Please cite this article as: Vivas D, Roldán V, Esteve-Pastor MA, Roldán I, Tello-Montoliu A, Ruiz-Nodar JM, Cosín-Sales J, María Gámez J, Consuegra L, Luis Ferreiro J, Marín F, Arrarte V, Anguita M, CequierÁ, Pérez-Villacastín J, Recomendaciones sobre el tratamiento antitrombótico durante la pandemia COVID-19. ABSTRACTThe new coronavirus SARS-CoV-2, which gives rise to the highly contagious COVID-19 disease, has caused a pandemic that is overwhelming health care systems worldwide. Affected patients have been reported to have a heightened inflammatory state that increases their thrombotic risk. However, there is very scarce information on the management of thrombotic risk, coagulation disorders, and anticoagulant therapy. In addition, the situation has also greatly influenced usual care in patients not infected with COVID-19.

The new coronavirus SARS-CoV-2, which gives rise to the highly contagious COVID-19 disease, has caused a pandemic that is overwhelming health care systems worldwide. Affected patients have been reported to have a heightened inflammatory state that increases their thrombotic risk. However, there is very scarce information on the management of thrombotic risk, coagulation disorders, and anticoagulant therapy. In addition, the situation has also greatly influenced usual care in patients not infected with COVID-19. This article by the Working Group on Cardiovascular Thrombosis of the Spanish Society of Cardiology aims to summarize the available information and to provide a practical approach to the management of antithrombotic therapy.

In cardiovascular disease (CVD), biomarkers (i.e., “biological markers”) could have multiple roles in understanding the complexity of cardiovascular (CV) pathophysiology and to offer an integrated approach to management. Biomarkers could help in daily practice as a diagnostic tool, to monitor therapy response, to assess prognosis and as early marker of CV damage, or to stratify risk. In recent years, the role of biomarkers in CVD is even more relevant and some have recently been included in clinical management guideline recommendations. The aim of this review is to discuss the recommendations in clinical guidelines of various biomarkers and to review their usefulness in daily clinical practice. Ultimately, a balance is needed between simplicity and practicality for clinical decision-making. Most biomarkers (whether blood, urine, or imaging-based) will improve on clinical risk stratification, but awaiting biomarker results may lead to delays in the initiation of therapy, for example, anticoagulation for stroke prevention in atrial fibrillation. Many biomarkers are nonspecific, being predictive of many CV and non-CV outcomes, so would be better as “rule-out” rather than “rule-in” assessments. Derivation of some biomarkers have also been made in highly selected clinical trial cohorts, where measurement is made at baseline but outcomes determined many years later; given the dynamic nature of risk in the “real world” where patients get older and develop incident risk factors, this may give a false impression of the risk profile. Finally, some laboratory biomarkers have a diurnal variation and inter-/intravariability (and lower limits of detection) in assays, which may be expensive, are added considerations.

BackgroundThe ABC‐stroke score (age, biomarkers [N‐terminal fragment B‐type natriuretic peptide, high‐sensitivity troponin], and clinical history [prior stroke/transient ischemic attack]) was proposed to predict stroke in atrial fibrillation (AF). This score was derived/validated in 2 clinical trial cohorts in which patients with AF were highly selected and carefully followed‐up. However, the median follow‐up was 1.9 years in the trial cohort; therefore, its long‐term predictive performance remains uncertain. This study aimed to compare the long‐term predictive performances of the ABC‐stroke and CHA 2 DS 2‐VASc (cardiac failure or dysfunction, hypertension, age ≥75 [doubled], diabetes mellitus, stroke [doubled]—vascular disease, age 65 to 74 years and sex category [female]) scores in a cohort of anticoagulated patients with AF.Methods and ResultsWe recruited 1125 consecutive patients with AF who were stable on vitamin K antagonists and followed‐up for a median of 6.5 years. ABC‐stroke and CHA 2 DS 2‐VASc (cardiac failure or dysfunction, hypertension, age ≥75 [doubled], diabetes mellitus, stroke [doubled]—vascular disease, age 65 to 74 years and sex category [female]) scores were calculated and compared. Median CHA 2 DS 2‐VASc and ABC‐stroke scores were 4 (interquartile range 3–5) and 9.1 (interquartile range 7.3–11.3), respectively. There were 114 ischemic strokes (1.55% per year) at 6.5 years. The C‐index of ABC‐stroke at 3.5 years was significantly higher than CHA 2 DS 2‐VASc (0.663 versus 0.600, P=0.046), but both C‐indexes were nonsignificantly different at 6.5 years. Integrated discrimination improvement showed a small improvement (<2%) in sensitivity at 3.5 and 6.5 years with ABC‐stroke. For ABC‐stroke, net reclassification improvement was nonsignificantly different at 3.5 years, and showed a negative reclassification at 6.5 years compared with CHA 2 DS 2‐VASc. Decision curve analyses did not show a marked improvement in clinical usefulness of the ABC‐stroke score over the CHA 2 DS 2‐VASc score.ConclusionsIn anticoagulated patients with AF followed‐up over a long‐term period, the novel ABC‐stroke score does not offer significantly better predictive performance compared with the CHA 2 DS 2‐VASc score.

Background Obesity and atrial fibrillation ( AF ) frequently coexist and independently increase mortality. We sought to assess the association between obesity and adverse events in patients receiving oral anticoagulants for AF . Methods and Results Consecutive AF outpatients receiving anticoagulant agents (both vitamin K antagonists and direct oral anticoagulants) were recruited into the FANTASIIA (Atrial fibrillation: influence of the level and type of anticoagulation on the incidence of ischemic and hemorrhagic stroke) registry. This observational, multicenter, and prospective registry of AF patients analyzes the quality of anticoagulation, incidence of events, and differences between oral anticoagulant therapies. We analyzed baseline patient characteristics according to body mass index, normal: <25 kg/m 2 , overweight: 25–30 kg/m 2 , and obese: ≥30 kg/m 2 ), assessing all‐cause mortality, stroke, major bleeding and major adverse cardiovascular events (a composite of ischemic stroke, myocardial infarction, and total mortality) at 3 years’ follow‐up. In this secondary prespecified substudy, the association of weight on prognosis was evaluated. We recruited 1956 patients (56% men, mean age 73.8±9.4 years): 358 (18.3%) had normal body mass index, 871 (44.5%) were overweight, and 727 (37.2%) were obese. Obese patients were younger ( P <0.01) and had more comorbidities. Mean time in the therapeutic range was similar across body mass index categories ( P =0.42). After a median follow‐up of 1070 days, 255 patients died (13%), 45 had a stroke (2.3%), 146 a major bleeding episode (7.5%) and 168 a major adverse cardiovascular event (8.6%). Event rates were similar between groups for total mortality ( P =0.29), stroke ( P =0.90), major bleeding ( P =0.31), and major adverse cardiovascular events ( P =0.24). On multivariate Cox analysis, body mass index was not independently associated with all‐cause mortality, cardiovascular mortality, stroke, major bleeding, or major adverse cardiovascular events. Conclusions In this prospective cohort of patients anticoagulated for AF , obesity was highly prevalent and was associated with more comorbidities, but not with poor prognosis.

BackgroundA simple method to assess renal function is the estimated glomerular filtration rate, and it shows prognostic implications. However, it remains unknown which equation should be used in patients with acute coronary syndrome. We compared the ability and correlation of the Cockcroft‐Gault, Modification of Diet in Renal Disease‐4 (MDRD‐4), and Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations and their predictive performance for major adverse cardiovascular events, all‐cause mortality, and major bleeding in a cohort of patients with acute coronary syndrome.Methods and ResultsMulticenter prospective registry involving 1699 consecutive patients with acute coronary syndrome from 3 tertiary institutions. At entry, renal function was assessed using the Cockcroft‐Gault, MDRD‐4, and CKD‐EPI‐creatinine equations. During 12 months of follow‐up, we recorded all major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke), bleeding events (Bleeding Academic Research Consortium classification), and all‐cause mortality. Receiver operating characteristic curve comparisons demonstrated that Cockcroft‐Gault equation had higher predictive ability compared with MDRD‐4 equation for major adverse cardiovascular events (0.651 versus 0.616; P=0.023), major bleeding (0.600 versus 0.551; P=0.005), and all‐cause mortality (0.754 versus 0.717; P=0.033), as well as higher predictive ability compared with CKD‐EPI equation for major bleeding (0.600 versus 0.564; P=0.018). Integrated discrimination improvement and net reclassification improvement analyses showed superior discrimination and reclassification of Cockcroft‐Gault equation. Decision curve analyses graphically demonstrated higher net benefit and clinical usefulness of the Cockcroft‐Gault equation in comparison with MDRD‐4 and CKD‐EPI equations.ConclusionsIn patients with acute coronary syndrome, the Cockcroft‐Gault equation presented superior predictive ability for major adverse cardiovascular events, major bleeding, and all‐cause mortality compared with MDRD‐4 equation, and superior predictive ability for major bleeding compared with CKD‐EPI equation. The Cockcroft‐Gault equation also showed higher net benefit and clinical usefulness.

Atrial fibrillation (AF) is the most frequent arrhythmia worldwide and it is associated with increased risk of stroke, thromboembolism and mortality. 1 Nevertheless, these risks can be reduced by using oral anticoagulation (OAC), both Direct Oral Anticoagulants (DOACs) or Vitamin K Antagonists (VKAs). 2 Despite the increasing use of DOACs, VKAs (mainly warfarin and acenocoumarol) are still widely used for stroke prevention in AF in several countries. Notwithstanding, the efficacy and safety of VKAs depend upon the quality of anticoagulation control, as reflected by the average time in therapeutic range (TTR) of international normalised ratio (INR) 2.0-3.0.

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