The Role of Implantable Loop Recorders in Guiding Anticoagulation Therapy in PAF: Anticoagulation “Pill-in-the-Pocket?”

[dave205]

Though anticoagulation is highly effective at preventing AF-related strokes, chronic anticoagulation exposes patients to a non-trivial risk of anticoagulant-induced hemorrhage. Major developments in both long-term continuous electrocardiogram (ECG) monitoring and oral anticoagulation, however, hold promise that continuous chronic anticoagulation may be avoidable in some subsets of AF patients who otherwise meet guideline criteria for lifelong anticoagulation.

The use of a small, leadless subcutaneous insertable cardiac monitors (ICM) with remote data transmission capabilities (Reveal XT™ and Reveal LINQ™, Medtronic Inc.) provide the ability to remotely and continuously evaluate a patient for AF recurrences. In addition, the novel oral anticoagulants (NOACS) (dabigatran, rivaroxaban, and apixaban) result in rapid onset anticoagulation within hours of a single oral dose. Together, these developments allow for continuous AF monitoring with targeted anticoagulation based on AF recurrence.

The Rhythm Evaluation for AntiCoagulaTion with COntinuous Monitoring (REACT.COM) pilot study (ClinicalTrials.gov NCT01706146) is designed to assess the feasibility of "pill-in-the-pocket" anticoagulation using daily remote transmissions from an ICM.

acc.org/latest-in-cardiolog...

[Finvola]

This would be a marvellous step forward - an unexpected possible benefit of the NOAC's.

I wonder who will be responsible for monitoring and (fast) decision making if it does happen.

Thank you for the link.

[BobD Volunteer]

Yes all good in theory but we have been told that just because we aren't having AF right now, our stroke risk does not change. I wish it were that simple but I'm sure the debate will go on for years.

[MarkS]

This new method is only suitable for people with very occasional AF - like once or twice a year. If the loop detects AF you have to take an NOAC for 30 days. So if you have AF once a month or more it becomes pointless. Additionally you have to take aspirin. This in itself has a higher risk of serious bleeding than well controlled warfarin.

This is a prospective trial so the results will take years to come out assuming it is carried out properly. I do wonder who is sponsoring this trial? Would it be the manufacturer of the loop recorder by chance?

[davee]

I have a Reveal loop fitted about 6 months now and been taking Dabigatran for about 16. This because due to having 2 haemorrhages it is the most suitable, against bleeds. Using it correctly, monitoring can be carried out by the hospital almost continually.