which are relevant for the local implementation of dose evaluation and optimisation.

Trial registration

NCT02944019; Date of registration 24 October 2016

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01518-7) contains supplementary material, which is available to authorized users.

Prevalence and prognostic value of left ventricular late gadolinium enhancement in patients with idiopathic outflow tract ventricular arrhythmias

Background

Patients with idiopathic outflow tract ventricular arrhythmias (OTVAs) and structurally normal heart by ECG and echocardiogram often undergo cardiac magnetic resonance (CMR) study to evaluate for presence of concealed myocardial abnormalities with late gadolinium enhancement (LGE). However, the clinical impact of incidental LGE finding in the left ventricle (LV) in patients with idiopathic OT-VAs is unclear. Accordingly, the aim of the present study was to investigate the prevalence, characteristics and prognostic significance of isolated LV LGE in a large population of patients with OTVA undergoing CMR.

Methods

A total of 364 consecutive patients (43±16 years, 53% male) with OTVA and negative routine diagnostic work-up were included. All patients underwent a CMR study with LGE imaging for detection of scar/replacement fibrosis. Presence of LGE was correlated with long term major adverse cardiovascular events including sudden cardiac death (SCD), resuscitated cardiac arrest and nonfatal documented sustained ventricular tachycardia.

Results

Isolated LGE in the LV was identified in 15 patients (4%), typically involving the inferolateral wall (11 cases, 73%) and having a median extension of 3 (2–5)% of the LV mass. All cases showed a midmyocardial/subepicardial distribution consistent with a possible prior myocarditis. Patients with incidental finding of LV-LGE were older (55±13 years vs. 42±16 years; p<0.01) and were more frequently males (80% vs. 51%; p=0.03). After a median follow-up of 69 (47–98) months, none of the patients in the LV-LGE group and 1 patient (0.3%) in the non-LGE group (p=1.0) experienced the composite end-point which consisted in an episode of sustained VT with hypotension and dizziness. The patient subsequently underwent effective radiofrequency ablation of the VT from the right ventricular outflow tract.

Conclusion

In this large CMR study, isolated LV scar was found in 4% of patients with idiopathic OT-VAs, was small in size with distribution consistent with prior myocarditis. The LGE abnormality did not portend a negative prognosis.

Funding Acknowledgement

Type of funding source: None

Prognostic value of non-ischemic ring-like left ventricular scar pattern in patients with apparently idiopathic ventricular arrhythmias: a CMR imaging study

Background

The presence of left ventricular (LV) late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) has been correlated to life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). Aim of the present study was to investigate the prognostic significance of a specific LV-LGE phenotype characterized by a subepicardial/midmyocardial “ring-like” pattern of fibrosis.

Methods

Out of a total of 518 consecutive patients with apparently idiopathic VAs who underwent CMR study, 79 (15%) had evidence of LV-LGE. Of these, 23 (4%) patients had LV LGE with ring-like pattern, defined as subepicardial or midmyocardial LGE involving at least 3 contiguous segments in the same slice (group A), while 56 (11%) patients had LV LGE with no ring-like pattern (group B). The remaining 439 patients had no LGE (group C). The end-point of the study was a composite SCD, resuscitated cardiac arrest and nonfatal episodes of ventricular fibrillation or documented sustained ventricular tachycardia.

Results

Group A patients were more frequently males compared to groups B and C (96% vs. 79% vs. 52%; p<0.01) and had more frequently a family history of SCD and/or cardiomyopathy (30% vs. 11% vs. 5%; p<0.01). All patients in Group A showed VAs with a predominant RBBB morphology vs. 38 (68%) patients in Group B and 65 (15%) in Group C (p<0.01). During a follow-up of 63±39 months, the composite outcome occurred in 13 patients (57%) in Group A vs. 11 (20%) in Group B and 2 (1%) in Group C (p<0.01).

Conclusion

In patients with apparently idiopathic VAs, a nonischemic LV-LGE with a ring-like pattern at CMR is associated with a high rate of malignant arrhythmic events during follow-up.

Funding Acknowledgement

Type of funding source: None

A cytologic diagnosis of BRAFV600E Erdheim-Chester disease on pericardial fluid

We report the case of a 74-year-old woman admitted to the emergency unit for resting dyspnea. Clinical presentation, cardiac MRI and echocardiography were consistent with cardiac tamponade requiring emergency pericardiocentesis. Cytologic examination of the pericardial fluid revealed the presence of CD68^pos CD1a^neg S100^neg foamy histiocytes (Fig. 1). Additional investigations complied with the diagnosis of Erdheim-Chester histiocytosis. Treatment with αIFN was initiated but the patient developed severe neutropenia that contraindicated further administration. The detection of BRAF^V600E mutation on histiocytes isolated from the pericardial liquid and CNS involvement (cerebral masses) prompted the administration of vemurafenib, a selective BRAF^V600E kinase inhibitor. Four months after the initiation of low-dose vemurafenib, pericarditis almost resolved and cerebral masses decreased by 50% (Fig. 2). To our knowledge, analysis of pericardial fluid allowing the diagnosis of Erdheim-Chester disease and the detection of the BRAF^V600E mutation has in fact been rarely described in the literature. This case report and the successful evolution under vemurafenib also support the use of BRAF^V600E inhibitors in αIFN-intolerant patients with BRAF^V600E mutation, particularly in case of heart and central nervous system involvement.

[Atrial fibrillation: recent progress]

Atrial fibrillation is the most common cardiac arrhythmia. Pharmacological treatment plays still an important role in the management of this disease. However, pulmonary vein isolation techniques are more and more important due to the high rate of recurrences and many side effects associated with antiarrhythmic drugs. This article is focused on the main changes that are important for the general practitioner in his daily clinical practice.