Turagam Mohit K, Parikh Valay, Afzal Muhammad R, Gopinathannair Rakesh, Lavu Madhav, Kanmanthareddy Arun, Pillarisetti Jayasree, Reddy Madhu, Atkins Donita, Bommana Sudharani, Jaeger Melissa, Jeffery Courtney, Mohanty Sanghamitra, Santangeli Pasquale, Cheng Jie, Di Biase Luigi, Narasimhan Calambur, Natale Andrea, Lakkireddy Dhanunjaya
Division of Cardiovascular Medicine, University of Missouri Hospital and Clinics, Columbia, MO, USA.
Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS, USA.
J Cardiovasc Electrophysiol. 2017 Aug;28(8):853-861. doi: 10.1111/jce.13254. Epub 2017 Jun 8.
A significant proportion of patients treated with warfarin for atrial fibrillation (AF) become warfarin ineligible (WI) due to major bleeding events (MBE) or systemic thromboembolism (STE). We report a large multicenter real-world experience of the use of direct oral antagonists (DOACs) in these WI patients.
We report the outcomes of 263 WI patients treated with DOACs. The primary objective was to evaluate clinical outcomes of STE and MBE with DOACs. Secondary objective was to assess clinical predictors of repeat MBE and STE on DOACs.
Note that 63% (166 of 263) patients had a repeat MBE on DOACs. Repeat MBE was significantly higher in patients with prior gastrointestinal bleeding (74.5% vs. 30%, P < 0.0001). Five percent (12 of 263) developed repeat STE. Higher mean CHA2DS2VASC (6.5 ± 1.7 vs. 3.3 ± 1.6 = 0.001) score was associated with repeat STE. About 34% (57 of 166) of patients had an intervention to manage repeat MBE. LAAO devices were successfully used in 67% (12 of 18) high-risk patients who underwent major interventions to manage MBE.
In WI patients rechallenged with DOACs, a significant proportion developed repeat MBE. LAAO devices seem reasonable in those patients who undergo major interventions to manage MBE with cautious and temporary continuation of DOAC.
因重大出血事件（MBE）或全身性血栓栓塞（STE），相当一部分接受华法林治疗心房颤动（AF）的患者不再适合使用华法林（WI）。我们报告了在这些WI患者中使用直接口服抗凝剂（DOACs）的大型多中心真实世界经验。
我们报告了263例接受DOACs治疗的WI患者的结果。主要目标是评估DOACs治疗STE和MBE的临床结果。次要目标是评估DOACs治疗后MBE和STE复发的临床预测因素。
注意到63%（263例中的166例）患者在使用DOACs时出现MBE复发。既往有胃肠道出血的患者MBE复发率显著更高（74.5%对30%，P<0.0001）。5%（263例中的12例）出现STE复发。较高的平均CHA2DS2VASC评分（6.5±1.7对3.3±1.6，P=0.001）与STE复发相关。约34%（166例中的57例）患者接受了处理MBE复发的干预措施。左心耳封堵（LAAO）装置在67%（18例中的12例）接受主要干预措施处理MBE的高危患者中成功使用。
在重新使用DOACs的WI患者中，相当一部分出现了MBE复发。对于那些接受主要干预措施处理MBE且谨慎并暂时继续使用DOAC的患者，LAAO装置似乎是合理的。
