Left Atrial Appendage Thrombi Formation in Japanese Non-Valvular Atrial Fibrillation Patients During Anticoagulation Therapy　― Warfarin vs. Direct Oral Anticoagulants ―

Abstract

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia, associated with increased cardiovascular morbidity and mortality including thromboembolic events. The aims of this study were to assess the prevalence of left atrial appendage (LAA) thrombi in Japanese non-valvular atrial fibrillation (NVAF) patients undergoing preprocedural transesophageal echocardiography (TEE) during anticoagulation therapy, and to compare the efficacy of warfarin and direct oral anticoagulants (DOAC). Methods and Results:This retrospective study reviewed records of 559 consecutive NVAF patients (445 men; age, 62±11 years) undergoing preprocedural TEE following at least 3 weeks of anticoagulation therapy. Of these, 275 patients had non-paroxysmal AF (49%). LAA thrombus was observed in 15 patients (2.7%). The prevalence of LAA thrombi was similar between the DOAC group (2.6%) and the warfarin group (2.8%, P=0.86). No patients with CHA2DS2-VASc score=0, or paroxysmal AF without prior stroke or transient ischemic attack, had LAA thrombi. On univariate analysis, non-paroxysmal AF, structural heart disease, antiplatelet therapy, larger left atrium, higher brain natriuretic peptide (BNP), reduced LAA flow, and higher CHA2DS2-VASc score were all associated with LAA thrombi. On multivariate analysis, BNP ≥173 pg/mL remained the only independent predictor of LAA thrombi.Conclusions: LAA thrombi were found in 2.7% of Japanese NVAF patients scheduled for procedures despite ongoing oral anticoagulation therapy. Incidence of thrombi was similar for patients on DOAC and on warfarin.

Use of the CHA 2 DS 2 VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation

“…None of the patients in this study taking a NOAC had LA/LAA thrombus; their demographics were comparable to the rest of the population, and the CHA 2 DS 2 VASc scores ranged from 0 to 5, similar to the population on warfarin. This finding is consistent with other studies that have shown that the incidence of thrombus in patients undergoing pre-ablation TOE is either similar (21) or less (22) than those patients on warfarin.…”

Impact of direct oral anticoagulant off‐label doses on clinical outcomes of atrial fibrillation patients: A systematic review

“…(C) Real‐world studies results concerning dose adjustments of apixaban. (D) Results from direct oral anticoagulants overall adjustments regarding dose appropriateness…”

“…Canadian study, 44 where a total of 47 patients were included, among (D) Results from direct oral anticoagulants overall adjustments regarding dose appropriateness 5,9,11,25,27,28,32,34,37,39,40,42,44,[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64] whom 25 (53%) were receiving apixaban inconsistent with the ARIS-TOTLE trial and the product monograph.…”

Stratifying Stroke Risk in Atrial Fibrillation

“…Furthermore, in a study of AF patients being treated with either a vitamin-K antagonist (warfarin) or a non-vitamin K antagonist oral anticoagulation (NOAC) drug, 2.7% had a LAA thrombus seen on transesophageal echocardiogram (TEE) despite compliance with anticoagulation. 54 Those with thrombus had a mean LA diameter of 47 mm compared with 41 mm in those without thrombus ( P = 0.003). 55 …”

“…54 Those with thrombus had a mean LA diameter of 47 mm compared with 41 mm in those without thrombus ( P = 0.003). 55 …”