Influencia de la enfermedad valvular y de la antiagregación concomitante en los eventos clínicos en pacientes con fibrilación auricular no valvular que Inician anticoagulación oral

Abstract

Objectives 1. To evaluate the prevalence of valve disease in patients with atrial fibrillation (AF) initiating direct oral anticoagulants (DOAC) in real-world clinical practice. 2. To evaluate the impact of valve disease on clinical events in these patients. 3. To evaluate the association between aortic stenosis (AS) and major bleeding in patients with AF initiating oral anticoagulants. 4. To assess the complementary predictive value of AS to bleeding risk scores for prediction of major bleeding in these patients. 5. To evaluate the prevalence of concomitant antiplatelet therapy in AF patients with no recent ischaemic events initiating DOAC in real-world clinical practice. 6. To evaluate the effectiveness of concomitant antiplatelet therapy in AF patients with no recent ischaemic events initiating DOAC. 7. To evaluate the security of concomitant antiplatelet therapy in AF patients with no recent ischaemic events initiating these anticoagulants. Methods Article 1: Prevalence and prognostic implications of valve disease in patients with atrial fibrillation initiating direct oral anticoagulants. Retrospective multicenter registry including 2297 consecutive patients with nonvalvular AF initiating DOAC between January 2013 and December 2016. Valvular heart disease was defined as moderate or severe involvement. The primary study endpoint was the composite of death, stroke or transient ischemic attack/systemic embolism or major bleeding. A competing risks analysis was carried out using a Fine and Gray regression model, with death being the competing event. Article 2: Aortic valve stenosis provides complementary information to bleeding risk scores in non-valvular atrial fibrillation patients initiating anticoagulation Retrospective multi-center study including 2880 consecutive non-valvular AF patients initiating oral anticoagulation between January 2013 and December 2016. AS was defined as moderate or severe according to European echocardiography guidelines criteria. HASBLED, ATRIA and ORBIT scores were used to evaluate the bleeding risk. Major bleeding was defined according to the International Society on Thrombosis and Haemostasia criteria and registered at 18 months of follow-up. Article 3: Effect of concomitant antiplatelet therapy in patients with non-valvular atrial fibrillation initiating non-vitamin K antagonists. Retrospective multicentre study including 2361 consecutive non-valvular AF patients initiating DOAC between January 2013 and December 2016. Patients with an acute ischaemic event within the last 12 months (acute coronary syndrome, stroke or revascularization) were excluded. Patients were followed-up and all clinical events were recorded at 3 months. The primary outcome of the study was major bleeding and the secondary outcomes were stroke, non-fatal myocardial infarction, intracranial bleeding and death. Conclusions 1. Valvular heart disease is common in patients with atrial fibrillation initiating DOAC in real-world clinical practice. The most common form was mitral regurgitation, followed by AS and aortic regurgitation. 2. Valvular heart disease is associated with a worse clinical profile and higher risk of death and major bleeding, but there was no association with thromboembolic events. 3. The prevalence of moderate or severe AS was not uncommon among AF patients initiating oral anticoagulants, and it was associated with an increased risk of bleeding events. 4. The addition of AS to bleeding risk scores was associated with a significant improvement in their predictive accuracy. 5. Prescription of concomitant antiplatelet therapy is uncommon in a 'real?world' contemporary cohort of AF patients with no recent ischaemic events who initiate DOAC. 6. The use of antiplatelets in these patients did not seem to be associated with lower rates of ischaemic events or death at short-term follow-up. 7. On the contrary, the use of antiplatelets was associated with an increased risk of major bleeding in these patients.