Effectiveness and safety of oral anticoagulants in older adults with non-valvular atrial fibrillation and heart failure

Comparative effectiveness and safety of rivaroxaban with other oral anticoagulants in older adults with nonvalvular atrial fibrillation: population-based analysis in response to updated Beers Criteria

BACKGROUND

Concerns have been raised regarding the updated Beers Criteria that recommended avoiding rivaroxaban use for long-term treatment of older adults with nonvalvular atrial fibrillation (AF).

OBJECTIVES

We sought to compare the effectiveness and safety of rivaroxaban with oral anticoagulants in older adults with nonvalvular AF.

METHODS

We used an administrative healthcare database and included adults with AF aged ≥65 years who were new users of rivaroxaban or the comparators. We created 3 pairwise comparisons: rivaroxaban vs warfarin; rivaroxaban vs dabigatran; and rivaroxaban vs apixaban. Study outcomes included stroke or systemic embolism (effectiveness) and gastrointestinal or intracranial bleeding (safety). In the propensity score-matched sample, we used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

In the matched cohorts, use of rivaroxaban (vs warfarin) increased risk of bleeding (HR, 1.13; 95% CI, 1.03-1.23) with no difference in ischemic stroke or systemic embolism (HR, 0.90; 95% CI, 0.79-1.02); use of rivaroxaban (vs dabigatran) increased risk of bleeding (HR, 1.18; 95% CI, 1.03-1.35) with no difference in ischemic stroke and systemic embolism (HR, 1.00; 95% CI, 0.83-1.22); and use of rivaroxaban (vs apixaban) increased risk of stroke and systemic embolism (HR, 1.23; 95% CI, 1.08-1.40) and bleeding (HR, 1.60; 95% CI, 1.45-1.76).

CONCLUSION

In this comparative effectiveness and safety study of older adults with nonvalvular AF, use of rivaroxaban was associated with a significantly increased risk of ischemic stroke and systemic embolism compared with apixaban and bleeding compared with warfarin, dabigatran, and apixaban. Our findings may inform anticoagulant selection in older adults with nonvalvular AF.

Comparative outcomes associated with rivaroxaban versus warfarin use in elderly patients with atrial fibrillation or acute venous thromboembolism managed in the United States: a systematic review of observational studies

BACKGROUND

Advancing age is a risk factor for developing non-valvular atrial fibrillation (NVAF) or acute venous thromboembolism (VTE). We assessed the comparative effectiveness, safety, costs, and healthcare utilization associated with rivaroxaban versus warfarin in patients of advanced age managed in the United States (US).

METHODS

We conducted a systematic review of Medline and Embase through April 2023 to identify real-world evidence (RWE) studies of older adults (at least 65+ years of age) with either NVAF or VTE who received either rivaroxaban or warfarin in the US and reported an outcome of stroke or systemic embolism (SSE), ischemic stroke (IS), recurrent VTE, major bleeding, intracranial hemorrhage, costs, or healthcare resource utilization. We classified each outcome of interest per study as "positive" (lower risk), "negative" (higher risk), or "neutral" based upon the summary effect size of rivaroxaban versus warfarin.

RESULTS

Twenty-nine RWE studies met inclusion criteria, mostly (83%) in NVAF populations. For SSE with rivaroxaban versus warfarin, 68.8% of studies showed positive effects and 31.2% showed neutral outcome. For major bleeding, 57.7% showed neutral effects, 38.5% showed negative effects, and 3.8% of studies showed positive effects with rivaroxaban versus warfarin. Of the two studies reporting cost data, both were positive, showing lower costs for SSE for rivaroxaban versus warfarin and neutral cost for major bleeding costs.

CONCLUSIONS

This systematic review supports findings from subgroup analyses of randomized controlled trials that, compared with warfarin, rivaroxaban is associated with generally neutral or positive effects on thrombosis and a mixed picture on bleeding outcomes in older adults with either NVAF or VTE treated in the United States.

Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant

BACKGROUND AND OBJECTIVES

Ischemic stroke despite a direct oral anticoagulant (DOAC) is increasingly common and portends a high risk of subsequent ischemic stroke. The efficacy and safety of antithrombotic regimens after the condition are unclear. We aimed to compare the outcomes of patients with ischemic stroke despite DOACs with and without an alternative antithrombotic regimen and determine the risk factors of recurrent ischemic stroke while on anticoagulation.

METHODS

In a population-based, propensity score-weighted, retrospective cohort study, we compared the clinical outcomes of DOAC-to-warfarin switch, DOAC-to-DOAC switch (DOACswitch), or addition of antiplatelet agents, with those of unchanged DOAC regimen (DOACsame) among patients with nonvalvular atrial fibrillation (NVAF) who developed the first ischemic stroke despite a DOAC from January 1, 2015, to December 31, 2020, in Hong Kong. The primary outcome was recurrent ischemic stroke. Secondary outcomes were intracranial hemorrhage, acute coronary syndrome, and death. We performed competing risk regression analyses to compare the clinical endpoints and determined the predictors of recurrent ischemic stroke in an unweighted multivariable logistic regression model.

RESULTS

During the 6-year study period, among 45,946 patients with AF on a DOAC as stroke prophylaxis, 2,908 patients developed ischemic stroke despite a DOAC. A total of 2,337 patients with NVAF were included in the final analyses. Compared with DOACsame, warfarin (aHR 1.96, 95% CI 1.27-3.02, p = 0.002) and DOACswitch (aHR 1.62, 95% CI 1.25-2.11, p < 0.001) were associated with an increased risk of recurrent ischemic stroke. In the DOACsame group, adjunctive antiplatelet agent was not associated with a reduced risk of recurrent ischemic stroke. Diabetes mellitus, concurrent cytochrome P450/P-glycoprotein (CYP/P-gp) modulators, and large artery atherosclerotic disease (LAD) were predictors of recurrent ischemic stroke.

DISCUSSION

In patients with NVAF with ischemic stroke despite a DOAC, the increased risk of recurrent ischemic stroke with switching to warfarin called for caution against such practice, while the increased ischemic stroke with DOAC-to-DOAC switch demands further studies. Adjunctive antiplatelet agent did not seem to reduce ischemic stroke relapse. Because diabetes mellitus, the use of CYP/P-gp modulators, and LAD were predictors of recurrent ischemic stroke, further investigations should evaluate whether strict glycemic control, DOAC level monitoring, and routine screening for carotid and intracranial atherosclerosis may reduce ischemic stroke recurrence in these patients.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in patients with NVAF experiencing an ischemic stroke while being treated with a DOAC, continuing treatment with that DOAC is more effective at preventing recurrent ischemic stroke than switching to a different DOAC or to warfarin.

Utility of short-term telemetry heart rhythm monitoring and CHA2DS2-VASc stratification in patients presenting with suspected cerebrovascular accident

BACKGROUND

Inpatient telemetry heart rhythm monitoring overuse has been linked to higher healthcare costs.

AIM

To evaluate if CHA2DS2-VASc score could be used to indicate if a patient admitted with possible cerebrovascular accident (CVA) or transient ischemic attack (TIA) requires inpatient telemetry monitoring.

METHODS

A total of 257 patients presenting with CVA or TIA and placed on telemetry monitoring were analyzed retrospectively. We investigated the utility of telemetry monitoring to diagnose atrial fibrillation/flutter and the CHA2DS2-VASc scoring tool to stratify the risk of having CVA/TIA in these patients.

RESULTS

In our study population, 63 (24.5%) of the patients with CVA/TIA and telemetry monitoring were determined to have no ischemic neurologic event. Of the 194 (75.5) patients that had a confirmed CVA/TIA, only 6 (2.3%) had an arrhythmia detected during their inpatient telemetry monitoring period. Individuals with a confirmed CVA/TIA had a statistically significant higher CHA2DS2-VASc score compared to individuals without an ischemic event (3.59 vs 2.61, P < 0.001).

CONCLUSION

Given the low percentage of inpatient arrhythmias identified, further research should focus on discretionary use of inpatient telemetry on higher risk patients to diagnose the arrhythmias commonly leading to CVA/TIA. A prospective study assessing event rate of CVA/TIA in patients with higher CHA2DS2-VASc score should be performed to validate the CHA2DS2-VASc score as a possible risk stratifying tool for patients at risk for CVA/TIA.

Impact of heart failure on the clinical profile and outcomes in patients with atrial fibrillation treated with rivaroxaban. Data from the EMIR study

BACKGROUND

The aim of this study was to analyze the impact of the presence of heart failure (HF) on the clinical profile and outcomes in patients with atrial fibrillation (AF) anticoagulated with rivaroxaban.

METHODS

Observational and non-interventional study that included AF adults recruited from 79 Spanish centers, anticoagulated with rivaroxaban ≥ 6 months before inclusion. Data were analyzed according to baseline HF status.

RESULTS

Out of 1,433 patients, 326 (22.7%) had HF at baseline. Compared to patients without HF, HF patients were older (75.3 ± 9.9 vs. 73.8 ± 9.6 years; p = 0.01), had more diabetes (36.5% vs. 24.3%; p < 0.01), coronary artery disease (28.2% vs. 12.9%; p < 0.01), renal insufficiency (31.7% vs. 22.6%; p = 0.01), higher CHA2DS2-VASc (4.5 ± 1.6 vs. 3.2 ± 1.4; p < 0.01) and HAS-BLED (1.8 ± 1.1 vs. 1.5 ± 1.0; p < 0.01). After a median follow-up of 2.5 years, among HF patients, annual rates of stroke/systemic embolism/transient ischemic attack, major adverse cardiovascular events (MACE) (non-fatal myocardial infarction, revascularization and cardiovascular death), cardiovascular death, and major bleeding were 1.2%, 3.0%, 2.0%, and 1.4%, respectively. Compared to those patients without HF, HF patients had greater annual rates of MACE (3.0% vs. 0.5%; p < 0.01) and cardiovascular death (2.0% vs. 0.2%; p < 0.01), without significant differences regarding other outcomes, including thromboembolic or bleeding events. Previous HF was an independent predictor of MACE (odds ratio 3.4; 95% confidence interval 1.6-7.3; p = 0.002) but not for thromboembolic events or major bleeding.

CONCLUSIONS

Among AF patients anticoagulated with rivaroxaban, HF patients had a worse clinical profile and a higher MACE risk and cardiovascular mortality. HF was independently associated with the development of MACE, but not with thromboembolic events or major bleeding.

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

PURPOSE

To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture.

METHOD

A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings.

RESULTS

There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants.

CONCLUSIONS

The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

Non-vitamin K antagonist oral anticoagulants versus warfarin in atrial fibrillation patients with heart failure and preserved, mildly reduced, and reduced ejection fraction: A systemic review and meta-analysis

Background

Patient prevalence of atrial fibrillation (AF) and heart failure (HF) is increasing, and anticoagulation for patients from heterogeneous backgrounds with both conditions remains controversial. In this meta-analysis, we are aiming to compare the effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in AF patients with HF and preserved (HFpEF), mildly reduced (HFmrEF), and reduced (HFrEF) ejection fraction.

Methods and results

We systematically searched the PubMed, Cochrane, and Embase databases until January 2022. The primary effectiveness and safety outcomes were stroke or systemic embolism (SSE) and major bleeding, respectively. We abstracted risk ratios (RR) and 95% confidence intervals (CIs) and compiled them using a random-effects model. We analyzed data of 266,291 patients from 10 studies. By comparing NOACs with warfarin, patients with AF and HF have reduced the risk of SSE (RR: 0.83, 95% CI 0.76–0.91), all-cause mortality (RR: 0.85, 95% CI 0.80–0.91), major bleeding (RR: 0.79, 95% CI 0.69–0.90), and intracranial hemorrhage (RR: 0.54, 95% CI 0.46–0.63). Further analyses based on the HF subtypes showed that NOACs reduced the chances of SSE (RR: 0.71, 95% CI 0.53–0.94) in the HFrEF group and major bleeding (RR: 0.74, 95% CI 0.57–0.95) in HFmrEF and HFpEF groups. There were no differences regarding SSE (RR: 0.91, 95% CI 0.76–1.09) in HFmrEF and HFpEF groups and major bleeding (RR: 0.99, 95% CI 0.79–1.23) in the HFrEF group.

Conclusion

For patients with AF and HF, NOACs have better or similar effectiveness and safety than warfarin, but the stroke prevention superiority of NOACs over warfarin varies in different HF subtypes.

Effectiveness and Safety of Apixaban in over 3.9 Million People with Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background: There is a plethora of real-world data on the safety and effectiveness of direct-acting oral anticoagulants (DOACs); however, study heterogeneity has contributed to inconsistent findings. We compared the effectiveness and safety of apixaban with those of other direct-acting oral anticoagulants (DOACs) and vitamin K antagonists (VKA e.g., warfarin). Methods: A systematic review and meta-analysis was conducted retrieving data from PubMed, SCOPUS and Web of Science from January 2009 to December 2021. Studies that evaluated apixaban (intervention) prescribed for adults (aged 18 years or older) with AF for stroke prevention compared to other DOACs or VKAs were identified. Primary outcomes included stroke/systemic embolism (SE), all-cause mortality, and major bleeding. Secondary outcomes were intracranial haemorrhage (ICH) and ischaemic stroke. Randomised controlled trials and non-randomised trials were considered for inclusion. Results: In total, 67 studies were included, and 38 studies were meta-analysed. Participants taking apixaban had significantly lower stroke/SE compared to patients taking VKAs (relative risk (RR) 0.77, 95% confidence interval (CI) 0.64–0.93, I² = 94%) and dabigatran (RR 0.84, 95% CI 0.74–0.95, I² = 66%), but not to patients administered rivaroxaban. There was no statistical difference in mortality between apixaban and VKAs or apixaban and dabigatran. Compared to patients administered rivaroxaban, participants taking apixaban had lower mortality rates (RR 0.83, 95% CI 0.71–0.96, I² = 96%). Apixaban was associated with a significantly lower risk of major bleeding compared to VKAs (RR 0.58, 95% CI 0.52–0.65, I² = 90%), dabigatran (RR 0.79, 95% CI 0.70–0.88, I² = 78%) and rivaroxaban (RR 0.61, 95% CI 0.53–0.70, I² = 87%). Conclusions: Apixaban was associated with a better overall safety and effectiveness profile compared to VKAs and other DOACs.

Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation

Background

The efficacy and safety of antithrombotic treatment with oral anticoagulants (OACs) in elderly patients with comorbidities of acute coronary syndrome (ACS) and atrial fibrillation (AF) are unclear.

Methods

A cohort of hospitalized elderly patients (≥65 years of age) diagnosed with ACS and AF and treated with oral antithrombotic agents were consecutively recruited. Follow-up was performed for at least 1 year. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. The safety outcomes of bleeding were defined according to the Bleeding Academic Research Consortium (BARC) criteria.

Results

A cohort of 548 eligible patients (76 ± 6.6 years) was analyzed. Compared to the patients with OAC treatment (n = 184, 33.6%), patients treated without OAC (n = 364, 66.4%) were older, had a lower prevalence of persistent AF and unstable angina (UA), and more often presented with paroxysmal AF, acute myocardial infarction (AMI), stent implantation and dual antiplatelet therapy (DAPT). Compared to the patients without OAC treatment (n = 364, 66.4%), patients treated with OAC (n = 184, 33.6%) had a lower risk of MACEs at both the 1-year (4.3 vs. 15.1%, adjusted HR: 0.34, 95% CI: 0.15–0.80, p = 0.014) and 5-year (17.5 vs. 48.4%, adjusted HR: 0.36, 95% CI: 0.19–0.67, p = 0.001) follow-up. No significant difference was observed for bleeding events of BARC ≥2 between the groups (8.0 vs. 9.0%, adjusted HR: 1.17, 95% CI: 0.58–2.34, p = 0.667). Compared with warfarin-treated patients, the non-vitamin K antagonist oral anticoagulant-treated patients had lower risks of all-cause mortality (2.1 vs. 9.5%, HR: 0.18, 95% CI: 0.03–0.98, p = 0.047) and bleeding events of BARC ≥ 3 (2.1 vs. 4.8%, HR: 0.14, 95% CI: 0.02–1.10, p = 0.062).

Conclusions

Antithrombotic therapy with OACs in elderly patients with ACS and AF was associated with a lower risk of ischemic events without an increase in bleeding events. In real-world practice, the clinical awareness of anticoagulation treatments in elderly patients with ACS and AF needs to be strengthened.

Antithrombotic Therapy in Elderly Patients with Acute Coronary Syndromes

The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.

Management of Atrial Fibrillation in Patients 75 Years and Older: JACC State-of-the-Art Review

The prevalence of atrial fibrillation (AF) is increasing as the population ages. AF treatment-related complications also increase markedly in older adults (defined as ≥75 years of age for this review). The older AF population has a high risk of stroke, bleeding, and death. Syncope and fall-related injuries are the most common reasons for nonprescription of oral anticoagulation (OAC), and are more common in older adults when OACs are used with antiarrhythmic drugs. Digoxin may be useful for rate control, but associations with increased mortality limit its use. Beyond rate and rhythm control considerations, stroke prophylaxis is critical to AF management, and the benefits of direct OACs, compared with warfarin, extend to older adults. Invasive procedures such as AF catheter ablation, pacemaker implantation/atrioventricular junction ablation, and left atrial appendage occlusion may be useful in appropriately selected cases. However, older adults have generally been under-represented in clinical trials.

Standard- vs. low-dose rivaroxaban in patients with atrial fibrillation: a systematic review and meta-analysis

PURPOSE

Low-dose rivaroxaban is often given to patients with atrial fibrillation (AF) around the world, but the rationale for its use remains unclear. We aimed to compare the efficacy and safety of standard- or low-dose rivaroxaban in patients with AF through systematic review of literature with meta-analysis.

METHODS

We searched PubMed, Web of Science, EMBASE, Clinical Trials.gov, the Cochrane Library, and Bayer trial website from inception of each database until June 2020. Randomized controlled trials (RCTs) and cohort studies were included in the meta-analysis. A random-effects model was employed to calculate the pooled effect estimates.

RESULTS

Two RCTs and 17 cohort studies were included in the qualitative analysis. Indirect comparison of RCTs showed no significant difference between the two rivaroxaban dosages in risk of efficacy or safety outcomes (p > 0.05). Indirect comparison of cohort studies showed a lower risk of MACE among Caucasians in standard-dose group (HR 0.779; 95% CI 0.687-0.884; p < 0.001). Bleeding outcomes did not differ significantly between the two dosage regimens in Asian or Caucasian populations, except that the standard dose was associated with higher risk of major bleeding among elderly Caucasian patients (HR 1.329; 95% CI 1.141-1.547; p < 0.001). The quality of evidence was rated ranging from very low to low for all the efficacy and safety outcomes.

CONCLUSION

In Caucasians with AF, standard-dose rivaroxaban may prevent MACE significantly better than low-dose treatment. Further studies in Asians are needed to verify the advantages of the standard dose.

Potentially Inappropriate Drug Duplication in a Cohort of Older Adults with Dementia

BACKGROUND

Concurrent use of 2 nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, loop diuretics, angiotensin-converting enzyme inhibitors, or anticoagulants is considered potentially inappropriate by Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment criteria.

OBJECTIVE

The objective was to examine drug duplication in a cohort of older adults with dementia.

METHODS

Cohort entry for Nova Scotia Seniors' Pharmacare Program beneficiaries was the date an International Classification of Diseases ninth edition or 10th edition code for dementia was recorded in accessed databases between March 1, 2005, and March 31, 2015. Medication dispensation and sociodemographic data were captured from the Nova Scotia Seniors' Pharmacare Program database between April 1, 2010, and March 31, 2015. Duplication was considered when 2 drugs from the same class were dispensed such that the supply in the patient's possession could overlap for more than 30 days. We reported number of cases of duplication and duration of overlap. Sex differences in drug duplication were assessed with bivariate logistic regression.

RESULTS

In the cohort of 28,953 Nova Scotia Seniors' Pharmacare Program beneficiaries with dementia, we documented concurrent use in 101 (1.7%) nonsteroidal anti-inflammatory drugs users (mean duration = 75.6 days), 95 (1.0%) selective serotonin reuptake inhibitors users (mean duration = 146.6 days), 5 (0.07%) loop diuretic users (mean duration = 530.6 days), 183 (2.0%) angiotensin-converting enzyme inhibitor users (mean duration = 123.9 days), and 160 (3.5%) anticoagulant users (mean duration = 63.6 days). Nonsteroidal anti-inflammatory drug pairs were most commonly celecoxib with naproxen or diclofenac. Selective serotonin reuptake inhibitors duplication was most commonly sertraline with citalopram. No sex differences in risk for drug duplication were identified.

CONCLUSIONS

Drug duplication was identified in a cohort of older adults with dementia and is a feasible target for intervention. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).

Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association

Atrial fibrillation and heart failure with reduced ejection fraction are increasing in prevalence worldwide. Atrial fibrillation can precipitate and can be a consequence of heart failure with reduced ejection fraction and cardiomyopathy. Atrial fibrillation and heart failure, when present together, are associated with worse outcomes. Together, these 2 conditions increase the risk of stroke, requiring oral anticoagulation in many or left atrial appendage closure in some. Medical management for rate and rhythm control of atrial fibrillation in heart failure remain hampered by variable success, intolerance, and adverse effects. In multiple randomized clinical trials in recent years, catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies. This has resulted in a paradigm shift in management toward nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction. The primary objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology and pathophysiology of atrial fibrillation in relation to heart failure and to provide guidance on the latest advances in pharmacological and nonpharmacological management of atrial fibrillation in patients with heart failure and reduced ejection fraction. The writing committee's consensus on the implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.

Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis

PURPOSE

To systematically review available evidence of indirect comparisons from RCTs and direct comparisons from observational studies regarding the comparative effectiveness and safety of DOACs in patients with AF.

METHODS

Electronic databases including EMBASE, MEDLINE, and PUBMED were searched up to June 5th, 2020. Primary endpoints included effectiveness (stroke or systemic embolism [SE]) and safety (major bleeding) outcomes. Bucher methods and random-effects models were conducted for indirect and direct comparisons among DOACs, respectively. Ranking probability analyses and the number needed to treat for net effect (NNTnet) were applied.

RESULTS

A total of 36 studies, involving 7 RCTs (n = 60,292 patients) and 29 observational studies (n = 1,164,821 patients), were included for analyses. Regarding the risk of stroke/SE, no significant differences were found from indirect comparisons of RCTs among the DOACs. For major bleeding, apixaban tended to be safer than rivaroxaban and dabigatran based on both direct and indirect comparisons (all p < 0.05; evidence quality: very low to moderate). Ranking probability analysis showed that apixaban had a high probability of being the best treatment in decreased risk of stroke/SE and major bleeding (80.30% and 91.30%, respectively). Likewise, apixaban was found to have the highest net clinical benefit (0.02, 95% CI: 0.014-0.029) and smallest NNTnet (48, 95% CI: 35-74).

CONCLUSIONS

Apixaban appeared to have a favorable effectiveness-safety profile compared with the other DOACs in AF for stroke prevention, based on evidence from both direct and indirect comparisons. However, additional high-quality evidence is needed to support firm recommendations on clinical decision-making.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF). Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019–2020. Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non–HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%—at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non–HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non–HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them. Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.

Impact of anticoagulant exposure misclassification on the bleeding risk of direct oral anticoagulants

Aims

Drug exposure status based on routinely collected data might be misclassified when the database contains only prescriptions from 1 type of prescriber (e.g. general practitioner and not specialist). This study aims to quantify the impact of such exposure misclassification on the risk of major bleeding and stroke/transient ischaemic attack (TIA)associated with direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs).

Methods

Incident anticoagulant users (>12 mo free of anticoagulation use) in the Dutch PHARMO Database Network between 2008 and 2017 were included. Drug exposure was assessed using pharmacy dispensing information. The risks of hospital admission of major bleeding for DOAC vs. VKA users was assessed with Cox regression analysis, where exposure was based on all dispensings, on general practitioner (GP)‐prescribed dispensings only or on specialist‐prescribed dispensings only. Hazard ratios (HRs) were estimated also for hospitalization for gastrointestinal bleeding, intracranial bleeding and stroke/TIA.

Results

We included 99 182 VKA‐initiators and 21 795 DOAC‐initiators. Use of DOAC was associated with a lower risk of major bleeding compared to VKA use; HR 0.79 (95% confidence interval 0.70–0.90), 0.78 (0.68–0.91) and 0.62 (0.50–0.76), for exposure based on complete dispensing information, only GP‐ and only specialist‐prescribed dispensings, respectively. Similar results were found for the other bleeding outcomes. For stroke/TIA the HRs were 0.96 (0.84–1.09), 1.00 (0.84–1.18) and 0.72 (0.58–0.90), respectively.

Conclusion

Including only GP‐prescribed anticoagulant dispensings in this case did not materially impact the effect estimates compared to including all anticoagulant dispensings. Including only specialist‐prescribed dispensings, however, strengthened the effect estimates.

Real-World Evidence: Bridging Gaps in Evidence to Guide Payer Decisions

Randomized controlled trials (RCTs) are preferred by payers for health technology assessments and coverage decisions. However, the inclusion of a highly selective patient population and the rigorously controlled conditions in RCTs may not be reflective of real-world clinical practice. Real-world evidence (RWE) obtained from an analysis of real-world data (RWD) from observational studies can bridge gaps in evidence not addressed by RCTs and is thus valuable to public and private payers for decision-making. Through a broad literature search to obtain insights into payers' experience, we found that payers have concerns about real-world studies with respect to data quality, poor internal validity, potential bias, and lack of meaningful endpoints. However, they valued RWE to fill evidence gaps not addressed by RCTs, such as high-quality, real-world, long-term effectiveness and safety data; head-to-head drug comparisons; cost analyses for tiering formulary placement; medication use and adherence patterns; identification of relevant responder and non-responder patient subpopulations; and patient-reported outcomes (PROs). RWE can be used to assess clinically meaningful endpoints and gauge the impact of interventions on the quality of healthcare. Here, we review how payers use or can use RWD on the comparative effectiveness and safety of treatments, PROs, medication adherence and persistence, prescribing patterns, healthcare resource utilization, and patient characteristics and/or biomarkers associated with treatment response when making health technology assessments and payer coverage decisions across therapeutic areas.

Bleeding Risk of Direct Oral Anticoagulants in Patients With Heart Failure And Atrial Fibrillation

BACKGROUND

Patients with heart failure and atrial fibrillation are an important atrial fibrillation subgroup in which direct oral anticoagulants (DOACs) have not been adequately studied in real-world settings. Since DOACs rely on renal elimination and renal dysfunction is prevalent in patients with heart failure, their use may increase bleeding risk, negating some of their advantage over warfarin.

METHODS

We conducted a retrospective cohort study using linked Veterans Administration databases of patients with heart failure newly started on warfarin or DOACs for atrial fibrillation from October 2010 to August 2017 (23 635 warfarin, 25 823 DOAC). Outcomes included time to first bleeding, stroke, and death using Cox proportional hazards models with inverse probability of treatment weighting.

RESULTS

Total bleeding (hazard ratio, 0.62 [95% CI, 0.56-0.68]), major bleeding (hazard ratio, 0.49 [95% CI, 0.40-0.61]), and death (hazard ratio, 0.74 [95% CI, 0.71-0.78]) were lower with DOAC than warfarin, and with apixaban and dabigatran, but not rivaroxaban. Moderate/severe chronic kidney disease was common (48.7%); moderate chronic kidney disease was associated with increased bleeding with DOACs but not warfarin. However, death and bleeding remained lower with DOACs than warfarin across all renal function levels and clinical subgroups. A >20% transient/persistent decline in renal function occurred in 53% of DOAC-treated patients at some point during follow-up, would have required dose reduction in 10.5% of patients, and was associated with increased bleeding. Dose adjustments were made more often, and bleeding and death were lower in patients seen by pharmacists or anticoagulation clinics. There were significant between-site variations in DOAC dosing.

CONCLUSIONS

DOACs overall, apixaban, and dabigatran, but not rivaroxaban, were associated with less total bleeding and death than warfarin in patients with heart failure and atrial fibrillation at all levels of renal function. Renal function decline resulted in increased bleeding in patients with DOACs. DOAC dose adjustment was often indicated, associated with increased bleeding when not adjusted, emphasizing the need for closer monitoring in these patients.

Real-world safety and efficacy of direct oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of 605 771 patients

AIMS

To analyse the safety and efficacy of direct oral anticoagulants (DOACs) in real-world studies including atrial fibrillation (AF) patients.

METHODS AND RESULTS

Systematic review and meta-analysis of observational studies including AF patients on DOACs. Primary endpoints: any, major, gastrointestinal (GI), intracranial haemorrhage (ICH), and haemorrhagic stroke (HS). Secondary endpoints: ischaemic stroke (IS), systemic embolism (SE), myocardial infarction (MI), and all-cause of death. A set of pair-wise meta-analyses using a random effect model and a random effect network meta-analysis under a Bayesian framework were performed. Prospero registration number: CRD42019137111. We included 21 studies with 605 771 AF patients. Apixaban was associated with lower major and GI bleeding compared with Rivaroxaban [hazard ratio (HR) 2.0, 95% confidence interval (CI) 1.6-2.5] and Dabigatran (HR 1.6, 95% CI 1.3-2.1). The latter drug performed better than Rivaroxaban (HR 1.2, 95% CI 1.0-1.5). Dabigatran and Apixaban had a similar association with HS, but Apixaban performed better than Rivaroxaban (HR 1.8, 95% CI 1.1-3.0). Apixaban had a similar association with Rivaroxaban and Dabigatran for ICH, the latter drug performing better than Rivaroxaban (HR 1.3, 95% CI 1.0-1.7). Rankograms showed that Apixaban was likely to be the first-choice treatment in relation to any (65%) major (100%) and GI bleeding (100%) followed by Dabigatran (46%, 100%, 99%, respectively). Dabigatran and Apixaban had similar rank as first choice for ICH (44% and 55%) and HS (52% and 48%). DOACs showed similar association with IS/SE, MI, all-cause of death.

CONCLUSIONS

Analysis of real-world studies shows significant differences for safety among DOACs.

Efficacy and safety of non-vitamin K anticoagulants and warfarin in patients with atrial fibrillation and heart failure: A network meta-analysis

BACKGROUND

To recommend the proper anticoagulant drug and its dose for patients with atrial fibrillation (AF) and heart failure (HF), we conducted a network meta-analysis (NMA) to make the comparisons among non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin with regard to efficacy (stroke or systemic embolism) and safety (major bleeding).

METHODS

We searched PubMed, EMBASE, Web of Science and Cochrane Library with the items: "dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, atrial fibrillation and heart failure" through April 14, 2020, focusing on the RCTs comparing the effect of NOACs to warfarin in patients with AF and HF. The NMA was performed based on R (version3.5.1) recalling JAGS (version4.3.0) with gemtc package. Moreover, NetMetaXL (version1.6.1) and winBUGS (version1.4.3) were employed to obtain the cumulative ranking curve area (SUCRA) of the anticoagulants.

RESULT

There was a high probability that dabigatran150 (SUCRA 0.82) ranked the first for the most effective drug, followed by apixaban (SUCRA 0.81), edoxaban60 (SUCRA 0.57) and rivaroxaban (SUCRA 0.52). However, with respect to safety for preventing major bleeding, edoxaban30 (SUCRA 0.99) ranked as the safest drug, followed by apixaban (SUCRA 0.71), edoxaban 60 (SUCRA 0.59) and dabigatran150 (SUCRA 0.55).

CONCLUSION

Apixaban, edoxaban60 and dabigatran150 were more likely to become the choice for preventing stroke or systemic embolism and major bleeding in patients with AF and HF. Nevertheless, more trials need to be performed to focus on the effect of NOACs on the efficacy outcome due to the sparse data. In addition, caution should be excised over selecting the NOAC and its dose on account of the lacking head-to-head comparisons.