Long-Term Clinical Outcomes of Underdosed Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Atrial Flutter

BackgroundAlthough direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF.MethodsWe conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHA₂DS₂-VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed.ResultsA total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis.ConclusionUnderdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality.     

Comparing outcomes after transcatheter aortic valve replacement in patients with stenotic bicuspid and tricuspid aortic valve: A systematic review and meta‐analysis

Background

Transcatheter aortic valve replacement (TAVR) has become an alternative treatment to surgery in patients with severe aortic stenosis. However, patients with bicuspid aortic stenosis (BAV) are usually excluded from major TAVR studies. The aim of this study is to reexamine current evidence of TAVR in patients with severe aortic stenosis and BAV compared with tricuspid aortic valve (TAV).

Hypothesis

There might be differences in outcomes post TAVR between patients with BAV comparing to TAV.

Method

Databases were systematically searched for relevant articles featuring cohort studies that included patients with BAV and TAV who underwent TAVR studies, of which reported outcomes of interest included mortality and complications in both groups. Pooled effect size was calculated with a random‐effect model and weighted for the inverse of variance, to compare outcomes post‐TAVR between BAV and TAV.

Results

Nine studies were included in the meta‐analysis. There was no difference in 30‐day mortality rate in patients with BAV compared with TAV (OR: 1.27, 95% CI: 0.84–1.93, I² = 0). Patients with BAV were more likely to have a moderate to severe paravalvular leak (9 studies; OR: 1.42, 95% CI: 1.08–1.87, I² = 0) and conversion to surgery (5 studies; OR: 5.48, 95% CI: 1.74–17.27, I² = 0), and less likely to have device success compared with patients with TAV (5 studies; OR: 0.57, 95% CI: 0.40–0.81, I² = 0%).

Conclusions

There was no difference in mortality post‐TAVR in patients with BAV compared with TAV. Further randomized studies should be done in newer‐generation prostheses to assess this association.     

Prolonged migraine aura resembling ischemic stroke following CoronaVac vaccination: an extended case series

BackgroundAfter the initiation of the COVID-19 vaccination program in Thailand, thousands of patients have experienced unusual focal neurological symptoms. We report 8 patients with focal neurological symptoms after receiving inactivated virus vaccine, CoronaVac.Case seriesPatients were aged 24–48 years and 75% were female. Acute onset of focal neurological symptoms occurred within the first 24 h after vaccination in 75% and between 1-7d in 25%. All presented with lateralized sensory deficits, motor deficits, or both, of 2–14 day duration. Migraine headache occurred in half of the patients. Magnetic resonance imaging of the brain during and after the attacks did not demonstrate any abnormalities suggesting ischemic stroke. All patients showed moderately large regions of hypoperfusion and concurrent smaller regions of hyperperfusion on SPECT imaging while symptomatic. None developed permanent deficits or structural brain injury.DiscussionsHere, we present a case series of transient focal neurological syndrome following Coronavac vaccination. The characteristic sensory symptoms, history of migraine, female predominant, and abnormal functional brain imaging without structural changes suggest migraine aura as pathophysiology. We propose that pain related to vaccine injection, component of vaccine, such as aluminum, or inflammation related to vaccination might trigger migraine aura in susceptible patients.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-022-01385-0.     

Blood stream infection is associated with cerebrovascular accident in patients with left ventricular assist device: a systematic review and meta-analysis

Cerebrovascular accident (CVA) is one of the major complications and a leading cause of death in patients with a left ventricular assist device (LVAD). Multiple studies of have shown that patients with blood stream infection (BSI) are more likely to develop CVA compared to patients without BSI. However, there is no meta-analysis to confirm this association. Studies were systematically acquired from MEDLINE and EMBASE electronic databases. Included studies assessed patients with heart failure requiring LVAD and reported the number of patients who had BSI post LVAD, incidence of ischemic CVA, hemorrhagic CVA, or any CVA. Pooled effect size was calculated with a random-effect model, weighted for the inverse of variance. Heterogeneity was assessed with I². Six studies were analyzed. Participants with LVAD who developed BSI were more likely to have a CVA compared to participants without BSI (RR 3.43, 95% CI 2.49–4.72, I²?=?0). In four studies, there was an association between BSI and increased incidence of hemorrhagic CVA post LVAD (RR 5.28, 95% CI 2.65–10.53) with minimal heterogeneity (I²?=?30%). In three studies, participants with BSI were more likely to develop ischemic CVA (RR 2.18, 95% CI 1.23–3.84) compared to patients without BSI. This meta-analysis suggested that there maybe an association between blood stream infection and cerebrovascular accident in patients with LVAD.     

Cognitive impairment and 30-day rehospitalization rate in patients with acute heart failure: A systematic review and meta-analysis

Background

Heart failure (HF) is one of the world leading causes of hospitalization and rehospitalization. Cognitive impairment has been identified as a risk factor for rehospitalization in patients with heart failure. However, previous studies reported mixed results. Therefore, we conducted a systematic review and meta-analysis to assess the association between cognitive impairment and 30-day rehospitalization in patients with HF.