Thromboembolism and bleeding complications in anticoagulated patients with atrial fibrillation and native aortic or mitral valvular heart disease: a descriptive nationwide cohort study

Melgaard, Line; Overvad, Thure Filskov; Jensen, Mogens Krogh; Lip, Gregory Y. H.; Larsen, Torben Bjerregaard; Nielsen, Peter Brønnum

doi:10.1093/ehjcvp/pvaa008

Cited by 14 publications

(15 citation statements)

References 36 publications

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“…Our observations indicate that anticoagulated patients with AF and isolated mitral stenosis may be a particular high‐risk subgroup that requires intensive follow‐up. In another recent study from our group, we have also made this observation 37 . However, a randomised trial specifically designed to investigate the optimal antithrombotic therapy regime in patients with AF and mitral stenosis is necessary to make any additional recommendations about the optimal antithrombotic management of this subgroup of AF patients with VHD.…”

Section: Discussionmentioning

confidence: 99%

Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study

Melgaard

Jensen

Overvad

et al. 2020

Int. J. Clin. Pract.

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Aims The risks of thromboembolism and bleeding in patients with atrial fibrillation (AF) and valvular heart disease (VHD) are sparsely described. We described the risk of events in non‐anticoagulated and anticoagulated patients with AF and VHD according to the evaluated heart valves, rheumatic or artificial valve classification (EHRA classification), EHRA Type 1 and Type 2 VHD, and within subgroups of EHRA Type 1 and Type 2 VHD. Methods and Results Cohort study of AF patients with coexisting VHD, identified in nationwide Danish registries from 2000 to 2018. Risk of thromboembolism and bleeding after 1 year of follow‐up were calculated in each group. We identified 28 770 incident AF patients with VHD. Not surprisingly, we observed the highest risks of thromboembolism in the non‐anticoagulated AF patients with EHRA Type 1 and Type 2 VHD (4.9% vs 2.6% and 3.2% vs 1.9%) and the highest risks of bleeding in the anticoagulated AF patients with EHRA Type 1 and Type 2 VHD (6.6% vs 4.3% and 6.1% vs 4.9%). However, within the subgroups of AF patients with EHRA Type 1 and Type 2 VHD, we observed a large proportion of non‐anticoagulated patients (32.9%‐49.2%), despite a CHA2DS2‐VASc score of 2≤ in the majority of these patients (81.9%‐95.6%). Conclusions When using data reflecting contemporary clinical practice, we observed markedly different risks of thromboembolism and bleeding in EHRA Type 1 and Type 2 VHD. Additionally, we observed a potential underuse of oral anticoagulation within the subgroups of AF patients with EHRA Type 1 and Type 2 VHD, underlining need for further attention on this patient group.

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Section: Discussionmentioning

confidence: 99%

Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study

Melgaard

Jensen

Overvad

et al. 2020

Int. J. Clin. Pract.

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“…Our observed incident rate is slightly lower than that reported in a recently published nationwide cohort study, which, however, assessed the thromboembolic events in a subgroup of incident AF patients with combined mitral and aortic regurgitation. 18 The overall low rates of observed thromboembolic events among our population could be explained by the protective effect of significant MR on stroke events. 19 In chronic MR, the left atrium is exposed to significant volume overload progressively leading to chamber dilatation and remodeling, which represents the physiopathological substrate for AF onset and maintenance.…”

Section: Discussionmentioning

confidence: 71%

Atrial Fibrillation and Mitral Regurgitation: Clinical Performance of Direct Oral Anticoagulants in a Real-World Setting

Melillo

Rago

Proietti

et al. 2020

J Cardiovasc Pharmacol Ther

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Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is frequently present in patients with mitral regurgitation (MR). Currently, there is a lack of real-world evidence specifically addressing the clinical performance of direct oral anticoagulants (DOACs) in patients with AF and concomitant MR. Therefore, the aim of the present study was to assess the efficacy and safety profile of DOACs therapy in patients with AF and MR. Methods: Data for this study were sourced from the Atrial Fibrillation Research Database in the Department of Cardiology at Monaldi Hospital. The database was queried for AF patients with MR who were prescribed DOACs therapy. The primary safety outcome was defined as the annual incidence rate of major bleeding events and the primary effectiveness outcome as the annual incidence rate of all events classified as ischemic stroke, transient ischemic attacks, and systemic embolisms. Results: Consecutive AF patients with concomitant mild to severe MR who received DOACs therapy (n = 259) were included. Patients were dichotomized in 2 groups according to MR severity: a mild-to-moderate group (MR 1-2+; n = 151) and a moderate-to-severe group (MR 3-4+; n = 108). The incidence rate of major bleedings was significantly higher in MR 3-4+ group (3.92%) compared with the MR 1-2+ group (1.18%; hazard ratio [HR]: 3.2; 95% CI: 1.4-7.3; P = .0059). The incidence rate of thromboembolic events between MR 3-4+ group (0.66%) and MR 1-2+ group (0.62%) was not significantly different (HR: 0.75; P = .823). Conclusions: In the present study, there was no difference in the efficacy profile of DOACs between AF patients with mild-to-moderate and moderate-to-severe MR. Considering the increased bleeding risk, a close and careful follow-up should be warranted for patients with moderate-to-severe MR.

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“…The association of individual valve lesions with clinical outcomes has been inadequately investigated in patients with AF. Few studies have reported on the prognostic value of AS [ 11 , 18 , 29 ]. A sub-analysis of the ROCKET-AF trial [ 29 ] and a Danish nationwide study [ 18 ] compared AS with AR and MR, showing its prognostic superiority for all-cause death, stroke/SEE and major bleeding.…”

Section: Discussionmentioning

confidence: 99%

“…Few studies have reported on the prognostic value of AS [ 11 , 18 , 29 ]. A sub-analysis of the ROCKET-AF trial [ 29 ] and a Danish nationwide study [ 18 ] compared AS with AR and MR, showing its prognostic superiority for all-cause death, stroke/SEE and major bleeding. In a post-hoc analysis of the ORBIT-AF trial, AS was associated with higher risk of death, but not stroke or major bleeding [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

“…Data from our study suggest that AS has a graded and independent association with increased risk of all-cause death, cardiovascular death and several net clinical outcomes. Patients with moderate/severe AS had 1-year mortality risk of 33.9%, which is considerably higher compared with cohorts of patients with [ 18 ] or without AF [ 30 ]. Stroke/SEE and major bleeding events did not differ based on VHD status in our study.…”

Section: Discussionmentioning

confidence: 99%

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Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation

Samaras

Vrana

Κάρτας

et al. 2021

BMC Cardiovasc Disord

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Background Valvular heart disease (VHD) in non-valvular atrial fibrillation (AF) is a puzzling clinical entity. The aim of this study was to evaluate the prognostic effect of significant VHD (sVHD) among patients with non-valvular AF. Methods This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction. Results In total, 983 patients with non-valvular AF (median age 76 [14] years) were analyzed over a median follow-up period of 32 [20] months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 6.5%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17–2.06; p = 0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR 1.70, 95% CI 1.09–2.66; p = 0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p = 0.02). The prognostic effect of sVHD was particularly evident in patients aged < 80 years and in those without history of heart failure (p for interaction < 0.05, in both subgroups). After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization. Conclusion Among patients with non-valvular AF, sVHD was highly prevalent and beared high prognostic value across a wide spectrum of clinical outcomes, especially in patients aged < 80 years or in the absence of heart failure. Predominantly AS, as well as MR and TR, were associated with worse prognosis.

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Thromboembolism and bleeding complications in anticoagulated patients with atrial fibrillation and native aortic or mitral valvular heart disease: a descriptive nationwide cohort study

Cited by 14 publications

References 36 publications

Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study

Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study

Atrial Fibrillation and Mitral Regurgitation: Clinical Performance of Direct Oral Anticoagulants in a Real-World Setting

Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation

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