Discontinuation of anticoagulation and its associated factors in atrial fibrillation

Abstract Background/Introduction Oral anticoagulation has been shown to reduce the incidence of embolic events associated with atrial fibrillation, however the discontinuation of these drugs observed in clinical trials may not be representative of the real-world setting due to the inclusion of selected populations. Purpose The objective of the study was to compare whether there is a difference in the incidence rate of discontinuation between vitamin K antagonists and direct anticoagulants and to evaluate the factors associated with non-adherence in patients newly diagnosed with atrial fibrillation. Methods This was a prospective cohort study. Adult patients (age >18 years) who had newly started anticoagulation therapy for atrial fibrillation or atrial flutter were enrolled. Patients with previous oral anticoagulation, mechanical prosthetic heart valves or creatinine clearance less than 30 mL/min were excluded. The follow-up period was 12 months. As the treatment allocation was not randomized, a propensity score weighting was performed considering baseline characteristics potentially associated with exposure and outcome. Factors associated with anticoagulant discontinuation were evaluated using a weighted Cox model. Results A total of 379 patients were included (mean age 78±9 years, 58% females). The median follow-up was 362 days (IQR 347–370). Loss to follow-up was 1%. The anticoagulation discontinuation rate was 24.6% in the direct anticoagulant group and 15.6% in the vitamin K antagonist group. A weighted model of time to discontinuation of anticoagulation treatment showed a crude HR of 1.40 (95% CI 0.79–2.48) for the direct anticoagulant therapy group compared to the vitamin K antagonist group, and a model adjusted for age, type of atrial fibrillation, radiofrequency ablation, bleeding, number of chronic drugs, and cardiology consultations during follow-up showed an adjusted HR of 1.26 (95% CI 0.75–2.12). The main reason for discontinuation of anticoagulation was high risk of bleeding in the vitamin K antagonist group and performance of a radiofrequency ablation procedure in the direct anticoagulant group. There was no statistically significant difference in the discontinuation rate between both groups when the baseline characteristics of the patients were considered. Conclusion(s) There was no statistically significant difference in the discontinuation rate between both groups when the baseline characteristics of the patients were considered. The study showed that the discontinuation of anticoagulants in atrial fibrillation in our setting was not associated with the type of drug used, the age of patients, or the type of arrhythmia. FUNDunding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim Figure 1

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Recommendations on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation (Based on 2018 European Heart Rhythm Association Practical Guide)

Kardiologiia ◽

10.18087/cardio.2019.5.2633 ◽

2019 ◽

Vol 59 (5) ◽

pp. 68-79

Author(s):

L. V. Popova ◽

T. B. Kondratieva ◽

M. B. Aksenova ◽

T. V. Khlevchuk ◽

M. Z. Kanevskaya

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Randomized Clinical Trials ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Heart Rhythm ◽

Vitamin K Antagonist ◽

Advanced Liver Disease ◽

Clinical Variants

Non-vitamin K antagonist oral anticoagulants (NOACs) – direct oral anticoagulants – are getting the ever-broadening use in clinical practice. However, many problems related to optimal use of NOACs in specific clinical situations remain unresolved. European Heart Rhythm Association in April 2018 issued the renovated recommendations on the use of NOACs in patients with atrial fibrillation. The authors of recommendations presented some specific clinical variants for which they formulated practical advices based on the evidence obtained in randomized clinical trials. They also outlined the indications for use of NOACs, formulated practical start-program and scheme of subsequent follow-up management of patients taking NOACs. Recommendations contain information on pharmacokinetics of NOACs and their interactions with other drugs, consideration of feasibility of NOACs use in patients with chronic renal insufficiency or advanced liver disease. Many other practical problems are covered as well.

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Radiofrequency Ablation versus Cryoablation in the Treatment of Paroxysmal Atrial Fibrillation: A Meta-Analysis

Cardiology Research and Practice ◽

10.1155/2018/6276241 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10 ◽

Cited By ~ 10

Author(s):

Ali H. Hachem ◽

Joseph E. Marine ◽

Housam A. Tahboub ◽

Sana Kamdar ◽

Shaffi Kanjwal ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Meta Analysis ◽

Fluoroscopy Time ◽

Radiofrequency Energy ◽

Cryoballoon Ablation ◽

Complication Rates ◽

Ablation Time ◽

Significant Difference

Background. Pulmonary vein isolation is commonly performed using radiofrequency energy with cryoablation gaining acceptance. We performed a meta-analysis of randomized controlled trials which compared radiofrequency versus cryoablation for patients with atrial fibrillation. Methods. A systematic search strategy identified both published and unpublished articles from inception to November 10, 2016, in multiple databases. The primary outcomes for this meta-analysis were long-term freedom from atrial fibrillation at 12-month follow-up and overall postoperative complication rates. For all included studies, the methodological quality was assessed through the Cochrane Collaboration’s tool for risk of bias. Results. A total of 247 articles were identified with eight being included in this review as they satisfied the prespecified inclusion criteria. Overall, there was no significant difference in freedom from atrial fibrillation at ≥12-month follow-up between those receiving cryoballoon and radiofrequency ablation, respectively (OR = 0.98, CI = 0.67–1.43, I2 = 56%, p=0.90). Additionally, the secondary outcomes of duration of ablation, fluoroscopy time, and ablation time failed to reach significance. Cryoballoon ablation had significantly greater odds of postoperative phrenic nerve injury at 12-month follow-up. Conclusions. Our meta-analysis suggests that cryoballoon ablation provides comparable benefits with regard to freedom from atrial fibrillation at medium-term follow-up, fluoroscopy time, ablation time, operative duration, and overall complication rate in comparison to radiofrequency ablation.

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Factors associated with silent cerebral events during catheter ablation for atrial fibrillation in the era of uninterrupted oral anticoagulation therapy

European Heart Journal ◽

10.1093/ehjci/ehaa946.0577 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Harada ◽

Y Nomura ◽

A Nishimura ◽

Y Motoike ◽

M Koshikawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Vitamin K ◽

Oral Anticoagulation ◽

Brain Mri ◽

Anticoagulation Therapy ◽

Surrogate Marker ◽

Brain Magnetic Resonance Imaging ◽

Vitamin K Antagonist ◽

Factors Associated

Abstract Background A silent cerebral event (SCE), detected by brain magnetic resonance imaging (MRI), is defined as an acute new brain lesion without clinically apparent neurological deficit, and is frequently observed after catheter ablation in atrial fibrillation (AF) patients. Although the small number of SCEs does not cause neurocognitive dysfunction, the greater volume and/or larger number of SCE lesions are reportedly related to neuropsychological decline; SCE incidence may be a surrogate marker for the potential thromboembolic risk. Thus, strategies to reduce SCEs would be beneficial. Uninterrupted oral anticoagulation strategy for peri-procedural period reportedly reduced the risk of SCEs, but the incidence hovers at 10% to 30%. We sought factors associated with SCEs during catheter ablation for AF in patients with peri-procedural uninterrupted oral anticoagulation (OAC) therapy. Methods AF patients undergoing catheter ablation were eligible (n=255). All patients took non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonist (VKA) for peri-procedural OAC (>4 weeks) without interruption during the procedure. Brain MRI was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure-related parameters were compared between patients with and without SCEs. Results SCEs were detected in 59 patients (23%, SCE[+]) but not in 196 patients (77%, SCE[-]). Average age was higher in SCE[+] than SCE[-] (66±10 years vs. 62±12 years, p<0.05). Persistent AF prevalence, CHADS2/CHA2DS2-VASc scores, and serum NT-ProBNP levels increased in SCE[+] vs. SCE[-]. In transthoracic/transesophageal echocardiography, left-atrial dimension (LAD) was larger and AF rhythm/spontaneous echo contrast were more frequently observed in SCE[+] than SCE[-]. SCE[+] had lower initial activated clotting time (ACT) before unfractionated heparin (UFH) injection and longer time to reach optimal ACT (>300 sec) before trans-septal puncture than SCE [-]. In multivariate analysis, LAD, initial ACT before UFH injection, and time to reach optimal ACT were predictors for SCEs. Conclusions LAD and intra-procedural ACT kinetics affect SCEs during the procedure in patients with uninterrupted OAC for AF ablation. Shortening time to achieve optimal ACT during the procedure may reduce the risk of SCEs. Funding Acknowledgement Type of funding source: None

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The preablation monocyte/ high density lipoprotein ratio predicts the late recurrence of paroxysmal atrial fibrillation after radiofrequency ablation

BMC Cardiovascular Disorders ◽

10.1186/s12872-020-01670-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

She-an Chen ◽

Man-man Zhang ◽

Meifang Zheng ◽

Fei Liu ◽

Lei Sun ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

High Density Lipoprotein ◽

Predictive Value ◽

Density Lipoprotein ◽

Late Recurrence ◽

High Density ◽

Significant Difference ◽

Af Recurrence

Abstract Background The monocyte/high-density lipoprotein ratio (MHR) has emerged as a promising alternative biomarker in the fields of cardiovascular disease and atrial fibrillation (AF). This retrospective study was aimed to explore the predictive value of the MHR for the late recurrence of AF after radiofrequency ablation. Methods From April 2015 to October 2018, patients with paroxysmal AF who had undergone radiofrequency catheter ablation at Subei People’s Hospital of Jiangsu Province were enrolled in our study. All the participants were observed until November 2019 after the procedure. During the postoperative follow up, the patients were categorized into the recurrence group and maintenance of sinus rhythm group based on who had experienced AF recurrence. Results One hundred twenty-five patients were diagnosed with paroxysmal AF, with an average age of 61.2 ± 9.3 years. Forty-seven patients had developed late recurrence during a mean follow up of 25.1 ± 12.0 months. The AF recurrence event rates were significantly increased in the highest MHR tertile compared with those in the lowest MHR tertile (22.0% vs. 57.1%; P < 0.05). On multivariate logistic regression analysis, the preablation MHR (OR = 1.34; 95% CI = 1.12 ~ 1.60; P = 0.001) and left atrial diameter (LAD) (OR = 1.21, 95% CI = 1.08 ~ 1.35; P = 0.001) were independent risk factors predicting the recurrence of AF after radiofrequency ablation. Furthermore, receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of the MHR was 0.712 (95% CI = 0.618 ~ 0.806; P = 0.000) and that of LAD was 0.739 (95% CI = 0.653 ~ 0.814; P = 0.000). Z-test found no significant difference between the MHR and LAD regarding the AUC (Z = 0.451; P = 0.652). Conclusion An elevated preablation MHR was associated with an increased risk of the postoperative recurrence of AF. Additionally, the MHR independently predicted the late recurrence of paroxysmal AF after radiofrequency ablation, with the same predictive value as LAD.

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64Risk of dementia in patients treated with non-vitamin k antagonist oral anticoagulant or warfarin for nonvalvular atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz747.0010 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D Kim ◽

P S Yang ◽

E Jang ◽

H T Yu ◽

T H Kim ◽

...

Keyword(s):

Atrial Fibrillation ◽

Confidence Interval ◽

Vascular Dementia ◽

Vitamin K ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Alzheimer Dementia ◽

Significant Difference ◽

Korean Ministry ◽

Prior Stroke

Abstract Background Evidence is accumulating that use of oral anticoagulants (OACs) decreases the risk of dementia in patients with atrial fibrillation (AF), but it is unclear if there is a difference between non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in protecting against dementia. Purpose To compare the risk of dementia between patients taking either NOAC or warfarin using a nationwide cohort data covering the entire Korean population. Methods Using the Korean national health insurance service database, 68,984 new OAC users with non-valvular AF aged ≥50 years and no prior diagnosis of dementia were identified during the period of 2013–2016 (39,687 NOAC users and 29,297 warfarin users). Starting from OAC initiation, participants were followed up until the date of dementia, death, or December 31, 2016. We compared the rates of dementia in 1:1 propensity score-matched cohorts of NOAC (n=18,925) and warfarin users (n=18,925). Results During the 52,259 person-years of follow-up, there were 2,750 dementia events. Use of NOAC was associated with significant lower risk of dementia [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.69–0.81], compared with warfarin. The risk reduction was prominent for vascular dementia (HR 0.60, 95% CI 0.52–0.71), whereas there was no significant difference in the risk of Alzheimer dementia (HR 0.92, 95% CI 0.83–1.02). Restricting the analyses to patients with no stroke diagnosis prior to OAC initiation (primary prevention) showed no significant difference between NOAC and warfarin in any types of dementia, but in the subgroup with prior stroke (secondary prevention), NOAC significantly reduced the risk of overall (HR 0.70, 95% CI 0.63–0.78) and vascular dementia (HR 0.59, 95% CI 0.49–0.69). Subgroup analysis according to stroke Hx Patient N Overall dementia Alzheimer dementia Vascular dementia HR (95% CI) P for interaction HR (95% CI) P for interaction HR (95% CI) P for interaction Total 37,850 0.75 (0.69–0.81) 0.92 (0.83–1.02) 0.60 (0.52–0.71) Without prior stroke 24,773 0.90 (0.78–1.05) 0.948 0.98 (0.83–1.15) 0.235 0.85 (0.56–1.28) 0.863 With prior stroke 13,077 0.70 (0.63–0.78) 0.90 (0.79–1.03) 0.59 (0.49–0.69) CI, confidence interval; HR, hazard ratio. KM curves of dementia incidence Conclusion In this propensity-weighted nationwide cohort of non-valvular AF patients, NOAC was associated with reduced risk of dementia, compared with warfarin. This association was the most pronounced for vascular dementia in patients with prior stroke. Acknowledgement/Funding The Korean Ministry of Education, Science and Technology (NRF-2017R1A2B3003303) and the Korean Ministry of Health & Welfare (HI16C0058, HI15C1200)

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Factors associated with non–vitamin K antagonist oral anticoagulants for stroke prevention in patients with new-onset atrial fibrillation: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II)

American Heart Journal ◽

10.1016/j.ahj.2017.03.024 ◽

2017 ◽

Vol 189 ◽

pp. 40-47 ◽

Cited By ~ 28

Author(s):

Benjamin A. Steinberg ◽

Peter Shrader ◽

Laine Thomas ◽

Jack Ansell ◽

Gregg C. Fonarow ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Prevention ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Factors Associated ◽

Informed Treatment ◽

Onset Atrial Fibrillation ◽

New Onset

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Time at home among nonvalvular atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants versus warfarin

European Heart Journal ◽

10.1093/eurheartj/ehab724.0573 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S Deitelzweig ◽

A Keshishian ◽

A Kang ◽

A Jenkins ◽

N Atreja ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Index Date ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Nursing Facility ◽

Home Setting ◽

The Impact ◽

At Home

Abstract Background Clinical trials and real-world database studies have shown the benefits of non-vitamin K antagonist oral anticoagulants (NOACs) compared to warfarin; however, measures of functional outcomes are critical in evaluating a patient's quality of life. Previous measures of time spent out of hospital in a home setting and time spent receiving disease-related care among non-valvular atrial fibrillation (NVAF) patients are lacking in the current literature. Purpose This analysis was based on the previously published ARISTOPHANES study, and used multiple data sources to evaluate the amount of time spent at a patient's home among NVAF patients who were prescribed NOACs versus warfarin. Methods This retrospective observational study used US data from CMS Medicare and four commercial databases to select adult NVAF patients who initiated apixaban, dabigatran, rivaroxaban, or warfarin (01JAN2013–30SEP2015). Time at home and time at home without external AF-related care were measured during the 180 days after the index date (OAC prescription). Time at home was defined as days from index date without any of the following: an inpatient, skilled nursing facility or nursing facility, hospice, or inpatient rehabilitation facility admission. Time at home and without external AF-related care was defined as days away from home and days with a claim for bleeding, stroke/systemic embolism, AF, or an INR test. Each day a claim was observed was counted as one day. In each database, three 1:1 NOAC-warfarin propensity-score-matched (PSM) cohorts were created before pooling the results. After PSM, a subgroup of patients who were alive and had ≥180 days of follow-up was created. Poisson regression was conducted in each NOAC-warfarin matched cohort to compare time at home and time at home without external AF-related care. Results After matching, a total of 100,977 apixaban-warfarin, 36,990 dabigatran-warfarin, and 125,068 rivaroxaban-warfarin patient pairs were selected. Of those patients, 38–46% had 180 days of follow-up available. Across treatment cohorts, approximately 75% of patients were at home for the 180-day follow-up. Apixaban, dabigatran, and rivaroxaban patients had 1.3, 0.9, and 0.8 more days at home, respectively, compared to warfarin patients. Patients treated with apixaban had 13.4 more days at home without AF-related care compared to warfarin, while dabigatran and rivaroxaban had 11.6 and 11.7 more days at home without AF-related care compared to warfarin. A greater proportion of warfarin patients than NOAC patients had an INR test (81–82% vs 14–21%), and days with INR testing were the main driver for external AF-related care for warfarin patients. Conclusion Among NVAF patients treated with OACs, NOACs were associated with a longer time at home and time at home without external AF-related care compared to warfarin. These results can help inform healthcare providers and patients regarding the impact of NOAC treatment in NVAF patients. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

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Patient-Reported Treatment Satisfaction with Dabigatran versus Warfarin in Patients with Non-Valvular Atrial Fibrillation in China

Thrombosis and Haemostasis ◽

10.1055/s-0038-1670661 ◽

2018 ◽

Vol 118 (10) ◽

pp. 1815-1822 ◽

Cited By ~ 7

Author(s):

Yan-Ping Geng ◽

Di-Hui Lan ◽

Nian Liu ◽

Xin Du ◽

Danni Zheng ◽

...

Keyword(s):

Atrial Fibrillation ◽

Treatment Satisfaction ◽

Insurance Coverage ◽

Critical Issue ◽

Discontinuation Rate ◽

Patient Reported ◽

Baseline Characteristics ◽

Adjusted Logistic Regression

Background Anti-coagulant therapy satisfaction for patients with atrial fibrillation is a critical issue, which impacts on their treatment adherence and clinical outcomes. The disadvantages of long-term warfarin treatment are well-described, and novel oral anti-coagulants have become an alternative option. Materials and Methods We compared patient-reported treatment satisfaction with dabigatran versus warfarin in non-valvular atrial fibrillation (NVAF) patients in China. Treatment satisfaction was assessed using the Anti-Clot Treatment Scale (ACTS) questionnaire, which included a 12-item ACTS Burdens scale and a 3-item ACTS Benefits scale. Results Among 834 patients, 246 patients (29.5%) were taking dabigatran and the others were on warfarin. Propensity score matching was employed to identify 182 patient pairs with balanced baseline characteristics. The global ACTS Burdens score and the global ACTS Benefits score were comparable between the dabigatran and warfarin groups (44.86 ± 3.95 vs. 44.28 ± 3.51, p = 0.423; 11.49 ± 2.92 vs. 11.42 ± 3.03, p = 0.194, respectively). The monthly cost of dabigatran was significantly higher compared with that of warfarin due to a lack of insurance coverage (USD 176.78 ± 9.15 vs. USD 2.49 ± 0.76, p = 0.000). The discontinuation rate of dabigatran was significantly higher than warfarin at the 6-month follow-up (33.5% vs. 19.2%, p = 0.003). Adjusted logistic regression showed that dabigatran was associated with a significant greater odds of non-persistence (odds ratio: 2.13, 95% confidence interval: 1.27–3.59, p = 0.004). Conclusion Dabigatran therapy in patients with NVAF in China associated with no improvement in satisfaction and a higher discontinuation rate compared with warfarin therapy largely due to increased economic burden.

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One-Year Course of Periprocedural Anticoagulation in Atrial Fibrillation Ablation: Results of a German Nationwide Survey

Cardiology ◽

10.1159/000509399 ◽

2020 ◽

Vol 145 (10) ◽

pp. 676-681

Author(s):

Alexandru Gabriel Bejinariu ◽

Hisaki Makimoto ◽

Reza Wakili ◽

Shibu Mathew ◽

Jedrzej Kosiuk ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Oral Anticoagulants ◽

Nationwide Survey ◽

Dual Therapy ◽

Vitamin K Antagonist ◽

Transseptal Puncture ◽

Af Ablation ◽

One Year

Introduction: Periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation procedures are changing rapidly. Objective: To assess the management and course of periprocedural OAC for AF ablation procedures in experienced electrophysiology (EP) centers in Germany over the last 12 months. Methods: The data are based on an electronic questionnaire, which was sent to 35 experienced EP centers in September 2018 and then exactly 1 year later. Participants provided information on their periprocedural OAC management, the handling with dual therapy (OAC plus single antiplatelet therapy), the availability of specific antidotes, the transseptal puncture approach, and noteworthy complications. Results: Responses were received from all 35 centers and represent 10,010 AF ablation procedures annually. In 2018, the administration of vitamin K antagonist (VKA) was continued throughout the procedure at all centers (100%). In contrast, the majority of centers used minimally interrupted periprocedural non-vitamin K antagonist oral anticoagulants (NOAC) (54.3%), 13 centers (37.2%) completely interrupted NOAC, and only 3 centers (8.5%) continued NOAC throughout the procedure. At the 1-year follow-up survey, 32 centers were found to have continued their previous strategy of periprocedural OAC and 3 changed from a minimally interrupted to a continued NOAC strategy. Of note, 30 centers (85.7%) performed transseptal puncture fluoroscopically without additional cardiac imaging. In the setting of uninterrupted periprocedural OAC management, no relevant complications were noted. Conclusion: Our survey shows marked heterogeneous periprocedural OAC management at experienced EP centers in Germany. Whereas continuation of VKA has already been integrated into clinical practice, the majority of centers still use a minimally interrupted NOAC strategy.

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