经导管主动脉瓣置换术后不同抗凝治疗的短期结局

目的比较经导管主动脉瓣置换术(TAVR)后合并抗凝指征的患者使用不同抗凝治疗的安全性及有效性。方法本研究为回顾性研究。选取2016年4月至2022年2月在广东省人民医院行TAVR治疗且存在抗凝指征的患者, 根据口服抗凝药的种类分为非维生素K拮抗剂口服抗凝药(NOAC)和华法林两组, 随访时间为30 d。终点事件包括主要终点及其组分。主要终点为死亡、卒中、心肌梗死、瓣膜血栓、心腔内血栓和大出血的复合终点。比较两组的终点事件发生情况, 并采用多因素logistic回归校正混杂因素的影响。结果共入选80例患者, 年龄(74.4±7.1)岁, 男性43例(53.8%)。其中, NOAC组49例(61.3%), 华法林组31例。抗凝指征为心房颤动的患者76例(95.0%)。NOAC组和华法林组相比, 校正后的主要终点发生风险(OR=0.23, 95%CI 0.06～0.94, P=0.040)更低, 主要归因于大出血的风险(OR=0.19, 95%CI 0.04～0.92, P=0.039)更低。结论 TAVR术后合并抗凝指征的患者使用NOAC的短期结局可能优于华法林, 但研究结论尚需大样本随机...     

冠心病药物支架术后合并非瓣膜性心房颤动的抗栓治疗

冠心病合并非瓣膜性心房颤动患者支架植入术后需要抗血小板及口服抗凝药物治疗。抗血小板及抗凝治疗在减少缺血事件的同时也增加了出血风险。抗血小板药物与传统口服抗凝药物维生素K拮抗剂或新型口服抗凝药物如何联合使用以最大程度减少支架内血栓、系统性栓塞等缺血事件,同时又不显著增加出血事件,有待更多研究。     

90岁及以上老年心房颤动患者口服抗凝药的安全性和有效性分析

目的评估90岁及以上老年心房颤动患者口服抗凝药的临床疗效和安全性。方法回顾性分析2014年1月至2017年12月于苏州大学附属第一医院心内科及神经内科病房或门诊记录的行抗凝治疗的125例90岁及以上非瓣膜性心房颤动患者,抗凝药物包含维生素K拮抗剂华法林、非维生素K拮抗剂口服抗凝药(NOAC)达比加群和利伐沙班。平均随访(14.0±5.2)个月,主要终点事件包括脑梗死、短暂性脑缺血发作(TIA)、系统性栓塞和大出血;次要终点事件包括全因死亡和停药。结果 125例患者中,华法林组54例,NOAC组71例,主要终点事件:缺血性事件7例,大出血事件14例;次要终点事件:停药36例,全因死亡19例。经R软件进行竞争风险生存分析显示,既往缺血性事件(脑卒中或TIA,SHR=3.47,95%CI:1.94～7.51,P=0.008)、血管性疾病(SHR=2.89,95%CI:1.27～6.60,P=0.012)、CHA_2DS_2-VASc≥2分(SHR=3.54,95%CI:0.46～7.60,P=0.048)是本研究中发生缺血性事件的独立预测因子,既往出血性事件(SHR=4.53,95%CI:1.37～4.64,P=0.002)、HAS-BLED≥3分(SHR=5.65,95%CI:0.76～6.71,P=0.005)是本研究中大出血的独立预测因子。结论 90岁及以上老年心房颤动患者行抗凝治疗是安全且有效的,既往发生过缺血性事件、有血管性疾病病史、CHA_2DS_2-VASc≥2分的患者更容易发生缺血性事件,有出血病史、HAS-BLED≥3分的患者更容易发生出血性事件。     

Meta分析:经导管主动脉瓣置入术后抗血小板治疗的有效性和安全性

目的系统评价经导管主动脉瓣置入术(transcatheter aortic valve implantation,TAVI)后抗血小板治疗的有效性和安全性。方法计算机检索Pub Med、EMbase、The Cochrane Library(2016年1期)、CBM、CNKI、万方数据库,收集TAVI术后单联抗血小板与双联抗血小板治疗的相关随机对照研究和队列研究。由2位研究者按照纳入与排除标准筛选文献,提取资料和评价质量后,采用Cochrane协作网提供的Rev Man 5.3统计软件进行Meta分析。结果共纳入4项研究,其中2项随机对照研究,2项队列研究。有效性结果分析显示:TAVI术后行单联抗血小板与双联抗血小板治疗随访1个月的脑卒中(OR 0.55,95%CI 0.22~1.35,P=0.19)、心肌梗死(OR 1.70,95%CI 0.25~11.65,P=0.59)以及全因死亡率(OR 0.77,95%CI 0.40~1.49,P=0.44)比较,差异均无统计学意义。安全性结果分析显示:TAVI术后行单联抗血小板较双联抗血小板治疗随访1个月出血事件发生率降低,差异有统计学意义(OR 0.37,95%CI 0.23~0.59,P0.0001)。结论单联抗血小板与双联抗血小板治疗在预防TAVI术后患者脑卒中、心肌梗死、全因死亡方面的疗效相当。单联抗血小板较双联抗血小板治疗的出血事件发生率降低。受纳入研究数量和质量的限制,上述结论尚需开展更多高质量随机对照试验予以验证。     

老年急性冠脉综合征患者应用替罗非班治疗出血危险因素分析

目的: 分析老年急性冠脉综合征(ACS)患者应用替罗非班抗血小板治疗出血的危险因素。方法: 67例年龄大于60岁的老年ACS患者接受替罗非班持续静脉滴注36～48 h,观察用药开始至停药3 d内患者出血情况,并对出血可疑危险因素进行单因素和多因素Logistic回归分析。结果: 发生出血6例（9%）,其中重度出血1例,轻度出血5例。多因素Logistic回归分析表明吸烟,OR=3.2, 95%CI 2.2-4.6;年龄每增加10岁,OR=1.4,95%CI 1.1-1.7;血小板聚集率每减少10%,OR=1.6,95%CI 1.2-1.9;肌酐清除率每减少10 ml/min,OR=1.2,95%CI 1.0-1.4;抗凝药及抗血小板药每增加一个,OR=4.2, 95%CI 2.0-5.2。结论: 抗血小板与抗凝药联合应用,吸烟、高龄、血小板聚集率降低、肌酐清除率降低为老年ACS患者应用替罗非班抗血小板治疗出血的主要危险因素。     

75岁以上钙化性主动脉瓣狭窄患者影响其预后的危险因素分析

目的:高龄(年龄≥75岁)钙化性主动脉瓣狭窄患者影响预后的危险因素分析,比较不同干预治疗方案的安全性。方法:回顾性分析2008-01-01至2015-01-01期间我院收治的所有年龄≥75岁且诊断为钙化性主动脉瓣狭窄的患者421例的临床资料,男性243例(57.7%),平均年龄为(79.1±3.5)岁。根据超声心动图检测的主动脉瓣口面积大小,将患者分为轻度狭窄组(n=112)、中度狭窄组(n=83)和重度狭窄组(n=226)。随访1年观察全因及心原性死亡终点。重度狭窄组患者比较不同治疗方案的死亡率的差异。采用Logistic回归分析与死亡相关的独立危险因素。结果:421例患者随访1年的全因及心原性死亡率分别为22.3%(94例)和19.7%(83例)。三组间1年全因死亡率及心原性死亡率比较差异均无统计学意义(P0.05)。多因素Logistic回归分析显示,外周血管病变[比值比(OR)=2.31,95%可信区间(CI):1.215~4.392]、左心室射血分数(LVEF,OR=0.966,95%CI:0.942~0.991)、不同氨基末端B型利钠肽原(NT-pro BNP)水平(OR=2.022,95%CI:1.140~3.586)是1年全因死亡的独立危险因素;糖尿病(OR=2.157,95%CI:1.213~3.836)、LVEF(OR=0.975,95%CI:0.950~1.000)、不同NT-proBNP水平(OR=2.786,95%CI:1.449~5.356)、血磷(OR=5.755,95%CI:1.462~22.657)是1年心原性死亡的独立危险因素。重度狭窄组的药物治疗、经皮球囊主动脉瓣成形术(PBAV)、经导管主动脉瓣置换术(TAVR)及外科主动脉瓣置换术(SAVR)的全因死亡率分别为43.6%、57.1%、7.3%、6.45%。TAVR、SAVR较药物治疗死亡率均明显降低(P0.0001),TAVR与SAVR死亡率比较差异无统计学意义(P0.05)。结论:高龄、不同程度的钙化性主动脉瓣狭窄患者的1年全因死亡及心原性死亡率随狭窄程度的加剧呈逐渐上升趋势,但死亡率与狭窄程度无关。外周血管病变和血磷是影响其预后的危险因素。重度狭窄患者行主动脉瓣膜置换术较药物治疗效果更佳,TAVR与SAVR疗效相当。     

75岁以上老年非瓣膜病性心房颤动患者抗凝治疗的临床分析

目的 了解老年非瓣膜病性心房颤动(房颤)患者的抗凝治疗现状及影响的因素。方法 纳入2020年1月至2021年9月于我院不同科室住院的75岁以上非瓣膜性房颤患者382例，其中心血管内科217例分布最多，根据出院时抗凝方案不同分为抗凝组260例及未抗凝组122例。对患者进行1年随访并记录出血、缺血性脑卒中及死亡事件的发生情况。分析影响老年房颤患者是否抗凝的相关因素。结果 抗凝组吸烟、饮酒、冠心病、出血史、肿瘤、抗血小板药物比例及HAS-BLED评分明显低于未抗凝组(P<0.05,P<0.01)。二元logistic回归分析显示，出血史(OR=0.320,95%CI:0.120～0.853,P=0.023)、肿瘤(OR=0.348,95%CI:0.139～0.869,P=0.024)、既往口服抗血小板药物(OR=0.095,95%CI:0.049～0.185,P=0.000)是影响老年房颤患者抗凝药物选择的相关因素。结论 出血史、肿瘤及既往口服抗血小板药物史可影响房颤患者出院时的选择。     

经皮冠状动脉介入术与冠状动脉旁路移植术治疗无保护左主干病变远期疗效的Meta分析

目的:比较经皮冠状动脉介入术(PCI)与冠状动脉旁路移植术(CABG)对无保护左主干病变(ULMCA)的远期疗效和安全性。方法:检索PubMed、EMBASE和Cochrane数据库,收集国内外公开发表的关于ULMCA行PCI与CABG术后长期随访的对比研究,研究的相关临床终点为全因死亡、心肌梗死、脑血管事件、靶血管血运重建。采用RevMan 5软件进行数据分析。结果:最终纳入文献8篇,共11 332例患者,3年以上随访结果显示,PCI组与CABG组全因死亡率(OR=1.02,95%CI:0.73~1.42,P=0.92)、脑血管事件发生率(OR=0.59,95%CI:0.33~1.07,P=0.08)差异无统计学意义,但PCI组心肌梗死率(OR=1.74,95%CI:1.43~2.11,P0.000 01)、靶血管血运重建发生率(OR=2.60,95%CI:1.81~3.72,P0.000 01)显著增高。亚组分析结果显示:5年随访,与CABG组相比,PCI组全因死亡率(OR=0.91,95%CI:0.64~1.28,P=0.59)轻微降低,脑血管事件发生率(OR=0.64,95%CI:0.28~1.48,P=0.29)无明显差异,但心肌梗死率(OR=2.08,95%CI:1.62~2.69,P0.000 01)、靶血管血运重建发生率(OR=2.70,95%CI:1.80~4.03,P0.000 01)仍显著增高。7年随访,与CABG组相比,PCI组全因死亡率(OR=0.61,95%CI:0.46~0.80,P=0.000 4)、脑血管事件发生率(OR=0.23,95%CI:0.16~0.32,P0.000 01)均显著降低,心肌梗死率(OR=2.00,95%CI:1.39~2.86,P=0.000 2)、靶血管血运重建发生率(OR=2.37,95%CI:1.65~3.41,P0.000 01)仍显著增高。结论:PCI与CABG治疗ULMCA患者3年随访全因死亡率、脑血管事件发生率相当,但PCI心肌梗死率与靶血管血运重建发生率较高。分层分析后7年随访,与CABG相比,PCI全因死亡率、脑血管事件发生率均显著降低,心肌梗死率、靶血管血运重建发生率仍显著增高。     

经导管主动脉瓣置换术后新发心房颤动的系统评价

目的:系统评价经导管主动脉瓣置换术后新发心房颤动(房颤)的发生率及预测因子。方法:全面检索Pub Med、Springer、Elsevier-SDOL、EMbase、SSCI、CNKI、VIP、中国生物医学文献数据库、万方数据资源系统在2009-01至2016-01期间发表的主动脉瓣置换术后新发房颤的研究文献。利用疾病患病率或发病率质量准则评价文献质量,运用Comprehensive Meta Analysis软件版本2.0进行Meta分析。结果:最终纳入14个研究,其中4个为多中心随机对照研究,共包含6 626例接受经导管主动脉瓣膜置换术的严重主动脉瓣狭窄患者。术后新发房颤的发生率为11.1%[95%可信区间(CI):10.3~11.9]。经导管主动脉瓣膜置换术后发生新发房颤的独立预测因子包括:经心尖途径[比值比(OR)=2.16,95%CI:1.58~2.94,P0.001]、手术相关心脏事件(OR=1.59,95%CI:1.08~2.36,P=0.01)、手术相关出血事件(OR=1.56,95%CI:1.00~2.45,P=0.04)、心房过大(每增加1mm/m~2,OR=1.21,95%CI:1.09~1.34,P0.001)。结论:经导管主动脉瓣置换术后新发房颤的发生率较高,且可能导致严重的临床不良事件。深入研究其预测因子有利于提高主动脉瓣置换术后的安全性。     

心脏机械瓣膜置换术后妊娠早期两种抗凝方案疗效Meta分析

目的:评价妊娠全程使用低剂量维生素K拮抗剂(VKA)的抗凝方案与妊娠早期短程使用低分子肝素/肝素的方案应用于心脏机械瓣膜置换术患者妊娠期的安全性与有效性。方法:计算机检索The Cochrane Library(2016年第2期)、Pub Med、EMbase、CBM、清华同方(CNKI)、万方数据库和维普(VIP)数据库,搜集妊娠全程使用低剂量维生素K拮抗剂的方案与妊娠早期短程使用低分子肝素/肝素的抗凝方案的相关文献,检索时限均为从建库至2016-06。由2位评价者独立筛选文献、提取资料和评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析。结果:最终纳入了12项队列研究。Meta分析结果显示:与妊娠早期短程使用低分子肝素/肝素的抗凝方案组相比,妊娠全程使用低剂量维生素K拮抗剂的抗凝方案组降低了瓣膜血栓发生率(OR=0.26,95%CI:0.13~0.54,P0.001)及自然流产率(OR=1.99,95%CI:1.21~3.26,P=0.006),增加了胎儿畸形发生率(OR=3.39,95%CI:1.11~10.37,P=0.03),两组差异有统计学意义;但是,在产妇死亡率(OR=0.79,95%CI:0.24~2.58,P=0.70)、围产期出血发生率(OR=0.56,95%CI:0.27~1.18,P=0.13)及死胎发生率(OR=1.80,95%CI:0.94~3.44,P=0.07)方面,两组差异无统计学意义。结论:当前证据显示,对于心脏机械瓣膜置换术后孕妇的抗凝治疗,与妊娠早期短程使用低分子肝素/肝素的抗凝方案组相比,妊娠全程使用低剂量维生素K拮抗剂抗凝方案组明显降低了瓣膜血栓发生率和自然流产率,但是增加了胎儿畸形发生率,受纳入研究治疗的限制,上述结论尚需开展更多高质量的研究予以验证。     

Oral Anticoagulant Type and Outcomes After Transcatheter Aortic Valve Replacement

ObjectivesThe purpose of the study was to investigate the impact of oral anticoagulation (OAC) type on clinical outcomes 1 year after transcatheter aortic valve replacement (TAVR).BackgroundNon–vitamin K oral anticoagulants (NOACs) are superior to vitamin K antagonists (VKAs) in nonvalvular atrial fibrillation (AF), while their comparative performance among patients in need of OAC undergoing TAVR is underinvestigated.MethodsThe study enrolled 962 consecutive patients who underwent TAVR in 4 tertiary European centers and were discharged on either NOACs (n = 326) or VKAs (n = 636). By using propensity scores for inverse probability of treatment weighting (IPTW), the comparison of treatment groups was adjusted to correct for potential confounding.ResultsMean age and Society of Thoracic Surgeons score of the population were 81.3 ± 6.3 years and 4.5% (interquartile range: 3.0% to 7.3%); 52.5% were women and a balloon-expandable valve was used in 62.7% of cases. The primary outcome of interest, combined incidence of all-cause mortality, myocardial infarction, and any cerebrovascular event at 1-year after TAVR, was 21.2% with NOACs versus 15.0% with VKAs (hazard ratio [HR]: 1.44; 95% confidence interval [CI]: 1.00 to 2.07; p = 0.050, IPTW-adjusted). The 1-year incidence of any Bleeding Academic Research Consortium bleeds and all-cause mortality were comparable between the NOAC and VKA groups, 33.9% versus 34.1% (HR: 0.97; 95% CI: 0.74 to 1.26; p = 0.838, IPTW-adjusted) and 16.5% versus 12.2% (HR: 1.36; 95% CI: 0.90 to 2.06; p = 0.136, IPTW-adjusted), respectively.ConclusionsChronic use of both NOACs and VKAs among patients in need of OAC after TAVR are comparable regarding 1-year bleeding risk. The higher ischemic event rate observed with NOACs needs to be evaluated in large randomized trials.     

Non‐vitamin K oral anticoagulants versus vitamin K antagonists in post transcatheter aortic valve replacement patients with clinical indication for oral anticoagulation: A meta‐analysis

BackgroundCurrent guidelines recommend oral anticoagulation (OAC) following transcatheter aortic valve replacement (TAVR) in patients with clinical indication, but the optimal antithrombotic regimen remains uncertain. We aimed to compare the efficacy and safety of non‐vitamin K oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in patients undergoing TAVR with concomitant indication of OAC.HypothesisComparing with VKAs therapy, NOACs are similar in reducing the all‐cause mortality and major bleeding in post‐TAVR patients requiring OAC medication.MethodsWe searched the databases of PubMed, Embase, and Cochrane library databases to identify studies that investigated NOACs versus VKAs after TAVR in patients with another indication of OAC, which were published before 28th September 28, 2021. The effectiveness of outcomes was all‐cause mortality and stroke or systemic embolism, while the main safety outcome was major and/or life‐threatening bleeding. The hazard ratio (HR) with 95% confidence interval (CI) was used as a measure of treatment effect.ResultsOur search identified eight studies. We included 4947 post‐TAVR patients with another indication of OAC allocated to the NOAC (n = 2146) or VKA groups (n = 2801). There were no significant differences in the all‐cause mortality (HR: 0.91, 95% CI: 0.77–1.08, p = .29, I ² = 47%), stroke or systemic embolism (HR: 0.96, 95% CI: 0.68–1.37, p = .84, I ² = 0%), and major and/or life‐threatening bleeding (HR: 1.09, 95% CI: 0.89–1.32, p = .40, I ² = 30%) in both groups.ConclusionAmong post‐TAVR patients who required OAC therapy, NOACs therapy compared to VKAs is similar in reducing the all‐cause mortality, stroke or systemic embolism, and major and/or life‐threatening bleeding events.     

Anticoagulation With or Without Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement for Patients With Atrial Fibrillation: A Meta-Analysis

BackgroundAlthough current guidelines recommend oral anticoagulants (OAC) with or without antiplatelet therapy (APT) following transcatheter aortic valve replacement (TVAR) in patients with an indication for long-term anticoagulation therapy, the optimal antithrombotic strategy remains unknown in these population. Herein, we conducted a meta-analysis comparing the outcome of OAC alone versus OAC with APT following TAVR in patients with atrial fibrillation (AF).MethodsMEDLINE and EMBASE were searched through May 2020 to identify clinical trials that investigated OAC alone versus OAC with APT following TAVR in patients with AF. From each study, we extracted the hazard ratios (HRs) or risk ratios of major or life threatening bleeding, stroke, all-cause mortality and cardiovascular mortality.Results1 randomized controlled trial and 3 observational studies were identified, which enrolled a total of 2032 patients with AF who underwent TAVR assigned to the OAC group (n = 722) or OAC with APT group (n = 1310). Pooled analyses demonstrated the rate of major or life threatening bleeding was significantly lower in the OAC group compared to the OAC with APT group (HR [95% Confidence Interval [CI] = 0.54 [0.38–0.77], P = .0006]). However, the rate of stroke was similar in both groups (HR [95% CI] = 1.22 [0.80–1.87], P = .36). All-cause and cardiovascular mortalities were also similar in both groups.ConclusionsWe observed that OAC with APT following TAVR in patients with AF increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke.     

Net Clinical Benefit of Non-Vitamin K Antagonist vs Vitamin K Antagonist Anticoagulants in Elderly Patients with Atrial Fibrillation

BackgroundThe risks of thromboembolic and hemorrhagic events in patients with atrial fibrillation both increase with age; therefore, net clinical benefit analyses of anticoagulant treatments in the elderly population are crucial to guide treatment. We evaluated the 1-year clinical outcomes with non-vitamin-K antagonist and vitamin K antagonist oral anticoagulants (NOACs vs VKAs) in elderly (≥75 years) patients with atrial fibrillation in a prospective registry setting.MethodsData on 3825 elderly patients were pooled from the PREFER in AF and PREFER in AF PROLONGATION registries. The primary outcome was the incidence of the net composite endpoint, including major bleeding and ischemic cardiovascular events on NOACs (n = 1556) compared with VKAs (n = 2269).ResultsThe rates of the net composite endpoint were 6.6%/year with NOACs vs 9.1%/year with VKAs (odds ratio [OR] 0.71; 95% confidence interval [CI], 0.51-0.99; P = .042). NOAC therapy was associated with a lower rate of major bleeding compared with VKA use (OR 0.58; 95% CI, 0.38-0.90; P = .013). Ischemic events were nominally reduced too (OR 0.71; 95% CI, 0.51-1.00; P = .050). Major bleeding with NOACs was numerically lower in higher-risk patients with low body mass index (BMI; OR 0.50; 95% CI, 0.22-1.12; P = .07) or with age ≥85 years (OR 0.44; 95% CI, 0.13-1.49; P = .17).ConclusionsOur real-world data indicate that, compared with VKAs, NOAC use is associated with a better net clinical benefit in elderly patients with atrial fibrillation, primarily due to lower rates of major bleeding. Major bleeding with NOACs was numerically lower also in higher-risk patients with low BMI or age ≥85 years.     

New Oral Anticoagulants in Nonvalvular Atrial Fibrillation

The choice of an oral anticoagulant (OAC) for patients with nonvalvular atrial fibrillation (NVAF) is a major and complex clinical decision taking into account the individual risk‐benefit ratio and bearing in mind the chronicity of therapy. This review focuses on the safety and efficacy of new oral anticoagulants (NOACs) compared with conventional vitamin K antagonists (VKA) in patients with NVAF. Current data suggest that NOACs are at least as effective and safe as VKAs for most NVAF subjects. The NOACs do not mandate dietary restrictions and regular pharmacodynamic monitoring, and they seem to have lesser incidence of intracranial or fatal bleeding when compared with VKAs. However, both dabigatran 150 twice daily and rivaroxaban have a slightly higher incidence of gastrointestinal bleeding when compared with VKAs. The article will delineate the current knowledge as well as scientific gaps related to the choice and dosage of anticoagulation regimens for various NVAF subsets and will address certain common clinical scenarios requiring special considerations. The article also addresses the shortcomings of NOACs: lack of therapeutic pharmacokinetic and pharmacodynamic targets, absence of tools to assess compliance and efficacy, rigid and limited dosage options, and absence of effective and inexpensive reversal agents.     

Efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients (≥80 years of age) with atrial fibrillation: systematic review and meta-analysis

Findings of prior studies about the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in patients (≥80 years of age) with atrial fibrillation (AF) are controversial. So we performed a meta-analysis to evaluate the efficacy and safety of NOACs versus vitamin K antagonists (VKAs) in patients (≥80 years of age) with AF. A systematic review of PubMed, Cochrane, Embase, Web of Science and Chinese BioMedical databases was conducted until 1 October 2022. Studies reporting the effects and safety of NOACs versus warfarin in patients (≥80 years of age) with AF were included. Two authors independently performed study selection and data extraction. Discrepancies were resolved by consensus or through an independent third reviewer. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews guidelines. We identified 15 studies providing data of 70 446 participants (≥80 years of age) suffering from AF. According to the meta-analysis (odds ratio (OR) (95% confidence interval, CI)), NOACs conferred better efficacy profile than VKAs in stroke and systemic embolism (0.8 (0.73–0.88)) and all-cause mortality (0.61 (0.57–0.65)). Otherwise, NOACs conferred a better safety profile than VKAs in major bleeding (0.76 (0.70–0.83)) and intracranial haemorrhage (ICH; 0.57 (0.47–0.68)). In conclusion, for patients (≥80 years of age) with AF, the risks of stroke and systemic embolism, all-cause mortality, were lower in NOACs compared to warfarin. The risks of major bleeding and ICH were also lower in NOACs compared to warfarin. NOACs showed better efficacy and safety than warfarin.     

Uninterrupted anticoagulation with non‐vitamin K antagonist oral anticoagulants in atrial fibrillation catheter ablation: Lessons learned from randomized trials

Catheter ablation has been established as a rhythm control strategy in selected patients with atrial fibrillation (AF) who have failed or wish to avoid anti‐arrhythmic drugs. Uninterrupted oral anticoagulation with vitamin K antagonists (VKAs) peri‐ablation is associated with a lower risk of thromboembolic and bleeding complications as compared to interrupted oral anticoagulation and bridging heparin. However, a substantial portion of patients with AF are treated with non‐vitamin K antagonist oral anticoagulants (NOACs). Herein, we perform an in‐depth review and comparison of three recent randomized trials of uninterrupted oral anticoagulation with NOACs vs VKAs in patients undergoing AF catheter ablation. Furthermore, we report pooled results of these randomized trials. The pooled incidence of major bleeding was significantly lower with NOACs as compared to VKAs (2% vs 4.9%, respectively; odds ratio [OR] 0.40; 95% confidence intervals [CI] 0.16‐0.99). Similarly, cardiac tamponade was also reduced in the NOAC group (0.4% vs 1.5%; OR 0.27; 95% CI 0.07‐0.97). Thromboembolic complications were not significantly different between groups. Overall, these findings support the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement's class I recommendation for uninterrupted NOAC use in patients undergoing AF catheter ablation.     

Safety and efficacy of anticoagulant monotherapy in atrial fibrillation and stable coronary artery disease: A systematic review and meta-analysis

BackgroundAdjunctive use of oral anticoagulant (OAC) and antiplatelet therapy (APT) in patients with stable coronary artery disease (CAD) and nonvalvular atrial fibrillation (AF) is a challenge of daily practice.MethodsA comprehensive literature search of databases was performed to identify studies comparing the safety and efficacy of OAC monotherapy and combined therapy (OAC plus single (S) APT). Events including major adverse cardiovascular events (MACE), all-cause mortality, stroke and major bleeding were analyzed.ResultsSeven articles comprising 11,070 subjects were identified. Combined therapy was associated with a significantly higher risk of major bleeding (pooled hazard ratio (HR) of 1.62, 95% CI 1.40–1.86, p=<0.0001) compared to the OAC monotherapy. There was no significant difference between the two comparison arms in terms of MACE (HR 1.14; 95% CI 0.97–1.34, p = 0.11), stroke (HR 1.05; 95% CI 0.77–1.43, p = 0.78) and all-cause mortality (HR 1.15; 95% CI 0.94–1.40, p = 0.16). Stratified analysis by inclusion of only patients with coronary stents attenuated the safety effect of monotherapy. Subgroup analysis based on the study design, type of OAC, major bleeding criteria and APT revealed findings consistent with the pooled HR. The combined therapy group had a 19% and 38% higher risk of MACE in studies with a history of MI (p = 0.03) and with the use of rivaroxaban (p = 0.02), respectively.ConclusionOAC monotherapy might have a lower incidence of major bleeding events with no higher overall risk of MACE, ischemic stroke and all-cause mortality compared to the combined therapy group.     

Antithrombotic Therapy and Cardiovascular Outcomes After Transcatheter Aortic Valve Replacement in Patients With Atrial Fibrillation

ObjectivesThe study sought to determine the patterns of antithrombotic therapy and association with clinical outcomes in patients with atrial fibrillation (AF) and CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65–74 years, sex category) score ≥2 following transcatheter aortic valve replacement (TAVR).BackgroundThe impact of antithrombotic regimens on clinical outcomes in patients with AF and severe aortic stenosis treated with TAVR is unknown.MethodsIn the randomized PARTNER II (Placement of Aortic Transcatheter Valve II) trial and associated registries, 1,621 patients with prior AF and CHA₂DS₂-VASc score ≥2 comprised the study cohort. Outcomes were analyzed according to antithrombotic therapy.ResultsDuring the 5-year enrollment period, 933 (57.6%) patients were discharged on oral anticoagulant therapy (OAC). Uninterrupted antiplatelet therapy (APT) for at least 6 months or until an endpoint event was used in 544 of 933 (58.3%) of patients on OAC and 77.5% of patients not on OAC. At 2 years, patients on OAC had a similar rate of stroke (6.6% vs. 5.6%; p = 0.53) and the composite outcome of death or stroke (29.7% vs. 31.8%; p = 0.33), compared with no OAC. OAC with APT was associated with a reduced rate of stroke (5.4% vs. 11.1%; p = 0.03) and death or stroke (29.7% vs. 40.1%; p = 0.01), compared with no OAC or APT. Following adjustment, OAC with APT and APT alone were both associated with reduced rates of stroke compared with no OAC or APT (hazard ratio for OAC+APT: 0.43, 95% confidence interval: 0.22 to 0.85; p = 0.015; hazard ratio for APT alone: 0.32, 95% confidence interval: 0.16 to 0.65; p = 0.002), while OAC alone was not.ConclusionsAmong patients with prior AF undergoing TAVR, antiplatelet with or without anticoagulant therapy was associated with a reduced risk of stroke at 2 years, implicating multifactorial stroke mechanisms in this population.     

TAVR Patients Requiring Anticoagulation: Direct Oral Anticoagulant or Vitamin K Antagonist?

ObjectivesUsing French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs).BackgroundThe choice of optimal drug for anticoagulation after TAVR remains debated.MethodsData from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety).ResultsA total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.12-1.67; P < 0.005) and major bleeding including hemorrhagic stroke (HR: 1.64; 95% CI: 1.17-2.29; P < 0.005) were lower in patients on DOACs compared with those on VKAs. The rates of ischemic stroke (HR: 1.32; 95% CI: 0.81-2.15; P = 0.27) and acute coronary syndrome (HR: 1.17; 95% CI: 0.68-1.99; P = 0.57) did not differ among groups.ConclusionsIn these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.