Patients with Atrial Fibrillation Switching Emphasis from stroke prevention to stroke and hemorrhage prevention. Michael D. Ezekowitz, MBChB, DPhil, FACC, FAHA, FRCP, MA Professor, Sidney Kimmel Medical School at Thomas Jefferson University Attending Cardiologist Lankenau Medical Center, Bryn Mawr, and Paoli hospitals No Citation Given. 1

Disclosures Michael D. Ezekowitz has received consulting fees from Boston Scientific , Boehringer Ingelheim, Pfizer, Sanofi, Bristol- Myers Squibb, Portola, Daiichi-Sankyo, Medtronic, Johnson & Johnson, and Janssen Scientific Affairs; grant support from Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb Co-PI PETRO, RE-LY, X-VeRT, EMANATE; Executive Committee ENSURE-AF, ENGAGE-AF.

Left atrial appendage thrombus migration captured by TEE (Parekh…Ezekowitz Circ 06 )

Contraindication to oral anticoagulation Redfors B , Gray W , Lee R , Ellenbogen K, Bonefede M and Ben –Yehuda JACC EP 2017 1.3 million patients with the new diagnosis of AF from the Medicare and Supplemental insurance USA data base were identified About 43, 000 were not receiving an anticoagulation because of a contra-indication defined as : History of hemorrhagic stroke; intracranial bleeding; intraocular bleeding Significant bleeding from the gastrointestinal, genitourinary, or respiratory tracts or the presence of aortic dissection or cerebral aneurysm not repaired at < 3 months The annual risk of stroke of the 43, 000 were 7.7% ( 3.2 % hemorrhagic) , major bleeding 8.2% and dying was 12.7 %

Clinical Therapeutics 2003;25: No 6. Factors Influencing Physician Use of Anticoagulation in Atrial Fibrillation Physicians more influenced by events induced (bleeds) than those prevented (strokes) The decision to use warfarin in NVAF is driven by perceived risks (intracerebral bleeds) Gross CP, Vogel EW, Dhond, AJ, Marple CB, Edwards RA, Hauch O, Demers EA, Ezekowitz MD. Factors Influencing Physician Use of Anticoagulation in Atrial Fibrillation. Clinical Therapeutics 2003;25: No 6.

Country-Based Variation in TTR Mean % time in therapeutic INR range 7

Major bleeding, treatment-independent (Kent …. Ezekowitz JACC 2018 )

Effect of NSAID use Stroke or systemic embolism, treatment-independent ( Kent … Ezekowitz JACC 2018 )

Major bleeding, treatment-dependent Kent … Ezekowitz ( Kent … Major bleeding, treatment-dependent Kent … Ezekowitz ( Kent …. Ezekowitz JACC 2018 )

Stroke or systemic embolism (S/SE), treatment-dependent (Kent … Ezekowitz JACC 2018 )

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