Jo-Nan Liao

Lee CC, et al. Korean Circ J. 2027 ;57:e14. https://doi.org/10.4070/kcj.2025.0547

Background Oral anticoagulation therapy (OAC) remains the gold standard for stroke prevention in patients with atrial fibrillation (AF). In real life, there are patients who do not receive OAC due to high bleeding risk. In those patients, left atrial appendage closure (LAAC) has emerged as a potential alternative for stroke prevention. With this study, we aimed to develop a clinical decision tool to identify patients expected to derive harm vs benefit from OAC therapy. Methods Among 14,915 AF patients with CHA2DS2-VASc ≥ 1 (2 for women) from CardioCHUVI-AF registry (78% with OAC), a prediction rule was derived using a linear regression model to predict the stroke-bleeding balance. This rule was externally validated in the Taiwan AF registry, with 26,595 patients (70.5% with non OAC therapy). Results A simplified risk score was created using 7 clinical variables. The low-score group (≤ −8 points) was associated with higher rates of bleeding than stroke (7.25 vs 1.11 and 3.27 vs 2.58 per 100 patients/year in derivation and validation cohorts, respectively; pConclusions A prediction rule balancing stroke and bleeding risks correctly identify patients with harm vs benefit from OAC therapy. This rule requires further prospective evaluation to assess potential effects on patient care to select candidates for LAAC. What is new? We developed and externally validated a simple user-friendly clinical tool -OAC score- to balance both embolic and bleeding risks in atrial fibrillation patients with CHA2DS2-VASC ≥1 (excluding female sex). According to OAC score, we can identify atrial fibrillation patients expected to derive benefit vs harm from anticoagulation therapy. Patients with a low OAC score have much higher rates of bleeding than stroke, which is exaggerated with anticoagulation. The opposite occurs in patients with a high score. What are the clinical implications? A standardised stratification of both stroke and bleeding risk in atrial fibrillation patients at high embolic risk can be performed using an user-friendly, comprehensive tool (the OAC score). In patients with low risk OAC score, despite high risk CHA2DS2-VASC, anticoagulation is not beneficial and left atrial appendage closure could be an alternative. Further studies are needed to assess the impact of oral anticoagulation and left atrial appendage closure in patients with atrial fibrillation according to the OAC score risk groups.

Background: To analyze the impact of using different renal function equations and stroke prevention strategy in atrial fibrillation (AF) across all chronic kidney disease (CKD) stages. Methods: We used the Cockcroft-Gault (CG), Modified Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations to classify 39,217 patients into stage 1 to 5 CKD during July 1 ^st , 2001, and September 30 ^st , 2018. The endpoint is a composite outcome including ischemic stroke or major bleeding or mortality. Results: More patients belonged to stage 1 and 2 CKD using the MDRD and CKD-EPI equations. In subgroups of patients with eGFR-MDRD or eGFR-CKD-EPI ≥ 60 mL/min, a 17-18% increase of event was observed in patients with eGFR-CG < 60 mL/min compared to those ≥ 60 mL/min. Compared to no oral anticoagulant (OAC), OAC use was associated with a significantly lower risk of event across stage 1 to 4 CKD but not in stage 5 CKD. Both warfarin and NOACs exhibited better outcome compared to no OAC across stage 1 to 4 CKD while NOACs was associated with more risk reduction compared to warfarin. Among patients on OACs, there was a trend toward better outcome with NOAC than warfarin across stage 2-4 CKD but not in stage 1 and 5 CKD. Conclusions: OAC should be used in stage 1 to 4 CKD with NOAC exhibiting the trend of better outcome through stage 2 to 4 CKD than warfarin. For stage 5 CKD, optimal strategy remains undetermined. Clinical Perspective: What Is New? The stages of renal function of AF patients varied significantly with different renal equations, and tthe CG equation remained effective in differentiating clnical outcomes for patients with eGFR-MDRD ≥ 60 mL/min or eGFR-CKD-EPI ≥ 60 mL/min What Are the Clinical Implications? OAC should be used in stage 1 to 4 CKD with NOAC exhibiting the trend of better outcome through stage 2 to 4 CKD than warfarin.

Background: Stroke prevention is central to the management of patients with atrial fibrillation (AF) but the impact of NOACs on stroke severity from a nationwide perspective, and the impact of changes in antithrombotic regimen following an ischaemic stroke on subsequent clinical events is unceratin. The aims of the present study were as follows: (i) to describe the temporal trends in OAC use between 2012-2018, and the relationship to stroke severity at presentation; (ii) to describe antithrombotic therapy prescribing patterns following an ischaemic stroke, and the impact of post-stroke thromboprophylaxis on outcomes; and (iii) to assess the impact of changing OAC strategy in AF patients on a NOAC presenting with an ischaemic stroke. Methods: From 2007 to 2018, a total of 63,365 patients were identified from the “National Health Insurance Research Database (NHIRD)” in Taiwan. The stroke prevention strategy before and after ischemic stroke and its association to stroke severity was analysed. Subsequent clinical events after ischaemic stroke included recurrent ischaemic stroke, intracranial haemorrhage (ICH), major bleeding, all-cause mortality and composite outcomes. Results: The temporal trend disclosed that the overall OAC prescription rate was rising, with warfarin used declining and NOACs use increasing, which was associated with a gradual decline of moderate-severe and severe strokes. The post-stroke antithrombotic strategy was variable. Compared to NOACs post-stroke, there was a significant increase in ischaemic stroke and mortality in non-anticoagulated (adjusted hazard ratios [aHRs] 1.804 and 3.441, respectively) and antiplatelet users (aHRs 1.785 and 1.483, respectively). Warfarin use post-stroke was associated with a significantly incresaed risk of major bleeding compared to NOACs (aHR 2.839). Non-anticoagulated and antiplatelet users were associated with higher risks of both composite outcomes compared to NOAC. Among 769 patients who received NOACs before stroke and continued NOAC post-stroke, there was a higher risk of ischaemic stroke and composite outcomes with no difference in major bleeding, mortality or ICH if patients were changed to a different NOAC post-stroke. Conclusions: In this nationwide cohort study, increasing use of NOACs was associated with a decline of moderate-severe and severe strokes. Compared to NOACs, non-anticoagulation and antiplatelet use were associated with a significant increase in ischaemic stroke, mortality, and the composite outcome with no significant differences in bleeding events. There was no significant difference of ischemic stroke, mortaltiy, and ICH between post-stroke warfarin and NOAC use but warfarin was associated with a significantly increased risk of major bleeding. A change of NOAC types after ischemic stroke was associated with a two-fold higher risk of ischaemic stroke and the composite outcomes.

Investigations on non-VKA oral anticoagulants (NOACs) for atrial fibrillation (AF) patients without taking any oral anticoagulants (OACs) or staying well on warfarin were limited. We aimed to investigate the associations between stroke prevention strategies and clinical outcomes among AF patients who were previously well without taking any OACs or stayed well on warfarin for years. The retrospective analysis included a total of 54 803 AF patients who did not experience an ischaemic stroke or intra-cranial haemorrhage (ICH) for years after AF was diagnosed. Among these patients, 32 917 patients who did not receive OACs were defined as the ‘original non-OAC cohort’ (group 1), and 8007 patients who continuously received warfarin were defined as the ‘original warfarin cohort’ (group 2). In group 1, compared to non-OAC, warfarin showed no significant difference in ischaemic stroke (aHR 0.979, 95%CI 0.863–1.110, P = 0.137) while those initiated NOACs were associated with lower risk (aHR 0.867, 95%CI 0.786–0.956, P = 0.043). When compared to warfarin, the composite of ‘ischaemic stroke or ICH’ and ‘ischaemic stroke or major bleeding’ was significantly lower in the NOAC initiator with an aHR of 0.927 (95%CI 0.865–0.994; P = 0.042) and 0.912 (95%CI 0.837–0.994; P < 0.001), respectively. In group 2, when compared to warfarin, those shifted to NOACs were associated with a lower risk of ischaemic stroke (aHR 0.886, 95%CI 0.790–0.993, P = 0.002) and major bleeding (aHR 0.849, 95%CI 0.756–0.953, P < 0.001). The NOACs should be considered for AF patients who were previously well without taking OACs and those who were free of ischaemic stroke and ICH under warfarin for years.

Chronic inflammation harbors a vulnerable substrate for atrial fibrillation (AF) recurrence after catheter ablation. However, whether the ABO blood types are associated with AF recurrence after catheter ablation is unknown. A total of 2106 AF patients (1552 men, 554 women) who underwent catheter ablation were enrolled retrospectively. The patients were separated into two groups according to the ABO blood types, the O-type (n = 910, 43.21%) and the non-O-type groups (A, B, or AB type) (n = 1196, 56.79%). The clinical characteristics, AF recurrence, and risk predictors were investigated. The non-O type blood group had a higher incidence of diabetes mellitus (11.90 vs. 9.03%, p = 0.035), larger left atrial diameters (39.43 ± 6.74 vs. 38.20 ± 6.47, p = 0.007), and decreased left ventricular ejection fractions (56.01 ± 7.33 vs. 58.65 ± 6.34, p = 0.044) than the O-type blood group. In the non-paroxysmal AF (non-PAF) patients, the non-O-type blood groups have significantly higher incidences of very late recurrence (67.46 vs. 32.54%, p = 0.045) than those in the O-type blood group. The multivariate analysis revealed the non-O blood group (odd ratio 1.40, p = 0.022) and amiodarone (odd ratio 1.44, p = 0.013) were independent predictors for very late recurrence in the non-PAF patients after catheter ablation, which could be applied as a useful disease marker. This work highlighted the potential link between the ABO blood types and inflammatory activities that contribute to the pathogenic development of AF. The presence of surface antigens on cardiomyocytes or blood cells in patients with different ABO blood types will have an impactful role in risk stratification for AF prognosis after catheter ablation. Further prospective studies are warranted to prove the translational benefits of the ABO blood types for the patients receiving catheter ablation.

(1) Background: Catheter ablation (CA) is an accepted treatment option for drug-refractory ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). This study investigates the effect of amiodarone on ablation outcomes in ARVC. (2) Methods: The study enrolled patients with ARVC undergoing CA of sustained VT. In all patients, substrate modification was performed to achieve non-inducible VT. The patients were categorized into two groups according to whether they had used amiodarone before CA. Baseline and electrophysiological characteristics, substrate, and outcomes were compared. (3) Results: A total of 72 ARVC patients were studied, including 29 (40.3%) “off” amiodarone and 43 (56.7%) “on” amiodarone. The scar area was similar between the two groups. Patients “off” amiodarone had smaller endocardial and epicardial areas with abnormal electrograms. Twenty of 43 patients (47.5%) “on” amiodarone discontinued it within 3 months after CA. During a mean follow-up period of 43.2 ± 29.5 months, higher VT recurrence was observed in patients “on” amiodarone. Patients “on” amiodarone who discontinued amiodarone after CA had a lower recurrence than those without. (4) Conclusions: Patients with ARVC “on” amiodarone before CA had distinct substrate characteristics and worse ablation outcomes than patients “off” amiodarone, especially in those who had used amiodarone continuously.

Autonomic system plays a pivotal role in the pathogenesis of paroxysmal atrial fibrillation (AF). Skin sympathetic nerve activity (SKNA) is a noninvasive tool for assessing sympathetic tone. However, data on changes in SKNA after ablation are limited. Here, we retrospectively enrolled 37 patients with symptomatic drug-refractory paroxysmal AF who underwent pulmonary vein isolation (PVI) with radiofrequency ablation (RFA) or cryoablation (CBA). SKNA was measured from the chest and right arm 1 day prior to ablation, as well as 1 day and 3 months after ablation. One day after ablation, the SKNA-Arm increased from 517.1 µV (first and third quartiles, 396.0 and 728.0, respectively) to 1226.2 µV (first and third quartiles, 555.2 and 2281.0), with an increase of 179.8% (125% and 376.0%) (p < 0.001); the SKNA-Chest increased from 538.2 µV (first and third quartiles, 432.9 and 663.9) to 640.0 µV (first and third quartiles, 474.2 and 925.6), with an increase of 108.3% (95.6% and 167.9%) (p = 0.004), respectively. In those without recurrence, there was a significant increase in SKNA 1 day after ablation as compared with those before ablation. Twelve patients received SKNA measurement 3 months after ablation; both SKNA-Arm (p = 0.31) and SKNA-Chest (p = 0.27) were similar to those before ablation, respectively. Among patients with symptomatic drug-refractory paroxysmal AF receiving PVI, increased SKNA was observed 1 day after ablation and returned to the baseline 3 months after ablation. Elevation of SKNA was associated with lower early and late recurrences following ablation.