DOAC versus warfarin in patients with atrial fibrillation and stage IV-V chronic kideny disease including patients on dialysis

Introduction

Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) were excluded from most phase III randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs). Evidence of warfarin versus DOAC in the AF population with stage IV-V CKD is therefore limited.

Aim

To evaluate the effectiveness and safety of DOAC compared with warfarin on this population including dialysis patients.

Methods

A systematic review and meta-analysis of RCTs and observational studies involving AF patients with stage IV-V CKD treated with warfarin versus DOACs were conducted to evaluate the following outcomes: stroke (ischemic and hemorrhagic) or systemic embolism (SE), all-cause mortality, major bleeding, gastrointestinal (GI) bleeding, and intracranial bleeding. If the heterogeneity between studies was moderate to high calculated as the I2 ≥50%, a meta regression was undertaken between baseline characteristics and the study outcomes. We conducted a literature search using key words related to AF, severe CKD, DOAC and warfarin in PubMed, Embase and Cochrane Library.

Results

Nine studies were included in the meta-analysis. Compared to warfarin, DOAC was significantly associated with a reduced risk of stroke or systemic embolism (SE) (risk ratio [RR] = 0.69; 95% confidence interval [CI] 0.50–0.95) (Figure 1), intracranial bleeding (RR=0.54; 95% CI 0.35–0.84) and hemorrhagic stroke (RR=0.39; 95% CI 0.16–0.95). There was no significant difference between DOACs and warfarin in the risk of all-cause mortality (RR=0.80; 95% CI 0.57–1.13), major bleeding (RR = 0.70; 95% CI 0.44–1.11) (Figure 2) and GI bleeding (RR=0.76; 95% CI 0.56–1.02). For the outcome stroke or SE, dabigatran (compared with apixaban) significantly eliminated the net effect of DOAC as compared with warfarin (coefficient, 0.8; P=0.003). Regarding major bleeding, rivaroxaban and dabigatran both eliminated the DOAC effect from the meta-analysis as compared to apixaban (P=0.01 & P<0.0001). Dabigatran significantly increased the risk of GI bleeding in comparison to apixaban (coefficient, 0.48; P=0.002) in comparison with the overall similar effect of warfarin in the meta-analysis.

Conclusion

Among patients with AF and stage IV or V CKD including dialysis patients, DOAC appears to have similar or better effectiveness and safety compared to warfarin.

Funding Acknowledgement

Type of funding sources: None. Stroke or systemic embolism

Gender differences in characteristics, treatment and outcomes in ST elevation myocardial infarction patients in four European countries

Introduction

Women receive less evidence-based care than men and have higher mortality after myocardial infarctions than men. But it is not known how the gender difference in risk factors, treatments and outcomes differs between European countries.

Purpose

In order to investigate the gender differences in European countries with different economic predispositions we aimed to describe and compare baseline characteristics, in-hospital management, medications at discharge and death outcomes of man and woman ST-elevation infarction (STEMI) patients following routine clinical practice in Sweden, Norway, Hungary and Estonia.

Methods

The study population is patients over the age of 18 with STEMI who were treated in hospital 2014–2017 (for Norway between 2013–2016) and registered in one of the national myocardial infarction registers. Patients with non-ST elevation infarction and unstable angina were excluded. Risk factors, hospital treatment, and prescription medications were obtained from the national myocardial infarction registries from each country. Mortality in-hospital, after 30 days and after 1 year, was obtained from national death registers.

Results

Women were on average older, had more comorbidities and higher mortality in hospital, after 30 days and one year after hospitalization. Women received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment and evidence-based drugs to a lesser extent than men.

Conclusions

The study illustrates that there are differences in characteristics, management, treatments and outcomes between men and women in all of the studied countries no matter economic predispositions. Generally, women are treated with guideline recommended therapy to a lesser extent than men in the studied countries.

Funding Acknowledgement

Type of funding sources: None.

Immediate versus staged revascularisation in multivessel coronary disease: an updated meta-analysis

Background

Percutaneous coronary interventions (PCIs) are often aimed at the culprit vessel in acute coronary syndromes (ACSs) followed by revascularisation of other stenoses later in the index hospitalisation or shortly after discharge. PCI delay of non-culprit coronary vessels stenoses is supported by lower contrast fluid use and thrombocyte aggregation. Distinct coronary interventions increase the risk of both non- and coronary artery complications, e.g. acute abdominal and periphery artery bleeding, suggesting undertaking all PCIs at the same time.

Purpose

To assess the effect on mortality and re-myocardial infarction (MI) of immediate versus staged revascularisation in multivessel coronary disease, with the latter constrained to initial PCI of the culprit coronary vessel.

Methods

The syntax of “randomised controlled trial (RCT) & acute coronary syndrome & complete revascularisation” was undertaken in PubMed.

Clinical characteristics were gathered at the index hospitalisation. The intervention scenario was acute coronary syndrome or not.

Meta-analyses calculated relative risk (RR) reductions on outcomes of 1) mortality and 2) re-MI. Meta-regression assessed linear difference between interventional treatment benefits and baseline characteristics.

Results

A total of 148 studies was found. Of those, 8 was found eligible for further analyses and their baseline characteristics are shown in Table 1.

Comparison of immediate versus staged revascularisation on mortality was nonsignificant (RR, 1.19; 95% CI: 0.78–1.81, p=0.43) (Figure 1). The impact of Immediate vs staged revascularisation on re-MI was also nonsignificant (RR, 0.83; 95% CI: 0.44–1.55, p=0.56). Meta-regression found no associations between the outcomes and study characteristics (not shown).

Conclusion

The intervention of immediate compared to staged revascularisation assessed on outcomes of all-cause mortality and re-MI were nonsignificant.

Figure 1

Funding Acknowledgement

Type of funding source: None

European differences in characteristics, treatments and outcomes in patients with non-ST-elevation myocardial infarction – novel insights from four national real-world registries

Background

Large-scale collection of standardized variables in patients with myocardial infarction (MI) in national real-world registries are only available in a few European countries and there is lack of cross-country comparisons.

Purpose

To compare demography, risk factors, hospital treatment and short- and long-term survival in patients hospitalized for non-ST elevation MI (NSTEMI) in four different European countries.

Methods

NSTEMI patients hospitalized and enrolled in national MI registries; EMIR (Estonia), HUMIR (Hungary), NORMI (Norway (2013–2016)) and SWEDEHEART (Sweden) from 2014 to 2017 were included.

Results

In total 119,191 patients with NSTEMI were included. The mean age at admission ranged from 70 years (Hungary) to 75 years (Estonia). The proportion of women was 36% in Sweden and 44% in Estonia. In Norway 24% were smokers, as compared to 17% in Sweden. Patients in Hungary had a high rate of diabetes mellitus (37%) and antihypertensive treatment (84%) but a low rate of lipid lowering treatment (32%). The proportion of patients with prior MI ranged from 28% (Norway) to 37% (Sweden). The presence of previous peripheral artery disease ranged from 7% (Sweden) to 17% (Hungary). The absolute proportion of performed coronary angiographies (58% versus 75%) and percutaneous coronary interventions (38% versus 56%), differed most between Norway and Hungary. Dual antiplatelet therapy ranged from 60% (Estonia) to 81% (Hungary) and statins from 78% (Norway) to 89% (Hungary), at discharge. The crude mortality rates at 1 month and 1 year are listed in table 1.

Conclusion

Cross-comparison of four national European MI registries provide new insights in differences in risk factors, treatment and outcomes. Possible reasons for the observed differences, include differences in the underlying expected mortality in the populations, inclusion-criteria and coverage of the registries and variable definitions, that need to be further explored.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council

P3120Prevention of heart failure in treatments with trastuzumab and anthracyclines: a meta-analysis

Background

Trastuzumab and anthracyclines are conventional chemotherapies used in breast cancer. Unfortunately, they are associated with a decrease in left ventricular function potentially leading to heart failure (HF). In order to prevent this, randomised controlled trials (RCTs) assess the preventive effect of concomitant beta-blocker (BB), angiotensin receptor blocker (ARB) and angiotensin converting enzyme inhibitor (ACEI) therapy during chemotherapy.

Purpose

To assess the preventive effect of BB, ARB or ACEIs on left ventricular ejection fraction (LVEF) during trastuzumab and anthracycline treatment in patients without HF.

Methods

Our primary outcomes were the effect of BBs or ARB/ACEIs during 1) trastuzumab and 2) anthracycline treatment.

Secondary outcomes were the distinct effects of 1) BBs and 2) ARB/ACEIs in either trastuzumab or anthracycline treatments.

Through the search term “(RCTs), prevention, cancer chemotherapy and cardiotoxicity” in PubMed, studies were selected, excluding those without randomising to a BB, ARB/ACEI and a placebo control group during chemotherapy.

Means of the LVEF and the standard deviation (SD) post-chemotherapy were applied.

Meta-analyses estimated the standardised mean difference (SMD) in the LVEF.

Heterogeneity was calculated as the I2.

Results

A total of 7 studies (Table 1) were included in the analysis. Between 93 and 100% were woman. Age varied from 41 to 51 years. Treatment time varied from 12 to 52 weeks.

Concomitant BB or ARB/ACEI therapy during trastuzumab treatment was not associated with the LVEF, significantly (Fig. 1A; p=0.07). Oppositely, in the anthracycline regime the LVEF remained significant higher in the concomitant BB and ARB/ACEI groups as compared to controls (Fig. 1B).

BB and ARB/ACEI separation in the analysis showed both to influence the LVEF positively independent of chemotherapy (P=0.03 & p=0.005).

Table 1 Study reference Year Chemotherapies Preventive drugs Pituskin et al., “Multidisciplinary Approach to Novel Therapies in Cardio-Oncology Research (MANTICORE 101-Breast): A Randomized Trial for the Prevention of Trastuzumab-Associated Cardiotoxicity.” 2017 Trastuzumab Perindopril. bisoprolol Gulati et al., “Prevention of Cardiac Dysfunction during Adjuvant Breast Cancer Therapy (PRADA).” 2016 Trastuzumab Candesartan, metoprolol Boekhout et al., “Angiotensin II-Receptor Inhibition With Candesartan to Prevent Trastuzumab-Related Cardiotoxic Effects in Patients With Early Breast Cancer: A Randomized Clinical Trial.” 2016 Trastuzumab Candesartan Janbabai et al., “Effect of Enalapril on Preventing Anthracycline-Induced Cardiomyopathy.” 2017 Anthracycline Enalapril Nabati et al., “Cardioprotective Effects of Carvedilol in Inhibiting Doxorubicin-Induced Cardiotoxicity.” 2017 Anthracycline Carvedilol Tashakori Beheshti et al., “Carvedilol Administration Can Prevent Doxorubicin-Induced Cardiotoxicity: A Double-Blind Randomized Trial.” 2016 Anthracycline Carvedilol Kaya et al., “Protective Effects of Nebivolol against Anthracycline-Induced Cardiomyopathy: A Randomized Control Study.” 2013 Anthracycline Nebivolol

Figure 1

Conclusions

Concomitant BB and ARB/ACEI therapy both favoured maintenance of the LVEF during trastuzumab and anthracyclines regimens as compared to controls.