Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Risk Score to Predict Serious Bleeding in Stable Outpatients With or at Risk of Atherothrombosis
Topic: Prevention/Vascular
Date Posted: 3/22/2010
Author(s): Ducrocq G, Wallace JS, Baron G, et al., on behalf of the REACH Investigators.
Citation: Eur Heart J 2010;Feb 24:[Epub ahead of print].
Clinical Trial: No
Study Question: What are the predictors of bleeding in outpatients with atherothrombosis?
Methods: The authors developed a risk model to predict major bleeding in 68,236 patients with or at risk of atherothrombosis enrolled in the REACH registry. The primary endpoint was serious bleeding (nonfatal hemorrhagic stroke or bleeding leading to hospitalization and transfusion) over 2 years. Risk factors for bleeding were assessed using modified regression analysis. Multiple potential scoring systems based on the least complex models were constructed and competing scores were compared on their discriminative ability. The final score was validated externally using the CHARISMA population.
Results: Serious bleeding occurred in 804 (1.42%, 95% confidence interval 1.32-1.52) patients between baseline and 2 years. A nine-item bleeding risk score was constructed based on age, peripheral arterial disease, congestive heart failure, diabetes, hypertension, smoking, antiplatelets, oral anticoagulants, and hypercholesterolemia, and the score ranged from 0-23 points. Observed incidence of bleeding at 2 years was 0.46% in patients with a score of ≤6, 0.95% with a score of 7-8, 1.25% with a score of 9-10, and 2.76% with a score of 11 or greater. The score had moderate discrimination in the CHARISMA (c-statistic 0.64) and REACH population (c-statistics 0.68).
Conclusions: This score can help predict future risk of bleeding in patients with atherothrombosis.
Perspective: The issue of bleeding in patients with atherothrombosis is becoming more relevant since a large number of patients are being placed on prolonged (and even lifelong) antithrombotic and/or antiplatelet therapy. This problem is likely to be compounded in the near future as more potent antiplatelet and antithrombotic drugs are approved for clinical use. This risk score provides the first step towards quantifying bleeding risk in patients with atherothrombosis, and further studies are warranted to confirm if the use of this score can help improve patient outcome. Hitinder S. Gurm, M.B.B.S., F.A.C.C

Title: The Risk of Thromboembolism and Need for Oral Anticoagulation After Successful Atrial Fibrillation Ablation
Topic: Arrhythmias
Date Posted: 3/19/2010
Author(s): Thermistoclakis S, Corrado A, Marchlinski FE, et al.
Citation: J Am Coll Cardiol 2010;55:735-743.
Clinical Trial: No
Related Resources
JACC Article: The Risk of Thromboembolism and Need for Oral Anticoagulation After Successful Atrial Fibrillation Ablation

Study Question: Is it safe to discontinue oral anticoagulation therapy (OAT) after catheter ablation of atrial fibrillation (AF)?
Methods: This was a multicenter, retrospective analysis of 3,355 patients who underwent catheter ablation of AF and either were taken off OAT 3-6 months later (Off-OAT group, n = 2,692, mean age 57 years) because of a successful outcome or remained on OAT because of recurrent AF, pulmonary vein stenosis, or severe left atrial mechanical dysfunction (On-OAT group, n = 663, mean age 59 years). The CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke) score was calculated for every patient. The study endpoints were ischemic stroke and major hemorrhage.
Results: In the Off-OAT group, 125 patients had a history of stroke/transient ischemic attack, and 2.9% of patients restarted OAT because of recurrent AF a mean of 10 months after OAT discontinuation. During 28 months of follow-up, ischemic stroke occurred in 0.07% of Off-OAT patients and 0.45% of On-OAT patients. No patient with a CHADS2 score ≥2 had a stroke. The prevalence of major hemorrhage was significantly lower in the Off-OAT group (0.04%) than in the On-OAT group (2%).
Conclusions: OAT can be safely discontinued after successful catheter ablation of AF, even in high-risk patients with a history of stroke. Ongoing OAT after catheter ablation is associated with a >10-fold higher risk of major hemorrhage.
Perspective: Current guidelines recommend indefinite OAT after catheter ablation of AF in high-risk patients, even when AF appears to have been successfully eliminated. This study brings this recommendation into question. Before incorporating the results into clinical practice, it would be prudent to wait for confirmation in a randomized clinical trial. Fred Morady, M.D., F.A.C.C.