1. In this retrospective cohort of patients with atrial fibrillation (AF) who underwent transcatheter aortic valve replacement (TAVR), the patients with a higher direct oral anticoagulants (DOAC) Score, had a higher bleeding risk. 

Evidence Rating Level: 2 (Good)

Atrial fibrillation (AF) is increasingly seen in the aging population and is associated with severe adverse health outcomes such as stroke or death. Thus, immediate and appropriate management is crucial to preventing these health outcomes. Oral anticoagulants (OACs) have been prescribed to patients with AF to manage outcomes. Specifically, direct oral anticoagulants (DOACs) are the preferred type due to their strong effectiveness in preventing strokes while limiting bleeding. The goal of this study was to evaluate the association between the DOAC Score and bleeding events in patients with AF after undergoing transcatheter aortic valve replacement (TAVR). This retrospective cohort study included patients with a diagnosis of AF from electrocardiogram. Patients were excluded if they had missing data, death within the hospital after TAVR, or were not on OAC treatment. Vitamin K antagonists (VKAs) doses were prescribed to maintain prothrombin time in the patients. Based on their DOAC score, patients were divided into 3 groups. These included the low and moderate-risk group (DOAC Score ≤7), high-risk group (DOAC Score 8-9 points) and very high-risk group (DOAC Score ≥ 10 points). There were 380 (30.1%) patients in the low and moderate-risk group, 497 (40.4%) in the high-risk group, and 353 (28.7%) patients in the very high-risk group. After meeting the eligibility criteria this study included 1230 patients (mean age, 84.6±5.1 years, 37.2% men). Of these patients, 465 (37.8%) received a VKA, while the rest received DOACs. Comparing the between-group results, 23 patients (6.1%), 34 patients (6.8%) and 50 (14.2%) of patients in the low and moderate-risk group, high-risk group, and very high-risk group, respectively, had bleeding events occur.  These groups also had significant differences in the 3-year cumulative incidence of all bleeding events. The low and moderate risk group had a 6.6% incidence, the high-risk group had a 6.9% incidence, and the very high-risk group had a 14.0% incidence (P<0.01). The 3-year cumulative incidence was also measured for the DOAC and VKA cohorts and was significantly different. The incidence was 5.5%, 6.7%, and 12.3% respectively, in the DOAC cohort (P=0.002), and 8.8%, 7.4%, and 16.0%, respectively, in the VKA cohort (P=0.04). When the DOAC score increased, there was a significantly higher incidence of bleeding events in all cohorts (HR, 1.22 [95% CI, 1.08-1.38]; P<0.01 for the overall population; HR, 1.20 [95% CI, 1.01-1.42]; P=0.04 for the DOAC cohort; and HR, 1.25 [95% CI, 1.04-1.50]; P=0.02 for the VKA cohort). Overall, there was a significant association between the DOAC score and risk of bleeding after TAVR in patients with AF. The DOAC score could be useful in future research in predicting bleeding risk in patients receiving OACs. 

Click to read the study in JAHA

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