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Background/Objectives: Despite the widespread use of oral anticoagulants (OACs), acute ischemic stroke (AIS) remains a significant risk for patients with atrial fibrillation (AF). The real-world effectiveness of OACs in preventing recurrent strokes, particularly following an initial stroke of cardioembolic (CE) origin, continues to be a major challenge for clinicians managing AF patients. This study evaluated the efficacy of OACs in secondary stroke prevention and investigated the influence of anticoagulation type and quality on recurrence risk. Methods: We analyzed data from 128 AF patients in the prospective Transzlációs Idegtudományi Nemzeti Laboratórium (TINL) STROKE-registry, admitted with CE stroke between February 2023 and September 2024. Patients were categorized by anticoagulation status at admission (OAC-users, n = 89; anticoagulation-naïve, n = 39). Recurrence rates were assessed using logistic regression models, adjusted for age, sex, hypertension, diabetes, and pre-stroke disability. Subgroup analyses explored the effects of anticoagulation type and quality. Results: Recurrence rates were similar between the OAC-treated and anticoagulation-naïve patients after adjusting for confounders (19.10% vs. 17.95%, p = 0.870). Among the anticoagulated patients, neither anticoagulation type nor quality alone significantly influenced the recurrence risk. However, their interaction was statistically significant (p = 0.049), suggesting that the effectiveness of anticoagulation in preventing strokes is strongly affected by treatment quality. Conclusions: Although OACs are a cornerstone of stroke prevention in patients with AF, their efficacy in reducing recurrence depends on optimal management. These findings highlight that adequate anticoagulation, not just its use, is critical to minimize recurrence risk. To effectively prevent strokes in high-risk AF patients, future strategies must focus on standardized protocols, tailored monitoring, and individualized dosing regimens. [ABSTRACT FROM AUTHOR]

Purpose: To estimate the strength of association between use of antithrombotics (AT) drugs with survival after spontaneous intracerebral hemorrhage (s-ICH) comparing oral anticoagulant (OAC) or platelet antiaggregants (PA) with no AT use and in active comparator analyses OAC vs PA, direct oral anticoagulant (DOAC) vs vitamin K antagonist (VKA), and clopidogrel vs aspirin. Patients and Methods: We identified patients ≥ 55 years with a first-ever s-ICH between 2015 and 2018 in Southern Denmark (population 1.2 million). From this population, patients who had used an AT at the time of ICH were identified and classified as OAC or PA vs no AT (reference group), and for active comparator analyses as OAC vs PA (reference group), DOAC vs VKA (reference group), or clopidogrel vs aspirin (reference group). We calculated adjusted relative risks (aRRs) and corresponding [95% confidence intervals] for 90-day all-cause mortality with adjustments for potential confounders. Results: Among 1043 patients who had s-ICH, 206 had used an OAC, 270 a PA, and 428 had no AT use. The adjusted 90-day mortality was higher in OAC- (aRR 1.68 [1.39-2.02]) and PA-users (aRR 1.21 [1.03-1.42]), compared with no AT. Mortality was higher in OAC- (aRR 1.19 [1.05-1.36]) vs PA-users. In analyses by antithrombotic drug type, 88 used a DOAC, 136 a VKA, 111 clopidogrel, and 177 aspirin. Mortality was lower among DOAC- vs VKA-users (aRR 0.82 [0.68-0.99]), but similar between clopidogrel vs aspirin users (aRR 1.04 [0.87-1.24]). Conclusion: In this unselected cohort from a geographically defined Danish population, 90-day mortality after s-ICH was higher in patients with prior use of an OAC compared with no AT use or patients using a PA. Mortality was slightly lower for patients using a DOAC than a VKA. Mortality was also higher in PA- vs no AT-users, but there were no differences in mortality between clopidogrel vs aspirin. [ABSTRACT FROM AUTHOR]

Background: Specific risk predictor scores of intracranial hemorrhage (ICH) risk in Asian subjects are lacking. We determined the incidence rate and predictors of ICH in patients with non‐valvular atrial fibrillation (AF). Methods: A prospective nationwide registry of patients with AF was conducted from 27 hospitals in Thailand. The adjudicated primary outcome was the development of ICH during follow‐up. Multivariable Cox proportional hazard model was performed to identify the independent predictors for ICH. A predictive model for ICH risk was developed and validated by bootstrap, calibration plot, C‐statistics, and decision curve analysis using our own data. Results: We studied a total of 3405 patients (mean age 67.8 years; 58.2% male) with an average follow‐up duration of 31.8 ± 8.7 months, during which ICH developed in 70 patients (2.06%). The incidence rate of ICH was 0.78 (0.61−0.98) per 100 person‐years. Predictors of ICH were chosen from the theory‐driven approaches in combination with the results of the univariable analysis. The predictive risk model had a c‐index of 0.717 (0.702−0.732) with good calibration, internal validation, and clinical usefulness using decision curve analysis. The probability of ICH at 3 years for an individual patient derived from the prediction model was compared with the probability derived from HAS‐BLED score by using the C‐statistics. The ICH probability from the COOL‐AF model was superior to the HAS‐BLED score in the prediction of ICH. Conclusion: The incidence rate of ICH was 0.78 (0.61−0.98) per 100 person‐years. Predictors of ICH were older age, male sex, nonsmoking, renal replacement therapy, and use of oral anticoagulants. [ABSTRACT FROM AUTHOR]

ABSTRACT No existing studies compare oral anticoagulants to treat heparin‐induced thrombocytopenia with or without thrombosis (HIT/HITT). This retrospective study evaluated thrombotic and bleeding outcomes in adults treated for HIT/HITT with a direct oral anticoagulant (DOAC) or warfarin between 2012 and 2023 within the Ochsner Health System. Patients with mechanical heart valves, valvular atrial fibrillation, antiphospholipid syndrome, active malignancy, or venous thromboembolism (VTE) within the previous 6 months were excluded. The primary outcome was a composite of new or progressive VTE or arterial thromboembolism. Secondary outcomes included major and clinically relevant non‐major bleeding, duration of hospitalization, time to platelet recovery, and incidence of skin necrosis, gangrene, and amputation. Forty‐nine patients receiving a DOAC and 30 patients receiving warfarin were included. Baseline characteristics were similar between cohorts. There were non‐statistically significant increased rates of both the primary outcome (8.9% vs. 4.3%, p = 0.65) and the composite bleeding outcome (32.7% vs. 23.3%, p = 0.37) in the DOAC cohort. Larger, prospective studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Anticoagulation therapy in patients with atrial fibrillation (AF) and concomitant cancer can be challenging due to the significantly increased risk of both embolism and bleeding. Moreover, the benefits and risks of vitamin K antagonists (VKA, eg. warfarin) versus non‐vitamin K antagonist oral anticoagulants (NOACs) in such patients are less well understood.From the prospective, global, multi‐centered Global Registry on Long‐Term Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA‐AF), we characterized these patients according to their history of prior cancer when enrolled. All patients received anticoagulant therapy. The primary outcome was the composite of all‐cause mortality, stroke, transient ischemic attack, systemic embolism. The secondary endpoints were all‐cause mortality, cardiovascular death, stroke, major bleeding and thromboembolism during the 3 years follow‐up period. Cox regression analyses were used to calculate the hazard ratio (HR) and confidence interval (CI) following propensity score matching (PSM).Overall, among 16,700 patients enrolled in Phase III in GLORIA‐AF, 1725 (10%) patients had concomitant cancer(s) at enrolment. After PSM, the primary outcome occurred in 250 (14.8%) of patients with cancer(s) and 160 (9.3%) without cancer(s) (HR, 1.62 [95% CI, 1.33–1.97], p < .001) during the 3 years follow‐up period. The risk of all‐cause mortality was significantly higher in patients with cancer(s) versus non‐ cancer(s) (HR, 1.71 [95% CI, 1.37–2.12], p < .001). In patients with cancer(s), after PSM, the use of NOACs was associated with reduced risk of the primary outcome compared with that of VKA (HR, .69 [95% CI, .49–.99], p = .043), as well as a lower risk of thromboembolism (HR, .49 [95% CI, .24–1.00], p = .051), but the risk of major bleeding was not significantly different (HR, .87 [95% CI, .48–1.56], p = .635). Subgroup analysis in patients with cancers showed a reduced risk of major bleeding with NOACs compared with VKA (HR, .18 [95% CI, .04–.8], p = .024) in patients with coronary artery disease (CAD). For the main cancer subtypes (genitourinary, breast, gastrointestinal, haematological and skin), the trends for the risk of primary outcome were consistently favouring NOACs compared with VKA without any significant interaction among these five cancers.Cancer is a common comorbidity in patients with AF and is associated with increased risk of composite of all‐cause mortality and thromboembolism. Compared with VKA, NOACs was associated with a lower risk of composite events and showed an advantage in lower risk of thromboembolism, as well as a reduced risk of major bleeding when CAD was also present. [ABSTRACT FROM AUTHOR]

We investigated bleeding complications in patients admitted to the emergency department (ED) who were taking oral anticoagulants and compared the rates of major and minor bleeding events between the direct oral anticoagulant (DOAC) and warfarin groups. We conducted a prospective, multicenter observational study of warfarinand DOAC-treated patients who presented to the EDs of tertiary-care hospitals between July 2020 and July 2021 with a bleeding event. Among 518 patients on anticoagulation therapy, 121 (23.4%) presented to EDs with bleeding events. A chart review revealed 73 (60.24%) patients with bleeding events who were taking a DOAC (i.e., apixaban, edoxaban, rivaroxaban, or dabigatran) and 48 who were taking warfarin. The rate of bleeding events was significantly higher among patients treated with warfarin than among those treated with DOACs (48/129 [37.2%] vs. 73/389 [18.8%], p<0,001). Subgroup analysis of the DOAC-treated patients revealed a significant difference in the frequency of bleeding events among the DOAC groups (p=0.016), with a significantly lower frequency in patients treated with rivaroxaban versus edoxaban (14.9% vs. 34.7%, p=0.002) and in those treated with apixaban versus edoxaban (18.8% vs. 34.7%, p=0.021). Our findings indicate that although the rates of overall bleeding events differed among DOAC-treated patients, the rates of bleeding events were lower than those in warfarin-treated patients. Additionally, major bleeding events occurred less frequently in patients treated with rivaroxaban or apixaban compared with edoxaban. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies—e.g., osocimab, anti-sense oligonucleotides—e.g., fesomersen, and small molecule inhibitors—e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease. [ABSTRACT FROM AUTHOR]

Cardiology, like other branches of medicine, is increasingly faced with the need not only to optimize patient treatment, reduce financial costs, but also to improve long-term outcomes. The volume of information required for such tasks is significant, and a doctor’s time is severely limited. Additional software capable of processing large amounts of data in a short period can assist doctors. Clinical decision support system (CDSS) is a type of software that, based on numerous clinical characteristics, provides doctors with information on the most likely diagnosis, patient risk profile, most suitable therapy, and more. Nowadays, CDSS finding more and more applications in cardiology and cardiovascular medicine. The experience of its clinical use has also been accumulated in the Russian Federation. The problem of the correct choice of anticoagulant therapy remains relevant in clinical practice. In addition, despite the proven benefit of prescribing anticoagulants in patients with atrial fibrillation (AF) at a high risk, the frequency of "underprescription" of oral anticoagulants (OACs) remains relatively high. The introduction of a strategy for a personalized approach to the selection of anticoagulants, based on individual patient characteristics, can significantly improve adherence to clinical guidelines and, as a result, reduce the risk of thromboembolic complications. This article discusses the positive and negative aspects of using CDSS in the management of patients with AF, highlighting the main limitations when using them in conditions close to real clinical practice.

Abstract Background The objective of this study is to investigate the incidence, potential risk factors, and clinical outcomes of incomplete device endothelialization (IDE) in atrial fibrillation (AF) patients undergoing Watchman left atrial appendage closure (LAAC). Methods In this study, 68 AF patients who underwent successful implantation of the Watchman device without peri-device leak (PDL) during follow-up were included. The endothelialization status was assessed using Transesophageal echocardiography (TEE) and LAA computed tomography angiography (CTA) at 6 weeks and 6 months post-implantation. Adverse cerebro-cardiac events were documented at one-year follow-up. Baseline characteristics, including age, device sizes, and clinical indicators, were analyzed as potential predictors for IDE. Results IDE was observed in 70.6% and 67.6% of patients at 6 weeks and 6 months after implantation, respectively. Higher levels of high-density lipoprotein cholesterol (HDL-C) [odds ratio (OR): 15.109, 95% confidence interval (CI): 1.637-139.478, p = 0.017 and OR: 11.015, 95% CI: 1.365–88.896, p = 0.024] and lower aspartate aminotransferase (AST) (OR 0.924, 95% CI: 0.865–0.986, p = 0.017 and OR: 0.930, 95% CI: 0.874–0.990, p = 0.023) at baseline were found to be significantly associated with IDE at 6 weeks and 6 months, respectively, although no significant difference in adverse cerebro-cardiac events was noted between incomplete and complete DE groups during 1-year follow-up Conclusions IDE is found to be a prevalent occurrence in humans following LAAC. Elevated HDL-C and reduced AST levels are shown to be linked to an increased risk of IDE after LAAC

Every third or fourth ischemic stroke is cardioembolic. Prescribing oral anticoagulants can significantly reduce the risk of recurrent stroke, but this strategy requires the physician to have a firm orientation in the “efficacy – safety” coordinate system. We formulate 10 rules that should help any interested specialist (neurologist, cardiologist, therapist) to decide on the prescription of oral anticoagulants for cardioembolic stroke in daily clinical practice. We discuss issues of selection of an anticoagulant in atrial fibrillation, mitral stenosis and mechanical heart valves, the timing of prescription (also in haemorrhagic transformation of ischemic stroke and after intracerebral hemorrhage), the special features of anticoagulant prophylaxis in comorbid and “fragile” patients are discussed, the development of a stroke while taking an anticoagulant, the timing of discontinuation and resumption of therapy during surgical interventions, the choice of dose and peculiarities of therapy in cognitively impaired patients.

Background: Oral anticoagulants (OACs) are essential for the prevention and treatment of thromboembolic disorders, but bleeding, a major complication, can have a fatal impact on the patient's treatment. Objectives: We aimed to estimate the nationwide, real-world incidence rate of bleeding in patients taking OACs and confirm the incidence by indications and risk factors. Methods: This cross-sectional study identified OAC users from April 1 to December 31, in both 2019 and 2020, using the HIRA-NPS database. The primary outcome variables were the incidence rate of major bleeding events during OAC treatment and within 30 days of treatment discontinuation. We estimated the adjusted incidence rate ratio (aIRR) in subpopulations. Results: Among 18,822 OAC users, the incidence rate of major bleeding was 27.9 (95% CI: 24.6-31.5) per 1,000 person-years. The incidence rate of major bleeding was higher in patients with a bleeding history, with an aIRR of 11.51; those at high bleeding risk (HAS-BLED score =3), with an aIRR of 1.51; those with high CCI scores =3, with an aIRR of 1.88; and those with liver disease, with an aIRR of 1.41. For indications, compared to patients with nonvalvular atrial fibrillation (NVAF), the aIRR of major bleeding was significantly higher at an aIRR of 2.35 in patients undergoing VTE treatment. Patients with ischemic stroke showed a higher incidence of major bleeding with an aIRR of 2.13 than NVAF patients. The aIRR of major bleeding in the oral anticoagulant group, compared to the matched control group, was 2.25 (95% CI: 1.93-2.63). Conclusion: These findings may be useful for implementing strategies to improve the evaluation and management of anticoagulation-related bleeding. [ABSTRACT FROM AUTHOR]

Introduction: Trans-radial access for coronary angiography and percutaneous coronary intervention (PCI) has gained popularity due to its advantages over the traditional transfemoral approach. However, radial artery occlusion (RAO) remains a common complication following trans-radial procedures. This study aimed to investigate the incidence of early and late RAO along with their risk factors. Methods: Six databases, Medline (Ovid), National Library of Medicine (MeSH), Cochrane Database of Systematic Reviews (Wiley), Embase, Scopus, and Global Index Medicus, were searched. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and analyzed. Using a random-effect model, the primary endpoint was the overall incidence of RAO after invasive coronary procedures. Subgroup analysis and meta-regression were also performed to identify possible predictors of RAO. Results: A total of 41 studies with 30,020 patients were included. The overall incidence of RAO was 13% (95% CI = 0.09–0.16). The incidence of early RAO (within 24 h) was 14% (95% CI = 0.10–0.18) in 26 studies, while the incidence of late RAO (after 24 h) was 10% (95% CI = 0.04–0.16) in 22 studies. The average incidence rates of early RAO in studies with catheter sizes of <6 Fr, 6 Fr, and >6 Fr were 9.8%, 9.4%, and 8.8%. The overall effect size of female gender as a predictor was 0.22 with a 95% CI of 0.00–0.44. Age was a potential predictor of early RAO (B = 0.000357; 95% CI = −0.015–0.0027, p: 0.006). Conclusions: This meta-analysis provides essential information on the incidence of early (14%) and late (10%) RAO following angiographic procedures. Additionally, our findings suggest that female sex and age are possible predictors of RAO. A larger catheter, especially (6 Fr) and hemostatic compression time <90 min post-procedure, substantially reduced the incidence of RAO. The use of oral anticoagulation and the appropriate dosage of low-molecular-weight heparin (LMWH) does reduce RAO, but a comparison between them showed no statistical significance. [ABSTRACT FROM AUTHOR]

• The incidence of major bleeding events in a contemporary European cohort of DOAC treated AF patients is low. • Both HAS-BLED and DOAC scores showed a significant association with the risk of major bleeding events, with only modest predictive ability. • As compared to DOAC score, HAS-BLED better identifies patients at very low risk of bleeding. • Reclassification analysis did not show a significant difference between the two scores, but compared with HAS-BLED, DOAC score had poorer calibration especially for those at high-risk. • Hence, our results do not support the preferential use one score over the other. The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC). To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC. We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores. A total of 2834 AF patients (median age [IQR] 69 [62–77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55–0.70; DOAC score AUC 0.62, 95 % CI 0.59–0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED. In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED. [ABSTRACT FROM AUTHOR]

It is still uncertain whether direct oral anticoagulants (DOACs) perform better than vitamin K antagonists (VKAs) in subjects with non-valvular atrial fibrillation (NVAF) and advanced chronic kidney disease (CKD). The aim of the study was to compare safety and effectiveness of DOACs and VKAs in patients with NVAF and stage 4 CKD (creatinine clearance 15–29 mL/min). We searched the hospital databases of two academic centers to retrospectively identify patients with stage 4 CKD who were on treatment with DOACs or VKAs for NVAF. Safety was the primary outcome of the study and was assessed in terms of incidence of major bleeding (MB). Secondary outcomes were clinically relevant non-major bleeding (CRNMB) and death for any cause. A total of 176 patients (102 on DOACs and 74 on VKAs) were found and included in the analysis. The incidence rate of MB was not statistically different between groups (8.6 per 100 patients-year in the DOAC group and 5.6 per 100 patients-year in the VKA group). Rates of IS/SSE and CRNMB were statistically similar in the two treatment groups, as well. There were less deaths for any cause in the DOAC group than in the VKA group (8.6 and 15.8 per 100 patients-year, respectively), but the difference was not statistically significant. This study found no difference in terms of safety and effectiveness between patients with NVAF and stage 4 CKD treated with DOACs and VKAs. Larger prospective or randomized studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

The peak prevalence of many brain tumors is in elderly patients. These patients are often treated with platelet inhibitors (PIs) or anticoagulants (ACs), creating a challenge for neurosurgeons concerning the perioperative management. The aim of this study is to analyze the effect of PI/AC treatment on the postoperative bleeding rates in patients undergoing craniotomy due to a brain tumor. Retrospective analysis of 415 consecutive patients undergoing craniotomy/craniectomy due to a brain tumor. Ninety-nine patients with PI/AC treatment (PI/AC group consisting of 64 PI, 29 AC, and six multiple) and 316 patients without PI/AC (control group) were primarily compared for hemorrhage rate. Secondary outcome measures were clinical outcome and mortality. The association between short preoperative discontinuation (≤5 days), early postoperative resumption time (≤5 days), as well as short total discontinuation time (≤5 days) of PI/AC and postoperative bleeding rates was analyzed. Postoperative bleeding rates were comparable between the groups (12.2% and 13.5% in the PI/AC and control group, respectively; p=.74). The majority of bleeds were asymptomatic (85.2%). No significant difference in the postoperative mortality rate was observed (1.0% and 1.6% in the PI/AC and the control group, respectively; p=.67). Shorter discontinuation time of PI/AC was not significantly associated with higher postoperative bleeding rates (preoperative: 12.1% vs. 12.3%; p=.94, postoperative: 11.1% vs. 12.5%, respectively; p=.87, total: 16.7% vs. 12%, respectively; p=.73). Patients treated with PI/AC undergoing craniotomy for the resection of brain tumor do not seem to have increased rates of postoperative bleeding or mortality. We did not find a significant correlation between short discontinuation time of PI/AC in the perioperative period and postoperative bleeding. [ABSTRACT FROM AUTHOR]

Abstract Background Nursing home residents with atrial fibrillation are at high risk for ischemic stroke, but most are not treated with anticoagulants. This study compared the effectiveness and safety between oral anticoagulant (OAC) users and non-users. Methods We conducted a new-user retrospective cohort study by using Minimum Data Set 3.0 assessments linked with Medicare claims. The participants were Medicare fee-for-service beneficiaries with atrial fibrillation residing in US nursing homes between 2011 and 2016, aged ≥ 65 years. The primary outcomes were occurrence of an ischemic stroke or systemic embolism (effectiveness), occurrence of intracranial or extracranial bleeding (safety) and net clinical outcome (effectiveness or safety outcomes). Secondary outcomes included total mortality and a net clinical and mortality outcome. Cox proportional hazards and Fine and Grey models estimated multivariable adjusted hazard ratios (aHRs) and sub-distribution hazard ratios (sHRs). Results Outcome rates were low (effectiveness: OAC: 0.86; non-users: 1.73; safety: OAC: 2.26; non-users: 1.75 (per 100 person-years)). OAC use was associated with a lower rate of the effectiveness outcome (sHR: 0.69; 95% Confidence Interval (CI): 0.61–0.77), higher rates of the safety (sHR: 1.70; 95% CI: 1.58–1.84) and net clinical outcomes (sHR: 1.20; 95% CI: 1.13–1.28) lower rate of all-cause mortality outcome (sHR: 0.60; 95% CI: 0.59–0.61), and lower rate of the net clinical and mortality outcome (sHR: 0.60; 95% CI: 0.59–0.61). Warfarin users, but not DOAC users, had a higher rate of the net clinical outcome versus OAC non-users. Conclusions Our results support the benefits of treatment with OACs to prevent ischemic strokes and increase longevity, while highlighting the need to weigh apparent benefits against elevated risk for bleeding. Results were consistent with net favorability of DOACs versus warfarin.

Emma L Veale Medway School of Pharmacy, University of Kent and University of Greenwich, Chatham Maritime, Kent, UKCorrespondence: Emma L Veale, Email e.l.veale@kent.ac.ukAbstract: The world’s population is ageing, with the number of those over 60 years expected to represent a fifth of the total population by 2050. Increases in chronic long-term health conditions (LTCs) associated with ageing, and requiring regular but often avoidable medical intervention, are pressurising already overloaded, health and social care systems. Atrial fibrillation (AF) is an LTC, which is most frequently diagnosed in the elderly. An often, asymptomatic condition, AF is associated with a 3- to 5-fold increased risk of severe ischemic stroke. Stroke prevention, with risk-stratified oral anticoagulants (OACs) is the standard recommended care for patients with AF. Stroke avoidance is, however, dependent on persistent adherence to OAC medication, with an adherence rate of > 80% considered necessary to achieve optimal health outcomes. Suboptimal adherence to OACs is common, with a third of all AF patients not taking their medication as prescribed. This combined with the short half-life of OACs can result in poor clinical outcomes for patients. Policy makers now consider improving adherence to prescribed medicines for LTCs, a public health priority, to ensure better health outcomes for patients, whilst minimising unnecessary health system costs. Prescribing medicines to treat LTCs, such as AF, is not enough, particularly when the patient may not experience any measurable benefit to the treatment and may instead, experience medication-associated adverse events, including a risk of bleeding. Pharmacists who are experts in medicines management are ideally placed to support medication adherence, to educate, and to improve health outcomes for patients with AF. In this review, I will consider the evidence for poor medication adherence in LTCs and in particular adherence to OACs in patients with AF and highlight the role that pharmacists can play in ensuring optimal adherence and showcase pharmacist-led interventions that effectively address this problem.Keywords: atrial fibrillation, oral anticoagulants, pharmacists, medication adherence, stroke, long-term conditions

Antiphospholipid syndrome (APS) is a systemic autoimmune pathology characterized by thrombotic manifestation associated with antiphospholipid antibodies (aPL) and phospholipid-binding proteins circulation. Long-term anticoagulant therapy is a cornerstone in the treatment and prevention of relapses and manifestations of APS-associated For high-risk APS phenotypes with arterial thrombosis, microthrombosis and triple aPL-positivity VKA use is the only possible option for anticoagulant therapy. The need for constant monitoring of international normalized relations (INR) for achievement and control of target values, intolerance and variability of INR reduce patient compliance in a certain category of patients, which limits their use in some clinical situations. Use of direct oral anticoagulants (DOAC) is an alternative option for anticoagulant therapy. Despite the benefits of using DOAC according to current international recommendations and guidelines their use is limited by the phenotype of APS with venous thrombosis and monoand double aPL-positivity if the patient is unable or unwilling to take VKA due to need for constant INR monitoring. In the obstetric version of APS during gestation, antithrombotic therapy is performed with aspirin and low molecular-weight heparins. The intensity and duration of antithrombotic prophylaxis determining at high-risk APS is a real challenge for the clinician due to the lack of tools for risk stratification and should be carried out depending on the individual characteristics of the patient and the course of APS.

Background: Nursing home residents with atrial fibrillation are at high risk for ischemic stroke, but most are not treated with anticoagulants. This study compared the effectiveness and safety between oral anticoagulant (OAC) users and non-users. Methods: We conducted a new-user retrospective cohort study by using Minimum Data Set 3.0 assessments linked with Medicare claims. The participants were Medicare fee-for-service beneficiaries with atrial fibrillation residing in US nursing homes between 2011 and 2016, aged ≥ 65 years. The primary outcomes were occurrence of an ischemic stroke or systemic embolism (effectiveness), occurrence of intracranial or extracranial bleeding (safety) and net clinical outcome (effectiveness or safety outcomes). Secondary outcomes included total mortality and a net clinical and mortality outcome. Cox proportional hazards and Fine and Grey models estimated multivariable adjusted hazard ratios (aHRs) and sub-distribution hazard ratios (sHRs). Results: Outcome rates were low (effectiveness: OAC: 0.86; non-users: 1.73; safety: OAC: 2.26; non-users: 1.75 (per 100 person-years)). OAC use was associated with a lower rate of the effectiveness outcome (sHR: 0.69; 95% Confidence Interval (CI): 0.61–0.77), higher rates of the safety (sHR: 1.70; 95% CI: 1.58–1.84) and net clinical outcomes (sHR: 1.20; 95% CI: 1.13–1.28) lower rate of all-cause mortality outcome (sHR: 0.60; 95% CI: 0.59–0.61), and lower rate of the net clinical and mortality outcome (sHR: 0.60; 95% CI: 0.59–0.61). Warfarin users, but not DOAC users, had a higher rate of the net clinical outcome versus OAC non-users. Conclusions: Our results support the benefits of treatment with OACs to prevent ischemic strokes and increase longevity, while highlighting the need to weigh apparent benefits against elevated risk for bleeding. Results were consistent with net favorability of DOACs versus warfarin. [ABSTRACT FROM AUTHOR]

Introduction: Limited data on atrial fibrillation (AF) are available from the Middle East and North Africa region (MENA). The aim of the FLOW-AF registry was to evaluate the characteristics, treatment patterns, and clinical and economic outcomes of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) in MENA. Methods: This multi-center, prospective, observational study (the FLOW-AF registry) enrolled patients newly diagnosed with NVAF across Egypt, Lebanon, Kingdom of Saudi Arabia, and United Arab Emirates. The data collection occurred at enrollment (baseline) and after 6- and 12-months (follow-up). Baseline data included demographics, AF characteristics, medical history, and anti-thrombotic treatment patterns. Clinical events, healthcare resource utilization, and direct costs were collected at follow-up. Results: The study enrolled a total of 1418 patients (52.7% males and 47.3% females). The mean age of the patients was 64.5 years and 90.6% were white. The mean (standard deviation) CHA2DS2-VASc and HAS-BLED risk scores were 2.7 (1.6) and 1.6 (1.2), respectively. Non-vitamin K antagonist oral anticoagulants, antiplatelet therapy, and vitamin K antagonists were prescribed to 65.8%, 16.4%, and 12.9% patients, respectively. During follow-up, the following rates of clinical outcomes were observed: bleeding events (1.7%), transient ischemic attack (1.7%), all-cause mortality (1.7%), stroke (0.6%), myocardial infarction (0.2%), and systemic embolism (0.08%). Conclusions: This MENA patient population was younger and had lower mean baseline CHA2DS2-VASc and HAS-BLED scores. The rates of clinical outcomes over 1-year in this study were low. Longer follow-up is required to comprehensively assess clinical outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Introduction: Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data. Methods: Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada. Results: The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%). Conclusions: The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching. [ABSTRACT FROM AUTHOR]

Background: Dabigatran etexilate is a pro-drug hydrolyzed into dabigatran by carboxylesterases (CES) and is a substrate of the P-Glycoprotein encoded by the adenosine-triphosphate-binding cassette sub-family B member (ABCB)1 genes. We evaluated the functional response to dabigatran according to different CES1 and ABCB1 single-nucleotide polymorphisms (SNPs) in patients with atrial fibrillation (AF). Methods: A total of 100 consecutive patients with AF taking dabigatran were enrolled by two Italian centers. A venous blood sample was drawn for genetic determinations, as well as a measurement of the diluted thrombin time (dTT) and drug plasma concentrations, at the trough and peak. The main objective was the relationship between the dTT values and CES1 rs2244613, CES1 rs8192935 and ABCB1 rs4148738 SNP while on two different dabigatran doses (110 and 150 mg BID). Results: A total of 43 patients were on a 110 mg dabigatran dose and 57 on 150 mg. The DTT values at the trough and at peak were not different among patients with different CES1 rs2244613 and CES1 rs8192935 genotypes, regardless of the dabigatran dose. In patients on 150 mg dabigatran, the dTT values at the trough were 77 (44–111) ng/mL in patients with the ABCB1 rs4148738 heterozygous CT genotype vs. 127 (85–147) ng/mL in the wild-type CC genotype vs. 110 (47–159) ng/mL in the mutant trait TT genotype (p = 0.048). In patients with the ABCB1 rs4148738 CT genotype, OR for having dTT values at a trough below the median was 3.21, 95% CI 1.04–9.88 (p = 0.042). Conclusions: ABCB1 rs4148738 CT heterozygous is associated with the reduced anticoagulant activity of dabigatran at the trough in patients receiving the higher dose regimen. [ABSTRACT FROM AUTHOR]

Background Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem. Methods and Results Retrospective observational cohort study of incident cases of atrial fibrillation from population‐based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow‐up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow‐up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels. Conclusions Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.

Carlo Rostagno,1,2 Giulio Maria Mannarino,2 Alessandro Cartei,2 Gaia Rubbieri,2 Alice Ceccofiglio,2 Anna Maria Gori,1– 4 Roberto Civinini,3 Rossella Marcucci1– 4 1Dipartimento Medicina sperimentale e clinica, Università di Firenze, Firenze, Italy; 2Medicina Interna e Post-Chirurgica, AOU Careggi, Firenze, Italy; 3Traumatologia e Ortopedia, AOU Careggi, Firenze, Italy; 4Malattie aterotrombotiche, AOU Careggi, Firenze, ItalyCorrespondence: Carlo Rostagno, Asssociate Professor of Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, Florence, 50134, Italy, Email carlo.rostagno@unifi.itPurpose: Aim of the present study was to evaluate whether monitoring direct oral anticoagulant (DOAC) levels may improve management of anticoagulated patients who need surgery for hip fracture.Patients and Methods: A total of 147 out of 2231 (7.7%) patients with hip fracture admitted to a tertiary teaching hospital were on DOACs (group A), whereas 206 patients matched for age, sex, and type of fracture not on anticoagulant or P2Y12 platelet inhibitors were considered as control group (group B). Patients on DOACs were divided into two subgroups: A1 in which intervention was scheduled in relation to the last drug intake according to current guidelines, and A2 included patients in whom time of surgery (TTS) was defined according to DOAC levels. Neuraxial anesthesia was considered with DOAC levels < 30 ng/mL, general anesthesia for levels in the range 30– 50 ng/mL.Results and conclusions: TTS was significantly lower in controls than in DOAC patients: surgery within 48 hours was performed in 80.6% of group B versus 51% in group A (p< 0.0001). In A2, 41 patients underwent surgery within 48 hours (56%) in comparison to 32 A1 patients (45.1%; p=0.03). TTS and length of hospitalization were on average 1 day lower in patients with assay of DOAC levels. Finally, 35/39 (89%) patients with DOAC levels < 50 ng/mL had surgery within 48 hours (26 under neuraxial anesthesia, without any neurological complication, and 13 in general anesthesia).Conclusion: DOAC assay in patients with hip fracture may be useful for correct definition of time to surgery, particularly in patients who are candidates for neuraxial anesthesia. Two-thirds of patients with DOAC levels < 50 ng/mL at 48 hours from last drug intake underwent uneventful neuraxial anesthesia, saving at least 24 hours in comparison to guidelines.Keywords: fragility fractures, oral anticoagulants, DOAC assay, safety

Lets organize a nice funeral for warfarin – told by Eugene Braunwald twenty years ago, when first large scale studies had been planned and started with direct oral anticoagulants (DOACs), earlier called novel oral anticoagulants (NOACS). However this funeral has not happened yet, the paradigm shift, the success, the safety, the accessibilty and the comfort of oral anticoagulant treatment has become part of our praxis. These medicines are currently accessible as generics, improving the general usage of them. Why we could not undertake coumadins, why these drugs still remained part of our medical activities – will be shown next.

Objectives: Patient information leaflets play a crucial role in educating patients about their conditions and in sharing the responsibility for treatment and follow-up with their physicians. Purpose of this study indentifying the readability level of prospectuses according to national education system of our country and comparing the readability ratios among each other. Materials and Methods: Fifteen oral anticoagulants and their equivalents, various readability analyses were performed, including the Gunning Fog Index (FOG), Automated Readability Index (ARI), Flesch-Kincaid Readability Analysis, Flesch Reading Ease (FRE), Ateşman, Coleman-Liau, and Powers-Sumner-Kearl (PSK). Results: The metrics we extracted were calculated according to the formulas developed for criteria, such as Simple Measure of Gobbledygook, FOG, ARI, Flesch-Kincaid, FRE, Ateşman, Coleman-Liau, and PSK which are primarily scientifically accepted and have been developed to understand readability. According to the Ateşman scale, the average readability value of patient information leaflets is 53.2. It is observed that the readability value of the patient information leaflets for 15 oral anticoagulant drugs is between 50 and 59 on the Ateşman scale. Leaflets are moderately difficult to understand and requires high school education. IN terms of comparison patient information forms of Eliquis 2.5/5 mg and Pradaxa 150 mg were easier to read, unlike Pradaxa 110 mg. Conclusion: All the 15 oral anticogulants’ prospectuses requires simplifying an education level that equivalent to the average schooling years in Turkey, which is 6 years, instead of a high school-level education.

Background: The impact of oral anticoagulants (OACs) on cognitive impairment and dementia in patients with atrial fibrillation (AF) is not well characterized. This systematic review aims to address this knowledge gap. Methods: SCOPUS and PubMed searches were conducted to identify articles in the English language investigating the association between the use of OACs and cognitive impairment and dementia. We excluded non-original research studies and studies that did not report data on cognitive impairment or included patients who underwent open heart surgery or had psychiatric illnesses or cancer. Results: Out of 22 studies (n = 606,404 patients), 13 studies (n = 597,744 patients) reported a reduction in cognitive impairment/dementia in those undergoing thromboprophylaxis. Using direct oral anticoagulants (DOACs) was associated with a lower incidence of cognitive impairment in 10 studies (n = 284,636 patients). One study found that patients undergoing dual therapy (n = 6794 patients) had a greater incidence of cognitive impairment compared to those undergoing monotherapy (n = 9994 patients). Three studies (n = 61,991 patients) showed that AF patients on DOACs had a lower likelihood of dementia diagnosis than those on vitamin K antagonists (VKAs). Dementia incidence was lower when VKAs were under good control. Conclusions: The use of oral anticoagulants has the potential to prevent cognitive impairment and dementia in patients with AF. Since most of the published research on this subject is observational in nature, more randomized controlled trials are needed to fully understand the effect of anticoagulants on cognitive function. [ABSTRACT FROM AUTHOR]

Oral anticoagulants (OACs) are recommended for patients with atrial fibrillation (AFib) having CHA2DS2-VASc score ≥ 2. However, the benefits of OAC initiation in patients with AFib and cancer at different levels of CHA2DS2-VASc is unknown. We included patients with new AFib diagnosis and a record of cancer (breast, prostate, or lung) from the 2012–2019 Surveillance, Epidemiology, and End Results (SEER)-Medicare database (n = 39,915). Risks of stroke and bleeding were compared between 5 treatment strategies: (1) initiated OAC when CHA2DS2-VASc ≥ 1 (n = 6008), (2) CHA2DS2-VASc ≥ 2 (n = 8694), (3) CHA2DS2-VASc ≥ 4 (n = 20,286), (4) CHA2DS2-VASc ≥ 6 (n = 30,944), and (5) never initiated OAC (reference group, n = 33,907). Confounders were adjusted using inverse probability weighting through cloning-censoring-weighting approach. Weighted pooled logistic regressions were used to estimate treatment effect [hazard ratios (HRs) and 95% confidence interval (95% CIs)]. We found that only patients who initiated OACs at CHA2DS2-VASc ≥ 6 had lower risk of stroke compared without OAC initiation (HR 0.64, 95% CI 0.54–0.75). All 4 active treatment strategies had reduced risk of bleeding compared to non-initiators, with OAC initiation at CHA2DS2-VASc ≥ 6 being the most beneficial strategy (HR = 0.49, 95% CI 0.44–0.55). In patients with lung cancer or regional/metastatic cancer, OAC initiation at any CHA2DS2-VASc level increased risk of stroke and did not reduce risk of bleeding (except for Regimen 4). In conclusion, among cancer patients with new AFib diagnosis, OAC initiation at higher risk of stroke (CHA2DS2-VASc score ≥ 6) is more beneficial in preventing ischemic stroke and bleeding. Patients with advanced cancer or low life-expectancy may initiate OACs when CHA2DS2-VASc score ≥ 6. [ABSTRACT FROM AUTHOR]

Introduction: Cardio- and cerebrovascular diseases are common among persons with Parkinson's disease (PD), but it is unknown how the prevalence of cardiovascular drug and oral anticoagulant use changes in relation to PD diagnosis. Methods: We investigated the prevalence of cardiovascular drug and oral anticoagulant use among persons with and without PD among 17,541 persons who received incident PD diagnosis in 2001–2015 in Finland and their 116,829 matched comparison persons. Prevalence was calculated in 6-month time windows from 5 years before to 5 years after PD diagnosis (index date) and compared to a matched cohort without PD using generalized estimating equations. Results: Persons with PD had higher prevalence of any cardiovascular drugs (unadjusted OR = 1.15; 95% CI: 1.11–1.18) and oral anticoagulants (unadjusted OR = 1.16; 95% CI: 1.11–1.22) before index date than those without PD. After index date, persons with PD had lower prevalence of cardiovascular drugs (0.94; 95% CI: 0.91–0.96), and no difference was observed for oral anticoagulants. Prevalence of any cardiovascular drugs on the index date was 66 and 61% for persons with and without PD, respectively. β-blockers were the most common cardiovascular drugs in both cohorts. Warfarin was the most common oral anticoagulant, but the use of direct oral anticoagulants increased during the last years of follow-up. Conclusion: Orthostatic hypotension and weight loss likely explain the decreased cardiovascular drug use after PD diagnosis. Results with oral anticoagulants may reflect clinical assessment of benefits being larger than risks, despite the risks associated with their use in persons with PD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To explore the bleeding risk of Chinese medicine decoctions for promoting blood circulation and removing blood stasis combined with oral anticoagulants. METHODS: A total of 158 patients who received oral anticoagulants and Chinese medicine decoctions for promoting blood circulation and removing blood stasis in the hospital in 2022 were extracted to be divided into the combined group (n = 80) and control group (n = 78) according to different treatment regimen of Chinese medicine decoctions for promoting blood circulation and removing blood stasis. The oral anticoagulants in the control group included warfarin, rivaroxaban, and dabigatran etexilate; while the Chinese medicine decoctions for promoting blood circulation and removing blood stasis used in the combined group included Radix Salviae, Chuanxiong Rhizoma, Achyranthis Bidentatae Radix, etc. . Prothrombin time-international normalized ratio (PT-INR), fibrinogen (FIB), D-dimer (D-D), activated partial thromboplastin time (APTT), thrombin time (TT) and incidence of bleeding events of two groups were observed. RESULTS: There were no significant differences in PT-INR, FIB, D-D, APTT and TT between the combined group and control group (P> 0. 05). The incidence of bleeding events in the combined treatment group was 66. 25% (53/80), higher than 42. 31% (33/78) in the control group, the difference was statistically significant (P < 0. 05). CONCLUSIONS: Although the relevant coagulation indicators do not change significantly after the combined use of Chinese medicine decoctions for promoting blood circulation and removing blood stasis and oral anticoagulants, the incidence of bleeding events in patients increased significantly. In clinical use, it is necessary to pay attention to Chinese medicine decoctions for promoting blood circulation and removing blood stasis, including Radix Salviae, Chuanxiong Rhizoma, Achyranthis Bidentatae Radix and Carthami Flos, or the combination of Chinese medicine decoctions and oral anticoagulants could increase the risk of bleeding. This study provides some reference for the study of interaction between Chinese and Western medicines. [ABSTRACT FROM AUTHOR]

Background A rapid shift has occurred from vitamin K antagonists toward direct oral anticoagulants, which have a lower risk of intracerebral hemorrhage (ICH). However, effects on clinical outcomes after ICH are understudied. We aimed to describe the prevalence of antithrombotic drugs and to study the prognosis among prestroke functionally independent Swedish patients with ICH. Methods and Results We identified all patients diagnosed with nontraumatic ICH in 2017 to 2021 from the Swedish Stroke Register (n=13 155) and assessed death and functional outcome at 3 months after ICH in prestroke functionally independent patients (n=10 014). Functional outcome was estimated among 3‐month survivors on the basis of self‐reported activities of daily living scores. Risks of outcomes were estimated using Poisson regression. In 13 155 patients, 14.5% used direct oral anticoagulant, 10.1% vitamin K antagonists, and 21.6% antiplatelets at ICH onset. Among 10 014 pre‐stroke activities of daily living–independent patients, oral anticoagulants and antiplatelets were associated with increased mortality risk (adjusted risk ratio, 1.27 [95% CI, 1.13–1.43]; P

The aim of the study was to investigate the dynamics of inpatient consumption of direct oral anticoagulants in different regions of the Russian Federation for the period from 2017 to 2022.Materials and methods. This study is a non-interventional, retrospective analysis of the electronic database records of Cursor Marketing LLC (Russia) about the announced by medical organizations and executed contracts for the purchase of direct oral anticoagulants (DOACs). The сonsumption was calculated on the basis of a DDD (defined-daily-dose) and estimated DDDTID (defined-daily-dose/1000-inhabitants/day) for each DOACs: rivaroxaban, dabigatran and apixaban. The Rosstat database available on its official website were used as a source of inhabitants data for the Russian regions.Results. A total of 57 866 records were entered into the analyzed databases of Cursor Marketing LLC (Russia) from 2017 to 2022, 47.38% of which indicated rivaroxaban as the drug being procured, 26.51% indicated dabigatran, and 26.11% indicated apixaban. Edoxaban was not procured by healthcare organizations. During the period investigated, there was an increase in the consumption of all DOACs studied, with a higher increase for apixaban (by an average of 284.6% per year), then rivaroxaban (by 144.8% per year) and, to a lesser extent, dabigatran (by 92.5% per year). The analysis of DOACs consumption in general showed that compared to 2017, the need for these drugs in medical organizations in 2022 increased by 18 times. The Urals Federal District consistently exceeds the national average in terms of DDTID consumption. Noteworthy is the consumption dynamics of the regions of the Central Federal District and the North-Western Federal District, which made it possible to achieve DDDTID values above the national average for 5 out of 6 observation years. The lowest rates of DOACs consumption were observed in the Volga Federal District, which, despite positive growth dynamics, failed to reach the national average values. A high level of consumption (>10 DDDTID) of rivaroxaban was noted for the Arkhangelsk region (2018) and the Nenets Autonomous District (in 2021), dabigatran – only for the Arkhangelsk region (in 2018). Many more regions reached high levels of the apixaban consumption, especially in 2021.Conclusion. Despite a number of limitations, the data on the volume of DOACs procurement can be used in the analysis of the consumption at both regional and national levels. When analyzing the DOACs consumption, the impact of COVID-19 pandemic and pharmacogenetic features of patients in different regions should be taken into account. During the studied period of time, a significant part of the Russian regions achieved a consumption level of rivaroxaban and apixaban, but not dabigatran, exceeding 1 DDDTID.

Yue Cao, Yue-Yue Feng, Wei Du, Jing Li, Ya-Lan Fei, Hao Yang, Meng Wang, Shi-Jie Li, Xian-Jin Li, Bing Han Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of ChinaCorrespondence: Bing Han, Division of Cardiology, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, People’s Republic of China, Tel +86-516-83985069, Fax +86-516-83956012, Email hbing777@hotmail.comPurpose: To investigate the reasons for elderly atrial fibrillation (AF) patients not continuing their oral anticoagulation (OAC) treatment and the factors that influence this behavior.Methods: Elderly AF patients (aged≥ 75 years) hospitalized from December 2019 to May 2022 were consecutively enrolled. Clinical, demographic, and concomitant medication data were collected. The endpoint was defined as OAC discontinuation for more than 30 days or a switch to an alternative therapy. Predictors of OAC non-persistence were investigated using a multivariable Cox regression model.Results: This study included 560 participants (51.1% men, mean age 80.9± 0.2 years). During a median follow-up of 20 months, medication persistence was observed in 322 patients (57.5%). Non-persistence was found to be significantly higher with warfarin than with NOAC (48.8% vs 33.6%, p = 0.006). In the multivariate analysis, OAC non-persistence was independently predicted by a history of permanent pacemaker implantation, the use of antiplatelet drugs, employee Medicare, living with children, college degree or above, and persistent AF (HR = 1.580, 1.586, 0.604, 0.668, 0.028, 0.769, p < 0.05, respectively). Treatment discontinuation within 3 months of discharge was observed in a large number of patients (81.8%). Medication discontinuation due to bleeding was more frequently observed in patients who continued for longer than 3 months (p < 0.001), while discontinuation due to patient preference was more frequent in those with shorter durations (≤ 3 months) (p = 0.049). Patient preference was the second leading cause of non-persistence in patients, regardless of whether they were taking warfarin or NOAC.Conclusion: OAC non-persistence remains high among elderly AF patients during long-term follow-up, with a significant proportion discontinuing shortly after discharge. This pattern of non-persistence is heavily influenced by demographic factors and patient preference. Further interventions should be developed based on the reasons and risk factors to improve persistence and initiated early in the treatment process.Keywords: atrial fibrillation, the elderly, oral anticoagulants, non-persistence

Background: In this study the organization of long-term anticoagulant treatment has been evaluated to estimate whether clinical practice is in accordance with current recommendations for optimal use and effective control of oral anticoagulant (OAC) treatment. Material and methods: Mixed (quantitative and qualitative), transversal, descriptive, selective study. Samples: quantitative study – 394 adult patients, eligible for anticoagulant treatment; qualitative study – 39 family doctors. Results: The rate of use of OAC treatment is 68%. The period from the diagnosis of the disease to the initiation of OAC treatment lasted one month or more in 59.1% of patients. 60.6% of patients do not have sufficient knowledge regarding the treatment of OAC. The high price is the most important barrier to direct oral anticoagulant administration (91.1%). Patients’ satisfaction with OAC treatment control is low, mainly for vitamin K antagonists (59.8%). 75.5% of respondents claim that OAC treatment control and management is poor. 40.3% do not perform safe therapeutic International Normalized Ratio control, and 54.7% are not in the optimal therapeutic range. Conclusions: The main barriers to adherence to OAC treatment: the burden of regular monitoring of blood parameters, perceived concern about complications, limited access to laboratory tests and specialist doctors, insufficient information about anticoagulation, and deficiencies in communication with medical staff. There is limited conviction, and uncertainty persists in the initiation and monitoring of OAC treatment by family doctors.

Left ventricular thrombosis (LVT) is a very serious condition and life-threatening complication that usually occurs after acute occlusion of the left anterior descending (LAD) coronary artery followed by acute myocardial infarction with ST-segment elevation (STEMI), which leads to significant regional wall motion abnormality (RWMA). It should be noted that its diagnosis, treatment, and management are challenging now and depend on various factors such as the type of thrombus, time of percutaneous coronary intervention (PCI), and underlying disease. The preferred diagnostic method is cardiovascular magnetic resonance imaging (CMR), but transthoracic echocardiography (TTE) is routinely used for diagnostic and screening purposes also follow-up of response to treatment. It is worth mentioning that when the diagnosis of left ventricular thrombus is not clear with conventional echocardiography, contrast echocardiography is used for more resolution and detailed information. Left ventricular thrombosis can appear in both acute and chronic forms and lead to significant complications, the most important of them are stroke and systemic arterial embolism (SE). According to previous studies, vitamin K antagonist (warfarin) by keeping INR within the therapeutic range currently used to treat left ventricular thrombosis. Although the use of direct oral anticoagulants (DOAC) has brought excellent outcomes, but due to the lack of large clinical trials, the routine use of these agents is controversial, and only in case of warfarin intolerance or contraindications, DOACs can be used as an alternative. Generally, the best way to prevent left ventricular thrombosis is primary percutaneous coronary angioplasty (primary PCI) which preserves left ventricular function. Depending on the sensitivity of the diagnostic method, thrombus will likely resolve in >50% of patients by six months after the MI. On the other hand, in rare cases, surgery is indicated if a thrombosis remains despite the medical treatment especially if it is accompanied by a left ventricular aneurysm. The purpose of this narrative review is to evaluate the latest evidence in the field of left ventricular thrombosis management and to adopt the best approach for these patients.

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies—e.g., osocimab, anti-sense oligonucleotides—e.g., fesomersen, and small molecule inhibitors—e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease.

Abstract Background The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations. Methods We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, − 1 and − 2 to each risk category, respectively. Results In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to − 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common. Conclusions While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.

Background: Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment. Methods: The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword. Results: Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001). Conclusions: A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.

Objective: Oral anticoagulant drugs, such as warfarin, are widely used for preventing and treating vascular and thromboembolic disease in patients with chronic atrial fibrillation, venous thrombosis, and coronary heart disease. As oral anticoagulant therapy has such a narrow therapeutic range, complications in administering these drugs can prove to have a detrimental effect on patients such as life-threatening bleeding might occur. It is therefore necessary to have an adequate knowledge about its actions and its interactions with other dietary factors or any other medication involved. This study was therefore formulated in order to evaluate the knowledge as well as to impart proper awareness to the medical undergraduate students about oral anticoagulation therapy such as to prevent any untoward situation that may arise from the process. Methods: A cross-sectional descriptive study was used to assess the knowledge on oral anticoagulant therapy among the medical undergraduates of a tertiary care hospital. A pre-validated structured questionnaire consisting of 28 questions was adopted, and a separate questionnaire was used for each student. Timing of answering the questionnaire was set at 30 minutes. Scores were evaluated such as a correct answer was given a score of one and wrong answer awarded as zero. Adequate knowledge sore was set above 70% and inadequate knowledge at less than 40%. Results: The response rate was found out to be 67.33% with gender distribution observed to be 71% females and 29% males. From the answers evaluated, overall average score of 67.3 ± 15.9 was obtained indicating that most of the respondents have adequate knowledge about the different mechanism, drug–drug interactions, drug–food interactions, and side effects of anticoagulant therapy, and 100% of the students are well aware about the complications and procedures involved to dissipate information about warfarin therapy. Conclusions: Adequate exposure of students to clinical cases will further help them to focus on the importance of anticoagulation and strengthening their knowledge regarding anticoagulant drug therapy. This will influence the process of physician–patient communication for improving anticoagulation outcome.

Abstract Background Anemia is encountered in patients with nonvalvular atrial fibrillation (NVAF) on oral anticoagulants (OACs) but the prognostic impact was not well scrutinized in real‐world settings. Methods We conducted a historical multicenter registry of patients with NVAF taking OACs at 71 centers in Japan. Those with mechanical heart valves or a history of pulmonary thrombosis or deep venous thrombosis were excluded. Anemic patients were divided into three groups of hemoglobin (Hb) level: moderate/severe (Hb

Abstract Background Treatment with oral anticoagulants (OACs) could prevent stroke in atrial fibrillation (AF), but side effects developed due to OACs may cause patients anxiety during decision making. This study aimed to investigate whether shared decision making (SDM) reduces anxiety and improves adherence to stroke prevention measures in patients with AF. Methods A one-group pretest–posttest design using a questionnaire survey was applied at the outpatient cardiology clinic between July 2019 until September 2020. A Patient Decision Aid (PDA) tool was used for the completion of the questionnaire survey after health education and counseling. Ten questions were included for patients’ recognition of SDM, and a 5-point scoring method was used, where “very much” was scored as 5 points, and “totally not” was scored as 1 point. Results Fifty-two patients with AF were enrolled. In terms of patients’ recognition of SDM, points of more than 4.17 out of 5 were noted, indicating recognition above the level of “very much.” The patients’ anxiety scores before SDM were 3.56 (1.2), with a decrease of 0.64 points (p

Study objective: This study aimed to identify factors associated with delayed oral anticoagulant (OAC) treatment initiation among atrial fibrillation (AF) patients in United States (US) clinical practice. Participants: Medicare beneficiaries newly diagnosed with AF without moderate-to-severe mitral stenosis or a mechanical heart valve, were aged ≥65 years and prescribed OAC on or after 10/1/2015 through 2019 were included. Delayed and early OAC initiation were defined as >3 months and 0–3 months initiation from first AF diagnosis, respectively. Main outcome measures: Association between delayed OAC initiation and patient demographics, clinical and index OAC coverage and formulary characteristics was examined using multivariable logistic regression. Results: A total of 446,441 patients met the inclusion criteria; 30.0 % (N = 131,969) were identified as delayed and 70.0 % (N = 314,472) as early OAC initiation. Median age for both cohorts was 78 years. In the early and delayed OAC cohorts, 47.1 % and 47.6 % were male and 88.8 % and 86.6 %, were White, respectively. Factors associated with delayed OAC initiation (odds ratio; 95 % confidence interval) included Black race (1.29; 1.25 to 1.33), west region (1.29; 1.26 to 1.32), comorbidities such as dementia (1.27; 1.23 to 1.30), recent bleeding hospitalization (1.22; 1.18 to 1.27), prior authorization (1.69; 1.66 to 1.71), tier 4 formulary for index OAC at AF diagnosis (1.26; 1.22 to 1.30). Conclusion: Our study revealed that nearly one-third of Medicare patients with AF experienced delayed OAC initiation. Key patient characteristics found to be associated with delayed OAC initiation included race and ethnicity, comorbidities, and formulary restrictions.

Cancer is a leading cause of morbidity and mortality worldwide. It is also one of the strongest risk factors for venous thromboembolism (VTE), reported in approximately 20% of all cases of VTE diagnosed. The thrombotic effect of cancer and its treatments, however, is highly variable among patients and changes over the course of their cancer. Anticoagulant therapy remains the cornerstone of VTE treatment, but it is associated with a substantial rate of VTE recurrence and the potential for serious bleeding. The risk of bleeding in patients with cancer is also dependent on the cancer type and its treatments, often revealing underlying tumor invasion of mucosal or parenchymal tissues, and treatment complications such as thrombocytopenia or coagulopathy. Over the past few decades, efforts to improve the efficacy and safety of anticoagulant therapy for the treatment and prevention of cancer-associated thromboembolism have resulted in changes in the standard of practice. This evolution has been made possible largely through the development of new anticoagulants. This review will reflect on the major advances in the treatment of cancer-associated thrombosis and offer insights on how to address unmet needs in this field. [ABSTRACT FROM AUTHOR]

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Copyright of Heart & Vascular Diseases / Choroby Serca & Naczyn is the property of VM Medica-VM Group (Via Medica) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: Patient information leaflets play a crucial role in educating patients about their conditions and in sharing the responsibility for treatment and follow-up with their physicians. Purpose of this study indentifying the readability level of prospectuses according to national education system of our country and comparing the readability ratios among each other. Materials and Methods: Fifteen oral anticoagulants and their equivalents, various readability analyses were performed, including the Gunning Fog Index (FOG), Automated Readability Index (ARI), Flesch-Kincaid Readability Analysis, Flesch Reading Ease (FRE), Ateşman, Coleman-Liau, and Powers-Sumner-Kearl (PSK). Results: The metrics we extracted were calculated according to the formulas developed for criteria, such as Simple Measure of Gobbledygook, FOG, ARI, Flesch-Kincaid, FRE, Ateşman, Coleman-Liau, and PSK which are primarily scientifically accepted and have been developed to understand readability. According to the Ateşman scale, the average readability value of patient information leaflets is 53.2. It is observed that the readability value of the patient information leaflets for 15 oral anticoagulant drugs is between 50 and 59 on the Ateşman scale. Leaflets are moderately difficult to understand and requires high school education. IN terms of comparison patient information forms of Eliquis 2.5/5 mg and Pradaxa 150 mg were easier to read, unlike Pradaxa 110 mg. Conclusion: All the 15 oral anticogulants' prospectuses requires simplifying an education level that equivalent to the average schooling years in Turkey, which is 6 years, instead of a high school-level education. [ABSTRACT FROM AUTHOR]

Background: Mechanical thrombectomy (MT) remains an effective treatment for patients with acute ischemic stroke receiving oral anticoagulation (OAC) and large vessel occlusion (LVO). However, to date, it remains unclear whether MT is safe in patients on treatment with OAC. Aims: In our study, we performed a propensity-matched analysis to investigate the safety and efficacy of MT in patients with acute ischemic stroke receiving anticoagulants. A propensity score method was used to target the causal inference of the observational study design. Methods: This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. Demographic, neuro-imaging and clinical data were collected and compared according to the anticoagulation status at baseline, patients on OAC vs those not on OAC. The primary study outcomes were the occurrence of any intracerebral haemorrhage (ICH) and symptomatic ICH. The secondary study outcomes were functional independence at 90 days after stroke (defined as modified Rankin Scale (mRS) scores of 0 through 2), mortality at 3 months and successful reperfusion rate according to the modified treatment in cerebral infarction (mTICI) score. Results: Overall, our cohort included 573 patients with acute ischemic stroke and LVO treated with MT. After propensity score matching, 495 patients were matched (99 OAC group vs 396 no OAC group). There were no differences in terms of clinical characteristics between the two groups, except for the rate of intravenous thrombolysis less frequently given in the OAC group. There was no significant difference in terms of the rate of any ICH and symptomatic ICH between the two groups. With regards to the secondary study outcome, there was no significant difference in terms of the rate of successful recanalization post-procedure and functional independence at 3 months between the two groups. Patients in the OAC group showed a reduced mortality rate at 90 days compared to the patients with no previous use of anticoagulation (20.2% vs 21.2%, p = 0.031). Logistic regression analysis did not reveal a statistically significant influence of the anticoagulation status on the likelihood of any ICH (OR = 0.95, 95% CI = 0.46–1.97, p = 0.900) and symptomatic ICH (OR = 4.87, 95% CI = 0.64–37.1, p = 0.127). Our analysis showed also that pre-admission anticoagulant use was not associated with functional independence at 90 days after stroke (OR = 0.76, 95% CI = 0.39–1.48, p = 0.422) and rate of successful reperfusion (OR = 0.81, 95% CI = 0.38–1.72, p = 0.582). Conclusion: According to our findings anticoagulation status at baseline did not raise any suggestion of safety and efficacy concerns when MT treatment is provided according to the standard guidelines. Confirmation of these results in larger controlled prospective cohorts is necessary. [ABSTRACT FROM AUTHOR]