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Background: Direct oral anticoagulants such as dabigatran are the preferred anticoagulant in treating atrial fibrillation (AF) patients due to their effectiveness and safety. Whether this applies to severely obese patients needs to be determined., Objective: To compare the effectiveness and safety of dabigatran with warfarin among AF patients with severe obesity., Design: Retrospective cohort study., Participants: AF patients with a BMI >40kg/m 2 or a weight >120kg receiving dabigatran or warfarin between 10/01/2010 and 12/31/2019 in a large integrated health system and followed through 08/01/2020., Interventions: Not applicable., Main Measures: Primary effectiveness outcome was composite thromboembolism including transient ischemic attack, ischemic stroke, or systemic embolism. Primary safety outcome was composite bleeding including gastrointestinal bleeding, intracranial bleeding, or other bleeding. Secondary outcomes included the individual outcomes and all-cause mortality. Propensity score matching (PSM) was performed to create a 1:1 matched cohort and Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome for dabigatran users compared to warfarin users., Key Results: A total of 6848 patients receiving either dabigatran or warfarin were identified. In a 1:1 matched cohort, dabigatran users had a HR of 0.71 (95% confidence interval (CI): 0.56-0.91) for composite thromboembolism, a HR of 1.24 (95%CI: 1.07-1.42) for composite bleeding, and a HR of 0.57 (95% CI: 0.45-0.71) for all-cause mortality when compared to warfarin users., Conclusions: Among AF patients with a BMI >40kg/m 2 or a weight >120kg in a real-world clinical setting, dabigatran was effective in reducing the risk of thromboembolism and mortality but was associated with an increased risk of bleeding when compared to warfarin. Dabigatran may be a reasonable option for AF patients with severe obesity., (© 2021. Society of General Internal Medicine.)

Background: Patients with left ventricular thrombus are at high risk for ischemic stroke and systemic embolization. The mainstay of treatment is anticoagulation, but it remains unclear if direct-acting oral anticoagulants (DOACs) are a safe and effective treatment strategy compared to warfarin. We conducted a population-based retrospective cohort study to evaluate the effectiveness and safety of DOACs compared to warfarin in an integrated health system in the United States., Methods: Consecutive patients with left ventricular thrombus on transthoracic echocardiogram from May 2010 to April 2020 were identified. Comparative effectiveness and safety of DOACs and warfarin were evaluated using multivariable Cox proportional hazard models and inverse probability of treatment weighting., Results: Among 433 patients with left ventricular thrombus, 134 (30.9%) were treated with DOACs and 299 (69.1%) were treated with warfarin. Patients were followed for a median of 3.4 years. For the primary effectiveness outcome of ischemic stroke, systemic embolism, and transient ischemic attack, no significant difference was observed between use of DOACs compared to warfarin (adjusted hazard ratio [HR] of 0.75, 95% confidence interval [CI] 0.48-1.18, p = 0.21). For the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed requiring hospitalization, DOAC usage was associated with a lower risk of bleeding (HR 0.58, 95% CI 0.39-0.87, p = 0.0008)., Conclusions: In this diverse population-based cohort of patients, DOAC treatment for left ventricular thrombus appears to be as safe and effective as warfarin treatment. These findings support the use of DOACs for patients with left ventricular thrombus., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban, or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2,672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96 to 1.48, p = 0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p < 0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Context: There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED)., Objective: To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED., Design: An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate., Main Outcome Measures: The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications., Results: A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p < 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95%confidence interval = 1.07-3.63). Length of stay, return visits, and hospital readmissionswere similar., Conclusion: A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety.

Background: The goal of this study was to determine the prevalence of atrial fibrillation and atrial flutter (AF) in pregnant women and to examine the impact of AF on maternal and fetal outcomes., Methods and Results: Between January 1, 2003 and December 31, 2013, there were 264 730 qualifying pregnancies (in 210 356 women) in the Kaiser Permanente Southern California hospitals, among whom AF was noted in 157 pregnancies (129 women; 61.3 per 100 000 women, or 59.3 per 100 000 pregnancies). Prevalence of AF (per 100 000 women) in white, black, Asian, and Hispanic women was 111.6, 101.7, 45.0, and 34.3, respectively. Older age was associated with higher odds of having AF. Compared to women <25 years of age, the odds ratio (OR) of AF was 4.1 in women age 30 to 34 years, 4.9 in women age 35 to 39 years, and 5.2 in women age ≥40. Odds of AF episodes were higher during the third trimester compared to the first trimester (OR, 3.2; 95% CI: 1.5-7.7). Among AF patients, adverse maternal cardiac events were rare-2 women developed heart failure and there were no strokes or systemic embolic events and no maternal death. There were 156 live births (99.4% of all pregnancies). Compared to women without AF, fetal birth weights were similar, but rate for neonates' admission to the neonatal intensive care unit was higher (10.8% vs 5.1%; P=0.003)., Conclusions: AF is rare in pregnant women. Certain factors such as increased maternal age and white race increase the odds of having AF. Major maternal and fetal complications are infrequent, albeit a source of concern., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Direct oral anticoagulants such as dabigatran are the preferred anticoagulant in treating atrial fibrillation (AF) patients due to their effectiveness and safety. Whether this applies to severely obese patients needs to be determined. Objective: To compare the effectiveness and safety of dabigatran with warfarin among AF patients with severe obesity. Design: Retrospective cohort study. Participants: AF patients with a BMI >40kg/m2 or a weight >120kg receiving dabigatran or warfarin between 10/01/2010 and 12/31/2019 in a large integrated health system and followed through 08/01/2020. Interventions: Not applicable. Main measures: Primary effectiveness outcome was composite thromboembolism including transient ischemic attack, ischemic stroke, or systemic embolism. Primary safety outcome was composite bleeding including gastrointestinal bleeding, intracranial bleeding, or other bleeding. Secondary outcomes included the individual outcomes and all-cause mortality. Propensity score matching (PSM) was performed to create a 1:1 matched cohort and Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome for dabigatran users compared to warfarin users. Key Results: A total of 6848 patients receiving either dabigatran or warfarin were identified. In a 1:1 matched cohort, dabigatran users had a HR of 0.71 (95% confidence interval (CI): 0.56–0.91) for composite thromboembolism, a HR of 1.24 (95%CI: 1.07–1.42) for composite bleeding, and a HR of 0.57 (95% CI: 0.45–0.71) for all-cause mortality when compared to warfarin users. Conclusions: Among AF patients with a BMI >40kg/m2 or a weight >120kg in a real-world clinical setting, dabigatran was effective in reducing the risk of thromboembolism and mortality but was associated with an increased risk of bleeding when compared to warfarin. Dabigatran may be a reasonable option for AF patients with severe obesity. [ABSTRACT FROM AUTHOR]