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News from EHRA 2018

The annual congress of the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC), was recently held in Barcelona, Spain.

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New practical NOACs guide

A new version of EHRA Practical Guide on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) was launched at the congress.

ESC guidelines state that NOACs should be preferred over vitamin K antagonists, such as warfarin, for stroke prevention in AF patients, except those with a mechanical heart valve or rheumatic mitral valve stenosis, and their use in clinical practice is increasing. The guide gives concrete, practical advice on how to use NOACs in specific clinical situations.

The guide is published in European Heart Journal (doi: 10.1093/eurheartj/ehy136).

Anticoagulation may reduce dementia risk

AF patients could reduce their risk of dementia by taking oral anticoagulants, according to recommendations in a consensus document on arrhythmias and cognitive function presented at EHRA 2018.It was developed by the EHRA, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

The document states that AF is associated with a higher risk for cognitive impairment and dementia, even in the absence of apparent stroke. This may be because AF is linked with a more than two-fold risk of silent strokes. The accumulation of silent strokes and the associated brain injuries over time may contribute to cognitive impairment.

The consensus document says that oral anticoagulation may reduce the risk of dementia. Adopting a healthy lifestyle may also reduce the risk of cognitive decline in AF patients. AF catheter ablation can itself lead to silent strokes and cognitive impairment.

The consensus document is published in Europace (doi:10.1093/europace/euy046).

ESC syncope guidelines

ESC guidelines on syncope were launched at EHRA 2018. Most syncope does not increase the risk of death but it can cause injury due to falls or be dangerous in certain occupations – such as airline pilots.

The guidelines provide recommendations on how to prevent syncope, which includes keeping hydrated, avoiding hot crowded environments, tensing the muscles, and lying down. Advice is also given on driving for patients with syncope. The document emphasises the value of video recording in hospital or at home to improve diagnosis, recommending that smartphones are used to film the attack and recovery.

The guidelines were published in the European Heart Journal (doi: 10.1093/eurheartj/ehy037 and 10.1093/eurheartj/ehy071).

Apixaban in AF catheter ablation

Apixaban and warfarin are equally safe during catheter ablation of AF, according to results of the AXAFA-AFNET 5 trial presented at EHRA 2018. There were similar rates of stroke and bleeding, and an improvement in cognitive function was shown for the first time.

Some 633 AF patients with additional stroke risk factors scheduled to undergo AF ablation in Europe and the US were randomised to receive either continuous apixaban or the locally used vitamin K antagonist (VKA) such as warfarin. The primary outcome was a composite of all-cause death, stroke, and major bleeding up to three months after ablation. It occurred in 22 patients randomised to apixaban and 23 randomised to VKA. The study assessed cognitive function at the beginning and end of the trial and found that it improved equally in both treatment groups.

NOAC reduces VTE recurrence in cancer patients

Cancer patients have an increased risk of developing blood clots, with roughly one in five experiencing venous thromboembolism (VTE) – either deep vein thrombosis or pulmonary embolism.

Current international guidelines recommend low molecular weight heparin (LMWH) to treat and prevent recurrence of VTE. New results from a large pilot trial, SELECT-D (Anticoagulation Therapy in Selected Cancer Patients at Risk of Recurrence of Venous Thromboembolism) suggest that the non-vitamin K antagonist oral anticoagulant (NOAC) rivaroxaban is an effective alternative for treating VTE in selected patients.

Research led by Professor Annie Young of Warwick Medical School found that rivaroxaban significantly reduced VTE recurrence among patients with cancer and VTE. The SELECT-D trial enrolled 406 patients who had cancer and VTE; most (69%) were receiving cancer treatment at the time of their VTE. Half were randomly assigned to receive the LMWH dalteparin and half were given rivaroxaban. After six months of treatment, the VTE recurrence rate was 4% and 11% in the rivaroxaban and dalteparin groups, respectively.

The results for secondary outcomes were mixed. Major bleeding events were similar in the two groups but a marked and significant increase in clinically relevant non-major bleeds (13%) was seen with rivaroxaban compared to those having LMWH (4%). The reason for increased bleeding is not known.

“We now need to be sitting down with each one of our cancer patients with VTE discussing their preference alongside looking at all their clinical details,” said Professor Young, “so that we can choose the optimal VTE treatment for each patient.”

The study was published online on May 10th 2018 in Journal of Clinical Oncology (doi: 10.1200/JCO.2018.78.8034).

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