Daily Cardiology Research Analysis

BACKGROUND: Combining antiplatelet therapy (APT) with conventional anticoagulants increases the risk of bleeding. In the AZALEA-TIMI 71 trial (Safety and Tolerability of Abelacimab [MAA868] vs Rivaroxaban in Patients With Atrial Fibrillation), the novel factor XI inhibitor abelacimab significantly reduced the risk of bleeding compared with rivaroxaban in patients with atrial fibrillation. Whether the safety of combination antithrombotic therapy differs in the context of factor XI inhibition has not been well characterized. METHODS: This prespecified analysis of AZALEA-TIMI 71, which randomized patients between March and December of 2021 to 1 of 2 subcutaneous monthly abelacimab doses (90 or 150 mg) or oral rivaroxaban (20 mg daily, dose reduced to 15 mg in patients with creatinine clearance ≤50 mL/min), stratified patients by planned use of concomitant APT. The primary composite end point of major or clinically relevant nonmajor bleeding and other safety and efficacy outcomes were examined by concomitant APT and randomized treatment. RESULTS: Of 1287 patients (44% female; median age 74 years [interquartile range, 69-78]), 318 (24.7%) were on APT at baseline with planned continuation (15.5% aspirin only, 7.5% P2Y CONCLUSIONS: Inhibition of factor XI with abelacimab consistently reduced bleeding compared with rivaroxaban regardless of concomitant APT use, with greater absolute reductions in bleeding in those requiring concomitant APT. These data suggest that factor XI inhibition may be a safe anticoagulant option in patients with atrial fibrillation requiring concomitant APT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04755283.

BACKGROUND: The optimal management of oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF) after intracerebral hemorrhage (ICH) remains uncertain. Although recent randomized controlled trials (RCTs) have investigated this clinical dilemma, findings have been inconclusive. OBJECTIVE: To evaluate the efficacy and safety of restarting OACs in patients with AF after ICH, we conducted a meta-analysis of RCTs. METHODS: We conducted a literature search in PubMed, Embase, and the Cochrane Central Register of Controlled Trials, identifying eligible RCTs from inception to March 2025. The primary outcomes were recurrent ICH and stroke or systemic embolism. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model. RESULTS: Three RCTs (Apixaban After Anticoagulation-Associated Intracerebral Haemorrhage in Patients With Atrial Fibrillation, Start or Stop Anticoagulants Randomised Trial, and Prevention of Stroke in Intracerebral Haemorrhage Survivors With Atrial Fibrillation), comprising a total of 623 patients with a median follow-up of 1.2-1.9 years, were included. Most patients received direct OACs. Compared with non-OAC therapy, OAC resumption was associated with a significantly increased risk of recurrent ICH (RR 3.32, 95% CI 1.28-8.61) and major bleeding (RR 3.33, 95% CI 1.54-7.22), without a significant reduction in stroke or systemic embolism (RR 0.68, 95% CI 0.38-1.23). No significant differences were observed in ischemic stroke, major vascular events, all-cause mortality, or cardiovascular mortality. CONCLUSION: In patients with AF with previous ICH, restarting OAC therapy is associated with increased risks of recurrent ICH and major bleeding, without a corresponding reduction in thromboembolic events or all-cause mortality.

OBJECTIVE: Orthotopic heart transplant is the definitive option for pediatric patients with end-stage heart failure. Unfortunately, the greatest contributor to waitlist mortality has been a shortage of available hearts for transplant. Donation after circulatory death with normothermic regional perfusion may mitigate this supply-demand mismatch. METHODS: Donation after circulatory death with normothermic regional perfusion recipients were matched to similar donation after brain death recipients. Primary end points included 1-year survival and episodes of primary graft dysfunction at 1 year. Secondary end points included treated rejection at 1 year and ventricular systolic and diastolic function on echocardiogram at time of discharge. Elevated filling pressures or decreased cardiac output were also examined via cardiac catheterization data at time of endomyocardial biopsy at 1 year. RESULTS: Twelve donation after circulatory death procurements were attempted and 9 hearts procured. Donor cardiac arrest and cardiac function before procurement were similar in both groups. Donation after brain death recipients spent more time on the waitlist. After transplant, biventricular function was similar in both groups at time of discharge and at 1-year follow-up. There were no differences between groups with regard to primary graft dysfunction or instances of treated rejection at 1 year. CONCLUSIONS: This study represents the largest single-institution cohort of pediatric recipients of hearts obtained after donation after circulatory death with normothermic regional perfusion compared with demographically similar donation after brain death cardiac transplant recipients. These results are indicative of equivalent outcomes at 1-year, suggesting that donation after circulatory death with normothermic regional perfusion is a viable method to expand the pediatric cardiac donor pool.