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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA 2024; 331:1565-1575. [PMID: 38619832 PMCID: PMC11019444 DOI: 10.1001/jama.2024.3867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/29/2024] [Indexed: 04/16/2024]
Abstract
Importance Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation. Objective To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. Design, Setting, and Participants This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024. Exposures Diltiazem and metoprolol. Main Outcomes and Measures The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting. Results The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26). Conclusions and Relevance In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, University of Miami, Miami, Florida
- Miami VA Healthcare System, Miami, Florida
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
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Harbison J, McCormack J, Brych O, Collins R, O'Connell N, Randles M, Kennedy C, Kelly PJ, Cassidy T. Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013-2021. Int J Stroke 2024; 19:342-347. [PMID: 37771031 DOI: 10.1177/17474930231206680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis. METHODS AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice were assessed. RESULTS AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and 56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total IS due to AF decreased by 15.3% (31.3%-26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes over time (r = -0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14, p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = -0.83, p = 0.006) and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = -0.89, p = 0.001). CONCLUSION DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.
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Affiliation(s)
- Joseph Harbison
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Joan McCormack
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Olga Brych
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Ronan Collins
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Niamh O'Connell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Mary Randles
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Cormac Kennedy
- Department of Pharmacology & Therapeutics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Peter J Kelly
- Department of Neurology, University College Dublin, Dublin, Ireland
- Institute of Neurology, The Mater Hospital, Dublin, Ireland
| | - Tim Cassidy
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Acute Stroke Service, St. Vincent's University Hospital, Dublin, Ireland
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Kozlowski S, Tworkoski E, Dharmarajan S, Flowers N, Kwist A, Shangguan S, Chillarige Y, Wernecke M, MaCurdy T, Kelman JA, Graham DJ. Dispensing pharmacy chains and direct anticoagulants: Potential associations with patient outcomes. Pharmacoepidemiol Drug Saf 2024; 33:e5749. [PMID: 38362655 DOI: 10.1002/pds.5749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024]
Abstract
PURPOSE Pharmacy chains can differ with respect to the characteristics of their patient populations as well as their nonprescription products, services, and practices, and thus may serve as a surrogate for potential unmeasured confounding in observational studies of prescription drugs. This study evaluates whether a single-source drug can have different patient outcomes based on the dispensing pharmacy chain. METHODS Separate analyses for two anticoagulant drugs, rivaroxaban and apixaban, were conducted using Medicare Fee-for-Service claims evaluating the association between dispensing pharmacy chain and outcomes of acute myocardial infarction, ischemic stroke, intracranial hemorrhage, gastrointestinal (GI) bleeding, all-cause mortality, and major GI bleeding. Inverse probability of treatment weighting (IPTW) was used to balance baseline covariates across pharmacy chain cohorts, and outcome association was assessed with a Cox Proportional Hazards model. RESULTS We observed no differences in outcomes across pharmacy chains for apixaban recipients. Rivaroxaban recipients from pharmacy chain C, however, had lower rates of GI bleeding (adjusted HR 0.83; 95% CI 0.69-1.00) and ischemic stroke (adjusted HR 0.57; 95% CI 0.38-0.87) as compared to chain A in primary analyses with a 3-day grace period. The results moved closer to the null when 14- and 30-day grace periods were implemented. CONCLUSIONS These results suggest that dispensing pharmacy chains may have the potential to act as a confounder of associations between drug exposure and outcome in some observational studies. Additional studies of potential confounding by pharmacy chain are needed. Further evaluation of potential pharmacy chain effects on safe use would be of value.
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Affiliation(s)
- Steven Kozlowski
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Sai Dharmarajan
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | | | | | | | | | | | - David J Graham
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Virk GS, Javed S, Chaudhry R, Moazam MM, Mahmood A, Mahmood F, Zaheer M, Khan SM, Rajasekaran V. Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis. Cureus 2024; 16:e54252. [PMID: 38496142 PMCID: PMC10944328 DOI: 10.7759/cureus.54252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.
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Affiliation(s)
- Ghazala S Virk
- Internal Medicine, Avalon University School of Medicine, Ohio, USA
| | - Sana Javed
- Medicine, University of Birmingham, Royal College of General Practitioners, Birmingham, GBR
| | | | - Mustafa M Moazam
- Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Arhum Mahmood
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | - Faraz Mahmood
- Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, USA
| | - Mohammed Zaheer
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Shahroz M Khan
- Medicine, Kansas Health Science Center (KHSC) College of Osteopathic Medicine, Wichita, USA
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Bergler-Klein J, Gotcheva N, Kalējs O, Kalarus Z, Kovačić D, Peršić V, Shlyakhto E, Uuetoa T, Huisman MV, Lip GYH, Vinereanu D. Antithrombotic Usage, Including Three-Year Outcomes With Dabigatran and Vitamin K Antagonists for Atrial Fibrillation, in Eastern Europe: A Descriptive Analysis From Phase 3 of the GLORIA-AF Registry. Am J Ther 2024; 31:e1-e12. [PMID: 38231576 DOI: 10.1097/mjt.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) is a prospective registry of outcomes from patients with newly diagnosed AF at risk of stroke. In the propensity score (PS)-matched global population of phase 3 GLORIA-AF, at 3 years, dabigatran-treated patients experienced reduced risk for major bleeding, and similar risk for stroke and myocardial infarction, compared with vitamin K antagonist (VKA)-treated patients. STUDY QUESTION Do patients in Eastern Europe benefit from treatment with dabigatran versus VKA? STUDY DESIGN Descriptive analysis, without PS matching. To contextualize the Eastern Europe results of GLORIA-AF phase 3, we also descriptively analyzed the global population without PS matching. Consecutive patients with newly diagnosed AF and CHA2DS2-VASc-score ≥1 were enrolled until December 2016 in 38 countries (9 in Eastern Europe). MEASURES AND OUTCOMES Three-year outcomes with dabigatran and VKA. RESULTS In Eastern Europe, 1341 patients were eligible (6% of patients globally), and incidence rates (per 100 patient-years) for the following outcomes were numerically lower with dabigatran (N = 498) versus VKA (N = 466): major bleeding (0.26 vs. 0.90), all-cause death (2.04 vs. 3.50), and a composite of stroke, systemic embolism, myocardial infarction, life-threatening bleeding, and vascular death (1.37 vs. 1.92); stroke was comparable (0.51 vs. 0.50). All incidence rates were numerically lower in Eastern Europe versus the global population for both treatments. Chronic concomitant use of high bleeding risk medications (eg, nonsteroidal anti-inflammatories) was lower in Eastern Europe (dabigatran 3.8%, VKA 9.3%) than globally (dabigatran 14.8%, VKA 20.6%) and persistence with dabigatran was higher in Eastern Europe (76%) than globally (64%). CONCLUSIONS Dabigatran was associated with numerically reduced major bleeding, all-cause death, and cardiovascular (CV) composite, with comparable risk of stroke versus VKA, in Eastern Europe. Limitations of this descriptive analysis include few CV events (n = 11 for stroke, in the dabigatran and VKA groups combined) and a lack of statistical analysis and PS matching, which precludes definitive conclusions; however, the CV outcomes in Eastern Europe were consistent with the beneficial impact of dabigatran versus VKA in the statistically analyzed global population with PS matching.
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Affiliation(s)
- Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nina Gotcheva
- Department of Cardiology, National Heart Hospital, Sofia, Bulgaria
| | - Oskars Kalējs
- Department of Arrhythmology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Dragan Kovačić
- Department of Cardiology, General Hospital Celje, Celje, Slovenia
| | - Viktor Peršić
- Department of Medical Rehabilitation, Medical Faculty, University of Rijeka, Rijeka, Croatia
- Division of Cardiology, Hospital for Medical Rehabilitation of the Heart and Lung Diseases and Rheumatism "Thalassotherapia Opatija," Opatija, Croatia
| | - Evgeny Shlyakhto
- Clinical Endocrinology Laboratory, Department of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - 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
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; and
- Department of Cardiology and Cardiovascular Surgery, University and Emergency Hospital, Bucharest, Romania
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Svaguša T, Šimić S, Grabant F, Kereš T, Čančarević O, Paić F, Grizelj D, Blivajs A, Bulum T, Prkačin I. Comparison of vitamin K and non-vitamin K oral anticoagulants and the bleeding frequency in the emergency department. High Blood Press Cardiovasc Prev 2024; 31:23-30. [PMID: 38190093 DOI: 10.1007/s40292-023-00616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Safety studies of anticoagulant therapy have so far been conducted on many subjects in controlled conditions (i.e., clinically monitored) and demonstrated the noninferiority of new ones over old anticoagulant drugs. Data on the propositions for the presence of symptoms and signs of bleeding among various anticoagulants in the emergency department indicate that these data do not match the data published so far. AIM The aim of the study was to investigate the differences in the frequency of bleeding and bleeding-related symptoms as a reason for emergency department attendance in patients on anticoagulant therapy. METHODS The study included patients from the emergency department of University Hospital for one year, who were on anticoagulant therapy and who met the inclusion criteria. Out of a total of 595 patients, 409 were on warfarin (68.74%), and the rest were taking direct oral anticoagulants (DOAC): dabigatran 71 (11.93%), rivaroxaban 66 (11.09%) and apixaban 49 (8.23%). RESULTS Out of 409 patients taking warfarin, 34.4% were adequately anticoagulated with the frequency of bleeding 13.7%, while in 57.2% of patients, PT INR was higher than the reference values with the frequency of bleeding 15.0%. A comparison between all DOAC groups and adequately anticoagulated warfarin patients in the frequency of bleeding and bleeding-related symptoms as a reason for emergency attendance yielded a difference that was marginally statistically significant (Pearson Chi-Square = 7.554, p = 0.052). CONCLUSION Monitoring the frequency of bleeding and bleeding-related symptoms in patients on oral anticoagulant therapy as a reason for emergency department attendance may be a new safety and efficacy factor in real-life patient scenarios.
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Affiliation(s)
- Tomo Svaguša
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Stjepan Šimić
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia
| | - Filip Grabant
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Tatjana Kereš
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Ognjen Čančarević
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Frane Paić
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Danijela Grizelj
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Aleksandar Blivajs
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Tomislav Bulum
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia.
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia.
| | - Ingrid Prkačin
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Internal Medicine, University Hospital Merkur, Zagreb, Croatia
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Popat A, Patel SK, Adusumilli S, Irshad A, Nagaraj A, Patel KK, Jani SY, Nawaz G, Wahab A, Bora S, Mittal L, Yadav S. Efficacy and Safety of Different Dosing Regimens of Rivaroxaban in Patients With Atrial Fibrillation for Stroke Prevention: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51541. [PMID: 38313978 PMCID: PMC10834223 DOI: 10.7759/cureus.51541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/06/2024] Open
Abstract
Atrial fibrillation (AF) poses a substantial risk of stroke, necessitating effective anticoagulation therapy. This systematic review and meta-analysis (SRMA) evaluates the efficacy and safety of different dosing regimens of rivaroxaban in patients with AF. A comprehensive search of relevant databases, focusing on studies published from 2017 onward, was conducted. Inclusion criteria comprised randomized controlled trials (RCTs) and observational studies comparing standard and reduced dosing of rivaroxaban in AF. Data extraction and risk of bias (ROB) assessment were performed, and a meta-analysis was conducted for relevant outcomes. A total of 21 studies fulfilled the inclusion criteria. Standard dosing demonstrates a slightly lower risk of composite effectiveness outcomes and safety outcomes (HR: 0.79, 95% CI: 0.66-0.94, P=0.01) compared to reduced dosing (HR: 0.83, 95% CI: 0.71-0.97, P=0.02). Notable differences in major bleeding, gastrointestinal bleeding (GIB), and intracranial bleeding favored standard dosing. Hemorrhagic stroke and all-cause stroke rates differed significantly, with standard dosing showing a more favorable profile for ischemic stroke prevention. This study highlights the pivotal role of personalized anticoagulation therapy in AF. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines. The study bridges evidence from clinical trials to real-world practice, offering insights into the evolving landscape of AF management.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | | | - Ahmed Irshad
- Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
| | - Aishwarya Nagaraj
- Surgery and Pharmacology, Our Lady of Fatima University, Bangalore, IND
| | - Krisha K Patel
- College of Medicine, Dr. M. K. Shah Medical College and Research Center, Ahmedabad, IND
| | - Stavan Y Jani
- Internal Medicine, Bukovinian State Medical University, Chernivtsi, UKR
| | - Gul Nawaz
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | - Abdul Wahab
- Internal Medicine, Sargodha Medical College, Sargodha, PAK
| | - Satya Bora
- Neurology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Ahmedabad, IND
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9
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Atreja N, Severtson SG, Jiang J, Gao C, Hines DM, Cheng D, Hagan M, Breeze JL, Paulus JK, Secemsky EA. The Association between Direct Oral Anticoagulants Prescribing Behavior and Non-Valvular Atrial Fibrillation Outcomes: An Instrumental Variable Analysis of Real-World Data. J Clin Med 2023; 12:7190. [PMID: 38002802 PMCID: PMC10671855 DOI: 10.3390/jcm12227190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/03/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
Several observational studies have compared apixaban with rivaroxaban in patients with non-valvular atrial fibrillation (NVAF), but these analyses may be confounded by unmeasured characteristics. This study used provider prescribing preference (PPP) as an instrumental variable (IV) to assess the association between prescriber choice of rivaroxaban vs. apixaban and the study outcomes of stroke/systemic embolism (SE), major bleeding, and death in a retrospective cohort of NVAF patients in the US. Initiators of either medication were linked to their prescribers and followed until the first of the study outcome, the end of rivaroxaban/apixaban use, or 365 days after initiation. PPP for each patient was the percent of rivaroxaban initiations issued by the provider for the prior 10 NVAF patients. Cox regression models tested associations between quintiles of PPP and each outcome. A total of 61,155 patients and 1726 providers were included. The IV was a strong predictor of rivaroxaban prescription (OR = 17.9; 95% CI: 16.6, 19.3). There were statistically significant associations between increasing preference for rivaroxaban and rates of major bleeding (ptrend = 0.041) and death (ptrend = 0.031), but not stroke/SE (ptrend = 0.398). This analysis provides evidence of the relative safety of apixaban over rivaroxaban for the risk of major bleeding and death.
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Affiliation(s)
- Nipun Atreja
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | - Jenny Jiang
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | - Chuan Gao
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | - Dong Cheng
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | | | | | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Ramalle-Gómara E, Palacios-Castaño MI, Martínez-Ochoa E, Quiñones-Rubio C, Julian-Villaverde FJ, Marzo-Sola ME. Trends in stroke mortality in La Rioja (Spain) from 1999 to 2022. J Stroke Cerebrovasc Dis 2023; 32:107334. [PMID: 37677897 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Stroke mortality has declined in recent decades, but there appears to be a slowdown in the decline in recent years. We analyze the trends in stroke mortality in La Rioja (Spain) for the period 1999-2022. METHODS We evaluated stroke mortality using statistical data from the mortality registry of La Rioja (Spain). We adjusted the rates by age and sex and analyzed both overall strokes and subtypes: hemorrhagic and ischemic. To analyze the trend in mortality rates we constructed joinpoint regression models, with associated annual percentage change (APC) RESULTS: Age-standardized stroke mortality declined between 1999 and 2022: females from 98.0 to 29.2 per 100 000; males, from 131.6 to 44.8 per 100 000. We found a decrease in overall stroke mortality in all age groups, except those under 65 years old. Ischemic stroke mortality showed declines in the first decade (APC: 7.3%, CI95%: 4.1-19.1%) and increases in the second decade (APC: 1.6%, CI95%: -1.6-11.7%) among men. In women, the rates declined between 2018 and 2022(APC: -6.6%, CI95%: -5.1-30.6%) after an increase between 2015 and 2017 (APC: 23.5%, CI95%: -20.2-38.3%). For hemorrhagic stroke, we found a consistent rate of decline throughout the entire time period in men (APC: 2.4%, CI95%: 0.9 a 4.0%). In women, rates increased during the period 1999-2009(APC: 1.9%, CI95%: -2.1-22.8%) and decreased 2010-2022 (APC: 6.5%, CI95%: 4.0-25.6%). CONCLUSIONS Stroke mortality rates have decreased, more so for haemorrhagic than ischaemic strokes.
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Affiliation(s)
- Enrique Ramalle-Gómara
- Epidemiology and Health Promotion Department. La Rioja Regional Authority, 26071 Logroño, Spain.
| | | | - Eva Martínez-Ochoa
- Epidemiology and Health Promotion Department. La Rioja Regional Authority, 26071 Logroño, Spain.
| | - Carmen Quiñones-Rubio
- Epidemiology and Health Promotion Department. La Rioja Regional Authority, 26071 Logroño, Spain.
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Angeli F, Reboldi G, Agnelli G, Ambrosio G, Capucci A, Carreras G, Cavallini C, Murrone A, Vaudo G, Zingarini G, Verdecchia P. Use of Oral Anticoagulants in Patients with Atrial Fibrillation: Preliminary Data from the Italian Atrial Fibrillation (ITALY-AF) Registry. Clin Pract 2023; 13:1173-1181. [PMID: 37887081 PMCID: PMC10605134 DOI: 10.3390/clinpract13050105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment. METHODS The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword. RESULTS Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001). CONCLUSIONS A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, 21100 Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, 21049 Varese, Italy
| | | | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine—Stroke Unit, University of Perugia, 06123 Perugia, Italy
- Maugeri Scientific Clinical Institutes—IRCCS, 27100 Pavia, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology, School of Medicine, University of Perugia, 06123 Perugia, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital Umberto I, Lancisi-Salesi, 60123 Ancona, Italy
| | - Giovanni Carreras
- Arrhythmology Unit, Cardiology Department, Terni University Hospital, 05100 Terni, Italy
| | - Claudio Cavallini
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
| | - Adriano Murrone
- Struttura Complessa di Cardiologia, Hospital of Città di Castello, Città di Castello, 06012 Perugia, Italy
| | - Gaetano Vaudo
- Department of Medicine, University of Perugia, 06123 Perugia, Italy
- Unit of Internal Medicine, Terni University Hospital, 05100 Terni, Italy
| | - Gianluca Zingarini
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
| | - Paolo Verdecchia
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
- Fondazione Umbra Cuore e Ipertensione-ONLUS, 06124 Perugia, Italy
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12
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Baker WL, Roberts MS, Bessada Y, Caroti KS, Ashton V, Bookhart BK, Coleman CI. 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. Curr Med Res Opin 2023; 39:1183-1194. [PMID: 37584187 DOI: 10.1080/03007995.2023.2247988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/17/2023]
Abstract
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.
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Affiliation(s)
- William L Baker
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
| | - Matthew S Roberts
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
| | - Kimberly S Caroti
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
| | - Veronica Ashton
- Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Brahim K Bookhart
- Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
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Shurrab M, Ko DT, Jackevicius CA, Tu K, Middleton A, Michael F, Austin PC. A review of the use of propensity score methods with multiple treatment groups in the general internal medicine literature. Pharmacoepidemiol Drug Saf 2023; 32:817-831. [PMID: 37144449 DOI: 10.1002/pds.5635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/31/2023] [Accepted: 04/30/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Propensity score (PS) methods with two treatment groups (e.g., treated vs. control) is a well-established technique for reducing the effects of confounding in nonrandomized studies. However, researchers are often interested in comparing multiple interventions. PS methods have been modified to incorporate multiple exposures. We described available techniques for PS methods in multicategory exposures (≥3 groups) and examined their use in the medical literature. METHODS A comprehensive search was conducted for studies published in PubMed, Embase, Google Scholar, and Web of Science until February 27, 2023. We included studies using PS methods for multiple groups in general internal medicine research. RESULTS The literature search yielded 4088 studies (2616 from PubMed, 86 from Embase, 85 from Google Scholar, 1671 from Web of Science, five from other sources). In total, 264 studies using PS method for multiple groups were identified; 61 studies were on general internal medicine topics and included. The most commonly used method was that of McCaffrey et al., which was used in 26 studies (43%), where the Toolkit for Weighting and Analysis of Nonequivalent Groups (TWANG) method and corresponding inverse probabilities of treatment weights were estimated via generalized boosted models. The next most commonly used method was pairwise propensity-matched comparisons, which was used in 20 studies (33%). The method by Imbens et al. using a generalized propensity score was implemented in six studies (10%). Four studies (7%) used a conditional probability of being in a particular group given a set of observed baseline covariates where a multiple propensity score was estimated using a non-parsimonious multinomial logistic regression model. Four studies (7%) used a technique that estimates generalized propensity scores and then creates 1:1:1 matched sets, and one study (2%) used the matching weight method. CONCLUSIONS Many propensity score methods for multiple groups have been adopted in the literature. The TWANG method is the most commonly used method in the general medical literature.
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Affiliation(s)
- Mohammed Shurrab
- Cardiology Department, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and North, Ontario, Canada
| | - Dennis T Ko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and North, Ontario, Canada
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and North, Ontario, Canada
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- Pharmacy Department, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Karen Tu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada
| | - Allan Middleton
- Cardiology Department, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Faith Michael
- Cardiology Department, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and North, Ontario, Canada
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Deitelzweig S, Terasawa E, Atreja N, Kang A, Hines DM, Dhamane AD, Hagan M, Noman A, Luo X. Payer formulary tier increases of apixaban: how patients respond and potential implications. Curr Med Res Opin 2023; 39:1093-1101. [PMID: 37519272 DOI: 10.1080/03007995.2023.2232636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To assess potential impacts of formulary tier increases of apixaban-an efficacious oral anticoagulant (OAC) for preventing stroke in patients with atrial fibrillation (AF)-on patients' prescription drug plan (PDP) switching and OAC treatment patterns. METHODS Nationwide claims data for Medicare beneficiaries with Parts A, B, and D (100% sample) were used to assess apixaban-treated AF patients who faced a formulary tier increase for apixaban in 2017 by their Part D PDP. Patients' out-of-pocket (OOP) costs for apixaban were described, along with PDP switching and OAC treatment patterns. RESULTS Among 1845 included patients, 97.7% had apixaban on tier 3 of their plan's formulary in 2016 and faced its increase to tier 4 for 2017. Approximately 4% (N = 81) of patients pre-emptively switched to a different PDP for 2017 with almost all switching to plans with apixaban on a lower formulary tier and 85.2% continuing apixaban treatment. Among the 96% (N = 1764) of patients who remained on the same PDP for 2017, over half (57.5%) continued apixaban treatment, despite increased OOP costs ($54 vs. $135 for a 30-day supply in 2016 vs. 2017). Only 12.4% of those who remained on the same plan for 2017 switched to another OAC, while as much as 30.1% discontinued OACs. These discontinuers exhibited higher comorbidity burdens than patients continuing on any OAC. CONCLUSION The majority of patients continued on apixaban despite higher OOP cost, suggesting patients' reluctance to change treatment for non-medical reasons; however, 30% of patients discontinued OAC treatment after higher apixaban tier placement.
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Affiliation(s)
- Steven Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
| | | | - Nipun Atreja
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | | | - Melissa Hagan
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
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15
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Ip YMB, Lau KK, Ko H, Lau L, Yao A, Wong GLH, Yip TCF, Leng X, Chan H, Chan H, Mok V, Soo YOY, Seiffge D, Leung TW. Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant. Neurology 2023; 101:e358-e369. [PMID: 37225430 PMCID: PMC10435051 DOI: 10.1212/wnl.0000000000207422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/03/2023] [Indexed: 05/26/2023] Open
Abstract
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.
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Affiliation(s)
- Yiu Ming Bonaventure Ip
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Kui Kai Lau
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Ho Ko
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Lucas Lau
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Alan Yao
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Grace Lai-Hung Wong
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Terry Cheuk-Fung Yip
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Xinyi Leng
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Howard Chan
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Helen Chan
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Vincent Mok
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Yannie O Y Soo
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - David Seiffge
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Thomas W Leung
- From the Department of Medicine and Therapeutics (Y.M.B.I., H.K., L.L., A.Y., G.L.-H.W., T.C.-F.Y., X.L., Howard Chan, Helen Chan, V.M., Y.O.Y.S., T.W.L.), Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong; Department of Medicine (K.K.L.), Queen Mary Hospital, University of Hong Kong; Li Ka Shing Institute of Health Sciences (H.K.), Faculty of Medicine; Medical Data Analytic Centre (G.L.-H.W., T.C.-F.Y.), The Chinese University of Hong Kong; and Department of Neurology (D.S.), Inselspital University Hospital Bern and University of Bern, Switzerland.
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Wang X, Wang T, Chen X, Tian W, Ma D, Zhang J, Li Q, Chen Z, Ju J, Xu H, Chen K. Efficacy and Safety of Oral Anticoagulants in Older Adult Patients With Atrial Fibrillation: Pairwise and Network Meta-Analyses. J Am Med Dir Assoc 2023:S1525-8610(23)00474-7. [PMID: 37355246 DOI: 10.1016/j.jamda.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of oral anticoagulants for older adult patients with atrial fibrillation (AF). DESIGN Pairwise and network meta-analyses. SETTING AND PARTICIPANTS Patients with AF aged ≥75 years. METHODS PubMed, Embase, and the Cochrane library were searched for published randomized controlled trials and adjusted observational studies evaluating the use of a non-vitamin K antagonist oral anticoagulants (NOACs), vitamin K antagonist, or antiplatelet drug for the prevention of stroke. The primary efficacy and safety outcomes were the composite of stroke and systemic embolism (SSE) and major bleedings. RESULTS This study included 38 studies enrolling 1,022,908 older adult patients with AF. Results from pairwise meta-analyses showed that NOACs were superior to warfarin for all outcomes, except that dabigatran increased the risk of gastrointestinal (GI) bleedings. Aspirin was associated with a higher risk of SSE and ischemic stroke than warfarin or NOACs. Results of network meta-analyses indicated that apixaban significantly reduced the risk of SSE, major bleedings, and GI bleedings than warfarin, rivaroxaban, and dabigatran. Apixaban, edoxaban, rivaroxaban, and dabigatran reduced the risk of ischemic stroke and intracranial bleeding compared to warfarin. Dabigatran showed lower risk of all-cause mortality than warfarin and of intracranial bleeding than rivaroxaban. CONCLUSIONS AND IMPLICATIONS NOACs are of at least equal efficacy, or even superior to warfarin. The safety profile of individual NOAC agents was significantly different, as apixaban performs better than the other oral anticoagulants in reducing major bleeding and GI bleeding, whereas dabigatran increased the risk of GI bleeding.
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Affiliation(s)
- Xinyi Wang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tongxin Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xuanye Chen
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Wende Tian
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dan Ma
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jie Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Qiuyi Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Zhuo Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianqing Ju
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hao Xu
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Keji Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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Williams JM, Lovelace B, Christoph MJ, Li S, Guo H, Hoover M, Coleman CI. Clinical and health care resource use burden of hospitalizations for oral factor Xa inhibitor-associated major bleeding: A real-world analysis of Medicare beneficiaries. J Am Coll Emerg Physicians Open 2023; 4:e12956. [PMID: 37223213 PMCID: PMC10202196 DOI: 10.1002/emp2.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/24/2023] [Accepted: 04/12/2023] [Indexed: 05/25/2023] Open
Abstract
Objective To characterize the burden of illness associated with oral factor Xa (FXa) inhibitor-related bleeding in the US Medicare population. Methods This retrospective cohort study used the full 20% Medicare random sample claims database to identify patients who experienced their first hospitalization for an FXa inhibitor-related major bleed between October 2013 and September 2017. Bleeding types were classified as intracranial hemorrhage (ICH), gastrointestinal (GI), and other. Associations between risk factors and outcomes (in-hospital and 30-day mortality, 30-day readmission, and discharge to a location other than home) adjusted for patient demographic characteristics, baseline clinical conditions, index event characteristics, treatment with hemostatic/factor replacement agents or transfusion (ie, usual care prereversal agent availability), multicompartment ICH and neurosurgical procedures (ICH cohort), and endoscopy (GI cohort) were assessed using multivariable regression and reported as crude incidences and adjusted odds ratios (ORs) stratified by bleed type. Results Of the 11,593 patients identified, 2737 (23.6%) had ICH, 8169 (70.5%) had GI bleeds, and 687 (5.9%) had other bleeds. The incidences of in-hospital mortality, 30-day mortality, need for postdischarge out-of-home care, and 30-day readmission were 15.7%, 29.1%, 78.3%, and 20.3% in the single-compartment ICH cohort, respectively; and 1.7%, 6.8%, 41.3%, and 18.8% in the GI bleeds cohort, respectively. Increased odds of both in-hospital mortality and 30-day mortality were significantly associated with: multicompartment ICH (reference, single compartment ICH; OR = 3.35 [95% confidence interval (CI): 2.41-4.66]; 2.18 [95% CI: 1.63-2.91]), loss of consciousness during index hospitalization (yes vs no; OR = 2.03 [95% CI: 1.38-2.97]; 1.49 [95% CI: 1.11-2.02]), receiving usual care (yes vs no; OR = 1.55 [95% CI: 1.22-1.98]; 1.33 [95% CI: 1.09-1.63]) during index hospitalization, and increasing number of Elixhauser comorbidities at baseline (OR = 1.07 [95% CI: 1.03-1.10]; 1.09 [95% CI: 1.06-1.12]) in the ICH cohort; intensive care unit admission (yes vs no; OR = 1.88 [95% CI: 1.32-2.67]; 1.51 [95% CI: 1.26-1.81]), increasing number of Elixhauser comorbidities at baseline (OR = 1.12 [95% CI: 1.07-1.18]; 1.15 [1.12-1.18]), and increasing age on index date (OR = 1.04 [95% CI: 1.02-1.07]; 1.05 [95% CI: 1.04-1.07]) in the GI bleeds cohort. Conclusions In this large sample of Medicare patients, FXa inhibitor-related major bleeding was associated with substantial burden in terms of adverse clinical outcomes and health care resource use. Incidence of ICH was lower than GI bleeds; however, burden of illness was notably higher with ICH.
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Affiliation(s)
- James M. Williams
- Medical Center Emergency DepartmentMeritus HealthHagerstownMarylandUSA
| | | | | | - Suying Li
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Haifeng Guo
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Madison Hoover
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Craig I. Coleman
- Department of Pharmacy PracticeUniversity of Connecticut School of PharmacyStorrsConnecticutUSA
- Evidence‐based Practice CenterHartford HospitalHartfordConnecticutUSA
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson AL, Murray KT. Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation : A Retrospective Cohort Study. Ann Intern Med 2023; 176:769-778. [PMID: 37216662 DOI: 10.7326/m22-3238] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding. OBJECTIVE For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants' elimination. DESIGN Retrospective cohort study. SETTING U.S. Medicare beneficiaries aged 65 years or older. PATIENTS Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs. MEASUREMENTS Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting. RESULTS There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: P = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (P = 0.001). LIMITATION Possible residual confounding. CONCLUSION In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - C Michael Stein
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
| | - Walter Smalley
- Departments of Health Policy and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (W.S.)
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee (E.Z.)
| | - William D Dupont
- Departments of Health Policy and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (W.D.D.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - James R Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - Katherine T Murray
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
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Ngufor C, Yao X, Inselman JW, Ross JS, Dhruva SS, Graham DJ, Lee JY, Siontis KC, Desai NR, Polley E, Shah ND, Noseworthy PA. Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method. Am Heart J 2023; 260:124-140. [PMID: 36893934 PMCID: PMC10615250 DOI: 10.1016/j.ahj.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/02/2023] [Accepted: 02/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. METHODS We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. RESULTS The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. CONCLUSIONS Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.
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Affiliation(s)
- Che Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN.
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Sanket S Dhruva
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA; Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Joo-Yeon Lee
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | | | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Eric Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | | | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Lawal OD, Aronow HD, Shobayo F, Hume AL, Taveira TH, Matson KL, Zhang Y, Wen X. Comparative Effectiveness and Safety of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Chronic Liver Disease: A Nationwide Cohort Study. Circulation 2023; 147:782-794. [PMID: 36762560 DOI: 10.1161/circulationaha.122.060687] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND The benefit-risk profile of direct oral anticoagulants (DOACs) compared with warfarin, and between DOACs in patients with atrial fibrillation (AF) and chronic liver disease is unclear. METHODS We conducted a new-user, retrospective cohort study of patients with AF and chronic liver disease who were enrolled in a large, US-based administrative database between January 1, 2011, and December 31, 2017. We assessed the effectiveness and safety of DOACs (as a class and individually) compared with warfarin, and between DOACs in patients with AF and chronic liver disease. The primary outcomes were hospitalization for ischemic stroke/systemic embolism and hospitalization for major bleeding. Inverse probability treatment weights were used to balance the treatment groups on measured confounders. RESULTS Overall, 10 209 participants were included, with 4421 (43.2%) on warfarin, 2721 (26.7%) apixaban, 2211 (21.7%) rivaroxaban, and 851 (8.3%) dabigatran. The incidence rates per 100 person-years for ischemic stroke/systemic embolism were 2.2, 1.4, 2.6, and 4.4 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. The incidence rates per 100 person-years for major bleeding were 7.9, 6.5, 9.1, and 15.0 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. After inverse probability treatment weights, the risk of hospitalization for ischemic stroke/systemic embolism was significantly lower between DOACs as a class (hazard ratio [HR], 0.64 [95% CI, 0.46-0.90]) or apixaban (HR, 0.40 [95% CI, 0.19-0.82]) compared with warfarin, but not significantly different between rivaroxaban versus warfarin (HR, 0.76 [95% CI, 0.47-1.21]) or rivaroxaban versus apixaban (HR, 1.73 [95% CI, 0.91-3.29]). Compared with warfarin, the risk of hospitalization for major bleeding was lower with DOACs as a class (HR, 0.69 [95% CI, 0.58-0.82]), apixaban (HR, 0.60 [95% CI, 0.46-0.78]), and rivaroxaban (HR, 0.79 [95% CI, 0.62-1.0]). However, the risk of hospitalization for major bleeding was higher for rivaroxaban versus apixaban (HR, 1.59 [95% CI, 1.18-2.14]). CONCLUSIONS Among patients with AF and chronic liver disease, DOACs as a class were associated with lower risks of hospitalization for ischemic stroke/systemic embolism and major bleeding versus warfarin. However, the incidence of clinical outcomes among patients with AF and chronic liver disease varied between individual DOACs and warfarin, and in head-to-head DOAC comparisons.
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Affiliation(s)
- Oluwadolapo D Lawal
- Department of Pharmacy Practice, College of Pharmacy (O.D.L., A.L.H., T.H.T., K.L.M., X.W.), University of Rhode Island, Kingston
| | - Herbert D Aronow
- Lifespan Cardiovascular Institute, Providence, RI (H.D.A., T.H.T.).,Warren Alpert Medical School of Brown University, Providence, RI (H.D.A., T.H.T.)
| | - Fisayomi Shobayo
- Department of Cardiology, University of Texas Health Science Center, Houston (F.S.)
| | - Anne L Hume
- Department of Pharmacy Practice, College of Pharmacy (O.D.L., A.L.H., T.H.T., K.L.M., X.W.), University of Rhode Island, Kingston
| | - Tracey H Taveira
- Department of Pharmacy Practice, College of Pharmacy (O.D.L., A.L.H., T.H.T., K.L.M., X.W.), University of Rhode Island, Kingston.,Lifespan Cardiovascular Institute, Providence, RI (H.D.A., T.H.T.).,Warren Alpert Medical School of Brown University, Providence, RI (H.D.A., T.H.T.).,Providence Veterans Affairs Medical Center, RI (T.H.T.)
| | - Kelly L Matson
- Department of Pharmacy Practice, College of Pharmacy (O.D.L., A.L.H., T.H.T., K.L.M., X.W.), University of Rhode Island, Kingston
| | - Yichi Zhang
- Department of Computer Sciences and Statistics (Y.Z.), University of Rhode Island, Kingston
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy (O.D.L., A.L.H., T.H.T., K.L.M., X.W.), University of Rhode Island, Kingston
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Moret C, Acosta-Isaac R, Mojal S, Corrochano M, Jiménez B, Plaza M, Souto JC. Clinical outcomes in patients with atrial fibrillation treated with DOACs in a specialized anticoagulation center: Critical appraisal of real-world data. PLoS One 2023; 18:e0279297. [PMID: 36827286 DOI: 10.1371/journal.pone.0279297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/04/2022] [Indexed: 02/25/2023] Open
Abstract
AIMS Direct oral anticoagulants (DOAC) are progressively replacing vitamin K antagonists in the prevention of thromboembolism in patients with atrial fibrillation. However, their real-world clinical outcomes appear to be contradictory, with some studies reporting fewer and others reporting higher complications than the pivotal randomized controlled trials. We present the results of a clinical model for the management of DOACs in real clinical practice and provide a review of the literature. METHODS The MACACOD project is an ongoing, observational, prospective, single-center study with unselected patients that focuses on rigorous DOAC selection, an educational visit, laboratory measurements, and strict follow-up. RESULTS A total of 1,259 patients were included. The composite incidence of major complications was 4.93% py in the whole cohort vs 4.49% py in the edoxaban cohort. The rate of all-cause mortality was 6.11% py for all DOACs vs 5.12% py for edoxaban. There weren't differences across sex or between Edoxaban reduced or standard doses. However, there were differences across ages, with a higher incidence of major bleeding complications in patients >85 years (5.13% py vs 1.69% py in <75 years). CONCLUSIONS We observed an incidence of serious complications of 4.93% py, in which severe bleeding predominated (3.65% py). Considering our results, more specialized attention seems necessary to reduce the incidence of severe complications and also a more critical view of the literature. Considering our results, and our indirect comparison with many real-world studies, more specialized attention seems necessary to reduce the incidence of severe complications in AF patients receiving DOACs.
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22
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Grymonprez M, De Backer TL, Bertels X, Steurbaut S, Lahousse L. Long-term comparative effectiveness and safety of dabigatran, rivaroxaban, apixaban and edoxaban in patients with atrial fibrillation: A nationwide cohort study. Front Pharmacol 2023; 14:1125576. [PMID: 36817122 PMCID: PMC9932194 DOI: 10.3389/fphar.2023.1125576] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Background: Although non-vitamin K antagonist oral anticoagulants (NOACs) are recommended over vitamin K antagonists (VKAs) in atrial fibrillation (AF) management, direct long-term head-to-head comparisons are lacking. Therefore, their risk-benefit profiles were investigated compared to VKAs and between NOACs. Methods: AF patients initiating anticoagulation between 2013-2019 were identified in Belgian nationwide data. Inverse probability of treatment weighted Cox regression was used to investigate effectiveness and safety outcomes and were additionally stratified by NOAC dose. Results: Among 254,478 AF patients (328,796 person-years of follow-up), NOACs were associated with significantly lower risks of stroke or systemic embolism (stroke/SE) (hazard ratio (HR) 0.68, 95% confidence interval (CI) (0.64-0.72)), all-cause mortality (HR 0.76, 95%CI (0.74-0.79)), major or clinically relevant non-major bleeding (MB/CRNMB) (HR 0.94, 95%CI (0.91-0.98)) and intracranial hemorrhage (HR 0.73, 95%CI (0.66-0.79)), but non-significantly different risks of myocardial infarction, gastrointestinal and urogenital bleeding compared to VKAs. Despite similar stroke/SE risks, dabigatran and apixaban were associated with significantly lower MB/CRNMB risks compared to rivaroxaban (HR 0.86, 95%CI (0.83-0.90); HR 0.86, 95%CI (0.83-0.89), respectively) and edoxaban (HR 0.91, 95%CI (0.83-0.99); HR 0.86, 95%CI (0.81-0.91), respectively), and apixaban with significantly lower major bleeding risks compared to dabigatran (HR 0.86, 95%CI (0.80-0.92)) and edoxaban (HR 0.79, 95%CI (0.72-0.86)). However, higher mortality risks were observed in some risk groups including with apixaban in patients with diabetes or concomitantly using digoxin compared to dabigatran and edoxaban, respectively. Conclusion: NOACs had better long-term risk-benefit profiles than VKAs. While effectiveness was comparable, apixaban was overall associated with a more favorable safety profile followed by dabigatran.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Xander Bertels
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.,Department of Hospital Pharmacy, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
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23
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Chugh Y, Gupta K, Krishna HB, Ayala RQ, Zepeda I, Grushko M, Faillace RT. Safety and efficacy of apixaban, dabigatran and rivaroxaban in obese and morbidly obese patients with heart failure and atrial fibrillation: A real-world analysis. Pacing Clin Electrophysiol 2023; 46:50-58. [PMID: 36419246 DOI: 10.1111/pace.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Atrial fibrillation and heart failure are combined risk factors for thromboembolic events. Obese and morbidly obese individuals have been underrepresented in clinical trials studying safety and efficacy of direct oral anticoagulants (DOACs). OBJECTIVES Study the comparative safety and efficacy of DOACs in obese and morbidly obese patients with atrial fibrillation or flutter, and concomitant congestive heart failure. METHODS In the present single-center retrospective observational study, patients with an ICD-9 code of atrial fibrillation or atrial flutter, and congestive heart failure on a DOAC (apixaban[n = 155], rivaroxaban[n = 335], dabigatran[n = 393]) were followed for a median 12.5 months (IQR: 22.1 months). Obesity was defined as a body mass index, BMI ≥ 30 and < 40 kg/m2 [n = 614], and morbid obesity as BMI ≥ 40 kg/m2 [n = 269]. Clinical endpoints were grouped into safety (composite of intracranial-hemorrhage, gastrointestinal-bleeds, hemorrhagic-stroke, and other bleeds), and efficacy (composite of ischemic-stroke and systemic-embolism) endpoints. Cox proportional hazard models were used to compare safety, efficacy, and all-cause mortality outcomes. RESULTS In obese patients, no statistical difference was observed in efficacy of DOACs. A statistical difference was observed in the safety of DOACs in obese patients. Apixaban was found to be safer than dabigatran [hazard ratio [HR] 0.37 (0.16-0.87), p = .02] and rivaroxaban [HR 0.29 (0.12-0.67), p = .004]. In morbidly obese patients, there was no overall statistical difference in the efficacy or safety of DOACs. CONCLUSION In obese patients with congestive heart failure and atrial fibrillation or atrial flutter on DOACs, apixaban has the most favorable safety profile compared to rivaroxaban and dabigatran.
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Affiliation(s)
- Yashasvi Chugh
- Baylor Heart and Vascular Hospital, Dallas, Texas, USA.,Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kashvi Gupta
- University of Missouri at Kansas City, Kansas City, Missouri, USA
| | | | - Renato Quispe Ayala
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ignacio Zepeda
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael Grushko
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert T Faillace
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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24
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Amin A, Keshishian A, Hines DM, Dina O, Le H, Rosenblatt L, Liu X, Zhang Q, Vo L. Risk of stroke/systemic embolism, major bleeding, and associated costs in non-valvular atrial fibrillation patients who initiated apixaban, dabigatran, or rivaroxaban compared with warfarin in the United States medicare population: updated analysis. Curr Med Res Opin 2022; 38:2131-2140. [PMID: 35993487 DOI: 10.1080/03007995.2022.2115772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an updated comparison of the risk and cost of stroke/systemic embolism (SE) and major bleeding between direct oral anticoagulants (DOAC: apixaban, rivaroxaban, dabigatran) and warfarin among non-valvular atrial fibrillation (NVAF) patients. METHODS Adults (≥65 years) initiating warfarin or DOACs between 1 January 2013 and 31 December 2014 were selected from the Medicare database and propensity scores matched 1:1 to balance baseline characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major bleeding-related medical costs in each matched cohort. RESULTS Of the 264,479 eligible patients, 38,740 apixaban-warfarin pairs, 76,677 rivaroxaban-warfarin pairs, and 20,955 dabigatran-warfarin pairs were matched. Apixaban (Hazard Ratio [HR] = 0.46; 95% Confidence Interval [CI] 0.38-0.56) and rivaroxaban (HR = 0.71; 95% CI 0.63-0.80) were associated with a significantly lower risk of stroke/SE compared to warfarin. Apixaban (HR = 0.57; 95% CI 0.51-0.63) and dabigatran (HR = 0.80; 95% CI 0.70-0.90) were associated with a significantly lower risk of major bleeding; rivaroxaban (HR = 1.14; 95% CI 1.07-1.21) was associated with a significantly higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban and rivaroxaban had significantly lower stroke/SE-related medical costs; and apixaban and dabigatran had significantly lower major bleeding-related medical costs. CONCLUSIONS This real-world analysis showed DOACs to be associated with a lower risk of stroke/SE and major bleeding, and lower medical costs compared to warfarin. Among them, only apixaban appears to be associated with a significantly lower risk of all three outcomes collectively: stroke/SE, major bleeding, and lower related medical costs compared to warfarin.
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Affiliation(s)
- Alpesh Amin
- University of California, Irvine, Irvine, CA, USA
| | | | | | | | - Hannah Le
- Bristol-Myers Squibb, Lawrenceville, NJ, USA
| | | | | | | | - Lien Vo
- Bristol-Myers Squibb, Lawrenceville, NJ, USA
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25
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Abstract
In recent years, US payers have increased usage of formulary exclusions as a means to help manage costs. Earlier this year, one of the largest pharmacy benefit managers in the country added Eliquis (apixaban), the most widely used anticoagulant, to its list of excluded medicines from its formulary, raising concerns by physicians and patients. In this commentary, we examine the potential impacts of formulary exclusion of a drug like apixaban-a treatment for patients with atrial fibrillation and venous thromboembolism to help prevent stroke and clotting events and which has been demonstrated to have a strong efficacy and safety profile. We discuss the effect of formulary exclusions on patients' ability to access the most clinically appropriate treatment for their health needs, along with possible effects on their health and well-being. We also report descriptive results on apixaban-treated patients with traditional Medicare coverage who faced a formulary exclusion of apixaban in 2017, and these patients' observed behaviors. We found that the majority of these patients remained on apixaban either through pre-emptively switching to a different Part D drug plan with apixaban coverage or applying for formulary exception. Our findings suggest that formulary exclusion did not help to achieve the goal of switching patients to less costly medications but created additional hurdles for patients to access their preferred treatment and increased patient burden. Alternative ways to manage payer costs may be needed to help avoid poor outcomes and reduce the burden placed on patients in their efforts to access life-saving medications.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | | | - Amiee Kang
- Bristol Myers Squibb, Inc., Lawrence, NJ, USA
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26
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Lau WCY, Torre CO, Man KKC, Stewart HM, Seager S, Van Zandt M, Reich C, Li J, Brewster J, Lip GYH, Hingorani AD, Wei L, Wong ICK. Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation : A Multinational Population-Based Cohort Study. Ann Intern Med 2022; 175:1515-1524. [PMID: 36315950 DOI: 10.7326/m22-0511] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Current guidelines recommend using direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), but head-to-head trial data do not exist to guide the choice of DOAC. OBJECTIVE To do a large-scale comparison between all DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) in routine clinical practice. DESIGN Multinational population-based cohort study. SETTING Five standardized electronic health care databases, which covered 221 million people in France, Germany, the United Kingdom, and the United States. PARTICIPANTS Patients who were newly diagnosed with AF from 2010 through 2019 and received a new DOAC prescription. MEASUREMENTS Database-specific hazard ratios (HRs) of ischemic stroke or systemic embolism, intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model. RESULTS A total of 527 226 new DOAC users met the inclusion criteria (apixaban, n = 281 320; dabigatran, n = 61 008; edoxaban, n = 12 722; and rivaroxaban, n = 172 176). Apixaban use was associated with lower risk for GIB than use of dabigatran (HR, 0.81 [95% CI, 0.70 to 0.94]), edoxaban (HR, 0.77 [CI, 0.66 to 0.91]), or rivaroxaban (HR, 0.72 [CI, 0.66 to 0.79]). No substantial differences were observed for other outcomes or DOAC-DOAC comparisons. The results were consistent for patients aged 80 years or older. Consistent associations between lower GIB risk and apixaban versus rivaroxaban were observed among patients receiving the standard dose (HR, 0.72 [CI, 0.64 to 0.82]), those receiving a reduced dose (HR, 0.68 [CI, 0.61 to 0.77]), and those with chronic kidney disease (HR, 0.68 [CI, 0.59 to 0.77]). LIMITATION Residual confounding is possible. CONCLUSION Among patients with AF, apixaban use was associated with lower risk for GIB and similar rates of ischemic stroke or systemic embolism, ICH, and all-cause mortality compared with dabigatran, edoxaban, and rivaroxaban. This finding was consistent for patients aged 80 years or older and those with chronic kidney disease, who are often underrepresented in clinical trials. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Wallis C Y Lau
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (W.C.Y.L., K.K.C.M.)
| | - Carmen Olga Torre
- IQVIA, Real-World Solutions, Brighton, United Kingdom (C.O.T., H.M.S., S.S.)
| | - Kenneth K C Man
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (W.C.Y.L., K.K.C.M.)
| | | | - Sarah Seager
- IQVIA, Real-World Solutions, Brighton, United Kingdom (C.O.T., H.M.S., S.S.)
| | - Mui Van Zandt
- IQVIA, Real-World Solutions, Plymouth Meeting, Pennsylvania (M.V., C.R.)
| | - Christian Reich
- IQVIA, Real-World Solutions, Plymouth Meeting, Pennsylvania (M.V., C.R.)
| | - Jing Li
- IQVIA, Real-World Solutions, Durham, North Carolina (J.L., J.B.)
| | - Jack Brewster
- IQVIA, Real-World Solutions, Durham, North Carolina (J.L., J.B.)
| | - 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, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (G.Y.H.L.)
| | - Aroon D Hingorani
- Institute of Cardiovascular Sciences, University College London, and University College London British Heart Foundation Research Accelerator, London, United Kingdom (A.D.H.)
| | - Li Wei
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (L.W.)
| | - Ian C K Wong
- Aston Pharmacy School, Aston University, Birmingham, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (I.C.K.W.)
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27
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Huang CW, Duan L, An J, Sim JJ, Lee MS. Effectiveness and Safety of Dabigatran in Atrial Fibrillation Patients with Severe Obesity: a Real-World Retrospective Cohort Study. J Gen Intern Med 2022; 37:2982-2990. [PMID: 34545470 PMCID: PMC9485368 DOI: 10.1007/s11606-021-07114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants such as dabigatran are the preferred anticoagulant in treating atrial fibrillation (AF) patients due to their effectiveness and safety. Whether this applies to severely obese patients needs to be determined. OBJECTIVE To compare the effectiveness and safety of dabigatran with warfarin among AF patients with severe obesity. DESIGN Retrospective cohort study. PARTICIPANTS AF patients with a BMI >40kg/m2 or a weight >120kg receiving dabigatran or warfarin between 10/01/2010 and 12/31/2019 in a large integrated health system and followed through 08/01/2020. INTERVENTIONS Not applicable. MAIN MEASURES Primary effectiveness outcome was composite thromboembolism including transient ischemic attack, ischemic stroke, or systemic embolism. Primary safety outcome was composite bleeding including gastrointestinal bleeding, intracranial bleeding, or other bleeding. Secondary outcomes included the individual outcomes and all-cause mortality. Propensity score matching (PSM) was performed to create a 1:1 matched cohort and Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome for dabigatran users compared to warfarin users. KEY RESULTS A total of 6848 patients receiving either dabigatran or warfarin were identified. In a 1:1 matched cohort, dabigatran users had a HR of 0.71 (95% confidence interval (CI): 0.56-0.91) for composite thromboembolism, a HR of 1.24 (95%CI: 1.07-1.42) for composite bleeding, and a HR of 0.57 (95% CI: 0.45-0.71) for all-cause mortality when compared to warfarin users. CONCLUSIONS Among AF patients with a BMI >40kg/m2 or a weight >120kg in a real-world clinical setting, dabigatran was effective in reducing the risk of thromboembolism and mortality but was associated with an increased risk of bleeding when compared to warfarin. Dabigatran may be a reasonable option for AF patients with severe obesity.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA.
| | - Lewei Duan
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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28
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Buckley BJR, Lane DA, Calvert P, Zhang J, Gent D, Mullins CD, Dorian P, Kohsaka S, Hohnloser SH, Lip GYH. Effectiveness and Safety of Apixaban in over 3.9 Million People with Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11133788. [PMID: 35807073 PMCID: PMC9267894 DOI: 10.3390/jcm11133788] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Benjamin J. R. Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Correspondence: ; Tel.: +44-(0)151-794-2000
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Clinical Medicine, Aalborg University, P.O. Box 159, DK-9100 Aalborg, Denmark
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - David Gent
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
| | - C. Daniel Mullins
- PHSR Department, School of Pharmacy, University of Maryland, Baltimore, MD 20742, USA;
| | - Paul Dorian
- Division of Cardiology, St Michael’s Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Shun Kohsaka
- Department of Cardiology, Keio University, Tokyo 108-8345, Japan;
| | - Stefan H. Hohnloser
- Department of Cardiology, J.W. Goethe University, 60590 Frankfurt, Germany;
- Centre of Thrombosis and Hemostasis, University of Mainz, 55122 Mainz, Germany
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (D.A.L.); (P.C.); (J.Z.); (D.G.); (G.Y.H.L.)
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Clinical Medicine, Aalborg University, P.O. Box 159, DK-9100 Aalborg, Denmark
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29
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Eckman MH, Wise R, Leonard AC, Baker P, Ireton R, Harnett BM, Dixon E, Awosika B, Ezigbo C, Flaherty ML, Adejare A, Knochelmann C, Mardis R, Wright S, Gummadi A, Becker R, Schauer DP, Costea A, Kleindorfer D, Sucharew H, Costanzo A, Anderson L, Kues J. Racial and sex differences in optimizing anticoagulation therapy for patients with atrial fibrillation. Am Heart J Plus 2022; 18:100170. [PMID: 38559416 PMCID: PMC10978356 DOI: 10.1016/j.ahjo.2022.100170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 04/04/2024]
Abstract
Study objective Atrial fibrillation (AF) is the most common cardiac rhythm disorder, responsible for 15 % of strokes in the United States. Studies continue to document underuse of anticoagulation therapy in minority populations and women. Our objective was to compare the proportion of AF patients by race and sex who were receiving non-optimal anticoagulation as determined by an Atrial Fibrillation Decision Support Tool (AFDST). Design setting and participants Retrospective cohort study including 14,942 patients within University of Cincinnati Health Care system. Data were analyzed between November 18, 2020, and November 20, 2021. Main outcomes and measures Discordance between current therapy and that recommended by the AFDST. Results In our two-category analysis 6107 (41 %) received non-optimal anticoagulation therapy, defined as current treatment category ≠ AFDST-recommended treatment category. Non-optimal therapy was highest in Black (42 % [n = 712]) and women (42 % [n = 2668]) and lower in White (39 % [n = 4748]) and male (40 % [n = 3439]) patients. Compared with White patients, unadjusted and adjusted odds ratios of receiving non-optimal anticoagulant therapy for Black patients were 1.13; 95 % CI, 1.02-1.30, p = 0.02; and 1.17; 95%CI, 1.04-1.31, p = 0.01; respectively, and 1.10; 95 % CI 1.03-1.18, p = 0.005; and 1.36; 95 % CI, 1.25-1.47, p < 0.001; for females compared with males. Conclusions and relevance In patients with atrial fibrillation in the University of Cincinnati Health system, Black race and female sex were independently associated with an increased odds of receiving non-optimal anticoagulant therapy.
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Affiliation(s)
- Mark H. Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Ruth Wise
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Anthony C. Leonard
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, United States of America
| | - Pete Baker
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Rob Ireton
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Brett M. Harnett
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Estrelita Dixon
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Bi Awosika
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Chika Ezigbo
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Matthew L. Flaherty
- Department of Neurology, University of Cincinnati College of Medicine, United States of America
| | - Adeboye Adejare
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, United States of America
| | - Carol Knochelmann
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Rachael Mardis
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Sharon Wright
- University of Cincinnati Health System, United States of America
| | - Ashish Gummadi
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Richard Becker
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Daniel P. Schauer
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Alexandru Costea
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Dawn Kleindorfer
- Department of Neurology, University of Michigan College of Medicine, United States of America
| | - Heidi Sucharew
- Cincinnati Children's Hospital Medical Center, United States of America
| | - Amy Costanzo
- University of Cincinnati College of Nursing, United States of America
| | | | - John Kues
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, United States of America
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Thomas A, Fang MC, Kogan S, Hubbard CC, Friedman PN, Gong L, Klein TE, Nutescu EA, O’Brien TJ, Tuck M, Perera MA, Schwartz JB. Apixaban Concentrations in Routine Clinical Care of Older Adults With Nonvalvular Atrial Fibrillation. JACC Adv 2022; 1:100039. [PMID: 37961076 PMCID: PMC10643025 DOI: 10.1016/j.jacadv.2022.100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Direct-acting oral anticoagulants are first-line agents for prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF), but data are limited for the oldest patients, and with reduced dosing. OBJECTIVES To determine steady-state apixaban peak and trough concentrations during routine care of older adults with NVAF, compare concentrations to clinical trial concentrations, and explore factors associated with concentrations. METHODS A cross-sectional study of medically stable older adults with NVAF (≥75 years or ≥70 years if Black) receiving apixaban. Peak (2-4.4 hours post-dose) and trough (before next dose) concentrations were determined by anti-Xa activity calibrated chromogenic assay. Patient characteristics associated with concentrations were determined by multivariate modeling. RESULTS The median age of patients (n = 115) was 80 (interquartile range: 77-84) years. The cohort comprised 46 women and 69 men; of which 98 are White, 11 Black, and 6 Asian. With 5 mg twice daily per labelling (n = 88), peak concentrations were higher in women: 248 ± 105 vs 174 ± 67 ng/mL in men (P < 0.001) and exceeded expected 95% range in 6 of 30 vs 0 of 55 men (P = 0.002). With 2.5 mg twice daily per label (n = 11), concentrations were <5 mg twice daily (peak: 136 ± 87 vs 201 ± 90 ng/mL, P = 0.026; trough: 65 ± 28 vs 109 ± 56 ng/mL, P < 0.001), but not different than 2.5 mg twice daily without reduction criteria (n = 13; peak: 132 ± 88; trough: 65 ± 31 ng/mL). Covariates associated with concentrations included sex, number of daily medications, and creatinine clearance. CONCLUSIONS Older women had higher than expected peak apixaban concentrations, and 2.5 mg twice daily produced lower concentrations than standard dosing. Factors not currently included in dosing recommendations affected concentrations. The impact of apixaban concentrations on outcomes needs evaluation.
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Affiliation(s)
- Alveena Thomas
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C. Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Scott Kogan
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Colin C. Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Paula N. Friedman
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Teri E. Klein
- Department of Biomedical Data Science and Department of Medicine, Stanford University, Stanford, California, USA
| | - Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Travis J. O’Brien
- Department of Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Matthew Tuck
- Washington DC VA Medical Center, Washington, District of Columbia, USA
- Department of Medicine, The George Washington University, Washington, District of Columbia, USA
| | - Minoli A. Perera
- Department of Pharmacology, Center for Pharmacogenomics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Janice B. Schwartz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Polymeris AA, Zietz A, Schaub F, Meya L, Traenka C, Thilemann S, Wagner B, Hert L, Altersberger VL, Seiffge DJ, Lyrer F, Dittrich T, Piot I, Kaufmann J, Barone L, Dahlheim L, Flammer S, Avramiotis NS, Peters N, De Marchis GM, Bonati LH, Gensicke H, Engelter ST, Lyrer PA. Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation. Eur Stroke J 2022; 7:221-229. [DOI: 10.1177/23969873221099477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Data on the safety and effectiveness of once-daily (QD) versus twice-daily (BID) direct oral anticoagulants (DOAC) in comparison to vitamin K antagonists (VKA) and to one another in patients with atrial fibrillation (AF) and recent stroke are scarce. Patients and methods: Based on prospectively obtained data from the observational registry Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients(NOACISP)-LONGTERM (NCT03826927) from Basel, Switzerland, we compared the occurrence of the primary outcome – the composite of recurrent ischemic stroke, major bleeding, and all-cause death – among consecutive AF patients treated with either VKA, QD DOAC, or BID DOAC following a recent stroke using Cox proportional hazards regression including adjustment for potential confounders. Results: We analyzed 956 patients (median age 80 years, 46% female), of whom 128 received VKA (13.4%), 264 QD DOAC (27.6%), and 564 BID DOAC (59%). Over a total follow-up of 1596 patient-years, both QD DOAC and BID DOAC showed a lower hazard for the composite outcome compared to VKA (adjusted HR [95% CI] 0.69 [0.48, 1.01] and 0.66 [0.47, 0.91], respectively). Upon direct comparison, the hazard for the composite outcome did not differ between patients treated with QD versus BID DOAC (adjusted HR [95% CI] 0.94 [0.70, 1.26]). Secondary analyses focusing on the individual components of the composite outcome revealed no clear differences in the risk-benefit profile of QD versus BID DOAC. Discussion and conclusion: The overall benefit of DOAC over VKA seems to apply to both QD and BID DOAC in AF patients with a recent stroke, without clear evidence that one DOAC dosing regimen is more advantageous than the other.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Louisa Meya
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Flurina Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ines Piot
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Josefin Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Lea Barone
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | | | - Sophie Flammer
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Nikolaos S Avramiotis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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Huisman MV, Teutsch C, Lu S, Diener HC, Dubner SJ, Halperin JL, Ma CS, Rothman KJ, Lohmann R, Gurusamy VK, Bartels DB, Lip GYH. Dabigatran versus vitamin K antagonists for atrial fibrillation in clinical practice: final outcomes from Phase III of the GLORIA-AF registry. Clin Res Cardiol 2022; 111:548-559. [PMID: 35294623 PMCID: PMC9054866 DOI: 10.1007/s00392-021-01957-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prospectively collected, routine clinical practice-based data on antithrombotic therapy in non-valvular atrial fibrillation (AF) patients are important for assessing real-world comparative outcomes. The objective was to compare the safety and effectiveness of dabigatran versus vitamin K antagonists (VKAs) in patients with newly diagnosed AF. METHODS AND RESULTS GLORIA-AF is a large, prospective, global registry program. Consecutive patients with newly diagnosed AF and CHA2DS2-VASc scores ≥ 1 were included and followed for 3 years. To control for differences in patient characteristics, the comparative analysis for dabigatran versus VKA was performed on a propensity score (PS)-matched patient set. Missing data were multiply imputed. Proportional-hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest. Between 2014 and 2016, 21,300 eligible patients were included worldwide: 3839 patients were prescribed dabigatran and 4836 VKA with a median age of 71.0 and 72.0 years, respectively; > 85% in each group had a CHA2DS2-VASc-score ≥ 2. The PS-matched comparative analysis for dabigatran and VKA included on average 3326 pairs of matched initiators. For dabigatran versus VKAs, adjusted HRs (95% confidence intervals) were: stroke 0.89 (0.59-1.34), major bleeding 0.61 (0.42-0.88), all-cause death 0.78 (0.63-0.97), and myocardial infarction 0.89 (0.53-1.48). Further analyses stratified by PS and region provided similar results. CONCLUSIONS Dabigatran was associated with a 39% reduced risk of major bleeding and 22% reduced risk for all-cause death compared with VKA. Stroke and myocardial infarction risks were similar, confirming a more favorable benefit-risk profile for dabigatran compared with VKA in clinical practice. Clinical trial registration https://www. CLINICALTRIALS gov . NCT01468701, NCT01671007.
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Affiliation(s)
- Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands.
| | - Christine Teutsch
- Department of CardioMetabolism and Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Shihai Lu
- Biostatistics, Biogen, Cambridge, MA, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University of Duisburg-Essen, Essen, Germany
| | - Sergio J Dubner
- Cardiology Department, Electrophysiology Service, Clínica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | - Jonathan L Halperin
- The Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chang-Sheng Ma
- Cardiology Department, Atrial Fibrillation Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Ragna Lohmann
- Clinical Operations, Boehringer Ingelheim Pharma and Co. KG, Ingelheim, Germany
| | | | - Dorothee B Bartels
- Institute for Epidemiology, Social Medicine and Health System, Hannover Medical School, Hannover, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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Lin KJ, Schneeweiss S, Pawar A, Singer DE, Liu J, Gagne JJ. Using a Simple Prescription Gap to Determine Warfarin Discontinuation Can Lead to Substantial Misclassification. Thromb Haemost 2022; 122:386-393. [PMID: 33984866 DOI: 10.1055/a-1508-8187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Warfarin remains widely used and a key comparator in studies of other direct oral anticoagulants. As longer-than-needed warfarin prescriptions are often provided to allow for dosing adjustments according to international normalized ratios (INRs), the common practice of using a short allowable gap between dispensings to define warfarin discontinuation may lead to substantial misclassification of warfarin exposure. We aimed to quantify such misclassification and determine the optimal algorithm to define warfarin discontinuation. METHODS We linked Medicare claims data from 2007 to 2014 with a multicenter electronic health records system. The study cohort comprised patients ≥65 years with atrial fibrillation and venous thromboembolism initiating warfarin. We compared results when defining warfarin discontinuation by (1) different gaps (3, 7, 14, 30, and 60 days) between dispensings and (2) having a gap ≤60 days or bridging larger gaps if there was INR ordering at least every 42 days (60_INR). Discontinuation was considered misclassified if there was an INR ≥2 within 7 days after the discontinuation date. RESULTS Among 3,229 patients, a shorter gap resulted in a shorter mean follow-up time (82, 95, 117, 159, 196, and 259 days for gaps of 3, 7, 14, 30, 60, and 60_INR, respectively; p < 0.001). Incorporating INR (60_INR) can reduce misclassification of warfarin discontinuation from 68 to 4% (p < 0.001). The on-treatment risk estimation of clinical endpoints varied significantly by discontinuation definitions. CONCLUSION Using a short gap between warfarin dispensings to define discontinuation may lead to substantial misclassification, which can be improved by incorporating intervening INR codes.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Daniel E Singer
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
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Perreault S, Dragomir A, Côté R, Lenglet A, de Denus S, Dorais M, White-Guay B, Brophy J, Schnitzer ME, Dubé MP, Tardif JC. Comparative Effectiveness and Safety of Low-Dose Oral Anticoagulants in Patients With Atrial Fibrillation. Front Pharmacol 2022; 12:812018. [PMID: 35095525 PMCID: PMC8795908 DOI: 10.3389/fphar.2021.812018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: Observational studies of various dose levels of direct oral anticoagulants (DOACs) for patients with atrial fibrillation (AF) found that a high proportion of patients received a dose lower than the target dose tested in randomized controlled trials. There is a need to compare low-dose DOACs with warfarin or other DOACs on effectiveness and safety. Methods: Using administrative data from Quebec province, Canada, we built a cohort of new warfarin or DOAC users discharged from hospital between 2011 and 2017. We determined CHA2DS2-VASc and HAS-BLED scores, and comorbidities for 3-year prior cohort entry. The primary effectiveness endpoint was a composite of ischemic stroke/systemic embolism (SE), and secondary outcomes included a safety composite of major bleeding (MB) events and effectiveness composite (stroke/SE, death) at 1-year follow-up. We contrasted each low-dose DOAC with warfarin or other DOACs as references using inverse probability of treatment weighting to estimate marginal Cox hazard ratios (HRs). Results: The cohort comprised 22,969 patients (mean age: 80-86). We did not find a significant risk reduction for the stroke/SE primary effectiveness endpoint for DOACs vs. warfarin; however, we observed a significantly lower risk for low-dose dabigatran vs. warfarin (HR [95%CI]: 0.59 [0.42-0.81]) for effectiveness composite, mainly due to a lower death rate. The differences in effectiveness and safety composites between low-dose rivaroxaban vs. warfarin were not significant. However, low-dose apixaban had a better safety composite (HR: 0.68 [0.53-0.88]) vs. warfarin. Comparisons of dabigatran vs. apixaban showed a lower risk of stroke/SE (HR: 0.53 [0.30-0.93]) and a 2-fold higher risk of MB. The MB risk was higher for rivaroxaban than for apixaban (HR: 1.58 [1.09-2.29]). Conclusions: The results of this population-based study suggest that low-dose dabigatran has a better effective composite than warfarin. Compared with apixaban, low-dose dabigatran had a better effectiveness composite but a worse safety profile. Low-dose apixaban had a better safety composite than warfarin and other low-dose DOACs. Given that the comparative effectiveness and safety seem to vary from one DOAC to another, pharmacokinetic data for specific populations are now warranted.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Alice Dragomir
- Department of Urology, Faculty of Medicine, University McGill, Montreal, QC, Canada
| | - Robert Côté
- Faculty of Medicine, Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Aurélie Lenglet
- Laboratory MP3CV, Faculty of Pharmacy, University of Picardie Jules Verne, Amiens, France.,Pharmacy, Amiens University Medical Center, Amiens, France
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.,Montreal Heart Institute, Montreal, QC, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, QC, Canada
| | - Brian White-Guay
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - James Brophy
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | | | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
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Tereshchenko SN, Uskach TM. Treatment strategies for patients with atrial fibrillation and chronic heart failure. TERAPEVT ARKH 2022; 93:1545-1550. [DOI: 10.26442/00403660.2021.12.201205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 11/22/2022]
Abstract
Atrial fibrillation (AF) is associated with significant morbidity and mortality and may lead to the development of chronic heart failure (CHF). Each condition predisposes to the other, requiring a careful choice of the treatment strategy. This article is devoted to the prevalence and prognostic implications of both diseases. The article presents data from meta-analyzes related to the management of this group of patients. The aspects of rhythm control strategy in AF and concomitant CHF are described according to the recent studies and clinical guidelines. The features of anticoagulant therapy in patients with AF and CHF are outlined. Much attention is given to the importance of the safety profile of the anticoagulant therapy in terms of the bleeding risk in patients with concomitant AF and CHF.
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Berns SA, Barbarash OL. How to level the risk of bleeding while taking anticoagulant therapy in patients with atrial fibrillation? Consilium Medicum 2022. [DOI: 10.26442/20751753.2022.1.201474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF) is one of the most common types of cardiac arrhythmias, while AF is the main risk factor for ischemic stroke. For a long time, vitamin K antagonists, primarily warfarin, have been the standard for the prevention of thromboembolic complications in patients with AF. 5 years ago, dabigatran, rivaroxaban and apixaban occupied the 2nd place in the structure of anticoagulant prescribing (AC), giving way to warfarin. The well-known reason for the inadequate use of AC is the risk of bleeding. There are a large number of validated scales for assessing the risk of hemorrhagic complications, in particular HAS-BLED, ABC, HEMORRHR2HAGES, ATRIA, ORBIT, but the estimated high risk of bleeding should not be the only and absolute limitation to the appointment of AC. Despite the real risk of bleeding on the background of taking AC in patients with AF, an integrated approach taking into account not only the risk factors of the thromboembolic complications, but also hemorrhagic complications, with an emphasis on the existing comorbidities, the presence of comorbidity, old age, etc., will allow an individual approach to the choice of AC and its dose, contributing to the optimization of the management of such kind of patients.
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Spyropoulos AC, Hartaigh BÓ, Cao Z, Caberwal H, Lipkin C, Petrini M, Wang C. Costs and Healthcare Resource Utilization Associated with Idarucizumab or Andexanet Alfa Oral Anticoagulant Reversal in Patients Hospitalized with Life-Threatening Bleeds. Clin Appl Thromb Hemost 2022; 28:10760296221110568. [PMID: 35792949 PMCID: PMC9272054 DOI: 10.1177/10760296221110568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: To assess costs and healthcare resource utilization (HCRU) associated with the use of idarucizumab for the reversal of dabigatran and andexanet alfa for the reversal of direct oral Factor Xa inhibitors. Methods: This retrospective study utilizing Premier Healthcare Database (PHD) included patients aged ≥18 years on direct oral anticoagulants (DOACs) who experienced life-threatening bleeds, discharged from the hospital during 5/1/2018–6/30/2019, and received idarucizumab or andexanet alfa. Inverse of treatment probability weighting (IPTW) method was used to balance patient and clinical characteristics between treatment cohorts. Results: Idarucizumab patients were older than andexanet alfa patients (median age 81 vs 77 years; p < 0.001), and less likely to experience intracranial hemorrhage (ICH) (37.1%vs 73.8%; p = 0.001). After IPTW adjustment, idarucizumab patients incurred lower mean total hospital costs ($30,413 ± $33,028 vs $44,477 ± $30,036; p < 0.001),and mean intensive care unit (ICU) cost ($25,114 ± $30,433 vs $43,484 ± $29,335; p < 0.001). Conclusions: Anticoagulant reversal therapy with idarucizumab was associated with significantly lower adjusted mean total hospital and ICU costs compared with andexanet alfa. However, a higher prevalence of ICH bleeds was noted in the andexanet alfa group. Trial Registration: Not applicable.
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Affiliation(s)
- Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Department of Medicine, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Zhun Cao
- 43690Premier, Inc, Charlotte, NC, USA
| | - Harjeet Caberwal
- 6893Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | | | - Michaela Petrini
- 6893Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Cheng Wang
- 6893Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
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Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Peter J Zimetbaum
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard Thorndike Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation. JAMA 2021; 326:2395-2404. [PMID: 34932078 PMCID: PMC8693217 DOI: 10.1001/jama.2021.21222] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The comparative effectiveness of rivaroxaban and apixaban, the most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation, is uncertain. OBJECTIVE To compare major ischemic and hemorrhagic outcomes in patients with atrial fibrillation treated with rivaroxaban or apixaban. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using computerized enrollment and claims files for US Medicare beneficiaries 65 years or older. Between January 1, 2013, and November 30, 2018, a total of 581 451 patients with atrial fibrillation began rivaroxaban or apixaban treatment and were followed up for 4 years, through November 30, 2018. EXPOSURES Rivaroxaban (n = 227 572) and apixaban (n = 353 879), either standard or reduced dose. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of major ischemic (stroke/systemic embolism) and hemorrhagic (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding) events. Secondary outcomes were nonfatal extracranial bleeding and total mortality (fatal ischemic/hemorrhagic event or other death during follow-up). Rates, hazard ratios (HRs), and rate differences (RDs) were adjusted for baseline differences in comorbidity with inverse probability of treatment weighting. RESULTS Study patients (mean age, 77.0 years; 291 966 [50.2%] women; 134 393 [23.1%] receiving reduced dose) had 474 605 person-years of follow-up (median [IQR] of 174 [62-397] days). The adjusted primary outcome rate for rivaroxaban was 16.1 per 1000 person-years vs 13.4 per 1000 person-years for apixaban (RD, 2.7 [95% CI, 1.9-3.5]; HR, 1.18 [95% CI, 1.12-1.24]). The rivaroxaban group had increased risk for both major ischemic events (8.6 vs 7.6 per 1000 person-years; RD, 1.1 [95% CI, 0.5-1.7]; HR, 1.12 [95% CI, 1.04-1.20]) and hemorrhagic events (7.5 vs 5.9 per 1000 person-years; RD, 1.6 [95% CI, 1.1-2.1]; HR, 1.26 [95% CI, 1.16-1.36]), including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; RD, 0.4 [95% CI, 0.2-0.7]; HR, 1.41 [95% CI, 1.18-1.70]). Patients receiving rivaroxaban had increased risk of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years; RD, 21.1 [95% CI, 20.0-22.3]; HR, 2.07 [95% CI, 1.99-2.15]), fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years; RD, 1.2 [95% CI, 0.8-1.6]; HR, 1.34 [95% CI, 1.21-1.48]), and total mortality (44.2 vs 41.0 per 1000 person-years; RD, 3.1 [95% CI, 1.8-4.5]; HR, 1.06 [95% CI, 1.02-1.09]). The risk of the primary outcome was increased for rivaroxaban in both those receiving the reduced dose (27.4 vs 21.0 per 1000 person-years; RD, 6.4 [95% CI, 4.1-8.7]; HR, 1.28 [95% CI, 1.16-1.40]) and the standard dose (13.2 vs 11.4 per 1000 person-years; RD, 1.8 [95% CI, 1.0-2.6]; HR, 1.13 [95% CI, 1.06-1.21]) groups. CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville Campus
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
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40
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Zhao M, Hou CR, Xiong X, Post F, Herold N, Yu J. Safety and effectiveness of left atrial appendage closure in patients with non-valvular atrial fibrillation and prior major bleeding. Expert Rev Med Devices 2021; 18:1209-1217. [PMID: 34886730 DOI: 10.1080/17434440.2021.2011718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To investigate safety and effectiveness of left atrial appendage closure (LAAC) in atrial fibrillation patients with prior major bleeding. METHODS A total of 377 consecutive patients scheduled for LAAC with Watchman device were divided into bleeding group (n = 137) and non-bleeding group (n = 240). Data were compared between groups. RESULTS The bleeding group had more patients ≥75 years old (P = 0.044), higher CHA2DS2-VASc (P = 0.029) and HAS-BLED scores (P = 0.001) than the non-bleeding group. During the long-term follow-up, except for thromboembolism event (P = 0.031), the incidences of major bleeding , all-cause death , co-primary efficacy events , and the cumulative survival ratio after adjustment of confounding factors were comparable. The observed thromboembolism rate was reduced by 86.3% (P = 0.0002) and 55.1% (P = 0.0293) and the observed major bleeding rate was decreased by 61.9% (P = 0.0393) and 35.7% (P = 0.2426) compared with expected risks in bleeding and non-bleeding groups, respectively. The risk reduction in thromboembolism and major bleeding were significantly greater in bleeding group versus non-bleeding group (all P < 0.0001). CONCLUSIONS Among patients with prior bleeding, LAAC is a safe and effective alternative to anticoagulation therapy and seems to emerge as a higher efficacy in risk reduction of thromboembolism and major bleeding compared to those without prior bleeding.
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Affiliation(s)
- Mingzhong Zhao
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,Heart Center, Zhengzhou Ninth People's Hospital, Zhengzhou, China
| | - Cody R Hou
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - Xiaolin Xiong
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,The Faculty of Medicine, The Faculty of MedicineUniversity of Cologne, Cologne, Germany
| | - Felix Post
- Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Nora Herold
- Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Jiangtao Yu
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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41
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VanDyck K, Dunn IF, Yates C, Robbs C, Tanaka KA. Hereditary Antithrombin Deficiency: A Balancing Act of Perioperative Hemostasis and Thromboprophylaxis-A Case Report. A A Pract 2021; 15:e01550. [PMID: 34929710 DOI: 10.1213/xaa.0000000000001550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hereditary deficiency of antithrombin (AT) is associated with increased risk of venous thromboembolism (VTE), especially under the circumstances of stress, vascular injury, and immobilization associated with surgery. To date, there is no consensus on the use of perioperative anticoagulant bridging in the setting of hereditary thrombophilia. Balancing hemorrhagic and thrombotic risks associated with anticoagulant bridging and AT deficiency can be challenging to perioperative physicians. We present a case of a 65-year-old woman with inherited AT deficiency with history of multiple VTEs who was admitted for presurgical anticoagulant bridging before microvascular decompression craniotomy for trigeminal neuralgia.
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Affiliation(s)
| | - Ian F Dunn
- Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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42
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Meid AD, Wirbka L, Groll A, Haefeli WE. Can Machine Learning from Real-World Data Support Drug Treatment Decisions? A Prediction Modeling Case for Direct Oral Anticoagulants. Med Decis Making 2021; 42:587-598. [PMID: 34911402 PMCID: PMC9189725 DOI: 10.1177/0272989x211064604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decision making for the "best" treatment is particularly challenging in situations in which individual patient response to drugs can largely differ from average treatment effects. By estimating individual treatment effects (ITEs), we aimed to demonstrate how strokes, major bleeding events, and a composite of both could be reduced by model-assisted recommendations for a particular direct oral anticoagulant (DOAC). METHODS In German claims data for the calendar years 2014-2018, we selected 29 901 new users of the DOACs rivaroxaban and apixaban. Random forests considered binary events within 1 y to estimate ITEs under each DOAC according to the X-learner algorithm with 29 potential effect modifiers; treatment recommendations were based on these estimated ITEs. Model performance was evaluated by the c-for-benefit statistics, absolute risk reduction (ARR), and absolute risk difference (ARD) by trial emulation. RESULTS A significant proportion of patients would be recommended a different treatment option than they actually received. The stroke model significantly discriminated patients for higher benefit and thus indicated improved decisions by reduced outcomes (c-for-benefit: 0.56; 95% confidence interval [0.52; 0.60]). In the group with apixaban recommendation, the model also improved the composite endpoint (ARR: 1.69 % [0.39; 2.97]). In trial emulations, model-assisted recommendations significantly reduced the composite event rate (ARD: -0.78 % [-1.40; -0.03]). CONCLUSIONS If prescribers are undecided about the potential benefits of different treatment options, ITEs can support decision making, especially if evidence is inconclusive, risk-benefit profiles of therapeutic alternatives differ significantly, and the patients' complexity deviates from "typical" study populations. In the exemplary case for DOACs and potentially in other situations, the significant impact could also become practically relevant if recommendations were available in an automated way as part of decision making.HighlightsIt was possible to calculate individual treatment effects (ITEs) from routine claims data for rivaroxaban and apixaban, and the characteristics between the groups with recommendation for one or the other option differed significantly.ITEs resulted in recommendations that were significantly superior to usual (observed) treatment allocations in terms of absolute risk reduction, both separately for stroke and in the composite endpoint of stroke and major bleeding.When similar patients from routine data were selected (precision cohorts) for patients with a strong recommendation for one option or the other, those similar patients under the respective recommendation showed a significantly better prognosis compared with the alternative option.Many steps may still be needed on the way to clinical practice, but the principle of decision support developed from routine data may point the way toward future decision-making processes.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Lucas Wirbka
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | | | - Andreas Groll
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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43
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Zawawi NA, Abdul Halim Zaki I, Ming LC, Goh HP, Zulkifly HH. Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation. Front Cardiovasc Med 2021; 8:736143. [PMID: 34869639 PMCID: PMC8635010 DOI: 10.3389/fcvm.2021.736143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022] Open
Abstract
Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.
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Affiliation(s)
- Nur Azyyati Zawawi
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Izzati Abdul Halim Zaki
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hui Poh Goh
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hanis Hanum Zulkifly
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
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Averkov OV, Mishchenko LN. Gastrointestinal Bleeding: a Cardiologist's Point of View. Racionalʹnaâ farmakoterapiâ v kardiologii 2021. [DOI: 10.20996/1819-6446-2021-10-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oral anticoagulant therapy is widely used in different patients for the prevention and treatment of thromboembolic events: in atrial fibrillation, deep vein thrombosis/pulmonary embolism, acute coronary syndrome, in the early postoperative period after orthopedic surgery. Nowadays it is possible to use vitamin K antagonists (warfarin) as well as direct oral anticoagulants (DOAC): dabigatran, rivaroxaban, apixaban and edoxaban. The mai complication of any anticoagulant therapy is bleeding (gastrointestinal, intracranial, etc.), which seriously limits its usage. In this review the incidence of gastrointestinal bleeding (GIB) associated with oral anticoagulants intake was analyzed according to the results of both large randomized and postregistration trials. Furthermore, the effect of age on the risk of GIB development is discussed, and also aspects of the pathophysiology of gastrointestinal mucosa lesions in patients taking DOAC are considered.
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Affiliation(s)
- O. V. Averkov
- Moscow City Clinical Hospital №15 n.a. O. M. Filatova
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45
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Liu Q, Schwartz JB, Slattum PW, Lau SWJ, Guinn D, Madabushi R, Burckart G, Califf R, Cerreta F, Cho C, Cook J, Gamerman J, Goldsmith P, van der Graaf PH, Gurwitz JH, Haertter S, Hilmer S, Huang SM, Inouye SK, Kanapuru B, Pirmohamed M, Posner P, Radziszewska B, Keipp Talbot H, Temple R. Roadmap to 2030 for Drug Evaluation in Older Adults. Clin Pharmacol Ther 2021; 112:210-223. [PMID: 34656074 DOI: 10.1002/cpt.2452] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
Changes that accompany older age can alter the pharmacokinetics (PK), pharmacodynamics (PD), and likelihood of adverse effects (AEs) of a drug. However, older adults, especially the oldest or those with multiple chronic health conditions, polypharmacy, or frailty, are often under-represented in clinical trials of new drugs. Deficits in the current conduct of clinical evaluation of drugs for older adults and potential steps to fill those knowledge gaps are presented in this communication. The most important step is to increase clinical trial enrollment of older adults who are representative of the target treatment population. Unnecessary eligibility criteria should be eliminated. Physical and financial barriers to participation should be removed. Incentives could be created for inclusion of older adults. Enrollment goals should be established based on intended treatment indications, prevalence of the condition, and feasibility. Relevant clinical pharmacology data need to be obtained early enough to guide dosing and reduce risk for participation of older adults. Relevant PK and PD data as well as patient-centered outcomes should be measured during trials. Trial data should be analyzed for differences in PK, PD, effectiveness, and safety arising from differences in age or from the presence of conditions common in older adults. Postmarket evaluations with real-world evidence and drug labeling updates throughout the product lifecycle reflecting new knowledge are also needed. A comprehensive plan is needed to ensure adequate evaluation of the safety and effectiveness of drugs in older adults.
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Affiliation(s)
- Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Janice B Schwartz
- Departments of Medicine, Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Patricia W Slattum
- Department of Pharmacotherapy and Outcomes Science and Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - S W Johnny Lau
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Califf
- Verily and Google Health (Alphabet), South San Francisco, California, USA
| | - Francesca Cerreta
- Portfolio office, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Carolyn Cho
- Oncology Early Development and Translational Research, Merck & Co., Kenilworth, New Jersey, USA
| | - Jack Cook
- Department of Clinical Pharmacology, Pfizer Global Research and Development, Groton, Connecticut, USA
| | - Jamie Gamerman
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul Goldsmith
- Lilly Exploratory Medicine and Pharmacology, Bracknell, UK
| | | | - Jerry H Gurwitz
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA
| | - Sebastian Haertter
- Boehringer Ingelheim Pharma, Translational Medicine & Clinical Pharmacology, Ingelheim, Germany
| | - Sarah Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Shiew-Mei Huang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston. Massachusetts, USA
| | - Bindu Kanapuru
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Phil Posner
- Patient-Centered Outcomes Research Institute Ambassador, Gainesville, Florida, USA
| | - Barbara Radziszewska
- National Institute of Aging, National Institute of Health, Bethesda, Maryland, USA
| | - H Keipp Talbot
- Departments of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Temple
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Han S, Han S, Suh HS, Bang OY, On YK, Lee MY, Jang SW, Won MM, Park YJ, Lee JM, Kang S, Kim YH. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: A nationwide, population-based study in Korea. J Arrhythm 2021; 37:1240-1249. [PMID: 34621422 PMCID: PMC8485801 DOI: 10.1002/joa3.12607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/25/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF), this retrospective study was conducted using the Korean Health Insurance Review & Assessment Service (HIRA) claims database. METHODS Patients with AF who initiated NOACs (apixaban, dabigatran, and rivaroxaban) from July 1, 2015 to November 30, 2016 were included. We applied inverse probability of treatment weighting (IPTW) method using propensity score to make weighted populations having similar characteristics between groups. Hazard ratio (HR) of S/SE and MB were estimated by Cox proportional hazard model. RESULTS Of the 39 783 patients with AF, 10 564; 11 418; and 17 801 used apixaban, dabigatran, and rivaroxaban, respectively. The mean CHA2DS2-VASc and HAS-BLED scores were 4.59 ~ 4.69 and 3.58 ~ 3.62, respectively, among all patients after applying IPTW. For S/SE, there were no significant differences between NOACs (HR [95% confidence interval (CI)]): apixaban vs dabigatran (0.99 [0.87-1.13]), apixaban vs rivaroxaban (0.95 [0.84-1.07]), and dabigatran vs rivaroxaban (0.96 [0.85-1.08]). For MB (HR [95% CI]), both apixaban (0.77 [0.68-0.86]) and dabigatran (0.88 [0.79-0.98]) had a significantly lower risk compared with rivaroxaban. Apixaban also had a significantly lower risk of MB compared with dabigatran (0.87 [0.76-0.99]). CONCLUSIONS In real-world practice among Korean AF patients with relatively high risk of stroke and bleeding, there were no significant differences in the risk of S/SE between all NOAC comparisons. Apixaban was associated with lower risk of MB than dabigatran and rivaroxaban.
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Affiliation(s)
- Seongwook Han
- Division of Cardiology Department of Internal Medicine Dongsan Hospital Keimyung University School of Medicine Daegu South Korea
| | - Sola Han
- Pharmaceutical Economics Big Data Analysis & Policy College of Pharmacy Kyung Hee University Seoul South Korea
| | - Hae Sun Suh
- Pharmaceutical Economics Big Data Analysis & Policy College of Pharmacy Kyung Hee University Seoul South Korea
| | - Oh Young Bang
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Young Keun On
- Department of Cardiology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Myung-Yong Lee
- Division of Cardiology Department of Internal Medicine Dankook University Chung Nam South Korea
| | - Sung-Won Jang
- Division of Cardiology Department of Internal Medicine Catholic University of Korea Seoul South Korea
| | | | | | | | | | - Young-Hoon Kim
- Division of Cardiology Department of Internal Medicine Korea University Seoul South Korea
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47
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Rivera-Caravaca JM, Harrison SL, Buckley BJR, Fazio-Eynullayeva E, Underhill P, Marín F, Lip GYH. Efficacy and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in COVID-19 outpatients with cardiometabolic diseases. Cardiovasc Diabetol 2021; 20:176. [PMID: 34481513 PMCID: PMC8417638 DOI: 10.1186/s12933-021-01368-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/23/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND It remains uncertain if prior use of oral anticoagulants (OACs) in COVID-19 outpatients with multimorbidity impacts prognosis, especially if cardiometabolic diseases are present. Clinical outcomes 30-days after COVID-19 diagnosis were compared between outpatients with cardiometabolic disease receiving vitamin K antagonist (VKA) or direct-acting OAC (DOAC) therapy at time of COVID-19 diagnosis. METHODS A study was conducted using TriNetX, a global federated health research network. Adult outpatients with cardiometabolic disease (i.e. diabetes mellitus and any disease of the circulatory system) treated with VKAs or DOACs at time of COVID-19 diagnosis between 20-Jan-2020 and 15-Feb-2021 were included. Propensity score matching (PSM) was used to balance cohorts receiving VKAs and DOACs. The primary outcomes were all-cause mortality, intensive care unit (ICU) admission/mechanical ventilation (MV) necessity, intracranial haemorrhage (ICH)/gastrointestinal bleeding, and the composite of any arterial or venous thrombotic event(s) at 30-days after COVID-19 diagnosis. RESULTS 2275 patients were included. After PSM, 1270 patients remained in the study (635 on VKAs; 635 on DOACs). VKA-treated patients had similar risks and 30-day event-free survival than patients on DOACs regarding all-cause mortality, ICU admission/MV necessity, and ICH/gastrointestinal bleeding. The risk of any arterial or venous thrombotic event was 43% higher in the VKA cohort (hazard ratio 1.43, 95% confidence interval 1.03-1.98; Log-Rank test p = 0.029). CONCLUSION In COVID-19 outpatients with cardiometabolic diseases, prior use of DOAC therapy compared to VKA therapy at the time of COVID-19 diagnosis demonstrated lower risk of arterial or venous thrombotic outcomes, without increasing the risk of bleeding.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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48
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Hallinen T, Soini E, Asseburg C, Linna M, Eloranta P, Sintonen S, Kosunen M. Cost-Effectiveness of Apixaban versus Other Direct Oral Anticoagulants and Warfarin in the Prevention of Thromboembolic Complications Among Finnish Patients with Non-Valvular Atrial Fibrillation. Clinicoecon Outcomes Res 2021; 13:745-755. [PMID: 34413661 PMCID: PMC8370583 DOI: 10.2147/ceor.s317078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Direct oral anticoagulant (DOAC) use for the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation (AF) has increased steadily in Finland. DOACs have been shown to be cost-effective in comparison to warfarin, but published evidence of relative cost-effectiveness between DOACs is still scarce and mostly based on indirect comparisons of clinical trial evidence. The aim of this study was to compare the cost-effectiveness of apixaban to dabigatran, rivaroxaban and warfarin in a Finnish setting using real-life evidence where available. Patients and Methods A lifetime Markov simulation model used previously in a published Finnish assessment comparing apixaban and warfarin was modified and updated with the relative effectiveness and safety data available from the real-world NAXOS-study and representative Finnish input data for patient characteristics, event risks, mortality, resource use, costs, and quality of life. Apixaban’s cost-effectiveness was assessed from health care payer perspective (using 3% per year discount rate) based on incremental cost-effectiveness ratio (ICER, cost per quality-adjusted life year [QALY] gained), probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY), and net monetary benefit (NMB). Results Apixaban increased the average modelled quality-adjusted life-expectancy and reduced the average total health care costs of AF patients when compared to warfarin (+0.14 QALYs, −3691 euros), dabigatran (+0.11 QALYs, −404 euros), and rivaroxaban (+0.03 QALYs, −43 euros). The resulting NMB of apixaban versus warfarin, dabigatran and rivaroxaban was 8723, 4168, and 1129 euros, respectively. The respective probabilities of apixaban being cost-effective against each comparator were 100%, 92.7%, and 64.0%. Conclusion In this modelling study, apixaban dominated other anticoagulants in the Finnish real-life setting.
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Affiliation(s)
| | | | | | - Miika Linna
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
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49
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Waranugraha Y, Rizal A, Syaban MFR, Faratisha IFD, Erwan NE, Yunita KC. Direct comparison of non-vitamin K antagonist oral anticoagulant versus warfarin for stroke prevention in non-valvular atrial fibrillation: a systematic review and meta-analysis of real-world evidences. Egypt Heart J 2021; 73:70. [PMID: 34379219 PMCID: PMC8357866 DOI: 10.1186/s43044-021-00194-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background To overcome the several drawbacks of warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were developed. Even though randomized controlled trials (RCTs) provided high-quality evidence, the real-world evidence is still needed. This systematic review and meta-analysis proposed to measure the safety and efficacy profile between warfarin and NOACs in non-valvular atrial fibrillation (NVAF) patients in preventing stroke. Results We collected articles about the real-world studies comparing warfarin and NOACs for NVAF patients recorded in electronic scientific databases such as Embase, ProQuest, PubMed, and Cochrane. The pooled hazard ratio (HR) and 95% confidence interval (CI) were estimated using the generic inverse variance method. A total of 34 real-world studies, including 2287288 NVAF patients, were involved in this study. NOACs effectively reduced the stroke risk than warfarin (HR 0.77; 95% CI 0.69 to 0.87; p < 0.01). Moreover, NOACs effectively lowered all-cause mortality risk (HR 0.71; 95% CI 0.63 to 0.81; p < 0.01). From the safety aspect, compared to warfarin, NOACs significantly reduced major bleeding risk (HR 0.68; 95% CI 0.54 to 0.86; p < 0.01) and intracranial bleeding risk (HR 0.54; 95% CI 0.42 to 0.70; p < 0.01). However, NOACs administration failed to decrease gastrointestinal bleeding risk (HR 0.78; 95% CI 0.58 to 1.06; p = 0.12). Conclusions In NVAF patients, NOACs were found to be more effective than warfarin at reducing stroke risk. NOACSs also lowered the risk of all-cause mortality, cerebral hemorrhage, and severe bleeding in NVAF patients compared to warfarin. Supplementary Information The online version contains supplementary material available at 10.1186/s43044-021-00194-1.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
| | - Ardian Rizal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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Schnabel RB, Wallenhorst C, Engler D, Blankenberg S, Pfeiffer N, Spruenker NA, Buettner M, Michal M, Lackner KJ, Münzel T, Wild PS, Martinez C, Freedman B. Refined atrial fibrillation screening and cost-effectiveness in the German population. Heart 2021; 108:451-457. [PMID: 34376487 PMCID: PMC8899485 DOI: 10.1136/heartjnl-2020-318882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Little is known on optimal screening population for detecting new atrial fibrillation (AF) in the community. We describe characteristics and estimate cost-effectiveness for a single timepoint electrocardiographic screening. METHODS We performed a 12-lead ECG in the German population-based Gutenberg Health Study between 2007 and 2012 (n=15 010), mean age 55±11 years, 51% men and collected more than 120 clinical and biomarker variables, including N-terminal pro B-type natriuretic peptide (Nt-proBNP), risk factors, disease symptoms and echocardiographic variables. RESULTS Of 15 010 individuals, 466 (3.1%) had AF. New AF was found in 32 individuals, 0.2% of the total sample, 0.5% of individuals aged 65-74 years and predominantly men (86%). The classical risk factor burden was high in individuals with new AF. The median estimated stroke risk was 2.2%/year, while risk of developing heart failure was 21% over 10 years. In the 65-74 year age group, the cost per quality-adjusted life-year gained resulting from a single timepoint screening was €30 361. In simulations, the costs were highly sensitive to AF detection rates, proportion of treatment and type of oral anticoagulant. Prescreening by Nt-proBNP measurements was not cost-effective in the current setting. CONCLUSIONS In our middle-aged population cohort, we identified 0.2% new AF by single timepoint screening. There was a significant estimated risk of stroke and heart failure in these individuals. Cost-effectiveness for screening may be reached in individuals aged 65 years and older. The simple age cut-off is not improved by using Nt-proBNP as a biomarker to guide a screening programme.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | | | - Daniel Engler
- Department of Cardiology, Universitäres Herzzentrum Hamburg (UHZ), Hamburg, Germany
| | - Stefan Blankenberg
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ngoc Anh Spruenker
- University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Matthias Buettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Matthias Michal
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Hamburg, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Medicine 2, University Medical Center Mainz, Mainz, Germany
| | - Philipp S Wild
- Department of Preventive Cardiology and Preventive Medicine, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
| | - Ben Freedman
- University of Sydney, Charles Perkins Centre, Heart Research Institute, Sydney, New South Wales, Australia
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