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Kadoglou NPE, Stasinopoulou M, Gkougkoudi E, Christodoulou E, Kostomitsopoulos N, Valsami G. The Complementary Effects of Dabigatran Etexilate and Exercise Training on the Development and Stability of the Atherosclerotic Lesions in Diabetic ApoE Knockout Mice. Pharmaceuticals (Basel) 2023; 16:1396. [PMID: 37895867 PMCID: PMC10609840 DOI: 10.3390/ph16101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023] Open
Abstract
Aim: To determine the complementary effects of dabigatran etexilate (DE), exercise training (ET), and combination (DE + ET) on the development and stability of the atherosclerotic lesions in diabetic apoE knockout (apoE-/-) mice. Methods: In 48 male apoE-/- diabetic mice, streptozotocin (STZ) was induced for 5 consecutive days. Mice received a high-fat diet (HFD) for 8 weeks and then were randomized into four groups (1. Control/CG, 2. DEG: HFD with DE, 3. ETG: ET on treadmill, 4. DE + ETG: combination DE and ET treatment). At the end of the eighth week, all mice were euthanatized and morphometry of the aortic lesions at the level of aortic valve was obtained. Collagen, elastin, MCP-1, TNF-a, matrix metalloproteinases (MMP-2,-3,-9), and TIMP-1 concentrations within plaques at the aortic valve were determined. Results: All active groups had significantly smaller aorta stenosis (DEG:7.9 ± 2.2%, ETG:17.3 ± 5.3%, DE + ETG:7.1 ± 2.7%) compared to CG (23.3 ± 5.5% p < 0.05), reduced the relative intra-plaque content of MCP-1, macrophages, MMP-3, and MMP-9, and considerably increased collagen, elastin, and TIMP-1 (p < 0.05). Group 4 showed the most pronounced results (p < 0.05). Both DEG and DE + ETG significantly reduced MMP-2 and TNF-a concentrations compared to ETG and CG (p < 0.010). Conclusion: DE and ET treatment of diabetic apoE-/- mice resulted in complementary amelioration of atherosclerotic lesions development and stability, mediated by the anti-inflammatory modulation of both DE and ET.
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Affiliation(s)
| | - Marianna Stasinopoulou
- Center of Experimental Surgery, Biomedical Research Foundation, Academy of Athens, 11527 Athens, Greece
| | | | - Eirini Christodoulou
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15771 Athens, Greece (G.V.)
| | - Nikolaos Kostomitsopoulos
- Center of Experimental Surgery, Biomedical Research Foundation, Academy of Athens, 11527 Athens, Greece
| | - Georgia Valsami
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15771 Athens, Greece (G.V.)
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2
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Zhang J, Wang X, Liu X, Larsen TB, Witt DM, Ye Z, Thabane L, Li G, Lip GYH. Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis. Eur J Epidemiol 2021; 36:793-812. [PMID: 33993379 DOI: 10.1007/s10654-021-00751-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/12/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To systematically review available evidence of indirect comparisons from RCTs and direct comparisons from observational studies regarding the comparative effectiveness and safety of DOACs in patients with AF. METHODS Electronic databases including EMBASE, MEDLINE, and PUBMED were searched up to June 5th, 2020. Primary endpoints included effectiveness (stroke or systemic embolism [SE]) and safety (major bleeding) outcomes. Bucher methods and random-effects models were conducted for indirect and direct comparisons among DOACs, respectively. Ranking probability analyses and the number needed to treat for net effect (NNTnet) were applied. RESULTS A total of 36 studies, involving 7 RCTs (n = 60,292 patients) and 29 observational studies (n = 1,164,821 patients), were included for analyses. Regarding the risk of stroke/SE, no significant differences were found from indirect comparisons of RCTs among the DOACs. For major bleeding, apixaban tended to be safer than rivaroxaban and dabigatran based on both direct and indirect comparisons (all p < 0.05; evidence quality: very low to moderate). Ranking probability analysis showed that apixaban had a high probability of being the best treatment in decreased risk of stroke/SE and major bleeding (80.30% and 91.30%, respectively). Likewise, apixaban was found to have the highest net clinical benefit (0.02, 95% CI: 0.014-0.029) and smallest NNTnet (48, 95% CI: 35-74). CONCLUSIONS Apixaban appeared to have a favorable effectiveness-safety profile compared with the other DOACs in AF for stroke prevention, based on evidence from both direct and indirect comparisons. However, additional high-quality evidence is needed to support firm recommendations on clinical decision-making.
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Affiliation(s)
- Junguo Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, 510317, China
| | - Xiaojie Wang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Xintong Liu
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Torben B Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah, Salt Lake City, USA
| | - Zebing Ye
- Department of Cardiology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, 510317, China.
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby St, Liverpool, L7 8TX, UK.
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3
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Liu L, Hong D, Ma K, Lu X. Cost-effectiveness of rivaroxaban versus warfarin in non-valvular atrial fibrillation patients with chronic kidney disease in China. J Clin Pharm Ther 2020; 46:658-668. [PMID: 33226144 DOI: 10.1111/jcpt.13318] [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: 07/17/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE In non-valvular atrial fibrillation (NVAF) patients with chronic kidney disease (CKD), rivaroxaban was not inferior to warfarin in preventing stroke and systemic embolism. However, a comparative evaluation of the cost-effectiveness of rivaroxaban and warfarin therapies for NVAF patients at different renal function levels has not yet been reported, and this study aimed to estimate the cost-effectiveness of rivaroxaban compared with warfarin in Chinese NVAF patients with CKD. METHODS A Markov model was constructed to estimate quality-adjusted life years (QALYs) and lifetime costs associated with the use of rivaroxaban relative to warfarin in patients with NVAF at different estimated glomerular filtration rate (eGFR) levels as follows: 30 to <50, 50 to <80 and ≥80 mL/min. Input parameters were sourced from the clinical literature. Probabilistic sensitivity analyses were performed to assess model uncertainty. RESULTS AND DISCUSSION The incrementalQALYs with rivaroxaban was slightly increased by approximately 0.3 QALY as compared with that with warfarin in all the subgroups, resulting in an ICER of $9,736/QALY (eGFR, 30 to <50 mL/min), $9,758/QALY (50 to <80 mL/min) and $9,969/QALY (≥80 mL/min). The probabilistic sensitivity analysis suggested a chance of >80% that the ICER would be lower than the willingness-to-pay threshold of three times the GDP of China in 2019 in all the subgroups. Results were consistent even under the assumption of anticoagulant discontinuation after major bleeding events. The model was most sensitive to event-free-related utility and survival rates. WHAT IS NEW AND CONCLUSION The existing evidence supports the cost-effectiveness of rivaroxaban therapy as an alternative anticoagulant to warfarin for patients with NVAF at different renal function levels.
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Affiliation(s)
- Lin Liu
- Department of Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Dongsheng Hong
- Department of Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Kuifen Ma
- Department of Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
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4
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Altawalbeh SM, Alshogran OY, Smith KJ. Cost-Utility Analysis of Apixaban versus Warfarin in Atrial Fibrillation Patients with Chronic Kidney Disease. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1365-1372. [PMID: 30502779 DOI: 10.1016/j.jval.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 05/08/2018] [Accepted: 06/14/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Warfarin use for stroke prevention in atrial fibrillation (AF) patients with chronic kidney disease is debated. Apixaban was shown to be safer than warfarin, with superior reduction in the risk of stroke, systemic embolism, mortality, and major bleeding irrespective of kidney function. OBJECTIVES To evaluate the cost-utility of apixaban compared with warfarin in AF patients at different levels of kidney function. METHODS A Markov model was used to estimate the cost effectiveness of apixaban compared with warfarin in AF patients at three levels of kidney function: estimated glomerular filtration rate (eGFR) of more than 80 ml/min, 50 to 80 ml/min, and 50 ml/min or less. Event rates and associated utilities were obtained from previous literature. The model adopted the US health care system perspective, with hospitalization costs extracted from the Healthcare and Utilization Project. Treatment costs were obtained from official price lists. Univariate and probabilistic sensitivity analyses were performed to evaluate the robustness of results. RESULTS Apixaban was a dominant treatment strategy compared with warfarin in AF patients with eGFR levels of 50 ml/min or less and 50 to 80 ml/min. In patients with an eGFR of more than 80 ml/min, apixaban was cost-effective compared with warfarin, costing $6307 per quality-adjusted life-year gained. Results were consistent assuming anticoagulant discontinuation after major bleeding events. Compared with dabigatran and rivaroxaban, apixaban was the only cost-effective anticoagulant strategy relative to warfarin in both mild and moderate renal impairment settings. CONCLUSIONS Apixaban is a favorably cost-effective alternative to warfarin in AF patients with normal kidney function and potentially cost-saving in those with renal impairment.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan.
| | - Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Kenneth J Smith
- Section of Decision Sciences, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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5
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Anticoagulantes orales directos para el tratamiento de los pacientes con fibrilación auricular no valvular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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6
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Rodríguez-Reyes H, Arauz-Góngora A, Asensio-Lafuente E, Celaya-Cota MDJ, Cordero-Cabra A, Guevara-Valdivia M, Izaguirre-Avila R, Lara-Vaca S, Mariona-Moreno V, Martínez-Flores E, Nava-Townsend S, Pozas-Garza G, Rodríguez-Diez G. [Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:124-143. [PMID: 27578566 DOI: 10.1016/j.acmx.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 11/27/2022] Open
Abstract
Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.
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Affiliation(s)
| | - Antonio Arauz-Góngora
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | | | | | - Milton Guevara-Valdivia
- UMAE Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza, Ciudad de México, México
| | - Raúl Izaguirre-Avila
- Departamento de Hematología, Clínica de anticoagulantes, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Susano Lara-Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
| | | | | | - Santiago Nava-Townsend
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Gerardo Pozas-Garza
- Instituto de Cardiología y Medicina vascular del TEC de Monterrey, Monterrey, México
| | - Gerardo Rodríguez-Diez
- Departamento de Electrofisiología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, México
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7
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Antoniou S. Rivaroxaban for the treatment and prevention of thromboembolic disease. J Pharm Pharmacol 2015; 67:1119-32. [DOI: 10.1111/jphp.12387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/21/2014] [Indexed: 12/26/2022]
Abstract
Abstract
Objectives
A number of direct oral anticoagulants are now available and offer alternative strategies for anticoagulation therapy. Rivaroxaban, a direct oral Factor Xa inhibitor, is approved for use across several thromboembolic indications. This article aims to provide an overview of the key pharmacological characteristics of rivaroxaban and the rationale and evidence for the use of different dose regimens across its licenced indications, and offer practical guidance to healthcare professionals on responsible use. References were sourced via PubMed searches using the search string (rivaroxaban AND (pharmacokinetics OR pharmacodynamics OR (clinical studies) OR (drug interaction)) NOT review NOT (children OR pediatrics OR paediatrics OR adolescent)).
Key findings
Rivaroxaban exhibits predictable pharmacokinetics and pharmacodynamics, and thus does not require routine coagulation monitoring, unlike vitamin K antagonists (e.g. warfarin). Rivaroxaban also has a lower potential for drug–drug and food–drug interactions compared with warfarin; however, co-administration with strong inhibitors of both cytochrome P450 3A4 and P-glycoprotein is not recommended. The data indicate that dose adjustment is not necessary for age, gender or body weight. The dosing regimens of rivaroxaban vary depending on the indication, and phase III studies have demonstrated a favourable benefit–risk profile of rivaroxaban compared with traditional standard of care.
Summary
Rivaroxaban may offer an anticoagulant option that could simplify and improve the management of patients with thromboembolic disorders.
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Affiliation(s)
- Sotiris Antoniou
- Clinical Pharmacy Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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8
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Koitabashi N, Niwamae N, Taguchi T, Ohyama Y, Takama N, Kurabayashi M. Remarkable regression of massive deep vein thrombosis in response to intensive oral rivaroxaban treatment. Thromb J 2015; 13:13. [PMID: 25788868 PMCID: PMC4364575 DOI: 10.1186/s12959-015-0045-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/06/2015] [Indexed: 01/14/2023] Open
Abstract
Deep vein thrombosis (DVT) is a common disease and is associated with pulmonary embolism (PE). Proximal iliofemoral DVT may lead to severe PE and chronic venous insufficiency. The standard therapy for DVT is anticoagulant therapy using heparin and a vitamin K antagonist, but a recent clinical study showed that rivaroxaban, an oral Xa inhibitor, was comparable to standard therapy and had less bleeding complications. Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment. The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events. His DVT was massive and was accompanied by proximal iliofemoral vein thrombus and iliac vein compression syndrome. Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.
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Affiliation(s)
- Norimichi Koitabashi
- Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Nogiku Niwamae
- Department of Cardiovascular Medicine, Maebashi Red Cross Hospital, Maebashi, Gunma Japan
| | - Tetsuya Taguchi
- Department of Internal Medicine, Fukaya Red Cross Hospital, Fukaya, Saitama Japan
| | - Yoshiaki Ohyama
- Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Noriaki Takama
- Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Masahiko Kurabayashi
- Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
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9
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Banerjee A, Pogge T. The Health Impact Fund: how might it work for novel anticoagulants in atrial fibrillation? Glob Heart 2015; 9:255-261.e2. [PMID: 25667097 DOI: 10.1016/j.gheart.2014.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/14/2014] [Accepted: 01/23/2014] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular diseases represent the greatest burden of global disease. Spending on cardiovascular diseases is higher than for other diseases, with the majority being spent on drugs. Therefore, these drugs and these diseases are hugely important to health systems, society, and pharmaceutical companies. The Health Impact Fund represents a new mechanism by which pharmaceutical innovators would be rewarded on the basis of the health impact of their new drugs. This review illustrates the concept of the Health Impact Fund using the example of novel anticoagulants for prevention of stroke and thromboembolism in atrial fibrillation. By considering existing data and the current situation for novel anticoagulants, we suggest that epidemiologic data and modeling techniques can be used to predict future trends in disease and the health impact of new drugs. The Health Impact Fund may offer potential benefits to pharmaceutical companies, patients, and governments and warrants proper investigation.
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Affiliation(s)
- Amitava Banerjee
- Centre for Cardiovascular Sciences, College of Medical and Dental Sciences, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.
| | - Thomas Pogge
- Department of Philosophy, Yale University, New Haven, CT, USA
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10
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Abstract
Vitamin K antagonists (VKAs) remain the standard therapy for anticoagulation in prevention and treatment of venous thromboembolism (VTE) and for the prevention of stroke in atrial fibrillation (AF). Due to numerous limitations of VKAs, target-specific oral anticoagulants have been developed. Edoxaban is a direct activated factor X inhibitor with attractive features among which are once daily dosing, no need for routine monitoring, and minimal drug–drug interactions. In patients undergoing orthopedic surgery, edoxaban was superior to enoxaparin in preventing VTE. Furthermore, a recent large-scale phase III trial in patients with symptomatic VTE demonstrated that edoxaban was noninferior to warfarin in preventing recurrent VTE and reduced bleeding. In the largest trial of anticoagulation in patients with AF to date, edoxaban was noninferior to warfarin in the prevention of stroke or systemic embolism and reduced bleeding and cardiovascular mortality. This review provides an overview of the pharmacology, clinical trial results, and potential indications for edoxaban.
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Affiliation(s)
| | - Robert P. Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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11
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Awad AJ, Walcott BP, Stapleton CJ, Yanamadala V, Nahed BV, Coumans JV. Dabigatran, intracranial hemorrhage, and the neurosurgeon. Neurosurg Focus 2013; 34:E7. [PMID: 23634926 DOI: 10.3171/2013.2.focus1323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dabigatran etexilate (Pradaxa) is a novel oral anticoagulant that has gained FDA approval for the prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In randomized trials, the incidence of hemorrhagic events has been demonstrated to be lower in patients treated with dabigatran compared with the traditional anticoagulant warfarin. However, dabigatran does not have reliable laboratory tests to measure levels of anticoagulation and there is no pharmacological antidote. These drawbacks are challenging in the setting of intracerebral hemorrhage. In this article, the authors provide background information on dabigatran, review the existing anecdotal experiences with treating intracerebral hemorrhage related to dabigatran therapy, present a case study of intracranial hemorrhage in a patient being treated with dabigatran, and suggest clinical management strategies. The development of reversal agents is urgently needed given the growing number of patients treated with this medication.
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Affiliation(s)
- Ahmed J Awad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, West Bank, Palestine
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13
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Canestaro WJ, Patrick AR, Avorn J, Ito K, Matlin OS, Brennan TA, Shrank WH, Choudhry NK. Cost-effectiveness of oral anticoagulants for treatment of atrial fibrillation. Circ Cardiovasc Qual Outcomes 2013; 6:724-31. [PMID: 24221832 DOI: 10.1161/circoutcomes.113.000661] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND New anticoagulants may improve health outcomes in patients with atrial fibrillation, but it is unclear whether their use is cost-effective. METHODS AND RESULTS A Markov state transition was created to compare 4 therapies: dabigatran 150 mg BID, apixaban 5 mg BID, rivaroxaban 20 mg QD, and warfarin therapy. The population included those with newly diagnosed atrial fibrillation who were eligible for treatment with warfarin. Compared with warfarin, apixaban, rivaroxaban, and dabigatran, costs were $93 063, $111 465, and $140 557 per additional quality-adjusted life year gained, respectively. At a threshold of $100 000 per quality-adjusted life year, apixaban provided the greatest absolute benefit while still being cost-effective, although warfarin would be superior if apixaban was 2% less effective than expected. Although apixaban was the optimal strategy in our base case, in probabilistic sensitivity analysis, warfarin was optimal in an equal number of iterations at a cost-effectiveness threshold of $100 000 per quality-adjusted life year. CONCLUSIONS While at a standard cost-effectiveness threshold of $100 000 per quality-adjusted life year, apixaban seems to be the optimal anticoagulation strategy; this finding is sensitive to assumptions about its efficacy and cost. In sensitivity analysis, warfarin seems to be the optimal choice in an equal number of simulations. As a result, although all the novel oral anticoagulants produce greater quality-adjusted life expectancy than warfarin, they may not represent good value for money.
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Affiliation(s)
- William J Canestaro
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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14
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Gazi E, Temiz A, Barutcu A, Colkesen Y. Novel Therapeutics for Thromboprophylaxis in Nonvalvular Atrial Fibrillation. Drug Dev Res 2013. [DOI: 10.1002/ddr.21106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Emine Gazi
- Department of Cardiology; Canakkale Onsekiz Mart University Faculty of Medicine; Canakkale; Turkey
| | - Ahmet Temiz
- Department of Cardiology; Canakkale Onsekiz Mart University Faculty of Medicine; Canakkale; Turkey
| | - Ahmet Barutcu
- Department of Cardiology; Canakkale Onsekiz Mart University Faculty of Medicine; Canakkale; Turkey
| | - Yucel Colkesen
- Department of Cardiology; Canakkale Onsekiz Mart University Faculty of Medicine; Canakkale; Turkey
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15
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Le Reste JY, Chiron B, Le Floch B, Nabbe P, Barrais M, Mansourati J, Cadier S, Barraine P, Lietard C. There are considerable drawbacks to oral anticoagulant for monitoring patients at home which should lead family physicians to discuss alternative or enhanced solutions: a cross-sectional study. BMC Cardiovasc Disord 2013; 13:71. [PMID: 24024556 PMCID: PMC3846900 DOI: 10.1186/1471-2261-13-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 09/04/2013] [Indexed: 11/30/2022] Open
Abstract
Background INR (International Normalized Ratio) is the biological reference test for the monitoring of vitamin K antagonist (VKA) therapy. Overdosage of VKAs causes about 17,000 hospitalizations and 5,000 deaths each year in France. To avoid these complications, monitoring and blood sampling conditions must be rigorous. In France, more than half of INRs are carried out at home. The aim was to determine blood-sampling conditions at home, transit time and the quality of the laboratory reagents used. Method Questionnaire-based, descriptive epidemiological cross-sectional prevalence study involving home care nurses, family physicians (FPs) and clinical laboratories. Setting: Brittany, France, 2008. Study of the pre-analytical phase of INRs sampled at home and its influence on INR results. Results The study included 291 FPs, 249 home care nurses, and 49 laboratories. 32.5% of reported INRs were outside the therapeutic range. Samples were drawn into unsuitable tubes in 5.5% of cases and delivered in a chilled condition in 9% of cases. In urban areas 50% of the tubes took more than 2 hours to reach the laboratory compared with 71% from rural areas. The average International Sensitivity Index (ISI) of the thromboplastin was 1.62. The INRs provided by the laboratories were not analyzable in 64.7% of cases where blood samples had been taken at home. Conclusion Blood sample quality, transit time and the reagents used are currently inadequate. The majority of INRs taken at home are not reliable. FPs should consider these drawbacks in comparison with alternative solutions to increase patient safety.
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Affiliation(s)
- Jean Yves Le Reste
- Département de médecine générale - UFR Brest, Rue Camille Desmoulins, 29200 Brest, France.
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16
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Costopoulos C, Niespialowska-Steuden M, Kukreja N, Gorog DA. Novel oral anticoagulants in acute coronary syndrome. Int J Cardiol 2013; 167:2449-55. [DOI: 10.1016/j.ijcard.2012.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 07/18/2012] [Accepted: 08/21/2012] [Indexed: 11/16/2022]
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17
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Angiolillo DJ, Ferreiro JL. Antiplatelet and anticoagulant therapy for atherothrombotic disease: the role of current and emerging agents. Am J Cardiovasc Drugs 2013; 13:233-50. [PMID: 23613159 DOI: 10.1007/s40256-013-0022-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Coronary atherothrombotic disease, including chronic stable angina and acute coronary syndromes (ACS), is associated with significant global burden. The acute clinical manifestations of atherothrombotic disease are mediated by occlusive arterial thrombi that impair tissue perfusion and are composed of a core of aggregated platelets, generated by platelet activation, and a superimposed fibrin mesh produced by the coagulation cascade. Long-term antithrombotic therapies, namely oral antiplatelet agents and anticoagulants, have demonstrated variable clinical effects. Aspirin and P2Y12 adenosine diphosphate (ADP) receptor antagonists have been shown to reduce the risk for thrombosis and ischaemic events by blocking the thromboxane (Tx) A2 and platelet P2Y12 activation pathways, respectively, whereas the benefits of oral anticoagulants have not been consistently documented. However, even in the presence of aspirin and a P2Y12 receptor antagonist, the risk for ischaemic events remains substantial because platelet activation continues via pathways independent of TxA2 and ADP, most notably the protease-activated receptor (PAR)-1 platelet activation pathway stimulated by thrombin. Emerging antithrombotic therapies include those targeting the platelet, such as the new P2Y12 antagonists and a novel class of oral PAR-1 antagonists, and those inhibiting the coagulation cascade, such as the new direct factor Xa antagonists, the direct thrombin inhibitors, and a novel class of factor IX inhibitors. The role of emerging antiplatelet agents and anticoagulants in the long-term management of patients with atherothrombotic disease will be determined by the balance of efficacy and safety in large ongoing clinical trials.
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Steinberg BA, Hasselblad V, Atwater BD, Bahnson TD, Washam JB, Alexander JH, Daubert JP, Piccini JP. Dabigatran for periprocedural anticoagulation following radiofrequency ablation for atrial fibrillation: a meta-analysis of observational studies. J Interv Card Electrophysiol 2013; 37:213-21. [PMID: 23881249 DOI: 10.1007/s10840-013-9813-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/15/2013] [Indexed: 01/18/2023]
Abstract
PURPOSE Dabigatran is approved for prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF). The safety and effectiveness of periprocedural dabigatran in ablation for AF are unknown. METHODS We performed a meta-analysis of all studies comparing periprocedural dabigatran with warfarin for anticoagulation in AF ablation. Studies of >100 patients with post-procedure follow-up were included. Outcomes were compared by calculating maximum likelihood estimates with confidence intervals. The co-primary endpoints were neurological events and major bleeding. RESULTS Ten cohort studies were included, including a total of 1,501 patients receiving dabigatran and 2,356 receiving warfarin. The mean age was 59-64 years and inclusion of women varied (10-33 %). Intra-procedural unfractionated heparin and irrigated ablation catheters were used routinely. Adverse events were low overall; however, the dabigatran group demonstrated a numerical excess of neurological events (10/1,501 [0.7 %] versus 4/2,356 [0.2 %]), but equivalent major bleeding outcomes (24/1,501 [1.6 %] versus 40/2,356 [1.7 %]). In the meta-analysis, there was a nonsignificant trend towards higher rates of the composite primary endpoints (any neurological event or major bleeding) in the dabigatran group. Dabigatran demonstrated a significantly higher rate of neurological events (estimated absolute risk difference 0.0047, 95 % confidence interval 0.0007 to 0.0099). CONCLUSIONS Compared with warfarin, dabigatran may be associated with a higher frequency of periprocedural neurological events following radiofrequency ablation of AF. Randomized clinical trials are needed to definitively assess the safety and efficacy of novel oral anticoagulant use for periprocedural anticoagulation for ablation of AF.
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Affiliation(s)
- Benjamin A Steinberg
- Duke Center for Atrial Fibrillation, Electrophysiology Section, Duke University Medical Center, Durham, NC, USA
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19
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Huber K, Connolly SJ, Kher A, Christory F, Dan GA, Hatala R, Kiss RG, Meier B, Merkely B, Pieske B, Potpara T, Stępińska J, Klun NV, Vinereanu D, Widimský P. Practical use of dabigatran etexilate for stroke prevention in atrial fibrillation. Int J Clin Pract 2013; 67:516-26. [PMID: 23557519 PMCID: PMC3712459 DOI: 10.1111/ijcp.12147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 02/02/2013] [Indexed: 01/16/2023] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, and is the most prevalent factor for cardioembolic stroke. Vitamin K antagonists (VKAs) have been the standard of care for stroke prevention in patients with AF since the early 1990s. They are very effective for the prevention of cardioembolic stroke, but are limited by factors such as drug-drug interactions, food interactions, slow onset and offset of action, haemorrhage and need for routine anticoagulation monitoring to maintain a therapeutic international normalised ratio (INR). Multiple new oral anticoagulants have been developed as potential replacements for VKAs for stroke prevention in AF. Most are small synthetic molecules that target thrombin (e.g. dabigatran etexilate) or factor Xa (e.g. rivaroxaban, apixaban, edoxaban, betrixaban, YM150). These drugs have predictable pharmacokinetics that allow fixed dosing without routine laboratory monitoring. Dabigatran etexilate, the first of these new oral anticoagulants to be approved by the United States Food and Drug Administration and the European Medicines Agency for stroke prevention in patients with non-valvular AF, represents an effective and safe alternative to VKAs. Under the auspices of the Regional Anticoagulation Working Group, a multidisciplinary group of experts in thrombosis and haemostasis from Central and Eastern Europe, an expert panel with expertise in AF convened to discuss practical, clinically important issues related to the long-term use of dabigatran for stroke prevention in non-valvular AF. The practical information reviewed in this article will help clinicians make appropriate use of this new therapeutic option in daily clinical practice.
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Affiliation(s)
- K Huber
- 3rd Department of Medicine (Cardiology and Emergency Medicine), Wilhelminen Hospital, Vienna, Austria.
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20
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Asghar O, Alam U, Hayat SA, Aghamohammadzadeh R, Heagerty AM, Malik RA. Obesity, diabetes and atrial fibrillation; epidemiology, mechanisms and interventions. Curr Cardiol Rev 2013; 8:253-64. [PMID: 22920475 PMCID: PMC3492809 DOI: 10.2174/157340312803760749] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/28/2012] [Accepted: 05/11/2012] [Indexed: 02/08/2023] Open
Abstract
The last few decades have witnessed a global rise in adult obesity of epidemic proportions. The potential impact of this is emphasized when one considers that body mass index (BMI) is a powerful predictor of death, type 2 diabetes (T2DM) and cardiovascular (CV) morbidity and mortality [1, 2]. Similarly we have witnessed a parallel rise in the incidence of atrial fibrillation (AF), the commonest sustained cardiac arrhythmia, which is also a significant cause of cardiovascular morbidity and mortality. Part of this increase is attributable to advances in the treatment of coronary heart disease (CHD) and heart failure (HF) improving life expectancy and consequently the prevalence of AF. However, epidemiological studies have demonstrated an independent association between obesity and AF, possibly reflecting common pathophysiology and risk factors for both conditions. Indeed, weight gain and obesity are associated with structural and functional changes of the cardiovascular system including left atrial and ventricular remodeling, haemodynamic alterations, autonomic dysfunction, and diastolic dysfunction. Moreover, diabetic cardiomyopathy is characterized by an adverse structural and functional cardiac phenotype which may predispose to the development of AF [3]. In this review, we discuss the pathophysiological and mechanistic relationships between obesity, diabetes and AF, and the challenges posed in the management of this high-risk group of individuals.
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Affiliation(s)
- O Asghar
- Division of Cardiovascular Sciences, The University of Manchester, UK
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21
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Howard PA. New oral anticoagulants for stroke prevention in atrial fibrillation: more choices bring more challenges. Hosp Pharm 2013; 48:366-71. [PMID: 24421491 PMCID: PMC3839470 DOI: 10.1310/hpj4805-366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
For patients with atrial fibrillation, anticoagulant therapy is essential to reduce the risk of ischemic stroke that is associated with this arrhythmia. Historically, warfarin has been the preferred treatment for patients at moderate to high risk despite many potential limitations. With the development of newer oral anticoagulants, clinicians now have 3 additional options: dabigatran, rivaroxaban, and apixaban. Although these agents clearly offer some advantages over warfarin, they may not be appropriate for all patients. This article will discuss factors that should be considered when selecting among these various anticoagulants.
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Affiliation(s)
- Patricia A Howard
- Professor and Vice Chair, Department of Pharmacy Practice, University of Kansas Medical Center, Mailstop 4047, 3901 Rainbow Boulevard, Kansas City, Kansas 66160; phone: 913-588-5391; fax: 913-588-2355; e-mail:
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22
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Kwong JSW, Lam YY, Yan BP, Yu CM. Bleeding of New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials. Cardiovasc Drugs Ther 2012; 27:23-35. [DOI: 10.1007/s10557-012-6426-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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23
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Philip I, Leblanc I, Berroëta C, Mouren S, Chterev V, Bourel P. Fibrillation atriale en anesthésie–réanimation : de la cardiologie médicale à la période périopératoire. ACTA ACUST UNITED AC 2012; 31:897-910. [DOI: 10.1016/j.annfar.2012.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/20/2012] [Indexed: 01/11/2023]
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24
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Limdi NA. Warfarin pharmacogenetics: challenges and opportunities for clinical translation. Front Pharmacol 2012; 3:183. [PMID: 23133417 PMCID: PMC3490409 DOI: 10.3389/fphar.2012.00183] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/28/2012] [Indexed: 01/21/2023] Open
Affiliation(s)
- Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham Birmingham, AL, USA ; Department of Epidemiology, University of Alabama at Birmingham Birmingham, AL, USA
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25
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26
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Anticoagulation d’une fibrillation auriculaire aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Lee IO, Kratz MT, Schirmer SH, Baumhäkel M, Böhm M. The effects of direct thrombin inhibition with dabigatran on plaque formation and endothelial function in apolipoprotein E-deficient mice. J Pharmacol Exp Ther 2012; 343:253-7. [PMID: 22837011 DOI: 10.1124/jpet.112.194837] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The recently developed oral anticoagulant dabigatran (Dabi) etexilate directly inhibits thrombin after activation by plasma esterases to dabigatran. Thrombin is involved in the pathogenesis of atherosclerosis. We investigated the effects of direct thrombin inhibition on atherosclerosis and endothelial function in a hypercholesterolemic mouse model with accelerated atherosclerosis {[apolipoprotein E-deficient (ApoE(-/-)] mice}. ApoE(-/-) mice were treated with a cholesterol-rich diet for 12 weeks and either dabigatran etexilate (900 mg/kg body weight) or vehicle. Wild-type (C57/B6) mice served as control. Endothelial function was assessed with carbachol (endothelium dependent) by using glyceroltrinitrate (endothelium independent) as control in aortic rings. Atherosclerotic lesion formation was evaluated with Oil Red staining, and vascular collagen content was determined by Sirius Red staining. Reactive oxygen species (ROS) production was determined by semiquantitative immunohistochemical staining. Measurement of dabigatran plasma levels (622.3±169 ng/ml) and a performed coagulation test (diluted thrombin time) revealed a relevant anticoagulatory concentration. Dabigatran etexilate attenuated increased atherosclerotic plaque formation [ApoE(-/-) Dabi: 16.1±3.8% of ApoE(-/-) control; p<0.001], decreased collagen content [ApoE(-/-) Dabi: 49.1±10% of ApoE(-/-) control; p=0.01], and ROS production in dihydroethidium staining [ApoE(-/-) Dabi: 46.3±5.4% of ApoE(-/-) control; p=0.005] in parallel to an improvement of endothelial function [ApoE(-/-) control 42.6±2.7 versus ApoE(-/-) Dabi 62.9±3.3% of phenylephrine-induced contraction; p=0.001] at 100 μmol carbachol. These data suggest that direct thrombin inhibition in a relevant dosage improved endothelial function and reduced atherosclerotic lesion size, collagen content, and oxidative stress in hypercholesterolemic atherosclerosis. Interference with the coagulation system might provide a therapeutic target to modify atherosclerotic disease progression.
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Affiliation(s)
- Illkyu-O Lee
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, D-66421 Homburg/Saar, Germany.
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28
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Maan A, Shaikh AY, Mansour M, Ruskin JN, Heist EK. Stroke and Death Prediction with the Impact of Vascular Disease in Patients with Atrial Fibrillation. J Atr Fibrillation 2012; 5:586. [PMID: 28496751 DOI: 10.4022/jafib.586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/15/2012] [Accepted: 05/15/2012] [Indexed: 12/22/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered in the U.S. and the growing burden of AF has profound health implications due to the association of AF with an increased risk of stroke, heart failure, and mortality. AF is a significant risk factor for thromboembolic stroke; and also independently increases total mortality in patients with and without cardiovascular disease. Various risk stratification schemes such as CHADS2 and CHA2DS2-VASc have been implemented in clinical practice to determine the risk of cardio-embolic stroke, and need for thrombo-prophylaxis in patients with AF. AF is also closely related to the pathophysiology of other cardiovascular and peripheral vascular disease. Many patients with AF have associated atherosclerosis given that many risk factors for atherosclerosis also predispose to AF. Myocardial infarction (MI) is also closely related to AF and its clinical course is affected by new onset AF. This review elucidates the impact of AF on major adverse cardiovascular events and mortality outcomes in relation to stroke, coronary artery disease and peripheral vascular disease.
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Affiliation(s)
- Abhishek Maan
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA 01655
| | - Amir Y Shaikh
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA 01655
| | - Moussa Mansour
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, GRB 109, 55 Fruit St, Boston MA 02115
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, GRB 109, 55 Fruit St, Boston MA 02115
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, GRB 109, 55 Fruit St, Boston MA 02115
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29
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Violi F, Lip GYH, Basili S. Peripheral artery disease and atrial fibrillation: a potentially dangerous combination. Intern Emerg Med 2012; 7:213-8. [PMID: 21667071 DOI: 10.1007/s11739-011-0637-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 05/20/2011] [Indexed: 01/13/2023]
Abstract
Atrial fibrillation (AF) is commonly associated with a significant increase in stroke and thromboembolic risk. Many patients with AF have associated atherothrombosis given the many risk factors for atherosclerosis that also predispose to AF. Vascular disease, whether peripheral artery disease or myocardial infarction, contributes to the increased risk of stroke and thromboembolism, and has been included in stroke risk assessment schema. This review analyzes the interplay between AF and peripheral artery disease in relation to their associated pathophysiology, as well as epidemiological data linking both conditions and the associated thromboembolic complications conferred by the presence of both.
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Affiliation(s)
- Francesco Violi
- Divisione di I Clinica Medica, Sapienza-University of Rome, Rome, Italy.
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30
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Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JWM, Oliver-McNeil SM, Popma JJ, Tommaso CL. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol 2012; 59:2221-305. [PMID: 22575325 DOI: 10.1016/j.jacc.2012.02.010] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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31
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Harburger JM, Aronow WS. Newer anticoagulants for non-valvular atrial fibrillation. Pharmaceuticals (Basel) 2012; 5:469-80. [PMID: 24281558 PMCID: PMC3763648 DOI: 10.3390/ph5050469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 04/28/2012] [Accepted: 04/28/2012] [Indexed: 11/26/2022] Open
Abstract
Non-valvular atrial fibrillation is a recognized risk factor for stroke and systemic embolism. It has been clearly established that warfarin reduces the risk of stroke and systemic embolism in persons with atrial fibrillation and additional risk factors for stroke. The use of warfarin, however, requires frequent monitoring, and there is great variability in patient response to warfarin. Warfarin interacts with several medications and foods. In addition, warfarin use portends a significant risk of bleeding. For these reasons, warfarin is frequently not prescribed to persons for whom the drug would provide a clear benefit. Over the past decade, attempts have been made to develop drugs that are at least as safe and effective as warfarin for the treatment of atrial fibrillation that do not require monitoring nor have as many interactions. Initial studies of compounds in this regard ultimately failed due to safety concerns, but over the past two years two novel agents have been approved by the United States Food and Drug Association for anticoagulation in non-valvular atrial fibrillation, another drug is under review, and additional compounds are being studied. This article will review the use of warfarin and these new agents in the treatment of non-valvular atrial fibrillation.
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Affiliation(s)
- Joseph M Harburger
- Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY 10595, USA.
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32
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33
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Aristizábal JM, Restrepo AM, Uribe W, Medina E, Marín JE, Velásquez JE, Miranda AC, Duque M. Consideraciones prácticas para el uso de los nuevos anticoagulantes orales. REVISTA COLOMBIANA DE CARDIOLOGÍA 2012. [DOI: 10.1016/s0120-5633(12)70120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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34
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Percutaneous closure of the left atrial appendage to prevent ischaemic stroke in patients with atrial fibrillation who require but have contraindications to oral anticoagulation. Neurol Neurochir Pol 2012; 46:87-91. [PMID: 22426767 DOI: 10.5114/ninp.2012.27178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Atrial fibrillation (AF) is associated with a five-fold increased risk for stroke due to cardioembolic events. Most strokes in patients with AF arise from thrombus formation in the left atrial appendage (LAA). Oral anticoagulation is a standard treatment of AF patients with high risk of stroke. However, the main drawbacks of oral anticoagulation are high risk of major bleeding and imperfect effectiveness dependent on a very narrow therapeutic range. In this article, based on two case reports, we describe a method of percutaneous closure of the LAA. We discuss indications, describe the procedure and mention possible complications. LAA closure seems to be a promising tool to prevent AF-related strokes in a selected group of patients.
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35
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36
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Davis EM, Packard KA, Knezevich JT, Campbell JA. New and emerging anticoagulant therapy for atrial fibrillation and acute coronary syndrome. Pharmacotherapy 2012; 31:975-1016. [PMID: 21950643 DOI: 10.1592/phco.31.10.975] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract Thrombosis is an underlying cause of many cardiovascular disorders, and generation of thrombi in the arterial circulation can lead to unstable angina, myocardial infarction, or ischemic stroke. Antithrombotic therapy is widely used, with proven benefit to prevent ischemic stroke and thromboembolic events in patients with atrial fibrillation (AF) or to prevent further ischemic complications in patients with acute coronary syndrome (ACS). Traditional anticoagulants (including unfractionated heparin, low-molecular-weight heparin, and warfarin) and antiplatelet agents (including aspirin, clopidogrel, and prasugrel) are typically used for these indications. Limitations to their use include variable pharmacokinetic and pharmacodynamic profiles, inability to inhibit fibrin-bound thrombin, risk of heparin-induced thrombocytopenia, delayed onset of action, numerous drug interactions, need for substantial laboratory monitoring and dosage titrations, hyporesponsiveness or resistance, hypersensitivity, adverse events, and bleeding. To overcome some of the limitations of traditional agents, new antithrombotic agents under development are highly selective for specific coagulation factors blocking the synthesis of thrombin. Clinicians must have an understanding of the new anticoagulants to aid in the selection of appropriate therapies for patients. We describe the most relevant phases II and III clinical trials that evaluated several recent emerging anticoagulant drugs for use in patients with AF or ACS. The advantages of many new agents include predictable pharmaco-dynamic response and pharmacokinetic parameters, allowing for fixed oral dosing with no need for laboratory monitoring. For patients with AF, dabigatran is already approved for the prevention of stroke and systemic embolism, rivaroxaban appears to be an effective alternative to warfarin in high-risk patients, and apixaban may also be an effective alternative to aspirin in patients unable to take warfarin. Otamixaban shows promise as an intravenous alternative for patients with ACS in the acute care setting. Likewise, rivaroxaban, dabigatran, and darexaban with or without dual antiplatelet therapy may be beneficial for secondary prevention of ischemic events in patients with ACS.
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Affiliation(s)
- Estella M Davis
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska 68178, USA
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37
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Demaria AN, Bax JJ, Ben-Yehuda O, Feld GK, Greenberg BH, Hall J, Hlatky M, Lew WYW, Lima JAC, Maisel AS, Narayan SM, Nissen S, Sahn DJ, Tsimikas S. Highlights of the Year in JACC 2011. J Am Coll Cardiol 2012; 59:503-37. [PMID: 22281255 DOI: 10.1016/j.jacc.2011.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony N Demaria
- University of California-San Diego, San Diego, California 92122, USA.
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38
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Jaquiss RDB, Lodge AJ. Pediatric Ventricular Assist Devices: The Future (as of 2011). World J Pediatr Congenit Heart Surg 2012; 3:82-6. [PMID: 23804689 DOI: 10.1177/2150135111423277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last decade, there have been enormous advances in the field of pediatric-specific mechanical circulatory support. In the past, small children requiring bridge to transplant or recovery were limited to extracorporeal membrane oxygenation. Now, in various stages of development, there are several devices that offer the promise of the same quality of support enjoyed by older teenagers and adolescents, with the potential to substantially reduce transplant waiting list mortality and optimize transplant outcomes. Advances have been driven by both industry and, for the first time, by funding from the US National Institutes of Health.
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Affiliation(s)
- Robert D B Jaquiss
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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39
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Kowey PR. What's a mother to do? J Cardiovasc Electrophysiol 2011; 23:269-70. [PMID: 21985438 DOI: 10.1111/j.1540-8167.2011.02194.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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40
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Toschi V, Lettino M. Inhibitors of propagation of coagulation: factors V and X. Br J Clin Pharmacol 2011; 72:563-80. [PMID: 21545479 PMCID: PMC3195734 DOI: 10.1111/j.1365-2125.2011.04001.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/05/2011] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular diseases are still the most important cause of morbidity and mortality in western countries and antithrombotic treatment is nowadays widely used. Drugs able to reduce coagulation activation are the treatment of choice for a number of arterial and/or venous thromboembolic conditions. Some of the drugs currently used for this purpose, such as heparins (UFH or LMWH) and VKA, have limitations consisting of a narrow therapeutic window and an unpredictable response with the need of laboratory monitoring in order to assess their efficacy and safety. These drawbacks have stimulated an active research aimed to develop new drugs able to act on single factors involved in the coagulation network, with predictable response. Intense experimental and clinical work on new drugs has focused on synthetic agents, which could preferably be administered orally and at fixed doses. The most advanced clinical development with new anticoagulants has been achieved for those inhibiting FXa and some of them, like fondaparinux, are already currently used in clinical practice. Other agents, such as rivaroxaban, apixaban, otamixaban and edoxaban are under development and have already been studied or are currently under investigation in large scale phase III clinical trials for prevention and treatment of venous thromboembolism, atrial fibrillation and acute coronary syndromes. Some of them have proved to be more effective than conventional therapy. Data on some agents inhibiting FVa are still preliminary and some of these drugs have so far been considered only in patients with disseminated intravascular coagulation secondary to sepsis.
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Affiliation(s)
- Vincenzo Toschi
- Department of Hematology and Blood Transfusion, Thrombosis Center, San Carlo Borromeo Hospital, Milan, Italy.
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41
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Preventing Thrombosis After the Fontan Procedure. J Am Coll Cardiol 2011; 58:652-3. [DOI: 10.1016/j.jacc.2011.01.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 01/04/2011] [Indexed: 01/19/2023]
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42
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DeLoughery TG. Practical aspects of the oral new anticoagulants. Am J Hematol 2011; 86:586-90. [PMID: 21674571 DOI: 10.1002/ajh.22021] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 02/25/2011] [Indexed: 12/21/2022]
Abstract
After years of only oral vitamin K antagonists, there are new many new antithrombotic agents in development and on entering the marketplace. This review will analyze clinical trial results for these new agents-especially dibigatran, rivaroxaban, and apixiban. Also to be discussed are practical aspects of use of these new agents such monitoring, reversal, and use before procedures.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health Sciences University, Portland, 97201-3098, USA.
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43
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Partida RA, Giugliano RP. Edoxaban: pharmacological principles, preclinical and early-phase clinical testing. Future Cardiol 2011; 7:459-70. [DOI: 10.2217/fca.11.28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Vitamin K antagonists have been the cornerstone of oral antithrombotic therapy to help prevent ischemic stroke in atrial fibrillation (AF) and reduce venous thromboembolic events. Despite proven clinical benefit, vitamin K antagonists have several limitations, including a narrow therapeutic window, slow onset/offset of action, need for close monitoring and significant drug/food interactions, highlighting the need for alternative therapies. Recently, the direct thrombin inhibitor dabigatran was approved by the US FDA for use in AF, and several factor Xa inhibitors are in late-stage clinical testing. Edoxaban is a novel, oral, reversible, direct factor Xa inhibitor with rapid absorption and predictable dose-dependent anticoagulation effects. Early clinical studies have shown promising results and it is currently undergoing large-scale Phase III trials for stroke prevention in AF and venous thromboembolic event prophylaxis and treatment. This review provides an overview of the current understanding, clinical trial results and pharmacology of edoxaban.
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Affiliation(s)
- Ramon A Partida
- Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, 350 Longwood Ave, 1st Floor Offices, Boston, MA 02115, USA
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44
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Prediction of Stroke Risk in Atrial Fibrillation, Prevention of Stroke in Atrial Fibrillation, and the Impact of Long-Term Monitoring for Detecting Atrial Fibrillation. Curr Atheroscler Rep 2011; 13:290-7. [DOI: 10.1007/s11883-011-0188-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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45
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Affiliation(s)
- Graeme J Hankey
- Department of Neurology, Royal Perth Hospital, 197 Wellington St, Perth, Australia 6001.
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46
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Doloresco F, Fominaya C, Schumock GT, Vermeulen LC, Matusiak L, Hunkler RJ, Shah ND, Hoffman JM. Projecting future drug expenditures—2011. Am J Health Syst Pharm 2011; 68:921-32. [DOI: 10.2146/ajhp100712] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Fred Doloresco
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, and Research Assistant Professor, Department of Social and Preventive Medicine, School of Public Health and Health Professions
| | - Cory Fominaya
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Glen T. Schumock
- Department of Pharmacy Practice, and Director, Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois—Chicago, Chicago
| | - Lee C. Vermeulen
- Center for Clinical Knowledge Management, University of Wisconsin Health, Madison, and Clinical Professor, School of Pharmacy, University of Wisconsin—Madison, Madison
| | - Linda Matusiak
- Professional Relations, IMS Health, Plymouth Meeting, PA
| | | | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic College of Medicine, Rochester, MN, and Senior Associate Consultant, Mayo Clinic, Rochester
| | - James M. Hoffman
- Pharmaceutical Department, St. Jude Children’s Research Hospital, Memphis, TN, and Associate Professor of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis
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47
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Yoshikawa K, Yoshino T, Yokomizo Y, Uoto K, Naito H, Kawakami K, Mochizuki A, Nagata T, Suzuki M, Kanno H, Takemura M, Ohta T. Design, synthesis and SAR of novel ethylenediamine and phenylenediamine derivatives as factor Xa inhibitors. Bioorg Med Chem Lett 2011; 21:2133-40. [DOI: 10.1016/j.bmcl.2011.01.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 01/27/2011] [Accepted: 01/28/2011] [Indexed: 12/16/2022]
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48
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Ogawa S, Koretsune Y, Yasaka M, Aizawa Y, Atarashi H, Inoue H, Kamakura S, Kumagai K, Mitamura H, Okumura K, Sugi K, Yamashita T. Antithrombotic Therapy in Atrial Fibrillation - Evaluation and Positioning of New Oral Anticoagulant Agents -. Circ J 2011; 75:1539-47. [DOI: 10.1253/circj.cj-11-0304] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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