Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa

Barriers to stroke prevention in Atrial Fibrillation: Insights from the global anticoagulation Roundtable

Atrial fibrillation (AF) accounts for one-quarter of the global ischemic stroke burden. Population growth and an increasing prevalence of stroke risk factors underscores the critical need to recognize and address the worldwide crisis in underutilization of antithrombotic therapy for patients with AF. Failure to address key patient, clinician, and societal gaps in AF care will result in a worldwide increase in stroke-related morbidity and mortality while overwhelming global healthcare systems. The failure to adhere to evidence-based guideline recommendations for stroke prevention in AF reflects a critical gap in implementation of best clinical practice among providers and healthcare systems. Globally, these include inadequate provider education, limited public awareness, underdiagnosis, and underutilization of treatments, including antithrombotic therapy. In specific regions, efforts are further complicated by availability of specific medications, variation in drug metabolism across racial and ethnic populations, socioreligious considerations, and lack of universally available electronic health records. Efforts are needed at both global and regional levels to address key barriers to evidence-based care for patients with AF. Investing in clinical tools and teams that improve stroke prevention for patients with AF will likely improve population health.

Medication errors associated with direct-acting oral anticoagulants: analysis of data from national pharmacovigilance and local incidents reporting databases

Background

For more than a decade, direct oral anticoagulants (DOACs) have been approved in clinical practice for multiple indications such as stroke prevention in non-valvular atrial fibrillation treatment of deep vein thrombosis and pulmonary embolism. This study aimed to explore the nature and contributory factors related to medication errors associated with DOACs in hospital settings.

Methods

Analysis of error reports using data from (a) Saudi Food and Drug Authority pharmacovigilance database and (b) local incidents reporting system from two tertiary care hospitals were included. Errors reported between January 2010 to December 2020 were also included. Statistical analyses were performed using IBM (SPSS) Statistics Version 24.0 software.

Results

A total of 199 medication error incidents were included. The mean (range) age of affected patients was 63.5 (19–96) years. The mean reported duration of treatment when incidents happened was 90 days, with a very wide range from one day to 12 months. Prescribing error was the most common error type representing 81.4% of all errors. Apixaban was the most frequent drug associated with error reporting with 134 (67.3%) incidents, followed by rivaroxaban (18.6%) and dabigatran (14.1%). The majority of the patients (n = 188, 94.5%) showed comorbidities in addition to the conditions related to DOACs. Polypharmacy, an indication of treatment and duration of therapy were amongst the important contributory factors associated with errors.

Conclusions

This observational study demonstrates the nature of DOAC related medication errors in clinical practice. Developing risk prevention and reduction strategies using the expertise of clinical pharmacists are imperative in promoting patient safety associated with DOAC use.

Use of NOACS in high-risk patients with atrial fibrillation in Saudi Arabia: Perspectives on improving patient care

BACKGROUND

Despite the widespread and increasing use of NOACs in Saudi Arabia, there is a lack of contemporary guidance specific to the region. In particular, guidance on NOAC use in high-risk patients who are more likely to experience bleeding with oral anticoagulant therapy is needed. There is an unmet need for a review of contemporary evidence coupled with expert insights on safe and effective NOAC use in high-risk patients with AF in Saudi Arabia.

RESEARCH DESIGN AND METHODS

This article provides a detailed review of contemporary literature on NOAC use in high-risk patients with AF. Additionally, key gaps in the literature are identified and expert insights are shared to guide effective management of patients and the significance of local data is evaluated with respect to challenges in optimizing the use of NOACs.

CONCLUSIONS

This article provides information that complements and expands on existing reviews and guidelines on NOAC use in patients with AF, with a focus on challenges specific to the Saudi Arabian context with the potential to make a positive contribution to the medical community in Saudi Arabia and in other nations.

The atrial FibriLlatiOn real World management registry in the Middle East and Africa: design and rationale

BACKGROUND

Atrial fibrillation is the most common cardiac arrhythmia, affecting 33.5 million patients globally. It is associated with increased morbidity, leading to significant clinical and economic burden. There exist only limited data in the Middle Eastern region from the existing registries. The goal of the FLOW-AF (atrial FibriLlatiOn real World management registry in the Middle East and Africa) registry is to evaluate the characteristics, treatment patterns, and clinical and economic outcomes associated with anticoagulation among patients newly diagnosed with nonvalvular atrial fibrillation in Egypt, Lebanon, the Kingdom of Saudi Arabia, and the United Arab Emirates.

METHODS

This study will be a multicountry, multicenter, prospective observational registry aiming to enroll 1446 newly diagnosed nonvalvular atrial fibrillation patients at more than 20 sites across the four countries. During the recruitment period, patients will be included if they were newly diagnosed with nonvalvular atrial fibrillation and had initiated treatment for the prevention of stroke/systemic embolism. Patient data will be assessed prospectively at 6 and 12 months from their enrollment date. Demographics, clinical characteristics, antithrombotic treatments received, clinical outcomes, adverse events, healthcare resource utilization, and direct costs associated with management of nonvalvular atrial fibrillation will be collected and analyzed overall, by country, and by groups created based on treatment, demographics, and clinical characteristics, medical history and risk factors.

CONCLUSION

The FLOW-AF registry will provide information on the uptake of oral anticoagulants, treatment patterns, clinical outcomes, and healthcare utilization and costs among newly diagnosed nonvalvular atrial fibrillation patients in the Middle Eastern region.

Timing to start anticoagulants after acute ischemic stroke with non-valvular atrial fibrillation

OBJECTIVE

To identify timing for initiation of anticoagulation therapy in acute ischemic stroke (AIS) with non-valvular AF as regards safety and efficacy by detecting the rate of intracranial haemorrhage (ICH) and recurrent ischemic symptoms (RIS) during follow-up.

METHODS

This is a prospective observational cohort study conducted at King Fahd Hospital of the University including 120 patients with AIS/TIAs from July 2016 till July 2018. We compared patients who received anticoagulants 1-6 days (Group I (45.83%), 7-14 days, Group II (35%), and > 14 days after the ischemic event (Group III (19.17%). Follow-up was at least 3 months and included identifying ICH or RIS.

RESULT

ICH has occurred in 26.67% (n = 32) patients with a highly statistically significant association with time of treatment (P-value = .01) being higher in group I (n = 17) compared to only 1 case in group III. Subgroup analyses on the ICH patients (n = 32) has revealed statistical significant association with higher NIHSS score (P = .001). Also, the type of anticoagulants used between three groups pointed to an association existence (p = .02), however, the direction of this association cannot be determined. There was no statistical significant association between RIS (occurred in 4.16% (n = 5) with time of treatment (P = .754). Functional outcome at 3-6 months measured by mRS did not differ between 3 groups (worst mRS in group I).

CONCLUSION

Early initiation of anticoagulation after stroke, especially in cases of large infarction, is associated with significant risk of ICH. This risk is highest with warfarin and lowest with DOAC.

Profiling Clinical Characteristics and Treatment Patterns Among Non-Valvular Atrial Fibrillation Patients: A Real-World Analysis in Dubai, United Arab Emirates

Background:

There is a dearth of real-world evidence regarding patient characteristics, Oral Anti-Coagulant (OAC) treatment, and International Normalized Ratio (INR) patterns in Dubai, United Arab Emirates (UAE).

Methods:

This was a retrospective observational study among newly diagnosed adult Non-valvular Atrial Fibrillation (NVAF) patients in the Dubai Real World Claims Database. Selected patients had at least one activity claim during the 12 months pre-index date (baseline period), and a pharmacy claim for apixaban, dabigatran, rivaroxaban, or warfarin from 01 JAN 2015-31 JUL 2017. Patients with valvular heart disease, cardiac surgery, venous thromboembolism, transient atrial fibrillation, pregnancy, or OAC claims during baseline were excluded. Comorbidities and treatment patterns related to OAC use, index dosing, baseline medications, and INR patterns were described.

Results:

Among 5,072 NVAF patients, 468 met the study criteria. A minority of them (14.3%) were prescribed warfarin, and the most frequently prescribed non-vitamin K antagonist OACs (NOACs) were rivaroxaban (33.3%) and apixaban (31.4%), followed by dabigatran (20.9%). Patients’ mean age was 59 years and mean CHA2DS2-VASc score was 2.3, with most frequent comorbidities of diabetes mellitus, hypertension, coronary artery disease, and peripheral vascular disease. Additionally, 51% and 33% were on statins and aspirin, respectively, while 39% were on other anticoagulant agents. A large proportion of dabigatran patients were on a lower dose (57%). INR patterns revealed 13% of rivaroxaban, 12% of apixaban, and 7% of dabigatran patients had INR claims.

Conclusion:

This study provides relevant insights into the use of OACs in real-world clinical practice settings in Dubai, UAE.

Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation

BACKGROUND

About 13-26% of all acute ischaemic strokes are related to non-valvular atrial fibrillation, the most common cardiac arrhythmia globally. Deciding when to initiate oral anticoagulation in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. Although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct. This assumption, and current treatment guidelines, are based on historical, mostly observational data from patients with ischaemic stroke and atrial fibrillation treated with heparins, heparinoids, or vitamin K antagonists (VKAs) to prevent recurrent ischaemic stroke. Randomised controlled trials have subsequently shown that direct oral anticoagulants (DOACs; ie, apixaban, dabigatran, edoxaban, and rivaroxaban) are at least as effective as VKAs in primary and secondary prevention of atrial fibrillation-related ischaemic stroke, with around half the risk of intracranial haemorrhage. However, none of these DOAC trials included patients who had experienced ischaemic stroke recently (within the first few weeks). Clinicians therefore remain uncertain regarding when to commence DOAC administration after acute ischaemic stroke in patients with atrial fibrillation.

RECENT DEVELOPMENTS

Prospective observational studies and two small randomised trials have investigated the risks and benefits of early DOAC-administration initiation (most with a median delay of 3-5 days) in mild-to-moderate atrial fibrillation-associated ischaemic stroke. These studies reported that early DOAC treatment was associated with a low frequency of clinically symptomatic intracranial haemorrhage or surrogate haemorrhagic lesions on MRI scans, whereas later DOAC-administration initiation (ie, >7 days or >14 days after index stroke) was associated with an increased frequency of recurrent ischaemic stroke. WHERE NEXT?: Adequately powered randomised controlled trials comparing early to later oral anticoagulation with DOACs in ischaemic stroke associated with atrial fibrillation are justified to confirm the acceptable safety and efficacy of this strategy. Four such randomised controlled trials (collectively planned to include around 9000 participants) are underway, either using single cutoff timepoints for early versus late DOAC-administration initiation, or selecting DOAC-administration timing according to the severity and imaging features of the ischaemic stroke. The results of these trials should help to establish the optimal timing to initiate DOAC administration after recent ischaemic stroke and whether the timing should differ according to stroke severity. Results of these trials are expected from 2021.