Diagnostic and therapeutic pathways for the malignant left atrial appendage: European Heart Rhythm Association physician survey

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Aims

Patients with atrial fibrillation who despite taking oral anti-coagulant therapy (OAT) suffer a stroke or systemic embolism (SSE) without vascular cause or who develop left atrial appendage (LAA) thrombus (LAAT) should be considered as having malignant LAA. The optimal treatment strategy to reduce SSE risk in such patients is unknown. The aim of the study is to investigate the diagnostic and therapeutic pathways for malignant LAA practiced in European cardiac centres.

Methods and results

An 18-item online questionnaire on malignant LAA was disseminated by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee. A total of 196 physicians participated in the survey. There seems to be high confidence in transoesophageal echocardiography (TEE) imaging, considering LAAT diagnosis. Switching to another direct oral anti-coagulant (DOAC) is the preferred initial step for the treatment of malignant LAA followed by a switch to vitamin K antagonist (VKA), low-molecular-weight heparin, or continued/optimized DOAC dosage, whereas LAA closure is the last option. Left atrial appendage closure is a viable option in patients with embolic stroke despite OAT and no evidence of thrombus at TEE (empty LAA) after comprehensive diagnostic measures to exclude other sources of embolism.

Conclusion

This EHRA survey provides a snapshot of the contemporary management of patients diagnosed with malignant LAA. Currently, the majority of patients are treated on an outpatient basis with either shifting from VKA to DOAC or from one DOAC to another. Left atrial appendage closure in this population seems to be reserved for patients with higher bleeding risk or complications of malignant LAA, such as stroke.

Graphical Abstract

Related collections

Most cited references 33

Record: found
Abstract: not found
Article: not found

OUP accepted manuscript

(2020)

0 comments Cited 2995 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Apixaban versus Warfarin in Patients with Atrial Fibrillation

Christopher B Granger, John H Alexander, John J.V. McMurray … (2012)

Vitamin K antagonists are highly effective in preventing stroke in patients with atrial fibrillation but have several limitations. Apixaban is a novel oral direct factor Xa inhibitor that has been shown to reduce the risk of stroke in a similar population in comparison with aspirin. In this randomized, double-blind trial, we compared apixaban (at a dose of 5 mg twice daily) with warfarin (target international normalized ratio, 2.0 to 3.0) in 18,201 patients with atrial fibrillation and at least one additional risk factor for stroke. The primary outcome was ischemic or hemorrhagic stroke or systemic embolism. The trial was designed to test for noninferiority, with key secondary objectives of testing for superiority with respect to the primary outcome and to the rates of major bleeding and death from any cause. The median duration of follow-up was 1.8 years. The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P<0.001 for noninferiority; P=0.01 for superiority). The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P<0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P=0.047). The rate of hemorrhagic stroke was 0.24% per year in the apixaban group, as compared with 0.47% per year in the warfarin group (hazard ratio, 0.51; 95% CI, 0.35 to 0.75; P<0.001), and the rate of ischemic or uncertain type of stroke was 0.97% per year in the apixaban group and 1.05% per year in the warfarin group (hazard ratio, 0.92; 95% CI, 0.74 to 1.13; P=0.42). In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. (Funded by Bristol-Myers Squibb and Pfizer; ARISTOTLE ClinicalTrials.gov number, NCT00412984.).

0 comments Cited 1144 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.

Manesh R Patel, Kenneth Mahaffey, Jyotsna Garg … (2012)

The use of warfarin reduces the rate of ischemic stroke in patients with atrial fibrillation but requires frequent monitoring and dose adjustment. Rivaroxaban, an oral factor Xa inhibitor, may provide more consistent and predictable anticoagulation than warfarin. In a double-blind trial, we randomly assigned 14,264 patients with nonvalvular atrial fibrillation who were at increased risk for stroke to receive either rivaroxaban (at a daily dose of 20 mg) or dose-adjusted warfarin. The per-protocol, as-treated primary analysis was designed to determine whether rivaroxaban was noninferior to warfarin for the primary end point of stroke or systemic embolism. In the primary analysis, the primary end point occurred in 188 patients in the rivaroxaban group (1.7% per year) and in 241 in the warfarin group (2.2% per year) (hazard ratio in the rivaroxaban group, 0.79; 95% confidence interval [CI], 0.66 to 0.96; P<0.001 for noninferiority). In the intention-to-treat analysis, the primary end point occurred in 269 patients in the rivaroxaban group (2.1% per year) and in 306 patients in the warfarin group (2.4% per year) (hazard ratio, 0.88; 95% CI, 0.74 to 1.03; P<0.001 for noninferiority; P=0.12 for superiority). Major and nonmajor clinically relevant bleeding occurred in 1475 patients in the rivaroxaban group (14.9% per year) and in 1449 in the warfarin group (14.5% per year) (hazard ratio, 1.03; 95% CI, 0.96 to 1.11; P=0.44), with significant reductions in intracranial hemorrhage (0.5% vs. 0.7%, P=0.02) and fatal bleeding (0.2% vs. 0.5%, P=0.003) in the rivaroxaban group. In patients with atrial fibrillation, rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism. There was no significant between-group difference in the risk of major bleeding, although intracranial and fatal bleeding occurred less frequently in the rivaroxaban group. (Funded by Johnson & Johnson and Bayer; ROCKET AF ClinicalTrials.gov number, NCT00403767.).

0 comments Cited 1140 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Contributors

Ante Anic:

ORCID: https://orcid.org/0000-0002-6864-3999

Darija Bakovic:

ORCID: https://orcid.org/0000-0001-6751-5242

Zrinka Jurisic:

ORCID: https://orcid.org/0000-0001-7583-9036

Michal Farkowski:

ORCID: https://orcid.org/0000-0003-1673-7712

Lucija Lisica:

ORCID: https://orcid.org/0000-0003-1904-0259

Toni Breskovic:

ORCID: https://orcid.org/0000-0001-7266-2087

Jens Erik Nielsen-Kudsk:

ORCID: https://orcid.org/0000-0002-6473-2900

Laura Perrotta:

ORCID: https://orcid.org/0000-0002-4322-1183

Carlo de Asmundis:

ORCID: https://orcid.org/0000-0001-9351-0760

Serge Boveda:

ORCID: https://orcid.org/0000-0002-1280-7042

Julian Chun:

ORCID: https://orcid.org/0000-0002-2355-6015

Journal

Journal ID (nlm-ta): Europace

Journal ID (iso-abbrev): Europace

Journal ID (publisher-id): europace

Title: Europace

Publisher: Oxford University Press (US )

ISSN (Print): 1099-5129

ISSN (Electronic): 1532-2092

Publication date Collection: July 2023

Publication date (Electronic): 13 July 2023

Publication date PMC-release: 13 July 2023

Volume: 25

Issue: 7

Electronic Location Identifier: euad204

Affiliations

Department for Cardiovascular Diseases, University Hospital Centre Split , Soltanska 1, 21000 Split, Croatia

School of Medicine, University of Split , Split, Croatia

Department for Cardiovascular Diseases, University Hospital Centre Split , Soltanska 1, 21000 Split, Croatia

School of Medicine, University of Split , Split, Croatia

Department of Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration , Warsaw, Poland

II Department of Heart Arrhythmia, National Institute of Cardiology , Warsaw, Poland

Department for Cardiovascular Diseases, University Hospital Centre Split , Soltanska 1, 21000 Split, Croatia

School of Medicine, University of Split , Split, Croatia

Aarhus University Hospital , Aarhus, Denmark

University Hospital Careggi, EP Lab , Florence, Italy

Heart Rhythm Management Centre, University Hospital (UZ) Brussels , Brussels, Belgium

Cardiology-Heart Rhythm Management Department, Clinique Pasteur , Toulouse, France

CCB, Cardiology, Med. Klinik III, Markus Krankenhaus , Frankfurt, Germany

Author notes

Corresponding author. Tel: +38521557531. E-mail address: anteanic@ 123456gmail.com

Author information

Ante Anic https://orcid.org/0000-0002-6864-3999

Darija Bakovic https://orcid.org/0000-0001-6751-5242

Zrinka Jurisic https://orcid.org/0000-0001-7583-9036

Michal Farkowski https://orcid.org/0000-0003-1673-7712

Lucija Lisica https://orcid.org/0000-0003-1904-0259

Toni Breskovic https://orcid.org/0000-0001-7266-2087

Jens Erik Nielsen-Kudsk https://orcid.org/0000-0002-6473-2900

Laura Perrotta https://orcid.org/0000-0002-4322-1183

Carlo de Asmundis https://orcid.org/0000-0001-9351-0760

Serge Boveda https://orcid.org/0000-0002-1280-7042

Julian Chun https://orcid.org/0000-0002-2355-6015

Article

Publisher ID: euad204

DOI: 10.1093/europace/euad204

PMC ID: 10359107

PubMed ID: 37440757

SO-VID: 3e079835-6c65-4d48-86ba-9573e3406cd6

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 17 January 2023

Date accepted : 29 May 2023

Page count

Pages: 8

Comments

Comment on this article

scite_

Smart Citations

Citing PublicationsSupportingMentioningContrasting

View Citations

See how this article has been cited at scite.ai

scite shows how a scientific paper has been cited by providing the context of the citation, a classification describing whether it supports, mentions, or contrasts the cited claim, and a label indicating in which section the citation was made.

Cited by 4

See all cited by

Most referenced authors 1,495

See all reference authors

Diagnostic and therapeutic pathways for the malignant left atrial appendage: European Heart Rhythm Association physician survey

Read this article at

Abstract

Aims

Methods and results

Conclusion

Graphical Abstract

Related collections

Karger: Neurology and Neuroscience

Most cited references 33

OUP accepted manuscript

Apixaban versus Warfarin in Patients with Atrial Fibrillation

Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.

Author and article information

Contributors

Journal

Affiliations

Author notes

Author information

Article

History

Page count

Categories

Comments

Comment on this article

Similar content 367

Cited by 4

Most referenced authors 1,495