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Amano M, Takegami M, Miyake M, Kitai T, Fujita T, Koyama T, Tanaka H, Ando K, Komiya T, Izumo M, Kawai H, Eishi K, Yoshida K, Kimura T, Nawada R, Sakamoto T, Shibata Y, Fukui T, Minatoya K, Tsujita K, Sakata Y, Sugio K, Nishimura K, Furukawa Y, Izumi C. Clinical effects of direct oral anticoagulants in elderly patients with a bioprosthetic valve and atrial fibrillation. Int J Cardiol 2024; 413:132375. [PMID: 39025133 DOI: 10.1016/j.ijcard.2024.132375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 06/27/2024] [Accepted: 07/15/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Current guidelines recommend direct oral anticoagulants (DOACs) and warfarin for patients with atrial fibrillation (AF) who have a bioprosthetic valve (BPV). However, the data related to elderly patients (aged ≥80 years) with BPV replacement and AF are limited. METHODS This post-hoc subgroup analysis of a BPV-AF Registry enrolled 752 patients with BPV replacement and AF. The primary net outcome was a composite of cardiac death, stroke, systemic embolism, major bleeding, and cardiovascular events. RESULTS Among 752 patients, 429 (57%) patients were ≥ 80 and 323 (43%) were < 80 years old. The higher risk in patients aged ≥80 than <80 years was significant for the net outcome (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.31-3.17; P = 0.001). After adjustment for confounders, there was no statistically significant difference between warfarin (reference) and DOAC users in the risk of net outcomes (adjusted HR, 1.26; 95% CI, 0.71-2.24; P = 0.44), stroke and systemic embolism (adjusted HR, 2.01; 95% CI, 0.48-8.38; P = 0.34), and major bleeding (adjusted HR, 0.73; 95% CI, 0.11-4.98; P = 0.75) in patients aged ≥80 years old as well as those aged <80 years. Among 489 warfarin users, the cumulative incidence of net outcomes tended to be higher in patients aged ≥80 than <80 years (12.2% vs. 5.7% at 1 year, log-rank P = 0.002). Among 263 DOAC users, however, it was similar between patients aged ≥80 and < 80 years. CONCLUSIONS The present study demonstrated that DOAC showed similar efficacy and safety compared with warfarin even in elderly patients aged ≥80 years with BPV replacement and AF.
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Affiliation(s)
- Masashi Amano
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kansai Medical University, Osaka. Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroya Kawai
- Department of Cardiology, Hyogo Prefectural Harima Himeji General Medical Center, Himeji, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Kiyoshi Yoshida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospial, Hirakata, Japan
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kumiko Sugio
- Department of Primary Medical Science, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chisato Izumi
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan.
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Yamashita T, Igawa Y, Fukuzawa M, Hayashi T, Hennig S, Okumura K. Pharmacokinetics of Edoxaban 15 mg in Very Elderly Patients with Nonvalvular Atrial Fibrillation: A Subanalysis of the ELDERCARE-AF Study. Thromb Haemost 2024; 124:874-882. [PMID: 38641335 PMCID: PMC11349424 DOI: 10.1055/s-0044-1785511] [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: 04/21/2023] [Accepted: 02/26/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We evaluated the pharmacokinetics (PK) of low-dose (15 mg) edoxaban in very elderly patients (≥80 years) with nonvalvular atrial fibrillation (NVAF) and high bleeding risk. METHODS This subanalysis of the phase 3, randomized, double-blind, placebo-controlled, multicenter ELDERCARE-AF study evaluated edoxaban plasma concentrations and compared them with the Japanese population of the ENGAGE AF-TIMI 48 and Japanese severe renal impairment (SRI) studies. RESULTS The PK analysis population included 451 patients, 53.8% of whom concomitantly used antiplatelet drugs, 41.0% had SRI, and 38.0% had low body weight. Edoxaban plasma concentrations at trough and 1 to 3 hours post-dose in ELDERCARE-AF were 17.3 ± 13.9 (n = 427) and 93.3 ± 57.8 ng/mL (n = 447), respectively. These values were slightly higher than the 15 mg group in ENGAGE AF-TIMI 48 (n = 79; 12.4 ± 12.1 and n = 115; 78.7 ± 45.0 ng/mL, respectively), lower than the ENGAGE AF-TIMI 48 high-dose reduced to 30 mg group (n = 83; 25.1 ± 36.6 and n = 111; 150 ± 91.6 ng/mL, respectively), but similar to the Japanese SRI study (n = 39; 18.4 ± 11.2 and n = 40; 96.8 ± 48.3 ng/mL, respectively). ELDERCARE-AF patients with SRI and low body weight (≤45 kg) had higher concentrations than those without, and those taking antiplatelet drugs had lower concentrations than those who were not. CONCLUSION PK data support edoxaban 15 mg once daily for very elderly NVAF patients with high bleeding risk, with caution for patients with SRI and/or low body weight.
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Affiliation(s)
- Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Masayuki Fukuzawa
- Japan Business Unit, Primary Medical Science Department, Cardiovascular Group, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takuya Hayashi
- Data Analysis Group, Data Intelligence Department, Global DX, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
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Zimerman A, Braunwald E, Steffel J, Van Mieghem NM, Palazzolo MG, Murphy SA, Chen CZL, Unverdorben M, Ruff CT, Antman EM, Giugliano RP. Dose Reduction of Edoxaban in Patients 80 Years and Older With Atrial Fibrillation: Post Hoc Analysis of the ENGAGE AF-TIMI 48 Randomized Clinical Trial. JAMA Cardiol 2024; 9:817-825. [PMID: 38985461 PMCID: PMC11238063 DOI: 10.1001/jamacardio.2024.1793] [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: 02/28/2024] [Accepted: 05/14/2024] [Indexed: 07/11/2024]
Abstract
Importance In older patients with atrial fibrillation who take anticoagulants for stroke prevention, bleeding is increased compared with younger patients, thus, clinicians frequently prescribe lower than recommended doses in older patients despite limited randomized data. Objective To evaluate ischemic and bleeding outcomes in patients 80 years and older with atrial fibrillation receiving edoxaban, 60 mg vs 30 mg, and edoxaban, 30 mg vs warfarin. Design, Setting, and Participants The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) was a parallel-design, double-blind, global clinical trial that randomized patients with atrial fibrillation to either one of 2 edoxaban dosing regimens or warfarin. This secondary analysis focused on patients 80 years or older without dose-reduction criteria receiving edoxaban, 60 mg vs 30 mg, as well as patients with or without dose-reduction criteria receiving edoxaban, 30 mg, vs warfarin. Study data were analyzed between October 2022 and December 2023. Interventions Oral edoxaban, 30 mg once daily; edoxaban, 60 mg once daily; or warfarin. Main Outcomes and Measures Primary net clinical outcome of death, stroke or systemic embolism, and major bleeding and each individual component. Results The current analysis included 2966 patients 80 years and older (mean [SD] age, 83 [2.7] years; 1671 male [56%]). Among 1138 patients 80 years and older without dose-reduction criteria, those receiving edoxaban, 60 mg vs 30 mg, had more major bleeding events (hazard ratio [HR], 1.57; 95% CI, 1.04-2.38; P = .03), particularly gastrointestinal hemorrhage (HR, 2.24; 95% CI, 1.29-3.90; P = .004), with no significant difference in efficacy end points. Findings were supported by analyses of endogenous factor Xa inhibition, a marker of anticoagulant effect, which was comparable between younger patients receiving edoxaban, 60 mg, and older patients receiving edoxaban, 30 mg. In 2406 patients 80 years and older with or without dose-reduction criteria, patients receiving edoxaban, 30 mg, vs warfarin had lower rates of the primary net clinical outcome (HR, 0.78; 95% CI, 0.68-0.91; P = .001), major bleeding (HR, 0.59; 95% CI, 0.45-0.77; P < .001), and death (HR, 0.83; 95% CI, 0.70-1.00; P = .046), whereas rates of stroke or systemic embolism were comparable. Conclusions and Relevance In this post hoc analysis of the ENGAGE AF-TIMI 48 randomized clinical trial, in patients 80 years and older with atrial fibrillation, major bleeding events were lower in patients randomized to receive edoxaban, 30 mg per day, compared with either edoxaban, 60 mg per day (in patients without dose-reduction criteria), or warfarin (irrespective of dose-reduction status), without an offsetting increase in ischemic events. These data support the concept that lower-dose anticoagulants, such as edoxaban, 30 mg, may be considered in older patients with atrial fibrillation even in the absence of dose-reduction criteria. Trial Registration ClinicalTrials.gov Identifier: NCT00781391.
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Affiliation(s)
- André Zimerman
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Michael G. Palazzolo
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Sabina A. Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Christian T. Ruff
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Elliott M. Antman
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Robert P. Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Fang CW, Hsieh CY, Yang HY, Tsai CF, Sung SF. Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia. Eur Stroke J 2024:23969873241274598. [PMID: 39215489 DOI: 10.1177/23969873241274598] [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: 09/04/2024] Open
Abstract
INTRODUCTION Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia. PATIENTS AND METHODS We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC. RESULTS There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome. DISCUSSION AND CONCLUSION Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.
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Affiliation(s)
- Chen-Wen Fang
- Department of Biomedical Engineering, National Cheng Kung University, Tainan City, Taiwan
- Department of Neurology, National Taiwan University Hospital, Yunlin Branch, Douliu City, Taiwan
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Hsin-Yi Yang
- Clinical Data Center, Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Ching-Fang Tsai
- Clinical Data Center, Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
- Department of Nursing, Fooyin University, Kaohsiung, Taiwan
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Chen KH, Hsu YY, Chou CY, Hsu CC, Chang SL, Yu WC, Chang YL. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in low-weight patients with atrial fibrillation. J Thromb Thrombolysis 2024:10.1007/s11239-024-03016-8. [PMID: 39143401 DOI: 10.1007/s11239-024-03016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 08/16/2024]
Abstract
It remains unclear whether non-vitamin K antagonist oral anticoagulants (NOACs) are more effective and safer than warfarin in low-weight patients with atrial fibrillation (AF). Here, we retrospectively compared the effectiveness and safety of NOACs with those of warfarin in low-weight patients with AF. We extracted the July 2011-September 2022 data of patients with AF treated with a NOAC (dabigatran, rivaroxaban, apixaban, or edoxaban) or warfarin at a tertiary hospital. The patients were divided into low-weight (body weight ≤ 60 kg) and non-low-weight (body weight = 60-100 kg) groups. The primary outcomes were hospitalization for ischemic stroke (IS) or systemic embolism (SE) and major bleeding, whereas the secondary outcomes were any ischemic and bleeding events. We used the inverse probability of treatment weighting to balance the baseline characteristics between the groups. In total, 5,044 patients (mean age = 73.7 years, mean CHA2DS2-VASc score = 3.0, mean HAS-BLED score = 2.3) were enrolled and divided into low-weight and non-low-weight groups-containing 1,666 (1,406 NOAC users, 260 warfarin users) and 3,378 (2,978 NOAC users, 400 warfarin users) patients, respectively. NOACs were associated with a lower risk of any bleeding event in the low-weight group (adjusted hazard ratio = 0.61, 95% confidence interval = 0.51-0.73). The between-group differences in the risks of IS/SE, any ischemic event, major bleeding, and any bleeding event were nonsignificant. Thus, the use of NOACs (specifically dabigatran or edoxaban) is associated with a lower risk of any bleeding event than warfarin use in low-weight patients with AF.
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Affiliation(s)
- Kuan-Hsuan Chen
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan.
| | - Yeh-Yun Hsu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Chian-Ying Chou
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Chung Yu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Divison of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taipei City, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan.
- Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
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Suzuki S, Yamashita T, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Morishima Y, Fukuzawa M, Takita A, Inoue H. Patient Outcomes in Very Elderly Patients With Non-Valvular Atrial Fibrillation - ANAFIE Registry. Circ Rep 2024; 6:283-293. [PMID: 39132332 PMCID: PMC11309779 DOI: 10.1253/circrep.cr-24-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 08/13/2024] Open
Abstract
Background The All Nippon Atrial Fibrillation In the Elderly Registry provides real-world insights into non-valvular atrial fibrillation (NVAF) in >30,000 elderly Japanese patients (aged ≥75 years), including >2,000 nonagenarians. We aimed to investigate outcomes in these patients by age and oral anticoagulant (OAC) type. Methods and Results This prospective, multicenter, observational, cohort, 2-year follow-up study included elderly patients with NVAF who were able to attend hospital visits. The incidences of stroke/systemic embolic events (SEE), major bleeding, intracranial hemorrhage (ICH), cardiovascular death, all-cause death, and major adverse cardiovascular or neurological events (MACNE) were evaluated by age. Incidence rates increased significantly with age. Stroke/SEE, major bleeding, and ICH incidences plateaued in patients aged ≥90 years. Direct OACs (DOACs) yielded a numerically lower event incidence vs. warfarin in all age groups and endpoints, except for major bleeding in patients aged ≥90 years. DOACs (vs. warfarin) were significantly associated with a lower risk of stroke/SEE, major bleeding, and ICH in the ≥80-<85 years group, and reduced cardiovascular and all-cause death in the ≥75-<80 years group. In the ≥90 years subgroup, major bleeding history was a risk factor for all-cause death. Conclusions Although DOAC vs. warfarin offers potential benefits for stroke prevention, limitations occurred in reducing major bleeding among those aged ≥90 years, indicating a potential benefit of very-low-dose DOAC for this demographic.
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Affiliation(s)
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center Kyoto Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine Tokyo Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center Kumamoto Japan
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital Tokyo Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital Fukuoka Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center Osaka Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | | | - Masayuki Fukuzawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd. Tokyo Japan
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Lucà F, Abrignani MG, Oliva F, Canale ML, Parrini I, Murrone A, Rao CM, Nesti M, Cornara S, Di Matteo I, Barisone M, Giubilato S, Ceravolo R, Pignalberi C, Geraci G, Riccio C, Gelsomino S, Colivicchi F, Grimaldi M, Gulizia MM. Multidisciplinary Approach in Atrial Fibrillation: As Good as Gold. J Clin Med 2024; 13:4621. [PMID: 39200763 PMCID: PMC11354619 DOI: 10.3390/jcm13164621] [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: 05/08/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 09/02/2024] Open
Abstract
Atrial fibrillation (AF) represents the most common sustained arrhythmia necessitating dual focus: acute complication management and sustained longitudinal oversight to modulate disease progression and ensure comprehensive patient care over time. AF is a multifaceted disorder; due to such a great number of potential exacerbating conditions, a multidisciplinary team (MDT) should manage AF patients by cooperating with a cardiologist. Effective management of AF patients necessitates the implementation of a well-coordinated and tailored care pathway aimed at delivering optimized treatment through collaboration among various healthcare professionals. Management of AF should be carefully evaluated and mutually agreed upon in consultation with healthcare providers. It is crucial to recognize that treatment may evolve due to the emergence of new risk factors, symptoms, disease progression, and advancements in treatment modalities. In the context of multidisciplinary AF teams, a coordinated approach involves assembling a diverse team tailored to meet individual patients' unique needs based on local services' availability.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | | | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.O.); (I.D.M.)
| | - Maria Laura Canale
- Division of Cardiology, Azienda USL Toscana Nord-Ovest, Versilia Hospital, 55049 Lido di Camaiore, Italy;
| | - Iris Parrini
- Division of Cardiology, Mauriziano Hospital, 10128 Turin, Italy;
| | - Adriano Murrone
- Cardiology-ICU Department, Ospedali di Città di Castello e di Gubbio-Gualdo Tadino, AUSL Umbria 1, Via Guerriero Guerra, 06127 Perugia, Italy;
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Martina Nesti
- Division of Cardiology Fondazione Toscana G. Monasterio, 56124 Pisa, Italy;
| | - Stefano Cornara
- Department of Translational Medicine, University of Piemonte Orientale, Via P. Solaroli, 17, 28100 Novara, Italy;
| | - Irene Di Matteo
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.O.); (I.D.M.)
| | - Michela Barisone
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Simona Giubilato
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Carlo Pignalberi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (C.P.); (F.C.)
| | - Giovanna Geraci
- Cardiology Division, Sant’Antonio Abate, ASP Trapani, 91100 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (C.P.); (F.C.)
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
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Alsoudi AF, Koo E, Wai K, Mruthyunjaya P, Rahimy E. Risk of ocular neovascular conversion and systemic bleeding complications in patients with AMD on DOACs or Warfarin. Ophthalmology 2024:S0161-6420(24)00459-7. [PMID: 39116948 DOI: 10.1016/j.ophtha.2024.07.034] [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: 04/21/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024] Open
Abstract
PURPOSE Conversion to neovascular disease in patients with non-neovascular age-related macular degeneration (AMD) initiated on direct oral anticoagulants (DOAC) compared to matched patients treated with warfarin. DESIGN Retrospective cohort study. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS The study included 20,300 patients and 13,387 patients with non-neovascular AMD initiated on DOACs or warfarin, respectively, before propensity score matching (PSM). METHODS, INTERVENTION, OR TESTING TriNetX (Cambridge, MA, USA), was used to identify patients diagnosed with non-neovascular AMD stratified by treatment with DOACs or warfarin with at least six months of follow-up. Propensity score matching was performed to control for baseline demographics and medical comorbidities. MAIN OUTCOME MEASURES Relative risk (RR) of developing neovascular AMD, macular hemorrhage (MH), vitreous hemorrhage (VH), and requiring an ocular intervention (intravitreal anti-vascular endothelial growth factor (VEGF) therapy or pars plana vitrectomy (PPV)) within six months and one year. Patients with chronic atrial fibrillation (AF) on anticoagulation were separately evaluated for the same measures within 5 years after initiating therapy. RESULTS Treatment with warfarin was associated with higher risk of developing neovascular AMD at six months (RR,1.24, 95% CI, 1.12 - 1.39; P<.001) and one year (RR, 1.26, 95% CI, 1.14 - 1.40; P<.001) when compared to matched patients treated with DOACs. There was an increased risk of requiring intravitreal anti-VEGF therapy (6 months: RR, 1.30; 95% CI, 1.13-1.49; P<.001; 1 year: RR, 1.31, 95% CI, 0.72 - 2.05; P<.001) and PPV (6 months: RR, 1.16; 95% CI, 1.16-3.94; P = .01; 1 year: RR, 2.29, 95% CI, 1.30 - 4.05; P=.003). Among patients with AMD and AF treated with warfarin, there was an increased risk of ocular complications (neovascular AMD: RR, 1.25; 95% CI, 1.14-1.38; P<.001; MH: RR, 1.86; 95% CI, 1.47-2.35; P<.001; VH: RR, 2.22; 95% CI, 1.51-3.26; P<.001) and need for intravitreal anti-VEGF therapy (RR, 1.34; 95% CI, 1.18-1.52; P<.001) over an extended 5-year period. There was no significant difference in the development of major systemic hemorrhagic events between the two cohorts over five years. CONCLUSIONS Patients with non-neovascular AMD treated with warfarin were more likely to develop neovascular disease and require ocular intervention for hemorrhagic complications when compared to matched patients initiated on DOACs.
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Affiliation(s)
- Amer F Alsoudi
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - Euna Koo
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Karen Wai
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Prithvi Mruthyunjaya
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ehsan Rahimy
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Ophthalmology, Palo Alto Medical Foundation, Palo Alto, CA, USA.
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Nakamaru R, Nishimura S, Kumamaru H, Shoji S, Nakatani E, Yamamoto H, Miyachi Y, Miyata H, Kohsaka S. Trajectories of Frailty and Clinical Outcomes in Older Adults With Atrial Fibrillation: Insights From the Shizuoka Kokuho Database. Circ Cardiovasc Qual Outcomes 2024; 17:e010642. [PMID: 39167767 DOI: 10.1161/circoutcomes.123.010642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/25/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The increasing prevalence of frailty has gained considerable attention due to its profound influence on clinical outcomes. However, our understanding of the progression of frailty and long-term clinical outcomes in older individuals with atrial fibrillation remains scarce. METHODS Using data from 2012 to 2018 from a comprehensive claims database incorporating primary and hospital care records in Shizuoka, Japan, we selected patients aged ≥65 years with atrial fibrillation who initiated oral anticoagulant therapy. The trajectory of frailty was plotted using Sankey plots, illustrating the annual changes in their frailty according to the electronic frailty index during a 3-year follow-up after oral anticoagulant initiation, along with the incidence of clinical adverse outcomes. For deceased patients, we assessed their frailty status in the year preceding their death. RESULTS Of 6247 eligible patients (45.1% women; mean age, 79.3±8.0 years) at oral anticoagulant initiation, 7.7% were categorized as fit (electronic frailty index, 0-0.12), 30.1% as mildly frail (>0.12-0.24), 35.4% as moderately frail (>0.24-0.36), and 25.9% as severely frail (>0.36). Over the 3-year follow-up, 10.4% of initially fit patients transitioned to moderately frail or severely frail. Conversely, 12.5% of severely frail patients improved to fit or mildly frail. Death, stroke, and major bleeding occurred in 23.4%, 4.1%, and 2.2% of patients, respectively. Among the mortality cases, 74.8% (N=1183) and 3.5% (N=55) had experienced moderately or severely frail and either a stroke or major bleeding in the year preceding their death, respectively. CONCLUSIONS In a contemporary era of atrial fibrillation management, a minor fraction of older patients on oral anticoagulants died following a stroke or major bleeding. However, their frailty demonstrated a dynamic trajectory, and a substantial proportion of death was observed after transitioning to a moderately or severely frail state.
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Affiliation(s)
- Ryo Nakamaru
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Shiori Nishimura
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Satoshi Shoji
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Cardiology (S.S., S.K.), Keio University School of Medicine, Tokyo, Japan
- Duke Clinical Research Institute, Durham, NC (S.S.)
| | - Eiji Nakatani
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Yoshiki Miyachi
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Health Policy and Management (H.M.), Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Cardiology (S.S., S.K.), Keio University School of Medicine, Tokyo, Japan
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10
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Liao JN, Chan YH, Kuo L, Tsai CT, Liu CM, Chen TJ, Lip GYH, Chen SA, Chao TF. Association between antithrombotic drug regimen changes and clinical outcomes after stroke in atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)03094-7. [PMID: 39094727 DOI: 10.1016/j.hrthm.2024.07.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 07/22/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The impact of post-stroke antithrombotic regimen in atrial fibrillation is uncertain. OBJECTIVE This study aimed to describe antithrombotic therapy prescribing patterns after ischemic stroke and the impact on outcomes. METHODS A total of 23,165 patients with atrial fibrillation experiencing ischemic stroke were identified. Subsequent post-stroke events included recurrent ischemic stroke, intracranial hemorrhage, major bleeding, mortality, and composite outcomes. RESULTS Of those who were nonanticoagulated before a stroke, 33.5% remained nonanticoagulated and 39.2% were prescribed only antiplatelet agents (APs) after a stroke. Compared with non-vitamin K antagonist oral anticoagulants (NOACs) after stroke, there was a significant increase in ischemic stroke and mortality in nonanticoagulated patients (adjusted hazard ratio [aHR], 2.09 and 3.92) and AP users (aHR, 1.32 and 1.28). Post-stroke warfarin was associated with a significantly increased risk of major bleeding compared with NOACs (aHR, 1.23). Of 769 patients receiving NOACs before stroke and continuing NOACs after stroke, those switching to a different NOAC were associated with significantly higher risk of ischemic stroke (aHR, 2.07) and composite outcomes (aHR, 1.36-1.85) with no difference in intracranial hemorrhage, major bleeding, or mortality compared with those receiving the same NOAC after stroke. Of patients receiving NOACs before stroke, the risks of clinical events were similar between patients taking NOACs alone and those taking NOAC plus AP after stroke. CONCLUSION NOAC alone after stroke was associated with a better clinical outcome compared with nonanticoagulation, AP, or warfarin. Of patients already taking NOACs before stroke, the addition of AP did not confer additional benefits compared with NOACs alone. A change of NOAC types after stroke was associated with a 2-fold higher risk of ischemic stroke and composite outcomes.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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11
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Mohanty S, Natale A. Reply to the letter from Kataoka et al. J Cardiovasc Electrophysiol 2024. [PMID: 39004812 DOI: 10.1111/jce.16368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Sanghamitra Mohanty
- Division of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Division of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
- Department of interventional electrophysiology, Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Division of Cardiology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
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12
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Kohsaka S, Nishimura S, Kumamaru H. Letter by Kohsaka et al Regarding Article, "Safety of Switching From a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients With Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial". Circulation 2024; 150:e28-e29. [PMID: 38976603 DOI: 10.1161/circulationaha.124.069363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.K.)
- Shizuoka Graduate University of Public Health, Japan (S.K., S.N., H.K.)
- Department of Healthcare Quality Assessment, University of Tokyo Graduate School of Medicine, Japan (S.K., S.N., H.K.)
| | - Shiori Nishimura
- Shizuoka Graduate University of Public Health, Japan (S.K., S.N., H.K.)
- Department of Healthcare Quality Assessment, University of Tokyo Graduate School of Medicine, Japan (S.K., S.N., H.K.)
| | - Hiraku Kumamaru
- Shizuoka Graduate University of Public Health, Japan (S.K., S.N., H.K.)
- Department of Healthcare Quality Assessment, University of Tokyo Graduate School of Medicine, Japan (S.K., S.N., H.K.)
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13
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Kataoka N, Imamura T. Optimal therapeutic strategy for patients with atrial fibrillation and cardiac amyloidosis. J Cardiovasc Electrophysiol 2024. [PMID: 38953219 DOI: 10.1111/jce.16354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 06/14/2024] [Indexed: 07/03/2024]
Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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14
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Kim JY, Kim J, Park SJ, Park KM, Han SJ, Kim DK, Park YM, Lee SH, Park JS, On YK. Optimal Dose of Edoxaban for Very Elderly Atrial Fibrillation Patients at High Risk of Bleeding: The LEDIOS Registry. Korean Circ J 2024; 54:398-406. [PMID: 38859644 PMCID: PMC11252638 DOI: 10.4070/kcj.2024.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Optimal anticoagulation in very elderly patients is challenging due to the high risk of anticoagulant-induced bleeding. The aim of this study was to assess outcomes of on-label reduced-dose edoxaban (30 mg) in very elderly patients who had additional risk factors for bleeding. METHODS This was a multi-center, prospective, non-interventional observational study to evaluate the efficacy and safety of on-label reduced-dose edoxaban in atrial fibrillation (AF) patients 80 years of age or older and who had more than 1 risk factor for bleeding. RESULTS A total of 2448 patients (mean age 75.0±8.3 years, 801 [32.7%] males) was included in the present study, and 586 (23.9%) were 80 years of age or older with additional risk factors for bleeding. Major bleeding events occurred frequently among very elderly AF patients who had additional bleeding risk factors compared to other patients (unadjusted hazard ratio [HR], 2.16; 95% confidence interval [CI], 1.16-4.02); however, there were no significant differences in stroke incidence (HR, 1.86; 95% CI, 0.98-3.55). There were no significant differences for either factor after adjusting for age and sex (adjusted HR, 1.65; 95% CI, 0.75-3.62 for major bleeding; adjusted HR, 1.13; 95% CI, 0.51-2.50 for stroke). CONCLUSIONS In very elderly AF patients with comorbidities associated with greater risk of bleeding, the incidence of major bleeding events was significantly increased. In addition, risk of stroke showed tendency to increase in same population. Effective anticoagulation therapy might be important in these high-risk population, and close observation of bleeding events might also be required. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03554837.
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Affiliation(s)
- Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juwon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Jin Han
- Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Dae Kyeong Kim
- Department of Cardiology, Busan Paik Hospital, Inje University College of Medicine , Busan, Korea
| | - Yae Min Park
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jong Sung Park
- Department of Cardiology, Dong-A University Hospital, Busan, Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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15
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Komiyama M, Iguchi M, Wada H, Ikeda T, Dan GA, Hasegawa K. What is the Future Position of Factor XIa Inhibitors for Patients with Atrial Fibrillation? Eur Cardiol 2024; 19:e10. [PMID: 39081482 PMCID: PMC11287653 DOI: 10.15420/ecr.2023.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/05/2024] [Indexed: 08/02/2024] Open
Abstract
Factor XIa (FXIa) may be involved in thrombus formation, but only to a lesser extent involved in haemostasis. Several novel FXIa inhibitors are under investigation, and Phase II trials demonstrated marked reduction of bleeding compared with standard treatment by factor Xa inhibitors. Asundexian is a small molecule that selectively inhibits FXIa. A large-scale Phase III clinical trial, OCEANIC-AF, has been initiated to compare the efficacy and safety between asundexian and apixaban. However, the OCEANIC-AF study was recently halted due to the inferior efficacy of asundexian versus the apixaban control arm. The present report describes up-to-date evidence of FXIa inhibitors and discusses the future position of FXIa inhibitors for patients with AF.
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Affiliation(s)
- Maki Komiyama
- Division of Translational Research, NHO Kyoto Medical CentreKyoto, Japan
| | - Moritake Iguchi
- Department of Cardiac Rehabilitation, NHO Kyoto Medical CentreKyoto, Japan
| | - Hiromichi Wada
- Division of Translational Research, NHO Kyoto Medical CentreKyoto, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of MedicineTokyo, Japan
| | - Gheorghe-Andrei Dan
- Carol Davila University of Medicine and PharmacyBucharest, Romania
- Romanian Academy of ScientistsBucharest, Romania
| | - Koji Hasegawa
- Division of Translational Research, NHO Kyoto Medical CentreKyoto, Japan
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16
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Kim D. What Is a Balanced Way of Anticoagulation for Efficacy and Safety in High-Risk Elderly Patients With Atrial Fibrillation? Korean Circ J 2024; 54:407-408. [PMID: 39005073 PMCID: PMC11252632 DOI: 10.4070/kcj.2024.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 07/16/2024] Open
Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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17
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Hashimoto S, Motozawa Y, Mano T. Selection criteria for anticoagulants: survey of Japanese cardiologists based on their daily clinical practice: the Selection DOAC study. Curr Med Res Opin 2024; 40:1077-1082. [PMID: 38850517 DOI: 10.1080/03007995.2024.2365999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND In patients with atrial fibrillation (AF), direct oral anticoagulants (DOACs) have been utilized as an alternative to warfarin, which is known to have several limitations. This study aimed to clarify the selection criteria for anticoagulants, considering both individual patient factors and the differences between various drugs. METHODS This study conducted a web-based questionnaire from September 20, 2023 to October 3, 2023, among physicians who were members of a cardiology-specific website. RESULTS In total, 172 respondents were enrolled in this study. Edoxaban was the most frequently selected anticoagulant (39.1%), followed by apixaban (32.7%) and rivaroxaban (16.8%). Logistic regression analysis revealed that increased concern for adherence enhanced the frequency of selecting edoxaban (odds ratio [OR] = 2.42; p = 0.047), with the opposite trend observed for dabigatran (OR = 0.404; p = 0.029). The selection of apixaban is related to whether the patient is able to maintain a regular lifestyle, including adherence to medication schedules (OR = 1.874; p = 0.031). Furthermore, detailing activities from a medical representative, especially regarding a new indication, were found to influence drug selection for rivaroxaban (OR = 2.422; p = 0.047). CONCLUSION This study revealed that edoxaban is the most frequently selected anticoagulant. Although prescribing cardiologists select drugs based on background factors, adherence to medication and information from medical representatives were also crucial factors in the selection process.
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Affiliation(s)
- Satoru Hashimoto
- Department of Strategic Business Management, TCROSS Co., Ltd, Tokyo, Japan
- Graduate School of Strategic Management, Chuo University, Tokyo, Japan
| | - Yoshihiro Motozawa
- Department of Strategic Business Management, TCROSS Co., Ltd, Tokyo, Japan
- Department of Internal Medicine, San-ikukai Hospital, Tokyo, Japan
| | - Toshiki Mano
- Graduate School of Strategic Management, Chuo University, Tokyo, Japan
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18
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Huang C, Li L, Liu W, Fang Y, Jiang S, Li Y, Fonarow GC, Sia CH, Yeo LLL, Tan BYQ, Lip GYH, Yang Q, Zhou X. Time to benefit and harm of direct oral anticoagulants in device-detected atrial fibrillation: A pooled analysis of the NOAH-AFNET 6 and ARTESiA trials. Heart Rhythm 2024:S1547-5271(24)02812-1. [PMID: 38925332 DOI: 10.1016/j.hrthm.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/07/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) reduce stroke risk in patients with device-detected atrial fibrillation (DD-AFib) but increase major bleeding risk. The time to benefit (TTB) and time to harm (TTH) are not well quantified. OBJECTIVE The purpose of this study was to determine TTB and TTH in DOAC-treated patients with DD-AFib. METHODS Studies were identified from PubMed searching until November 2023. The primary efficacy outcome was the time to the first stroke event, and the primary safety outcome was the time to the first major bleeding event. Pooled hazard ratio (HR) and its confidence interval (CI) were calculated through reconstructed patient-level data and study-level data. Weibull model and Markov chain Monte Carlo simulation were applied to determine time to specific absolute risk change thresholds. RESULTS Two trials involving DOACs-NOAH-AFNET 6 (Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes) and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation)-were identified, which randomized 6548 adults with a mean age of >75 years and a median atrial high-rate episode duration ranging from 1.5 to 2.8 hours. DOACs decreased the risk of stroke (HR 0.67; 95% CI 0.50-0.90) but increased the risk of major bleeding (HR 1.57; 95% CI 1.21-2.04). A TTB of 2.67 years was needed to prevent 1 stroke per 100 DOAC-treated patients, while a TTH of 1.67 years was needed to observe 1 major bleeding. CONCLUSION In elderly patients with low durations of DD-AFib, DOACs result in a delayed and restricted stroke-preventive benefit while posing an early-onset bleeding risk. Our findings offer new insights into the risk-benefit profile and provide clinicians an additional dimension to facilitate shared decision-making discussions with patients.
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Affiliation(s)
- Chuanyi Huang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Linjie Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wennan Liu
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yiwen Fang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Shichen Jiang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Ching-Hui Sia
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard L L Yeo
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Benjamin Y Q Tan
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
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19
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Wang C, Fan X, Nie L, Wang Q, Li S, Zheng W, Zhang W, Dai W, Chen M. Efficacy and Safety of Rivaroxaban for Extremely Aged Patients with Venous Thromboembolism: A Retrospective, Cross-Sectional Real-World Study. Clin Interv Aging 2024; 19:1103-1116. [PMID: 38915432 PMCID: PMC11194160 DOI: 10.2147/cia.s405075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/15/2024] [Indexed: 06/26/2024] Open
Abstract
Background Rivaroxaban, a non-vitamin K antagonist oral anticoagulant, has become widely used for the management of venous thromboembolism (VTE) in adult patients. However, few trials have explored the efficacy and safety of rivaroxaban in VTE patients over 80 years of age. This necessitates further real-world studies of rivaroxaban across elderly populations. Methods We performed a retrospective single center study involving extremely aged VTE sufferers treated with rivaroxaban. The sample comprised 121 patients newly initiated on rivaroxaban diagnosed between January 2018 and January 2020. Patients were followed up for no less than 2 years. The effectiveness outcome was the disappearance of thromboembolism. The safety outcome was the incidence of major bleeding events. Comorbidities and complications were recorded throughout the entire study. Results The efficacy outcome occurred in 114 of 121 patients (94.21%) and the safety outcome occurred in 12 of 121 patients (9.91%). Increased hemorrhages were observed in patients with infection (15.15% vs 7.80%), but no significant difference was observed due to limited sample size (P=0.3053). Patients with an age-adjusted Charlson comorbidity index score higher than 6 points exhibited higher bleeding rates (14.08% vs 4.00%; P=0.0676) and lower thrombus cure rates (88.73% vs 100%; P=0.0203). Key conclusions Patients with infection should be more careful of bleeding events during rivaroxaban therapy. An age-adjusted Charlson comorbidity index score higher than 6, which predicted poor survival, indicated inferior safety and efficacy of rivaroxaban. Aim To investigate the efficacy and safety of Rivaroxaban in an aged venous thromboembolism patient population under real-world conditions.
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Affiliation(s)
- Chun Wang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Xiaohong Fan
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Li Nie
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Qing Wang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Shanshan Li
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wen Zheng
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wei Zhang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wangshu Dai
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Minmin Chen
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
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20
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Choi J, Lee SR, Kwon S, Ahn HJ, Lee KY, Park JS, Choi JI, Lee SH, Heo JH, Oh IY, On YK, Yu HT, Lee KN, Kim NH, Park HW, Lee KH, Shin SY, Oh S, Lip GYH, Han S, Choi EK. Clinical characteristics of apixaban prescription in AF patients with single dose-reduction criterion: the ASPIRE (efficAcy and safety of aPixaban in rEal-world practice in Korean frail patients with atrial fibrillation) study. Front Cardiovasc Med 2024; 11:1367623. [PMID: 38915744 PMCID: PMC11194408 DOI: 10.3389/fcvm.2024.1367623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/30/2024] [Indexed: 06/26/2024] Open
Abstract
Background Data on off-label reduced dose risk among patients with atrial fibrillation (AF) who qualify for a single-dose reduction of apixaban is scarce. Objectives We prospectively assessed apixaban dosing and clinical characteristics in AF patients meeting a dose reduction criterion. Methods The multicentre, prospective cohort study, the efficAcy and Safety of aPixaban In REal-world practice in Korean frail patients with AF (ASPIRE), encompasses patients with AF who met the criteria for a single-dose reduction of apixaban and were given varying doses of apixaban, either the on-label standard dose or the off-label reduced dose. Results Of 2,000 patients (mean age 74.3 ± 7.9 years, 55.8% women), 29.7% were ≥80 years, 62.6% weighed ≤60 kg, and 7.8% had serum creatinine ≥1.5 mg/dL. Of these, 51.3% were prescribed an off-label reduced dose of apixaban. The off-label group was characterized with older age, more comorbidities, and antiplatelet agents, while the on-label group had more prior strokes. Physicians preferred off-label reduced dose in the "marginal zone," defined as age 75-80 years, weight 60-65 kg, and creatinine levels 1.2-1.5 mg/dL. Conclusions In real-world clinical setting of the Korean population, off-label reduced dose apixaban was administered to nearly half of the patients who qualified for a single dose reduction. This reduced dosage was more commonly prescribed to patients with frail characteristics, while patients with a history of stroke were more often given the standard dose as per the label. A future study is planned to contrast the safety and effectiveness of the standard dose against the reduced dose of apixaban in this population.
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Affiliation(s)
- JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Sung Park
- Department of Cardiology, Dong-A University Hospital, Busan, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sung Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Ho Heo
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Il-Young Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Young Keun On
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Tae Yu
- Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwang-No Lee
- Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Hyung Wook Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ki Hong Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seung Yong Shin
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Chest and Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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21
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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22
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Stuby J, Haschke M, Tritschler T, Aujesky D. Oral anticoagulant therapy in older adults. Thromb Res 2024; 238:1-10. [PMID: 38636204 DOI: 10.1016/j.thromres.2024.04.009] [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: 12/13/2023] [Revised: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.
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Affiliation(s)
- J Stuby
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - M Haschke
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Clinical Pharmacology & Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - T Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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23
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Lee KH, Yeh JT, Wu ML, Yeh WY, Lip GYH, Chiang CE, Chen CH, Cheng HM. Oral anticoagulants and cognitive impairment in patients with atrial fibrillation: A systematic review with meta-analysis and trial sequential analysis. Thromb Res 2024; 238:132-140. [PMID: 38704897 DOI: 10.1016/j.thromres.2024.04.032] [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: 02/28/2024] [Revised: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND This systematic review assesses the likelihood of developing dementia and cognitive impairment in patients with atrial fibrillation (AF) receiving non-vitamin K antagonist oral anticoagulants (NOACs) as opposed to vitamin K antagonists (VKAs). METHODS We performed a systematic review with meta-analysis and trial sequential analysis (TSA), which encompassed both randomized controlled trials (RCTs) and observational studies. The objective was to assess the impact of NOACs and VKAs on the incidence of dementia in individuals diagnosed with AF. RESULTS Out of 1914 studies that were screened, 31 studies were included in the final analysis, which consisted of nine RCTs or their subsequent post-hoc analyses, in addition to 22 observational studies. The meta-analysis shows that NOACs were associated with a decreased probability of developing dementia of any cause [Rate Ratio (RR): 0.88; 95 % confidence interval (95 % CI): 0.82-0.94], especially in patients below the age of 75 (RR: 0.78; 95 % CI: 0.73-0.84). Consistent patterns were observed across all forms of dementia and cognitive function decline. The overall evidence indicates notable variability in the outcome with a moderate-to-low degree of certainty. The TSA suggests that the total sample size of the included trials (155,647 patients) was significantly smaller than the required information size of 784,692 patients to discern the true effect of NOAC versus VKA in terms of reducing dementia risk. CONCLUSION NOACs may reduce the likelihood of developing dementia in patients with AF, particularly in those under the age of 75. This review highlights the urgent necessity for thorough research to determine the efficacy of NOACs in safeguarding cognitive health.
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Affiliation(s)
- Kun-Han Lee
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiunn-Tyng Yeh
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meng-Lun Wu
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yu Yeh
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chern-En Chiang
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Chen-Huan Chen
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan; ReShining Clinic, Taipei, Taiwan
| | - Hao-Min Cheng
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan; College of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Ph.D. Program of Interdisciplinary Medicine (PIM), National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Division of Faculty Development, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.
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24
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Hara H, Kubo S, Nakajima Y, Matsumoto T, Kondo Y, Sugane H, Okubo K, Nakagawa K, Nagatomo D, Hachinohe D, Kusa S, Goya M, Nanasato M, Arita T, Yamasaki H, Kuwabara K, Yoshiyama T, Tanaka N, Masuda M, Sakamoto T, Nakashima M, Ohno Y, Saito S, Fukunaga M. Initial results of transcatheter modification of left atrial appendage by obliteration with device in patients with nonvalvular atrial fibrillation: Real-world data from the TERMINATOR registry. J Cardiol 2024; 83:298-305. [PMID: 37802202 DOI: 10.1016/j.jjcc.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/15/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has increased for those who need alternative to long-term anticoagulation with non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS From September 2019, after initiating WATCHMAN (Boston Scientific, Maple Grove, MN, USA) device implantation, we established Transcatheter Modification of Left Atrial Appendage by Obliteration with Device in Patients from the NVAF (TERMINATOR) registry. Utilizing 729 patients' data until January 2022, we analyzed percutaneous LAAC data regarding this real-world multicenter prospective registry. A total of 729 patients were enrolled. Average age was 74.9 years and 28.5 % were female. Paroxysmal AF was 37.9 % with average CHADS2 3.2, CHA2DS2-VASc 4.7, and HAS-BLED score of 3.4. WATCHMAN implantation was successful in 99.0 %. All-cause deaths were 3.2 %, and 1.2 % cardiovascular or unexplained deaths occurred during follow-up [median 222, interquartile range (IQR: 93-464) days]. Stroke occurred in 2.2 %, and the composite endpoint which included cardiovascular or unexplained death, stroke, and systemic embolism were counted as 3.4 % [median 221, (IQR: 93-464) days]. Major bleeding defined as BARC type 3 or 5 was seen in 3.7 %, and there was 8.6 % of all bleeding events in total [median 219, (IQR: 93-464) days]. CONCLUSIONS These preliminary data demonstrated percutaneous LAAC with WATCHMAN device might have a potential to reduce stroke and bleeding events for patients with NVAF. Further investigation is mandatory to confirm the long-term results of this strategy using this transcatheter local therapy instead of life-long systemic anticoagulation.
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Affiliation(s)
- Hidehiko Hara
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | | | - Takashi Matsumoto
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroki Sugane
- Division of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Kenji Okubo
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Hospital, Okayama, Japan
| | - Daisuke Nagatomo
- Division of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Daisuke Hachinohe
- Department of Cardiovascular Medicine, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Shigeki Kusa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Takeshi Arita
- Division of Cardiovascular Medicine, Fukuoka Wajiro Hospital, Fukuoka, Japan
| | - Hiro Yamasaki
- Department of Cardiology, University of Tsukuba, Tsukuba, Japan
| | - Kensuke Kuwabara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Tomotaka Yoshiyama
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Tanaka
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Masaharu Masuda
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tomohiro Sakamoto
- Cardiovascular Center Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Shigeru Saito
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Fukunaga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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25
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Lee KH, Hung WT, Huang WY, Ovbiagele B, Lee M. Direct oral anticoagulants compared with other strategies in patients with atrial fibrillation and stroke or transient ischemic attack: Systematic review. J Formos Med Assoc 2024; 123:551-560. [PMID: 37838540 DOI: 10.1016/j.jfma.2023.10.007] [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: 07/12/2023] [Revised: 09/17/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND For patients with atrial fibrillation and a prior stroke or transient ischemic attack (TIA), the risk-benefit of direct oral anticoagulants (DOACs) compared to alternative treatment approaches has not been firmly established. We conducted a systematic review of randomized controlled trials (RCTs) to investigate efficacy and safety of DOACs vs warfarin and DOACs vs aspirin or placebo in patients with AF and a prior stroke or TIA. METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from January 1, 2000, to January 31, 2023, to find RCTs. Risk ratio (RR) with 95 % CI measured the association of DOACs vs warfarin, and DOACs vs aspirin or placebo, with clinical outcomes. Primary efficacy outcome was stroke or systemic embolism and primary safety outcome was ICH. RESULTS We identified 7 RCTs with 19,111 patients with AF and a prior stroke or TIA, of which 5 trials compared DOACs with warfarin and 2 trials compared DOACs vs aspirin or placebo. Compared with warfarin, DOACs were associated with a lower risk of stroke or systemic embolism (RR, 0.85; 95 % CI, 0.75-0.97) and ICH (RR, 0.53; 95 % CI, 0.41-0.68). Compared with aspirin or placebo, DOACs were associated with a reduced risk of stroke or systemic embolism (RR, 0.33; 95 % CI, 0.19-0.58) and risk of ICH did not differ between apixaban and aspirin. CONCLUSION This contemporary evaluation of the literature indicates that DOACs, rather than other antithrombotic agents or no treatment, should be used in patients with AF and a prior stroke or TIA.
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Affiliation(s)
- Kuan-Hsin Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
| | - Wei-Tse Hung
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan.
| | - Wen-Yi Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
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26
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Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
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Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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27
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Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H. Characteristics and outcomes in elderly patients with non-valvular atrial fibrillation and high bleeding risk: subanalysis of the J-RHYTHM Registry. Heart Vessels 2024; 39:330-339. [PMID: 38103100 PMCID: PMC10920444 DOI: 10.1007/s00380-023-02343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
Recently, a once-daily dose of edoxaban (15-mg) has been approved for stroke prevention in non-valvular atrial fibrillation (NVAF) patients aged ≥ 80 years, in whom standard oral anticoagulants are not recommended because of high bleeding risk (HBR), based on the ELDERCARE-AF trial. However, information regarding the characteristics and clinical outcomes among such patients is limited. Thus, this study aimed to clarify the characteristics and event rates in elderly patients with NVAF and HBR defined by the ELDERCARE-AF criteria. Of the 7406 NVAF outpatients included in the J-RHYTHM Registry, 60 patients with creatinine clearance (CrCl) < 15 mL/min were excluded. The remaining 7346 patients (age, 69.7 ± 9.9 years; men, 70.9%; warfarin use, 78.7%) were divided into three groups: Group 1, aged < 80 years (n = 6165); Group 2, aged ≥ 80 years without HBR (n = 584); and Group 3, aged ≥ 80 years with HBR (at least one of the followings; CrCl, 15-30 mL/min, history of bleeding, body weight ≤ 45 kg, and antiplatelet use) (n = 597, eligible for 15-mg edoxaban). Patients in Group 3 had a higher prevalence of comorbidities, and therefore, both higher thromboembolic and bleeding risk scores than in the other groups. During the 2-year follow-up period, the incidence rates (per 100 person-years) of thromboembolism in Groups 1, 2, and 3 were 0.7, 1.5, and 2.1 (P < 0.001), major hemorrhage, 0.8, 1.2, and 2.0 (P < 0.001), and all-cause death, 0.8, 2.6, and 4.6 (P < 0.001), respectively. Adjusted hazard ratios of Group 3 were 1.64 (95% confidence interval 0.89-3.04, P = 0.116) for thromboembolism, 1.53 (0.85-2.72, P = 0.154) for major hemorrhage, and 1.84 (1.19-2.85, P = 0.006) for all-cause death compared with Group 1. The NVAF Patients aged ≥ 80 years with HBR defined by the ELDERCARE-AF criteria were certainly at a higher adverse event risk, especially for all-cause death. Clinical trial registration: The J-RHYTHM Registry is registered in the University Hospital Medicine Information Network (UMIN) Clinical Trials Registry (unique identifier: UMIN000001569) http://www.umin.ac.jp/ctr/ .
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Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 206-8512, Japan.
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Nguyen TN, Ahmad F, Lindley RI. Frailty in clinical drug trials: Frailty assessments, subgroup analyses and outcomes. Br J Clin Pharmacol 2024. [PMID: 38509766 DOI: 10.1111/bcp.16034] [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: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/18/2024] [Indexed: 03/22/2024] Open
Abstract
With population ageing, drug trials are increasingly turning their attention to including older, frailer people. This review aimed to provide an overview of how frailty was assessed in published studies related to clinical pharmacological trials, and on the interaction of frailty on the efficacy of the treatments. We searched MEDLINE, EMBASE and Cochrane for clinical drug trials in older people. A total of 4031 abstracts were screened and 17 relevant studies were included in this review. We summarized the findings of these 17 trials into five main clinical areas: cardiovascular (eight studies), cognition (one study), vaccination (two studies), cancer (four studies) and other (two studies). Frailty was assessed retrospectively in most of the studies. Frailty was treated as an ordinal variable (with different levels of frailty) or binary variable (frail/non-frail) using cut-offs in some studies, and as a continuous in some other studies. The effect of frailty on the treatment efficacy was not consistent among the studies. While several trials, such as the Action in Diabetes and Vascular Disease-Preterax and Diamicron Modified Release Controlled Evaluation trials, the Systolic Blood Pressure Intervention Trial and the Aspirin in Reducing Events in the Elderly trial, showed some reduced effects of the treatment in frail patients, most of the trials showed that the benefits of the treatment are not affected by frailty. Some trials even showed that the benefits of the treatment were more significant in frailer patients (the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure and the Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure trials). The results of this review suggest that routine measurement of frailty in participants in clinical drug trials would improve our knowledge of the effect of treatment in the frail and identify those who have more or least to gain from treatment.
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Affiliation(s)
- Tu N Nguyen
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fahed Ahmad
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Richard I Lindley
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
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Griffin M, Lip GY. Clinical trial evaluation: the EDOSURE clinical trial program. Future Cardiol 2024; 20:171-177. [PMID: 39049770 DOI: 10.1080/14796678.2024.2354079] [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: 09/11/2023] [Accepted: 05/08/2024] [Indexed: 07/27/2024] Open
Abstract
EDOSURE is a trial program of the direct oral anticoagulant drug edoxaban, comprising ten randomized clinical trials of which eight are currently published. They evaluate the use of edoxaban in the treatment of nonvalvular atrial fibrillation and acute venous thromboembolism, including in special circumstances such as patients undergoing cardiac procedures, cancer-associated venous thromboembolism, and elderly patients whose bleeding risk precludes conventional anticoagulation strategies. As a result of the collective evidence generated by EDOSURE, edoxaban is now recommended as a treatment option by numerous international guidelines. This review summarizes the context, rationale, and key findings of the studies.
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Affiliation(s)
- Michael Griffin
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University & Liverpool Heart & Chest Hospital, L14 3PE, Liverpool, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University & Liverpool Heart & Chest Hospital, L14 3PE, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9260, Aalborg, Denmark
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31
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Wing SL, Mavrakanas TA, Harel Z. Oral Anticoagulation Use in Individuals With Atrial Fibrillation and Chronic Kidney Disease: A Review. Semin Nephrol 2024; 44:151517. [PMID: 38744617 DOI: 10.1016/j.semnephrol.2024.151517] [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] [Indexed: 05/16/2024]
Abstract
Atrial fibrillation (AF) is highly prevalent in patients with chronic kidney disease (CKD). It is associated with an increased risk of stroke, which increases as kidney function declines. In the general population and in those with a moderate degree of CKD (creatinine clearance 30-50 mL/min), the use of oral anticoagulation to decrease the risk of stroke has been the standard of care based on a favorable risk-benefit profile that had been established in seminal randomized controlled trials. However, evidence regarding the use of oral anticoagulants for stroke prevention is less clear in patients with severe CKD (creatinine clearance <30 mL/min) and those receiving maintenance dialysis, as these individuals were excluded from such large randomized controlled trials. Nevertheless, the direct oral anticoagulants have invariably usurped vitamin K antagonists as the preferred choice for oral anticoagulation among patients with AF across all strata of CKD based on their well-defined safety and efficacy and multiple pharmacokinetic benefits (e.g., less drug-drug interactions). This review summarizes the current literature on the role of oral anticoagulation in the management of AF among patients with CKD and highlights current deficiencies in the evidence base and how to overcome them.
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Affiliation(s)
- Sara L Wing
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada
| | - Ziv Harel
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
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32
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Iguchi M, Tamargo J, Hasegawa K. Are NOACs always the best strategy in elderly AF patients? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:100-102. [PMID: 38031332 DOI: 10.1093/ehjcvp/pvad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Moritake Iguchi
- Department of Cardiac Rehabilitation, National Hospital Organization Kyoto Medical Center, 612-8555 Kyoto, Japan
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, 28040 Madrid, Spain
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, 612-8555 Kyoto, Japan
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Yamashita Y, Fukasawa T, Takeda C, Takeuchi M, Ono K, Kawakami K. Clinical Characteristics and Outcomes of Patients With Venous Thromboembolism Receiving Edoxaban in the Real World. Circ J 2024; 88:371-379. [PMID: 38143083 DOI: 10.1253/circj.cj-23-0818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND The effectiveness and safety of edoxaban for venous thromboembolism (VTE) in unselected real-world patients have not been fully evaluated. METHODS AND RESULTS In the Japanese nationwide administrative database, we identified 6,262 VTE patients in whom edoxaban was initiated; these patients were divided into 3 groups based on their index doses: 15 mg/day (n=235), 30 mg/day (n=4,532), and 60 mg/day (n=1,495). We evaluated patient characteristics, recurrent VTEs, and a composite endpoint of intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding. Patient characteristics among the 15-, 30-, and 60-mg edoxaban groups varied widely regarding several aspects, including age (mean 81.0, 76.2, and 65.0 years, respectively) and body weight (mean 49.5, 51.8, and 70.3 kg, respectively). At 180 days, the cumulative incidence of recurrent VTEs in the 15-, 30-, and 60-mg edoxaban groups was 4.4%, 2.6%, and 1.8%, respectively, whereas that of ICH or GI bleeding was 7.3%, 5.4%, and 3.3%, respectively. Subgroup analyses showed that the cumulative incidence of ICH or GI bleeding in patients in the 15-mg edoxaban group was 3.6% for patients aged ≥80 years, 8.4% for those with a body weight <60 kg, and 31.3% for those with renal dysfunction. CONCLUSIONS Only a minority of patients with VTEs received a super low dose (15 mg) of edoxaban, and these patients may be at higher risk of bleeding as well as VTE recurrence.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Toshiki Fukasawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
- Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
- Department of Anesthesia, Kyoto University Hospital
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
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34
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Adachi S, Adachi T, Nakano Y. Unapproved Dose of Direct Oral Anticoagulants for Venous Thromboembolism - Right or Wrong? Circ J 2024; 88:380-381. [PMID: 38296552 DOI: 10.1253/circj.cj-24-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Shiro Adachi
- Department of Cardiology, Nagoya University Hospital
| | | | - Yoshihisa Nakano
- Center for Advanced Medicine and Clinical Research, Department of Advanced Medicine, Nagoya University Hospital
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35
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Akao M, Yamashita T, Fukuzawa M, Hayashi T, Okumura K. Efficacy and Safety of Low-Dose Edoxaban by Body Weight in Very Elderly Patients With Atrial Fibrillation: A Subanalysis of the Randomized ELDERCARE-AF Trial. J Am Heart Assoc 2024; 13:e031506. [PMID: 38240204 PMCID: PMC11056111 DOI: 10.1161/jaha.123.031506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/30/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND The ELDERCARE-AF trial showed that low-dose edoxaban benefits elderly patients with nonvalvular atrial fibrillation considered ineligible for standard oral anticoagulants due to high bleeding risk, but whether this applied to patients with extremely low body weight was unclear. METHODS AND RESULTS This was a prespecified subanalysis by body weight (≤45, >45 kg) of the phase 3, multicenter, randomized, double-blind, placebo-controlled, event-driven ELDERCARE-AF trial, which compared low-dose edoxaban (15 mg once daily) with placebo in Japanese patients considered ineligible for oral anticoagulants at the recommended therapeutic strength or the approved doses. The primary efficacy and safety end points were stroke or systemic embolism and major bleeding (International Society on Thrombosis and Hemostasis definition), respectively. The ≤45-kg weight group included 374/984 patients (38.0%), and the >45-kg group included 610/984 patients (62.0%). The stroke or systemic embolism rate was lower with edoxaban than placebo in both weight groups (≤45 kg: hazard ratio [HR], 0.36 [95% CI, 0.16-0.80]; >45 kg: HR, 0.31 [95% CI, 0.13-0.73]; interaction P=0.82). Major bleeding incidence was numerically higher with edoxaban than placebo (≤45 kg: HR, 3.05 [95% CI, 0.84-11.11]; >45 kg: HR, 1.40 [95% CI, 0.56-3.48), with no interaction with body weight (interaction P=0.33). All-cause mortality was higher in the ≤45-kg group, with no significant difference between treatment groups. CONCLUSIONS The benefit of edoxaban 15 mg was consistent in elderly patients with atrial fibrillation and extremely low body weight, though clinicians must remain vigilant about the risk of major bleeding, especially gastrointestinal bleeding. REGISTRATION INFORMATION ClinicalTrials.gov. Identifier: NCT02801669.
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Affiliation(s)
- Masaharu Akao
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | | | - Masayuki Fukuzawa
- Cardiovascular Group, Primary Medical Science Department, Japan Business Unit, Daiichi Sankyo Co., Ltd.TokyoJapan
| | - Takuya Hayashi
- Data Intelligence Group, Data Intelligence Department, Digital Transformation Management Division, Daiichi Sankyo Co., Ltd.TokyoJapan
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
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36
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Guo X, Du J, Yang Y, Wu M, Ou W, Han X, Wang Z, Jin J, Zhang P, Zhang Z, Chen G, Long M, Yin G, Liu T, Wang X, Li D, Chen M, Dong Y, Lai C, Zhang X, Yi Y, Xiang J, Chen C, Unverdorben M, Ma C. Edoxaban for stroke prevention in atrial fibrillation and factors associated with dosing: patient characteristics from the prospective observational ETNA-AF-China registry. Sci Rep 2024; 14:2778. [PMID: 38307927 PMCID: PMC10837439 DOI: 10.1038/s41598-024-51776-3] [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: 10/18/2023] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
Real-world data on effectiveness and safety of a single non-vitamin K antagonist oral anticoagulant in the Chinese population with atrial fibrillation (AF) are limited. This study reports characteristics of patients treated with edoxaban and factors associated with dosing patterns from routine care in China. ETNA-AF-China (NCT04747496) is a multicentre, prospective, observational study enrolling edoxaban-treated patients from four economic regions with a targeted 2-year follow-up. Of the 4930 patients with AF (mean age: 70.2 ± 9.5 years; male, 57.1%), the mean creatinine clearance (CrCl), CHA2DS2-VASc, and HAS-BLED scores were 71.2 mL/min, 2.9, and 1.6. Overall, 6.4% of patients were perceived as frail by investigators. Available label dose reduction criteria (N = 4232) revealed that 3278 (77.5%) patients received recommended doses and 954 (22.5%) non-recommended doses. Northeast (53.0%) and West (43.1%) regions had the highest prescriptions of 60 mg and 30 mg recommended doses, respectively. Non-recommended 30 mg doses were more frequently prescribed in patients with antiplatelet use and history of heart failure than recommended 60 mg. Multivariate analysis identified advanced age as the strongest associated factor with non-recommended doses. Frailty had the strongest association with 30 mg except for age, and history of TIA was the most relevant factor associated with 60 mg. In conclusion, patients in the ETNA-AF-China study were predominantly aged 65 years and older, had mild-to-moderate renal impairment and good label adherence. Advanced age was associated with non-recommended doses, with frailty most common for non-recommended 30 mg and a history of TIA for the non-recommended 60 mg dose.
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Affiliation(s)
- Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Juan Du
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Yang Yang
- Department of Cardiology, The Second Affiliated Hospital of Shenyang Medical College, Shenyang, 110004, Liaoning, China
| | - Mingxing Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411199, Hunan, China
| | - Wenchao Ou
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Xuebin Han
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, 030024, Shanxi, China
| | - Zhifang Wang
- Deparment of Vasculocardiology, Xinxiang Central Hospital, Xinxiang, 453001, Henan, China
| | - Jing Jin
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, China
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, 102218, Beijing, China
| | - Zheng Zhang
- Department of Cardiology, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201799, Shanghai, China
| | - Guoqin Chen
- Department of Cardiology, Guangzhou Panyu Central Hospital, Guangzhou, 511486, Guangdong, China
| | - Mingzhi Long
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210003, Jiangsu, China
| | - Guotian Yin
- Department of Cardiology, The Third Affiliated Hospital Of Xinxiang Medical University, Xinxiang, 453699, Henan, China
| | - Tong Liu
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, Tianjin, China
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, 214125, Jiangsu, China
| | - Dongsheng Li
- Department of Cardiology, Wuhan Third Hospital, Wuhan, 430074, Hubei, China
| | - Manhua Chen
- Department of Cardiology, The Central Hospital of Wuhan, Wuhan, 430014, Hubei, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Chunlin Lai
- Department of Cardiology, Shanxi Provincial People's Hospital, Taiyuan, 043599, Shanxi, China
| | - Xuelian Zhang
- Department of Cardiology, Jilin Province People's Hospital, Changchun, 130021, Jilin, China
| | - Yuan Yi
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Jing Xiang
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Cathy Chen
- Medical Department, Daiichi Sankyo Inc., Basking Ridge, NJ, 07920-2311, USA
| | - Martin Unverdorben
- Medical Department, Daiichi Sankyo Inc., Basking Ridge, NJ, 07920-2311, USA
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
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Chao TF, Potpara TS, Lip GY. Atrial fibrillation: stroke prevention. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100797. [PMID: 38362551 PMCID: PMC10867001 DOI: 10.1016/j.lanepe.2023.100797] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024]
Abstract
Stroke prevention is central to the management of patients with atrial fibrillation (AF) which has moved towards a more holistic or integrative care approach. The published evidence suggests that management of AF patients following such a holistic approach based on the Atrial fibrillation Better Care (ABC) pathway is associated with a lower risk of stroke and adverse events. Risk assessment, re-assessment and use of direct oral anticoagulants (DOACs) are important for stroke prevention in AF. The stroke and bleeding risks of AF patients are not static and should be re-assessed regularly. Bleeding risk assessment is to address and mitigate modifiable bleeding risk factors, and to identify high bleeding risk patients for early review and follow-up. Well-controlled comorbidities and healthy lifestyles also play an important role to achieve a better clinical outcome. Digital health solutions are increasingly relevant in the diagnosis and management of patients with AF, with the potential to improve stroke prevention. In this review, we provide an update on stroke prevention in AF, including importance of holistic management, risk assessment/re-assessment, and stroke prevention for special AF populations. Evidence-based and structured management of AF patients would reduce the risk of stroke and other adverse events.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tatjana S. Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Goldhaber SZ, Bassand JP, Camm AJ, Virdone S, Pieper K, Cools F, Corbalan R, Gersh BJ, Goto S, Haas S, Misselwitz F, Parkhomenko A, Steffel J, Stepinska J, Turpie AGG, Verheugt FWA, Kayani G, Kakkar AK. Clinical Outcomes in Older Patients with Atrial Fibrillation: Insights from the GARFIELD-AF Registry. Am J Med 2024; 137:128-136.e13. [PMID: 37918777 DOI: 10.1016/j.amjmed.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underutilized in older patients with atrial fibrillation, despite proven clinical benefits. Our objective was to investigate baseline characteristics, treatment patterns, and impact of anticoagulation upon clinical outcomes with respect to age. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed up for 24 months. Adjusted hazard ratios (HR) were obtained via Cox proportional-hazards models with applied weights, to quantify the association of age with clinical outcomes. Comparative effectiveness of OAC vs No OAC and non-vitamin K oral anticoagulants (NOAC) vs vitamin K antagonists (VKA) were assessed using a propensity score with an overlap weighting scheme. RESULTS Of 52,018 patients, 32.6% were 65-74 years of age, 29.3% were 75-84 years, and 7.9% were ≥85 years. OAC treatment was associated with a numerical reduction in all-cause mortality among those aged 65-74 years (HR; 95% confidence interval) (0.86; 0.69-1.06) and aged 75-84 years (0.89; 0.75-1.05) and a significant reduction in patients ≥85 years (0.77; 0.63-0.95) vs no OAC. Similarly, OACs were associated with a decrease in stroke: 65-74 (0.51; 0.35-0.76) and ≥85 years (0.58; 0.34-0.99) and a numerical decrease in 75-84 years (0.84; 0.59-1.18). No increase in major bleeding was observed in patients aged ≥85 treated with OACs. Compared with VKA, NOACs were associated with a significant reduction in all-cause mortality in patients aged <65 and 65-74, with numerical reductions in those aged 75-84 and ≥85 years. CONCLUSIONS Older patients using OACs saw lower all-cause mortality and stroke risk; NOACs had less mortality and major bleeding compared with VKAs.
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Affiliation(s)
| | | | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's University of London, London, UK
| | | | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Ramon Corbalan
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Technical University of Munich, Germany
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Kreutz R, Deray G, Floege J, Gwechenberger M, Hahn K, Luft AR, Persson P, Axthelm C, Beer JH, Bergler-Klein J, Lellouche N, Taggeselle J, Coleman CI, Beyer-Westendorf J. Rivaroxaban vs Vitamin K Antagonist in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease. JACC. ADVANCES 2024; 3:100813. [PMID: 38939389 PMCID: PMC11198259 DOI: 10.1016/j.jacadv.2023.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 06/29/2024]
Abstract
Background Treatment with vitamin K antagonists (VKAs) has been linked to worsening of kidney function in patients with atrial fibrillation (AF). Objectives XARENO (Factor XA-inhibition in RENal patients with non-valvular atrial fibrillation Observational registry; NCT02663076) is a prospective observational study comparing adverse kidney outcomes in patients with AF and advanced chronic kidney disease receiving rivaroxaban or VKA. Methods Patients with AF and an estimated glomerular filtration rate (eGFR) of 15 to 49 mL/min/1.73 m2 were included. Blinded adjudicated outcome analysis evaluated adverse kidney outcomes (a composite of eGFR decline to <15 mL/min/1.73 m2, need for chronic kidney replacement therapy, or development of acute kidney injury). A composite net clinical benefit outcome (stroke or systemic embolism, major bleeding, myocardial infarction, acute coronary syndrome, or cardiovascular death) was also analyzed. HRs with 95% CIs were calculated using propensity score overlap weighting Cox regression. Results There were 1,455 patients (764 rivaroxaban; 691 VKA; mean age 78 years; 44% females). The mean eGFR was 37.1 ± 9.0 in those receiving rivaroxaban and 36.4 ± 10.1 mL/min/1.73 m2 in those receiving VKA. After a median follow-up of 2.1 years, rivaroxaban was associated with less adverse kidney outcomes (HR: 0.62; 95% CI: 0.43-0.88) and all-cause death (HR: 0.76, 95% CI: 0.59-0.98). No significant differences were observed in net clinical benefit. Conclusions In patients with AF and advanced chronic kidney disease, those receiving rivaroxaban had less adverse kidney events and lower all-cause mortality compared to those receiving VKA, supporting the use of rivaroxaban in this high-risk group of patients.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Gilbert Deray
- Department of Nephrology, Pitié-Salpêtrière Hospital, Paris, France
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Marianne Gwechenberger
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Kai Hahn
- Nephrologische Praxis, Dortmund, Germany
| | - Andreas R. Luft
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
- Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Pontus Persson
- Institut für Vegetative Physiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Juerg Hans Beer
- Department Innere Medizin, Kantonsspital Baden, Baden, Switzerland
- Center of Molecular Cardiology, University of Zürich, Zürich, Switzerland
| | - Jutta Bergler-Klein
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nicolas Lellouche
- Service de Cardiologie 1, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | | | - Craig I. Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division Thrombosis & Hemostasis, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Liuzzo G, Patrono C. Edoxaban for atrial high-rate episodes: more harm than good? Eur Heart J 2024; 45:330-331. [PMID: 38073245 DOI: 10.1093/eurheartj/ehad791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Affiliation(s)
- Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F. Vito 1, Rome 00168, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, Rome 00168, Italy
| | - Carlo Patrono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F. Vito 1, Rome 00168, Italy
- Department of Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, Rome 00168, Italy
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Doni K, Bühn S, Weise A, Mann NK, Hess S, Sönnichsen A, Salem S, Pieper D, Thürmann P, Mathes T. Safety outcomes of direct oral anticoagulants in older adults with atrial fibrillation: a systematic review and meta-analysis of (subgroup analyses from) randomized controlled trials. GeroScience 2024; 46:923-944. [PMID: 37261677 PMCID: PMC10828375 DOI: 10.1007/s11357-023-00825-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023] Open
Abstract
Balancing stroke prevention and risk of bleeding in patients with atrial fibrillation (AF) is challenging. Direct oral anticoagulants (DOACs) are by now considered standard of care for treating patients with AF in international guidelines. Our objective was to assess the safety of long-term intake of DOACs in older adults with AF. We included RCTs in elderly (≥ 65 years) patients with AF. A systematic search in MEDLINE and EMBASE was performed on 19 April 2022. For determination of risk of bias, the RoB 2 tool was applied. We pooled outcomes using random-effects meta-analyses. The quality of evidence was assessed using GRADE. Eleven RCTs with a total of 63,374 patients were identified. Two RCTs compared apixaban with either warfarin or aspirin, four edoxaban with either placebo, aspirin, or vitamin K antagonists (VKAs), two dabigatran with warfarin and three rivaroxaban with warfarin. DOACs probably reduce mortality in elderly patients with AF (HR 0.89 95%CI 0.77 to 1.02). Low-dose DOACs likely reduce bleeding compared to VKAs (HR ranged from 0.47 to 1.01). For high-dose DOACS the risk of bleeding varied widely (HR ranged from 0.80 to 1.40). We found that low-dose DOACs probably decrease mortality in AF patients. Moreover, apixaban and probably edoxaban are associated with fewer major or clinically relevant bleeding (MCRB) events compared to VKAs. For dabigatran and rivaroxaban, the risk of MCRB varies depending on dose. Moreover, subgroup analyses indicate that in the very old (≥ 85) the risk for MCRB events might be increased when using DOACs.Registration: PROSPERO: CRD42020187876.
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Affiliation(s)
- Katharina Doni
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
- Institute for Health Economics and Clinical Epidemiology of the University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Stefanie Bühn
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Alina Weise
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Nina-Kristin Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | | | - Susanna Salem
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Tim Mathes
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany.
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.
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Kataoka N, Imamura T. How to Improve Very Low Adherence to Anticoagulation Therapy in Elderly Patients with Non-Valvular Atrial Fibrillation [Letter]. Patient Prefer Adherence 2024; 18:91-92. [PMID: 38223439 PMCID: PMC10788068 DOI: 10.2147/ppa.s455391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Hashimoto S, Motozawa Y, Mano T. Digital marketing innovation: New business models for pharmaceutical and medical device product marketing. Digit Health 2024; 10:20552076241279186. [PMID: 39224793 PMCID: PMC11367697 DOI: 10.1177/20552076241279186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024] Open
Abstract
Background Within the rapidly evolving healthcare landscape in Japan, digital marketing innovations are transforming pharmaceutical and medical device marketing. This study explores the emergence of new business models in the digital marketing, highlighting a transition from traditional methods to more dynamic, data-driven strategies. Methods InsighTCROSS® is a business model that qualitatively and quantitatively examines three steps based on stratified persona images: (1) verifying the effectiveness of product marketing promotions, (2) identifying competitors from the users' perspective, and (3) developing marketing strategies to counter competition. To demonstrate the effectiveness of this model, a case study was conducted focusing on the current anticoagulant drugs, including apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin. Results Rivaroxaban, the only drug prescribed for the prevention of thrombus and embolism formation in patients with peripheral artery disease after lower limb revascularization, garnered the most interest from interventional cardiologists performing peripheral vascular interventions, as determined by InsighTCROSS® factor analysis, confirming that the manufacturer's marketing activities have effectively penetrated the market. A survey conducted between 20 September 2023 and 3 October 2023, among members of a cardiology website, identified edoxaban as the market leader with a 39.1% share, followed by apixaban (32.7%) and rivaroxaban (16.8%). The main competitor of edoxaban was warfarin, whereas that of rivaroxaban was apixaban. Decision tree analysis was conducted using InsighTCROSS®, highlighting the strengths and weaknesses of each anticoagulant, providing strategic approaches to exploit competitive weaknesses. For edoxaban, increased use was driven by elderly and poorly adherent patients; for apixaban, high-volume percutaneous coronary intervention centers; and for rivaroxaban, the influence of medical representative detailing. It is recommended to avoid markets where these drugs have a strong presence and to focus marketing activities on leveraging their specific strengths. Conclusion The findings suggest that digital marketing enhances product visibility and patient engagement, providing valuable insights into market behavior and consumer preferences.
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Affiliation(s)
- Satoru Hashimoto
- Department of Strategic Business Management, TCROSS Co., Ltd, Tokyo, Japan
- Graduate School of Strategic Management, Chuo University, Tokyo, Japan
| | - Yoshihiro Motozawa
- Department of Strategic Business Management, TCROSS Co., Ltd, Tokyo, Japan
- Department of Internal Medicine, San-ikukai Hospital, Tokyo, Japan
| | - Toshiki Mano
- Graduate School of Strategic Management, Chuo University, Tokyo, Japan
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Kessler A, Kolben Y, Puris G, Ellis M, Alperin M, Simovich V, Lerman Shivek H, Muszkat M, Maaravi Y, Biton Y. Direct Oral Anticoagulants in Special Patient Populations. J Clin Med 2023; 13:216. [PMID: 38202223 PMCID: PMC10779957 DOI: 10.3390/jcm13010216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.
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Affiliation(s)
- Asa Kessler
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Yotam Kolben
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Gal Puris
- Faculty of Medicine, Institute for Research in Military Medicine, Hebrew University of Jerusalem, Israel Defense Force Medical Corps, Jerusalem 9112002, Israel;
| | - Martin Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba 4428164, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mordechai Alperin
- Department of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Clalit Health Services, Haifa and Western Galilee District, Tel Aviv 6209804, Israel
| | | | - Hila Lerman Shivek
- Hospital Pharmacy Department, Hospitals Division, Clalit Health Services, Tel Aviv 6209804, Israel;
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Mt. Scopus, Jerusalem 9112002, Israel;
| | - Yoram Maaravi
- The Jerusalem Institute of Aging Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel;
- Department of Geriatrics and Rehabilitation and the Center for Palliative Care, Hadassah Medical Center, Jerusalem 9371125, Israel
| | - Yitschak Biton
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
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Chan YH, Chao TF, Chen SW, Lee HF, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. Clinical outcomes in elderly atrial fibrillation patients at increased bleeding risk treated with very low dose vs. regular-dose non-vitamin K antagonist oral anticoagulants: a nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:681-691. [PMID: 37580139 DOI: 10.1093/ehjcvp/pvad058] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/11/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023]
Abstract
AIMS The Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial showed that edoxaban at a very low dosage (VLD) of 15 mg/day was more effective than a placebo at preventing stroke/systemic embolism without significantly increasing the risk of serious bleeding. We aimed to compare the effectiveness and safety for VLD non-vitamin K antagonist oral anticoagulants (NOACs) [edoxaban 15 mg o.d., dabigatran 110 or 150 o.d., apixaban 2.5 mg o.d., or rivaroxaban 10 mg (without the diagnosis of chronic kidney disease) or <10 mg o.d.] vs. regular-dosage (RD) NOACs (edoxaban 60/30 mg o.d. or other labeling-dosage NOACs) among a real-world cohort of elderly atrial fibrillation (AF) population similar to the ELDERCARE-AF cohort. METHODS AND RESULTS In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database (NHIRD), we identified a total of 7294 and 4151 consecutive AF patients aged 80 years or older with a CHADS2 (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack (2 points) score ≥2 who met the enrollment criteria (generally similar to ELDERCARE-AF) taking VLD and RD NOACs from 1 June 2012 to 31 December 2019, respectively. Propensity-score stabilized weighting (PSSW) was used to balance covariates across study groups. Patients were followed up from the first date of prescription for NOACs until the first occurrence of any study outcome, death, or until the end date of the study period (31 December 2020). After PSSW, VLD NOAC was associated with a comparable risk of ischemic stroke/systemic embolism and major bleeding but a higher risk of major adverse limb events (MALEs) requiring lower limb revascularization or amputation [hazard ratio (HR): 1.54, 95% confidential interval (CI): 1.09-2.18; P = 0.014), venous thrombosis (HR: 3.75, 95% CI: 1.56-8.97; P = 0.003), and all-cause mortality (HR: 1.21, 95% CI: 1.15-1.29; P <0.001) compared with RD NOACs. VLD NOACs showed worse outcomes in most net clinical outcome (NCO) benefits. The main result was consistent based on on-treatment analysis or accounting for death as a competing risk. In general, the advantage of NCOs for the RD NOACs over VLD NOACs persisted in most high-risk subgroups, consistent with the main analysis (P for interaction > 0.05). CONCLUSION Use of VLD NOACs was associated with a greater risk of arterial and venous thrombosis, death as well as the composite outcomes, when compared with that of RD NOAC in high-risk elderly AF patients at increased bleeding risk. Thromboprophylaxis with RD NOAC is still preferable over VLD NOAC for the majority of elderly AF patients at increased bleeding risk.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 112304, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng Branch), New Taipei City 236017, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City 33302, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
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Agewall S. The search for the perfect antiplatelet treatment continues. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:671-672. [PMID: 38093457 DOI: 10.1093/ehjcvp/pvad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Stefan Agewall
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, 171 77 Stockholm, Sweden
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Lin DS, Lo H, Huang K, Lin T, Lee J. Efficacy and Safety of Direct Oral Anticoagulants for Stroke Prevention in Older Patients With Atrial Fibrillation: A Network Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2023; 12:e030380. [PMID: 38014696 PMCID: PMC10727327 DOI: 10.1161/jaha.123.030380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Although older patients with atrial fibrillation are at heightened risk of thromboembolic and bleeding events, their optimal treatment choice remains uncertain. METHODS AND RESULTS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, EMBASE, and Cochrane databases for randomized controlled trials that compared thromboembolic or bleeding outcomes between a direct oral anticoagulant (DOAC) and a vitamin K antagonist (VKA) and reported outcomes for patients aged ≥75 years with atrial fibrillation. The efficacy outcome was the composite of stroke and systemic embolism. Safety outcomes included major bleeding, any clinically relevant bleeding, and intracranial hemorrhage. Each DOAC and VKA was compared pairwise in a network meta-analysis. High- and low-dose regimens and factor IIa and Xa inhibitors were also compared. Seven randomized controlled trials were included in the analysis. Stroke and systemic embolism risks did not differ significantly among DOACs. There were no significant differences in major bleeding between each DOAC and VKA. Intracranial hemorrhage risk was significantly lower with dabigatran, apixaban, and edoxaban than with VKA and rivaroxaban, which had similar risks. High-dose regimens led to lower risks of stroke or systemic embolism compared with VKA and low-dose regimens, with both doses having similar bleeding risks. CONCLUSIONS In patients aged ≥75 years with atrial fibrillation, DOACs were associated with fewer thromboembolic events compared with VKA, whereas dabigatran, apixaban, and edoxaban were associated with lower risks of intracranial hemorrhage compared with VKA and rivaroxaban. REGISTRATION URL: www.crd.york.ac.uk/prospero/. Unique identifier: CRD42022329557.
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Affiliation(s)
- Donna Shu‐Han Lin
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho‐Su Memorial HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Hao‐Yun Lo
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalHsin‐Chu BranchHsinchuTaiwan
| | - Kuan‐Chih Huang
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalHsin‐Chu BranchHsinchuTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
| | - Ting‐Tse Lin
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
| | - Jen‐Kuang Lee
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Department of Laboratory MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Cardiovascular CenterNational Taiwan University HospitalTaipeiTaiwan
- Telehealth CenterNational Taiwan University HospitalTaipeiTaiwan
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48
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Kailey BS, Koa-Wing M, Sutaria N, Mott T, Sohaib A, Qureshi N, Shi C, Padam P, Howard J, Kanagaratnam P. Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis. J Cardiovasc Electrophysiol 2023; 34:2552-2562. [PMID: 37962263 DOI: 10.1111/jce.16105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited. OBJECTIVES To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients. METHODS Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan-Meier survival analysis, with logrank testing for statistical significance. RESULTS Seventy-five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes. CONCLUSIONS Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.
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Affiliation(s)
- Balrik Singh Kailey
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | | | | | | | - Afzal Sohaib
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Uchiyama S. Anticoagulation in people with atrial fibrillation after intracranial haemorrhage. Lancet Neurol 2023; 22:1091-1092. [PMID: 37839435 DOI: 10.1016/s1474-4422(23)00331-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo 107-8332, Japan.
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Al-Shahi Salman R, Stephen J, Tierney JF, Lewis SC, Newby DE, Parry-Jones AR, White PM, Connolly SJ, Benavente OR, Dowlatshahi D, Cordonnier C, Viscoli CM, Sheth KN, Kamel H, Veltkamp R, Larsen KT, Hofmeijer J, Kerkhoff H, Schreuder FHBM, Shoamanesh A, Klijn CJM, van der Worp HB. Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials. Lancet Neurol 2023; 22:1140-1149. [PMID: 37839434 DOI: 10.1016/s1474-4422(23)00315-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The safety and efficacy of oral anticoagulation for prevention of major adverse cardiovascular events in people with atrial fibrillation and spontaneous intracranial haemorrhage are uncertain. We planned to estimate the effects of starting versus avoiding oral anticoagulation in people with spontaneous intracranial haemorrhage and atrial fibrillation. METHODS In this prospective meta-analysis, we searched bibliographic databases and trial registries using the strategies of a Cochrane systematic review (CD012144) on June 23, 2023. We included clinical trials if they were registered, randomised, and included participants with spontaneous intracranial haemorrhage and atrial fibrillation who were assigned to either start long-term use of any oral anticoagulant agent or avoid oral anticoagulation (ie, placebo, open control, another antithrombotic agent, or another intervention for the prevention of major adverse cardiovascular events). We assessed eligible trials using the Cochrane Risk of Bias tool. We sought data for individual participants who had not opted out of data sharing from chief investigators of completed trials, pending completion of ongoing trials in 2028. The primary outcome was any stroke or cardiovascular death. We used individual participant data to construct a Cox regression model of the time to the first occurrence of outcome events during follow-up in the intention-to-treat dataset supplied by each trial, followed by meta-analysis using a fixed-effect inverse-variance model to generate a pooled estimate of the hazard ratio (HR) with 95% CI. This study is registered with PROSPERO, CRD42021246133. FINDINGS We identified four eligible trials; three were restricted to participants with atrial fibrillation and intracranial haemorrhage (SoSTART [NCT03153150], with 203 participants) or intracerebral haemorrhage (APACHE-AF [NCT02565693], with 101 participants, and NASPAF-ICH [NCT02998905], with 30 participants), and one included a subgroup of participants with previous intracranial haemorrhage (ELDERCARE-AF [NCT02801669], with 80 participants). After excluding two participants who opted out of data sharing, we included 412 participants (310 [75%] aged 75 years or older, 249 [60%] with CHA2DS2-VASc score ≤4, and 163 [40%] with CHA2DS2-VASc score >4). The intervention was a direct oral anticoagulant in 209 (99%) of 212 participants who were assigned to start oral anticoagulation, and the comparator was antiplatelet monotherapy in 67 (33%) of 200 participants assigned to avoid oral anticoagulation. The primary outcome of any stroke or cardiovascular death occurred in 29 (14%) of 212 participants who started oral anticoagulation versus 43 (22%) of 200 who avoided oral anticoagulation (pooled HR 0·68 [95% CI 0·42-1·10]; I2=0%). Oral anticoagulation reduced the risk of ischaemic major adverse cardiovascular events (nine [4%] of 212 vs 38 [19%] of 200; pooled HR 0·27 [95% CI 0·13-0·56]; I2=0%). There was no significant increase in haemorrhagic major adverse cardiovascular events (15 [7%] of 212 vs nine [5%] of 200; pooled HR 1·80 [95% CI 0·77-4·21]; I2=0%), death from any cause (38 [18%] of 212 vs 29 [15%] of 200; 1·29 [0·78-2·11]; I2=50%), or death or dependence after 1 year (78 [53%] of 147 vs 74 [51%] of 145; pooled odds ratio 1·12 [95% CI 0·70-1·79]; I2=0%). INTERPRETATION For people with atrial fibrillation and intracranial haemorrhage, oral anticoagulation had uncertain effects on the risk of any stroke or cardiovascular death (both overall and in subgroups), haemorrhagic major adverse cardiovascular events, and functional outcome. Oral anticoagulation reduced the risk of ischaemic major adverse cardiovascular events, which can inform clinical practice. These findings should encourage recruitment to, and completion of, ongoing trials. FUNDING British Heart Foundation.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jayne F Tierney
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Philip M White
- Department of Neuroradiology, Newcastle-upon-Tyne Hospitals National Health Service Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stuart J Connolly
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Oscar R Benavente
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and Hospital Research Institute, Ottawa, ON, Canada
| | - Charlotte Cordonnier
- University of Lille, INSERM, CHU Lille, U1172-Lille Neuroscience & Cognition, Lille, France
| | - Catherine M Viscoli
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Roland Veltkamp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Kristin T Larsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Jeannette Hofmeijer
- Department of Neurology and Clinical Neurophysiology, Rijnstate Hospital, and University of Twente, Arnhem, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
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