Search

Background: Data on the effectiveness and safety of oral anticoagulant (OAC) agents in very elderly nonvalvular atrial fibrillation patients with high bleeding risk are lacking., Objectives: This study examined 2-year outcomes and effects of OAC agents among these patients using the ANAFIE (All Nippon Atrial Fibrillation in the Elderly) registry (N = 32,275) data., Methods: Patients were classified into high-risk (age: ≥80 years; CHADS 2 score: ≥2; and presence of ≥1 bleeding risk factor: creatinine clearance of 15-30 mL/minute, prior bleeding at critical sites, body weight of ≤45 kg, or continuous antiplatelet use) and reference groups., Results: In the high-risk (n = 7,104) and reference (n = 25,171) group patients, 89.0% and 93.4%, respectively, used OAC agents. Of these, respectively, 30.1% and 24.2% used warfarin, and 58.9% and 69.1% used direct-acting OAC (DOAC) agents. Compared with the reference group, the high-risk group had higher incidences of stroke/systemic embolism, major bleeding, intracranial hemorrhage, gastrointestinal bleeding, cardiovascular events, and all-cause death. In the high-risk group, DOAC agent use vs nonuse of OAC agents was associated with reduced incidences of stroke/systemic embolism (HR: 0.53; 95% CI: 0.36-0.79) and all-cause death (HR: 0.65; 95% CI: 0.52-0.81) but not with major bleeding (HR: 1.09; 95% CI: 0.63-1.89). DOAC agents were superior to warfarin in effectiveness and safety. For high-risk patients, history of major bleeding, severe liver dysfunction, and falls within 1 year were independent risk factors for major bleeding., Conclusions: High-risk elderly nonvalvular atrial fibrillation patients had higher event incidences. DOAC agents were associated with reduced risk of stroke/systemic embolism and all-cause death vs nonuse of OAC agents or warfarin. (Prospective Observational Study in Late-Stage Elderly Patients With Nonvalvular Atrial Fibrillation [ANAFIE registry]; UMIN000024006)., Competing Interests: This research was supported by Daiichi Sankyo Co, Ltd. Dr Okumura received remuneration from Nippon Boehringer Ingelheim, Daiichi Sankyo, Johnson & Johnson, and Medtronic. Dr Yamashita has received research funding from Bristol-Myers Squibb, Bayer, and Daiichi Sankyo; manuscript fees from Daiichi Sankyo and Bristol-Myers Squibb; and remuneration from Daiichi Sankyo, Bayer, Pfizer Japan, Bristol-Myers Squibb, and Ono Pharmaceutical. Dr Akao has received research funding from Bayer and Daiichi Sankyo and remuneration from Bristol-Myers Squibb, Nippon Boehringer Ingelheim, Bayer, and Daiichi Sankyo. Dr Atarashi has received remuneration from Daiichi Sankyo. Dr Ikeda has received research grants from Daiichi Sankyo, Medtronic Japan, and Japan Lifeline; has received honoraria from Ono Pharma, Bayer Yakuhin, Daiichi Sankyo, Bristol-Myers Squibb, and Pfizer; and was a member of the Advisory Board for Bayer Yakuhin, Bristol-Myers Squibb, and Daiichi Sankyo. Dr Koretsune has received remuneration from Daiichi Sankyo, Bayer, and Nippon Boehringer Ingelheim. Dr Shimizu has received research funding from Bristol-Myers Squibb, Daiichi Sankyo, and Nippon Boehringer Ingelheim and patent royalties/licensing fees from Daiichi Sankyo, Pfizer Japan, Bristol-Myers Squibb, Bayer, and Nippon Boehringer Ingelheim. Dr Suzuki has received remuneration from Bristol-Myers Squibb and Daiichi Sankyo. Dr Tsutsui has received research funding from Daiichi Sankyo, Mitsubishi Tanabe Pharma, Nippon Boehringer Ingelheim, and IQVA Services Japan; remuneration from Daiichi Sankyo, Bayer, Nippon Boehringer Ingelheim, Pfizer Japan, Otsuka Pharmaceutical, and Mitsubishi Tanabe Pharma; scholarship funding from Daiichi Sankyo, Mitsubishi Tanabe Pharma, and Teijin Pharma; and consultancy fees from Novartis Pharma, Pfizer Japan, Bayer, Nippon Boehringer Ingelheim, and Ono Pharmaceutical. Dr Toyoda has received honoraria from Daiichi Sankyo, Bayer, Bristol-Myers Squibb, and Takeda. Dr Hirayama participated in a course endowed by Boston Scientific Japan; has received research funding from Daiichi Sankyo and Bayer; has received remuneration from Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Nippon Boehringer Ingelheim, Sanofi, Astellas Pharma, Sumitomo Dainippon Pharma, Amgen Astellas BioPharma, and AstraZeneca; and has received patent royalties/licensing fees from Toa Eiyo M. Dr Yasaka received research funding from Nippon Boehringer Ingelheim and remuneration from Nippon Boehringer Ingelheim, Daiichi Sankyo, Bayer, Bristol-Myers Squibb, Pfizer Japan, and CSL Behring. Dr Yamaguchi acted as an Advisory Board member of Daiichi Sankyo; and has received honoraria from Daiichi Sankyo and Bristol-Myers Squibb. Dr Teramukai has received research funding from Nippon Boehringer Ingelheim and remuneration from Daiichi Sankyo, Sanofi, Takeda, Chugai Pharmaceutical, Solasia Pharma, Bayer, Sysmex, Nipro, NapaJen Pharma, Gunze, and Atworking. Dr Kimura has stock and is an employee of Daiichi Sankyo. Dr Morishima and Atsushi Takita are employees of Daiichi Sankyo. Dr Inoue has received honoraria from Daiichi Sankyo, Bayer, Bristol-Myers Squibb and consultancy fees from Daiichi Sankyo., (© 2022 The Authors.)

Background: Data regarding the incidence, predictive factors, and clinical outcomes of post-transcatheter aortic valve replacement (TAVR) bleeding is limited in the Asian cohort., Objectives: This study sought to assess the predictors and prognostic impact of post-TAVR late bleeding., Methods: This study used the Japanese multicenter registry data to analyze 2,518 patients (mean age: 84.3 ± 5.2 years) who underwent TAVR. Late bleeding was defined as any postdischarge bleeding events after TAVR. Baseline characteristics, predictive factors, and clinical outcomes including death and rehospitalization were assessed in patients with and without late bleeding events., Results: The cumulative incidence rate of all and major late bleeding and ischemic stroke were 7.4%, 5.2%, and 3.4%, respectively, 3 years after TAVR. The independent predictive factors of late bleeding were low platelet count, high score (≥4) on the clinical frailty scale, and a New York Heart Association functional class III/IV. The cumulative mortality rates up to 3 years were significantly higher in patients with late bleeding than in those without bleeding ( P < 0.001). The multivariate Cox regression analysis revealed that late bleeding, included as a time-varying covariate in the model, was associated with an increased risk of mortality following TAVR (HR: 5.63; 95% CI: 4.28-7.41; P < 0.001)., Conclusions: Late bleeding after TAVR was not a rare complication, and it significantly increased long-term mortality. It should be carefully managed, especially when it is predictable in the high-risk cohort, and efforts should be taken to reduce bleeding complications even after a successful procedure., Competing Interests: The OCEAN-TAVI registry is supported by Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Medical, and Daiichi-Sankyo Company. Drs Yamamoto, Tada, Naganuma, Shirai, Mizutani, Tabata, Ueno, Watanabe, and Hayashida are clinical proctors for Edwards Lifesciences and Medtronic. Drs Koyama and Takagi are clinical proctors of Edwards Lifesciences. Dr Yashima is a clinical proctor for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement., Competing Interests: This work was supported in part by grants from the Ministry of Health and Welfare (MOHW111-TDU-B-211-134001) and intramural grants from the Taipei Veterans General Hospital (V111C-194). Dr Chiang has received honoraria from AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Merck Sharpe & Dohme, Novartis, Pfizer, and Sanofi. Dr Chao has received honoraria for lectures from Boehringer Ingelheim, Bayer, Pfizer, and Daiichi Sankyo. Dr Choi has received research grants or speaker fees from Bayer, Bristol Myers Squibb/Pfizer, Biosense Webster, Daiichi Sankyo, and Medtronic. Dr Krittayaphong has received honoraria from Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer. Dr Li has received honoraria from Bayer and Boehringer Ingelheim. Dr Chen has received honoraria from Biosense Webster, St. Jude Medical, Medtronic, Bayer, and Boehringer Ingelheim. Dr Okumura has received honoraria from Daiichi Sankyo, Boehringer Ingelheim, Bristol Myers Squibb, Medtronic, Japan Lifeline, and Johnson & Johnson. Dr Lip is a consultant and speaker for Bristol Myers Squibb/Pfizer, Boehringer Ingelheim, and Daiichi Sankyo (no fees are received personally). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement., Competing Interests: This work was supported, in part, by grants from the Ministry of Health and Welfare (MOHW111-TDU-B-211-134001), and intramural grants from the Taipei Veterans General Hospital (V111C-194). Dr Chiang has received honoraria from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, MSD, Novartis, Pfizer, and Sanofi. Dr Chao has received honoraria for lectures from Boehringer Ingelheim, Bayer, Pfizer, and Daiichi Sankyo. Dr Choi has received research grants or speaking fees from Bayer, BMS/Pfizer, Biosense Webster, Daiichi-Sankyo, and Medtronic. Dr Krittayaphong has received honoraria from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, and Pfizer. Dr Li has received honoraria from Bayer and Boehringer Ingelheim. Dr Chen has received honoraria from Biosense Webster, St Jude Medical, Medtronic, Bayer, and Boehringer Ingelheim. Dr Okumura has received honoraria from Daiichi-Sankyo, Boehringer Ingelheim, Bristol-Myers Squibb, Medtronic, Japan lifeline, and Johnson and Johnson. Dr Lip consults and is a speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo, with no fees are received personally. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored., (© 2020 2666-6936/ All rights reserved. \xA9 2021 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals Inc. on behalf of the International Society for Holter and Noninvasive Electrocardiology / Cardiovascular Digital Health Journal published by Elsevier Inc. on behalf of the Heart Rhythm Society / Circulation: Arrhythmia and Electrophysiology published by Wolters Kluwer Health, Inc. on behalf of the American Heart Association, Inc. / European Heart Journal \x96 Digital Health published by Oxford University Press on behalf of the European Society of Cardiology / Journal of Arrhythmia published by Wiley and Sons Australia Ltd on behalf of the Japanese Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. This article is published under the Creative Commons CC-BY license, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. This is an open access article under the CC BY license.)

This paper discusses the evolving concept of atrial myopathy by presenting how it develops and how it affects the properties of the atria. It also reviews the complex relationships among atrial myopathy, atrial fibrillation (AF), and stroke. Finally, it discusses how to apply the concept of atrial myopathy in the clinical setting-to identify patients with atrial myopathy and to be more selective in anticoagulation in a subset of patients with AF. An apparent lack of a temporal relationship between episodes of paroxysmal AF and stroke in patients with cardiac implantable electronic devices has led investigators to search for additional factors that are responsible for AF-related strokes. Multiple animal models and human studies have revealed a close interplay of atrial myopathy, AF, and stroke via various mechanisms (e.g., aging, inflammation, oxidative stress, and stretch), which, in turn, lead to fibrosis, electrical and autonomic remodeling, and a pro-thrombotic state. The complex interplay among these mechanisms creates a vicious cycle of ever-worsening atrial myopathy and a higher risk of more sustained AF and strokes. By highlighting the importance of atrial myopathy and the risk of strokes independent of AF, this paper reviews the methods to identify patients with atrial myopathy and proposes a way to incorporate the concept of atrial myopathy to guide anticoagulation in patients with AF., (© 2019 The Authors.)