High B-type natriuretic peptide levels predict a hypercoagulable state in otherwise low-risk patients with atrial fibrillation

The D-dimer and B-type natriuretic peptide (BNP) levels in relation to CHADS2 and CHA2DS2–VASc scores in 59 patients with atrial fibrillation who were not receiving anticoagulant therapy were analyzed. Among 19 patients with CHADS2 scores of 0–1, 3 of the 7 patients with elevated BNP levels also had elevated D-dimer levels. Among 8 patients with CHA2DS2–VASc scores of 1, 2 of the 3 patients with elevated BNP levels also had elevated D-dimer levels. Therefore, D-dimer levels can be elevated in low-risk patients when BNP levels are high, and anticoagulation therapy should be considered for these patients

Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report

Background: Protocols on the use of novel oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) undergoing electrical cardioversion (ECV) are lacking. Aim: The study was aimed at evaluating the efficacy of dabigatran (Dabi) treatment in preventing peri-ECV stroke. Methods: A retrospective survey of the incidence and fate of left atrial (LA) thrombus during Dabi therapy in patients with AF was conducted between December 2012 and January 2013 by the Japanese Heart Rhythm Society. Results: A total of 198 patients from 299 institutions underwent transesophageal echocardiography (TEE) to rule out LA thrombus before ECV. Of these, LA thrombus was found in eight patients (4%), who tended to be older (67.3 vs. 61.3 years, p=0.175), had higher CHADS2 scores (1.88 vs. 0.95, p=0.058), and a higher prevalence of prior stroke or transient ischemic attack (22.2% vs. 2.6%, p=0.034) than those without LA thrombus. Of the eight patients with LA thrombus, one had LA thrombus during a Dabi 150 mg b.i.d treatment, whereas the remaining seven were receiving 110 mg b.i.d for 3 weeks or longer. In 6 of the 8 patients with LA thrombus, a second TEE was performed, revealing complete resolution of LA thrombus in five; among these five patients, one received Dabi dosage of 150 mg b.i.d unchanged, two received an increased dosage from 110 mg to 150 mg b.i.d, and two were switched to warfarin. Two patients had a stroke 3 and 15 days after ECV, and one had a major large intestine bleeding episode during Dabi therapy. Conclusions: LA thrombus developed in 4% of patients with AF receiving Dabi. Older patients with a higher CHADS2 score receiving a lower Dabi dosage were more likely to develop LA thrombus, which was resolved with a prolonged or increased dosage. A higher Dabi dosage may be more beneficial before ECV but prospective randomized studies would be needed to confirm these results

Nationwide survey of catheter ablation for atrial fibrillation: The Japanese catheter ablation registry of atrial fibrillation (J-CARAF)–A report on periprocedural oral anticoagulants

Background: Catheter ablation has become an established therapy for the treatment of atrial fibrillation (AF). To obtain a perspective on the current status of this therapy in Japan, the Japanese Heart Rhythm Society (JHRS) conducted a nationwide survey, the Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF). In this study, we focused on whether periprocedural use of novel oral anticoagulants (NOACs) was related with excessive thromboembolic or bleeding complications. Methods: Using an online questionnaire, JHRS requested electrophysiology centers in Japan to register the data of patients who underwent AF ablations in September 2011, March 2012, and September 2012. We compared the clinical profiles and ablation data, including the incidence of complications among patients in whom warfarin, a NOAC or neither was used as a periprocedural anticoagulant. Results: A total of 179 centers submitted data relating to 3373 patients (62.2±10.6 years). Paroxysmal atrial fibrillation (PAF) was observed in 64.4% of patients. Warfarin, as a periprocedural oral anticoagulant, was used by 53.6% (1808/3373) of patients. A NOAC was given to 541 subjects (dabigatran: 504 [16.1%], rivaroxaban: 37 [1.1%]). In the remaining 1024 patients (30.4%), no periprocedural oral anticoagulants (OACs) were used. The proportion of PAF in warfarin-treated patients (61.1%) was significantly lower than that in NOAC-treated patients (70.1%, p<0.01) or in patients not treated with an OAC (67.4%, p<0.01). Patients treated with uninterrupted warfarin therapy were associated with significantly higher CHA2DS2-VASc scores. A total of 158 complications occurred in 151 subjects (4.5%). The incidence of complications in NOAC-treated patients (14/541 [2.6%]) was lower than that in patients receiving uninterrupted warfarin therapy (4.8%, p<0.05). The incidence of pericardial effusion in NOAC-treated patients (0.7%) was lower than in warfarin-treated patients (2.6%, p<0.05). The difference in the periprocedural anticoagulant strategy was not related to the frequency of other bleeding events. Cerebral infarction occurred in one patient from each patient group. Conclusions: Our results suggest that NOACs are safe for use as substitutes for warfarin without causing excessive increases in the rates of thromboembolic or bleeding complications