European Heart Journal - Cardiovascular Pharmacotherapy最新文献

Background: Left ventricular (LV) thrombus is a severe complication of acute myocardial infarction (AMI) and chronic heart failure. While current guidelines support the use of direct oral anticoagulants (DOAC) as alternatives to vitamin K antagonists (VKA), their benefit across different aetiologies remains uncertain. This study aimed to compare the efficacy and safety of DOAC versus VKA across different aetiologies of LV dysfunction.

Methods: We conducted a multi-centre observational study including 901 patients with confirmed LV thrombus treated with either a VKA or DOAC. The primary outcome was thrombus resolution, secondary outcomes included stroke and systemic embolisation (SSE), major bleeding and mortality with analyses performed by aetiology.

Results: The principal aetiologies were AMI (38.3%), ischaemic cardiomyopathy (ICM) (38.0%) and non-ischaemic cardiomyopathy (NICM) (23.7%). Overall, thrombus resolution was significantly higher in DOAC treated patients, but this was driven by the AMI sub-group (p=0.018). DOAC use independently predicted thrombus resolution (OR 2.0, 95% Cl 1.29-3.24, p=0.010). Major bleeding events (BARC ≥3) were more common with VKA use (p=0.008). NICM had the highest SSE rate (15.3%, p=0.002), which were significantly raised in those treated with DOAC (p<0.001).

Conclusions: The underlying aetiology of LV dysfunction significantly influences both treatment response and outcomes in patients with LV thrombus. DOAC were associated with superior efficacy and safety in AMI-related LV thrombus, but were linked to increased rates of SSE in NICM. These findings highlight the importance of aetiology on LV thrombus management and the potential need for tailored approaches.

Aims: To assess whether rivaroxaban is associated with a decreased risk of major adverse limb events (MALE), stroke, systemic embolism (SE), and major bleeding (MB) among patients with non-valvular atrial fibrillation (NVAF) and peripheral artery disease (PAD), compared with apixaban.

Methods and results: We conducted a population-based cohort study using the UK Clinical Practice Research Datalink. Patients aged ≥45 years with incident NVAF and PAD who initiated rivaroxaban or apixaban between 2013 and 2021 were included. Primary effectiveness outcomes were MALE, and a composite of ischaemic stroke, transient ischaemic attack (TIA), or SE. The primary safety outcome was MB. The risk of major cardiovascular events (MACE) was assessed as a secondary outcome. Confounding was addressed using propensity score fine stratification and weighting. Weighted Cox proportional hazards models estimated hazard ratios (HRs) with 95% confidence intervals (CIs). The cohort included 6170 new users of rivaroxaban and 9990 new users of apixaban (44% female; mean [SD] age 78.5 [9.2] years). Incidence rates were similar for MALE (6.7 vs. 5.6/1000 person-years; adjusted HR (aHR): 1.20; 95% CI 0.87-1.65), stroke/TIA/SE (24.5 vs. 21.3/1000 person-years; aHR: 1.15; 95% CI 0.97-1.36), and MACE (40.1 vs. 35.9 per 1000 person-years; aHR 1.10: 95% CI 0.94-1.28). Major bleeding rates were higher with rivaroxaban (46.1 vs. 29.8/1000 person-years; aHR: 1.55; 95% CI 1.36-1.77).

Conclusion: In patients with NVAF and PAD, rivaroxaban was associated with a similar risk of MALE and stroke/TIA/SE, but a higher risk of MB compared with apixaban. These findings support apixaban as a potentially safer anticoagulant in this high-risk population.

Post-operative atrial fibrillation (POAF) is common after non-cardiac surgery. Because often transient, there are uncertainties on the associated risk of stroke, possibly driving the need for long-term anticoagulation. We performed a systematic PubMed search until 16 January 2025, related to the incidence of stroke in patients with POAF after non-cardiac surgery. We included papers reporting outcomes, excluding studies only dealing with epidemiology, mechanisms, management, and treatment. We excluded studies reporting on POAF after cardiac surgery. Risk of bias was assessed for each study, and the certainty of evidence was evaluated using the GRADE methodology. We retrieved and included 40 studies (including review papers) for the systematic review. These were then further selected to create a final list of 19 studies included in the meta-analysis. The reported incidence of stroke after POAF was found to be widely variable, ranging between 0.4% and 16.7% at 1 year. Stroke incidence also varies widely according to the type of surgery and patient characteristics. With only three exceptions, all studies, however, reported a risk of stroke higher in the POAF group than in the no-POAF group, with a mean odds ratio of 3.02. POAF on average triples the risk of stroke, with variations related to patient characteristics and type of surgery. Patients after non-cardiac surgery should be monitored at least during hospitalisation to detect POAF. Future studies are necessary to evaluate optimal duration and modalities of monitoring, as well as to assess the relevance of symptomatic vs asymptomatic AF episodes.