1
|
Fumagalli S, Di Pasquale G, Pupo S, Agnelli G, Marchionni N. Patient-reported outcomes and apixaban therapy in older patients. Eur J Intern Med 2024; 124:156-159. [PMID: 38472046 DOI: 10.1016/j.ejim.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy.
| | - Giuseppe Di Pasquale
- Direzione Generale Cura della Persona, Salute e Welfare, Regione Emilia-Romagna, Bologna, Italy
| | - Simone Pupo
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine, University of Perugia, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy
| |
Collapse
|
2
|
Lin S, Liao Y, Tang S, Lin CC, Wang C. Changing or Retaining Direct Oral Anticoagulant After Ischemic Stroke Despite Direct Oral Anticoagulant Treatment. J Am Heart Assoc 2024; 13:e032454. [PMID: 38293918 PMCID: PMC11056173 DOI: 10.1161/jaha.123.032454] [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: 09/01/2023] [Accepted: 12/15/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND The optimal antithrombotic strategies for patients with atrial fibrillation who experience ischemic stroke (IS) despite direct oral anticoagulant (DOAC) therapy remain inconclusive. This study compared outcomes for patients with DOAC treatment failure who changed or retained their prestroke DOAC. METHODS AND RESULTS This retrospective cohort study analyzed data from the National Health Insurance Research Database from 2012 to 2020. Patients with atrial fibrillation who experienced IS during DOAC therapy were assigned to either (1) the DOAC-change group: changing prestroke DOAC or (2) the DOAC-retain group: retaining prestroke DOAC. The primary outcome was a composite of recurrent IS and transient ischemic attack. The secondary outcomes included intracranial hemorrhage, major bleeding, systemic thromboembolism, and all-cause death. Propensity score-based inverse probability of treatment weighting was applied to balance the baseline characteristics between the DOAC-change and DOAC-retain groups. The Cox proportional hazards model compared the risk of outcomes between the 2 groups. In total, 1979 patients were enrolled (609 DOAC-change patients and 1370 DOAC-retain patients). The incidence rates of recurrent IS or transient ischemic attack were 7.20 and 6.56 per 100 person-years in the DOAC-change and DOAC-retain groups, respectively (hazard ratio [HR], 1.07 [95% CI, 0.87-1.30]). A nonsignificantly higher incidence rate of intracranial hemorrhage was observed in the DOAC-change group compared with the DOAC-retain group (0.75 versus 0.53 per 100-person-years; HR, 1.49 [95% CI, 0.78-2.83]). The systemic thromboembolism, major bleeding, and death rates were comparable between the DOAC-change and DOAC-retain groups. CONCLUSIONS Changing prestroke DOAC does not reduce the risk of recurrent cerebral ischemia in patients with atrial fibrillation who develop IS during DOAC therapy. However, future studies should continue to observe the potential trends of increased intracranial hemorrhage risk.
Collapse
Affiliation(s)
- Shin‐Yi Lin
- Department of PharmacyNational Taiwan University HospitalTaipeiTaiwan
- School of Pharmacy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Yun‐Tsz Liao
- Department of PharmacyNational Taiwan University HospitalTaipeiTaiwan
- Institute of Health Policy and ManagementCollege of Public Health, National Taiwan UniversityTaipeiTaiwan
- Master of Public Health ProgramCollege of Public Health, National Taiwan UniversityTaipeiTaiwan
| | - Sung‐Chun Tang
- Stroke Center and Department of NeurologyNational Taiwan University HospitalTaipeiTaiwan
| | - Ching‐Ching Claire Lin
- Institute of Health Policy and ManagementCollege of Public Health, National Taiwan UniversityTaipeiTaiwan
- Master of Public Health ProgramCollege of Public Health, National Taiwan UniversityTaipeiTaiwan
| | - Chi‐Chuan Wang
- Department of PharmacyNational Taiwan University HospitalTaipeiTaiwan
- School of Pharmacy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
- Graduate Institute of Clinical Pharmacy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| |
Collapse
|
3
|
Dietrich F, Polymeris AA, Albert V, Engelter ST, Hersberger KE, Schaedelin S, Lyrer PA, Arnet I. Intake reminders are effective in enhancing adherence to direct oral anticoagulants in stroke patients: a randomised cross-over trial (MAAESTRO study). J Neurol 2024; 271:841-851. [PMID: 37831125 PMCID: PMC10827905 DOI: 10.1007/s00415-023-12035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) effectively prevent recurrent ischaemic events in atrial fibrillation (AF) patients with recent stroke. However, excellent adherence to DOAC is mandatory to guarantee sufficient anticoagulation as the effect quickly subsides. AIM To investigate the effect of intake reminders on adherence to DOAC. METHODS MAAESTRO was a randomised, cross-over study in DOAC-treated AF patients hospitalised for ischaemic stroke. Adherence was measured by electronic monitoring for 12 months. After an observational phase, patients were randomised to obtain an intake reminder either in the first or the second half of the subsequent 6-month interventional phase. The primary outcome was 100%-timing adherence. Secondary outcomes were 100%-taking adherence, and overall timing and taking adherence. We analysed adherence outcomes using McNemar's test or mixed-effects logistic models. RESULTS Between January 2018 and March 2022, 130 stroke patients were included, of whom 42 dropped out before randomisation. Analysis was performed with 84 patients (mean age: 76.5 years, 39.3% women). A 100%-timing adherence was observed in 10 patients who were using the reminder, and in zero patients without reminder (p = 0.002). The reminder significantly improved adherence to DOAC, with study participants having 2.7-fold increased odds to achieve an alternative threshold of 90%-timing adherence (OR 2.65; 95% CI 1.05-6.69; p = 0.039). A similar effect was observed for 90%-taking adherence (OR 3.06; 95% CI 1.20-7.80; p = 0.019). Overall timing and taking adherence increased significantly when using the reminder (OR 1.70; 95% CI 1.55-1.86, p < 0.01; and OR 1.67; 95% CI 1.52-1.84; p < 0.01). CONCLUSION Intake reminders increased adherence to DOAC in patients with stroke attributable to atrial fibrillation. TRIAL REGISTRATION ClinicalTrials.gov: NCT03344146.
Collapse
Affiliation(s)
- Fine Dietrich
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland.
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Valerie Albert
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Burgfelderstrasse 101, 4055, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| |
Collapse
|
4
|
Peasah SK, Liu Y, Krohe S, Campbell V, Lee C, Mathur A, Stevenson H, Manolis C, Good CB. Assessing the impact of a financial incentive and refill reminder program on medication adherence and costs. J Manag Care Spec Pharm 2024; 30:43-51. [PMID: 38153862 PMCID: PMC10776251 DOI: 10.18553/jmcp.2024.30.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
BACKGROUND Improving medication adherence remains an important goal to improve therapeutic outcomes and lower health care costs. Point-of-sale prescription costs and forgetfulness remain top reasons why patients do not adhere to medications. Programs using both text message-based reminders and financial incentives may encourage patients to refill their prescriptions on time by reducing copays through discounts at the point of sale. Sempre Health, the subject of our analysis, provides both text message refill reminders and a dynamic discount incentive program to improve medication adherence. OBJECTIVE To evaluate the impact of a financial incentive/refill reminder program on medication adherence and total cost of care for patients taking the antithrombotic agents ticagrelor, apixaban, or rivaroxaban in a large regional health plan. METHODS After propensity-score matching on demographics, socioeconomic status, baseline copay, prior pharmacy/medical spend, and morbidity, we compared-using a difference-in-differences analytic approach-adherence (measured by proportion of days covered), unplanned health care utilization, and costs (total cost of care, medical, and pharmacy cost) of health plan members who did and did not enroll in the financial incentive/refill reminder program between February 1, 2019, and October 31, 2021, over 1 and 2 years. Because of differences in patient characteristics, we analyzed patients on ticagrelor (the antiplatelet group), apixaban, and rivaroxaban (the anticoagulant group) separately. RESULTS There were a total of 1,292 one-to-one program and control propensity-matched patients: 166 each for the antiplatelet group and 480 each for the anticoagulant group. The average age of the anticoagulant group was 62 years; more than 60% were male, and approximately 45% had no prior unplanned care events. In contrast, the average age of the antiplatelet group was 57 years; more than 70% were male, and approximately 21% had no prior unplanned care events. In the antiplatelet group, the proportions adherent (proportion of days covered ≥80%) were 63.3% vs 42.8% (P = 0.0002) for program vs controls. Similarly, in the anticoagulant group, the proportion adherent was 77.9% vs 60.2% (P < 0.0001) for program vs controls. Reflecting improved adherence, costs of apixaban and rivaroxaban increased by $79 per member per month (PMPM) (P < 0.0001), with no statistically significant differences in other costs. Similarly, the cost of ticagrelor increased by $77 PMPM (P = 0.0102) with no statistically significant differences in other costs. Finally, there was a 16% (P = 0.032) reduction in emergency department use for those in the program. CONCLUSIONS The financial incentive and refill reminder program was associated with improved adherence to antithrombotic medications, reduced emergency department use, and increased medication costs, but not in total pharmacy, medical, or total cost of care in both subgroups.
Collapse
Affiliation(s)
- Samuel K. Peasah
- UPMC Health Plan, Center for Value-based Pharmacy Initiatives, Pittsburgh, PA
| | - Yushi Liu
- UPMC Health Plan, Division of Health Economics, Pittsburgh, PA
| | - Shannon Krohe
- UPMC Health Plan, Administration and Operations, Pittsburgh, PA
| | - Vanessa Campbell
- UPMC Health Plan, Department of Pharmacy Services, Pittsburgh, PA
| | | | | | - Heidi Stevenson
- UPMC Health Plan, Division of Health Economics, Pittsburgh, PA
| | - Chronis Manolis
- UPMC Health Plan, Department of Pharmacy Services, Pittsburgh, PA
| | - Chester B. Good
- UPMC Health Plan, Center for Value-based Pharmacy Initiatives, Pittsburgh, PA
| |
Collapse
|
5
|
Rusin G, Konieczyńska M, Natorska J, Malinowski KP, Undas A. Low bleeding acceptance is associated with increased death risk in patients with atrial fibrillation on oral anticoagulation. J Thromb Thrombolysis 2024; 57:155-163. [PMID: 37598109 PMCID: PMC10830776 DOI: 10.1007/s11239-023-02878-8] [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] [Accepted: 07/22/2023] [Indexed: 08/21/2023]
Abstract
Bleeding is the most feared complication of anticoagulation. We sought to investigate whether the bleeding risk acceptance has a prognostic value during long-term follow-up in the era of direct oral anticoagulants (DOACs) among patients with atrial fibrillation (AF). We studied 167 consecutive AF outpatients [aged 68.8 SD 10.6 years; 141 (84.4%) on DOACs]. The bleeding acceptance was assessed based on the Bleeding Ratio defined as the declared maximum number of major bleedings that a patient would be willing to accept to prevent one major stroke. We recorded cerebrovascular ischemic events, major or clinically relevant non-major bleeds (CRNMB), and mortality. A median Bleeding Ratio was 4 (IQR 2-5). During follow-up of 946 patient-years, cerebrovascular ischemic events and/or death were observed in 28 patients (3.3%/ year) and major bleeding or CRNMB in 33 (4.6%/ year). The Bleeding Ratio was lower in patients who experienced cerebrovascular events or death (p = 0.004), but not bleeding. Patients with the Bleeding Ratio 0-3 were more often non-persistent to the OAC therapy, and more likely to have cerebrovascular event or die than those with higher bleeding acceptance (odds ratio 2.55; 0.95% CI 1.08-6.02) which was driven by the impact on mortality. The multiple Cox proportional hazards model showed that lower Bleeding Ratio, higher CHA2DS2-VASc score, and older age predicted cerebrovascular events or death during follow-up. AF patients who are willing to accept fewer serious bleedings to avoid major stroke during anticoagulation are more likely to experience death and/or cerebrovascular ischemic events, but not bleeding, what might be related to non-persistence.
Collapse
Affiliation(s)
- Gabriela Rusin
- Department of Neurology, University Hospital, Kraków, Poland
| | - Małgorzata Konieczyńska
- Department of Diagnostic Medicine, John Paul II Hospital, Kraków, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-202, Kraków, Poland
| | - Joanna Natorska
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-202, Kraków, Poland
| | - Krzysztof Piotr Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-202, Kraków, Poland.
- Center for Research and Innovative Technology John Paul II Hospital, Kraków, Poland.
| |
Collapse
|
6
|
Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
Collapse
Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
| |
Collapse
|
7
|
Sehrawat O, Kashou AH, Van Houten HK, Cohen K, Joe Henk H, Gersh BJ, Abraham NS, Graff-Radford J, Friedman PA, Siontis KC, Noseworthy PA, Yao X. Contemporary trends and barriers to oral anticoagulation therapy in Non-valvular atrial fibrillation during DOAC predominant era. IJC HEART & VASCULATURE 2023; 46:101212. [PMID: 37168417 PMCID: PMC10164915 DOI: 10.1016/j.ijcha.2023.101212] [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: 01/30/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023]
Abstract
There is a need to reassess contemporary oral anticoagulation (OAC) trends and barriers against guideline directed therapy in the United States. Most previous studies were performed before major guideline changes recommended direct oral anticoagulant (DOAC) use over warfarin or have otherwise lacked patient level data. Data on overuse of OAC in low-risk group is also limited. To address these knowledge gaps, we performed a nationwide analysis to analyze current trends. This is a retrospective cohort study assessing non-valvular AF identified using a large United States de-identified administrative claims database, including commercial and Medicare Advantage enrollees. Prescription fills were assessed within a 90-day follow-up from the patient's index AF encounter between January 1, 2016, and December 31, 2020. Among the 339,197 AF patients, 4.4%, 8.0%, and 87.6% were in the low-, moderate-, and high-risk groups (according to CHA2DS2-VASc score). An over (29.6%) and under (52.2%) utilization of OAC was reported in low- and high-risk AF patients. A considerably high frequency for warfarin use was also noted among high-risk group patients taking OAC (33.1%). The results suggest that anticoagulation use for stroke prevention in the United States is still comparable to the pre-DOAC era studies. About half of newly diagnosed high-risk non-valvular AF patients remain unprotected against stroke risk. Several predictors of OAC and DOAC use were also identified. Our findings may identify a population at risk of complications due to under- or over-treatment and highlight the need for future quality improvement efforts.
Collapse
Affiliation(s)
- Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Anthony H. Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, MN, United States
| | - Henry Joe Henk
- UnitedHealthcare, 9700 Health Care Lane, Minnetonka, MN 55343, USA
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Neena S. Abraham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | | | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Corresponding author at: Department of Cardiovascular Medicine Mayo Clinic, 200 First Street SW |, Rochester, MN 55905, United States.
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
8
|
Patsiou V, Samaras A, Kartas A, Moysidis DV, Papazoglou AS, Bekiaridou A, Baroutidou A, Ziakas A, Tzikas A, Giannakoulas G. Prognostic implications of adherence to oral anticoagulants among patients with atrial fibrillation: Insights from MISOAC-AF trial. J Cardiol 2023; 81:390-396. [PMID: 36179772 DOI: 10.1016/j.jjcc.2022.09.009] [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: 08/01/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To explore the implications of adherence to oral anticoagulants (OACs) on all-cause mortality and cardiovascular outcomes in patients with atrial fibrillation (AF). METHODS This post-hoc analysis of the MISOAC-AF trial included recently hospitalized patients with AF. Adherence to OACs was assessed by the proportion of days covered (PDC). Good adherence was defined as PDC >80 %. Cox regression models were used to associate PDC with clinical outcomes of all-cause death, cardiovascular death (CVD), stroke, and bleeding. A sub-analysis was performed among adherent patients to compare outcomes between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). RESULTS During a median 31-month follow-up, 778 cardiac patients with comorbid AF who had been prescribed OACs upon hospital discharge were studied. The mean PDC was 0.78; 66 % of patients had good adherence (>80 %) which was associated with lower risk of all-cause death [adjusted hazard ratio (aHR): 0.64; 95 % confidence interval (CI): 0.46 to 0.84, p < 0.001] and CVD (aHR: 0.70; 95 % CI: 0.50 to 0.97, p = 0.03). The risk of stroke and major or non-major bleeding did not differ by adherence status. Among adherent patients to OACs, VKA use was associated with higher rates of all-cause death (p < 0.001), CVD (p < 0.001), and stroke (p = 0.01); no differences were found regarding major or non-major bleeding risk. CONCLUSIONS In recently hospitalized patients with AF, good adherence to OACs was associated with a reduced risk of all-cause death and CVD. The rates of stroke or bleeding events were not significantly different. VKAs were associated with more adverse events compared to DOACs.
Collapse
Affiliation(s)
- Vasiliki Patsiou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| |
Collapse
|
9
|
Guérios EE, Chamié F. Percutaneous left atrial appendage closure: beyond the classic indications. ASIAINTERVENTION 2023; 9:70-77. [PMID: 36936101 PMCID: PMC10015488 DOI: 10.4244/aij-d-22-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/29/2022] [Indexed: 03/16/2023]
Abstract
Percutaneous left atrial appendage closure (LAAC) has proven to be an effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). International guidelines traditionally recommend LAAC for NVAF patients at high thromboembolic risk and contraindication to or at high risk for OAC. However, there are many other clinical situations in which this procedure may also be beneficial. This paper discusses the potential role of LAAC in specific haemorrhagic diseases (cerebral amyloid angiopathy, age-related macular degeneration, hereditary haemorrhagic telangiectasia, and Moyamoya disease), after left atrial appendage (LAA) electrical isolation, in cases of persistent thrombus inside the LAA, in end-stage renal disease and in special groups of patients for whom low compliance and persistence to OAC may be anticipated.
Collapse
Affiliation(s)
- Enio E Guérios
- Department of Interventional Cardiology, Pilar Hospital, Curitiba, Brazil
| | - Francisco Chamié
- Department of Interventional Cardiology, Hospital dos Servidores do Estado, Rio de Janeiro, Brazil
| |
Collapse
|
10
|
Burnett A, Rudd KM, Triller D. Advancing anticoagulation stewardship: A call to action for stewardship from the US-based anticoagulation forum. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
11
|
Fender AC, Dobrev D. The temporal context of oral anticoagulation outcome in atrial fibrillation. IJC HEART & VASCULATURE 2022; 40:101051. [PMID: 35663453 PMCID: PMC9157463 DOI: 10.1016/j.ijcha.2022.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
12
|
Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study. J Clin Med 2022; 11:jcm11061520. [PMID: 35329845 PMCID: PMC8948620 DOI: 10.3390/jcm11061520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.
Collapse
|