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Kany S, Schnabel RB. [Genetic basis of atrial fibrillation-on the road to precision medicine]. Herzschrittmacherther Elektrophysiol 2024; 35:3-8. [PMID: 37932605 PMCID: PMC10879292 DOI: 10.1007/s00399-023-00974-z] [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: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 11/08/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and has complex genetic underpinnings. Despite advancements in treatment, mortality of AF patients remains high. This review discusses the genetic basis of AF and its implications for diagnosis and therapy. Although AF pathology has long been known to include a hereditary component, the first genes associated with AF were not identified until the early 2000s. Subsequent research with genome-wide association studies (GWAS) has implicated other genes and numerous genetic variants in AF. These studies have revealed nearly 140 different regions in the DNA with genome-wide significance associated with AF. In addition to common variants, rare variants with large effects have also been identified. The integration of these genetic findings into clinical practice holds promise for improving AF diagnosis and treatment, moving us closer to precision medicine. However, challenges remain, including the need for more diverse genetic data of non-European ancestry and improved genetic analyses of responses to AF therapy.
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Affiliation(s)
- Shinwan Kany
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland.
- Standort Hamburg/Kiel/Lübeck, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Hamburg, Deutschland.
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
| | - Renate B Schnabel
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
- Standort Hamburg/Kiel/Lübeck, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Hamburg, Deutschland
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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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Agewall S. The search for the perfect antiplatelet treatment continues. Eur Heart J Cardiovasc Pharmacother 2023; 9:671-672. [PMID: 38093457 DOI: 10.1093/ehjcvp/pvad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Stefan Agewall
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, 171 77 Stockholm, Sweden
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Grymonprez M, Petrovic M, De Backer TL, Steurbaut S, Lahousse L. Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study. Int J Cardiol Heart Vasc 2023; 47:101223. [PMID: 37252193 PMCID: PMC10209699 DOI: 10.1016/j.ijcha.2023.101223] [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] [Received: 04/11/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023]
Abstract
Background Data on non-vitamin K antagonist oral anticoagulant (NOAC) use in patients with atrial fibrillation (AF) and a history of falls are limited. Therefore, we investigated the impact of a history of falls on AF-related outcomes, and the benefit-risk profiles of NOACs in patients with a history of falls. Methods Using Belgian nationwide data, AF patients initiating anticoagulation between 2013 and 2019 were included. Previous falls that occurred ≤ 1 year before anticoagulant initiation were identified. Results Among 254,478 AF patients, 18,947 (7.4%) subjects had a history of falls, which was associated with higher risks of all-cause mortality (adjusted hazard ratio (aHR) 1.11, 95%CI (1.06-1.15)), major bleeding (aHR 1.07, 95%CI (1.01-1.14)), intracranial bleeding (aHR 1.30, 95%CI (1.16-1.47)) and new falls (aHR 1.63, 95%CI (1.55-1.71)), but not with thromboembolism. Among subjects with a history of falls, NOACs were associated with lower risks of stroke or systemic embolism (aHR 0.70, 95%CI (0.57-0.87)), ischemic stroke (aHR 0.59, 95%CI (0.45-0.77)) and all-cause mortality (aHR 0.83, 95%CI (0.75-0.92)) compared to vitamin K antagonists (VKAs), while major, intracranial, and gastrointestinal bleeding risks were not significantly different. Major bleeding risks were significantly lower with apixaban (aHR 0.77, 95%CI (0.63-0.94)), but similar with other NOACs compared to VKAs. Apixaban was associated with lower major bleeding risks compared to dabigatran (aHR 0.78, 95%CI (0.62-0.98)), rivaroxaban (aHR 0.78, 95%CI (0.68-0.91)) and edoxaban (aHR 0.74, 95%CI (0.59-0.92)), but mortality risks were higher compared to dabigatran and edoxaban. Conclusions A history of falls was an independent predictor of bleeding and death. NOACs had better benefit-risk profiles than VKAs in patients with a history of falls, especially apixaban.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Tine L. De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, Rotterdam 3000, CA, the Netherlands
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Atrial fibrillation has gone from a boring disease to a very hot condition. Why is that? Eur Heart J Cardiovasc Pharmacother 2023:pvad049. [PMID: 37486237 DOI: 10.1093/ehjcvp/pvad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
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Voss A, Kollhorst B, Platzbecker K, Amann U, Haug U. Risk Profiles of New Users of Oral Anticoagulants Between 2011 and 2019 in Germany. Clin Epidemiol 2023; 15:827-837. [PMID: 37483262 PMCID: PMC10362862 DOI: 10.2147/clep.s405585] [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: 02/14/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose Over the last decade, the use of direct oral anticoagulants (DOACs) has strongly increased. We aimed to describe and compare risk profiles including potential changes over time among persons with non-valvular atrial fibrillation initiating treatment with different DOACs or phenprocoumon (vitamin K antagonist) between 2011 and 2019 in Germany. Patients and Methods Using the German Pharmacoepidemiological Research Database (GePaRD; claims data of ~20% of the German population), we identified persons with a first dispensing of phenprocoumon or a DOAC and a diagnosis of non-valvular atrial fibrillation between August 2011 and December 2019. We described the morbidity of included patients prior to treatment initiation, stratified by year of treatment initiation. Results Overall, we included 448,028 new users (phenprocoumon: N = 118,117, rivaroxaban: N = 130,997, apixaban: N = 130,300, edoxaban: N = 38,128, dabigatran: N = 30,486). Comparing new DOAC users in 2019, the proportion with prior ischemic stroke was highest for dabigatran (17%) and lowest for rivaroxaban (8%). The proportion with prior major bleeding was also highest for dabigatran (25%) and lowest for edoxaban (20%). New users of apixaban were oldest and, eg, showed the highest prevalence of congestive heart failure. Changes over time were most pronounced for phenprocoumon. For example, among persons initiating phenprocoumon in 2012 vs 2019, the proportion with prior major bleeding increased from 18% to 35%; the proportion with renal disease increased from 20% to 36% and the proportion with liver disease from 18% to 24%. Conclusion This study demonstrated differences in risk profiles between new users of different oral anticoagulants and substantial changes over time among new phenprocoumon users. These differences have to be considered in head-to-head comparisons of these drugs based on observational data, especially regarding potential unmeasured confounding.
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Affiliation(s)
- Annemarie Voss
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Bianca Kollhorst
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Katharina Platzbecker
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ute Amann
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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Armentaro G, D’Arrigo G, Bo M, Cassano V, Miceli S, Pitino A, Tripepi G, Romeo SMG, Sesti G, Lip GYH, Pastori D, Gori M, Sciacqua A. Medium-term and long-term renal function changes with direct oral anticoagulants in elderly patients with atrial fibrillation. Front Pharmacol 2023; 14:1210560. [PMID: 37469870 PMCID: PMC10352777 DOI: 10.3389/fphar.2023.1210560] [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] [Received: 04/22/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
Objective: Atrial Fibrillation (AF) and chronic kidney disease frequently coexist in the elderly. Warfarin-like drugs (WLDs) may be associated with a relatively greater decrease of estimated glomerular filtration rate (eGFR) as compared to direct oral anticoagulants (DOACs), but there is no evidence on the medium- and long-term changes. To further elucidate this issue in elderly patients with AF, we investigated the renal function deterioration in the two groups of the study (DOACs or WLDs). Patients and Methods: A total of 420 AF patients were enrolled (mean age: 77.0 ± 6.0 years; 136 on WLDs and 284 on DOACs). These patients underwent three eGFR measurements during the follow-up period. The between-arms difference of eGFR decline over time was investigated by Linear Mixed Models and group-based trajectory model analyses. Results: In the whole study cohort, after a median follow-up of 4.9 years (interquartile range: 2.7-7.0 years), eGFR decreased from 67.4 ± 18.2 to 47.1 ± 14.3 mL/min/1.73 m2 (p < 0.001). Remarkably, patients on DOACs experienced a significantly smaller eGFR decline than WLDs patients (-21.3% vs. -45.1%, p < 0.001) and this was true both in the medium-term (-6.6 vs. -19.9 mL/min/1.73 m2) and in the long-term (-13.5 versus -34.2 mL/min/1.73 m2) period. After stratification into five subgroups according to trajectories of renal function decline over time, logistic regression showed that DOACs patients had from 3.03 to 4.24-fold greater likelihood to belong to the trajectory with less marked eGFR decline over time than WLDs patients. Conclusion: Elderly patients with AF on treatment with DOACs had a relatively smaller decline of eGFR over time compared to those on treatment with WLDs. This is consistent with what was partly reported in the literature.
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Affiliation(s)
- Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Graziella D’Arrigo
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Molinette Hospital, Turin, Italy
| | - Velia Cassano
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Sofia Miceli
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Annalisa Pitino
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Giovanni Tripepi
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | | | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University Rome-Sapienza, Rome, Italy
| | - Gregory Y. H. Lip
- Department of Clinical MedicineAalborg University, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, Denmark
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mercedes Gori
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
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Fredenburgh JC, Weitz JI. News at XI: moving beyond factor Xa inhibitors. J Thromb Haemost 2023; 21:1692-1702. [PMID: 37116752 DOI: 10.1016/j.jtha.2023.04.021] [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: 04/05/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
Oral anticoagulants are a mainstay for the prevention and treatment of arterial and venous thrombosis. Direct oral anticoagulants (DOACs) have replaced vitamin K antagonists for many indications. Currently available DOACs include dabigatran, which inhibits thrombin, and apixaban, edoxaban, and rivaroxaban, which inhibit factor (F) Xa. A new class of DOACs is under development. These new DOACs, which include asundexian and milvexian, inhibit FXIa, which is positioned in the intrinsic pathway of coagulation. Anticoagulants that target FXIa have the potential to be safer than the current DOACs because there is emerging evidence that FXI is essential for thrombosis but mostly dispensable for hemostasis. In addition to the oral inhibitors of FXIa, parenteral inhibitors are also under development. These include fesomersen, an antisense oligonucleotide that reduces the hepatic synthesis of FXI; abelacimab, an antibody that binds to FXI and blocks its activation; and osocimab, an FXIa inhibitory antibody. Focusing on these new agents, this article describes the unmet needs in oral anticoagulation therapy, explains why FXI is a promising target for new oral anticoagulants, reviews phase 2 clinical data on new agents, describes ongoing phase 3 trials, and provides a perspective on the opportunities and challenges for FXI inhibitors.
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Affiliation(s)
- James C Fredenburgh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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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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Xu H, Chen X, Zhang Y, Zhu K, Zhao J, Qin F, Tao H. Clinical Outcomes and Predictors of Late Recurrence in Young Patients with Atrial Fibrillation after Catheter Ablation. Comput Math Methods Med 2023; 2023:7892185. [PMID: 37284170 PMCID: PMC10241581 DOI: 10.1155/2023/7892185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 02/05/2023] [Accepted: 02/10/2023] [Indexed: 06/08/2023]
Abstract
Background Catheter ablation (CA) is an established treatment for atrial fibrillation (AF), but the recurrence of AF is not neglected. Young patients with AF were generally more symptomatic and intolerant to long-term drug treatment. We aim to explore clinical outcomes and predictors of late recurrence (LR) in AF patients younger than 45 years after CA to better manage them. Methods We retrospectively studied 92 symptomatic AF patients who accepted CA from September 1, 2019, to August 31, 2021. Baseline clinical data (including N-terminal prohormone of brain natriuretic peptide, NT-proBNP), ablation outcomes, and follow-up outcomes were collected. Patients were followed up at 3, 6, 9, and 12 months. Follow-up data were available for 82/92 (89.1%) patients. Results One-year arrhythmia-free survival was 81.7% (67/82) in our study group. Major complications occurred in 3/82 (3.7%) patients with an acceptable rate. The value of ln(NT-proBNP) (P = 0.025, odds ratio [OR] = 1.977, 95% confidence interval [CI] 1.087-3.596) and a family history of AF (P = 0.041, HR = 9.269, 95% CI 1.097-78.295) could independently predict AF recurrence. The ROC analysis of ln(NT-proBNP) showed that NT-proBNP greater than 200.05 pg/ml (area under the curve: 0.772, 95% CI 0.642-0.902, P = 0.001, sensitivity 0.800, specificity 0.701) was the cut-off point for predicting late recurrence. Conclusions CA is a safe and effective treatment for AF patients younger than 45 years. Elevated NT-proBNP level and a family history of AF could be used as predictors for late recurrence in young patients. The result of this study may help us take more comprehensive management of those with high-recurrence risks to reduce disease burden and improve quality of life.
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Affiliation(s)
- Haonan Xu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Xiaowei Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Yubin Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Kui Zhu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Jiangtao Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Fen Qin
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
| | - Hailong Tao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Longhu Middle Ring Road, Zhengzhou 450000, China
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Rodilla E, Orts-Martínez MI, Sanz-Caballer MA, Gimeno-Brosel MT, Arilla-Morel MJ, Navarro-Gonzalo I, Castillo-Valero I, Salvador-Mercader I, Carral-Tatay A. Patterns and outcomes of switching direct oral anticoagulants in non-valvular atrial fibrillation: a real-world experience from Spain. Rev Clin Esp 2023:S2254-8874(23)00055-3. [PMID: 37105383 DOI: 10.1016/j.rceng.2023.04.005] [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: 04/29/2023]
Abstract
AIMS The aim is to evaluate a management program for direct oral anticoagulants (DOACs) in non-valvular atrial fibrillation (NVAF) patients according to their profiles, appropriateness of dosing, patterns of crossover, effectiveness and safety. This is an observational and longitudinal prospective study in a cohort of patients attended in daily clinical practice in a regional hospital in Spain with 3-year a follow-up plan for patients initiating dabigatran, rivaroxaban or apixaban between JAN/2012-DEC/2016. METHODS We analyzed 490 episodes of treatment (apixaban 2.5 9.4%, apixaban 5 21.4%, dabigatran 75 0.6%, dabigatran 110 12,4%, dabigatran 150 19.8%, rivaroxaban 15 17.8% and rivaroxaban 20 18.6%) in 445 patients. 13.6% of patients on dabigatran, 9.7% on rivaroxaban, and 3.9% on apixabanswitched to other DOACs or changed dosing. RESULTS Apixaban was the most frequent DOAC switched to. The most frequent reasons for switching were toxicity (23.8%), bleeding (21.4%) and renal deterioration (16.7%). Inappropriateness of dose was found in 23.8% of episodes. Rates of stroke/transient ischemic attack (TIA) were 1.64/0.54 events/100 patients-years, while rates of major, clinically relevant non-major (CRNM) bleeding and intracranial bleeding were 2.4, 5, and 0.5 events/100 patients-years. Gastrointestinal and genitourinary bleeding were the most common type of bleeding events (BE). On multivariable analysis, prior stroke and age were independent predictors of stroke/TIA. Concurrent platelet inhibitors, male gender and age were independent predictors of BE. CONCLUSION This study complements the scant data available on the use of DOACs in NVAF patients in Spain, confirming a good safety and effectiveness profile.
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Affiliation(s)
- E Rodilla
- Internal Medicine Department, Hypertension and Vascular Risk Unit, Hospital Universitario de Sagunto, Department of Medicine, Valencia, Spain; Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain.
| | - M I Orts-Martínez
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M A Sanz-Caballer
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M T Gimeno-Brosel
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M J Arilla-Morel
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Navarro-Gonzalo
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Castillo-Valero
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Salvador-Mercader
- Internal Medicine Department, Cardiology, Hospital Universitario de Sagunto, Spain
| | - A Carral-Tatay
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
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12
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Xu W, Lv M, Wu S, Jiang S, Zeng Z, Fang Z, Qian J, Chen M, Chen J, Zhang J. Severe Bleeding Risk of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Stroke Prevention and Treatment in Patients with Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. Cardiovasc Drugs Ther 2023; 37:363-377. [PMID: 34436708 DOI: 10.1007/s10557-021-07232-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to determine the safety of direct oral anticoagulants (DOACs) for stroke prevention and treatment in patients with atrial fibrillation (AF). METHODS A systematic search of four databases (PubMed, EMBASE, Web of Science, and Cochrane Library) was performed to identify randomized controlled trials (RCTs) reporting severe bleeding events in patients taking DOACs or vitamin K antagonists (VKAs). In this frequency-based network meta-analysis, odds ratios and 95% confidence intervals were used for reporting. Based on the surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. RESULTS Twenty-three RCTs met the inclusion criteria, and a total of 87,616 patients were enrolled. The bleeding safety of DOACs for stroke prevention and treatment in patients with AF was ranked from highest to lowest as follows: fatal bleeding: edoxaban (SUCRA,80.2), rivaroxaban (SUCRA,68.3), apixaban (SUCRA,48.5), dabigatran (SUCRA,40.0), VKAs (SUCRA,12.9); major bleeding: dabigatran (SUCRA,74.0), apixaban (SUCRA,71.5), edoxaban (SUCRA,66.5), rivaroxaban (SUCRA,22.7), VKAs (SUCRA,15.4); gastrointestinal bleeding: apixaban (SUCRA,55.9), VKAs (SUCRA,53.7), edoxaban (SUCRA,50.5), rivaroxaban (SUCRA,50.4), dabigatran (SUCRA,39.5); intracranial hemorrhage: dabigatran (SUCRA,84.6), edoxaban (SUCRA,74.1), apixaban (SUCRA,65.8), rivaroxaban (SUCRA,24.4), VKAs (SUCRA,1.1). CONCLUSION Based on current evidence, for stroke prevention and treatment in patients with AF, the most safe DOAC is edoxaban in terms of fatal bleeding; dabigatran in terms of major bleeding and intracranial hemorrhage and apixaban in terms of gastrointestinal bleeding. However, given the nature of indirect comparisons, more high-quality evidence from head-to-head comparisons is still needed to confirm them.
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Affiliation(s)
- Wenlin Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zhiwei Zeng
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zongwei Fang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiafen Qian
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Mingrong Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China.
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13
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Hirsh J, de Vries TAC, Eikelboom JW, Bhagirath V, Chan NC. Clinical Studies with Anticoagulants that Have Changed Clinical Practice. Semin Thromb Hemost 2023; 49:242-254. [PMID: 36603813 DOI: 10.1055/s-0042-1760330] [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: 01/07/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment and prevention of arterial and venous thromboembolism. Taking a historical perspective, starting in the 1960s, and progressing through to 2022, we discuss key clinical trials of anticoagulants that have changed clinical practice, and examine obstacles encountered in bringing these anticoagulants to the clinic. The design of some of the early studies that shaped clinical practice was poor by current standards, but their results were influential because nothing better was available. Both heparin and vitamin K antagonists had been in clinical use for several decades before well-designed trials in the 1980s optimized their dosing and enhanced their safety and efficacy. Low-molecular-weight heparin then replaced unfractionated heparin because it had a more predictable dose-response and a longer half-life, thereby allowing it to be used conveniently in out-of-hospital settings. More recently, direct oral anticoagulants became the oral anticoagulants of choice for most indications because they were shown to be at least as safe and effective as vitamin K antagonists when used in fixed doses without the need for laboratory monitoring. The design of the trials that led to the approval of the direct oral anticoagulants was excellent, but further studies are required to optimize their dosing in selected patients who were underrepresented in these trials.
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Affiliation(s)
- Jack Hirsh
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim A C de Vries
- Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - John W Eikelboom
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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14
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Yu HT, Chen KH, Lin CJ, Hsu CC, Chang YL. Evaluation of the timing of using direct oral anticoagulants after ischemic stroke for patients with atrial fibrillation. Heliyon 2023; 9:e14456. [PMID: 36967931 PMCID: PMC10031334 DOI: 10.1016/j.heliyon.2023.e14456] [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: 08/26/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023] Open
Abstract
Background and objective Patients with atrial fibrillation (AF) are prescribed oral anticoagulants for stroke prevention; however, no evidence indicates that the use of direct oral anticoagulants (DOACs) in the first few days after ischemic stroke (IS) would result in favorable outcomes. This study evaluated the association between the timing of using DOACs after IS and their effectiveness and safety to determine the optimal timing. Methods In this retrospective cohort study, we reviewed the electronic medical records of Taipei Veterans General Hospital. The 1-year outcomes of patients after DOAC initiation were evaluated. Different initiation time windows were compared (initiation time ≤3 days and >3 days in primary analysis). The primary composite outcome was stroke, transient ischemic attack, systemic embolism, or death due to IS. The primary safety outcome was major bleeding or clinically relevant nonmajor bleeding. The secondary composite outcome was all-cause mortality, thromboembolic event, or acute myocardial infarction/hemorrhagic events. Results This study included 570 patients. The median initiation time of DOACs after IS in the patients with AF was 14 days. Compared the patients in whom DOACs were initiated after >3 days with those DOACs were initiated after ≤3 days, the adjusted hazard ratios (aHRs) of the primary composite outcome was 0.73 (95% confidence interval [CI]: 0.23-1.79), the aHR of primary safety outcome was 0.87 (95% CI: 0.34-1.90), and the aHR of secondary composite outcome was 0.65 (95% CI: 0.32-1.19). All the results were not statistically significant. In secondary analysis, we tested multiple time points of initiating DOACs. Compared with DOAC initiation after >14 days, the primary composite outcomes in the patients in whom DOACs were initiated ≤3, 4-7, and 8-14 days after IS were the same as the findings of the main analysis. After separating patients into different stroke severity groups, the results were similar to those in the main analysis. Conclusion No significant association was observed between the timing of using DOACs and ischemic or hemorrhagic outcomes. The findings did not differ among different time points. Although we do not recommend avoiding the initiation of DOACs in the first few days after IS, we should consider that the early initiation of DOACs (≤3 days) would be appropriate only for patients who tend to experience thromboembolic events and have a low risk of bleeding. The optimal timing of initiation still must be confirmed by randomized controlled trials.
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15
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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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16
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Frol S, Šabovič M, Oblak JP. Apixaban for the Treatment of Cerebral Venous Sinus Thrombosis: A Single-Centre Experience and Systematic Review of the Literature. CNS Drugs 2023; 37:133-141. [PMID: 36646983 DOI: 10.1007/s40263-022-00981-7] [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] [Accepted: 12/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Cerebral venous thrombosis (CVT) is a rare disease, and data regarding direct oral anticoagulant therapy are insufficient. Apixaban could have a safer profile than other direct oral anticoagulants. We present our case series of patients with CVT treated with apixaban and a systematic review of published real-world cases. METHODS We described our series of patients with CVT treated with apixaban and searched PubMed for similar published cases with reported complete outcome data: recanalisation rate, recurrent CVT, modified Rankin score, intracranial haemorrhage, other bleedings and mortality. RESULTS Four male patients (average age 43.5 years) with idiopathic CVT, who presented with a headache and/or seizure without neurological deficits/symptoms or cerebral infarcts/haemorrhage were treated with apixaban 5 mg twice daily for an average 28 months (18-46 months) and followed for on average 2.8 years. In two patients, a partial/complete recanalisation was achieved, there was no recurrent CVT, all patients achieved a modified Rankin score of 0, none experienced an intracranial haemorrhage, other bleedings or died. One patient, in whom anti-phospholipid syndrome was later diagnosed, had a recurrence of CVT after stopping apixaban. Our systematic review identified only 15 eligible patients (average age 39 years, 60% female). Partial/complete recanalisation was achieved in 74% of cases, there was no recurrent CVT, 95% achieved a modified Rankin score of ≤ 2, none experienced an intracranial haemorrhage, other bleedings or died. CONCLUSIONS Our cases and the review of similar published cases, albeit obtained on a smaller scale, suggest that apixaban may be a safe and effective therapy for CVT. This assumption should be tested in a large randomised study.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Mišo Šabovič
- Department of Vascular Disorders, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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17
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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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18
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Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, Sanmartin Fernández M, Arribas F, Masjuan J, Barrios V, Cosin-Sales J, Freixa-Pamias R, Recalde E, Pérez-Cabeza AI, Manuel Vázquez Rodríguez J, Ràfols Priu C, Anguita Sánchez M, Lip GYH, Marin F. Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry. Eur Heart J Cardiovasc Pharmacother 2022; 9:38-46. [PMID: 36318457 DOI: 10.1093/ehjcvp/pvac060] [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] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study. METHODS AND RESULTS EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2 ± 9.7 (44.5% female). Mean HAS-BLED score was 1.6 ± 1.0 and ORBIT score was 1.1 ± 1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P <0.001] and AUC 0.765 (95% CI 0.672-0.858; P <0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P = 0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P = 0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients. CONCLUSION In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.
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Affiliation(s)
- María A Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - José M Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, IMIB-Arrixaca, 30008 Murcia, Spain
| | | | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigacion Sanitaria Hospital 12 de Octubre (IMAS 12); CIBERCV, 28041 Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Juan Cosin-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, 46015 Valencia, Spain
| | | | - Esther Recalde
- Department of Cardiology, Hospital Universitario de Basurto, 48013 Bilbao, Spain
| | - Alejandro I Pérez-Cabeza
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, CIBERCV, 29010 Málaga, Spain
| | | | | | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Reina Sofía Córdoba, IMIBIC, University of Cordoba, 14004 Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, L69 7TX Liverpool, UK.,Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
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19
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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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20
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Agewall S. Treating patients with anticoagulants and antiplatelet drugs is always a balance between risk for thrombosis vs. risk for bleeding. Eur Heart J Cardiovasc Pharmacother 2022; 8:645-647. [PMID: 36172980 DOI: 10.1093/ehjcvp/pvac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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21
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Szyszkowska A, Kuźma Ł, Wożakowska-Kapłon B, Gorczyca-Głowacka I, Jelonek O, Uziębło-Życzkowska B, Krzesiński P, Wójcik M, Błaszczyk R, Gawałko M, Kapłon-Cieślicka A, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Szpotowicz A, Krzciuk M, Bednarski J, Bakuła E, Wełnicki M, Mamcarz A, Tomaszuk-Kazberuk A. Do Patients with Atrial Fibrillation and a History of Ischemic Stroke Overuse Reduced Doses of NOACs?-Results of the Polish Atrial Fibrillation (POL-AF) Registry. Int J Environ Res Public Health 2022; 19:11939. [PMID: 36231257 PMCID: PMC9564626 DOI: 10.3390/ijerph191911939] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The aim of our study was to assess if patients with AF (atrial fibrillation) and a history of ischemic stroke (IS) excessively receive reduced doses of NOACs (non-vitamin K antagonist oral anticoagulants). METHODS The Polish AF (POL-AF) registry is a prospective, observational, multicenter study, including patients with AF from 10 cardiology hospital centers. In this study we focused on patients with IS in their past. RESULTS Among 3999 patients enrolled in the POL-AF registry, 479 (12%) had a previous history of IS. Compared to patients without IS history, post-stroke subjects had a higher CHA2DS2-VASc score (median score 7 vs. 4, p < 0.05). Of these subjects, 439 (92%) had anticoagulation therapy, 83 (18.9%) were treated with a vitamin K antagonist (VKA), 135 (30.8%) with rivaroxaban, 112 (25.5%) with dabigatran, and 109 (24.8%) with apixaban. There were a significant number of patients after IS with reduced doses of NOACs (48.9% for rivaroxaban, 45.5% for dabigatran, and 36.7% for apixaban). In many cases, patients were prescribed reduced doses of NOACs without any indication for reduction (28.8% of rivaroxaban use, 56.9% of dabigatran use, and 60.0% of apixaban use-out of reduced dosage groups, p = 0.06). CONCLUSIONS A significant proportion of AF patients received reduced doses of NOAC after ischemic stroke in a sizeable number of cases, without indication for dose reduction.
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Affiliation(s)
- Anna Szyszkowska
- Department of Cardiology, Medical University of Bialystok, 15-276 Bialystok, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, 15-276 Bialystok, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland
| | - Iwona Gorczyca-Głowacka
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland
| | - Olga Jelonek
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland
| | - Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Monika Gawałko
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
- Department of Cardiology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, 6229 ER Maastricht, The Netherlands
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, 45147 Essen, Germany
| | | | - Tomasz Tokarek
- Center for Invasive Cardiology, Electrotherapy and Angiology, 38-400 Nowy Sacz, Poland
| | - Renata Rajtar-Salwa
- Cardiology and Cardiovascular Interventions Clinical Department, The University Hospital, 30-688 Krakow, Poland
| | - Jacek Bil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, 02-776 Warsaw, Poland
| | - Michał Wojewódzki
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, 02-776 Warsaw, Poland
| | - Anna Szpotowicz
- Department of Cardiology, Regional Hospital, 27-400 Ostrowiec Swietokrzyski, Poland
| | - Małgorzata Krzciuk
- Department of Cardiology, Regional Hospital, 27-400 Ostrowiec Swietokrzyski, Poland
| | - Janusz Bednarski
- Department of Cardiology, St. John Paul’s II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland
| | - Elwira Bakuła
- Department of Cardiology, St. John Paul’s II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland
| | - Marcin Wełnicki
- 3rd Department of Internal Diseases and Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Artur Mamcarz
- 3rd Department of Internal Diseases and Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
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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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Dhamane AD, Hernandez I, Di Fusco M, Gutierrez C, Ferri M, Russ C, Tsai WL, Emir B, Yuce H, Keshishian A. Non-persistence to Oral Anticoagulation Treatment in Patients with Non-valvular Atrial Fibrillation in the USA. Am J Cardiovasc Drugs 2022; 22:333-343. [PMID: 34671944 PMCID: PMC9061668 DOI: 10.1007/s40256-021-00501-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies have shown that patients with non-valvular atrial fibrillation (NVAF) who discontinue oral anticoagulants (OACs) are at higher risk of complications such as stroke. OBJECTIVE This analysis compared the risk of non-persistence with OACs among patients with NVAF. METHODS Adult patients with NVAF who initiated apixaban, dabigatran, rivaroxaban, or warfarin were identified using 01JAN2013-30JUN2019 data from Centers for Medicare and Medicaid Services and four US commercial claims databases. Non-persistence was defined as discontinuation (no evidence of index OAC use for ≥ 60 days from the last days' supply) or switch to another OAC. Kaplan-Meier curves were generated to illustrate time to non-persistence along with cumulative incidences of non-persistence. Baseline and time-varying covariates were evaluated, and adjusted Cox proportional hazards models were used to evaluate non-persistence risk. RESULTS In total, 363,823 patients receiving apixaban, 57,121 receiving dabigatran, 282,831 receiving rivaroxaban, and 317,337 receiving warfarin were included. Of these, 47-72% discontinued/switched OAC therapy within an average 9-month follow-up. Apixaban was associated with a lower risk of non-persistence than were dabigatran (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.61-0.62), rivaroxaban (HR 0.76; 95% CI 0.75-0.76), and warfarin (HR 0.74; 95% CI 0.74-0.75). Dabigatran was associated with a higher risk of non-persistence than were warfarin (HR 1.21; 95% CI 1.19-1.22) and rivaroxaban (HR 1.23; 95% CI 1.22-1.25), and rivaroxaban was associated with a lower risk of non-persistence than was warfarin (HR 0.98; 95% CI 0.97-0.98). Clinical events (stroke/systemic embolism and major bleeding [MB]) during follow-up were predictors of non-persistence (stroke HR 1.57; 95% CI 1.53-1.61; MB HR 2.96; 95% CI 2.92-3.00). CONCLUSION In over one million patients with NVAF, our results suggest differences in anticoagulation treatment persistence across OAC agents, even after accounting for clinical events after OAC initiation. It is important for clinicians and patients to take these differences into consideration, especially as non-persistence to OAC therapy is associated with thromboembolic complications.
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Affiliation(s)
| | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | - Wan-Lun Tsai
- STATinMED Research, 4110 Varsity Dr, Ann Arbor, MI, 48108, USA
| | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
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24
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Pérez Cabeza AI, Rivera-Caravaca JM, Roldán-Rabadán I, García Seara J, Bertomeu-Gonzalez V, Leal M, García-Fernandez A, Tercedor Sanchez L, Ayarra M, Ciudad M, Castaño S, Maestre A, Anguita M, Garcia Bolao I, Marín F. Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry. Eur J Clin Invest 2022; 52:e13709. [PMID: 34757635 DOI: 10.1111/eci.13709] [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: 10/20/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry. METHODS The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up. RESULTS 729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA2 DS2 -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates. CONCLUSIONS In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.
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Affiliation(s)
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom
| | | | - Javier García Seara
- Department of Cardiology, Hospital Clinico Universitario Santiago de Compostela, CIBERCV, Santiago de Compostela, Spain
| | - Vicente Bertomeu-Gonzalez
- Department of Cardiology, University Hospital San Juan de Alicante, Universidad Miguel Hernandez, CIBERCV, Alicante, Spain
| | - Mariano Leal
- Primary Care Health Center of San Andrés, Murcia, Spain
| | - Amaya García-Fernandez
- Department of Cardiology, Arrhythmias Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
| | - Luis Tercedor Sanchez
- Department of Cardiology, University Hospital Virgen de las Nieves, Instituto de Investigación Biosanitaria ibs.Granada, Granada, Spain
| | | | - Marianela Ciudad
- Department of Internal Medicine, University Hospital de La Princesa, Madrid, Spain
| | - Sara Castaño
- Department of Cardiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Ana Maestre
- Department of Internal Medicine, Hospital Universitario del Vinalopó, Elche, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica (IMIBIC), Córdoba, Spain
| | - Ignacio Garcia Bolao
- Department of Cardiology, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - 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
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Roy Chowdhury K, Michaud J, Yu OHY, Yin H, Azoulay L, Renoux C. Effectiveness and safety of apixaban vs. rivaroxaban in patients with atrial fibrillation and type 2 diabetes mellitus. Thromb Haemost 2022; 122:1794-1803. [PMID: 35292949 DOI: 10.1055/a-1798-2116] [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: 10/18/2022]
Abstract
AIMS To evaluate the effectiveness and safety of apixaban vs. rivaroxaban among patients with non-valvular atrial fibrillation (NVAF) and type 2 diabetes mellitus (T2DM). METHODS AND RESULTS Using the United Kingdom's Clinical Practice Research Datalink linked to the Hospital Episode Statistics repository, and the Office for National Statistics database, we identified a cohort of patients with NVAF and T2DM newly treated with apixaban or rivaroxaban between 2013 and 2020. Propensity scores with standardised mortality ratio weighting were used to control for confounding. We used weighted Cox proportional hazards models to estimate separately the hazard ratios (HRs) with 95% confidence intervals (CIs) of ischemic stroke, major bleeding, and major adverse limb events associated with use of apixaban compared with rivaroxaban. We also evaluated whether the risk was modified by age, sex, duration of diabetes, microvascular and macrovascular complications of diabetes, nephropathy, CHA2DS2-VASc and HAS-BLED scores, and by dose (standard vs low dose). RESULTS The cohort included 11,561 apixaban and 8,265 rivaroxaban users. Apixaban was associated with a similar risk of stroke (HR 0.99, 95% CI 0.79-1.23), and a 32% reduced risk of major bleeding (HR 0.68, 95% CI 0.59-0.78), compared with rivaroxaban. The risk of major adverse limb events was similar between apixaban and rivaroxaban (HR 0.75, 95% CI 0.54-1.04). Overall, the risk of ischemic stroke and major bleeding was consistent in stratified analyses. CONCLUSIONS Among patients with NVAF and T2DM, apixaban was associated with a similar risk of stroke, and a lower risk of major bleeding compared with rivaroxaban.
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Affiliation(s)
- Krishna Roy Chowdhury
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Jonathan Michaud
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Oriana Hoi Yun Yu
- Division of Endocrinology, Jewish General Hospital, Montreal, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Christel Renoux
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Neurology and Neurosurgery, McGill University, Montreal, Canada
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Proietti M, Camera M, Gallieni M, Gianturco L, Gidaro A, Piemontese C, Pizzetti G, Redaelli F, Scimeca B, Tadeo CS, Cesari M, Bellelli G, Dalla Vecchia LA. Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document. J Pers Med 2022; 12:jpm12030469. [PMID: 35330468 PMCID: PMC8955844 DOI: 10.3390/jpm12030469] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/25/2022] Open
Abstract
In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 3FA, UK
| | - Marina Camera
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, 20131 Milan, Italy;
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Luigi Gianturco
- Cardiology Unit, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy;
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Carlo Piemontese
- Cardiology Unit, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Giuseppe Pizzetti
- Division of Cardiology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | | | - Barbara Scimeca
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, 20122 Milan, Italy;
| | | | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, 20900 Monza, Italy
| | - Laura Adelaide Dalla Vecchia
- Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
- Correspondence: ; Tel.: +39-02-50725120
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Mamas MA, Batson S, Pollock KG, Grundy S, Matthew A, Chapman C, Manuel JA, Farooqui U, Mitchell SA. Meta-Analysis Comparing Apixaban Versus Rivaroxaban for Management of Patients With Nonvalvular Atrial Fibrillation. Am J Cardiol 2022; 166:58-64. [PMID: 34949473 DOI: 10.1016/j.amjcard.2021.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 09/24/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022]
Abstract
To compare the efficacy and safety of apixaban and rivaroxaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) by way of a meta-analysis informed by real-world evidence. Systematic review and meta-analysis of observational studies including patients with NVAF on apixaban and rivaroxaban, which reported stroke/systemic embolism and/or major bleeding. Prospero registration number: CRD42021251719. Estimates of relative treatment effect (based on hazard ratios[HRs]) were pooled using the inverse variance method. Fixed-effects and random effect analyses were conducted. Exploratory meta-regression analyses that included study-level covariates were conducted using the metareg (meta-regression) command of Stata Statistical Software: Release 15.1 (College Station, Texas. StataCorp LLC.). Study level covariates explored in the meta-regression analyses were CHA2DS2-VASc and HAS-BLED scores. A total of 10 unique retrospective real-world evidence studies reported comparative estimates for apixaban versus rivaroxaban in patients with NVAF and were included in the meta-analysis. Adjusted HR was 0.88 (95% [confidence interval] CI 0.81 to 0.95), indicating a significantly lower hazard of stroke/systemic embolism associated with apixaban versus rivaroxaban. Pairwise meta-analysis for a major bleeding episode was significantly lower with apixaban compared with rivaroxaban (HR 0.62; 95% CI 0.56 to 0.69), whereas apixaban was associated with a lower risk of gastrointestinal bleeding compared with rivaroxaban (HR 0.57; 95% CI 0.50 to 0.64). In conclusion, this study suggests that patient CHA2DS2-VASc and HAS-BLED scores might be an important factor when selecting which direct oral anticoagulants to use, given the relation these scores have on treatment outcomes. Apixaban is associated with lower rates of both major and gastrointestinal bleeding than rivaroxaban, with no loss of efficacy.
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Affiliation(s)
- Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Sarah Batson
- Mtech Access, Bicester, Oxfordshire, United Kingdom
| | - Kevin G Pollock
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom.
| | - Sarah Grundy
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom
| | - Andrew Matthew
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom
| | - Chris Chapman
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom
| | - Joana Assis Manuel
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom
| | - Usman Farooqui
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, United Kingdom
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Ip BY, Ko H, Wong GLH, Yip TCF, Lau LHS, Lau AYL, Leng X, Leung H, Chan HHW, Chan HYF, Mok VCT, Soo YOY, Leung TW. Thromboembolic Risks with Concurrent Direct Oral Anticoagulants and Antiseizure Medications: A Population-Based Analysis. CNS Drugs 2022; 36:1313-1324. [PMID: 36424415 PMCID: PMC9712286 DOI: 10.1007/s40263-022-00971-9] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Drug-drug interactions between direct oral anticoagulants (DOAC) and antiseizure medications via the cytochrome P450 (CYP) or the P-glycoprotein (P-gp) systems may lead to under-anticoagulation. The clinical relevance of these interactions is unclear. We aimed to elucidate the risk of thromboembolism with concurrent DOAC and CYP/P-gp modulating antiseizure medications. METHODS In this propensity score-weighted population-based retrospective cohort study, we used competing risk regression analyses to determine the risks of ischemic stroke, venous thromboembolism, and death in DOAC recipients taking CYP/P-gp-modulating antiseizure medications (phenytoin, valproate, levetiracetam, carbamazepine, or phenobarbital) versus those taking CYP/P-gp-neutral antiseizure medications (pregabalin, gabapentin, or clobazam). We also performed secondary analyses for the epilepsy and atrial fibrillation subgroups. RESULTS Among DOAC users, CYP/P-gp-modulating antiseizure medications were collectively associated with an increased risk of ischemic stroke (adjusted hazard ratio 1.28, 95% confidence interval 1.05-1.57, p = 0.017). In addition, phenytoin (adjusted hazard ratio 1.34, 95% confidence interval 1.07-1.68, p = 0.011) and valproate (adjusted hazard ratio 1.38, 95% confidence interval 1.10-1.74, p = 0.006) were associated with increased mortality. In the epilepsy subgroup, the risk of ischemic stroke and venous thromboembolism did not differ between CYP/P-gp-modulating and CYP/P-gp-neutral antiseizure medications. CONCLUSIONS Although CYP/P-gp-modulating antiseizure medications were associated with an increased risk of ischemic stroke when paired with DOAC in the primary analysis, such a phenomenon was not found among patients with epilepsy who took phenytoin, valproate, or levetiracetam with DOAC. Therefore, these antiseizure medication options among patients with epilepsy with concurrent DOAC should not be restricted solely based on their potential drug-drug interactions. Yet, the increased mortality during concurrent use of DOAC with phenytoin or valproate might call for caution.
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Affiliation(s)
- Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ho Ko
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace LH Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Terry CF Yip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Louis HS Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Alexander YL Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Howan Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Howard HW Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Helen YF Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent CT Mok
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie OY Soo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas W. Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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29
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Ording AG, Søgaard M, Skjøth F, Grove EL, Lip GYH, Larsen TB, Nielsen PB. Hematuria in anticoagulated patients with atrial fibrillation and urologic cancer. Res Pract Thromb Haemost 2022; 6:e12629. [PMID: 35059549 PMCID: PMC8756162 DOI: 10.1002/rth2.12629] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/29/2021] [Accepted: 10/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Based on their renal excretion, direct oral anticoagulants (DOACs) may increase the risk of hematuria in patients with atrial fibrillation (AF) and urologic cancer compared with vitamin K antagonists. OBJECTIVES To examine the risk of bleeding associated with DOAC versus warfarin in patients with AF and urologic cancer. METHODS We conducted a Danish nationwide cohort study with individually linked registry data on patients with AF and active or a history of urologic cancer. We calculated crude rates per 100 person-years of hospital episodes of major bleeding and hematuria. We then compared rates of hematuria during the year after initial oral anticoagulation filled prescription by treatment regimen using inverse probability of treatment weighting and Cox regression. RESULTS The study population included 2615 patients with AF and urologic cancer (6.1% women; median age, 76 years) initiating a DOAC or warfarin. One-year risk of hematuria was 4.8% in the DOAC group and 4.7% in the warfarin group with a corresponding weighted hazard ratio (HR) of 1.21 (95% confidence interval [CI], 0.81-1.81). HRs for hematuria were generally similar in analyses restricted to patients treated with standard-dose DOAC and patients with active cancer. For those with cancer of the kidney, renal pelvis, ureter, and bladder, the HR was 0.82 (95% CI, 0.44-1.54). Results were mirrored for other bleeding events, whereas the risk for intracranial bleeding was lower with DOACs. CONCLUSION In patients with AF and urologic cancer, there was a similar risk of hematuria associated with DOAC and warfarin treatment.
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Affiliation(s)
- Anne Gulbech Ording
- Unit for Thrombosis and Drug ResearchDepartment of CardiologyAalborg University HospitalAalborgDenmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug ResearchDepartment of CardiologyAalborg University HospitalAalborgDenmark
- Aalborg Thrombosis Research UnitAalborg UniversityAalborgDenmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research UnitAalborg UniversityAalborgDenmark
- Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Erik Lerkevang Grove
- Department of CardiologyAarhus University HospitalAarhus NDenmark
- Department of Clinical MedicineFaculty of HealthAarhus UniversityAarhus NDenmark
| | - Gregory Y. H. Lip
- Unit for Thrombosis and Drug ResearchDepartment of CardiologyAalborg University HospitalAalborgDenmark
- Liverpool Centre for Cardiovascular SciencesUniversity Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Torben Bjerregaard Larsen
- Unit for Thrombosis and Drug ResearchDepartment of CardiologyAalborg University HospitalAalborgDenmark
- Aalborg Thrombosis Research UnitAalborg UniversityAalborgDenmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug ResearchDepartment of CardiologyAalborg University HospitalAalborgDenmark
- Aalborg Thrombosis Research UnitAalborg UniversityAalborgDenmark
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30
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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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31
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Yen CC, Wang CK, Chaou CH, Chen SY, Lin JP, Ng CJ. Anticoagulant Therapy Is Associated With Decreased Long-Term Mortality in Splenic Infarction Patients: A Multicenter Study. Front Med (Lausanne) 2021; 8:778198. [PMID: 34912831 PMCID: PMC8666632 DOI: 10.3389/fmed.2021.778198] [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: 09/16/2021] [Accepted: 11/09/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Patients with splenic infarction (SI) are associated with a prothrombotic state and are vulnerable to subsequent thromboembolic complications. However, due to its rarity, there is no established treatment modality in this population. We aimed to examine the effect of anticoagulant therapy in SI patients. Methods: We performed a multicenter retrospective cohort study of 86 SI patients. Patients were categorized as anticoagulant users and anticoagulant non-users. The associations between anticoagulant therapy, all-cause mortality, thromboembolic events and bleeding events were evaluated. Results: Forty-five patients (52.3%) received anticoagulant therapy during the follow-up periods. The all-cause mortality rate was 6.86 per 100 patient-years. Anticoagulant therapy was associated with 94% improved survival (HR = 0.06; Cl 0.007–0.48; p = 0.008), while the risk factors for all-cause mortality were prior stroke (HR = 13.15; Cl 2.39–72.27; p = 0.003) and liver cirrhosis (HR = 8.71; Cl 1.29–59.01; p = 0.027). Patients with anticoagulant therapy had a higher event-free survival curve for thromboembolic complications (p = 0.03) but did not achieve a significant difference after adjustment using the Cox regression model as a time-dependent covariate (HR = 0.57; Cl 0.13–2.45; p = 0.446). There was no significant difference in the risk of bleeding events between the groups (p = 0.728). Conclusions: Anticoagulant therapy in patients with SI was associated with better survival and was not related to an increased bleeding risk.
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Affiliation(s)
- Chieh-Ching Yen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chih-Kai Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Medical Education Research Center, Taoyuan, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Medical Education Research Center, Taoyuan, Taiwan
| | - Jhe-Ping Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Wang X, Luo Y, Xu D, Zhao K. Effect of Digoxin Therapy on Mortality in Patients With Atrial Fibrillation: An Updated Meta-Analysis. Front Cardiovasc Med 2021; 8:731135. [PMID: 34660731 PMCID: PMC8517124 DOI: 10.3389/fcvm.2021.731135] [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: 06/26/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Whether digoxin is associated with increased mortality in atrial fibrillation (AF) remains controversial. We aimed to assess the risk of mortality and clinical effects of digoxin use in patients with AF. Methods: PubMed, Embase, and the Cochrane library were systematically searched to identify eligible studies comparing all-cause mortality of patients with AF taking digoxin with those not taking digoxin, and the length of follow-up was at least 6 months. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted and pooled. Results: A total of 29 studies with 621,478 patients were included. Digoxin use was associated with an increased risk of all-cause mortality in all patients with AF (HR 1.17, 95% CI 1.13–1.22, P < 0.001), especially in patients without HF (HR 1.28, 95% CI 1.11–1.47, P < 0.001). There was no significant association between digoxin and mortality in patients with AF and HF (HR 1.06, 95% CI 0.99–1.14, P = 0.110). In all patients with AF, regardless of concomitant HF, digoxin use was associated with an increased risk of sudden cardiac death (SCD) (HR 1.40, 95% CI 1.23–1.60, P < 0.001) and cardiovascular (CV) mortality (HR 1.27, 95% CI 1.08–1.50, P < 0.001), and digoxin use had no significant association with all-cause hospitalization (HR 1.13, 95% CI 0.92–1.39, P = 0.230). Conclusion: We conclude that digoxin use is associated with an increased risk of all-cause mortality, CV mortality, and SCD, and it does not reduce readmission for AF, regardless of concomitant HF. Digoxin may have a neutral effect on all-cause mortality in patients with AF with concomitant HF. Systematic Review Registration:https://www.crd.york.ac.ukPROSPERO.
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Affiliation(s)
- Xiaoxu Wang
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Luo
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Xu
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Zhao
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, China
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33
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Lip GYH, Gue Y, Zhang J, Chao TF, Calkins H, Potpara T. Stroke Prevention in Atrial Fibrillation. Trends Cardiovasc Med 2021; 32:501-510. [PMID: 34619337 DOI: 10.1016/j.tcm.2021.10.001] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) is the commonest sustained cardiac rhythm disorder associated with an increased risk of stroke and systemic embolic events. The prevention of stroke using oral anticoagulants has been a pivotal component of AF management. The purpose of this review is to summarize recent advances in the treatment and prevention of stroke in AF over the last 5 years. We performed a comprehensive structured literature search using MEDLINE for publications from 11th March 2015 through to 31st December 2020. We focused mainly on primarily published research articles and systematic reviews including updates in different international guidelines. We found that improved awareness and detection of AF and use of clinical risk stratification are central to the identification of patients at risk of stroke who would benefit from oral anticoagulation. The recommendation of non-vitamin K antagonist oral anticoagulants over warfarin in both efficacy and safety perspective is represented in all international guidelines. Beyond stroke prevention, there is a move to more holistic or integrated care management of AF, which has been shown to improve outcomes. We conclude that stroke prevention remains a dominant part of the management of patients with AF. Not all stroke risk factors carry equal weight, and many require additional scrutiny (e.g. severity of CAD, type of diabetes, duration of hypertension). The utilization of clinical risk scores to help decision-making should take into account that these scores are mere simplification tools to aid decision-making and the additional clinical benefit with more complex risk scores and addition of biomarkers is limited. Also, stroke and bleeding risks are dynamic and require regular review. Instead of arbitrarily categorizing patients into (artificial) low, moderate, and high stroke risk strata, anticoagulation should be offered to all patients with AF unless they are low risk with no risk factors for stroke. Stroke prevention is also part of the proactive, integrated care approach to holistic management of patients with AF, which can be simplified in the ABC (Atrial fibrillation Better Care) pathway: 'A' Avoid stroke/Anticoagulation; 'B' Better symptom management emphasising patient-centred symptom directed decisions on rate or rhythm control strategies; and 'C' refers to Cardiovascular risk and comorbidity optimization, including lifestyle changes and attention to patient values and preferences, as well as the psychological morbidity associated with AF.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Ying Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore MD USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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34
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Ording AG, Søgaard M, Skjøth F, Grove EL, Lip GYH, Larsen TB, Nielsen PB. Bleeding complications in patients with gastrointestinal cancer and atrial fibrillation treated with oral anticoagulants. Cancer Med 2021; 10:4405-4414. [PMID: 34114733 PMCID: PMC8267127 DOI: 10.1002/cam4.4012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 02/11/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) may increase the risk of gastrointestinal (GI) bleeding in patients with atrial fibrillation (AF) and GI cancer compared with vitamin K antagonists (VKA). Methods We conducted a Danish nationwide cohort study comparing the bleeding risk associated with DOAC versus VKA in patients with AF and GI cancer. We calculated crude bleeding rates per 100 person‐years (PYs) for GI and major bleeding. We then compared rates of bleeding at 1 year after initial oral anticoagulation filled prescription by treatment regimen using inverse probability of treatment weighting and Cox regression. Results The unweighted study population included 1476 AF patients with GI cancer (41.6% women, median age 78 years) initiating a DOAC and 652 initiating a VKA. One‐year risk of GI bleeding was 5.0% in the DOAC group and 4.7% in the VKA group with a corresponding weighted hazard ratio (HR) of 0.95 (95% confidence interval [CI]: 0.63, 1.45). For patients with active cancer, weighted GI bleeding rates were slightly higher in both the VKA and DOAC group, and the weighted HR was 1.00 (95% CI: 0.53, 1.88). The HR was 1.12 (95% CI: 0.71, 1.76) for all bleedings. Hazard ratios for GI bleeding were 0.61 (95% CI: 0.25, 1.52) for patients with upper GI cancer, and 0.92 (95% CI: 0.58, 1.46) in patients with colorectal cancer. Conclusion Evidence from this nationwide cohort study suggests a comparable 1‐year risk of bleeding associated with DOAC compared with VKA among patients with AF and GI cancer.
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Affiliation(s)
- Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark.,Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus C, Denmark
| | - Gregory Y H Lip
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Sciences, University Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Torben Bjerregaard Larsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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Granger CB, Pokorney SD. Preventing and Managing Bleeding With Anticoagulation for Atrial Fibrillation. J Am Coll Cardiol 2021; 77:3002-3004. [PMID: 34140102 DOI: 10.1016/j.jacc.2021.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Christopher B Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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36
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Ingrasciotta Y, Fontana A, Mancuso A, Ientile V, Sultana J, Uomo I, Pastorello M, Calabrò P, Andò G, Trifirò G. Comparison of Direct Oral Anticoagulant Use for the Treatment of Non-Valvular Atrial Fibrillation in Pivotal Clinical Trials vs. the Real-World Setting: A Population-Based Study from Southern Italy. Pharmaceuticals (Basel) 2021; 14:ph14040290. [PMID: 33805899 PMCID: PMC8064382 DOI: 10.3390/ph14040290] [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: 02/10/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
Patients enrolled into pivotal randomized controlled trials (RCTs) may differ substantially from those treated in a real-world (RW) setting, which may result in a different benefit–risk profile. The aim of the study was to assess the external validity of pivotal RCT findings concerning direct oral anticoagulants (DOACs) for the treatment of nonvalvular atrial fibrillation (NVAF) by comparing patients recruited in RCTs to those treated with DOACs registered in a southern Italian local health unit (LHU) in the years 2013–2017. The Palermo LHU claims database was used to describe the baseline characteristics of incident DOAC users (washout > 1 year) with NVAF compared with those of enrolled patients in DOAC pivotal RCTs. In the RW, DOAC treatment discontinuation was calculated during the follow-up and compared with DOAC treatment discontinuation of enrolled patients in DOAC pivotal RCTs. Rates of effectiveness and safety outcomes during the follow-up were calculated in an unmatched and in a simulated RCT population, by matching individual incidental RW and RCT DOAC users (excluding edoxaban users) on age, sex, and CHADS2 score. Overall, 42,336 and 7092 incident DOAC users with NVAF were identified from pivotal RCTs and from the RW setting, respectively. In RCTs, DOAC use was more common among males (62.6%) compared with an almost equal sex distribution in the RW. RCT patients were younger (mean age ± standard deviation: 70.7 ± 9.2 years) than RW patients (76.0 ± 8.6 years). Compared with RCTs, a higher proportion of RW dabigatran users (30.4% vs. 19.6%) and a lower proportion of RW apixaban (15.9% vs. 25.3%) and rivaroxaban (20.4% vs. 23.7%) users discontinued the treatment during the follow-up (p-value < 0.001). The rate of ischemic stroke was lower in RW high-dose dabigatran users (unmatched/-matched population: 0.40–0.11% per year) than in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) population (0.93% per year). Major bleeding rates were lower in RW users than in RCT users. In conclusion, except for dabigatran, a lower proportion of DOAC discontinuers was observed in the real-world than in pivotal RCT settings. This study provides reassurance to practicing physicians that DOAC use appears to be effective in stroke prevention and is likely safer in RW patients than in RCT enrolled patients. These results may be related to a lower burden of comorbidities despite more advanced age in the RW population compared to the pivotal RCT population.
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Affiliation(s)
- Ylenia Ingrasciotta
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
- Correspondence: ; Tel.: +39-0902213877
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Anna Mancuso
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Valentina Ientile
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Ilaria Uomo
- Department of Pharmacy, Palermo Local Health Unit, 90100 Palermo, Italy; (I.U.); (M.P.)
| | - Maurizio Pastorello
- Department of Pharmacy, Palermo Local Health Unit, 90100 Palermo, Italy; (I.U.); (M.P.)
| | - Paolo Calabrò
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, 98158 Messina, Italy;
| | - Gianluca Trifirò
- Department of Diagnostic Public Health, University of Verona, 37129 Verona, Italy;
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