More knowledge about atrial fibrillation, still we need to learn

Atrial fibrillation (AF) is the most common cardiac arrhythmia and its prevalence increases with advancing age.1,2 Dr Wilson and coworkers from Ireland have conducted a systematic review and meta-analysis to establish if there is evidence as to which drug, either flecainide or dronedarone, is more effective to maintain sinus rhythm following electrocardioversion for persistent AF. The authors concluded that dronedarone and flecainide displayed similar efficacy in maintaining SR in patients following electrocardioversion for persistent AF. Patients with AF treated with oral anticoagulants (OACs) have an increased risk of bleeding including hematuria.1,3–5 Since hematuria may be associated with urinary tract cancer, Dr Rasmussen et al. from Denmark, aimed to investigate the potential association between gross hematuria and urinary tract cancer in anticoagulated patients with AF. They included 125 063 AF patients from Danish nationwide registers. They concluded that gross hematuria was associated with clinically relevant risks of urinary tract cancer in anticoagulated patients with AF. Dr Elgandy and coworkers from the United States have examined the efficacy and safety of direct oral anticoagulants (DOACs) versus low molecular weight heparin (LMWH) in patients with cancer-related venous thromboembolism (VTE). They used four randomized trials with a total of 2907 patients and found that compared with LMWH, DOACs were associated with lower risk of VTE recurrence and similar risk of major bleeding (MB) compared with LMWH. Oral anticoagulants, including vitamin K antagonists (VKAs) and DOACs, are usually given lifelong to prevent stroke in patients with nonvalvular atrial fibrillation (NVAF).1 The prolonged use of VKAs is a concern, given their potential detrimental effect on bone metabolism.6 Dr Renoux et al. from Canada, have used Quebec administrative healthcare databases, including 10 306 new users of DOACs and 15 357 new users of VKAs. After propensity score-based fine stratification and weighting, the authors found that prolonged use of DOACs is associated with a lower risk of fracture compared with VKAs. Left ventricular thrombus is a recognized complication of acute myocardial infarction (AMI) and is associated with a significant thromboembolic risk when left untreated.7 Current guidelines recommend the use of VKA for up to 3–6 months for treatment of LV thrombus post AMI. However, NOACs are being increasingly used off license for the treatment of LV thrombus post AMI. Dr Rathod and coworkers from UK performed an observational study of 2 328 consecutive patients undergoing coronary angiography. Left ventricular thrombus was diagnosed in 4.3% of the patients. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin during the follow-up period. Polypharmacy is prevalent among NVAF patients and is associated with negative clinical outcomes including potentially serious drug–drug interactions, adverse drug reactions, and related hospitalizations.8–12 Dr Lip and coworkers from UK compared the risk of stroke/systemic embolism (SE) and MB among NVAF patients with polypharmacy newly prescribed OACs, using US CMS Medicare and four commercial databases. A total of 188 893 patients with polypharmacy (defined as ≥ 6 concomitant medications) were included. Compared to warfarin, apixaban and rivaroxaban were associated with a lower risk of stroke/SE after using propensity score analysis. Apixaban and dabigatran were associated with a decreased risk of MB compared with warfarin. Compared with dabigatran and rivaroxaban, apixaban was associated with a lower risk of stroke/SE and MB. The authors state that different effectiveness and safety profiles are evident for the different OACs in polypharmacy patients.13 Dr Choi and coworkers from Korea have compared the effectiveness and safety of off-label underdosed apixaban with on-label standard dose apixaban14 in Asian patients with AF. They used the Korean nationwide claims database and identified patients who were prescribed apixaban and did not fulfil the dose reduction criteria for apixaban. Compared to patients prescribed on-label standard dose apixaban, patients prescribed off-label underdosed apixaban showed a higher risk of ischemic stroke and all-cause death, but with no significant differences in MBs between the two groups. The authors concluded that off-label underdosed apixaban group showed higher risks of ischemic stroke, all-cause death, and composite clinical outcomes than the on-label standard dose apixaban group, but both showed comparable risks of MB. This paper is accompanied by an editorial by Dr Takahashi from Japan. In a study from Dr Liabeuf et al. from France, the aim was to describe the characteristics of patients hospitalized with COVID-19 (long-term at-home treatment), and compare them with regard to the course of the disease and to assess the association between renin-angiotensin system inhibitors (RASIs) and disease progression and critical outcomes. The authors highlighted a potential safety signal for RASIs. The topic has previously been discussed in the journal with conflicting opinions.15–17 Dr Zambon et al. from Italy publish a current opinion paper describing the evidence supporting a causal link between lifelong elevations in atherogenic lipoproteins and future risk of atherosclerosis.18,19 In another current opinion paper, Dr De Luca presents a paper entitled ‘Pre-Treatment with Dual Antiplatelet Therapy in Non-ST-Segment Elevation Acute Coronary Syndromes: Landing from Guidelines Recommendations to Real-World Ground.’20 Dr Pontremoli and coworkers from Italy present a review paper about renal protection in chronic heart failure with focus on sacubitril/valsartan.21 We are also very pleased to publish the second review paper about clinical trials, written by Dr Drexel and coworkers. This paper is entitled ‘The Age of Randomized Clinical Trials: Three Important Aspects of Randomized Clinical Trials in Cardiovascular Pharmacotherapy with Examples from Lipid, Diabetes, and Antithrombotic Trials. Review Article #2: Reasons for Early Stopping of an RCT.’22