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'As needed' oral anticoagulation similar in safety, effectiveness to daily use for some patients with AF
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SAN FRANCISCO — The use of oral anticoagulants on “as needed” basis by certain patients with atrial fibrillation is as safe and effective for lowering stroke risk as daily use, researchers reported at the Heart Rhythm Society Annual Scientific Sessions.
“Many of our patients come here for curative procedures, but based on the guidelines they still need anticoagulation, so we thought of a process where we could lower their stroke risk by treating their AF and also lower their bleeding risk from these medicines,” Monica Pammer, PA-C, physician assistant in electrophysiology at the Hospital of the University of Pennsylvania, told Cardiology Today in an interview.
Pammer, Francis E. Marchlinski, MD, FHRS, director of Electrophysiology for the University of Pennsylvania Health System and Richard T. and Angela Clark President’s Distinguished Professor in the Perelman School of Medicine at the University of Pennsylvania and their colleagues enrolled 100 patients with AF aged 45 to 78 years (mean age, 64 years; 81% men) with high risk for stroke (median CHA2DS2-VASc score, 2; range, 1-5). Eighty-four percent of the patients had AF ablation, and the rest were treated with medication.
Pammer said the study included only “highly motivated patients” — they are very proactive with their health, very symptomatic with their arrhythmias, and showed ability to document their own pulse in the office. Patients also had to be free from AF recurrence for a minimum of 6 months documented on trans telephonic monitors.
“There are a certain group of patients that absolutely need blood thinners every day,” Pammer told Cardiology Today. “This is just a very, very select group of the patient population.”
Patients were instructed to monitor their pulse twice a day and with symptoms either manually or with a smartphone-enabled device (AliveCor).
“If they had a detected or suspected or EKG-confirmed episode of AF that was ongoing for more than an hour or repeated shorter-lived episodes, meaning frequent shorter episodes lasting a minute several times a day, they were instructed to take their novel oral anticoagulant (NOAC),” Pammer said. “Once they took their NOAC, they called the office and we gave them further instruction from there.”
According to the results, during a mean follow-up of 23 months, 28 patients used the NOAC at least once for a detected AF episode and 10 patients transitioned back to daily use. No major complications such as stroke, embolism or massive bleeding were discovered; only one minor nose bleed was reported.
“This is an option for patients with stroke risk and symptomatic AF who have very good arrhythmia control and who are not ready to accept the risk for bleeding from blood thinners,” Pammer told Cardiology Today. – by Tracey Romero
Reference:
Pammer M, et al. Session AB21-06. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 4-7, 2016; San Francisco.
Disclosure: Pammer reports no relevant financial disclosures.
Perspective
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M. Rizwan Afzal, MD
Pammer et al report an interesting study; however, there are several issues which limit the applicability of the study. The authors have enrolled relatively low-risk patients (2.2% annual risk for stroke based on CHA2DS2-VASc score) and a small sample is not sufficient to detect the incidence of stroke. The “pill in the pocket approach” is not a safe strategy for prevention of a catastrophic complication such as stroke. It is well known that several patients have silent episodes of AF. Although the patients enrolled in this study were reportedly able to detect the onset of AF, the possibility of silent episodes cannot be ruled out without monitoring with an implantable loop recorder. We anxiously wait for the final publication of this study for more details.
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