EvaluatioN of ApiXaban in strOke and systemic embolism prevention in patients with non-valvular atrial fibrillation in clinical practice Setting in France, rationale and design of the NAXOS: SNIIRAM study

Gender differences in the detection of carotid atherosclerosis: DUPLEX registry cross-sectional study results

The aim of this study was to assess the features of detecting carotid atherosclerosis depending on gender, age, the presence of arterial hypertension, other major diseases and conditions according to  The Duplex Registry Database. The registry sequentially included the results of duplex scanning of the carotid arteries (DSCA) of all patients who underwent it at the United Hospital with Outpatient Department in 2013 (n=2548). The incidence of carotid atherosclerosis (CAS) was higher in men than in women (58.6% (n=763) vs 45.5% (n=568), p<0.0000001). This was noted in all categories according to the gradation of stenosis, including in the category of the most severe lesion (>70%): 2.9% (n=32) vs 1.0% (n=13), p=0.003. The presence of CAD significantly increased the chances of detecting CAS in men (OR 4.47 vs 2.6, p<0.0000001). Signs more significant in their influence in women compared to men were the following: age (OR 5.3 [4.12; 6.71] p<0.0000001); arterial hypertension (OR 2.7 [2.12; 3.39] p<0.0000001) and cerebrovascular disease (OR 1.63 [1.13; 2.36] p=0.004). The OR of CAS detection for the "acute cerebrovascular accident" diagnosis in men and women differed 2 times (OR 1.2, p=0.4 vs 2.4, p=0.15). The "hypercholesterolemia" diagnosis when referred for DSCA did not show itself as a predictor of CAS detection in all study groups. Disorders of autonomic nervous system, hearing loss and screening examination showed a significant decrease in the probability of CAS detecting for the whole group (OR 0.14 [0.08;0.24] p<0.0000001; OR 0.16 [0.02;0.66] p=0.004 and OR 0.3 [0.25 0.37] p<0.0000001, respectively), so and separately for males and females. The present study revealed significant gender differences in the prevalence of carotid atherosclerosis and in the influence of various signs on an increase in the chances of its detection. The most significant signs were (OR men vs women): gender (1.3 vs 0.8), age (4.2 vs 5.3), arterial hypertension (1.8 vs 2.7), CAD (4.4 vs 2.6), cerebrovascular disease (1.26 vs 1.63).

Comparative Safety and Effectiveness of Oral Anticoagulants in Nonvalvular Atrial Fibrillation: The NAXOS Study

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Background and Purpose:

The effects of direct oral anticoagulants in nonvalvular atrial fibrillation should be assessed in actual conditions of use. France has near-universal healthcare coverage with a unified healthcare information system, allowing large population-based analyses. NAXOS (Evaluation of Apixaban in Stroke and Systemic Embolism Prevention in Patients With Nonvalvular Atrial Fibrillation) aimed to compare the safety, effectiveness, and mortality of apixaban with vitamin K antagonists (VKAs), rivaroxaban, and dabigatran, in oral anticoagulant-naive patients with nonvalvular atrial fibrillation.

Methods:

This was an observational study using French National Health System claims data and including all adults with nonvalvular atrial fibrillation who initiated oral anticoagulant between 2014 and 2016. Outcomes of interest were major bleeding events leading to hospitalization (safety), stroke and systemic thromboembolic events (effectiveness), and all-cause mortality. Four approaches were used for comparative analyses: matching on propensity score (PS; 1:n); as a sensitivity analysis, matching on high-dimensional PS; adjustment on PS; and adjustment on known confounders. For each outcome, cumulative incidence rates accounting for competing risks of death were estimated.

Results:

Overall, 321 501 patients were analyzed, of whom 35.0%, 27.2%, 31.1%, and 6.6% initiated VKAs, apixaban, rivaroxaban, and dabigatran, respectively. Apixaban was associated with a lower PS–matched risk of major bleeding compared with VKAs (hazard ratio [HR], 0.43 [95% CI, 0.40–0.46]) and rivaroxaban (HR, 0.67 [95% CI, 0.63–0.72]), but not dabigatran (HR, 0.93 [95% CI, 0.81–1.08]). Apixaban was associated with a lower risk of stroke and systemic thromboembolic event compared with VKAs (HR, 0.60 [95% CI, 0.56–0.65]), but not rivaroxaban (HR, 1.05 [95% CI, 0.97–1.15]) or dabigatran (HR, 0.93 [95% CI, 0.78–1.11]). All-cause mortality was lower with apixaban than with VKAs, but not lower than with rivaroxaban or dabigatran.

Conclusions:

Apixaban was associated with superior safety, effectiveness, and lower mortality than VKAs; with superior safety than rivaroxaban and similar safety to dabigatran; and with similar effectiveness when compared with rivaroxaban or dabigatran. These observational data suggest potentially important differences in outcomes between direct oral anticoagulants, which should be explored in randomized trials.

EvaluatioN of ApiXaban in strOke and systemic embolism prevention in patients with non-valvular atrial fibrillation in clinical practice Setting in France, rationale and design of the NAXOS: SNIIRAM study

Non-vitamin K antagonists oral anticoagulants (NOACs) have recently challenged vitamin-K antagonists (VKAs) for stroke and systemic embolism prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Nevertheless, little information is available in routine clinical practice for France. The aim of this study is to describe the effectiveness and safety of apixaban, rivaroxaban, dabigatran or VKAs in routine clinical practice in adult NVAF patients for the prevention of stroke and systemic embolism in France. The NAXOS study is a nationwide observational retrospective cohort generated from the French national healthcare insurance database (SNIIRAM-a comprehensive in- and outpatient healthcare consumption database), consisting of eight distinct sub-cohorts of anticoagulant-naive or anticoagulant-experienced patients diagnosed with NVAF, newly initiated with either NOACs (dabigatran, rivaroxaban or apixaban) or VKAs. Patients will be included if initiating a new anticoagulant treatment for AF during the study period from 1 January 2014 to 31 December 2016. Primary effectiveness outcome will be the incidence of stroke or systemic thromboembolic events; primary safety outcome will be the incidence of major bleeding during the exposure period. The NAXOS study will provide routine clinical practice data on the effectiveness and safety profiles of apixaban vs other NOACs and VKAs in the prevention of stroke and systemic embolism in adult patients with NVAF in clinical practice conditions in France.