Sotiris Antoniou

Aims: Left ventricular (LV) thrombus is a severe complication of acute myocardial infarction (AMI) and chronic heart failure. While current guidelines support the use of direct oral anticoagulants (DOACs) as alternatives to vitamin K antagonists (VKA), their benefit across different aetiologies remains uncertain. This study aimed to compare the efficacy and safety of DOAC vs. VKA across different aetiologies of LV dysfunction. Methods and results: We conducted a multi-centre observational study including 901 patients with confirmed LV thrombus treated with either a VKA or DOAC. The primary outcome was thrombus resolution, secondary outcomes included stroke and systemic embolization (SSE), major bleeding and mortality with analyses performed by aetiology. The principal aetiologies were AMI (38.3%), ischaemic cardiomyopathy (ICM) (38.0%) and non-ischaemic cardiomyopathy (NICM) (23.7%). Overall, thrombus resolution was significantly higher in DOAC treated patients, but this was driven by the AMI sub-group (P = 0.018). Direct oral anticoagulant use independently predicted thrombus resolution (OR 2.0, 95% Cl 1.29–3.24, P = 0.010). Major bleeding events (BARC ≥3) were more common with VKA use (P = 0.008). Non-ischaemic cardiomyopathy had the highest SSE rate (15.3%, P = 0.002), which were significantly raised in those treated with DOAC (P < 0.001). Conclusion: The underlying aetiology of LV dysfunction significantly influences both treatment response and outcomes in patients with LV thrombus. Direct oral anticoagulant were associated with superior efficacy and safety in AMI-related LV thrombus, but were linked to increased rates of SSE in NICM. These findings highlight the importance of aetiology on LV thrombus management and the potential need for tailored approaches.

The complexity of atrial fibrillation (AF) requires an integrated, multifaceted, multidisciplinary, and holistic team approach to optimize the management of AF patients. Active engagement of patients and involvement of nurses and various allied professionals (AP) and a strong collaboration with physicians is crucial in this respect as indicated by the 2024 European Society of Cardiology Guidelines on the management of AF. This is also reflected in these latest guidelines by the concept of AF-CARE, which emphasizes the importance of including the patient, carers, and various healthcare professionals. In this Clinical Consensus Statement, the role of nurses and APs is highlighted and includes optimal approaches on their involvement in the implementation and execution for these guideline recommendations in daily clinical practice. Moreover, additional detail will be provided to the key components and their requirements to allow this integrated multidisciplinary care to be implemented alongside the perspective of the patient. This Statement also examines the challenges and opportunities in relation to their application to clinical practice and how optimal multidisciplinary care can be implemented.

The level of evidence (LOE) grading system for ESC Clinical Practice Guidelines classifies the quality of the evidence supporting a recommendation. However, the current taxonomy does not fully consider the optimal study design necessary to establish evidence for such recommendations. Therefore, two separate taskforces of clinical and methodological experts were appointed by the Clinical Practice Guidelines Committee, with the first tasked with updating the LOE grading system for therapy and prevention, and the second responsible for developing a LOE grading system for diagnosis and prediction. The updated system for therapy and prevention presented here maintains the three-level grading structure but uses revised definitions. Level of evidence A represents conclusive evidence usually from ≥2 adequately powered randomized controlled trials (RCTs) free from major bias, with substantial evidence against the play of chance when combined in a meta-analysis (e.g. P < .005 for superiority). Additional criteria are specified to define substantial evidence against the play of chance in case of non-inferiority, equivalence, and harm. Level of evidence B is now subdivided into B1 and B2. Level of evidence B1 represents suggestive evidence usually from ≥1 adequately powered RCT free from major bias, or a meta-analysis of such RCTs, with some evidence against the play of chance (e.g. P < .05 for superiority). Level of evidence B2 represents limited evidence from ≥2 adequately powered non-randomized studies with careful control of major sources of bias or from a meta-analysis of small, underpowered RCTs. Level of evidence C represents preliminary evidence from either non-randomized studies without careful control of major sources of bias, a single small, underpowered RCT, or expert consensus.

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional–led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single–time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Introduction Direct oral anti-coagulants (DOACs) have been developed that provide simplified, fixed dose regimes over variable dosing with vitamin K anticoagulants. However, DOAC dosing is dependent on indication, demographics and co-morbidities, such as renal impairment. Inappropriate dosing is associated with harm with both unintentional under- and excessive-dosing [1]. The purpose of this study is to describe the appropriateness of DOAC prescribing with respect to the criteria set out in summary of product characteristics (sPC) and British National Formulary [2,3]. Methods A retrospective audit of consecutive in-patients, over a 3-month period, prescribed DOACs in St Bartholomew’s and Royal London hospitals from November 2018 was performed. Data was extracted from electronic healthcare and pharmacy records. Inclusion criteria: prescribed a DOAC (apixaban, dabigatran, edoxaban and rivaroxaban), recorded dose and frequency, patient sex, age and weight; serum creatinine (sCr). Exclusion criteria: use of non-DOAC anticoagulant, record duplication and incomplete records. Dosing appropriateness was compared for each of the drugs with respect to indication and criteria set in individual sPCs. Results 360 patients were prescribed DOACs, of whom 203 (56%) satisfied inclusion/exclusion criteria. Main reasons for non-inclusion were incomplete records (n=54) and record duplication (n=91). Mean age was 76±24 years, with 23% of patients >80 years-old and 15% Conclusion In our university hospital network, more patients were underdosed relative to their indication than was expected. This may be due to usage of clinically available eGFR, which is routinely available as part of hospital systems, rather than using manually calculated CrCl and the multiple criteria required to dose apixaban correctly. Further education of prescribers and ward-based pharmacists is required to improve the prescribing quality with the aim of improving treatment efficacy and safety outcomes. References Yao X, et al. J Am Coll Cardiol 2017;69:2780. www.medicines.org.uk www.bnf.nice.org.uk Conflict of Interest nil

Summary: The lack of antidotes for activated factor X‐inhibitor direct oral anticoagulants (DOACs) means that management of bleeding consists largely of existing supportive therapies. This study aimed to: (i) examine the relative frequency of DOAC‐related major bleeding in relation to DOAC prescriptions over the study period; (ii) describe the presentation and haematological management of DOAC‐related major bleeding; and (iii) evaluate the association between the use of prothrombin‐complex‐concentrate (PCC) and in‐hospital mortality. Over a 3‐year period, 32 UK hospitals submitted data on haematological management of DOAC‐related bleeding. Data consisted of 421 episodes (67%, 21%, 11% and 1% on rivaroxaban, apixaban, dabigatran and edoxaban respectively) of major bleeding on DOACs. The proportion of major bleeds on DOACs and DOAC prescriptions increased throughout the study. Overall, 44% and 37% of patients presented with gastrointestinal bleeding and intracranial haemorrhage (ICH) respectively. Drug concentrations were seldom measured. Compared to no PCC, there was a borderline evidence that receiving low dose PCC (≤25 iu/kg) was associated with better outcomes in terms of mortality (sub‐distribution hazard ratio: 0·15; 95% confidence interval: 0·02–1·19; P = 0·07): but this was not the case for higher doses. DOAC concentrations are seldom measured. There was no evidence of benefit for PCC on in‐hospital mortality.