Matthew W Sherwood1, Jonathan P Piccini2, DaJuanicia N Holmes2, Karen S Pieper3, Benjamin A Steinberg4, Gregg C Fonarow5, Larry A Allen6, Gerald V Naccarelli7, Peter R Kowey8, Bernard J Gersh9, Kenneth W Mahaffey10, Daniel E Singer11, Jack E Ansell12, James V Freeman13, Paul S Chan14, James A Reiffel15, Rosalia Blanco2, Eric D Peterson2, Sunil V Rao2. 1. Inova Heart and Vascular Institute, Falls Church, VA (M.W.S.). 2. Duke Clinical Research Institute, Durham, NC (J.P.P., D.N.H., R.B., E.D.P., S.V.R.). 3. Thrombosis Research Institute, London, United Kingdom (K.S.P.). 4. Cardiovascular Medicine, University of Utah Hospitals, Salt Lake City (B.A.S.). 5. University of California Los Angeles Medical Center (G.C.F.). 6. University of Colorado School of Medicine, Aurora (L.A.A.). 7. Penn State Heart and Vascular Institute, Hershey, PA (G.V.N.). 8. Lankenau Heart Institute, Lancaster, PA (P.R.K.). 9. Mayo Clinic, Rochester, MN (B.J.G.). 10. Stanford Center for Clinical Research, CA (K.W.M.). 11. Massachusetts General Hospital, Boston (D.E.S.). 12. Hofstra North Shore-LIJ School of Medicine, Hempstead, NY (J.E.A.). 13. Yale New Haven Hospital, CT (J.V.F.). 14. Saint Luke's Hospital, Kansas City, MO (P.S.C.). 15. Columbia University Medical Center, NY (J.A.R.).
Abstract
BACKGROUND: Patients with atrial fibrillation on oral anticoagulation (OAC) undergoing cardiac catheterization face risks for embolic and bleeding events, yet information on strategies to mitigate these risks in contemporary practice is lacking. METHODS: We aimed to describe the clinical/procedural characteristics of a contemporary cohort of patients with atrial fibrillation on OAC who underwent cardiac catheterization. Use of bleeding avoidance strategies and bridging therapy were described and outcomes including death, stroke, and major bleeding at 30 days and 1 year were compared by OAC type. RESULTS: Of 13 404 patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II Registry from 2013 to 2016, 741 underwent cardiac catheterization (139 with percutaneous coronary intervention) in the setting of OAC. The patients' median age was 71, 61.8% were male, white (87.2%), had hypertension (83.7%), hyperlipidemia (72.1%), diabetes mellitus (31.6%), and chronic kidney disease (28.2%); 20.2% received warfarin while 79.8% received direct acting oral anticoagulant. One third of patients underwent radial artery access, and bivalirudin was used in 4.6%. Bridging therapy was used more often in patients on warfarin versus direct acting oral anticoagulant (16.7% versus10.0%). OAC was interrupted in 93.8% of patients. Patients on warfarin versus direct acting oral anticoagulant were equally likely to restart OAC (58.0% versus 60.7%), had similar use of antiplatelet therapy (44.0% versus 41.3%) after catheterization, and had similar rates of myocardial infarction and death at 1 year, but higher rates of major bleeding (43.3 versus 12.9 events/100 patient years) and stroke (4.9 versus 1.9 events/100 patient years). CONCLUSIONS: In a real-world registry of patients with atrial fibrillation undergoing cardiac catheterization, most cases are elective, performed by femoral access, with interruption of OAC. Bleeding avoidance strategies such as radial artery access and bivalirudin were used infrequently and use of bridging therapy was uncommon. Nearly 40% of patients did not restart OAC postprocedure, exposing patients to risk for stroke. Further research is necessary to optimize the management of patients with atrial fibrillation undergoing cardiac catheterization.
BACKGROUND:Patients with atrial fibrillation on oral anticoagulation (OAC) undergoing cardiac catheterization face risks for embolic and bleeding events, yet information on strategies to mitigate these risks in contemporary practice is lacking. METHODS: We aimed to describe the clinical/procedural characteristics of a contemporary cohort of patients with atrial fibrillation on OAC who underwent cardiac catheterization. Use of bleeding avoidance strategies and bridging therapy were described and outcomes including death, stroke, and major bleeding at 30 days and 1 year were compared by OAC type. RESULTS: Of 13 404 patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II Registry from 2013 to 2016, 741 underwent cardiac catheterization (139 with percutaneous coronary intervention) in the setting of OAC. The patients' median age was 71, 61.8% were male, white (87.2%), had hypertension (83.7%), hyperlipidemia (72.1%), diabetes mellitus (31.6%), and chronic kidney disease (28.2%); 20.2% received warfarin while 79.8% received direct acting oral anticoagulant. One third of patients underwent radial artery access, and bivalirudin was used in 4.6%. Bridging therapy was used more often in patients on warfarin versus direct acting oral anticoagulant (16.7% versus10.0%). OAC was interrupted in 93.8% of patients. Patients on warfarin versus direct acting oral anticoagulant were equally likely to restart OAC (58.0% versus 60.7%), had similar use of antiplatelet therapy (44.0% versus 41.3%) after catheterization, and had similar rates of myocardial infarction and death at 1 year, but higher rates of major bleeding (43.3 versus 12.9 events/100 patient years) and stroke (4.9 versus 1.9 events/100 patient years). CONCLUSIONS: In a real-world registry of patients with atrial fibrillation undergoing cardiac catheterization, most cases are elective, performed by femoral access, with interruption of OAC. Bleeding avoidance strategies such as radial artery access and bivalirudin were used infrequently and use of bridging therapy was uncommon. Nearly 40% of patients did not restart OAC postprocedure, exposing patients to risk for stroke. Further research is necessary to optimize the management of patients with atrial fibrillation undergoing cardiac catheterization.
Authors: Matthew W Sherwood; Aakriti Gupta; Sreekanth Vemulapalli; Zhuokai Li; Jonathan Piccini; J Kevin Harrison; David Dai; Amit N Vora; Michael J Mack; David R Holmes; John S Rumsfeld; David J Cohen; Vinod H Thourani; Ajay J Kirtane; Eric D Peterson Journal: Circ Cardiovasc Interv Date: 2021-04-20 Impact factor: 6.546