Comparison of early and delayed anticoagulation therapy after ischemic stroke in patients with atrial fibrillation: a systematic review and meta-analysis.

The optimal initiation timing of oral anticoagulants (OACs) remains controversial in patients with atrial fibrillation (AF)-related acute ischemic stroke (AIS). The aim of this study is to compare the efficacy and safety of early OACs initiation with that of the delayed initiation for AIS and AF.We searched systematically the following mainstream databases: PubMed, Embase, and Web of Science from the inception to July 2023 for studies that compared the early initiation with the delayed initiation of OACs for AF-related AIS patients. Outcome measures were the incidence of hemorrhagic events, ischemic events, and combined outcomes, as well as all-cause mortality.There were 12 eligible articles included (10 cohort studies and 2 RCT), involving 11421 patients (5690 patients in the early-initiation group and 5731 in the delayed-initiation group). Meta-analysis revealed that patients receiving OACs at the early stage of stroke had a lower incidence of ischemic events (OR: 0.68; 95% CI: 0.55,0.84; p = 0.0003) and combined outcomes (OR=0.74, 95% CI (0.57,0.95), p=0.02). No significant differences were identified in the incidence of hemorrhagic events (p = 0.26) and all-cause mortality ( p = 0.20) between the groups.Early initiation of anticoagulation therapy would be preferable in lowering the incidence of ischemic events and combined outcomes in AIS patients with AF. It is safe compared to the delayed-initiation strategy. However, the conclusion of this study needs to be further validated by more well-designed RCTs.

Variations in the light absorption coefficients of phytoplankton, non-algal particles and dissolved organic matter in reservoirs across China.

Reservoirs were critical sources of drinking water for many large cities around the world, but progress in the development of large-scale monitoring protocols to obtain timely information about water quality had been hampered by the complex nature of inland waters and the various optical conditions exhibited by these aquatic ecosystems. In this study, we systematically investigated the absorption coefficient of different optically-active constituents (OACs) in 120 reservoirs of different trophic states across five eco-regions in China. The relationships were found between phytoplankton absorption coefficient at 675 nm (aph (675)) and Chlorophyll a (Chla) concentration in different regions (R2:0.60-0.82). The non-algal particle (NAP) absorption coefficient (aNAP) showed an increasing trend for reservoirs with trophic states. Significant correlation (p < 0.05) was observed between chromophoric dissolved organic matter (CDOM) absorption and water chemical parameters. The influencing factors for contributing the relative proportion of OACs absorption including the hydrological factors and water quality factors were analyzed. The non-water absorption budget from our data showed the variations of the dominant absorption types which underscored the need to develop and parameterize region-specific bio-optical models for large-scale assessment in water reservoirs.

A Low-Cost Digital Colorimetry Setup to Investigate the Relationship between Water Color and Its Chemical Composition.

Developments in digital image acquisition technologies and citizen science lead to more water color observations and broader public participation in environmental monitoring. However, the implications of the use of these simple water color indices for water quality assessment have not yet been fully evaluated. In this paper, we build a low-cost digital camera colorimetry setup to investigate quantitative relationships between water color indices and concentrations of optically active constituents (OACs). As proxies for colored dissolved organic matter (CDOM) and phytoplankton, humic acid and algae pigments were used to investigate the relationship between water chromaticity and concentration. We found that the concentration fits an ascending relationship with xy chromaticity values and a descending relationship with hue angle. Our investigations permitted us to increase the information content of simple water color observations, by relating them to chemical constituent concentrations in observed waters.

Mentha piperita L. Micropropagation and the Potential Influence of Plant Growth Regulators on Volatile Organic Compound Composition.

Due to the industrial use of Mentha piperita L. (peppermint), it is important to develop an optimal method to obtain standardized plant material with specific quality parameters. In vitro cultures may allow the production of desirable odor-active compounds (OACs) and improve their share in the plant aroma profile. There are two types of explants that are commonly used, apical meristems and nodal segments. In this study, the best overall effects were shown to be produced by the combination of MS medium with the addition of 0.5 mg·dm-3 indolyl-3-butyric acid. In this case, a very high degree of rooting was found (97% for apical meristems, 100% for nodal meristems), lateral shoots were induced in 83% of both types of explant, and the content of OACs in the plant aroma profile increased significantly, especially menthofurolactone and cis-carvone oxide, responsible in this case for a characteristic mint-like aroma. The comparison of the volatile organic compounds (VOCs) obtained from plants of different origin by GC-MS showed no significant differences in their qualitative composition. Moreover, in-vitro-cultivated peppermint on a medium containing 0.5 mg·dm-3 2-isopentinloadenine and 0.1 mg·dm-3 indolyl-3-acetic acid showed significant amounts of menthofurolactone in its VOC composition.

Applicability of human osteoarthritic chondrocytes for in vitro efficacy testing of anti-TNFα drugs.

In vitro cell-based models are important tools for assessing efficacies of new leads in early phases of drug development. Human osteoarthritic chondrocytes (OACs), obtained from biomedical waste material, represent a valuable, relatively accessible cellular source that could be used for this purpose. By employing reverse transcription-polymerase chain reaction (qRT-PCR) we compared gene expression profiles of key anabolic, catabolic and inflammatory genes of freshly isolated vs. monolayer cultured OACs (passages P0-P2) and non-stimulated vs. tumor necrosis factor alpha (TNF-α) stimulated P2 OACs. After expansion of OACs in monolayer cultures, the expression of almost all analyzed genes significantly decreased. The subsequent addition of TNF-α to OACs at P2 significantly increased expressions of all catabolic and inflammatory genes, leaving the anabolic profile almost unchanged. TNF-α-treated OACs were later utilized for efficacy testing of anti-TNF-α drugs infliximab and etanercept and both significantly reduced the expressions of all catabolic and inflammatory genes tested.

Utility of TTR-INR guided warfarin adjustment protocol to improve time in therapeutic range in patients with atrial fibrillation receiving warfarin.

Warfarin remains the most prescribed oral anticoagulant of choice in atrial fibrillation (AF) patient in resource-limited settings. Despite evidence linking Time in Therapeutic Range (TTR) to patient outcomes, its use in clinical practice is not widespread. This prospective study explores the impact of a TTR-INR guided Warfarin adjustment protocol on TTR in AF patients. Conducted at the Warfarin clinic of King Chulalongkorn Memorial Hospital. TTR was calculated using the Rosendaal linear interpolation method at baseline, and then at 6 and 12 months post-protocol implementation. The primary outcome was the improvement in TTR following the protocol's implementation. The study analyzed 57 patients, with a mean age of 72 years and an even gender distribution. At baseline, 53% of patients had a TTR of less than 65%. However, TTR significantly improved from 65% at baseline to 80% after 12 months of protocol implementation (p < 0.001). Furthermore, there was a significant increase in the proportion of patients with a TTR of 65% or more, from 47 to 88% (p < 0.001). During the follow-up period in the first 12 months, three patients died, but no ischemic or major bleeding events occurred. The significant improvement in TTR after 12 months of protocol implementation suggests that this strategy could provide additional value in improving TTR and outcomes in AF patients receiving Warfarin.

Real-world national trends and influencing factors preference of non-vitamin K antagonist oral anticoagulants in China.

Backgrounds: Non-vitamin K antagonist oral anticoagulants (NOACs) have been recommended as the first choice over warfarin for non-valvular atrial fibrillation (AF). However, there is limited data about their usage in mainland China. Methods: Prescriptions of patients diagnosed with AF and containing OACs were extracted from Hospital Prescription Cooperation Project from January 2016 to March 2021. The primary outcome was the changing percentage of different OACs. The secondary outcomes were frequencies as well as factors with the choice of different OACs and dosage of NOACs. Univariate and Multivariate logistic regressions were conducted to explore possible factors. All statistical analyses were performed using SAS software (Version 9.4). Results: Among the 220,083 distinct prescriptions diagnosed with AF and prescribed with OACs, the percentage of NOACs increased over years, exceeding warfarin in 2018. Until March 2021, 83.53% of included patients were prescribed with NOACs. Rivaroxaban (62.25%) and dabigatran (37.65%) were the most commonly prescribed NOACs. Low dosage was common for NOACs (44.54%), this was mainly driven by rivaroxaban, 67.98% of which were low dosage. Multivariate logistic regression indicated that several factors were positively associated with the preference of low dosage, including outpatients (OR 1.32, 95% CI 1.26-1.39), patients with hypertension (OR 1.49, 95% CI 1.40-1.58), acute coronary syndrome (OR 1.17, 95% CI 1.12-1.22), stroke (OR 1.42, 95% CI 1.33-1.52), and kidney disease (OR 1.63, 95% CI 1.34-1.97), as well as concomitantly using antiplatelet agents (OR 1.52, 95% CI 1.40-1.66), and steroids (OR 1.76, 95% CI 1.50-2.07). On the contrary, they were less common in health insurance holder (OR 0.79, 95% CI 0.75-0.84), patients taking apixaban (vs. rivaroxaban, OR 0.39, 95% CI 0.18-0.81), dabigatran (vs. rivaroxaban, OR 0.01, 95% CI 0.01-0.01), edoxaban (vs. rivaroxaban, OR 0.36, 95% CI 0.23-0.55), diagnosed with heart failure (OR 0.87, 95% CI 0.81-0.93), deep vein thrombosis (OR 0.36, 95% CI 0.29-0.46), pulmonary embolism (OR 0.35, 95% CI 0.28-0.43), and peripheral artery disease (OR 0.68, 95% CI 0.55-0.85). Conclusion: The usage of OACs for AF was overall complying with updated guidelines. Low dosage was common for NOACs, further studies were warranted to verify its effectiveness and explore the underlying mechanism.

Seasonal variations in CDOM characteristics and effects of environmental factors in coastal rivers, Northeast China.

Colored dissolved organic matter (CDOM) is highly spatiotemporally varied due to the effects of complex environmental factors within a catchment or system. The seasonal nutritional status and potential risks of heavy metals in the coastal rivers of the Liaohe River basin were evaluated based on 40 water samples in January, April, May, and September. Meanwhile, the effects of environmental factors on CDOM, especially human activities, were quantitatively analyzed. The trophic state index (TSI) and the potential ecological risk index (RI) of heavy metals in the Liaohe River basin exhibited significant differences. The rivers were mesotrophic in January, lightly eutrophic in May, and highly eutrophic in April and September. An extremely high RI was shown in April and May, while a high RI was exhibited in September. CDOM exhibited great seasonal characteristics and showed significant seasonal correlations with environmental factors. Based on multiple general linear model analysis, total phosphorus (TP) was the most influential factor and significantly explained 62.1% of aCDOM(440) (p < 0.01) among the water parameters, followed by total alkalinity (38.3%). The percentages of built-up area exerted significantly positive effects on aCDOM(440) (R2 = 0.44), while distance from oil extraction sites significantly negatively affected aCDOM(440) (r = - 0.328, p < 0.05). Polluting enterprises showed non-significant correlation with CDOM (r = 0.314, p = 0.178).

Sex and gender differences in the use of oral anticoagulants for non-valvular atrial fibrillation: A population-based cohort study in primary health care in catalonia.

Objectives: To describe the sex and gender differences in the treatment initiation and in the socio-demographic and clinical characteristics of all patients initiating an oral anticoagulant (OAC), and the sex and gender differences in prescribed doses and adherence and persistence to the treatment of those receiving direct oral anticoagulants (DOAC). Material and methods: Cohort study including patients with non-valvular atrial fibrillation (NVAF) who initiated OAC in 2011-2020. Data proceed from SIDIAP, Information System for Research in Primary Care, in Catalonia, Spain. Results: 123,250 people initiated OAC, 46.9% women and 53.1% men. Women were older and the clinical characteristics differed between genders. Women had higher risk of stroke than men at baseline, were more frequently underdosed with DOAC and discontinued the DOAC less frequently than men. Conclusion: We described the dose adequacy of patients receiving DOAC, finding a high frequency of underdosing, and significantly higher in women in comparison with men. Adherence was generally high, only with higher levels in women for rivaroxaban. Persistence during the first year of treatment was also high in general, being significantly more persistent women than men in the case of dabigatran and edoxaban. Dose inadequacy, lack of adherence and of persistence can result in less effective and safe treatments. It is necessary to conduct studies analysing sex and gender differences in health and disease.

A cross-sectional study of appropriateness evaluation of anticoagulation therapy for inpatients with nonvalvular atrial fibrillation.

Background: Oral anticoagulants (OACs) are essential for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the appropriateness of anticoagulation treatment in locally practice remains unclear. This study evaluated compliance with anticoagulation therapy concerning the guidelines and drug labels in patients with NVAF. Methods: Hospitalized patients diagnosed with NVAF between 1 November 2020, and 31 December 2021, were retrospectively enrolled. The appropriateness of anticoagulation regimens at discharge was evaluated based on a flowchart designed according to atrial fibrillation (AF) guidelines and medication labels. Furthermore, we explored factors potentially influencing the "no-use of OACs" using binary logistic regression and verified anticoagulation-related issues through a physician questionnaire. Results: A total of 536 patients were enrolled in this study, including 254 patients (47.4%) with inappropriate anticoagulation regimens. 112 patients (20.9%) were categorized as "underdosing-use of OACs," 134 (25%) who needed anticoagulation therapy were "no-use of OACs" and eight (1.5%) were "over-use of OACs." The results of a binary logistic regression analysis showed that paroxysmal AF (odds ratio [OR], 7.74; 95% confidence interval [CI], 4.57-13.10), increased blood creatinine levels (OR, 1.88; 95% CI, 1.11-3.16), hospitalized pacemaker implantation (OR, 6.76; 95% CI, 2.67-17.11), percutaneous coronary intervention (OR, 3.35; 95% CI, 1.44-7.80), and an increased HAS-BLED score (OR, 1.62; 95% CI, 1.11-2.35) were associated with "no-use of OACs" in patients with NVAF who had indications for anticoagulation therapy. Conclusion: For patients with NVAF with severe renal dysfunction and paroxysmal AF, anticoagulation therapy was inadequate. The underdosing-use of OACs in patients with NVAF was frequently observed. We recommend an anticoagulation management team to tailor anticoagulation regimens to suit each patient's needs.

Effect of oral anticoagulation therapy in atrial fibrillation patients with a history of intracranial hemorrhage: a systematic review and meta-analysis.

BACKGROUND: Use of oral anticoagulants (OACs) among atrial fibrillation (AF) patients surviving intracranial hemorrhage (ICH) represents a challenge due to the difficult balance between thrombosis and hemorrhage. METHODS: We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of OACs resumption in AF patients with a history of ICH during long-term follow-up. The outcome measures were ischemic stroke (IS), IS or systemic embolism (SE), all-cause death, recurrent ICH and major bleeding. Meta-analyses of pooled odds ratios (ORs) were conducted with random-effects models. RESULTS: A total of 2 randomized controlled trials (RCTs) and 9 observational studies were included, covering 18,115 patients with AF and a history of ICH. The risk of IS was not statistically different between the group of patients receiving OAC therapy and the no-OAC group (OR: 0.41, 95% CI: 0.16 to 1.0, P=0.05). The rate of IS or SE (OR: 0.42, 95% CI: 0.27 to 0.70, P=0.0008), all-cause death (OR: 0.54, 95% CI: 0.41 to 0.70, I2=42%, P<0.00001) were significantly decreased in patients receiving OAC therapy compared to those with no-OAC therapy. The pooled OR estimates for ICH recurrence (OR: 1.46, 95% CI: 0.94 to 2.26, P=0.09) and major bleeding (OR: 1.35, 95% CI: 0.86 to 2.11, P=0.19) were not significantly increased in the OAC therapy group. There was heterogeneity between the results of observational studies and RCTs in terms of all-cause death (I2=83.4%). CONCLUSIONS: Considering the heterogeneity in results between observational studies and RCTs, as well as the limited number and small size of RCTs, high grade evidences are needed. Pooled analysis is required when more RCTs are completed in the future to resolve this therapeutic dilemma.

Coriandrum sativum L.-Effect of Multiple Drying Techniques on Volatile and Sensory Profile.

Coriandrum sativum L. is a medicinal and aromatic plant spread around the world, with beneficial properties that are well recognized. Both coriander seeds and leaves are used for pharmaceutical and flavoring purposes. Even though coriander seeds tend to be more popular, the leaves are receiving a consistently growing interest, especially because of popularization of Mexican, Northern African, and Indian cuisines. This increased attention brings about the necessity for providing the product with guaranteed quality, which will retain its valuable characteristics, even after post-harvest treatment. For this reason, it is highly necessary to determine reliable protocols for cilantro preservation, which usually include drying procedures; in order to identify the optimal drying treatments, a spectrum of drying techniques-convective, vacuum-microwave, and a combination of convective and vacuum-microwave-were evaluated. Cilantro-based dried products were examined from the perspectives of volatile organic constituent composition and sensory quality. After headspace solid-phase microextraction-GC/MS analysis and sensory tests, the results demonstrate that convective drying at 70 °C for 120 min followed by vacuum-microwave drying at 360 W and convective drying at 70 °C were the optimal drying methods for preserving cilantro aroma quality, while convective drying at 70 °C for 120 min followed by convective finishing drying at 50 °C decreased cilantro aroma quality.

Optimisation of oral anticoagulants for patients with atrial fibrillation within 12 months after percutaneous coronary intervention: A meta-analysis and systematic review.

BACKGROUND: The optimal antithrombotic strategy, especially regarding oral anticoagulants (OACs) for atrial fibrillation (AF) patients with bleeding and thrombosis risk after percutaneous coronary intervention (PCI), remains unknown. This study explored the optimal oral anticoagulants for AF patients after PCI using a meta-analysis. METHODS: Randomised controlled trials were identified from PubMed, Embase, and the Cochrane Library through December 2020. Risk ratios, 95% confidence intervals, and random-effects models were used to compare different antithrombotic strategies through network meta-analysis, and the combination of antithrombotic agents was ranked according to the surface under the cumulative ranking curve and rankograms. Interval plots were drawn to observe pairwise comparisons between the different strategies. RESULTS: Five studies of 11,532 patients were included. Factor IIa inhibitor 110 mg bid plus a P2Y12 inhibitor had the greatest advantage for reducing Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding; Factor Xa inhibitor plus a P2Y12 inhibitor had the greatest advantage for reducing International Society on Thrombosis and Hemostasis major bleeding. For patients at risk of stroke plus all-cause death, factor IIa inhibitor 150 mg bid plus a P2Y12 inhibitor should be prioritised, and for those at risk of myocardial infarction and stent thrombosis, vitamin K antagonists plus a P2Y12 inhibitor were preferred. CONCLUSION: Factor IIa inhibitor 110 mg, factor IIa inhibitor 150 mg, factor Xa inhibitor and vitamin K antagonists should be selected in different situations.

Robotics-assisted epicardial left atrial appendage clip exclusion.

OBJECTIVES: We demonstrate the feasibility and safety of robotics-assisted left atrial appendage clip exclusion in clinical practice. METHODS: Analysis of a single center robotics-assisted left atrial appendage clip exclusion experience using an epicardial linear clip device in patients with atrial fibrillation with high-risk of thromboembolic stroke and intolerance to oral anticoagulants. RESULTS: During the period from December 2017 to September 2020, we performed 42 robotics-assisted left atrial appendage clip exclusions in response to increased risk of bleeding in patients with atrial fibrillation and intolerance to oral anticoagulants. The average congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease score was 5.2 ± 1.6 and hypertension, abnormal liver or kidney function, stroke, bleeding, labile international normalized ratio, elderly, drugs (aspirin, other antiplatelets, or anticoagulants) score was 4.5 ± 0.9. No patients died intraoperatively or within 30 days, or due to conversion to thoracotomy, intraoperative complications, or failure to apply the clip satisfactorily. The procedure was successfully completed despite pericardial adhesions in 2 patients with prior coronary bypass grafts and 3 with postpericarditis scars. Intraoperative transesophageal echocardiography was performed in 38 out of 42 patients; satisfactory exclusion with left atrial appendage stump <5 mm was confirmed in all. Average length of stay was 3.4 ± 3 days with 12 out of 42 patients discharged within 24 hours. Oral anticoagulants were discontinued in 41 out of 42 patients and no cases of 30-day stroke, myocardial ischemia, or new arrhythmias were observed. One case of hemothorax required thoracoscopy a day later. There was no reported thromboembolic stroke or transient ischemic attack at 12 months. One case of late lacunar stroke was due to in situ small intracranial vessel thrombosis without left atrial appendage thrombus on imaging. CONCLUSIONS: Robotics-assisted left atrial appendage clip exclusion is a safe and feasible minimally invasive method for left atrial appendage management in patients with atrial fibrillation with intolerance to oral anticoagulants and increased risk of thromboembolic stroke.

Assessing Adherence and Persistence to Non-vitamin K Antagonist Oral Anticoagulants (NOACs) among Patients with Atrial Fibrillation in Tertiary-care Referral Centers in Malaysia.

INTRODUCTION: Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran and rivaroxaban, are now available for stroke prevention in patients with atrial fibrillation (AF) and are often clinically preferred over vitamin K antagonists (VKAs), such as warfarin. Data describing adherence and persistence to NOACs in real-life clinical practice in Malaysia are scarce. This study aimed to assess adherence and persistence to NOACs in patients with AF in two tertiary-care referral centers: Hospital Kuala Lumpur (HKL) and Hospital Serdang (HSDG). MATERIALS AND METHODS: This was a retrospective cohort study that included all patients with AF who were treated with NOACs (dabigatran or rivaroxaban) in HKL and HSDG. Data were obtained from medical records and pharmacy databases. Adherence was assessed using proportion of days covered (PDC) over a 1-year duration. High adherence was defined as PDC ≥80%. A gap of >60 days between two consecutive refills was used to define non-persistence. RESULT: There were 281 patients who met the inclusion criteria, with 54.1% (n = 152) male. There were 75.1% (n = 211) patients on dabigatran and others on rivaroxaban. Only 66.9% (n = 188) of patients achieved high adherence with PDC ≥80% and 69.8% (n = 196) were persistence with >60-day gap over 12 months. Adherence and persistence were both influenced by treatment center, whereas polypharmacy only influenced adherence. CONCLUSION: Overall adherence and persistence to NOACs were suboptimal and varied between treatment centers, potentially due to institution-specific administrative and clinical practice differences. Clinical care and outcomes can potentially be optimized by identifying factors affecting adherence and persistence and by implementing interventions to improving them.

Relationship between initial international normalized ratio and prognosis in patients with cardiogenic cerebral embolism.

BACKGROUND: Cardiogenic cerebral embolism is one of the most common causes of ischemic stroke. In general, cardioembolic stroke is associated with more severe neurological deficits and higher early mortality, as well as a worse functional outcome. Oral anticoagulant (OAC) therapy could reduce the risk of stroke significantly. However, several limitations have led to it being underused, which raises the failure of anticoagulant therapy. This study aimed to investigate the patients with atrial fibrillation presented cardioembolic stroke who underwent OAC therapy, and to assess treatment efficacy, and outcomes, especially the international normalized ratio (INR) value in the acute phase. METHODS: Clinical data of 306 patients with cardioembolic stroke and etiology of atrial fibrillation were retrospectively analyzed, and demographics, cardiovascular risk factors, embolic cardiopathy, CHADS2 and CHA2DS2-VASc score, HAS-BLED score, INR value, TOAST subtypes, OCSP classification, modified Rankin Scale (mRS) scores and prognosis were evaluated. RESULTS: The median score on the CHADS2 and CHA2DS2-VASc scales was 3 and 4, respectively; The median score on the HAS-BLED scale was 2. Only 33 patients (10.8%) were in therapeutic INR range at the onset of stroke. In the acute phase, 233 patients (76.1%) continued to use OAC therapy, and 73 patients were suspended. Eighteen patients (24.7%) resumed treatment after an average of 32 days. Thirty-nine of 251 survivors with nonvalvular atrial fibrillation were modified to novel oral anticoagulants (NOACs). At 3 months follow-up, patients with INR ≥1.7 had significantly better prognosis than those with INR <1.7, both in the percentage of patients with functional independence (78.9% vs. 41.2%) and in mortality (7.0% vs. 25.0%) (P<0.001). CONCLUSIONS: Patients presented cardioembolic stroke despite being treated with OAC, especially those with a subtherapeutic INR value, raises the failure of anticoagulant therapy. Despite the ineffectiveness of the OAC, the prognosis is better when the INR ≥1.7 at the initiation of the stroke.

Switching of Oral Anticoagulation Therapy After PCI in Patients With Atrial Fibrillation: The RE-DUAL PCI Trial Subanalysis.

OBJECTIVES: The aim of this study was to assess if prior oral anticoagulant agent (OAC) use modifies the lower bleeding risk observed with dabigatran dual therapy (dabigatran twice daily plus a P2Y12 inhibitor) versus warfarin triple therapy (warfarin plus a P2Y12 inhibitor plus aspirin) in patients with atrial fibrillation who underwent percutaneous coronary intervention (PCI). BACKGROUND: In the RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran Versus Triple Therapy With Warfarin in Patients With Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) trial, the primary outcome of major bleeding or clinically relevant nonmajor bleeding was lower with dabigatran dual therapy versus warfarin triple therapy in patients with atrial fibrillation who underwent PCI. METHODS: A total of 2,725 patients were randomized to dual therapy with dabigatran (110 or 150 mg twice daily) plus clopidogrel or ticagrelor or triple therapy with warfarin plus aspirin and clopidogrel or ticagrelor. Subgroup analysis compared risk for major bleeding or clinically relevant nonmajor bleeding and a composite thromboembolic endpoint in patients with prior OAC use and in those who were OAC treatment naive. RESULTS: Risk for major bleeding or clinically relevant nonmajor bleeding was reduced with both dabigatran dual therapies compared with warfarin triple therapy in both the prior OAC use group (hazard ratios: 0.58 [95% confidence interval (CI): 0.42 to 0.81] and 0.61 [95% CI: 0.41 to 0.92] with 110 and 150 mg dabigatran, respectively) and the OAC-naive group (hazard ratios: 0.49 [95% CI: 0.38 to 0.63] and 0.76 [95% CI: 0.59 to 0.97] with 110 and 150 mg dabigatran) (p for interaction = 0.42 and 0.37, 110 and 150 mg dabigatran, respectively). The risk for thromboembolic events seemed similar with dabigatran dual therapy (both doses) and warfarin triple therapy across subgroups. CONCLUSIONS: Bleeding risk was reduced with dabigatran dual therapy versus warfarin triple therapy in patients with atrial fibrillation after PCI, regardless of whether they were prior OAC users or OAC treatment naive. These results suggest that it is also safe to switch patients on OAC pre-PCI to dabigatran dual therapy post-PCI.

Can oral anticoagulants be stopped safely after a successful atrial fibrillation ablation?

Ablations of atrial fibrillation (AF) have become more widely performed, and the strategy about long-term usage of oral anticoagulants (OACs) after catheter ablation is an important issue, especially for patients without obvious evidences of recurrences. The annual rate of thromboembolic (TE) event after catheter ablation was less than 1%. CHADS2 and CHA2DS2-VASc scores could be used to identify patients at the risk of TE events after ablations who should continue OACs regardless of the status of recurrence. Despite the improvement in understanding of AF and advancement of technology in catheter ablation, the long-term successful rates of paroxysmal and non-paroxysmal AF are around 50% and 30%, respectively. Patients with a high CHADS2 score are at a high risk of recurrence which could continuously occur after the catheter ablation without reaching a plateau. Among the patients with a CHADS2 score of ≥3, 26.9% of the recurrences happened 2 years post catheter ablation. Compared to the episodes of AF before catheter ablation, the AF episodes after ablation procedures are less symptomatic and shorter in duration. Therefore, it may not be safe to stop OACs for patients with a high risk score since the AF episodes are difficult to be detected after ablation procedures, but remain dangerous. In conclusion, the decision about the long-term strategy of OACs should be based on patients' baseline clinical risk scores, such as CHADS2 and CHA2DS2-VASc scores, rather than the status of recurrence.