scholarly journals Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or Heart Failure: A Comparative Meta-Analysis

Stroke ◽  
2021 ◽  
Author(s):  
Catriona Reddin ◽  
Conor Judge ◽  
Elaine Loughlin ◽  
Robert Murphy ◽  
Maria Costello ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Treatment Effect ◽  
Oral Anticoagulation ◽  
Clinical Benefit ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Major Hemorrhage ◽  
Net Clinical Benefit

Background and Purpose: Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit. Methods: PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I 2 among all trials and testing the between-trial-population P -interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage. Results: Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I 2 =12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations. Conclusions: The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.

Catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction: a systematic review and meta-analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
O.M Aldaas ◽  
F Lupercio ◽  
C.L Malladi ◽  
P.S Mylavarapu ◽  
D Darden ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Systematic Review ◽  
Catheter Ablation ◽  
Ejection Fraction ◽  
Meta Analysis ◽  
Preserved Ejection Fraction ◽  
Patients With Heart Failure ◽  
One Year

Abstract Background Catheter ablation improves clinical outcomes in symptomatic atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, the role of catheter ablation in HF patients with a preserved ejection fraction (HFpEF) is less clear. Purpose To determine the efficacy of catheter ablation of AF in patients with HFpEF relative to those with HFrEF. Methods We performed an extensive literature search and systematic review of studies that compared AF recurrence at one year after catheter ablation of AF in patients with HFpEF versus those with HFrEF. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method for dichotomous variables, where a RR<1.0 favors the HFpEF group. Results Four studies with a total of 563 patients were included, of which 312 had HFpEF and 251 had HFrEF. All patients included were undergoing first time catheter ablation of AF. Patients with HFpEF experienced similar recurrence of AF one year after ablation on or off antiarrhythmic drugs compared to those with HFrEF (RR 0.87; 95% CI 0.69–1.10, p=0.24), as shown in Figure 1. Recurrence of AF was assessed with electrocardiography, Holter monitoring, and/or event monitoring at scheduled follow-up visits and final follow-up. Conclusion Based on the results of this meta-analysis, catheter ablation of AF in patients with HFpEF appears as efficacious in maintaining sinus rhythm as in those with HFrEF. Funding Acknowledgement Type of funding source: None

Abstract 17223: Castle of Stone or Straw, Radiofrequency Ablation of Atrial Fibrillation in Heart Failure?

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Brian D McCauley ◽  
Esseim Sharma ◽  
John Dudley ◽  
Antony Chu
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Sinus Rhythm ◽  
Meta Analysis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Prospective Trials

Introduction: Based on the data from CASTLE-AF trial, in patient with Atrial Fibrillation (AF) and heart failure (HF) catheter ablation may offer a significant reduction in both death, and hospitalization, while promoting maintenance of sinus rhythm as well as improvement in left ventricular ejection fraction (LVEF). This multi-center randomized trial is hailed as a paradigm shifting study in catheter ablation, however it is not without fault. One of the critiques of the CASTLE-AF trial was the high frequency of crossover between the treatment arms. To help sort out this potential source of confounding, we performed a systematic meta-analysis of prospective trials for catheter ablation in AF in patients with Class II through IV heart failure. Hypothesis: The reduction in death, and hospitalization, as well as the maintenance in sinus rhythm and improvement in LVEF seen CASTLE-AF trial are support by other similarly designed AF ablation trials. Methods: Using the inclusion/exclusion criteria from the CASTLE-AF trial, we performed a systematic meta-analysis of 28 published studies. Randomized and non-randomized observational studies comparing the impact of catheter ablation of AF in HF. Studies were identified using the Cochrane Library, EMBASE, and PubMed. Results: A total of 29 studies were identified (n =2,339). Mean follow-up was 25 (95% confidence interval, 18-40) months. Efficacy in maintaining sinus rhythm at follow-up end was 60% (43%-76%). Left ventricular ejection fraction improved significantly during follow-up by 15% (P<0.001). Conclusions: Following our meta-analysis, we found data to support the findings of improved LVEF and maintenance of sinus rhythm reported in the CASTLE-AF trial. However, due to differences in study design, we were unable to further validate the reduction in both hospitalization and death seen in CASTLE-AF. We recommend future prospective trials be conducted without cross over to further explore this topic.

P663Identifying patients at risk for atrial fibrillation in the community: a systematic review and meta-analysis of prediction models

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J C L Himmelreich ◽  
L Veelers ◽  
W A M Lucassen ◽  
H C P M Van Weert ◽  
R E Harskamp
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
At Risk ◽  
Prediction Models ◽  
Evidence Synthesis ◽  
Meta Analysis ◽  
Risk Scores ◽  
Risk Models ◽  
C Statistic

Abstract Background Atrial fibrillation (AF) presents a considerable burden on our health care systems. Early detection of AF may prevent AF-associated complications, such as stroke and heart failure. Given our aging populations, the number of new AF cases is expected to double over the next decades. As such, there is renewed interest to screen for AF in the community. To optimise screening efforts, risk prediction models may help us identify at-risk patients. Purpose To identify and evaluate the performance of prediction models for AF that may be applicable for screening in community settings. Methods We searched PubMed, Embase, and CINAHL databases for studies that derived and/or validated AF risk models from population-based cohorts. Three investigators independently assessed risk of bias (CHARMS checklist), and performed data extraction and evidence synthesis. The primary expression of associations in meta-analysis was the C-statistic for discrimination between AF and non-AF cases during follow-up, using a random effects model. We calculated 95% prediction intervals (PI) due to high heterogeneity (I2 >30%) in all analyses. Results We identified 23 studies that presented data on 8 risk models derived from 18 cohorts with a total of 1,4 million participants from across the globe. Average age in these cohorts ranged from 43–76 years and follow-up ranged from 3 to 20 years. Two of the 8 risk models had a sufficient number of validation studies to be included in the meta-analysis. The CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology) score had a summary C-statistic of 0.72 (95%-PI: 0.67–0.77; n=7 cohorts, n=53.040 patients). The FHS (Framingham Heart Study) score for AF had a summary C-statistic of 0.71 (95%-PI: 0.59–0.83; n=4 cohorts, n=19.300 patients). Both models include age, height and weight, blood pressure, prevalent heart failure, and antihypertensive medication use as variables. CHARGE-AF additionally includes race, current smoking, and history of diabetes and myocardial infarction. FHS additionally includes sex, PR interval, and significant murmur. Conclusions Currently two risk scores, CHARGE-AF and FHS, have been rigorously tested for predicting atrial fibrillation in general populations. The CHARGE-AF score may present the more promising, user-friendly score for future community screening efforts, as it solely relies on readily available clinical parameters. Acknowledgement/Funding This work was supported by the Netherlands Organisation for Health Research and Development (ZonMw) [80-83910-98-13046]

scholarly journals Net Clinical Benefit of Oral Anticoagulation Among Older Adults With Atrial Fibrillation

2019 ◽  
Vol 12 (11) ◽  
Author(s):  
Sachin J. Shah ◽  
Daniel E. Singer ◽  
Margaret C. Fang ◽  
Kristi Reynolds ◽  
Alan S. Go ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Older Adults ◽  
Oral Anticoagulation ◽  
Clinical Benefit ◽  
Net Clinical Benefit

Abstract TP429: Early Oral Anticoagulation After Acute Ischemic Stroke in Patients With Atrial Fibrillation

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Andrew B Buletko ◽  
Rejo P Cherian ◽  
Christine Ahrens ◽  
Ken Uchino ◽  
Andrew Russman
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Oral Anticoagulation ◽  
Infarct Volume ◽  
Cleveland Clinic ◽  
Early Initiation ◽  
Stroke Severity ◽  
Major Hemorrhage

Introduction: Uncertainty exists as to the optimum interval for initiation of oral anticoagulation (OAC) after an acute ischemic stroke (AIS) in patients with atrial fibrillation (AF). Randomized clinical trials of novel oral anticoagulants excluded patients with AIS within 7-14 days. We sought to identify patients at low risk for early initiation of OAC after AIS. Hypothesis: The benefit of starting OAC within 2 days to prevent recurrent AIS outweighs the risk of hemorrhagic transformation (HT) in select patients. Methods: Following IRB approval, we completed a retrospective review of patients from the Cleveland Clinic from 2012-2014 with AIS, AF, and at least 1 follow up visit. In addition to demographic and medical history, acute infarct volume on imaging, presence of HT on imaging prior to OAC, timing and type of oral anticoagulation, and ischemic and hemorrhagic complications were noted. Early OAC was defined as starting within 48 hours after stroke onset, and late OAC was thereafter. The two groups were compared using Fisher’s exact test for categorical and Wilcoxon Rank Sum for numeric variables. Results: One hundred patients (median age 76, interquartile range 66-84) met our study criteria. Thirty-one patients were started on OAC within 2 days vs 53 patients after 2 days (median 1 days vs median 11 days). Compared to patients started on OAC after 2 days, those who initiated OAC within 2 days had significantly lower infarct volume (median 3.35 ml vs median 9.8 ml; p<0.0001), initial NIHSS (median 3 vs median 7; p <0.0001), and fewer people with blood on brain imaging (3% vs 26%; p= 0.0074). Age, prior stroke, and choice of OAC were not significantly associated with timing of OAC. No patients had recurrent AIS or symptomatic HT at median follow-up observation of 37 days. One patient had a non-CNS major hemorrhage after starting OAC. Sixteen patients were not started on OAC for a variety of reasons. Conclusions: Our results suggest the safety of early initiation of OAC with 2 days in an appropriately selected population of patients with AIS, who have small infarct volumes, mild stroke severity, and lack of HT.

Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation

2013 ◽  
Vol 109 (02) ◽  
pp. 328-336 ◽  
Author(s):  
Ron Pisters ◽  
Robby Nieuwlaat ◽  
Deirdre Lane ◽  
Harry Crijns ◽  
Gregory Lip
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Clinical Benefit ◽  
Vitamin K Antagonists ◽  
The Novel ◽  
Major Cardiovascular Events ◽  
Numbers Needed To Treat ◽  
One Year ◽  
Net Clinical Benefit

SummaryVitamin K antagonists (e.g. warfarin) are commonly underutilised, due to limitations such as the need for monitoring, in high-risk atrial fibrillation (AF) patients. We therefore aimed to model the potential impact on clinical outcomes in patients with AF with the use of the novel oral anticoagulant (OAC) drugs, apixaban and dabigatran. We identified all high-risk (CHA2DS2-VASc score ≥2) patients with non-valvular AF and known one-year follow-up from the EuroHeart Survey on AF (EHS-AF). We modelled the expected numbers of clinical events on the novel OACs using published hazard ratios from their respective phase 3 clinical trials and calculated the numbers needed to treat and the mathematical net clinical benefit. Our analysis included 3,400 patients [39% females; mean (SD) age 67 (12) years; CHA2DS2-VASc score 3.0 (1.8)] of which 330 were excluded from the modelling analysis due to concomitant use of OAC and antiplatelet drugs. During one-year follow- up, 108 (3.2%) patients experienced thromboembolism, 51 (1.5%) major bleeds and 146 (4.3%) died. Compared to current treatments (i.e. warfarin, aspirin or nothing) the use of apixaban in highrisk patients would have potentially prevented an additional 17 deaths, 27 strokes and eight major bleeds within this cohort. With use of dabigatran 150 mg BID, 34 strokes could have been prevented and for dabigatran110 mg BID, 16 strokes and six major bleeds would be avoided. Extrapolation of the data from the EHS-AF to the whole of Europe would translate into the prevention of an additional 64,573 major cardiovascular events and deaths each year among patients with a CHA2DS2-VASc ≥2, by the use of apixaban, 43,235 with the use of dabigatran 150 mg bid and 27,272 with the use of dabigatran 110 mg bid. In conclusion, based on this modelling exercise, the utilisation of apixaban and dabigatran for thromboprophylaxis could provide a profound annual mathematical net clinical benefit on stroke and major bleeds, in European AF patients.Note: The editorial process for this paper was fully handled by Prof. C. Weber, Editor in Chief.

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