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Thromboembolic and bleeding events after valvular intervention in patients with atrial fibrillation

Ebba-Louise Skogseid1, Gorav Batra2,3, Johan Westerbergh2

  • 1Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden ebba-louise.skogseid@medsci.uu.se.

Open Heart
|January 30, 2024
PubMed

Insights

Non-vitamin K antagonist oral anticoagulants (NOACs) showed similar efficacy and safety to warfarin in atrial fibrillation patients undergoing valvular interventions. However, patients not on oral anticoagulants faced higher cardiovascular risks, and NOACs increased CV death in specific surgical subgroups.

Area of Science:

  • Cardiology
  • Pharmacology
  • Public Health

Background:

  • Atrial fibrillation (AF) is common in patients undergoing valvular heart interventions.
  • Optimal oral anticoagulant (OAC) management post-intervention is crucial for preventing cardiovascular (CV) events and bleeding.
  • Understanding the comparative effectiveness and safety of different OACs, including non-vitamin K antagonist oral anticoagulants (NOACs) versus warfarin, is essential.

Purpose of the Study:

  • To evaluate outcomes in patients with AF undergoing surgical biological valve replacement, valve repair, or transcatheter aortic valve implantation (TAVI).
  • To compare the efficacy and safety of NOACs and warfarin in this patient population.
  • To assess the impact of OAC exposure on cardiovascular events and major bleeding.

Main Methods:

  • A Swedish registry-based cohort study included patients with AF undergoing valvular intervention.
  • Cox regression analysis was used to investigate associations between OAC exposure and composite CV events (CV death, ischemic stroke, systemic embolism) and major bleeding.
  • Analyses were stratified into early (0-3 months) and later (3-12 months) postoperative periods.

Main Results:

  • Among 4730 patients, NOAC use was associated with similar risks of CV outcomes and major bleeding compared to warfarin in the 0-3 month period.
  • Patients not receiving OACs had a significantly increased risk of CV events (HR 1.71) but similar bleeding risk.
  • In the surgical bioprosthetic valve replacement subgroup, NOACs and no OAC were associated with increased CV death compared to warfarin in the early postoperative phase.

Conclusions:

  • NOACs appear comparable to warfarin for efficacy and safety in AF patients undergoing various valvular interventions.
  • Patients not on OACs have a higher risk of CV events, highlighting the importance of anticoagulation.
  • Caution is advised when extrapolating NOAC data to all patient groups, particularly in the early post-surgical bioprosthetic valve replacement phase, warranting further investigation.
Abstract

Keywords:
Atrial FibrillationHeart Valve DiseasesHeart Valve ProsthesisHeart Valve Prosthesis ImplantationTranscatheter Aortic Valve Replacement

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