Raphael Philippart

Prognostic value of CHA2DS2-VASc score in patients with ‘non-valvular atrial fibrillation’ and valvular heart disease: the Loire Valley Atrial Fibrillation Project

AIMS The CHA2DS2VASc score is a clinical risk stratification tool which estimates the risk of stroke and thromboembolism in non-valvular atrial fibrillation (AF). We aimed to establish the value of this score for risk evaluation in patients with non-valvular AF and valvular heart disease. METHODS AND RESULTS Among 8053 patients with non-valvular AF (ESC guidelines definition), patients were categorized into Group 1 (no valve disease, n = 6851; 85%) and Group 2 (valve disease with neither rheumatic mitral stenosis nor valve prothesis, n = 1202; 15%). After follow-up of 868 ± 1043 days, 627 stroke/ thromboembolic (TE) events were recorded. Group 2 was significantly older, had a higher CHA2DS2VASc score and had a higher risk of thromboembolic events [hazard ratio (HR) 1.39; 95% CI 1.14-1.69, P = 0.001] compared with Group 1. Severe valve disease was not associated with worse prognosis for stroke/TE events. In the two groups, stroke/TE risk increased with a higher CHA2DS2VASc score. Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95% CI 1.14-1.36 per 10-year increase, P < 0.0001) and higher CHA2DS2VASc score (HR 1.33, 95% CI 1.23-1.45, P < 0.0001). The predictive value (c-statistic) of the CHA2DS2VASc score was similar in the two groups. CONCLUSION In patients with non-valvular AF, left-sided valvular heart disease (excluding mitral stenosis and protheses) was associated with an increased risk of stroke/TE events. A higher CHA2DS2VASc score in these patients is likely to explain these results.

CHA2DS2-VASc Score for Predicting Stroke and Thromboembolism in Patients With AF and Biological Valve Prosthesis.

Patients with valvular atrial fibrillation (AF), as defined in the 2012 European Society of Cardiology guidelines (those with a valvular prosthesis or rheumatic mitral disease) should receive anticoagulation regardless of the CHA2DS2-VASc score, with vitamin K antagonist being recommended [(1–3)][

Non-Vitamin K Oral Anticoagulants for Stroke Prevention in Special Populations with Atrial Fibrillation

Atrial fibrillation (AF) is associated with an increased risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. These strokes may efficiently be prevented in patients with risk factors using oral anticoagulant therapy, with either vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulants (NOACs) (i.e., direct thrombin inhibitors or direct factor Xa inhibitors). Owing to their specific risk profiles, some AF populations may have increased risks of both thromboembolic and bleeding events. These AF patients may be denied oral anticoagulants, whilst evidence shows that the absolute benefits of oral anticoagulants are greatest in patients at highest risk. NOACs are an alternative to VKAs to prevent stroke in patients with “non-valvular AF”, and NOACs may offer a greater net clinical benefit compared with VKAs, particularly in these high-risk patients. Physicians have to learn how to use these drugs optimally in specific settings. We review concrete clinical scenarios for which practical answers are currently proposed for use of NOACs based on available evidence for patients with kidney disease, elderly patients, women, patients with diabetes, patients with low or high body weight, and those with valve disease.

Aortic valve anatomy and outcomes after transcatheter aortic valve implantation in bicuspid aortic valves

This original clinical research study id focused on description of baseline anatomy and outcomes after transcatheter aortic valve implantation (TAVI) in patients presenting with severe aortic stenosis (AS) and bicuspid aortic valve (BAV). We compared this BAV population with a population of patients with AS and tricuspid aortic valves after a propensity score matching developed by a multivariate logistic regression according to a non-parsimonious approach. Baseline anatomical characteristics were obtained by transthoracic echocardiography (TTE) and multi-sliced computed tomography (MSCT) and compared by chi-square and t-student tests. Outcomes were evaluated by correct fisher test at in hospital and 30 days follow-up. We found that BAV patients presents more complicated baseline anatomy as compared to patients with tricuspid valves. These anatomical features lead to higher procedural complications as the need for a second device implantation. However this does not translate into increase in mortality rate at 30 days follow-up but rather correlate to a lower device success rate.

TCT-161 Impact of Pre-existent Prosthesis-Patient Mismatch on Survival Following Aortic Valve-in-Valve Procedures

Transcatheter valve-in-valve (ViV) implantation is an alternative for the treatment of patients with degenerated bioprostheses. Small label size of the surgical valve was associated with increased mortality after ViV. Our objective was to determine whether this association is, at least in part,

0358: Incidence and predictors of major haemorrhagic complications in pulmonary embolism patients receiving thrombolytic therapy

Thrombolytic therapy (TT) has a beneficial risk to benefit ratio for patients presenting with massive pulmonary embolism (PE). The PEITHO study suggested that patients with sub massive PE may improve their hemodynamic status and prognosis after TT but with an excess of haemorrhagic complications (HC). Elderly patients are also more likely to experience sever HC and it has been suggested that half doses TT may be indicated in this population. TT indication remains questionable in these borderline patients. To investigate incidence and predictors of major HC in our population we performed a retrospective analysis of all PE patients treated with TT in the Cardiac Intensive Care Unit of our university hospital from 1992 to 2014. From February 1992 to December 2014, 293 PE patients received TT. Among them 35 experienced severe HC following the PEITHO study definition. 23 (8%) patients died during the acute phase, 7 from HC and 16 from haemodynamic complications. Although before 1996 TT was frequently administered in sub massive PE and elderly patients we didn’t observed a significantly higher rate of severe HC in the 1992-1996 period. Bleeders were not significantly older than non-bleeders (72 vs 67, p=0,09) and were more likely to receive alteplase as TT (p=0,045). Severe HC were significantly more frequent in patients presenting with syncope (37% vs 15%, p=0,0064) or shock (66% vs 36%, p=0,0006). Patients with severe HC had a significantly higher death rate during hospitalisation (23% vs 6%, p=0,0005). From our observational data we derived the HACASSP score that robustly predicts severe haemorrhagic complications in our population combining hypertension, age>75, cancer, anemia, shock, sex, platelet count (C statistic=0.73). Our analysis suggests that it may be possible to predict high risk of severe haemorrhagic complications of TT in PE patients and therefore to improve the risk to benefit ratio of TT especially in patients with sub massive PE at presentation.

0356: Prognostic value of CHA2DS2-VASc score in patients with atrial fibrillation and valvular heart disease

The CHA2DS2-VASc score estimates the risk of stroke in non-valvular atrial fibrillation (AF). Nonetheless, there are limited data on the risk of stroke/thromboembolic (TE) complications in AF patients with valvular heart disease, other than those with valvular prosthesis or rheumatic mitral valve disease. Methods Among 8962 patients with AF seen between 2000 and 2010, patients were categorised into Group 1 “non valvular AF” (n=6851; 78%), Group 2 “quasi valvular AF” ie. valve disease with neither rheumatic mitral stenosis nor valve prothesis (n=1202; 13%) and Group 3 “valvular AF” (n=909; 9%) using ESC AF guidelines definition. Results In group 2, 61% of the patients had mitral regurgitation (n=917, non severe in 52%, severe in 9%), 24% had aortic regurgitation (n=414, non severe in 22%, severe in 2%) and 32% had aortic stenosis (n=555, non severe in 18%, severe in 14%). In group 3, 88% of the patients with valvular AF had valve prostheses (n=797) and 14% had mitral stenosis (n=124). After follow up of 884±1084 days, 715 stroke/TE events were recorded. Group 2 was significantly older, had a higher CHA2DS2-VASc score and had a higher risk of TE events (relative risk 1.39; 95%CI 1.14–1.69) compared with Group 1. Severe valve disease was not associated with worse prognosis for stroke/TE events (relative risk 1.12, 95%CI 0.78–1.61). In the 3 groups, stroke/TE risk increased with a higher CHA2DS2-VASc score. Factors independently associated with increased risk of stroke/TE events were older age (RR 1.02, 95%CI 1.01–1.03) and higher CHA2DS2-VASc score (RR 1.33, 95%CI 1.23–1.45). The increased risk of stroke/TE events in patients from Group 2 (compared to those from Group 1) did not reach statistical significance in multivariate analysis. Conclusions In patients with AF, left-sided valvular heart disease (excluding mitral stenosis and protheses) was associated with an increased risk of stroke/TE events. A higher CHA2DS2-VASc score was the main driver of these events.