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AF after TAVR confers increased risk for poor outcomes
Patients with new-onset atrial fibrillation after transcatheter aortic valve replacement had elevated rates of stroke, mortality and bleeding that required rehospitalization, which confirmed previously presented results, according to a study published in JACC: Cardiovascular Interventions.
Among those with new-onset AF after TAVR, less than 30% were discharged from the hospital on oral anticoagulation therapy.
“Current guidelines are murky regarding the optimal treatment strategy for these patients who often tend to be at high risk for stroke, but also high risk for bleeding,” Amit N. Vora, MD, MPH, interventional cardiologist and researcher from Duke University Medical Center and the Duke Clinical Research Institute, said in a press release. “Although there are a number of trials that are examining various strategies for this population, we need to continue to look very closely at this and determine the best care management for these high-risk patients.”
As Cardiology Today’s Intervention previously reported, the results were initially presented at the American College of Cardiology Scientific Session in March 2017.
Researchers analyzed data from the Society of Thoracic Surgeons/ACC Transcatheter Valve Therapy Registry that were linked to Medicare data of 13,556 patients who underwent TAVR between November 2011 and September 2015. Exclusion criteria included patients with a prior history of AF and those already on anticoagulant therapy.
In-hospital outcomes of interest were mortality and stroke. One-year outcomes of interest were all-cause mortality, stroke and bleeding.
Of the patients in the study, 8.4% were diagnosed with new-onset AF after TAVR. The rate was lower in patients who underwent transfemoral access (4.4%) vs. those who underwent transapical access (16.5%). Patients who developed new-onset AF were more likely to be women, older and had a higher median STS risk score compared with those who did not develop AF (6.5 vs. 6; P < .01).
The median CHA2DS2-VASc score among all patients was 5, and 28.9% who developed new-onset AF were discharged on oral anticoagulant therapy.
Compared with those who did not develop AF, the new-onset AF group had higher rates of in-hospital death (7.8% vs. 3.4%; P < .01) and stroke (4.7% vs. 2%; P < .01).
At 1 year, patients who developed AF after TAVR had higher rates of stroke (adjusted HR = 1.5; 95% CI, 1.14-1.98), all-cause mortality (aHR = 1.37; 95% CI, 1.19-1.59) and bleeding (aHR = 1.24; 95% CI, 1.1-1.4) than those who remained in sinus rhythm.
The rate of mortality at 1 year was elevated in patients who developed new-onset AF but did not receive anticoagulation upon discharge.
“In our study, patients with new-onset AF had a higher risk for stroke as well as a higher risk for in-hospital bleeding and bleeding requiring rehospitalization than those without new AF despite no significant differences in objective bleeding risk as calculated by the ATRIA score,” Vora and colleagues wrote. “This suggests that a more granular approach may be necessary to classify bleeding risk in patients who may be likely to derive ischemic benefit from anticoagulation.”
In a related editorial, David Hildick-Smith, MD, professor of interventional cardiology and consultant cardiologist at Sussex Cardiac Centre at Brighton and Sussex University Hospitals in the United Kingdom, wrote: “Developing AF after TAVR is certainly an adverse clinical feature associated with worse outcomes. To what extent it is a cause rather than a marker of adverse outcomes, however, is difficult to assess, and it is not clear that greater use of anticoagulation in the post-procedure phase would necessarily be in these patients’ best interests.” – by Darlene Dobkowski
Disclosures: Vora reports no relevant financial disclosures. Hildick-Smith reports he served as a proctor and on advisory boards for Abbott, Boston Scientific, Edwards Lifesciences and Medtronic. Please see the study for all other authors’ relevant financial disclosures.