Aims: We compared thromboembolic (TE) and bleeding risks in patients with atrial fibrillation (AF) according to the new 'Evaluated Heartvalves, Rheumatic or Artificial' (EHRA) valve classification. Methods: Patients were divided into 3 categories: (i) EHRA type 1 corresponds to the previous 'valvular' AF patients, with either rheumatic mitral valve stenosis or mechanical prosthetic heart valves; (ii) EHRA type 2 includes AF patients with other valvular heart disease (VHD) and valve bioprosthesis or repair; and (iii) 'non-VHD controls' i.e. all AF patients with neither VHD nor post-surgical valve disease. Results: Among 8962 AF patients seen between 2000 and 2010, 357 (4%) were EHRA type 1, 1754 (20%) were EHRA type 2 and 6851 (76%) non-VHD controls. EHRA type 2 patients were older and had a higher CHA(2)DS(2)-VASc and HAS-BLED scores than either type 1 and non-VHD patients. After a mean follow-up of 1264 +/- 1160 days, the occurrence of TE events was higher in EHRA type 2 than non-VHD patients (HR (95% CI): 1.30 1.09-1.54), p = 0.003; also, p = 0.31 for type 1 vs 2, p = 0.68 for type 1 vs non-VHD controls). The rate of major BARC bleeding events for AF patients was higher in either EHRA type 1 (HR (95% CI): 3.16(2.11-4.72), p < 0.0001) or type 2 (HR (95% CI): 2.19(1.69-2.84), p < 0.0001) compared to non-VHD controls. Conclusion: The EHRA valve classification of AF patients with VHD appears useful in categorizing these patients, in terms of TE and bleeding risks. This classification can be used in clinical practice for appropriate choices of oral anticoagulation therapy and follow-up. (c) 2018 Elsevier B.V. All rights reserved.

Background: The DAPT score identifies patients with expected benefit from extended dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention (PCI). In a post-hoc analysis from the AFCAS registry, we explored the value of DAPT score to predict outcome in patients with atrial fibrillation (AF) undergoing PCI. Methods and results: Outcome measures included major adverse cardiac/cerebrovascular events (MACCE) [all-cause death, myocardial infarction, repeat revascularization, stent thrombosis, or stroke/transient ischemic attack] and bleeding events. At 12-month follow-up, patients with a DAPT score >= 1 had a higher incidence of MACCE, all-cause death, myocardial infarction (p = 0.004, p = 0.006, and p = 0.013, respectively), but a similar bleeding rate (p = 0.66), versus those with a DAPT score <1. In a subgroup of patients at high risk of stroke who received triple therapy for 1 month only, DAPT score >= 1 was associated with a higher incidence of MACCE, all-cause death, myocardial infarction (p = 0.002, p = 0.015, and p = 0.039, respectively), but a similar bleeding rate (p = 0.81). Conclusions: In AF patients undergoing PCI, a DAPT score >= 1 was associated with a higher incidence of thrombotic events, and a similar incidence of bleeding events, compared with a DAPT score <1. These results were consistent in patients at high risk of stroke who received triple therapy for 1 month. (c) 2017 Elsevier B.V. All rights reserved.

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) have been proposed as an alternative to vitamin K antagonists (VKA) for atrial fibrillation (AF) patients. Some studies have proposed that well-managed warfarin therapy is still a valid alternative as efficacious as NOACs but the potential impact and absolute effect of NOACs in real world optimally management of VKA AF patients is unknown. Purpose: To estimate the potential absolute benefit in clinical outcome rates if the optimally anticoagulated real-world AF patients with acenocoumarol had been treated with NOACs. Methods: We included 1361 patients stable on acenocoumarol with a time in therapeutic range of 100% for the previous 6 months and 6.5 years of follow-up. The estimation of clinical events avoided was calculated applying absolute risk reductions, relative risk reductions and hazard ratios from the pivotal clinical trials, relative to acenocoumarol. Results: Compared to acenocoumarol, the highest estimated event reduction for stroke was seen with dabigatran 150 mg, with an estimated reduction of 0.53%/year. For major bleeding, the highest estimated reduction was seen with apixaban (0.88%/year). For mortality, the largest estimated reduction was with dabigatran 150 mg (0.75%/year). In net clinical outcome, apixaban had the estimated highest reduction (1.23%/year). All NOACs showed significantly lower rates for intracranial haemorrhage. Conclusion: In optimally acenocoumarol anticoagulated AF patients, estimated reductions in stroke, bleeding and net clinical outcomes with various NOACs are evident. NOACs would potentially show an improvement even among optimally VKA AF patients. (c) 2017 Elsevier B.V. All rights reserved.

Background: Atrial fibrillation (AF) is associated with high morbidity and mortality, also among anticoagulated patients. Our aim was to evaluate the predictive role for long-term mortality of a series of risk stratification scores associated with cardiovascular or thromboembolic outcomes (CHADS(2), CHA(2)DS(2)-VASc, ATRIA, TIMI-AF), and bleeding complications (HAS-BLED) in an unselected population of patients with AF. Methods: Single center, observational, prospective registry of consecutive patients with AF, undergoing clinical/echocardiographic evaluation in a University Hospital, as either in-patients or out-patients. We assessed the role of each single score as predictors of long-term survival according to clinical setting. Results: We enrolled 1051 patients, mean age 72 +/- 12 years, whowere followed for 797 +/- 298 days. All the tested scores showed a good performance in prediction of mortality, together with several clinical factors (older age, chronic heart failure, diabetes, renal impairment, previous transient ischemic attack, left ventricular ejection fraction). The values at C-statistics ranged between modest (0.608-0.684) of inpatients to good (0.708-0.751) in outpatients without any statistical difference between the scores, excepted a lower performance of HAD-BLED. Conclusions: Risk scores currently adopted for decision making on starting oral anticoagulation provide good prediction of long-term survival in unselected AF patients, especially in the outpatient setting. (c) 2017 Published by Elsevier B.V.

Previous studies in patients with atrial fibrillation showed that a history of heart failure (HF) could negatively impact anticoagulation quality, as measured by the average time in therapeutic range (TTR). Whether additional markers of HF severity are associated with TTR has not been investigated thoroughly. We aimed to examine the potential role of HF severity in the quality of warfarin control in patients with HF with reduced ejection fraction. Data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial were used to investigate the association between TTR and HF severity. Multivariable logistic regression models were used to examine the association of markers of HF severity, including New York Heart Association (NYHA) class, Minnesota Living with HF (MLWHF) score, and frequency of HF hospitalization, with TTR >= 70% (high TTR). We included 1,067 participants (high TTR, N = 413; low TTR, N = 654) in the analysis. In unadjusted analysis, patients with a high TTR were older and less likely to have had strokes or receive other antiplatelet agents. Those patients also had lower NYHA class, better MLWHF scores, greater 6-minute walk distance, and lower frequency of HF hospitalizations. Multivariable analysis showed that NYHA class III and/or IV (Odds ratio [OR] 0.68 [95% confidence intervals [CIs] 0.49 to 0.94]), each 10-point increase in MLWHF score (i.e., worse health-related quality of life) (OR 0.92 [0.86 to 0.99]), and higher number of HF hospitalization per year (OR0.45 [0.30 to 0.67]) were associated with decreased likelihood of having high TTR. In HF patients with systolic dysfunction, NYHA class III and/or IV, poor health-related quality of life, and a higher rate of HF hospitalization were independently associated with suboptimal quality of warfarin anticoagulation control. These results affirm the need to assess the new approaches, such as direct oral anticoagulants, to prevent thromboembolism in this patient population. (C) 2018 Elsevier Inc. All rights reserved.

The CHA(2)DS(2)-VASc score may identify patients at higher risk of atrial fibrillation (AF) following ischemic stroke (IS) in patients without known AF. We compared gender related differences in items from CHA(2)DS(2)-VASc score and their relation with AF occurrence after IS. This French cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Of 336,291 patients with IS, 240,459 (71.5%) had no AF at baseline. Women were older, more frequently had hypertension, heart failure, and had a higher CHA(2)DS(2)-VASc score than men (4.63 vs 4.39, p<2DS(2)-VASc score items were independent predictors of incident AF, except diabetes and vascular disease). Results were mostly similar in men and women when one analyzed separately these predictors. Predictive value of the CHA(2)DS(2)-VASc score for identifying patients at higher risk of incident AF was somewhat higher in men (C statistic 0.720, 95% confidence interval 0.717 to 0.722) than in women (0.702, 95% confidence interval 0.699 to 0.704). Coronary artery disease, valvular disease, and history of pacemaker or defibrillator implantation were also independent predictors of incident AF. In conclusion, there were significant differences in co-morbidities, possible mechanisms, incidence, and predictors of AF between men and women after IS. However, a strategy using CHA(2)DS(2)-VASc score for identifying a higher risk of incident AF following IS was useful in both genders. (C) 2017 Elsevier Inc. All rights reserved.