- Email: [email protected]
USING INSERTABLE CARDIAC MONITORS TO RISK STRATIFY PATIENTS AND MANAGE ANTICOAGULATION IN ATRIAL FIBRILLATION
695 JACC April 5, 2016 Volume 67, Issue 13
Arrhythmias and Clinical EP USING INSERTABLE CARDIAC MONITORS TO RISK STRATIFY PATIENTS AND MANAGE ANTICOAGULATION IN ATRIAL FIBRILLATION Oral Contributions Room S501 Sunday, April 03, 2016, 9:00 a.m.-9:12 a.m. Session Title: Highlighted Original Research: Arrhythmias and Clinical EP and the Year in Review Abstract Category: 16. Arrhythmias and Clinical EP: AF/SVT Presentation Number: 902-10 Authors: Mohammad Umar Farooq, Daniel Mascarenhas, Bharat Kantharia, Easton Hospital, Easton, PA, USA, Drexel University, Philadelphia, PA, USA
Background: Oral anticoagulants (OACs) have an established role in the prevention of thromboembolic stroke in atrial fibrillation (AF). However in real world clinical practice settings, we find many such patients are at high risk of bleeding and/or insisting on withdrawal of OAC. Recent data has shown that the risk of stroke diminishes as the AF burden decreases. We aimed to ascertain whether an insertable cardiac monitor (ICM)-guided rhythm control strategy might obviate long-term use of OACs in AF patients at high bleeding risk.
Methods: We implanted ICMs in 96 AF patients with high risk of stroke [CHADS2≥2, CHA2DS2-VASc score ≥2] and bleeding [HAS-BLED score ≥3] after restoration of normal sinus rhythm (NSR) for continuous rhythm monitoring and optimization of antiarrhythmic drugs (AADs). Monthly AF burden was followed and patients were risk stratified into: (i) Group A (always NSR/low AF burden, <1%), (ii) Group B (variable AF burden), and (iii) Group C (high AF burden, always AF). If patients maintained NSR/AF burden<1% for ≥3 consecutive months, they were offered the option to stop OAC after counseling of risks and benefits. Strict monthly ICM checks would continue. If AF burden rose to >1%, OAC would be restarted while AADs were titrated and risk factors controlled. All patients (age 73.3±11.7 years; 53% male) were followed clinically and with ICM monitoring for 22.04±11.24 months for outcomes including stroke, bleeding, and AAD’s adverse effects. Results: Patients in Group A (n=60), B (n=24), and C (n=12) had similar CHADS2 (2.10±0.66, 2.05±0.51 and 2.14±0.38, respectively), CHA2DS2-VASc (3.05±1.01, 2.85±0.99, and 2.43±0.53, respectively) and HAS-BLED (3.02±1.01, 3.40±0.68, and 3.00±0.58, respectively) scores (p>0.05). At study end, 85% patients (n=82) maintained NSR with low risk of stroke, therefore eligible to discontinue OAC. Of those, 72% patients (n=59) discontinued OACs with no subsequent stroke. 39% (n=37) patients remained on OAC, and 11% patients on OAC (n=4) suffered severe bleeding. Conclusions: In AF patients with high bleeding risk, ICM-guided rhythm control with AADs and assessment of AF burden may allow safe discontinuation of OACs.
Arrhythmias and Clinical EP USING INSERTABLE CARDIAC MONITORS TO RISK STRATIFY PATIENTS AND MANAGE ANTICOAGULATION IN ATRIAL FIBRILLATION Oral Contributions Room S501 Sunday, April 03, 2016, 9:00 a.m.-9:12 a.m. Session Title: Highlighted Original Research: Arrhythmias and Clinical EP and the Year in Review Abstract Category: 16. Arrhythmias and Clinical EP: AF/SVT Presentation Number: 902-10 Authors: Mohammad Umar Farooq, Daniel Mascarenhas, Bharat Kantharia, Easton Hospital, Easton, PA, USA, Drexel University, Philadelphia, PA, USA
Background: Oral anticoagulants (OACs) have an established role in the prevention of thromboembolic stroke in atrial fibrillation (AF). However in real world clinical practice settings, we find many such patients are at high risk of bleeding and/or insisting on withdrawal of OAC. Recent data has shown that the risk of stroke diminishes as the AF burden decreases. We aimed to ascertain whether an insertable cardiac monitor (ICM)-guided rhythm control strategy might obviate long-term use of OACs in AF patients at high bleeding risk.
Methods: We implanted ICMs in 96 AF patients with high risk of stroke [CHADS2≥2, CHA2DS2-VASc score ≥2] and bleeding [HAS-BLED score ≥3] after restoration of normal sinus rhythm (NSR) for continuous rhythm monitoring and optimization of antiarrhythmic drugs (AADs). Monthly AF burden was followed and patients were risk stratified into: (i) Group A (always NSR/low AF burden, <1%), (ii) Group B (variable AF burden), and (iii) Group C (high AF burden, always AF). If patients maintained NSR/AF burden<1% for ≥3 consecutive months, they were offered the option to stop OAC after counseling of risks and benefits. Strict monthly ICM checks would continue. If AF burden rose to >1%, OAC would be restarted while AADs were titrated and risk factors controlled. All patients (age 73.3±11.7 years; 53% male) were followed clinically and with ICM monitoring for 22.04±11.24 months for outcomes including stroke, bleeding, and AAD’s adverse effects. Results: Patients in Group A (n=60), B (n=24), and C (n=12) had similar CHADS2 (2.10±0.66, 2.05±0.51 and 2.14±0.38, respectively), CHA2DS2-VASc (3.05±1.01, 2.85±0.99, and 2.43±0.53, respectively) and HAS-BLED (3.02±1.01, 3.40±0.68, and 3.00±0.58, respectively) scores (p>0.05). At study end, 85% patients (n=82) maintained NSR with low risk of stroke, therefore eligible to discontinue OAC. Of those, 72% patients (n=59) discontinued OACs with no subsequent stroke. 39% (n=37) patients remained on OAC, and 11% patients on OAC (n=4) suffered severe bleeding. Conclusions: In AF patients with high bleeding risk, ICM-guided rhythm control with AADs and assessment of AF burden may allow safe discontinuation of OACs.