Role of cardiovascular implantable electronic devices in delivering individualized disease-guided management of patients with non-valvular atrial fibrillation and high bleeding risk

Abstract

Background: Many patients with non-valvular atrial fibrillation (NVAF) with high risk for thromboembolic stroke and bleeding may not wish to continue long-term oral anticoagulants (OACs) to avoid bleeding complications. We aimed to investigate whether AF burden assessment by cardiovascular implantable electronic devices (CIEDs) would allow an individualised disease-guided approach for safe withdrawal of long-term OAC in high-risk patients.

Methods and results: We studied 145 patients (age 77.6 ± 10.6 years; 49.7% females) with NVAF, CHA₂DS₂-VASc score ≥2, HAS-BLED score ≥3, in whom CIEDs were implanted. These patients wished to stay off long-term OAC based on their previous adverse bleeding event/s or due to similar events witnessed in the family or friend circle. These patients were grouped into ‘low AF burden’ [n = 121 (83%)], or ‘high AF burden’ [n = 24 (17%)] defined as <24 hours or >24 hours cumulatively in 30 consecutive days respectively, and followed for 51.2 ± 29.8 months. All patients with ‘low AF burden’ were allowed to discontinue OAC, but OAC was resumed in 1 patient who experienced TIA. Bleeding events developed in 9 out of 24 (37.5%) patients with ‘high AF burden’ who were maintained on OAC, as compared to 3 out of 121 (2.47%) patients with ‘low AF burden’ who were off OAC (p <.05). There were 9 (6.2%) deaths unrelated to AF treatment approach.

Conclusions: In NVAF patients, AF burden assessment by CIEDs allows an individualised disease-guided approach to safe withdrawal of long-term OAC in patients with high bleeding risk who do not wish to continue long-term anticoagulation.

Keywords:

• Non-valvular atrial fibrillation
• stroke
• CHA2DS2-VASc score
• cardiovascular implantable electronic devices
• atrial fibrillation burden
• oral anticoagulants
• antiarrhythmic drugs

Acknowledgements

The authors would like to thank Dr. David Livert for his invaluable assistance with statistical analysis of the study data.

Disclosure statement

No potential conflict of interest was reported by the authors. Mr. Ziegler is an employee and stock holder of Medtronic.