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Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
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Echocardiographic hemodynamics correlate with differences in DOAC-specific bleeding and stroke rates in non-valvular

Michael P O'Shea1,2,3, Ali Yusuf4, Eiad Habib4

  • 1Mayo Clinic, 134000 E Shea Blvd, Scottsdale, AZ, 85259, USA. osheam12@tcd.ie.

BMC Cardiovascular Disorders
|October 29, 2025
PubMed

Insights

Direct oral anticoagulants (DOACs) reduce stroke risk in non-valvular atrial fibrillation. Elevated right ventricular systolic pressure (RVSP) increases bleeding risk with dabigatran and rivaroxaban, but not apixaban.

Area of Science:

  • Cardiology
  • Pharmacology
  • Medical Imaging

Background:

  • Direct oral anticoagulants (DOACs) are standard for stroke prevention in non-valvular atrial fibrillation/flutter (NVAF).
  • Different DOACs exhibit varying bleeding profiles, with apixaban noted for the lowest risk.
  • Right ventricular systolic pressure (RVSP) is an echocardiographic measure that may influence bleeding risk.

Purpose of the Study:

  • To investigate the interaction between DOAC selection and RVSP on echocardiogram concerning bleeding rates.
  • To test the hypothesis that elevated RVSP is linked to increased bleeding, potentially modulated by DOAC pharmacologic properties.

Main Methods:

  • Retrospective analysis of a clinical database involving patients who underwent echocardiography.
  • Multivariable regression models were employed to assess bleeding rates, adjusting for confounders.
  • Interaction terms for DOAC choice and RVSP status were incorporated into the models.

Main Results:

  • Apixaban was associated with lower bleeding rates compared to rivaroxaban and dabigatran overall.
  • No significant difference in bleeding rates was observed between DOACs in patients without elevated RVSP.
  • In patients with RVSP ≥45mmHg, dabigatran and rivaroxaban showed significantly increased bleeding rates (90% and 86% increase, respectively) compared to apixaban.

Conclusions:

  • Elevated RVSP is a significant risk factor for excess bleeding in patients on certain DOACs.
  • The increased bleeding risk associated with elevated RVSP was observed with dabigatran and rivaroxaban, but not apixaban.
  • These findings highlight the importance of considering RVSP in conjunction with DOAC choice for personalized bleeding risk assessment in NVAF patients.
Abstract

Keywords:
AnticoagulationApixabanAtrial FibrillationBleedingDOACDabigatranPulmonary HypertensionRight ventricular systolic pressureRivaroxaban

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