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Anand SS, Aboyans V, Bosch J, Debus S, Gay A, Patel MR, Vogtländer K, Welsh RC, Zeymer U, Fox KAA. Identifying the highest risk vascular patients: Insights from the XATOA registry. Am Heart J 2024; 269:191-200. [PMID: 38218425 DOI: 10.1016/j.ahj.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Patients with coronary and peripheral artery disease (PAD) have a residual risk of major adverse cardiovascular and limb events despite standards of care. Among patients with coronary artery disease (CAD) and/or PAD selected for low dose rivaroxaban (2.5 mg BID) and aspirin, we sought to determine the highest risk vascular patients. METHODS Xarelto pluc Acetylsalicylic acid: Treatment patterns and Outcomes in patients with Atherosclerosis (XATOA) is a single-arm registry of CAD and/or PAD patients. All participants were initiated on low dose rivaroxaban (2.5 mg BID) and aspirin. We report the incidence risk of major adverse cardiovascular events (MACE) or major adverse limb events (MALE) and major bleeding. A classification and regression tree analysis determined independent subgroups. RESULTS Between November 2018 and May 2020, 5,808 participants were enrolled in XATOA; 5,532 were included in the full analysis. The median follow-up (interquartile range) was 462 (371-577) days. The incidence risk per 100 patient-years of MACE or MALE was highest among participants with polyvascular disease (2 or more vascular beds affected, n = 2,889). The incidence risk was 9.16 versus 2.48 per 100 patient-years in polyvascular and nonpolyvascular patients respectively. Other subgroups of high-risk patients included participants 75 years or older, with a history of diabetes, heart failure, or chronic renal insufficiency (CRI). Rates of major bleeding were low overall. A classification and regression tree analysis showed that polyvascular disease was the most dominant factor separating higher from lower risk participants, and this was heightened with CRI or diabetes. CONCLUSION Patients with polyvascular disease represent a substantial subset of patients in clinical practice and should be prioritized to receive maximal medical therapy including low dose rivaroxaban (2.5 mg BID) and aspirin.
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Affiliation(s)
- Sonia S Anand
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and Inserm 1094/IRD270, Limoges University, Limoges, France
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Robert C Welsh
- Mazankowski Alberta Heart Insitute and University of Alberta, Edmonton, Alberta, Canada
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh United Kingdom
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Thomas R, Benken J, Belcher RM, Palmer ME, Benedetti E, Benken ST. Catecholamine Vasopressor Exposure Is Associated With Early Poor Allograft Function and Adverse Events in Living Donor Kidney Transplant Recipients. Transplant Proc 2023; 55:1543-1550. [PMID: 37414695 DOI: 10.1016/j.transproceed.2023.03.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/26/2023] [Accepted: 03/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Hypoperfusion leads to allograft injury during kidney transplantation. Catecholamine vasopressors are used to maintain blood pressure in the perioperative period but have demonstrated negative outcomes in the deceased-donor kidney transplant population. Little is known regarding living donor kidney transplants (LDKTs) and vasopressor use. The aim of this study is to describe the incidence of vasopressor use in LDKT and characterize its effects on allograft function and patient outcomes. METHODS This retrospective, observational cohort study included adult patients who underwent an isolated LDKT between August 1, 2017, and September 1, 2018. Patients were divided into those who received perioperative vasopressors and those who did not. The primary objective was to compare allograft function between LDKT recipients that received vasopressors and those who did not. Secondary outcomes included safety endpoints and the identification of clinical variables associated with vasopressor use. RESULTS A total of 67 patients received an LDKT during the study period. Of those, 25 (37%) received perioperative vasopressors, and 42 (62%) did not. Poor graft function, as defined by the development of slow or delayed graft function, occurred more frequently in patients receiving perioperative vasopressors compared with those who did not (6 [24%] vs 1 [2.4%], P = .016). In multivariable regression modeling, only perioperative vasopressors were statistically significantly associated with poor graft function. In addition, patients exposed to vasopressors experienced more postoperative arrhythmias (8 [32%] vs 1 [4.8%], P = .0025). CONCLUSION Using perioperative vasopressors was independently associated with worsened early renal allograft function, including delayed graft function and adverse events in the LDKT population.
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Affiliation(s)
- Riya Thomas
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Jamie Benken
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois; Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Rachel M Belcher
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Mary E Palmer
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Enrico Benedetti
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Scott T Benken
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois; Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois.
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Li X, Gu Z, Wang Z, Xu Q, Ma C, Lv Q. Mutant CYP3A4/5 Correlated with Clinical Outcomes by Affecting Rivaroxaban Pharmacokinetics and Pharmacodynamics in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07495-4. [PMID: 37542618 DOI: 10.1007/s10557-023-07495-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE This study was designed to investigate the impact of single-nucleotide polymorphism-encoded cytochrome P450 enzymes (CYP3A4/5) on clinical outcomes of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) based on pharmacokinetics and pharmacodynamics (PK/PD) aspects. METHOD A prospective study enrolling 165 rivaroxaban-treated patients with NVAF was conducted. Genotyping of CYP3A4 (rs2242480, rs2246709, rs3735451, and rs4646440) and CYP3A5 (rs776746) was performed to explore their impact on the trough plasma concentrations (Ctrough) of rivaroxaban, coagulation indicators at the Ctrough including activated partial thromboplastin time (APTT) and prothrombin time (PT), and clinical outcomes. RESULTS Patients with mutant genotype CYP3A4 (rs2242480, rs2246709, and rs3735451) and CYP3A5 (rs776746) had higher levels of rivaroxaban Ctrough, PT values than that of wild-type. Furthermore, a positive relationship was revealed between Ctrough and PT (r = 0.212, p = 0.007), while no significant correlation was found between Ctrough and APTT. Regarding the clinical outcomes, the minor allele carriers on rs3735451 and the minor allele (A) carriers on rs2246709 were associated with higher incidence of minor bleeding (p = 0.028 and p = 0.038, respectively) and were identified as the independent risk factors of minor bleeding treated with rivaroxaban (p = 0.024 and p = 0.036, respectively), with the receiver operating characteristic (ROC) curve validated (AUC = 0.8956, 95% CI: 0.829-0.962). CONCLUSION The CYP3A4 polymorphisms (rs2242480, rs2246709, and rs3735451) and CYP3A5 rs776746 were associated with variations in rivaroxaban PK/PD. The minor allele (C) carriers on rs3735451 and the minor allele (A) carriers on rs2246709 were correlated with clinical outcomes.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhichun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing Xu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunlai Ma
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China.
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China.
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Bielecka B, Gorczyca-Głowacka I, Ciba-Stemplewska A, Wożakowska-Kapłon B. Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6145. [PMID: 37372735 PMCID: PMC10298142 DOI: 10.3390/ijerph20126145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be 'tailored' in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004-2011 and beyond (years 2012-2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients' sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004-2011 and 2012-2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012-2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.
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Affiliation(s)
- Bernadetta Bielecka
- 1st Clinic of Cardiology and Electrotherapy, Świętokrzyskie Cardiology Centre, 25-736 Kielce, Poland; (B.B.); (B.W.-K.)
| | | | - Agnieszka Ciba-Stemplewska
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland;
- Clinic of Internal Medicine, 25-736 Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Świętokrzyskie Cardiology Centre, 25-736 Kielce, Poland; (B.B.); (B.W.-K.)
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland;
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Rusin G, Kubica J, Malinowski KP, Słowik A, Undas A. Factors affecting self-reported bleeding acceptance in acute ischemic stroke survivors on various types of antithrombotic therapy. J Stroke Cerebrovasc Dis 2023; 32:106894. [PMID: 36402092 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106894] [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: 08/04/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Prior ischemic cerebrovascular event and younger age have been shown to increase bleeding acceptance among anticoagulated outpatients with atrial fibrillation (AF). We sought to determine factors affecting bleeding acceptance in acute ischemic stroke (AIS) survivors on various types of antithrombotic therapy. MATERIALS AND METHODS We enrolled 173 consecutive patients hospitalized for AIS (aged 68.2±11.7 years, 54.9% male), including 54 (31.2%) with AF, who had favorable functional outcome. On discharge, the Bleeding ratio, defined as the declared maximum number of major bleedings that a patient is willing to accept to prevent one major stroke, was evaluated. We assessed the predicted bleeding risk in non-cardioembolic and cardioembolic stroke survivors using S2TOP-BLEED and HAS-BLED scores, respectively. RESULTS Patients with the low Bleeding ratio, defined as 5 (median) or less accepted bleeds (n=92; 53.2%), were older and more likely to receive thrombolysis and/or thrombectomy, with no impact of previous stroke. Prior major bleed (odds ratio [OR] 4.67; 95% confidence interval [CI] 0.92-23.72), AF with use of oral anticoagulants (OR 2.35, 95% CI 1.12-4.93), reperfusion treatment (OR 1.95, 95% CI 1.02-3.76), and hospitalization ≤10 days (OR 4.56; 95% CI 1.50-13.87) were associated with the low Bleeding Ratio. Prior use of anticoagulants or aspirin as well as HAS-BLED and S2TOP-BLEED scores did not affect the bleeding acceptance. CONCLUSIONS Lower bleeding acceptance declared on discharge by AIS survivors is determined by prior bleeding, anticoagulation in AF, reperfusion treatment, and duration of hospitalization, which might affect medication adherence. The results might help optimize post-discharge management and educational efforts in patients on antithrombotic therapy.
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Affiliation(s)
- Gabriela Rusin
- Department of Neurology, University Hospital, Krakow, Poland
| | - Jadwiga Kubica
- Department of Neurology, University Hospital, Krakow, Poland; Institute of Physiotherapy, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Piotr Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Słowik
- Department of Neurology, University Hospital, Krakow, Poland; Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland; Center for Research and Innovative Technology John Paul II Hospital, Kraków, Poland.
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Yan X, Wang B, Xia P, Lan C, Wang Q, Ge W, Zhou Y, Jiang C. Efficacy and Safety of Anticoagulant Therapy Versus Antiplatelet Therapy in Acute Ischemic Stroke Patients with Atrial Fibrillation. Clin Appl Thromb Hemost 2023; 29:10760296231213070. [PMID: 37956462 PMCID: PMC10644758 DOI: 10.1177/10760296231213070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The efficacy and safety of anticoagulant therapy in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF) remain uncertain. This study enrolled 431 AIS and AF patients from Nanjing Drum Tower Hospital between January 2019 and December 2021 and followed for 365 days to determine the associations between anticoagulants and clinical outcomes by assessing modified Rankin Scale (mRS) score, recurrent ischemic stroke/systemic embolism (IS/SE), all-cause mortality, intracranial hemorrhage (ICH) and major bleeding. Final analysis included 400 eligible patients and divided them into antiplatelet group (n = 191) and anticoagulant group (n = 209). Anticoagulant therapy was associated with excellent (mRS 0-1; adjusted odds ratio (aOR), 2.63; 95% confidence interval (CI), 1.61-4.30) and favorable functional outcomes (mRS 0-2; aOR, 2.82; 95% CI, 1.69-4.70) and lower risk of all-cause mortality (adjusted hazard ratio (aHR), 0.35; 95% CI, 0.21-0.57), ICH (aHR, 0.45; 95% CI, 0.23-0.87) and major bleeding (aHR, 0.51; 95% CI, 0.28-0.94), without increasing the risk of recurrent IS/SE (aHR, 0.75; 95% CI, 0.45-1.24). In conclusion, anticoagulant therapy may be a more effective and safer option than antiplatelet therapy for AIS patients with AF.
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Affiliation(s)
- Xiaodi Yan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Baoyan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Peng Xia
- Department of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chen Lan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Qian Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yujie Zhou
- Department of Respiratory Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Chenxiao Jiang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
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Yamashita T, Suzuki S, Inoue H, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A. Two-year outcomes of more than 30 000 elderly patients with atrial fibrillation: results from the All Nippon AF In the Elderly (ANAFIE) Registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:202-213. [PMID: 33822030 PMCID: PMC8888123 DOI: 10.1093/ehjqcco/qcab025] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/23/2021] [Accepted: 04/01/2021] [Indexed: 12/14/2022]
Abstract
AIMS To clarify the real-world clinical status and prognosis of elderly and very elderly non-valvular atrial fibrillation (NVAF) patients, more than 30 000 elderly patients with NVAF aged ≥75 years were enrolled in the ANAFIE Registry. METHODS AND RESULTS This multicentre, prospective, observational study followed elderly NVAF patients in Japan for ∼2 years. Among 32 275 patients (mean age, 81.5 years; men, 57.3%; mean CHA2DS2-VASc score, 4.5), 2445 (7.6%) were not receiving oral anticoagulants (OACs) and 29 830 (92.4%) were given OACs. Of these, 21 585 (66.9%) were receiving direct OACs (DOACs) and 8233 (25.5%), warfarin (mean time in therapeutic range: ∼75%). In total, the 2-year incidence rate was 3.01% for stroke/systemic embolic events (SEE); 2.00%, major bleeding; and 6.95%, all-cause death. When compared with the warfarin group, the DOAC group had a lower hazard ratio (HR) for stroke/SEE, major bleeding, and all-cause death after adjusting for confounders. The group without OACs had a higher HR for stroke/SEE and all-cause death, with a lower HR for major bleeding. History of falls within 1 year at enrolment and of catheter ablation were positive and negative independent risk factors, respectively, for stroke/SEE, major bleeding, and all-cause death. CONCLUSION In Japan, a large proportion of elderly and very elderly NVAF patients were receiving DOACs, which was significantly associated with lower rates of stroke/SEE, major bleeding, and all-cause death vs. well-controlled warfarin. History of falls and of catheter ablation were independently associated with stroke/SEE, major bleeding, and all-cause death.
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Affiliation(s)
- Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishi-azabu, Minato-ku, Tokyo 106-0031, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishi-azabu, Minato-ku, Tokyo 106-0031, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, 33-1 Kusunoki, Toyama 931-8442, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1 Fukakusa Mukaihatacho, Kyoto 612-8555, Japan
| | - Hirotsugu Atarashi
- Minami Hachioji Hospital, 4-21-4 Myojincho, Hachioji, Tokyo 192-0046, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 5-21-16 Omorinishi, Ota-ku, Tokyo 143-8540, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami, Minami-ku, Kumamoto 861-4193, Japan
| | - Yukihiro Koretsune
- Institute for Clinical Research, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan
| | - Atsushi Hirayama
- Osaka Police Hospital, 10-31 Kitayamacho, Tennoji-ku, Osaka 543-0035, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810-8563, Japan
| | - Takenori Yamaguchi
- National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Tetsuya Kimura
- Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8426, Japan
| | - Jumpei Kaburagi
- ASCA Company, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8426, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8426, Japan
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Aminian A, De Backer O, Nielsen-Kudsk JE, Lam S, Freixa X, Gage R, Diener HC, Schmidt B, Lam SCC, Freixa X, Gage R, Diener HC, Schmidt B. Incidence and clinical impact of major bleeding following left atrial appendage occlusion: insights from the Amplatzer Amulet Observational Post-Market Study. EUROINTERVENTION 2021; 17:774-782. [PMID: 33495144 PMCID: PMC9724974 DOI: 10.4244/eij-d-20-01309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Major bleeding (MB) events are independent predictors of mortality after cardiac interventional procedures. The clinical relevance of MB following left atrial appendage occlusion (LAAO) remains unclear. AIMS This study aimed to investigate the incidence and clinical impact of MB after LAAO in a real-world population at high risk for bleeding and contraindicated to anticoagulation. METHODS The two-year results of the Amplatzer Amulet Observational Post-Market Study were analysed. An independent committee adjudicated MBs according to the Bleeding Academic Research Consortium scale. Cox proportional hazards regression identified variables associated with MB events and mortality. RESULTS The MB rate was 7.2%/year, with a rate of 10.1%/year during year one, decreasing to 4.0%/year over year two. The most common bleeding location was gastrointestinal, accounting for 48% of MBs. Pre-LAAO MB was associated with an increased risk for post-LAAO MB (HR 2.34, 95% CI: 1.37-3.99). The occurrence of post-LAAO MB was associated with increased mortality (37.3% vs 12.7%; p<0.0001), driven mainly by events occurring beyond the periprocedural period. The annualised rate of ischaemic stroke or TIA was similar in patients with and without MB (2.3% vs 3.3%; p=0.446). MB post LAAO was a strong independent predictor of mortality (HR 3.07, 95% CI: 2.15-4.40). CONCLUSIONS In real-world patients at high bleeding risk, MB following LAAO was not uncommon and associated with a significant increase in mortality, without increasing the risk of stroke. ClinicalTrials.gov Identifier: NCT02447081. https://clinicaltrials.gov/ct2/show/NCT02447081.
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Affiliation(s)
- Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Chaussée de Bruxelles 140, 6042 Charleroi, Belgium
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Simon Lam
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | | | - Ryan Gage
- Structural Heart Clinical Affairs, Abbott, St. Paul, MN, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Medizinische Klinik 3 – Kardiologie, Frankfurt, Germany
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Kozieł M, Simovic S, Pavlovic N, Nedeljkovic M, Kocijancic A, Paparisto V, Music L, Trendafilova E, Dan AR, Manola S, Kusljugic Z, Dan G, Lip GYH, Potpara TS. Treatment implications of renal disease in patients with atrial fibrillation: The BALKAN-AF survey. J Arrhythm 2020; 36:863-873. [PMID: 33024464 PMCID: PMC7532276 DOI: 10.1002/joa3.12404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/10/2020] [Accepted: 06/24/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) often co-exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF. METHODS In this post hoc analysis of the BALKAN-AF survey, patients were classified according to RF (Cockcroft-Gault formula) as: preserved/mildly depressed RF (P-RF) ≥50 mL/min, moderately depressed RF (MD-RF) 30-49 mL/min, and severely depressed RF (SD-RF) <30 mL/min. RESULTS Of 2712 enrolled patients, 2062 (76.0%) had data on RF. Patients with SD-RF and MD-RF were older, had higher mean value of European Heart Rhythm Association score, stroke and bleeding risk scores, and more comorbidities than patients with P-RF (all P < .05). They received oral anticoagulants (OAC), AF catheter ablation, and electrical cardioversion less often than those with P-RF (all P < .05). Rate control, no OAC, single-antiplatelet therapy (SAPT) alone, and loop diuretics were more prevalent in patients with SD-RF and MD-RF than in subjects with P-RF (all P < .005). An important change in NOAC therapy could appear in <1% of patients (Modification of Diet in Renal Disease formula) and in <1% of patients (Chronic Kidney Disease Epidemiology Collaboration group formula). CONCLUSIONS Patients with SD-RF and MD-RF were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with P-RF. They were less likely to receive OAC and more likely to use rate control strategy, SAPT alone, and no OAC than subjects with P-RF.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- 1st Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
| | - Stefan Simovic
- Cardiology ClinicUniversity Clinical Center of KragujevacKragujevacSerbia
| | | | - Milan Nedeljkovic
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
| | | | - Vilma Paparisto
- Clinic of CardiologyUniversity Hospital Center Mother TheresaTiranaAlbania
| | - Ljilja Music
- Cardiology ClinicUniversity Clinical Center of MontenegroUniversity of PodgoricaMedical FacultyPodgoricaMontenegro
| | | | - Anca Rodica Dan
- Cardiology DepartmentColentina University HospitalBucharestRomania
| | - Sime Manola
- Clinical Center Sestre MilosrdniceZagrebCroatia
| | - Zumreta Kusljugic
- Cardiology DepartmentClinic of Internal MedicineMedical FacultyUniversity Clinical Center TuzlaTuzlaBosnia and Herzegovina
| | - Gheorghe‐Andrei Dan
- Medicine University "Carol Davila"Colentina University HospitalBucharestRomania
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- 1st Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
- School of MedicineBelgrade UniversityBelgradeSerbia
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Tatjana S. Potpara
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
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10
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Rusin G, Konieczyńska M, Bijak P, Desteghe L, Heidbuchel H, Malinowski KP, Undas A. Bleeding Tolerance Among Patients With Atrial Fibrillation on Oral Anticoagulation. Can J Cardiol 2020; 36:500-508. [DOI: 10.1016/j.cjca.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022] Open
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11
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Masarova L, Novak J, Pesl M, Ondrasek J, Semenka J, Simarova E, Panovsky R. Reccurent thrombus in the gigantic left atrium during effective anticoagulant therapy: case report. BMC Cardiovasc Disord 2020; 20:86. [PMID: 32085730 PMCID: PMC7035782 DOI: 10.1186/s12872-019-01279-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 11/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gigantic left atrium is defined in the current literature as an excessive dilatation of the left atrium above 65mm. Chronic mitral valve disease is associated with the development of thrombus in the left atrium in up to 19% of all cases of mitral insufficiency and appropriate treatment must be initiated to prevent thromboembolic events. In order to diagnose thrombi in the left atrium or left atrial appendage, various imaging methods may be used, including cardiac magnetic resonance. CASE PRESENTATION The case report describes a 73-year-old male who developed recurrent sessile thrombus on the posterior wall of the gigantic left atrium. A large thrombus was first detected following mitral valve surgery despite effective vitamin K antagonist anticoagulation therapy. Echocardiography and cardiac magnetic resonance were used within the diagnostic procedure and to monitor the treatment outcomes. Cardiac magnetic resonance was shown to be beneficial as it provided a more precise description of the intra-atrial masses located on the posterior left atrial wall, and in such situations, is of greater benefit than standard echocardiography. This led to the surgical removal of the intra-atrial mass; nevertheless, it was quickly followed by the recurrence of the thrombus. The anticoagulant therapy was adjusted and fortified by the introduction of acetylsalicylic acid and sequentially clopidogrel, but this also did not resolve the thrombus formation. Finally, employing a combination of rivaroxaban and clopidogrel resulted in partial thrombus regression. Therefore, various pathophysiological aspects of thrombus formation and used anticoagulation strategies are discussed. CONCLUSIONS We describe a unique case of a recurrent thrombus located on the posterior wall of the gigantic left atrium. Cardiac magnetic resonance was shown to be beneficial in providing a more precise description of the intra-atrial masses located on the posterior left atrial wall as compared to standard echocardiographic examination. Development of a thrombus after mitral valve surgery despite effective anticoagulant therapy and its final resolution by introducing a combination of rivaroxaban and clopidogrel highlights the complex etiopathogenesis of thrombus formation. This supports the potential use of this combination in tailoring an individual personalized therapy for patients with recurrent atrial thrombi.
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Affiliation(s)
- Lucia Masarova
- First Department of Cardioangiology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center (ICRC), St. Anne's University Hospital, Brno, Czech Republic
| | - Jan Novak
- Second Department of Internal Medicine, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic. .,Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Martin Pesl
- First Department of Cardioangiology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center (ICRC), St. Anne's University Hospital, Brno, Czech Republic.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiri Ondrasek
- Center for Cardiovascular Surgery and Organ Transplantation, Brno, Czech Republic
| | - Jiri Semenka
- First Department of Cardioangiology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center (ICRC), St. Anne's University Hospital, Brno, Czech Republic
| | - Eva Simarova
- Department of Radiology, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Roman Panovsky
- First Department of Cardioangiology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center (ICRC), St. Anne's University Hospital, Brno, Czech Republic
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12
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Zhang H, Zhang J, Li HB, Chen YX, Yang B, Guo YT, Chen YD. Validation of Single Centre Pre-Mobile Atrial Fibrillation Apps for Continuous Monitoring of Atrial Fibrillation in a Real-World Setting: Pilot Cohort Study. J Med Internet Res 2019; 21:e14909. [PMID: 31793887 PMCID: PMC6918204 DOI: 10.2196/14909] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/20/2019] [Accepted: 10/19/2019] [Indexed: 12/17/2022] Open
Abstract
Background Atrial fibrillation is the most common recurrent arrhythmia in clinical practice, with most clinical events occurring outside the hospital. Low detection and nonadherence to guidelines are the primary obstacles to atrial fibrillation management. Photoplethysmography is a novel technology developed for atrial fibrillation screening. However, there has been limited validation of photoplethysmography-based smart devices for the detection of atrial fibrillation and its underlying clinical factors impacting detection. Objective This study aimed to explore the feasibility of photoplethysmography-based smart devices for the detection of atrial fibrillation in real-world settings. Methods Subjects aged ≥18 years (n=361) were recruited from September 14 to October 16, 2018, for screening of atrial fibrillation with active measurement, initiated by the users, using photoplethysmography-based smart wearable devices (ie, a smart band or smart watches). Of these, 200 subjects were also automatically and periodically monitored for 14 days with a smart band. The baseline diagnosis of “suspected” atrial fibrillation was confirmed by electrocardiogram and physical examination. The sensitivity and accuracy of photoplethysmography-based smart devices for monitoring atrial fibrillation were evaluated. Results A total of 2353 active measurement signals and 23,864 periodic measurement signals were recorded. Eleven subjects were confirmed to have persistent atrial fibrillation, and 20 were confirmed to have paroxysmal atrial fibrillation. Smart devices demonstrated >91% predictive ability for atrial fibrillation. The sensitivity and specificity of devices in detecting atrial fibrillation among active recording of the 361 subjects were 100% and about 99%, respectively. For subjects with persistent atrial fibrillation, 127 (97.0%) active measurements and 2240 (99.2%) periodic measurements were identified as atrial fibrillation by the algorithm. For subjects with paroxysmal atrial fibrillation, 36 (17%) active measurements and 717 (19.8%) periodic measurements were identified as atrial fibrillation by the algorithm. All persistent atrial fibrillation cases could be detected as “atrial fibrillation episodes” by the photoplethysmography algorithm on the first monitoring day, while 14 (70%) patients with paroxysmal atrial fibrillation demonstrated “atrial fibrillation episodes” within the first 6 days. The average time to detect paroxysmal atrial fibrillation was 2 days (interquartile range: 1.25-5.75) by active measurement and 1 day (interquartile range: 1.00-2.00) by periodic measurement (P=.10). The first detection time of atrial fibrillation burden of <50% per 24 hours was 4 days by active measurement and 2 days by periodic measurementThe first detection time of atrial fibrillation burden of >50% per 24 hours was 1 day for both active and periodic measurements (active measurement: P=.02, periodic measurement: P=.03). Conclusions Photoplethysmography-based smart devices demonstrated good atrial fibrillation predictive ability in both active and periodic measurements. However, atrial fibrillation type could impact detection, resulting in increased monitoring time. Trial Registration Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191.
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Affiliation(s)
- Hui Zhang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jie Zhang
- Huawei Device Co, Ltd, Shenzhen, China
| | | | | | - Bin Yang
- Huawei Device Co, Ltd, Shenzhen, China
| | - Yu-Tao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yun-Dai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
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13
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Fan YY, Li YG, Li J, Cheng WK, Shan ZL, Wang YT, Guo YT. Diagnostic Performance of a Smart Device With Photoplethysmography Technology for Atrial Fibrillation Detection: Pilot Study (Pre-mAFA II Registry). JMIR Mhealth Uhealth 2019; 7:e11437. [PMID: 30835243 PMCID: PMC6423467 DOI: 10.2196/11437] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/12/2018] [Accepted: 02/17/2019] [Indexed: 01/16/2023] Open
Abstract
Background Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The asymptomatic nature and paroxysmal frequency of AF lead to suboptimal early detection. A novel technology, photoplethysmography (PPG), has been developed for AF screening. However, there has been limited validation of mobile phone and smart band apps with PPG compared to 12-lead electrocardiograms (ECG). Objective We investigated the feasibility and accuracy of a mobile phone and smart band for AF detection using pulse data measured by PPG. Methods A total of 112 consecutive inpatients were recruited from the Chinese PLA General Hospital from March 15 to April 1, 2018. Participants were simultaneously tested with mobile phones (HUAWEI Mate 9, HUAWEI Honor 7X), smart bands (HUAWEI Band 2), and 12-lead ECG for 3 minutes. Results In all, 108 patients (56 with normal sinus rhythm, 52 with persistent AF) were enrolled in the final analysis after excluding four patients with unclear cardiac rhythms. The corresponding sensitivity and specificity of the smart band PPG were 95.36% (95% CI 92.00%-97.40%) and 99.70% (95% CI 98.08%-99.98%), respectively. The positive predictive value of the smart band PPG was 99.63% (95% CI 97.61%-99.98%), the negative predictive value was 96.24% (95% CI 93.50%-97.90%), and the accuracy was 97.72% (95% CI 96.11%-98.70%). Moreover, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of mobile phones with PPG for AF detection were over 94%. There was no significant difference after further statistical analysis of the results from the different smart devices compared with the gold-standard ECG (P>.99). Conclusions The algorithm based on mobile phones and smart bands with PPG demonstrated good performance in detecting AF and may represent a convenient tool for AF detection in at-risk individuals, allowing widespread screening of AF in the population. Trial Registration Chinese Clinical Trial Registry ChiCTR-OOC-17014138; http://www.chictr.org.cn/showproj.aspx?proj=24191 (Archived by WebCite at http://www.webcitation/76WXknvE6)
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Affiliation(s)
- Yong-Yan Fan
- College of Medicine, Nankai University, Tianjin, China.,Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yan-Guang Li
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jian Li
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Wen-Kun Cheng
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhao-Liang Shan
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yu-Tang Wang
- College of Medicine, Nankai University, Tianjin, China.,Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yu-Tao Guo
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
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14
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Lynch KT, Mehaffey JH, Hawkins RB, Hassinger TE, Hallowell PT, Kirby JL. Bariatric surgery reduces incidence of atrial fibrillation: a propensity score–matched analysis. Surg Obes Relat Dis 2019; 15:279-285. [DOI: 10.1016/j.soard.2018.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/02/2018] [Accepted: 11/20/2018] [Indexed: 01/06/2023]
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15
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Lip GYH. The safety of NOACs in atrial fibrillation patient subgroups: A narrative review. Int J Clin Pract 2019; 73:e13285. [PMID: 30334313 DOI: 10.1111/ijcp.13285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/01/2018] [Accepted: 10/14/2018] [Indexed: 12/17/2022] Open
Abstract
AIM Four non-vitamin K oral anticoagulants (NOACs) have been evaluated in clinical trials for the prevention of stroke in patients with atrial fibrillation (AF). Although each of the NOACs have been shown to be at least non-inferior to warfarin for efficacy and safety outcomes, controversy remains over the relative safety of each NOAC inpatient subgroups. This narrative review provides an overview of phase III data on NOAC trials for the prevention of stroke in AF, with a focus on reporting the safety of each agent in key patient subgroups based on age, gender, accumulated risk factors, and primary or secondary prevention of stroke. METHODS A comprehensive literature search was completed and, where data permit, analyses of phase III trials of the NOACs are presented for each patient subgroup. RESULTS Analyses of key safety outcomes from NOAC trials were completed using primary trial data, including major bleeding and all-cause mortality. The safety of NOACs was generally consistent and favourable compared with warfarin according to patient age, gender, previous history of stroke, and the presence of risk factors for stroke. CONCLUSIONS The safety of the NOACs compared with warfarin was generally favourable across different patient subgroups, including those perceived to be at "high risk" for adverse outcomes. However, certain NOACs may be preferable to warfarin in some subgroups, based on indirect analyses.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Dannenberg L, Mourikis P, Naguib D, Zako S, Helten C, M'Pembele R, Trojovsky K, Konsek D, Wolff G, Brockmeyer M, Schulze V, Levkau B, Hohlfeld T, Zeus T, Kelm M, Polzin A. Antiplatelet effects of aspirin and clopidogrel after left atrial appendage (LAA) occluder implantation. Int J Cardiol 2019; 275:95-100. [DOI: 10.1016/j.ijcard.2018.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/20/2022]
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17
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Fanola CL, Ruff CT, Murphy SA, Jin J, Duggal A, Babilonia NA, Sritara P, Mercuri MF, Kamphuisen PW, Antman EM, Braunwald E, Giugliano RP. Efficacy and Safety of Edoxaban in Patients With Active Malignancy and Atrial Fibrillation: Analysis of the ENGAGE AF - TIMI 48 Trial. J Am Heart Assoc 2018; 7:e008987. [PMID: 30369307 PMCID: PMC6201390 DOI: 10.1161/jaha.118.008987] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/09/2018] [Indexed: 12/21/2022]
Abstract
Background Anticoagulation in patients with malignancy and atrial fibrillation is challenging because of enhanced risks for thrombosis and bleeding and the frequent need for invasive procedures. Data on direct oral antagonists in such patients are sparse. Methods and Results The ENGAGE AF - TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction Study 48) trial randomized 21 105 patients with atrial fibrillation to edoxaban or warfarin. Patients with malignancy, defined as a postrandomization new diagnosis or recurrence of remote cancer, were followed up over a median of 2.8 years. Adjusted Cox proportional hazard models were used to evaluate the safety and efficacy of edoxaban versus warfarin. Over a median of 495 days (interquartile range, 230-771 days), 1153 patients (5.5%) were diagnosed with new or recurrent malignancy, most commonly involving the gastrointestinal tract (20.6%), prostate (13.6%), and lung (11.1%). Malignancy was associated with increased risk of death (adjusted hazard ratio [HR], 3.12; 95% confidence interval [CI], 2.78-3.50) and major bleeding (adjusted HR, 2.45; 95% CI, 2.07-2.89), but not stroke/systemic embolism (adjusted HR, 1.08; 95% CI, 0.83-1.42). Relative outcomes with higher-dose edoxaban versus warfarin were consistent regardless of malignancy status for stroke/systemic embolism ( HR , 0.60 [95% CI, 0.31-1.15] for malignancy versus HR , 0.89 [95% CI, 0.76-1.05] for no malignancy; interaction P=0.25) and major bleeding ( HR , 0.98 [95% CI, 0.69-1.40] for malignancy versus HR , 0.79 [95% CI, 0.69-1.05] for no malignancy; interaction P=0.31). There was, however, a significant treatment interaction for the composite ischemic end point (ischemic stroke/systemic embolism/myocardial infarction), with greater efficacy of higher-dose edoxaban versus warfarin in patients with malignancy ( HR , 0.54; 95% CI, 0.31-0.93) compared with no malignancy ( HR , 1.02; 95% CI, 0.88-1.18; interaction P=0.026). Conclusions In patients with atrial fibrillation who develop malignancy, the efficacy and safety profile of edoxaban relative to warfarin is preserved, and it may represent a more practical alternative.
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Affiliation(s)
- Christina L. Fanola
- Division of CardiologyUniversity of MinnesotaMinneapolisMN
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Christian T. Ruff
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Sabina A. Murphy
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - James Jin
- Daiichi Sankyo Pharma DevelopmentEdisonNJ
| | | | | | - Piyamitr Sritara
- Division of CardiologyFaculty of MedicineRamathibodi HospitalMahidol UniversityBangkokThailand
| | | | | | - Elliott M. Antman
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Eugene Braunwald
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Robert P. Giugliano
- TIMI Study GroupCardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMA
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18
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Mazurek M, Huisman MV, Rothman KJ, Paquette M, Teutsch C, Diener HC, Dubner SJ, Halperin JL, Zint K, França LR, Lu S, Lip GYH. Gender Differences in Antithrombotic Treatment for Newly Diagnosed Atrial Fibrillation: The GLORIA-AF Registry Program. Am J Med 2018; 131:945-955.e3. [PMID: 29654720 DOI: 10.1016/j.amjmed.2018.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/14/2023]
Abstract
AIMS Data on gender differences in oral anticoagulation for stroke prevention in patients with atrial fibrillation are conflicting, largely limited to regional reports and vitamin K antagonist use. We aimed to analyze gender-specific anticoagulant prescription patterns early following the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) in a large, global registry on atrial fibrillation. METHODS The Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) is an international registry program involving patients with newly diagnosed atrial fibrillation (<3 months from arrhythmia onset). We used data from 15,092 consecutive patients (median age, 71.0 years; 45.5% were women) enrolled between 2011 and 2014. Globally, 79.7% of women and 80.2% of men were anticoagulated; the absolute between-gender difference in prevalence of anticoagulant use was -0.5% (95% confidence interval, -1.8% to 0.8%). Vitamin K antagonists were prescribed to 32.8% and 31.9% (NOACs 46.8% and 48.3%) of women and men, respectively. RESULTS No confounder for the association between gender and anticoagulant prescription was identified. Between-gender differences in anticoagulant use (lower use in women compared with men by decreasing order of magnitude of the difference) were found for CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category [female]) score = 1; CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke) score = 0; previous bleeding; age <65 years; no history of hypertension; myocardial infarction; coronary artery disease; North America region; and specialist office setting. CONCLUSION Globally, the prevalence of anticoagulant use is similar in women and men. The decision to prescribe oral anticoagulation seems to depend predominantly on guideline-related differences in stroke risk stratification rather than on gender.
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Affiliation(s)
- Michał Mazurek
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kenneth J Rothman
- RTI Health Solutions, Research Triangle Institute, Research Triangle Park, NC
| | - Miney Paquette
- Department of Medicine, Boehringer Ingelheim, Burlington, Canada
| | - Christine Teutsch
- Department of Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma GmbH und Co KG, Ingelheim, Germany
| | | | - Sergio J Dubner
- Clínica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | | | - Kristina Zint
- Global Epidemiology Department, Boehringer Ingelheim, Ingelheim, Germany
| | - Lionel Riou França
- Global Epidemiology Department, Boehringer Ingelheim, Ingelheim, Germany
| | - Shihai Lu
- Biostatistics and Data Sciences Department, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Conn
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Ugowe FE, Jackson LR, Thomas KL. Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: A systematic review. Heart Rhythm 2018; 15:1337-1345. [PMID: 29803022 DOI: 10.1016/j.hrthm.2018.05.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and is associated with increased morbidity, mortality, and health care expenditures. In this review, our aim was to assess the racial and ethnic differences in the epidemiology, management, and outcomes of patients with AF. A search of relevant studies from January 1, 2007, to December 30, 2017, was conducted in PubMed, EMBASE, and Web of Science and supplemented by manual searches of the bibliographies of retrieved articles. We identified 152 studies of which 64 were subsequently included. We found that underrepresented racial and ethnic groups have a higher prevalence of established risk factors associated with the development of AF but an overall lower incidence and prevalence of AF as compared with non-Hispanic whites. Moreover, racial and ethnic differences exist in detection, awareness, and AF-associated symptoms. Nonwhite populations also experience decreased use of rhythm control modalities and anticoagulation for stroke prevention. Lastly, among those with AF, underrepresented racial and ethnic groups had increased morbidity and mortality relative to white groups. Racial and ethnic differences exist in the prevalence, quality of life, management, and outcomes of individuals with AF; however, the mechanisms for these differences have yet to be fully elucidated. Racial and ethnic differences in AF warrant further analysis to understand the factors contributing to the differences in prevalence and management to ensure the delivery of high quality care that prevents stroke, reduces deaths, and decreases expenses associated with caring for underrepresented populations with AF.
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Affiliation(s)
| | - Larry R Jackson
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Pandya EY, Anderson E, Chow C, Wang Y, Bajorek B. Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting. Ther Adv Drug Saf 2018; 9:97-111. [PMID: 29387335 PMCID: PMC5772521 DOI: 10.1177/2042098617744926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/07/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To document antithrombotic utilization in patients with nonvalvular atrial fibrillation (NVAF), particularly, recently approved NOACs (nonvitamin K antagonist oral anticoagulants) and warfarin; and identify factors predicting the use of NOACs versus warfarin. METHODS A retrospective audit was conducted in an Australian hospital. Data pertaining to inpatients diagnosed with atrial fibrillation (AF) admitted between January and December 2014 were extracted. This included patient demographics, risk factors (stroke, bleeding), social history, medical conditions, medication history, medication safety issues, medication adherence, and antithrombotic prescribed at admission and discharge. RESULTS Among 199 patients reviewed, 84.0% were discharged on antithrombotics. Anticoagulants (± antiplatelets) were most frequently (52.0%) prescribed (two-thirds were prescribed warfarin, the remainder NOACs), followed by antiplatelets (33.0%). Among 41 patients receiving NOACs, 59.0% were prescribed rivaroxaban, 24.0% dabigatran, and 17.0% apixaban. Among patients aged 75 years and over, antiplatelets were most frequently used (37.0%), followed by warfarin (33.0%), then NOACs (14.0%). Compared with their younger counterparts, patients aged 75 years and over were significantly less likely to receive NOACs (14.0% versus 28.0%, p = 0.01). Among the 'most eligible' patients (Congestive Cardiac Failure, Hypertension (, Age ⩾ 75 years, Age= 65-74 years, Diabetes Mellitus, Stroke/ Transient Ischaemic Attack/ Thromboembolism, Vascular disease, Sex female[CHA2DS2-VASc] score ⩾2 and no bleeding risk factors), 46.0% were not anticoagulated on discharge. Patients with anaemia (68.0% versus 86.0%, p = 0.04) or a history of bleeding (65.0% versus 87.0%, p = 0.01) were less likely to receive antithrombotics compared with those without these risk factors. Warfarin therapy was less frequently prescribed among patients with cognitive impairment compared with patients with no cognitive issues (12.0% versus 23.0%, p = 0.01). Multivariate logistic regression modelling identified that patients with renal impairment were 3.6 times more likely to receive warfarin compared with NOACs (odds ratio = 3.6, 95% confidence interval = 0.08-0.90, p = 0.03, 60.0% correctly predicted; Cox and Snell R2 = 0.51, Nagelkerke R2 = 0.69). CONCLUSION Despite the availability of NOACs, warfarin remains a preferred treatment option, particularly among patients with renal impairment. The high proportion of eligible patients still being prescribed antiplatelet therapy or 'no therapy' needs to be addressed.
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Affiliation(s)
- Ekta Yogeshkumar Pandya
- University of Technology Sydney Faculty of Health, Broadway, Ultimo, Sydney, NSW 2007, Australia
| | | | - Clara Chow
- Westmead Hospital, Westmead, NSW, Australia
| | - Yishen Wang
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
| | - Beata Bajorek
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
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Yokoyama S, Tanaka Y, Nakagita K, Hosomi K, Takada M. Bleeding Risk of Warfarin and Direct Oral Anticoagulants in Younger Population: A Historical Cohort Study Using a Japanese Claims Database. Int J Med Sci 2018; 15:1686-1693. [PMID: 30588192 PMCID: PMC6299405 DOI: 10.7150/ijms.28877] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022] Open
Abstract
A historical cohort analysis of the Japan medical data center (JMDC) claims databases was performed to compare the incidence rates of bleeding events with warfarin (WF) versus direct oral anticoagulant (DOAC) treatment in patients with non-valvular atrial fibrillation. The aim of this study is to clarify the risk factors for bleeding events in younger patients newly treated with WF or DOAC in clinical practice setting. Patients who newly initiated WF or DOAC treatment from April 2012 to March 2015 were selected from the JMDC claims database. A 1:1 propensity score matching analysis was used for new users of WF or DOAC. Kaplan-Meier curves were generated to depict the time to bleeding event (total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage) during the follow-up period. Cox proportional regression models were used to estimate the hazard ratios for total bleeding events caused by oral anticoagulants. Overall, 2,046 patients (503 WF and 1,543 DOAC) were included. After applying propensity score matching, Kaplan-Meier analysis of the WF and DOAC groups displayed comparable incidences of total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage. Cox proportional hazards modeling showed that the use of WF was not associated with total bleeding events compared with DOAC (hazard ratio: 1.21, 95% confidence interval: 0.93-1.54, p = 0.15). This historical cohort study using a claims database indicates that the bleeding risk of DOAC was comparable to that of WF in Japanese younger population.
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Affiliation(s)
- Satoshi Yokoyama
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Yuki Tanaka
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Kazuki Nakagita
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan.,Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
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Ueberham L, Dagres N, Potpara TS, Bollmann A, Hindricks G. Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation. Adv Ther 2017; 34:2274-2294. [PMID: 28956288 PMCID: PMC5656712 DOI: 10.1007/s12325-017-0616-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.
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Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany.
| | - Nikolaos Dagres
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Bollmann
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
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Mazurek M, Shantsila E, Lane DA, Wolff A, Proietti M, Lip GYH. Guideline-Adherent Antithrombotic Treatment Improves Outcomes in Patients With Atrial Fibrillation: Insights From the Community-Based Darlington Atrial Fibrillation Registry. Mayo Clin Proc 2017; 92:1203-1213. [PMID: 28778255 DOI: 10.1016/j.mayocp.2017.05.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/10/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the influence of guideline-adherent vs nonadherent antithrombotic treatment (ATT) on stroke and mortality rates in an atrial fibrillation (AF) primary care population. PATIENTS AND METHODS We used the Darlington Registry cohort, which included 105,000 patients from March 31, 2012, through March 31, 2013. Guideline adherence in ATT was assessed against 2014 National Institute for Health and Care Excellence guidelines, which recommend oral anticoagulation for stroke prevention as a default management unless a truly low risk of stroke (CHA2DS2-VASc=0 in men and 1 in women) is evident. RESULTS Of 2259 patients with AF (2.15%), 36.1% were undertreated, 50.8% were guideline adherent, and 13.1% were overtreated. Oral anticoagulation was declined by 5.0% and contraindicated in 8.3%. Of 67 incident strokes (3.0%), 66 (98.5%) occurred in high-risk patients (CHA2DS2-VASc ≥2). For the high-risk cohort, 1-year stroke rates were 4.5% (95% CI, 3.2%-6.3%) for undertreatment, 1.9% (95% CI, 1.2%-2.9%) for guideline adherence, and 7.2% (95% CI, 4.4%-11.6%) for overtreatment; corresponding mortality rates were 16.1% (95% CI, 13.6%-19.0%), 8.0% (95% CI, 6.5%-9.8%), and 8.2% (95% CI, 5.2%-12.7%), respectively. On multivariable analysis, both undertreatment and overtreatment of high-risk patients were associated with significant increases in stroke rates (odds ratio [OR]=2.32; 95% CI, 1.30-3.14; P=.005 and OR=2.28; 95% CI, 1.12-4.63; P=.02, respectively). Undertreatment was also associated with a significant increase in all-cause mortality (OR=1.59; 95% CI, 1.14-2.21; P=.006). CONCLUSION Only half of all eligible patients with AF are prescribed oral anticoagulation in accordance with guideline recommendations. Guideline-adherent ATT significantly reduces the risk of stroke and improves survival.
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Affiliation(s)
- Michał Mazurek
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Eduard Shantsila
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre A Lane
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Andreas Wolff
- Division of Family Practice, Chilliwack General Hospital, Chilliwack, British Columbia, Canada
| | - Marco Proietti
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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Mazurek M, Shantsila E, Lane DA, Wolff A, Proietti M, Lip GYH. Secondary Versus Primary Stroke Prevention in Atrial Fibrillation: Insights From the Darlington Atrial Fibrillation Registry. Stroke 2017; 48:2198-2205. [PMID: 28679859 DOI: 10.1161/strokeaha.116.016146] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 05/22/2017] [Accepted: 06/06/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Although patients with atrial fibrillation (AF) who experienced an acute stroke are at high risk for recurrence, many patients are untreated or treated suboptimally for stroke prevention. The objective of this study is to compare clinical outcomes of AF patients with versus without previous stroke in relation to guideline-adherent antithrombotic treatment in a contemporary primary care population. METHODS Community cohort of 105 000 patients from 11 general practices in Darlington, England, was used to assess AF stroke prevention strategies against 2014 National Institute for Health and Care Excellence guidelines. RESULTS Overall, 2259 (2.15%) patients with AF were identified, of which 18.9% constituted a secondary prevention cohort. For secondary prevention, antithrombotic treatment was guideline adherent in 56.3%, 18.9% were overtreated, and 24.8% undertreated; corresponding proportions for primary prevention were 49.5%, 11.7%, and 38.8%, respectively. One-year stroke rates were 8.6% and 1.6% for secondary and primary prevention, respectively (P<0.001); corresponding all-cause mortality rates were 9.8% and 9.4%, respectively (P=0.79). On multivariable analysis, lack of antithrombotic treatment guideline adherence was associated with increased stroke risk for primary prevention (odds ratio, 2.95; 95% confidence interval, 1.26-6.90; P=0.013 for undertreatment); for secondary prevention, lack of guideline adherence was associated with increased risk of recurrent stroke (odds ratio, 2.80; 95% confidence interval, 1.25-6.27; P=0.012 for overtreatment) and all-cause death (odds ratio, 2.75; 95% confidence interval, 1.33-5.69; P=0.006 for undertreatment). CONCLUSIONS Only approximately half of eligible patients with AF are prescribed oral anticoagulation in line with guidelines. Guideline-adherent antithrombotic treatment significantly reduces the risk of stroke among primary prevention patients and both risk of recurrent stroke and death in patients with previous stroke.
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Affiliation(s)
- Michał Mazurek
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.)
| | - Eduard Shantsila
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.)
| | - Deirdre A Lane
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.)
| | - Andreas Wolff
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.)
| | - Marco Proietti
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.)
| | - Gregory Y H Lip
- From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.).
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25
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Potpara TS, Boriani G, Lip GYH. Evaluating adherence to non-vitamin-K antagonist oral anticoagulants in post-approval observational studies of patients with atrial fibrillation. Curr Med Res Opin 2017; 33:1175-1177. [PMID: 28398081 DOI: 10.1080/03007995.2017.1313210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Tatjana S Potpara
- a School of Medicine , Belgrade University , Belgrade , Serbia
- b Cardiology Clinic, Clinical Centre of Serbia , Belgrade , Serbia
| | - Giuseppe Boriani
- c Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine , University of Modena and Reggio Emilia, Policlinico di Modena , Modena , Italy
| | - Gregory Y H Lip
- a School of Medicine , Belgrade University , Belgrade , Serbia
- d University of Birmingham Institute of Cardiovascular Science, City Hospital , Birmingham , United Kingdom
- e Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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26
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Potpara TS, Dagres N, Mujović N, Vasić D, Ašanin M, Nedeljkovic M, Marin F, Fauchier L, Blomstrom-Lundqvist C, Lip GYH. Decision-Making in Clinical Practice: Oral Anticoagulant Therapy in Patients with Non-valvular Atrial Fibrillation and a Single Additional Stroke Risk Factor. Adv Ther 2017; 34:357-377. [PMID: 27933569 PMCID: PMC5331111 DOI: 10.1007/s12325-016-0458-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Indexed: 01/27/2023]
Abstract
Approximately 1 in 3-4 patients presenting with an ischemic stroke will also have atrial fibrillation (AF), and AF-related strokes can be effectively prevented using oral anticoagulant therapy (OAC), either with well-controlled vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulants (NOACs). In addition, OAC use (both VKAs and NOACs) is associated with a 26% reduction in all-cause mortality (VKAs) or an additional 10% mortality reduction with NOACs relative to VKAs. The decision to use OAC in individual AF patient is based on the estimated balance of the benefit from ischemic stroke reduction against the risk of major OAC-related bleeding [essentially intracranial hemorrhage (ICH)]. Better appreciation of the importance of VKAs' anticoagulation quality [a target time in therapeutic range (TTR) of ≥70%] and the availability of NOACs (which offer better safety compared to VKAs) have decreased the estimated threshold for OAC treatment in AF patients towards lower stroke risk levels. Still, contemporary registry-based data show that OAC is often underused in AF patients at increased risk of stroke. The uncertainty whether to use OAC may be particularly pronounced in AF patients with a single additional stroke risk factor, who are often (mis)perceived as having a "borderline" or insufficient stroke risk to trigger the use of OAC. However, observational data from real-world AF cohorts show that the annual stroke rates in such patients are higher than in patients with no additional stroke risk factors, and OAC use has been associated with reduction in stroke, systemic embolism, or death in comparison to no therapy or aspirin, with no increase in the risk of bleeding relative to aspirin. In this review article, we summarize the basic principles of stroke risk stratification in AF patients and discuss contemporary real-world evidence on OAC use and outcomes of OAC treatment in AF patients with a single additional stroke risk factor in various real-world AF cohorts.
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Santangelo G, Ielasi A, Antonio Scopelliti P, Pattarino F, Tespili M. Apixaban-Induced Resolution of A Massive Left Atrial and Appendage Thrombosis in a Very Elderly Patient. J Atr Fibrillation 2016; 9:1509. [PMID: 29250263 PMCID: PMC5673322 DOI: 10.4022/jafib.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/19/2016] [Accepted: 12/24/2016] [Indexed: 11/10/2022]
Abstract
A 86-year-old woman with first diagnosed atrial fibrillation (AF) underwent mitral valve annuloplasty 10 years before was admitted to our Unit due to congestive heart failure. Trans-thoracic echocardiogram (TTE) revealed a large fluctuant echogenic mass in the posterior wall of the left atrium. Trans-esophageal echo (TEE) showed the origin of the mass within the left atrial appendage. An adjusted dose of the novel oral anticoagulant (NOAC) apixaban, was prescribed. A complete disappearance was appreciated by examination at 12 weeks after the first drug administration. Although apixaban, resulted superior to warfarin in preventing stroke and thrombo-embolic events in patients with non valvular AF, while causing less bleeding, few data are actually available regarding the efficacy and safety of this drug in left atrium and appendage thrombosis management. Our report shows that this NOAC could be a simple and useful option to manage huge atrial thrombosis in very elderly patients.
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Affiliation(s)
- Gloria Santangelo
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Alfonso Ielasi
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Pasquale Antonio Scopelliti
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Francesco Pattarino
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Maurizio Tespili
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
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Barrios V, Masjuan J. Use of direct oral anticoagulants in patients with nonvalvular atrial fibrillation according to clinical profile. Future Cardiol 2016; 13:49-64. [PMID: 27731650 DOI: 10.2217/fca-2016-0061] [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: 11/21/2022] Open
Abstract
The majority of patients with atrial fibrillation should receive oral anticoagulation to reduce the risk of stroke. The limitations of vitamin K antagonists have led to an underuse of anticoagulants in clinical practice which has been associated with a higher risk of stroke, hospitalizations and healthcare costs. Direct oral anticoagulants (DOACs) overcome some of the limitations of vitamin K antagonists and may therefore increase the use of oral anticoagulants in clinical practice. Since no head-to-head trials have been performed, only indirect comparisons can be made among them. In this review, the results of the Phase III randomized controlled trials with DOACs were analyzed, trying to determine whether one or more DOACs could be especially recommended according to different clinical conditions.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, University of Alcalá, Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, University Hospital Ramón y Cajal, University of Alcalá, Madrid, Spain
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29
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Bang OY, Hong KS, Heo JH. Asian Patients with Stroke plus Atrial Fibrillation and the Dose of Non-Vitamin K Oral Anticoagulants. J Stroke 2016; 18:169-78. [PMID: 27170995 PMCID: PMC4904388 DOI: 10.5853/jos.2016.00052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/01/2016] [Accepted: 03/26/2016] [Indexed: 12/31/2022] Open
Abstract
After recent randomized control trials (RCTs), non-vitamin K oral anticoagulants (NAOAs) are now widely being used in patients with atrial fibrillation (AF) worldwide. However, current guidelines for the use of NOACs in patients with AF are derived mostly using a Caucasian population and non-stroke patients. Relatively few Asian patients with AF and stroke are included in the recent RCTs. As a result, the optimal use of NOACs in this particular group of patients is remains to be settled. The optimal dose of NOACs and response to current dose of NOACs of Asian patients with AF and stroke may differ from those of westerners and patients without stroke. We reviewed available research on NOACs by searching PubMed and ClinicalTrials.gov published in English up to December 2015. In this review, the characteristics of Asian AF patients with prior stroke/transient ischemic attack, which might influence the efficacy and safety profiles of NOACs, are discussed. In addition, we summarize the risk factors for bleeding complications on NOACs, which are related or unrelated with the blood level of NOACs. Lastly, we provide recent data of reduced dose of NOACs from RCTs or large cohorts. The results reviewed herein call for clinical trials to test whether a reduced dose of NOACs is beneficial in Asian patients with AF and stroke. In the meantime, further researches are needed to establish the safety and efficacy of dose-adjusted NOACs considering both blood levels of NOACs and fragility of patients in Asian patients with AF and stroke.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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