Christine Blank is a contributing editor. 

Christine Blank

Ischemic events and mortality were higher in transcatheter aortic valve replacement (TAVR) patients taking non-VKA oral anticoagulants (NOACs) compared to those taking vitamin K antagonists (VKAs), a study says.

David Joccheim, MD, lead author, and his colleagues, set out to study NOACs versus VKAs because, while NOACs are superior to VKAs in nonvalvular atrial fibrillation (AF), their comparative performance among patients undergoing TAVR has been underinvestigated, he writes. Joccheim is professor at Ludwig-Maximilians University in Munich, Germany. The registry study enrolled 962 consecutive patients who underwent TAVR at four European centers and who were discharged on either NOACs or VKAs. A balloon-expandable valve was used in 62.7% of cases.

The combined incidence of all-cause mortality, myocardial infarction, and any cerebrovascular event measured at one year after TAVR was 21.2% with NOACs compared to 15% with VKAs.

However, the one-year incidence of any Bleeding Academic Research Consortium bleeds and all-cause mortality were comparable between the NOAC (33.9%) and VKA groups (34.1%).

Atrial Fibrillation Patients Often Overestimate Stroke and Bleeding Risks

“Chronic use of both NOACs and VKAs among patients in need of OAC after TAVR are comparable regarding one-year bleeding risk. The higher ischemic event rate observed with NOACs needs to be evaluated in large randomized trials,” Joccheim writes.

 say the increased risk of ischemic events was of “borderline statistical significance.”

“While the authors attribute the increased risk of thrombotic complications with a NOAC to its lesser degree of anticoagulation effect compared with a VKA, this did not result in an increase in bleeding,” writes Dominick J. Angiolillo, MD, PhD, professor at the University of Florida College of Medicine-Jacksonville.

Still, the results of this study, along with another small study must be “seriously considered”, he adds.

“Despite the supportive data associated with the use of NOACs in patients with atrial fibrillation, including among those undergoing other interventional procedures such as coronary stenting, to date there is [a] lack of evidence that these should be preferred over a VKA after TAVR. Until then, NOACs should be used with caution and the choice of antithrombotic therapy should be individualized, taking into account patients’ bleeding and thrombotic risk profile,” Angiolillo writes.

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Study finds higher Ischemic events and mortality in transcatheter valve replacement patients taking non-vitamin K antagonist oral anticoagulants versus vitamin K antagonists.

Study: VKAs Better Protect Aortic Valve Replacement Patients

Older, low-risk atrial fibrillation (AF) patients who take oral anticoagulants (OACs) have a lower risk of dementia than those who do not, a recent study says. However, the risks outweigh this benefit in patients under age 60.

, was conducted to discover if there was a link between reduced dementia and anticoagulants.  “Recent observational studies have shown that AF patients using oral anticoagulant drugs have almost half as high risk of dementia as AF patients not using OAC,” the authors write. The researchers are from the Karolinska Institute in Stockholm.

“From a global brain protection perspective, ie, with the objective to shield the brain from dementia as well as from embolic stroke and intracerebral bleedings (ICHs), it is possible that low-risk patients would be better off with OAC than without,” the researchers added.

The study results come from a retrospective study of cross-matched national registries of all individuals in Sweden with a hospital diagnosis of AF between 2006 and 2014. Of the 91,254 patients included in the study, 43% used OAC at baseline.

Treatment with OAC was associated with lower risk of dementia after adjustment for death as a competing risk. OAC treatment was associated with an overall 12% lower risk when the composite brain protection endpoint was evaluated.

“This apparent benefit was restricted to patients over 65  years old, whereas OAC treatment of patients below 60  years of age without risk factors appeared to do more harm than good,” they write.

“The brains of AF patients over 65  years appeared to fare better with OAC than without OAC, irrespective of other risk factors. If this observation holds true and can be confirmed by others, counting of risk scores may not be needed in order to decide whether to offer OAC or not since age alone is enough to tip the balance in favor of treatment (unless there are strong reasons against),” the authors write.

Low-risk atrial fibrillation patients who take oral anticoagulants have a lower risk of dementia than those who do not, a study says.

AF Patients Taking OACs Have Lower Dementia Risk

A study of nursing home residents with atrial fibrillation (AF) has found that the use of direct-acting oral anticoagulants (DOACs) has greatly increased since their introduction. As their use increased, use of warfarin decreased.

Nursing home residents with AF have a high risk for ischemic stroke and bleeding events, which is why researchers set out to find out whether DOAC use in nursing home residents was changing.

A national estimate in 2004 indicated that less than one-third of this highârisk population were using anticoagulants, writes Matthew Alcusky, PharmD, lead author and assistant professor of epidemiology at the University of Massachusetts Medical School in Worcester The study was 

Journal of the American Heart Association.

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Alcusky and colleagues estimated the prevalence of oral anticoagulant (OAC) use among Medicare fee-for-service beneficiaries with AF who resided in long-term nursing homes from 2011 through 2016. They examined Medicare Part D claims for apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa, Lixiana), rivaroxaban (Xarelto), and warfarin (Coumadin).

The proportion of residents with AF treated with oral anticoagulants was 42.4% as of July 1, 2011, at which time the majority of those treated were using warfarin. Anticoagulant use remained stable through the close of 2013, at which time 42.8% of residents were treated, 35.2% with warfarin and 7.7% with DOACs.

Then, starting in the first half of 2014, the prevalence of anticoagulant use increased during each halfâyear through the end of the study (December 31, 2016), at which time 47.8% of residents were treated. “This period (2014–2016) of increasing anticoagulant use coincided with a decline in warfarin use and a rise in DOAC use such that by the end of 2016, the prevalence of warfarin use (24.7%) was nearly equal to DOAC use (23.1%),” Alcusky writes.

Dabigatran use increased during the early study period and peaked in the first half of 2012 before stabilizing in the range of 2.2% to 3.1% through 2016. In contrast, the prevalence of rivaroxaban and apixaban use continued to rise through the end of the study.

Over the five years (2012-2016) after its market entry, rivaroxaban use increased from 0.4% to 8.3%. During the four full years after market entry (2013–2016), apixaban use also rose from 0.1% to 12.6%. In contrast, edoxaban use remained rare after its approval in 2015.

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“Increases in anticoagulant use among U.S. nursing home residents with atrial fibrillation coincided with declining warfarin use and increasing DOAC use,” Alcusky writes.

Before the availability of DOACs, use of oral anticoagulants was reported to be low among highârisk older adults with AF in the United States and internationally, according to the researchers. Estimates of anticoagulant use among U.S. nursing home residents with AF in the 1990s and early 2000s suggested that around two-thirds of residents were not treated with warfarin.

“At that time, reports of high rates of adverse events and labile international normalized ratios for nursing home residents were accompanied by physician uncertainty about the relative benefits and risks of warfarin in the longâterm care setting. This uncertainty about the net benefit of treatment continues to affect anticoagulant prescribing decisions for highârisk older adults,” Alcusky writes.

Even after a marked increase in anticoagulant use between 2004 and 2016, more than half of nursing home residents with AF remain untreated, the researchers discovered. “The large majority of residents with AF are at high risk for stroke, evidenced by 85% of residents with a CHA2DS2âVasc score of ≥4,” Alcusky writes.

However, with recent availability of DOAC reversal agents and emerging observational evidence reinforcing trial findings in realâworld populations, including the frail, it is likely the gradual increase in anticoagulation of nursing home residents and ongoing shift from warfarin to DOACs will continue, according to Alcusky.

The use of direct‐acting oral anticoagulants has increased among nursing home residents with atrial fibrillation.

DOAC Use Increasing in Nursing Homes

Patients with atrial fibrillation (AF) “markedly overestimated” the perceived risks of stroke and bleeding. This poor understanding of the risks can impact whether they take oral anticoagulants, according to a recent study.

, the researchers described the results from a survey of 227 patients with AF. It is the only published survey on patient perceptions of the risks of AF-associated stroke or the risk and benefits of anticoagulation, Mohamad Alkhouli, MD, tells 

He is lead author and interventional cardiologist at the West Virginia University Heart and Vascular Institute.

“We felt it is important to assess this because of the implications of taking or not taking long-term anticoagulation in these patients, as well as the impact of good patient understanding on compliance with the medicine,” Alkhouli says.

Alkhouli and his colleagues surveyed patients with chronic AF who presented for an outpatient cardiology visit or who were admitted to a noncritical care cardiology ward service from September 2017, through December 2017. Participants were asked to estimate their stroke risk without oral anticoagulation (OAC) and bleeding risk with OAC using a quantitative risk scale.

Most patients (40.5%) had a history of bleeding, and most of them overestimated their risks of stroke and bleeding, the researchers found. Nearly 53% perceived an annual stroke risk greater than 20%, and 53.5% perceived an annual bleeding risk with OAC greater than 10%.

Most patients perceived that OAC would reduce their annual stroke risk by at least 50%. Around 76% of patients were taking OACs. Among the 54 patients who were not taking OACs, fear of bleeding was the predominant reason.

Patients who were taking OACs did so to reduce their risk of stroke (75.7%), due to physician recommendations (12%), and for uncertain reasons (8.7%). Approximately half of the patients were not aware or did not know of any other prevention option besides blood thinners.

“Perceived risks of stroke and bleeding are markedly overestimated in most patients with AF. Further research is needed to discern the root causes and to identify effective methods of bridging this alarming disparity,” Alkhouli says.

However, Alkhouli was not surprised by the results because “the medical community has embraced the relative risk terminology, which is a language that is not plausible for most patients,” he says.

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“We suspected a large discrepancy between predicted and perceived risk. For example, when patients ask about the benefit of anticoagulation, they are often told that it would reduce the annual stroke risk by 50%, which is true, but this can mean reducing the actual annual risk from 2.2% to 1.1%, which is a much more plausible number to understand. Patients live in the absolute world and information needs to be related to them in a simple, relevant method,” Alkhouli says.

Emphasizing the need to understand the risk and benefit of the treatment can help AF patients become more compliant and make informed decisions about their health, Alkhouli adds.

Overestimating the bleeding risk of anticoagulants may lead to poor compliance.