Single Center Study Of Stroke Prevention In Hospitalized Elderly Patients With Atrial Fibrillation

BackgroundAtrial fibrillation is the most common cardiac arrhythmia seen in clinical practice,and its incidence increases with age.The prevalence increases to about 6 percent in people 65 years of age or older.The rate of stroke that is the most serious complication among patients with atrial fibrillation averages 5 percent per year and increases with age.The stroke brings a heavy economic burden and great challenges to society and families.Stroke prevention in patients with atrial fibrillation is quite complicated and has a long way to go.Anticoagulant therapy is an important method for preventing stroke in patients with atrial fibrillation.Poor compliance with anticoagulant therapy,the huge economic differences and the different levels of medical development in different regions of China all contributes to the suitation that the antithrombotic strategies of patients with atrial fibrillation cannot be unified.Some studies have shown that there is a great gap between the antithrombotic strategies of hospitalized patients and the recommended strategies in atrial fibrillation management guidelines.Many studies have shown that left atrial appendage closure is not inferior to warfarin in preventing stroke in patients with non-valvular atrial fibrillation,especially in these with high risk of stroke but not suitable or willing to take oral anticoagulants.So left atrial appendage closure is no doubt an alternative treatment option.After nearly 20years of clinical practice,the technology has been proved as theoretical and reliable and has a long-term effect.Not only does it avoid the risk of bleeding due to oral anticoagulant drugs,but also it overcomes many problems in surgery.However,left atrial appendage closure was not approved by China for stroke prevention in patients with non-valvular atrial fibrillation until 2014.To this emerging technology,our center is still in its infancy and needs to accumulate clinical experience continuously.Objective1.To investigate the current antithrombotic status in hospitalized elderly patients with atrial fibrillation and the gap with current clinical guidelines.2.To observe the safety and efficacy of left atrial appendage closure proformed for stroke prevention in elderly patients with non-valvular atrial fibrillation.Methods1.Single center survey of antithrombotic status in hospitalized elderly patients with atrial fibrillationA total of 578 cases of hospitalized patients with atrial fibrillation diagnosed in our center are collected during the period from May 2016 to March 2017.A retrospective analysis is done with the patients'baseline data,antithrombotic status at admission and the anticoagulation strategy at discharge.To do group analysis with patients divided into groups based on the presence or absence of coronary heart disease,stroke and post-hospital treatment.2.Efficay observation of left atrial appendage closure on stroke prevention in elderly patients with non-valvular atrial fibrillationFrom June 2016 to July 2018,100 patients with non-valvular atrial fibrillation who was proformed left atrial appendage closure are included.Inclusion criteria:Age?65years old;CHA₂DS₂-VASc score?1;Not suitable for long-term use of anticoagulant medication,such as warfarin.All left atrial appendage closures were performed under general anesthesia or local anesthesia.All patients are followed up by telephone,outpatient or hospitalization.The primary endpoints are thromboembolic events,major bleeding events,and all-cause death during follow-up;secondary endpoint events are puncture site complications,small bleeding events,leaks around the occluder,occluder displacement or detachment,non-fatal myocardial infarction,pericardial effusion or cardiac tamponade,infective endocarditis,etc.Results1.Single center survey of antithrombotic status in hospitalized elderly patients with atrial fibrillation?1?The proportions of hypertension,heart failure,coronary heart disease,diabetes,and stroke were high,which were 67.1%,54.3%,45.8%,23.7%,and 17.8%,respectively.The scores of CHA₂DS₂-VASc and HAS-BLED were?1,which were 3.83±1.65 and2.69±1.02,respectively.?2?The overall anticoagulation rate was significantly higher at discharge than when admitted to hospital?48.2%VS 22.7%,?2=81.722,P<0.001?,the proportion of non-antithrombotic treatment decreased significantly?8.9%VS 39.4%,?2=145.471,P<0.001?,and there was no significant difference in the proportion of antiplatelet therapy alone??2=3.004,P=0.081?.?3?Comparison of non-valvular atrial fibrillation with stroke group and non-stroke group:There was no significant difference of anticoagulation rate between the non-stroke group and the stroke group?27.8%VS 20.1%,?2=2.808,P=0.094?,the proportion of simple antiplatelet therapy was significantly higher than that of non-stroke group?49.4%VS 36.2%,?2=6.110,P=0.013?,and the proportion of non-antithrombotic treatment was significantly lower than that of non-stroke group?22.8%VS 43.6%,?2=14.953,P<0.001?.?4?Comparison of non-valvular atrial fibrillation with coronary heart disease group and non-coronary heart disease group:The anticoagulant rate of patients with coronary heart disease was not significantly different from that of non-coronary heart disease group?18.6%VS 24.1%,?2=2.336,P=0.126?,the proportion of antiplatelet therapy was significantly higher than that of non-stroke group?54.9%VS 24.4%,?2=53.400,P<0.001?,the proportion of non-antithrombotic treatment was significantly lower than that of non-stroke group?26.5%VS 51.5%,?2=35.854,P<0.001?.?5?Antiplatelet therapy was used after percutaneous coronary intervention,and the antithrombotic regimen was significantly changed;the anticoagulation rate after cardiac pacemaker implantation was significantly higher than that before surgery?39.4%VS19.7%,?2=6.151,P=0.013?;the anticoagulant rate after radiofrequency ablation of atrial fibrillation was 98.0%,and the anticoagulation rate was significantly increased??2=83.523,P<0.001?.All patients underwent left atrial appendage closure were treated with double antiplatelet therapy.2.Efficay observation of left atrial appendage closure on stroke prevention in elderly patients with non-valvular atrial fibrillation?1?The scores of CHA₂DS₂-VASc and the HAS-BLED are both?1,which are4.56±1.51 and 3.26±1.00,respectively.The preoperative anticoagulation rate is 52.0%.?2?Left atrial appendage closure was performed under local anesthesia?61.0%?or general anesthesia?39.0%?,and 4 cases underwent atrial septal defect closure and 1 case underwent patent foramen ovale closure simultaneously.The successful rate was 97.0%.Patients were implanted with 28 Lacbes occluders,59 Watchman occluders and 10 ACP occluders,and the average size of occluders was 26.22±4.04 mm.Perioperative period of pericardial effusion or pericardial tamponade occurred in 5 cases,occluder detachment in1 case and puncture site complications in 1 case.?3?94.0%of the patients are followed up.The average follow-up duration is19.1±8.0 months,and the longest follow-up is 32 months.96.6%of the surviving patients are treated with single antiplatelet therapy now.The incidence of stroke in the primary endpoint was 2.7%/year,which was 53.4%lower than the predicted one in patients with warfarin,and the incidence of major bleeding was 1.3%/year,which was80.6%lower than the predicted one in patients with warfarin.Conclusions1.The anticoagulation rate of elderly hospitalized patients with atrial fibrillation is low,which has been significantly improved after admission.Patients with coronary heart disease or stroke pay more attention to antiplatelet therapy,which is quite different from the guidelines for the management of atrial fibrillation.2.The successful rate of left atrial appendage closure is high in our center.It is not inferior to anticoagulant therapy in preventing stroke in patients with non-valvular atrial fibrillation and can significantly reduce the occurrence of major bleeding and simplify the antithrombotic regimen.Left atrial appendage occlusion can be used as analternative treatment for stroke prevention in elderly patients with atrial fibrillation.