 in TAVR patients ranges from 15 to 30%, depending on series.){kind=link}
The prevalence of atrial fibrillation (AF) in TAVR patients ranges from 15 to 30%, depending on series. This arrhythmia has been associated to higher risk of thromboembolic events and ischemic stroke, which increases the risk of hospitalization, mortality, and disability, as well as costs.
The use of anticoagulants in this context is crucial. However, at present there are no conclusive data to enable an informed choice between using vitamin K antagonists (VKA) or the new oral
The prospective and randomized ENVISAGE-TAVI AF included 1,377 TAVR patients with atrial fibrillation. 41 of these patients (3%) presented ischemic stroke: 19 received edoxaban (EDX) and 22 VKA. The 1,336 remaining patients with no ischemic stroke were divided into 673 who received EDX, and 663 receiving VKA.
Patients were randomized to anticoagulation within 12 and 7 days after TAVR.
The groups had similar baseline characteristics: mean age 81, approximately half were men, with mean CHA2DS2-VASc score 4.5, HAS-BLED 1.6, and 18% had a history of stroke or transient ischemic attack (TIA). 90% were hypertensive, 35% diabetic, 80% cardiac failure, 9% a bleeding history, mean creatinine depuration was 60 ml/min. STS surgical risk was 4.5%, and there were no significant differences in the use of VKA or EDX before TAVR.
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Patients with ischemic stroke prior TAVR presented higher incidence of myocardial infarction (AMI) and non-cerebral thromboembolic events.
There were no differences in ischemic stroke rate (3%) between the groups. Events rate resulted 2.0/100 patient-years for EDX patients and 2.7/100 patient-years for VKA (HR: 1.3; CI 95%: 0.81-2.09).
Interdependent risk factors associated to higher risk of stroke were: a history of systemic thromboembolic events (HR 2.96; CI 95%: 1.42-6.14), use of VKA before TAVR (HR 2.17; CI 95%: 1.09-4.32) and older age (especially over 80).
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The highest frequency of ischemic stroke occurred within 180 after TAVR, being most common in the first three months.
Conclusion
The incidence of ischemic stroke was lower in patients with atrial fibrillation treated with edoxaban or VKA after successful TAVR. However, those with a history of systemic thromboembolic events or those using VKA before procedure might have been at higher risk of ischemic events after TAVR.
Reference: Christian Hengstenberg, et a. American Journal of Cardiology, Volume 227, 98 – 104.
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