Optimizing Stroke and Bleeding Risk Assessment in Patients with Atrial Fibrillation: A Balance of Evidence, Practicality and Precision

Proietti, Marco; Mujović, Nebojša; Potpara, Tatjana

doi:10.1055/s-0038-1676074

Cited by 43 publications

(40 citation statements)

References 34 publications

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“…Thaat review pointed out that CHADS2, CHA2DS2‐VASc, and ABC risk scores were best for predicting thromboembolic risk, whereas the HAS‐BLED was the best at predicting bleeding risk . Moreover, the use of HAS‐BLED score did not preclude the use of oral anticoagulants, whereas it could identify high‐risk patients to modify bleeding risk factors . However, the comprehensive results regarding the diagnostic values regarding HAS‐BLED and other assessment tools were not addressed using a quantitative approach.…”

Section: Discussionmentioning

confidence: 99%

“…8 Moreover, the use of HAS-BLED score did not preclude the use of oral anticoagulants, whereas it could identify high-risk patients to modify bleeding risk factors. 40 However, the comprehensive results regarding the diagnostic values regarding HAS-BLED and other assessment tools were not addressed using a quantitative approach. Therefore, the current network meta-analysis was conducted to compare the value of HAS-BLED with other bleeding risk assessment tools for predicting major bleeding in AF patients.…”

Section: Discussionmentioning

confidence: 99%

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Accuracy of HAS‐BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta‐analysis

Chang

Xie

et al. 2020

Journal of Thrombosis and Haemostasis

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Background Preventing thrombosis is an important part of atrial fibrillation (AF) treatment. However, it may increase the risk of bleeding, and bleeding risk assessment tools' predictive value remains unclear. This network meta‐analysis investigated the sensitivity and specificity of HAS‐BLED, and other bleeding risk assessment tools, to predict major bleeding events in AF patients. Methods The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched using keywords, including “AF,” “bleeding,” and “HAS‐BLED,” for results published through 30 November 2018. The predictive sensitivity and specificity of each bleeding risk assessment tool was analyzed by network meta‐analysis. Results Our analysis included 18 studies, recruiting a total of 321 888 people. The bleeding risk assessment tools analyzed in this study included the ABC‐bleeding score, ATRIA, European score, GARFIELD‐AF, HAS‐BLED, HEMORR2HAGES, ORBIT, Shireman, and mOBRI. A comprehensive analysis of sensitivity and specificity, based on an inconsistency model, showed that European score, ABC, and mOBRI have relatively high‐sensitivity but low‐specificity tools, whereas HAS‐BLED and HEMORR2HAGES have balanced sensitivity and specificity. ORBIT, ATRIA, Shireman, and GARFIELD‐AF had relatively high specificity but low sensitivity. A consistency model analysis showed similar results. Conclusions HAS‐BLED is a balanced bleeding risk assessment tool in terms of sensitivity and specificity, whereas the European score, ABC, and mOBRI are high‐sensitivity tools and ORBIT, ATRIA, Shireman, and GARFIELD‐AF are high‐specificity tools.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Accuracy of HAS‐BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta‐analysis

Chang

Xie

et al. 2020

Journal of Thrombosis and Haemostasis

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“…Those patients should have been regularly reminded by physicians about the significance of OACs in stroke prevention. Regular re‐assessment should be a part of a comprehensive and holistic approach to the management of high‐risk patients with AF which is The Atrial fibrillation Better Care 21…”

Section: Discussionmentioning

confidence: 99%

Comparing TEE‐ vs Non–TEE‐guided cardioversion of atrial fibrillation: The ENSURE‐AF trial

Kozieł

Merino

Caterina

et al. 2020

Eur J Clin Investigation

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Background ENSURE‐AF (NCT 02072434) assessed therapy with edoxaban vs enoxaparin‐warfarin in patients with nonvalvular atrial fibrillation (AF) undergoing elective electrical cardioversion (ECV). Objectives To evaluate clinical features and primary efficacy (composite of stroke, systemic embolic events, myocardial infarction and cardiovascular mortality during study period) and safety endpoints (composite of major and clinically relevant nonmajor bleeding during on‐treatment period) in patients awaiting ECV of AF with a transesophageal echocardiography (TEE)‐guided vs a non–TEE‐guided strategy. Methods In this prospective, randomized, open‐label, blinded endpoint study, 2199 patients were randomized to edoxaban 60 mg once‐daily (30 mg for creatinine clearance 15‐50 mL/min, weight ≤60 kg and/or concomitant use of P‐glycoprotein inhibitor) or enoxaparin‐warfarin. Primary efficacy endpoint and safety endpoint were reported. Associates of TEE use, efficacy endpoint and safety endpoint were explored using multivariable logistic regression. Results In total, 589 patients from the edoxaban stratum and 594 from the enoxaparin‐warfarin stratum were allocated to the TEE‐guided strategy. Primary efficacy was similar regardless of TEE approach (P = .575). There were no significant differences in bleeding rates, regardless of TEE approach (P = .677). Independent predictors of TEE use were as follows: history of ischaemic stroke/ transient ischaemic attack, hypertension and valvular heart disease. Mean CHA2DS2VASc and HAS‐BLED score were independent predictors of the efficacy endpoint whilst mean age was an independent predictor of the safety endpoint. Conclusions Thromboembolic and bleeding events were not different between patients undergoing TEE‐guided strategy and in those undergoing an optimized conventional anticoagulation approach for ECV of AF.

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“…This requires a delicate balancing of the risk of thromboembolic and atherothrombotic events against the increased chance of bleeding, and should be undertaken on an individual patient basis. 1,2 In 2014, a joint consensus document was published to provide guidance on the management of ATT in AF patients presenting with ACS and/or undergoing PCI 3 in the setting of limited available evidence from randomized controlled trials (RCTs) about the optimal antithrombotic strategy post-ACS in patients with AF. Since 2014, further observational studies and RCT data has been published and non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used.…”

Section: Introductionmentioning

confidence: 99%

Antithrombotic treatment in patients with atrial fibrillation and acute coronary syndromes: results of the European Heart Rhythm Association survey

et al. 2019

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The management of an acute coronary syndrome (ACS) in a patient with existing atrial fibrillation (AF) often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment to reduce the risk of in-stent thrombosis or recurrent cardiac events. Current practice recommendations are based largely on consensus option as there is limited evidence from randomized controlled trials. Prior to the launch of the new European Heart Rhythm Association (EHRA) consensus document, a survey was undertaken to examine current clinical management of these patients across centres in Europe. Forty-seven centres submitted valid responses, with the majority (70.2%) being university hospitals. This EHRA survey demonstrated overall the management of ACS in AF patients is consistent with the available guidance. Most centres would use triple therapy for a short duration (4 weeks) and predominantly utilize a strategy of OAC (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) plus aspirin and clopidogrel, followed by dual therapy [(N)OAC plus clopidogrel] until 12 months post-percutaneous coronary intervention, followed by (N)OAC monotherapy indefinitely. Where NOAC was used in combination with antiplatelet(s), the lower dose of the respective NOAC was preferred, in accordance with current recommendations.

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Optimizing Stroke and Bleeding Risk Assessment in Patients with Atrial Fibrillation: A Balance of Evidence, Practicality and Precision

Cited by 43 publications

References 34 publications

Accuracy of HAS‐BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta‐analysis

Accuracy of HAS‐BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta‐analysis

Comparing TEE‐ vs Non–TEE‐guided cardioversion of atrial fibrillation: The ENSURE‐AF trial

Antithrombotic treatment in patients with atrial fibrillation and acute coronary syndromes: results of the European Heart Rhythm Association survey

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