NOACs for Atrial Tachyarrhythmias in Congenital Heart Disease (NOTE)

Prospective Registry of Non-vitamin K Antagonist Oral Anticoagulants for ThromboEmbolic Prevention in Adult Patients With Atrial Tachyarrhythmias and Congenital Heart Disease (NOTE)

Rationale: Adult patients with congenital heart disease (CHD) with atrial tachyarrhythmias need to be anticoagulated. It is not known whether non-vitamin K antagonist oral anticoagulants (NOAC) in this patient group are efficient and safe.

Aim: The purpose of the NOTE registry is to evaluate the efficacy and safety of NOACs for thromboembolic prevention in atrial tachyarrhythmias in adult patients with congenital heart disease (CHD).

Methods: In this multicenter prospective registry adult CHD patients with atrial tachyarrhythmias on NOACs (switch from VKA or new on anticoagulants) will be followed for a minimum of two years.

Primary efficacy endpoints are defined as thromboembolism, i.e. the composite of ischemic stroke, systemic and pulmonary embolism and intracardiac thrombosis, and as the composite of stroke and systemic embolism. Primary safety endpoint is defined as major bleeding according to the ISTH criteria. Secondary endpoints include each thromboembolic or bleeding event analysed separately, all-cause mortality, therapy adherence, quality of life, risk assessment of stroke and evaluation of natural history of atrial tachyarrhythmia in adult CHD patients.

Primary endpoint assessment will be performed with a per protocol analysis, and demonstrated as Kaplan Meyer estimates of event free survival and event rates per year.

Study Overview

• Status: Unknown
• Conditions: Atrial Fibrillation; Congenital Heart Defects; Ectopic Atrial Tachycardia

Detailed Description

Rationale: Adult patients with congenital heart disease (CHD) with atrial tachyarrhythmias need to be anticoagulated. It is not known whether non-vitamin K antagonist oral anticoagulants (NOAC) in this patient group are efficient and safe.

Aim: The purpose of the NOTE registry is to evaluate the efficacy and safety of NOACs for thromboembolic prevention in atrial tachyarrhythmia's in adult patients with CHD.

Methods: In this multicenter prospective registry adult CHD patients with atrial tachyarrhythmia's on NOACs will be followed for a period of two years.

Patient population: Registry population consists of CHD patients with tachyarrhythmia's, defined as atrial fibrillation (AF) or atrial tachycardia's (AT), including atrial flutter, on NOACs. Patients with new-onset atrial tachyarrhythmia's who are eligible for NOACs, will be started directly on a NOAC. Patients on vitamin K antagonists (VKA) can be switched actively to NOACs during outpatient clinic visits, in case of agreement of both patient and physician. The switch can be initiated for various reasons, including bleeding complications on VKA, unstable INR measurements, and user friendliness. Eligibility for NOAC use is defined conform clinical practice, i.e. a patient with nonvalvular atrial tachyarrhythmia's, but without a mechanical heart valve, significantly elevated risk of bleeding, impaired renal function, or pregnancy.

Registration process: Patients will be included in the registry at start of NOAC treatment. Exclusion criteria are an expected survival of less than two years and an additional indication for anticoagulation besides atrial tachyarrhythmia's. At baseline general patient characteristics will be registered. Standard echocardiography and laboratory assessments for follow-up in adult CHD patients will be recorded during the registration period. Quality of life and therapy adherence will be assessed with questionnaires. Registry follow-up will be warranted by telephone contact or during outpatient clinic visits. At each follow-up point the occurrence of pre-defined events will be recorded. A detailed description of each variable used by the registry is provided in the protocol. Anonymized data will be collected at each investigational site and entered in a central database at the main investigational site (Academic Medical Center, Amsterdam, The Netherlands).

Quality assurance: At all investigational sites the investigators are trained to the registry protocol, case report forms and registry procedures prior to enrolling subjects. The assigned monitoring investigator at the main site, will assure regular site monitoring and auditing at all investigational sites. Source data will be verified by comparing the data to medical records and case report forms in the form of a random sample. To avoid or minimize bias, an independent clinical events committee at the main investigational site, consisting of independent physicians, assesses all primary endpoint clinical events. Intermediate evaluation will take place one year after enrollment of the last patient and consists of a verification of recorded data, assessment of accuracy of patient follow-up and primary endpoint analysis.

Drop-outs: Patients who quite NOACs or are lost to follow-up are considered drop-outs. Those who (temporarily) quite NOACs will be followed until the total follow-up of 2 years will be completed. The events that occur in the period off-NOAC will not be included in the analyses. A clear description of the reason of NOAC arrest or interruption and possible alternative anticoagulant therapy is assessed.

Endpoints: Primary efficacy endpoints are defined as thromboembolism, i.e. the composite of ischemic stroke, systemic and pulmonary embolism and intracardiac thrombosis, and as the composite of stroke and systemic embolism. Primary safety endpoint is defined as major bleeding according to the ISTH criteria. Secondary endpoints include each thromboembolic or bleeding event analyzed separately, all-cause mortality, therapy adherence, quality of life, risk assessment of stroke and evaluation of natural history of atrial tachyarrhythmia in adult CHD patients.

Sample size: By using estimates of event rates in the described patient population (thromboembolism event rate of 1.4% per year, mainly on VKA; unpublished data) and a relative risk reduction of 0.81 for stroke or systemic embolism on NOACs compared to VKA [Ruff et al, Lancet 2013], a sample size of 300 patients followed for two years is necessary to demonstrate the safety of NOACs for thromboembolic prevention with a safety margin of 2.7% thromboembolic events per year.

Statistical analysis: Endpoint assessment will be performed with a per protocol analysis, and demonstrated as Kaplan Meyer (KM) estimates of event free survival and event rates per year. The results will be compared with KM estimates and event rates from a historical similar cohort on VKA in a non-inferiority assay. Drop-outs (see below) will be censored at time of drop-out in time-to-event analyses, and included for event-rate analyses up to time of drop-out. No adjustment or imputation of missing data will be performed and all available data will be presented.

• Study Type: Observational
• Enrollment (Anticipated): 300

Contacts and Locations

Study Locations

• Netherlands
  • Amsterdam, Netherlands, 1105AZ
    • Recruiting
    • Academic Medical Center
    • Principal Investigator: Hayang Yang, MD
    • Principal Investigator: Berto Bouma, MD PhD
    • Principal Investigator: Barbara Mulder, MD PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 100 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Registry population consists of CHD patients with tachyarrhythmia's, defined as atrial fibrillation (AF) or atrial tachycardia's (AT), including atrial flutter, on NOACs. Patients with new-onset atrial tachyarrhythmia's who are eligible for NOACs, will be started directly on a NOAC. Patients on vitamin K antagonists (VKA) can be switched actively to NOACs during outpatient clinic visits, in case of agreement of both patient and physician. The switch can be initiated for various reasons, including bleeding complications on VKA, unstable INR measurements, and user friendliness. Eligibility for NOAC use is defined conform clinical practice, i.e. a patient with nonvalvular atrial tachyarrhythmia's, but without a mechanical heart valve, significantly elevated risk of bleeding, impaired renal function, or pregnancy.

Description

Inclusion Criteria:

• Atrial tachyarrhythmia
• Congenital heart disease
• Treatment with NOAC

Exclusion Criteria:

• expected survival of less than two years
• additional indication for anticoagulation besides atrial tachyarrhythmia's

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Thromboembolism	The composite of ischemic stroke, systemic and pulmonary embolism and intracardiac thrombosis	2 years after enrolment
Stroke		2 years after enrolment
Major bleeding	The composite of fatal bleeding, symptomatic bleeding in a critical organ (e.g. central nervous system, retroperitoneal, pericardial, intramuscular with compartment syndrome), and bleeding of any kind with the need for >1 packed cell, or a decrease in hemoglobin of more than 2 g/l / 1,24 mmol/l. [International Society of Thrombosis and Hemostasis (ISTH) criteria]	2 years after enrolment
Systemic embolism		2 years after enrolment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
All-cause mortality		2 years after enrolment
Myocardial infarction	Defined as the detection of a significant rise/fall of cardiac biomarkers in association with symptoms of ischemia, ECG changes, proof of ischemia on imaging or intracoronary thrombus at angiography. [Third definition of myocardial infarction; European Society of Cardiology (ESC) 2012]	2 years after enrolment
Cardiac or non-cardiac surgical and percutaneous interventions		2 years after enrolment
Minor bleedings	Defined as all bleedings that do not meet the criteria for major bleedings [ISTH criteria]	2 years after enrolment
General quality of life	Quality of life assessed with questionnaire SF-36	2 years after enrolment
Quality of life under anticoagulation	Quality of life assessed with questionnaire PACT-Q	2 years after enrolment
Therapy adherence	Therapy adherence assessed with questionnaire Morisky-8	2 years after enrolment

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Natural history of atrial tachyarrhythmias in CHD	Progression of symptoms in EHRA classification	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Change of antiarrhythmic medication	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Occurence of ablations	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Occurence of electrical cardioversion	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Occurence of heart failure described with NYHA classification	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Occurence of heart failure described by echocardiography, ejection fraction	2 years after enrolment
Natural history of atrial tachyarrhythmias in CHD	Occurence of heart failure by measuring NT-proBNP	2 years after enrolment

Collaborators and Investigators

• Sponsor: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
• Collaborators: The Interuniversity Cardiology Institute of the Netherlands
• Investigators: Principal Investigator: Hayang Yang, MD, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA); Study Chair: Barbara Mulder, MD PhD, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA); Study Chair: Berto Bouma, MD PhD, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

Study record dates

Study Major Dates

• Study Start: April 1, 2014
• Primary Completion (Anticipated): May 1, 2018

Study Registration Dates

• First Submitted: December 21, 2015
• First Submitted That Met QC Criteria: October 6, 2016
• First Posted (Estimate): October 10, 2016

Study Record Updates

• Last Update Posted (Estimate): October 10, 2016
• Last Update Submitted That Met QC Criteria: October 6, 2016
• Last Verified: October 1, 2016

More Information

Terms related to this study

• Keywords: Atrial fibrillation; Thromboembolism; Congenital heart disease; Atrial tachyarrhythmia; Non-vitamin K antagonist oral anticoagulant (NOAC)
• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Congenital Abnormalities; Arrhythmias, Cardiac; Cardiac Conduction System Disease; Cardiovascular Abnormalities; Tachycardia, Supraventricular; Heart Diseases; Atrial Fibrillation; Tachycardia; Heart Defects, Congenital; Tachycardia, Ectopic Atrial
• Other Study ID Numbers: 036.19