Morbidity and mortality in 229 elderly patients with nonrheumatic atrial fibrillation. A five-year follow-up. [Study of combined anticoagulant (fluindione)-aspirin therapy in patients with atrial fibrillation at high risk for thromboembolic complications. A randomized trial (FFAACS)]. Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH–AFNET 6) trial Anticoagulant (Fluindione)-Aspirin Combination in Patients with High-Risk Atrial Fibrillation Thromboembolic stroke in patients with a HeartMate-II left ventricular assist device – the role of anticoagulation Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study. Anticoagulant and/or Antiplatelet Treatment in Patients with Atrial Fibrillation after Percutaneous Coronary Intervention Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. Multicenter randomized study of anticoagulation guided by remote rhythm monitoring in patients with implantable cardioverter-defibrillator and CRT-D devices: Rationale, design, and clinical characteristics of the initially enrolled cohort The IMPACT study. Novel oral anticoagulants in a real-world cohort of patients undergoing catheter ablation of atrial fibrillation. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. Atrial thrombi-a prospective follow-up study over 3 years with transesophageal echocardiography and cranial magnetic resonance imaging. EDUC’AVK: Reduction of Oral Anticoagulant-related Adverse Events After Patient Education: A Prospective Multicenter Open Randomized Study Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study.
BACKGROUND In the elderly the impact of atrial fibrillation on mortality and morbidity is substantial . Oral anticoagulant therapy reduces the risk of stroke by 70 % ; nevertheless , it remains largely underused . We evaluated , in a community prospect i ve study , the factors associated with embolic events and death and the feasibility of oral anticoagulant therapy managed by general practitioners . METHODS We enrolled at the Trieste Cardiovascular Center 229 patients aged > or = 65 years with non-rheumatic atrial fibrillation . At baseline , each patient underwent a transesophageal echocardiography and received instructions about oral anticoagulation . Patients were regularly followed by their general practitioner and finally evaluated at the Center . RESULTS At baseline , the mean age was 73 years , 14 % of patients were free of heart disease , 27 % had had a previous embolic event , and 33 % had an atrial thrombus . After a 5-year follow-up , 85 % of the patients had been admitted to hospital , 17 % had suffered an embolic event , and 35 % were dead . Diabetes and the presence of a low flow in the left atrial appendage were predictive of embolic events . Heart failure , spontaneous echocontrast and aortic plaques were predictive of death . Anticoagulant therapy increased from 14 to 34 % but the incidence of major bleeding did not change . The patients on anticoagulant therapy at follow-up constituted the group with the worst cardiovascular profile and embolic rate , but had a lower death rate ( 19 % ) compared with those on antiplatelet therapy ( 32 % ) and with those without antithrombotic therapy ( 67 % ) . The hospitalization rates were respectively 78 , 83 and 100 % . CONCLUSIONS In a group of elderly patients followed by their general practitioner with the support of a specialized cardiologic unit , oral anticoagulant therapy was well tolerated and associated with a significant decrease in mortality and hospitalization BACKGROUND A combination of low-dose aspirin ( A ) and anticoagulation ( AC ) may provide better protection against thromboembolic events compared with AC alone in high-risk patients with atrial fibrillation ( AF ) . METHODS We performed a multicentric placebo-controlled double blind-trial to test the preventive efficacy against thromboembolic events of the addition of aspirin ( A ) ( 100 mg ) or placebo ( P ) to anticoagulant treatment in patients with high-risk atrial fibrillation . A total of 157 patients were included , with atrial fibrillation and previous thromboembolic event or older than 65 years with either a history of hypertension , a recent episode of heart failure or a left ventricular dysfunction . All patients received fluindione ( F ) and P or F and A , with an INR target between 2 and 2.6 . The primary endpoint was a combined endpoint of stroke ( ischaemic or haemorrhagic ) , myocardial infa rct ion , systemic arterial emboli or vascular death . RESULTS The study had to be stopped prematurely owing to a too low recruitment rate . During follow-up ( 0.84 years ) 3 non-fatal thromboembolic events were recorded ( 1P , 2A ) and 6 patients died ( 3P , 3A ) , none of them from a thromboembolic complication . However , 3 deaths were secondary to severe haemorrhagic complications ( 1P , 2A ) . Non-fatal haemorrhagic complications occurred more often in group A ( n = 10 , 13.1 pour cent ) compared with group P ( n = 1 , 1.2 pour cent ) , p = 0.003 . CONCLUSION The FFAACS study was not able to show any therapeutic benefit from the addition of aspirin to anticoagulant in patients with high-risk AF . Such a combination increased the incidence rate of bleeding complications , which therefore greatly reduces its potential overall benefit Background Oral anticoagulation prevents ischemic strokes in patients with atrial fibrillation ( AF ) . Early detection of AF and subsequent initiation of oral anticoagulation help to prevent strokes in AF patients . Implanted cardiac pacemakers and defibrillators allow seamless detection of atrial high rate episodes ( AHRE ) , but the best antithrombotic therapy in patients with AHRE is not known . Rationale Stroke risk is higher in pacemaker patients with AHRE than in those without , but the available data also show that stroke risk in patients with AHRE is lower than in patients with AF . Furthermore , only a minority of patients with AHRE will develop AF , many strokes occur without a temporal relation to AHRE , and AHRE can reflect other arrhythmias than AF or artifacts . An adequately powered controlled trial of oral anticoagulation in patients with AHRE is needed . Design The Non – vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes ( NOAH – AFNET 6 ) trial tests whether oral anticoagulation with edoxaban is superior to prevent the primary efficacy outcome of stroke or cardiovascular death compared with aspirin or no antithrombotic therapy based on evidence ‐based indications . The primary safety outcome will be major bleeding . NOAH – AFNET 6 will r and omize 3,400 patients with AHRE , but without documented AF , aged ≥65 years with at least 1 other stroke risk factor , to oral anticoagulation therapy ( edoxaban ) or no anticoagulation . All patients will be followed until the end of this investigator‐driven , prospect i ve , parallel‐group , r and omized , event‐driven , double‐blind , multicenter phase IIIb trial . Patients will be censored when they develop AF and offered open‐label anticoagulation . The sponsor is the Atrial Fibrillation NETwork ( AFNET ) . The trial is supported by the DZHK ( German Centre for Cardiovascular Research ) , the BMBF ( German Ministry of Education and Research ) , and Daiichi Sankyo Europe . Conclusion NOAH – AFNET 6 will provide robust information on the effect of oral anticoagulation in patients with atrial high rate episodes detected by implanted devices . Graphical abstract Figure . No Caption available Background : A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation . Objective : Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin ( 100 mg ) in patients with high-risk atrial fibrillation . Methods : A multicenter , placebo-controlled , double-blind , r and omized trial was conducted at 49 investigating centers in France . Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension , a recent episode of heart failure or decreased left ventricular function were included in the study . Patients were treated with fluindione plus placebo ( i.e. anticoagulant alone ) or fluindione plus aspirin ( i.e. combination therapy ) , with an international normalized ratio target of between 2 and 2.6 . The combined primary endpoint was stroke ( ischemic or hemorrhagic ) , myocardial infa rct ion , systemic arterial emboli or vascular death . The secondary endpoint was the incidence of hemorrhagic complications . Results : The 157 participants ( average age 74 years ; 52 % women ; 42 % with paroxysmal atrial fibrillation ) were followed for an average of 0.84 years . Three nonfatal thromboembolic events were observed ( 1 in the anticoagulation group , 2 in the combination group ) and 6 patients died ( 3 in the anticoagulation group , 3 in the combination group ) , none of them from a thromboembolic complication . However , 3 deaths were secondary to severe hemorrhagic complications ( 1 in the anticoagulation group , 2 in the combination group ) . Nonfatal hemorrhagic complications occurred more often in the combination group ( n = 10 , 13.1 % ) compared to the anticoagulation group ( n = 1 , 1.2 % ) ( p = 0.003 ) . Conclusion : The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients . The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events Background and purpose It is unknown what the optimal anticoagulant level is to prevent thromboembolic stroke in patients with left ventricular assist device ( LVAD ) support . We aim ed to evaluate the relation between coagulation status and the occurrence of thromboembolic stroke in HeartMate-II LVAD assisted patients . Methods Thirty-eight consecutive patients with a HeartMate-II LVAD were included . Coagulation status was classified according to INR and aPTT ratio at : 1 ) the moment of first thromboembolic stroke ; and 2 ) during the two weeks preceding the first thromboembolic stroke to assess long-term coagulation status . In patients without stroke , coagulation status was determined just before heart transplant , VAD explantation or death , whichever came first , and at two weeks preceding these surrogate endpoints . Based on coagulation status , patients were divided in two groups : Group I ( reference group ) was defined as INR below 2 and aPTT ratio below 1.5 ; Group II ( adequate anticoagulation ) as INR above 2 or aPTT ratio above 1.5 . Logistic regression analysis was performed to assess the odds ratio for developing stroke for patients with adequate anticoagulation compared to the reference Group . Results Thromboembolic stroke occurred in six ( 16 % ) patients , none within 2 weeks after LVAD implantation . Considering coagulation status at the time of event , patients in coagulation Group II had no decreased risk for thromboembolic stroke ( OR 0.78 ; 95 % CI 0.12–5.0 ) . Results for coagulation status 2 weeks prior of event could not be calculated as all six strokes occurred in Group II . Conclusion In our experience anticoagulation within predefined targets is not associated with a reduced thromboembolic stroke risk in patients with a HeartMate-II LVAD on antiplatelet therapy . However , no firm statement about the effect of either anticoagulant or antiaggregant therapy can be made based on our study . A larger r and omized study is needed to support the hypothesis that there may be no additional benefit of coumarin or heparin therapy compared with antiplatelet therapy alone OBJECTIVES The primary objective was to evaluate the usefulness of transesophageal echocardiography (TEE)-guided cardioversion to prevent thromboembolic complications in patients with atrial fibrillation ( AF ) and effective anticoagulation ( International Normalized Ratio of 2 or 3 ) at least three weeks before cardioversion . BACKGROUND Transesophageal echocardiography has been proposed as a method of screening patients for left atrial thrombi before direct-current cardioversion of AF . The usefulness of TEE as a screening tool has always been evaluated in patients without long-term anticoagulation before cardioversion . METHODS This prospect i ve , single-center , observational study , performed on an intention-to-cardiovert basis , comprised 1,076 consecutive , unselected patients with AF . The initial two years were design ed to be the control phase , during which the conventional approach was used . After that , cardioversion guided by TEE was performed in consecutive patients . RESULTS The prevalence of left atrial thrombi was 7.7 % in patients with persistent AF and effective anticoagulation . During the first four weeks after electrical cardioversion , six thromboembolic complications were observed in patients in whom the TEE-guided approach was employed ( 6 [ 0.8 % ] of 719 patients ) , compared with three thromboembolic complications in patients in whom the conventional approach was used ( 3 [ 0.8 % ] of 357 patients ) . None of the patients in whom electrical cardioversion was not performed experienced an embolic event . CONCLUSIONS There were no differences in the rate of embolic events between the two treatment groups . In patients with AF and effective anticoagulation , TEE-guided electrical cardioversion does not reduce the embolic risk . However , TEE revealed left atrial thrombi in 7.7 % of patients with AF and effective anticoagulation , before direct-current cardioversion Background : Atrial fibrillation ( AF ) is the most common cardiac arrhythmia sustained and frequently occurs in patients with coronary heart disease . Thus , a large number of patients requiring percutaneous coronary intervention ( PCI  ) also suffer from AF . An anticoagulant regimen has not been st and ardized for patients with AF after coronary stent implantation . Patients and Methods : The authors investigated data from 159 patients with AF who underwent PCI in their department . Baseline variables and incidence of a combined endpoint ( stroke , myocardial infa rct ion , cardiovascular death , severe bleeding ) were compared in patients receiving clopidogrel and acetylsalicylic acid ( ASA ; group 1 ) versus patients receiving the combination of clopidogrel and ASA with low-molecular-weight heparin ( LMWH ; group 2 ) versus patients receiving the combination of clopidogrel and ASA with oral anticoagulation ( OAC ; group 3 )  at discharge . Results : Patients discharged with triple therapy including OAC seemed to be at higher risk : patients in group 3 had decreased left ventricular ejection fraction and increased inflammatory state as measured by plasma fibrinogen and C-reactive protein . Moreover , previous OAC treatment and strokes were found more often in this subgroup of patients . In a median follow-up of 1.4 years , two severe bleeding events ( both in group 1 ) , four myocardial infa rct ions ( all in group 1 ) , 13 strokes ( nine in group 1 , four in group 2 ) , and nine cardiovascular deaths ( three in group 1 , five in group 2 , one in group 3 ) occurred . Conclusion : In this analysis , no treatment regimen seemed to be clearly superior . It underlines the importance of prospect i ve , r and omized trials to investigate the optimal antithrombotic/antiplatelet treatment for patients with AF after PCI.ZusammenfassungHintergrund : Vorhofflimmern ( VHF ) ist die häufigste Herzrhythmusstörung und wichtige Komorbidität bei Patienten mit koronarer Herzkrankheit . Welche antithrombotische/antithrombozytäre Therapiestrategie bei Patienten mit Vorhofflimmern nach perkutaner Koronarintervention ( PCI ) verfolgt werden sollte , ist aktuell nicht eindeutig zu beantworten . Patienten und Method ik : Die Autoren identifizierten retrospektiv 159 Patienten mit VHF , die in ihrer Abteilung in den Jahren 1999–2004 eine PCI erhalten hatten . Die Grunderkrankungen und die Inzidenz eines kombinierten Endpunkts ( Schlaganfall , Myokardinfarkt , kardiovaskulär bedingter Tod , schwere Blutung ) wurden bei Patienten verglichen , die Clopidogrel und Acetylsalicylsäure ( ASS ; Gruppe 1 ) , Clopidogrel und ASS in Kombination mit niedermolekularem Heparin ( Gruppe 2 ) sowie Clopidogrel und ASS und zusätzlich orale Antikoagulation erhalten hatten ( Gruppe 3).Ergebnisse : Die Grunderkrankungen der Patienten in den drei Gruppen waren nicht signifikant unterschiedlich . In einem medianen Beobachtungszeitraum von 1,4 Jahren konnten zwei schwere Blutungen ( in Gruppe 1 ) , vier Myokardinfarkte ( in Gruppe 1 ) , 13 Schlaganfälle ( neun in Gruppe 1 , vier in Gruppe 2 ) und neun kardiovaskulär bedingte Todesfälle ( drei in Gruppe 1 , fünf in Gruppe 2 , einer in Gruppe 3 ) nachgewiesen werden . Schlussfolgerung : In dieser Untersuchung erwies sich keine Therapiestrategie einer and eren gegenüber als eindeutig überlegen . Die erhobenen Date n zeigen , wie wichtig es ist , prospektive , r and omisierte Studien bezüglich der antithrombotischen/antithrombozytären Therapie durchzuführen , um Patienten mit AF nach PCI optimal beh and eln zu können BACKGROUND Because atrial thrombi are poorly detected by conventional noninvasive techniques such as transthoracic echocardiography , patients with prolonged atrial fibrillation usually receive several weeks of oral anticoagulation therapy before cardioversion is attempted . We wondered whether transesophageal echocardiography , an accurate method of detecting atrial thrombi , would allow early cardioversion to be performed safely if no thrombi were identified . METHODS A total of 669 consecutive patients admitted with the diagnosis of atrial fibrillation were screened . Patients were excluded if they were receiving long-term anticoagulation , if the duration of atrial fibrillation was two days or less , if they were not c and i date s for cardioversion , or if transesophageal echocardiography was contraindicated . Of 119 qualifying patients , 94 agreed to participate ; the average duration of atrial fibrillation was 4.5 weeks . Participating patients underwent transthoracic echocardiography and transesophageal echocardiography followed by cardioversion if no thrombi were seen . Short-term anticoagulation with heparin was used in 80 patients before cardioversion , and 60 patients received warfarin for one month after cardioversion . RESULTS Fourteen atrial thrombi were identified in 12 patients ( 13 percent ) , and 12 of the 14 thrombi were visualized only on transesophageal echocardiography . Cardioversion was deferred in all 12 patients . Two of these 12 patients died suddenly ; 4 of the 10 surviving patients underwent uneventful cardioversion after prolonged oral anticoagulation . Seventy-eight of the 82 patients without thrombi underwent successful cardioversion to sinus rhythm ( 47 by means of antiarrhythmic drugs and 31 by electrical cardioversion ) , all without long-term oral anticoagulation . None of these patients ( 95 percent confidence interval , 0 to 4.6 percent ) had an embolic event . CONCLUSIONS In patients with atrial fibrillation of unknown or prolonged duration who are not receiving long-term anticoagulation , atrial thrombi are detected by transesophageal echocardiography in only a small minority ( 13 percent in our study ) . Our preliminary data suggest that if transesophageal echocardiography excludes the presence of thrombi , early cardioversion can be performed safely without the need for prolonged oral anticoagulation before the procedure Atrial fibrillation and atrial flutter are common cardiac arrhythmias associated with an increased risk of stroke in patients with additional risk factors .  Anticoagulation ameliorates stroke risk , but because these arrhythmias may occur intermittently without symptoms , initiation of prophylactic therapy is often delayed until electrocardiographic documentation is obtained . The IMPACT study is a multicenter , r and omized trial of remote surveillance technology in patients with implanted dual-chamber cardiac resynchronization therapy defibrillator ( CRT-D ) devices design ed to test the hypothesis that initiation and withdrawal of oral anticoagulant therapy guided by continuous ambulatory monitoring of the atrial electrogram improve clinical outcomes by reducing the combined rate of stroke , systemic embolism , and major bleeding compared with conventional clinical management . For those in the intervention group , early detection of atrial high-rate episodes ( AHRE ) generates an automatic alert to initiate anticoagulation based on patient-specific stroke risk stratification . Subsequently , freedom from AHRE for predefined periods prompts withdrawal of anticoagulation to avoid bleeding . Patients in the control arm are managed conventionally , the anticoagulation decision prompted by incidental detection of atrial fibrillation or atrial flutter during routine clinical follow-up . The results will help define the clinical utility of wireless remote cardiac rhythm surveillance and help establish the critical threshold of AHRE burden warranting anticoagulant therapy in patients at risk of stroke . In this report , we describe the study design and baseline demographic and clinical features of the initial cohort ( 227 patients ) AIMS Experiences with novel oral anticoagulants ( NOACs )  early after atrial fibrillation ( AF ) catheter ablation are limited and show controversial results . We aim ed to assess the longer-term safety , efficacy , and acceptance of NOACs in a large real-world cohort of patients presenting for AF catheter ablation . METHODS AND RESULTS From July 2010 until June 2012 , 259 patients undergoing AF catheter ablation were prospect ively included .  Novel oral anticoagulants were given for at least 3 months post-ablation . Clinical outcome ( stroke , thromboembolic events , major bleeding ) , adverse effects , and drug adherence were assessed at discharge and follow-up . On admission patients were presented with a variety of  anticoagulants  including 54 patients ( 21 % ) already on NOACs prior ablation . After ablation 38 % of patients received dabigatran 110 mg , 56 % 150 mg , and 6 % received rivaroxaban 20 mg . There were four periprocedural thromboembolic and major bleeding complications ( 1.5 % ) , all in patients without NOACs prior ablation ( two on warfarin and two on heparin ) . During long-term follow-up [ 311 ( 199 ; 418 ) days ] no stroke , systemic embolism , or major haemorrhage could be observed . Uneventful electrical cardioversions and reablation procedures were performed in 27 and 12 patients on dabigatran , respectively . Novel oral anticoagulants were prematurely stopped or switched to another anticoagulant due to side effects or at the preference of the treating general practitioner in 9 and 10 patients , respectively . CONCLUSION In this prospect i ve observational study , anticoagulation with NOACs following AF catheter ablation was safe and effective at long-term follow-up . Fast onset of action makes NOACs especially attractive in patients without effective anticoagulation on admission and in patients following periprocedural complications AIMS Atrial tachyarrhythmias ( ATs ) detected by implanted devices are often atrial fibrillation or flutter ( AF ) associated with stroke . We hypothesized that introduction and termination of anticoagulation based upon AT monitoring would reduce both stroke and bleeding . METHODS AND RESULTS We r and omized 2718 patients with dual-chamber and biventricular defibrillators to start and stop anticoagulation based on remote rhythm monitoring vs. usual office-based follow-up with anticoagulation determined by st and ard clinical criteria .  The primary analysis compared the composite endpoint of stroke , systemic embolism , and major bleeding with the two strategies . The trial was stopped after 2 years median follow-up based on futility of finding a difference in primary endpoints between groups . A total of 945 patients ( 34.8 % ) developed AT , 264 meeting study anticoagulation criteria . Adjudicated atrial electrograms confirmed AF in 91 % ; median time to initiate anticoagulation was 3 vs. 54 days in the intervention and control groups , respectively ( P < 0.001 ) . Primary events ( 2.4 vs. 2.3 per 100 patient-years ) did not differ between groups ( HR 1.06 ; 95 % CI 0.75 - 1.51 ; P = 0.732 ) . Major bleeding occurred at 1.6 vs. 1.2 per 100 patient-years ( HR 1.39 ; 95 % CI 0.89 - 2.17 ; P = 0.145 ) . In patients with AT , thromboembolism rates were 1.0 vs. 1.6 per 100 patient-years ( relative risk -35.3 % ; 95 % CI -70.8 to 35.3 % ; P = 0.251 ) . Although AT burden was associated with thromboembolism , there was no temporal relationship between AT and stroke . CONCLUSION In patients with implanted defibrillators , the strategy of early initiation and interruption of anticoagulation based on remotely detected AT did not prevent thromboembolism and bleeding . CLINICAL TRIAL REGISTRATION IMPACT Clinical Trials.gov identifier : NCT00559988 ( http:// clinical trials.gov/ct2/show/NCT00559988?term=NCT00559988&rank=1 ) BACKGROUND Patients with atrial fibrillation ( AF ) and atrial thrombi have an increased risk for cerebral embolism . However , there is little knowledge about the long-term fate of atrial thrombi and the incidence of cerebral embolism in patients under oral anticoagulation . METHODS Consecutive patients with persistent or permanent AF and left atrial ( LA ) thrombi were included in the study . We performed serial and prospect i ve transesophageal echocardiography , cranial magnetic resonance imaging , and clinical examinations during a period of 3 years . Oral anticoagulation was continued or initiated in all patients . A target INR of 2.5 was intended in all patients . RESULTS Forty-three patients with LA thrombi and persistent or permanent AF were included . During the follow-up period 31(72 % ) of the thrombi disappeared . Patients with disappearance of thrombi had significantly smaller thrombi ( P < 0.01 ) , a lower echogenicity of thrombi ( P < 0.01 ) , and a lower LA volume ( P = 0.02 ) . Twenty-two ( 51 % ) patients suffered from cerebral embolism and /or death during the observation period . Five patients died due to embolic events . The only independent predictors of cerebral embolism were an elevated peak emptying velocity of the LA appendage ( P < 0.001 ) and a history of previous thromboembolism ( P < 0.01 ) . CONCLUSIONS Patients with persistent or permanent AF and atrial thrombi have a high long-term risk of cerebral embolism and /or death ( 51 % ) even despite the oral anticoagulation therapy . Thrombus size may predict thrombus resolution under continued anticoagulation Background Long-term oral anticoagulation treatment is associated with potential morbidity . Insufficient patient education is linked to poorly controlled anticoagulation . However the impact of a specific educational program on anticoagulation related morbidity remains unknown . Objective To evaluate the effect of an oral anticoagulation patient education program in reducing both hemorrhagic and recurrent thrombotic complications . Design / Participants We conducted a prospect i ve , multicenter open r and omized study , comparing an interventional group who received a specific oral anticoagulation treatment educational program with a control group . Eligible patients were older than 18 and diagnosed as having deep vein thrombosis or pulmonary embolism requiring therapy with a vitamin K antagonist for 3 months or more . Our primary outcome was the occurrence of hemorrhagic or thromboembolic events . Results During the 3-month follow-up the main outcome criteria were observed 20 times ( 6.6 % of patients ) , 5 ( 3.1 % ) in the experimental and 15 ( 10.6 % ) in the control group . Consequently , in multivariate analysis , the cumulative risk reduction in the experimental group was statistically significant ( OR 0.25 , 95 % CI 0.1 – 0.7 , p < 0.01 ) . Conclusions Patient education using an educational program reduced VKA-related adverse event rates BACKGROUND A number of studies have demonstrated the efficacy of oral anticoagulant therapy in reducing the risk of stroke and systemic embolism in patients with nonrheumatic atrial fibrillation . However , both the targeted and the actual levels of anticoagulation differed widely among the studies , and a number of studies failed to report st and ardized prothrombin-time ratios as international normalized ratios ( INRs ) . We therefore performed an analysis to determine the intensity of oral anticoagulant therapy in nonrheumatic atrial fibrillation that provides the best balance between the prevention of thromboembolism and the occurrence of bleeding complications . METHODS We calculated INR-specific incidence rates for both ischemic and major hemorrhagic events occurring in 214 patients who received anticoagulant therapy in the European Atrial Fibrillation Trial , a secondary -prevention trial in patients with nonrheumatic atrial fibrillation and a recent episode of minor cerebral ischemia . RESULTS The optimal intensity of anticoagulation was found to lie between an INR of 2.0 and an INR of 3.9 . No treatment effect was apparent with anticoagulation below an INR of 2.0 . The rate of thromboembolic events was lowest at INRs from 2.0 to 3.9 , and most major bleeding complications occurred with treatment at intensities with INRs of 5.0 or above . CONCLUSIONS To achieve optimal levels of anticoagulation with the lowest risk in patients with atrial fibrillation and a recent episode of cerebral ischemia , the target value for the INR should be set at 3.0 , and values below 2.0 and above 5.0 should be avoided Patients with mechanical prosthetic heart valves require long-term oral anticoagulant therapy ( OAT ) . During the temporary interruption of OAT , bridging anticoagulant therapy with unfractionated heparin ( UFH ) or low-molecular-weight heparin ( LMWH ) is recommended . This prespecified subgroup analysis from REGIMEN-a large , prospect i ve , multicenter registry-compared UFH  ( n = 73 ) and  LMWH  ( n = 172 ) as bridging anticoagulation in patients with mechanical heart valves on long-term OAT . Patient demographics and co-morbidities were generally similar between groups . There were more bileaflet valves in the LMWH group ( 67.4 % vs 43.8 % , p = 0.0005 ) , but no differences in valve positions between groups . The LMWH group was less likely to undergo major surgery ( 33.7 % vs 58.9 % , p = 0.0002 ) and cardiothoracic surgery ( 7.6 % vs 19.2 % , p = 0.008 ) , and to receive intraprocedural anticoagulants or thrombolytics  ( 4.1 % vs 13.7 % , p = 0.007 ) . Major adverse event rates ( 5.5 % vs 10.3 % , p = 0.23 ) and major bleeds ( 4.2 % vs 8.8 % , p = 0.17 ) were similar in the LMWH and UFH groups , respectively ; 1 arterial thromboembolic event occurred in each group . More LMWH-bridged patients were treated as out patients or discharged from the hospital in < 24 hours ( 68.6 % vs 6.8 % , p < 0.0001 ) . Multivariate logistic analysis found no significant differences in major bleeds and major composite adverse events when adjusting for cardiothoracic or major surgery between groups . In conclusion , for patients with mechanical prosthetic heart valves on long-term OAT , mostly outpatient-based LMWH bridging therapy appears to be feasible for selected procedures , is as safe as UFH , and is associated with a low arterial thromboembolic rate Several studies have established the value of anticoagulation for primary prevention of thromboembolic events in patients with non-rheumatic atrial fibrillation ( NRAF ) . However , in patients with a recent transient ischaemic attack ( TIA ) or minor ischaemic stroke the preventive benefit of anticoagulation or aspirin remains unclear . Physicians in 108 centres from 13 countries collaborated to study this question . 1007 NRAF patients with a recent TIA or minor ischaemic stroke were r and omised to open anticoagulation or double-blind treatment with either 300 mg aspirin per day or placebo ( group 1 , 669 ) . Patients with contraindications to anticoagulation were r and omised to receive aspirin or placebo ( group 2,338 ) . The measure of outcome was death from vascular disease , any stroke , myocardial infa rct ion , or systemic embolism . During mean follow-up of 2.3 years , the annual rate of outcome events was 8 % in patients assigned to anticoagulants vs 17 % in placebo-treated patients in group 1 ( hazard ratio [ HR ] 0.53 ; 95 % confidence interval [ CI ] 0.36 - 0.79 ) . The risk of stroke alone was reduced from 12 % to 4 % per year ( HR 0.34 ; 95 % CI 0.20 - 0.57 ) . Among all patients assigned to aspirin ( groups 1 and 2 ) , the annual incidence of outcome events was 15 % , against 19 % in those on placebo ( HR 0.83 ; 95 % CI 0.65 - 1.05 ) . Anticoagulation was significantly more effective than aspirin ( HR 0.60 ; 95 % CI 0.41 - 0.87 ) . The incidence of major bleeding events was low , both on anticoagulation ( 2.8 % per year ) and on aspirin ( 0.9 % per year ) . No intracranial bleeds were identified in patients assigned to anticoagulation . We conclude that anticoagulation is effective in reducing the risk of recurrent vascular events in NRAF patients with a recent TIA or minor ischaemic stroke . In absolute terms : 90 vascular events ( mainly strokes ) are prevented if 1000 patients are treated with anticoagulation for one year . Aspirin is a safe , though less effective , alternative when anticoagulation is contraindicated ; it prevents 40 vascular events each year for every 1000 treated patients OBJECTIVES The aim of the study was to test the value of low dose aspirin associated with st and ard oral anticoagulants ( OAC )  after mechanical mitral valve replacement ( MMRV ) to reduce str and s , thrombi and thromboembolic events . BACKGROUND Str and s and thrombi are thought to increase the risk of embolic events after MMVR , particularly in the immediate postoperative period . METHODS Two hundred twenty-nine patients were prospect ively recruited : 109 patients ( group A+ ) were r and omly assigned to aspirin ( 200 mg per day ) with OAC and 120 patients ( group A- ) to OAC alone ( international normalized ratio 2.5 to 3.5 ) . All patients were subjected to multiplane transesophageal echocardiography at nine days and five months and were followed up for one year . RESULTS At nine days and five months , there was a high and comparable incidence of str and s in the two groups ( group A+ : 44 % , 58 % ; group A- : 49 % , 63 % ) . However , the incidence of nonobstructive periprosthetic valve thrombi was significantly lower in group A+ at 9 days : 5 % versus 13 % , p = 0.03 . Total thromboembolic events were reduced in group A+ ( 9 % vs. 25 % , p = 0.004 ) although there was an increased incidence of gastrointestinal hemorrhage ( 7 % vs. 0 % ) . Overall mortality was 9 % in group A+ and 4 % in group A- . Valve-related events were similar in both groups . Early thrombi , but not str and s , were associated with higher morbidity , especially thromboembolic events ( 30 % vs. 13 % , p = 0.003 ) . CONCLUSIONS One year after MMVR , the association of aspirin with OAC reduced thrombi and thromboembolic events , but not morbidity , due to an increase in hemorrhagic complications
Limited evidence from r and omized trials and observational studies found a reduction in mortality and cardiovascular events with anticoagulants compared to controls .
Although oral anticoagulation is indicated in certain groups of patients with heart failure ( e.g. atrial fibrillation ) , the available data do not support its routine use in heart failure patients who remain in sinus rhythm
BACKGROUND Patients with chronic heart failure ( heart failure ) are at risk of thromboembolic events , and coronary ischaemic events also contribute to the progression of heart failure .
Long-term oral anticoagulation is established in certain groups , including patients with heart failure and atrial fibrillation , but there is wide variation in the use of oral anticoagulation in the broader heart failure population .
OBJECTIVE To determine whether long-term oral anticoagulation reduces total deaths and /or major thromboembolic events in patients with heart failure .