Is There a Role for Vitamin K Antagonist in the Management of Atrial Fibrillation in 2023?

PURPOSE OF REVIEW: To address the following question: Are vitamin K antagonists (VKA) obsolete as stroke prevention therapy for patients with atrial fibrillation (AF) and thromboembolic risk factors? RECENT FINDINGS: A patient-level meta-analysis of the pivotal phase III randomized trials confirmed the favorable treatment effect of direct oral anticoagulants (DOAC) over VKA in multiple key patient subgroups. Among patients with AF and rheumatic heart disease (85% of whom had mitral stenosis), a randomized trial showed that rivaroxaban was not superior to VKA for stroke prevention. Caution should be exercised when prescribing DOAC for AF-related stroke prevention for patients with elevated body mass indices or history of bariatric surgery, patients with bioprosthetic heart valves, and those who require treatment with drugs that interact with cytochrome P450 and P-glycoprotein. Drug costs associated with DOAC remain considerably higher than VKA, by up to 30-fold. Direct oral anticoagulants are preferable over VKA in the large majority of eligible patients with AF and thromboembolic risk factors. The use of DOAC should be avoided for patients with mechanical heart valves or moderate/severe rheumatic mitral stenosis. Vitamin K antagonist is a reasonable option for patients who are under-represented in randomized trials, when there are significant drug-drug interactions or when patients cannot afford DOAC agents due to their higher costs.

Health Care Utilization After Ventricular Tachycardia Ablation: A Propensity Score-Matched Cohort Study.

BACKGROUND: Catheter ablation of ventricular tachycardia (VT) can reduce the burden of ventricular arrhythmia (VA) but its effect on health care utilization and costs after such therapy is poorly known. We sought to compare the rates of cardiovascular (CV)-related hospitalizations, survival, and health care costs in patients with recurrent VT treated either with VT ablation or with medical therapy. METHODS: One-hundred implantable cardioverter-defibrillator patients with structural heart disease who underwent VT ablation were included. Propensity score-matched patients with recurrent VT treated with medical therapy were identified from a prospective registry of approximately 7000 de novo implantable cardioverter-defibrillator patients. Outcomes and costs were ascertained using health administrative databases. RESULTS: Among patients who underwent VT ablation, the cumulative rates of VA-related hospitalizations were lower in the 2 years after their ablation procedure compared with the year before (rate ratio, 0.3; 95% confidence interval [CI], 0.22-0.43). Rates of CV-related hospitalization and hospitalization because of VA post index date were similar between the VT ablation and medical therapy groups (hazard ratio [HR], 0.94; 95% CI, 0.57-1.54 and HR, 1.04; 95% CI, 0.57-1.91, respectively). Health care costs in the VT ablation patients were not increased post-ablation compared with the medical management group. The risk of all-cause mortality was lower among patients in the VT ablation group relative to the medical therapy group (HR, 0.64; 95% CI, 0.4-0.99). CONCLUSIONS: Patients who underwent VT ablation experienced a significant reduction in their rate of VA-related hospitalizations. Patients treated with VT ablation had similar rates of CV-related hospitalization compared with those treated with medical therapy without increased health care-related costs.

Real-world outcomes, complications, and cost of catheter-based ablation for atrial fibrillation: an update.

PURPOSE OF REVIEW: Catheter-based ablation for atrial fibrillation is a useful and effective form of rhythm-control therapy for symptomatic patients. This article reviews the 'real-world' experience on the outcomes, complications, and costs of atrial fibrillation ablation. RECENT FINDINGS: Currently, real-world outcomes of atrial fibrillation ablation are derived from retrospective analysis of administrative databases or prospective registries from selected centers and patients. The rate of atrial fibrillation recurrence was reported to be as high as 60% and the rate of repeat ablation ranged from ≈10 to 18% within 1 year after ablation. All-cause hospitalizations after atrial fibrillation ablation were frequent, at up to ≈30% within 1 year and with up to half of them related to atrial fibrillation recurrence or repeat procedures. Rates of periprocedural complications were relatively low (≈3%). Female sex was associated with higher risk of complications such as bleeding, vascular injury, and tamponade. Markov models examining the cost-effectiveness of ablation yielded favorable results when success rates of more than 70% were assumed with long time horizons (>5 years). SUMMARY: The real-world outcomes of atrial fibrillation ablation are sobering. Confirmation of these findings with prospective, population-based, minimally biased studies is needed. There is a critical need to delineate the downstream economic impact of atrial fibrillation ablation on society to justify its continued delivery and growth.

Management of postoperative atrial fibrillation after cardiac surgery.

PURPOSE OF REVIEW: Postoperative atrial fibrillation (POAF) occurs commonly after cardiac surgery and is associated with a number of adverse outcomes. This article will review the available evidence on the prevention and treatment of atrial fibrillation after cardiac surgery. Using this knowledge, we propose a conceptual framework on the management of patients with POAF during various phases after cardiac surgery. RECENT FINDINGS: Perioperative ß-blockade is the cornerstone in preventing POAF after cardiac surgery. Results from randomized trials do not support routine use of colchicine or corticosteroids to prevent POAF. There is no study examining the impact of rate versus rhythm control on 'hard' clinical outcomes such as mortality or stroke in the cardiac surgical population. Furthermore, there is a paucity of research on the optimal timing and choice of oral anticoagulation among POAF cardiac surgical patients who are at risk for stroke. SUMMARY: In spite of the plethora of therapies available to treat and prevent POAF in the cardiac surgical population, there is little data to address whether they can improve key clinical outcomes such as death or stroke. Guideline recommendations on rate/rhythm control and oral anticoagulation for stroke prevention in the cardiac surgical population are largely extrapolated from studies of nonsurgical atrial fibrillation patients. Further research is needed to address these key atrial fibrillation management issues specific to the cardiac surgical population.

Health-related quality of life questionnaires: an important method to evaluate patient outcomes in atrial fibrillation ablation.

Improvement of symptoms and health-related quality of life (HRQoL) are important treatment goals in the management of patients with atrial fibrillation (AF). For patients with symptomatic AF, catheter ablation is a commonly performed therapy for rhythm control. As a result, accurate documentation of the changes in HRQoL for these patients is necessary. This paper will review why HRQoL questionnaires are important in evaluating patient outcomes for AF ablation. First, we discuss how the results of these questionnaires can influence the cost-effectiveness of AF ablation. This may, in turn, affect healthcare resource allocation in favor of this therapy. Also, these questionnaires can provide additional information over traditional quantitative measures of AF burden in assessing post-ablation outcomes. By standardizing the way by which HRQoL is measured and reported, these questionnaires are valuable in evaluating this important patient-reported outcome in AF ablation trials.

The role of device diagnostic algorithms in the assessment and management of patients with systolic heart failure: a review.

Hospitalization due to heart failure (HF) exacerbation represents a major burden in health care and portends a poor long-term prognosis for patients. As a result, there is considerable interest to develop novel tools and strategies to better detect onset of volume overload, as HF hospitalizations may be reduced if appropriate interventions can be promptly delivered. One such innovation is the use of device-based diagnostic parameters in HF patients with implantable cardioverter defibrillators (ICD) and/or cardiac resynchronization therapy (CRT) devices. These diagnostic algorithms can effectively monitor and detect changes in patients' HF status, as well as predict one's risk of HF hospitalization. This paper will review the role of these device diagnostics parameters in the assessment and management of HF patients in ambulatory settings. In addition, the integration of these novel algorithms in existing HF disease management models will be discussed.

In vivo assessment of myocardial glucose uptake by positron emission tomography in adults with the PRKAG2 cardiac syndrome.

BACKGROUND: The PRKAG2 cardiac syndrome is an inherited metabolic disease of the heart characterized by excessive myocardial glycogen deposition. The biochemical alterations associated with this condition remain controversial and have not previously been studied in affected humans. METHODS AND RESULTS: Positron emission tomography (PET) imaging was used to quantitatively assess myocardial glucose uptake (MGU) in 6 adult subjects with the PRKAG2 cardiac syndrome and 6 healthy, matched control subjects using the glucose analogue (18)F-Fluoro-2-deoxyglucose (FDG). Studies were performed under a euglycemic hyperinsulinemic clamp to ensure stable blood glucose levels. Rubidium-82 perfusion scans were performed to ensure that myocardial differences in myocardial glucose uptake were not the result of significant myocardial scar. In adult patients with phenotypic expression of disease, the median myocardial glucose uptake of the left ventricle was 0.18 mumol/min/g (interquartile range, 0.14, 0.24), compared with 0.40 mumol/min/g (interquartile range, 0.30 to 0.45) in the control group (P=0.01). The median blood glucose during FDG-PET imaging was 4.72 mmol/L (interquartile range, 4.32 to 4.97) in the PRKAG2 group and 4.38 mmol/L (interquartile range, 3.90, 4.79) in the control group (P=NS). The significant decrease observed in myocardial glucose uptake in affected patients occurred in the absence of significant myocardial scar. CONCLUSIONS: The PRKAG2 cardiac syndrome is associated with a reduction of glucose uptake in adult patients affected with this genetic condition. In this pilot study, (18)F-FDG-PET imaging is a useful tool to assess alterations in myocardial glucose transport in this inherited metabolic disease and provide insight into the biochemical pathophysiology of the diseased state.