Prophylactic rivaroxaban in the early post-discharge period reduces the rates of hospitalization for AF and sudden cardiac death, 2023

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Prophylactic rivaroxaban in the early post-discharge period reduces the rates of hospitalization for atrial fibrillation and incidence of sudden cardiac death during long-term follow-up in hospitalized COVID-19 survivors
Fiedler, Lukas; Motloch, Lukas J.; Dieplinger, Anna-Maria; Jirak, Peter; Davtyan, Paruir; Gareeva, Diana; Badykova, Elena; Badykov, Marat; Lakman, Irina; Agapitov, Aleksandr; Sadikova, Liana; Pavlov, Valentin; Föttinger, Fabian; Mirna, Moritz; Kopp, Kristen; Hoppe, Uta C.; Pistulli, Rudin; Cai, Benzhi; Yang, Baofeng; Zagidullin, Naufal

Introduction: While acute Coronavirus disease 2019 (COVID-19) affects the cardiovascular (CV) system according to recent data, an increased CV risk has been reported also during long-term follow-up (FU). In addition to other CV pathologies in COVID-19 survivors, an enhanced risk for arrhythmic events and sudden cardiac death (SCD) has been observed. While recommendations on post- discharge thromboprophylaxis are conflicting in this population, prophylactic short-term rivaroxaban therapy after hospital discharge showed promising results. However, the impact of this regimen on the incidence of cardiac arrhythmias has not been evaluated to date.

Methods: To investigate the efficacy of this therapy, we conducted a single center, retrospective analysis of 1804 consecutive, hospitalized COVID-19 survivors between April and December 2020. Patients received either a 30-day post- discharge thromboprophylaxis treatment regimen using rivaroxaban 10mg every day (QD) (Rivaroxaban group (Riva); n = 996) or no thromboprophylaxis (Control group (Ctrl); n = 808). Hospitalization for new atrial fibrillation (AF), new higher-degree Atrioventricular-block (AVB) as well as incidence of SCD were investigated in 12-month FU [FU: 347 (310/449) days].

Results: No differences in baseline characteristics (Ctrl vs Riva: age: 59.0 (48.9/ 66.8) vs 57 (46.5/64.9) years, p = n.s.; male: 41.5% vs 43.7%, p = n.s.) and in the history of relevant CV-disease were observed between the two groups. While hospitalizations for AVB were not reported in either group, relevant rates of hospitalizations for new AF (0.99%, n = 8/808) as well as a high rate of SCD events (2.35%, n = 19/808) were seen in the Ctrl. These cardiac events were attenuated by early post-discharge prophylactic rivaroxaban therapy (AF: n = 2/ 996, 0.20%, p = 0.026 and SCD: n = 3/996, 0.30%, p < 0.001) which was also observed after applying a logistic regression model for propensity score matching (AF: χ2-statistics = 6.45, p = 0.013 and SCD: χ2-statistics = 9.33, p = 0.002). Of note, no major bleeding complications were observed in either group.

Conclusion: Atrial arrhythmic and SCD events are present during the first 12 months after hospitalization for COVID-19. Extended prophylactic Rivaroxaban therapy after hospital discharge could reduce new onset of AF and SCD in hospitalized COVID-19 survivors.

Link | PDF (Frontiers in Pharmacology)

 

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All included patients were 18 years or older and had presented with moderate COVID-19-related pneumonia requiring hospitalization. Exclusion criteria were defined as: history of AF or other pathologies which required therapeutic anticoagulation using Vitamin K antagonists, heparinoids or DOAC therapy before enrollment, including history of relevant thrombotic disorders requiring anticoagulation therapy. Although at the beginning of the pandemic dipyridamole was also prescribed in our center as a standard antithrombotic regime in hospitalized COVID-19 patients after hospital discharge, patients receiving this treatment were excluded from further analyses.

In the present trial, we decided to investigate the effect of Rivaroxaban only. Thus, patients treated with other prophylactic DOAC (edoxaban, apixaban and dabigatran) or heparins regimes upon discharge were also excluded. Concomitant treatment with antithrombotics including acetylsalicylic acid (ASA), clopidogrel, prasugrel or ticagrelor was not an exclusion criterion. To account for disease severity and associated arrhythmic burden, patients with severe COVID-19 pneumonia (WHO, 2020) including those with requirement for mechanical ventilation support, defined as the need for endotracheal intubation and/or the need for non-invasive ventilation including mechanical ventilation involving end-expiratory and inspiratory positive air pressure support pressure via a tightly fitted face mask/helmet or the usage of High Flow Nasal Oxygen Canula were excluded from further analyses.

 

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See also Early antithrombotic post-discharge therapy using prophylactic DOAC or dipyridamole improves survival and cardiovascular outcomes in COVID-19 (2022)