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Li S, Zhang Y. Do Oral Factor Xa Inhibitors have a Role in Patients with Mechanical Heart Valves? Am J Cardiovasc Drugs 2022; 22:595-600. [DOI: 10.1007/s40256-022-00544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/01/2022]
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Gerfer S, Grandoch M, Wahlers TCW, Kuhn EW. Factor Xa Inhibitors for Patients after Mechanical Heart Valve Replacement? Thorac Cardiovasc Surg 2021; 71:189-194. [PMID: 34894638 DOI: 10.1055/s-0041-1736242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients with a mechanical heart valve need a lifelong anticoagulation due to the increased risk of valve thrombosis and thrombo-embolism. Currently, vitamin K antagonists (VKA) are the only approved class of oral anticoagulants, but relevant interactions and side effects lead to a large number of patients not achieving the optimal therapeutic target international normalized ration (INR). Therefore, steady measurements of the INR are imperative to ensure potent anticoagulation within a distinctive range. Direct oral anticoagulants (DOACs) with newer agents could serve as a possible alternative to VKAs in this patient cohort. DOACs are approved for several indications, e.g., atrial fibrillation (AF). They only have a minor interaction potential, which is why monitoring is not needed. Thereby, DOACs improve the livability of patients in need of chronical anticoagulation compared with VKAs. In contrast to dual platelet inhibition using aspirin in combination with an ADP receptor antagonist and the direct thrombin inhibitor dabigatran, the oral factor Xa inhibitors apixaban and rivaroxaban show promising results according to current evidence. In small-scale studies, factor Xa inhibitors were able to prevent thrombosis and thrombo-embolic events in patients with mechanical heart valves. Finally, DOACs seem to represent a feasible treatment option in patients with mechanical heart valves, but further studies are needed to evaluate clinical safety. In addition to the ongoing PROACT Xa trial with apixaban in patients after aortic On-X valve implantation, studies in an all-comer collective with rivaroxaban could be promising.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Maria Grandoch
- Institute of Pharmacology and Clinical Pharmacology, Medical Faculty and University Hospital of Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Thorsten C W Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
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Montinari MR, Minelli S, De Caterina R. Eighty years of oral anticoagulation: Learning from history. Vascul Pharmacol 2021; 141:106918. [PMID: 34537376 DOI: 10.1016/j.vph.2021.106918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 02/05/2023]
Abstract
In the year 2021 we celebrate the 80th anniversary of the first clinical use of vitamin K antagonists (VKAs), the mainstay of prevention and long-term treatment of thromboembolic disease. The discovery and development of oral anticoagulants is one of the most important chapters in the history of medicine, a goal pursued by physicians trying to combat the clinical manifestations of thrombosis since ancient times. Until the last decade, VKAs were the only oral anticoagulants available and used in clinical practice. Today, their clinical use has progressively shrunk, as the non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly replacing VKAs in various conditions after the successful completion of several large randomized controlled trials. Currently, new research is tackling upstream components of the intrinsic pathway - particularly factor XI and factor XII - for the development of new, even safer anticoagulants promising to reduce bleeding without compromising efficacy. This review highlights the evolution of oral anticoagulant therapy tracing the key stages of a long and fascinating history that has unfolded from the first part of the twentieth century until today, indeed an intriguing journey where serendipity is intertwined with the tenacious work of many researchers.
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Affiliation(s)
- Maria Rosa Montinari
- Chair of History of Medicine, Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | | | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa, University Cardiology Division, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Fondazione VillaSerena, Città Sant'Angelo, Pescara, Italy.
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Rivaroxaban Versus Warfarin in Patients with Mechanical Heart Valves: Open-Label, Proof-of-Concept trial-The RIWA study. Am J Cardiovasc Drugs 2021; 21:363-371. [PMID: 33150497 DOI: 10.1007/s40256-020-00449-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE To date, vitamin K antagonists are the only available oral anticoagulants in patients with mechanical heart valves. In this way, we developed a pilot trial with rivaroxaban. METHODS The RIWA study was a proof-of-concept, open-label, randomized clinical trial and was designed to assess the incidence of thromboembolic and bleeding events of the rivaroxaban-based strategy (15 mg twice daily) in comparison to dose-adjusted warfarin. Patients were randomly assigned in a 1:1 ratio and were followed prospectively for 90 days. RESULTS A total of 72 patients were enrolled in the present study. Of these, 44 patients were randomized: 23 patients were allocated to the rivaroxaban group and 21 to the warfarin group. After 90 days of follow-up, the primary outcome occurred in one patient (4.3%) in the rivaroxaban group and three patients (14.3%) in the warfarin group (risk ratio [RR] 0.27; 95% confidence interval [CI] 0.02-2.85; P = 0.25). Minor bleeding (without discontinuation of medical therapy) occurred in six patients (26.1%) in the rivaroxaban group versus six patients (28.6%) in the warfarin group (RR 0.88; 95% CI 0.23-3.32; P = 0.85). One patient in the warfarin group died from myocardial infarction. No cases of hemorrhagic stroke, valve thrombosis, peripheral embolic events, or new intracardiac thrombus were related in both groups. CONCLUSIONS In this pilot study, rivaroxaban 15 mg twice daily had thromboembolic and bleeding events similar to warfarin in patients with mechanical heart valves. These data confirm the authors' proof-of-concept and suggest that a larger trial with a similar design is not unreasonable. CLINICALTRIAL. GOV IDENTIFIER NCT03566303.
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Wang M, Chen Z, Wong M, Thabane L, Mbuagbaw L, Siegal D, Le Gal G, Holbrook A. Are the correct outcomes being measured in studies of oral anticoagulants? A systematic survey. Thromb Res 2021; 201:30-49. [PMID: 33631520 DOI: 10.1016/j.thromres.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/26/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Oral anticoagulant (OAC) intervention trials have typically included clinical event outcomes. However, there is no standard list of outcomes to be used in OAC research. This study aimed to describe and classify the outcomes used in recent prospective clinical studies involving OACs. MATERIALS AND METHODS We searched MEDLINE, EMBASE, and CINAHL databases from January 2009 to July 2019 for prospective studies with an intervention or control group that included one or more oral anticoagulants. We abstracted details about each included study and the outcomes used from the study report and its accompanying protocol. Using the Core Outcome Measures in Effectiveness Trials (COMET) Initiative recommendations, we categorised each outcome into one of five domains (mortality/survival, physiological/clinical, life impact, resource use, and adverse events). Our primary outcome was the prevalence of use of an outcome domain across studies. RESULTS We included 70 prospective studies, including 52 randomized controlled trials and 18 prospective cohort studies. A total of 121 different outcomes were reported. The COMET domains were represented in the 70 studies as follows: mortality (63/70, 90.0%); physiological/clinical domain (70/70, 100%), life impact domain (43/70, 61.4%), resource use domain (26/70, 37.1%), and adverse events domain (55/70, 78.6%). CONCLUSION Outcome reporting in prospective studies of OACs more frequently concentrates on mortality, physiological/clinical domains, and adverse events compared to life impact and resource utilization domains, the latter uncommonly used. A priority for future research includes developing a core outcome set (COS) for OAC research that represents all domains.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada.
| | - Zhiyuan Chen
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Michael Wong
- Bachelor Life Sciences Program, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada
| | - Deborah Siegal
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth, Ottawa K1H 8L6, ON, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada; Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
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Wang Y, Lin M, Ge S, Feng J. Mechanical valve replacement without anticoagulation: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytaa566. [PMID: 33644653 PMCID: PMC7898660 DOI: 10.1093/ehjcr/ytaa566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/16/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022]
Abstract
Background For patients who undergo mechanical valve replacement, the greatest disadvantage is that they require long-term or permanent use of anticoagulant therapy to prevent thromboembolism. To date, mechanical valve replacement without anticoagulation has been published in the literature. Case summary We present the case of a 75-year-old female who underwent mechanical mitral valve replacement (MVR) on mid-June, 2007. However, this patient had not been taking anticoagulant medication since she experienced warfarin overdose in the first month after the operation. She had been well without using any anticoagulation, and there were no complications of the mechanical valve. Discussion There was no thrombosis for such a long period of time because she suffered from FX deficiency. To the best of our knowledge, she may be the only patient who has been well without any anticoagulation since not taking warfarin 12 years ago.
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Affiliation(s)
- Yapeng Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 230022, Anhui, People's Republic of China
| | - Min Lin
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 230022, Anhui, People's Republic of China
| | - Shenglin Ge
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 230022, Anhui, People's Republic of China
| | - Junbo Feng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 230022, Anhui, People's Republic of China
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Rivaroxaban: Expanded Role in Cardiovascular Disease Management-A Literature Review. Cardiovasc Ther 2021; 2021:8886210. [PMID: 33505518 PMCID: PMC7810545 DOI: 10.1155/2021/8886210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/22/2020] [Accepted: 01/04/2021] [Indexed: 01/20/2023] Open
Abstract
Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation, treatment of deep venous thrombosis and pulmonary embolism, and as prophylaxis after hip and knee surgery after approval by the Food and Drug Administration. In the last decade, DOACs were studied for various indications; this review is focused on rivaroxaban, a factor Xa inhibitor, which is used in an expanded evidence-based fashion for coronary artery disease, peripheral artery disease, heart failure, malignancy, and prophylaxis of deep venous thrombosis in acute medical illnesses.
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Wadsworth D, Sullivan E, Jacky T, Sprague T, Feinman H, Kim J. A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant. J Clin Pharm Ther 2021; 46:560-570. [PMID: 33393699 DOI: 10.1111/jcpt.13343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
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Affiliation(s)
- Daniel Wadsworth
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Emma Sullivan
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas Jacky
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Taylor Sprague
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Hannah Feinman
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer Kim
- Cone Health Department of Internal Medicine, Greensboro, NC, USA
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Affiliation(s)
- Fiona Catterall
- 1Medical Unit and 2Department of Haematology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Paul Rj Ames
- 1Medical Unit and 2Department of Haematology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Chris Isles
- 1Medical Unit and 2Department of Haematology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
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Vatutin NT, Taradin GG, Ignatenko GA, Gasendich ES, Harchenko AV, Povaljaeva IB. Decrease in Efficacy of Warfarin as a Result of Drug-Drug Interaction (Case Report). RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-02-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The one of the main aims in modern clinical pharmacology is to provide safe and effective therapy considering a frequent administration of several drugs having different drug-drug interactions. Warfarin belongs to the number of popular anticoagulants which along with its efficiency not infrequently alters anticoagulant characteristics when administered with other drugs and food products. A case of a decrease in the efficacy of warfarin in a patient with mitral stenosis while taking a combined choleretic drug is presented in the article. The components of this choleretic drug (dry animal bile, dry garlic extract, dry nettle extract, activated charcoal) could impair the absorption of warfarin, increase intestinal absorption of vitamin K, and have a negative effect on the anticoagulant effect of warfarin. Management of patients receiving anticoagulants should be performed in accordance with clinical recommendations. Prescription of drugs, including multicomponent ones, without proven efficacy, for such patients should be considering the potential drug interaction.
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Affiliation(s)
- N. T. Vatutin
- Donetsk National Medical University named after M. Gorky;
Institute of Urgent and Reconstructive Surgery named after V.K. Gusak
| | - G. G. Taradin
- Donetsk National Medical University named after M. Gorky;
Institute of Urgent and Reconstructive Surgery named after V.K. Gusak
| | | | | | | | - I. B. Povaljaeva
- Institute of Urgent and Reconstructive Surgery named after V.K. Gusak
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" A Tale of Two Cities": Anticoagulation Management in Patients with Atrial Fibrillation and Prosthetic Valves in the Era of Direct Oral Anticoagulants. ACTA ACUST UNITED AC 2019; 55:medicina55080437. [PMID: 31382702 PMCID: PMC6722984 DOI: 10.3390/medicina55080437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/22/2023]
Abstract
Valvular heart disease and atrial fibrillation often coexist. Oral vitamin K antagonists have represented the main anticoagulation management for antithrombotic prevention in this setting for decades. Novel direct oral anticoagulants (DOACs) are a new class of drugs and currently, due to their well-established efficacy and security, they represent the main therapeutic option in non-valvular atrial fibrillation. Some new evidences are exploring the role of DOACs in patients with valvular atrial fibrillation (mechanical and biological prosthetic valves). In this review we explore the data available in the medical literature to establish the actual role of DOACs in patients with valvular heart disease and atrial fibrillation.
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Hosseindokht M, Boroumand M, Salehi R, Mandegary A, Hajhosseini Talasaz A, Pourgholi L, Zare H, Ziaee S, Sharifi M. Association between four microRNA binding site-related polymorphisms and the risk of warfarin-induced bleeding complications. EXCLI JOURNAL 2019; 18:287-299. [PMID: 31338002 PMCID: PMC6635724 DOI: 10.17179/excli2019-1352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022]
Abstract
Bleeding is the most serious complication of warfarin anticoagulation therapy and is known to occur even at patients with therapeutic international normalized ratio (INR) range. Recently, it has been shown that microRNAs play a significant role in pharmacogenetics by regulating genes that are critical for drug function. Interaction between microRNAs and these target genes could be affected by single-nucleotide polymorphisms (SNPs) located in microRNA-binding sites. This study focused on 3′-untranslated region (3′-UTR) SNPs of the genes involved in the warfarin action and the occurrence of bleeding complications in an Iranian population receiving warfarin. A total of 526 patients under warfarin anticoagulation therapy with responding to the therapeutic dose and maintenance of the INR in the range of 2.0-3.5 in three consecutive blood tests were included in the study. Four selected 3'-UTR SNPs (rs12458, rs7294, rs1868774 and rs34669593 located in GATA4, VKORC1, CALU and GGCX genes, respectively) with the potential to disrupt/eliminate or enhance/create microRNA-binding site were genotyped using a simple PCR-based restriction fragment length polymorphism (PCR-RFLP) method. Patients with the rs12458 AT or TT genotypes of the GATA4 gene had a lower risk of bleeding compared to patients with the AA genotype (adjusted OR: 0.478, 95% CI: 0.285-0.802, P= 0.005, OR: 0.416, 95% CI: 0.192-0.902, P= 0.026, respectively). 3'-UTR polymorphisms in other genes were not significantly associated with the risk of bleeding complications. In conclusion, the SNP rs12458A>T in the 3′UTR region of GATA4 is associated with the incidence of warfarin-related bleeding at target range of INR, likely by altering microRNA binding and warfarin metabolism. Further genetics association studies are needed to validate these findings before they can be implemented in clinical settings.
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Affiliation(s)
- Maryam Hosseindokht
- Department of Genetics and Molecular Biology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadali Boroumand
- Department of Pathology and Laboratory Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasoul Salehi
- Department of Genetics and Molecular Biology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Mandegary
- Department of Pharmacology and Toxicology, School of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran; Gastroenterology and Hepatology Research Center, Afzalipour's Hospital, Imam Highway, Kerman, Iran
| | - Azita Hajhosseini Talasaz
- Department of Cardiac Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences
| | - Leyla Pourgholi
- Department of Pathology and Laboratory Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Zare
- Cellular and Molecular Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Shayan Ziaee
- Department of Pathology and Laboratory Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Sharifi
- Department of Genetics and Molecular Biology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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