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Østergaard L, Olesen JB, Petersen JK, Nielsen LS, Kristensen SL, Schou M, Køber L, Fosbøl E. Arterial Thromboembolism in Patients With Atrial Fibrillation and CHA 2DS 2-VASc Score 1: A Nationwide Study. Circulation 2024; 149:764-773. [PMID: 38152890 DOI: 10.1161/circulationaha.123.066477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/01/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Oral anticoagulation is suggested in patients with atrial fibrillation and a CHA2DS2-VASc score ≥1 (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, and sex score). To assess granular differences within CHA2DS2-VASc 1, the incidence of arterial thromboembolism according to CHA2DS2-VASc 1 subgroups was examined. METHODS The Danish National Patient Registry and the Danish Prescription Registry were linked on a nationwide level to identify patients with atrial fibrillation from 2000 to 2021 without oral anticoagulation and categorized according to CHA2DS2-VASc score: CHA2DS2-VASc 0 (male and female subjects); CHA2DS2-VASc 1 (hypertension, heart failure, diabetes, vascular disease, and age 65-74 years); or CHA2DS2-VASc 2 (age ≥75 years without other risk factors). Female sex was not considered a risk factor in any risk group. The outcome was arterial thromboembolism (ischemic stroke, embolism of extremity, or transient cerebral ischemia). Study groups were compared using Cox regression analysis. RESULTS We included 26 701 patients with a CHA2DS2-VASc 0 score; 22 915 with CHA2DS2-VASc 1 (1483 patients with heart failure, 9066 with hypertension, 843 with diabetes, 770 with vascular disease, and 10 753 who were 65 to 74 years of age); and 14 525 patients with CHA2DS2-VASc 2 (≥75 years of age without other risk factors). With a median of 1 year of observation time, the cumulative incidence of arterial thromboembolism was 0.6% (n=154 [95% CI, 0.6%-0.8%]), 1.4% (n=16 [95% CI, 0.8%-2.2%]), 1.9% (n=141 [95% CI, 1.6%-2.2%]), 1.7% (n=12 [95% CI, 0.9%-2.9%]), 2.0% (n=13 [95% CI, 1.1%-3.4%]), 2.3% (n=187 [95% CI, 2.0%-2.7%]), and 4.4% (n=533 [95% CI, 4.1%-4.8%]) for CHA2DS2-VASc 0, heart failure, hypertension, diabetes, vascular disease, age 65 to 74 years (CHA2DS2-VASc 1), and age ≥75 years (CHA2DS2-VASc 2), respectively. No statistically significant difference was identified among subgroups of CHA2DS2-VASc 1 (P=0.15 for difference). CONCLUSIONS For patients with atrial fibrillation, all subgroups of CHA2DS2-VASc 1 were associated with lower incidence of arterial thromboembolism compared with age ≥75 years without other risk factors (ie, CHA2DS2-VASc 2) and a higher incidence compared with CHA2DS2-VASc 0. No statistically significant difference was identified between the subgroups of CHA2DS2-VASc 1. These findings support current recommendations that patients within this intermediate risk group could be identified with a similar risk of arterial thromboembolism.
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Affiliation(s)
- Lauge Østergaard
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev-Gentofte Hospital (J.B.O., M.S.), University of Copenhagen, Denmark
| | - Jeppe Kofoed Petersen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Lukas Schak Nielsen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Søren Lund Kristensen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital (J.B.O., M.S.), University of Copenhagen, Denmark
| | - Lars Køber
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Emil Fosbøl
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
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Ballegaard ELF, Lindhard K, Lindhardt M, Peters CD, Thomsen Nielsen F, Tietze IN, Borg R, Boesby L, Bertelsen MC, Brøsen JMB, Cibulskyte-Ninkovic D, Rantanen JM, Mose FH, Kampmann JD, Nielsen AS, Breinholt JK, Kofod DH, Bressendorff I, Clausen PV, Lange T, Køber L, Kamper AL, Bang CNF, Torp-Pedersen C, Hansen D, Grove EL, Gislason G, Dam Jensen J, Olesen JB, Hornum M, Rix M, Schou M, Carlson N. Protocol for a randomised controlled trial comparing warfarin with no oral anticoagulation in patients with atrial fibrillation on chronic dialysis: the Danish Warfarin-Dialysis (DANWARD) trial. BMJ Open 2024; 14:e081961. [PMID: 38413147 PMCID: PMC10900386 DOI: 10.1136/bmjopen-2023-081961] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is highly prevalent in patients on chronic dialysis. It is unclear whether anticoagulant therapy for stroke prevention is beneficial in these patients. Vitamin K-antagonists (VKA) remain the predominant anticoagulant choice. Importantly, anticoagulation remains inconsistently used and a possible benefit remains untested in randomised clinical trials comparing oral anticoagulation with no treatment in patients on chronic dialysis. The Danish Warfarin-Dialysis (DANWARD) trial aims to investigate the safety and efficacy of VKAs in patients with atrial fibrillation on chronic dialysis. The hypothesis is that VKA treatment compared with no treatment is associated with stroke risk reduction and overall benefit. METHODS AND ANALYSIS The DANWARD trial is an investigator-initiated trial at 13 Danish dialysis centres. In an open-label randomised clinical trial study design, a total of 718 patients with atrial fibrillation on chronic dialysis will be randomised in a 1:1 ratio to receive either standard dose VKA targeting an international normalised ratio of 2.0-3.0 or no oral anticoagulation. Principal analyses will compare the risk of a primary efficacy endpoint, stroke or transient ischaemic attack and a primary safety endpoint, major bleeding, in patients allocated to VKA treatment and no treatment, respectively. The first patient was randomised in October 2019. Patients will be followed until 1 year after the inclusion of the last patient. ETHICS AND DISSEMINATION The study protocol was approved by the Regional Research Ethics Committee (journal number H-18050839) and the Danish Medicines Agency (case number 2018101877). The trial is conducted in accordance with the Helsinki declaration and standards of Good Clinical Practice. Study results will be disseminated to participating sites, at research conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT03862859, EUDRA-CT 2018-000484-86 and CTIS ID 2022-502500-75-00.
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Affiliation(s)
- Ellen Linnea Freese Ballegaard
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Morten Lindhardt
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine 1, Holbæk Hospital, Holbæk, Denmark
| | - Christian Daugaard Peters
- Dept. of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Finn Thomsen Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Bornholms Hospital, Ronne, Denmark
| | | | - Rikke Borg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lene Boesby
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Marianne Camilla Bertelsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | | | | | - Frank Holden Mose
- Department of Nephrology, Gødstrup Regional Hospital, Herning, Denmark
| | - Jan Dominik Kampmann
- Internal medicine, Hospital of Southern Jutland Sonderborg Branch, Sonderborg, Denmark
| | - Alice Skovhede Nielsen
- Department of Medicine, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Johanne Kodal Breinholt
- Department of Clinical Biochemistry, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Dea Haagensen Kofod
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Iain Bressendorff
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilhelm Clausen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Kobenhavns, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper Niels Furbo Bang
- Department of Cardiology, Copenhagen University Hospital - Frederiksberg and Bispebjerg, Copenhagen, Denmark
| | | | - Ditte Hansen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Binding C, Blanche P, Lip GYH, Kamper AL, Lee CJY, Staerk L, Gislason G, Torp-Pedersen C, Olesen JB, Bonde AN. Efficacy and safety of oral anticoagulants according to kidney function among patients with atrial fibrillation. Eur Heart J Cardiovasc Pharmacother 2024:pvae016. [PMID: 38402466 DOI: 10.1093/ehjcvp/pvae016] [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] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND AIMS Patients with severely reduced kidney function have been excluded from randomized controlled trials and data on safety and efficacy of direct oral anticoagulants (DOACs) according to kidney function remain sparse. The aim was to evaluate safety and efficacy of the DOACs across subgroups of kidney function. METHODS Using multiple Danish nationwide registers and laboratory databases, we included patients initiated on oral anticoagulants (OACs) with atrial fibrillation and available creatinine level and followed patients for 2 years to evaluate occurrence of stroke/thromboembolism (TE) and major bleeding. RESULTS Among 26,686 included patients, 3667 (13.7%) had an estimated glomerular filtration rate (eGFR) of 30-49 mL/min/1.73m2 and 596 (2.2%) had an eGFR below 30 mL/min/1.73m2. We found no evidence of differences regarding the risk of stroke/TE between the OACs (p-value interaction>0.05 for all). Apixaban was associated with a lower 2-year risk of major bleeding compared to VKA (risk ratio 0.79, 95% confidence interval (CI) 0.67-0.93), and the risk difference was significantly larger among patients with reduced kidney function (p-value interaction 0.018). Rivaroxaban was associated with higher risk of bleeding compared to apixaban (risk ratio 1.78, 95%CI 1.32-2.39) among patients with eGFR 30-49 mL/min/1.73m2. CONCLUSIONS Overall, we found no differences regarding the risk of stroke/TE, but apixaban was associated with a 21% lower relative risk of major bleeding compared to VKA. This risk reduction was even greater when comparing apixaban and rivaroxaban among patients with eGFR 15-30 mL/min/1.73m2, and when comparing apixaban to dabigatran and rivaroxaban among patients with eGFR 30-49 mL/min/1.73m2.
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Affiliation(s)
- Casper Binding
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Aalborg Universitetshospital, Denmark
| | - Paul Blanche
- Department of Public Health, Section of Biostatistics, University of Copenhagen, 1014 Copenhagen K, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christina J Y Lee
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Nordsjællands Hospital, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
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Strange JE, Nouhravesh N, Schou M, Christensen DM, Holt A, Østergaard L, Køber L, Olesen JB, Fosbøl EL. High-risk admission prior to transcatheter aortic valve replacement and subsequent outcomes. Am Heart J 2024; 268:53-60. [PMID: 37972676 DOI: 10.1016/j.ahj.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Severe, symptomatic aortic stenosis may cause heart failure, acute myocardial infarction, or syncope; limited data exist on the occurrence of such events before transcatheter aortic valve replacement (TAVR) and their impact on subsequent outcomes. Thus, we investigated the association between a preceding event and outcomes after TAVR. METHODS From 2014 to 2021 all Danish patients who underwent TAVR were included. Preceding events up to 180 days before TAVR were identified. A preceding event was defined as a hospitalization for heart failure, acute myocardial infarction, or syncope. The 1-year risk of all-cause death, and cardiovascular or all-cause hospitalization was compared for patients with versus without a preceding event using Kaplan-Meier, Aalen-Johansen, and in Cox regression analyses adjusted for patient characteristics. RESULTS Of 5,851 patients included, 759 (13.0%) had a preceding event. The median age was 81 years in both groups. Male sex and frailty were more prevalent in patients with a preceding event (males: 64.7% vs 55.2%, frailty: 49.6% vs 40.6%). The most common type of preceding event was a hospitalization for heart failure (n = 524). For patients with a preceding event, the 1-year risk of death was 11.7% (95% CI: 9.4%-14.1%) versus 8.0% (95% CI: 7.2%-8.7%) for patients without. The corresponding adjusted hazard ratio (aHR) was 1.29 (95%CI: 1.01-1.64). Mortality was highest for patients with a preceding event of a heart failure admission (1-year risk: 13.5% [95%CI: 10.5%-16.5%]). Comparing patients with a preceding event to those without, the 1-year risk for cardiovascular rehospitalization was 15.0% versus 8.2% (aHR 1.60 [95%CI: 1.29-1.99]) and 57.6% versus 50.6% for all-cause rehospitalization (aHR 1.08 [95%CI: 0.87-1.20]). CONCLUSIONS A hospitalization for heart failure, myocardial infarction, or syncope prior to TAVR was associated with a poorer prognosis and could represent a group to focus resource management on. Interventions to prevent preceding events and improvements in pre- and post-TAVR optimization of these patients are warranted.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark.
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | | | - Anders Holt
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Lauge Østergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Strange JE, Østergaard L, Køber L, Bundgaard H, Iversen K, Voldstedlund M, Gislason GH, Olesen JB, Fosbøl EL. Patient Characteristics, Microbiology, and Mortality of Infective Endocarditis After Transcatheter Aortic Valve Implantation. Clin Infect Dis 2023; 77:1617-1625. [PMID: 37470442 PMCID: PMC10724461 DOI: 10.1093/cid/ciad431] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/18/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is associated with high mortality and surgery is rarely performed. Thus, to inform on preventive measures and treatment strategies, we investigated patient characteristics and microbiology of IE after TAVI. METHODS Using Danish nationwide registries, we identified patients with IE after TAVI, IE after non-TAVI prosthetic valve (nTPV), and native valve IE. Patient characteristics; overall, early (≤12 m), and late IE (>12 m) microbiology; and unadjusted and adjusted mortality were compared. RESULTS We identified 273, 1022, and 5376 cases of IE after TAVI, IE after nTPV, and native valve IE. Age and frailty were highest among TAVI IE (4.8%; median age: 82 y; 61.9% frail). Enterococcus spp. were common for IE after TAVI (27.1%) and IE after nTPV (21.2%) compared with native valve IE (11.4%). Blood culture-negative IE was rare in IE after TAVI (5.5%) compared with IE after nTPV (15.2%) and native valve IE (13.5%). The unadjusted 90-day mortality was comparable, but the 5-year mortality was highest for IE after TAVI (75.2% vs 57.2% vs 53.6%). In Cox models adjusted for patient characteristics and bacterial etiology for 1-90 days and 91-365 days, there was no significant difference in mortality rates. CONCLUSIONS Patients with IE after TAVI are older and frailer, enterococci and streptococci are often the etiologic agents, and are rarely blood culture negative compared with other IE patients. Future studies regarding antibiotic prophylaxis strategies covering enterococci should be considered in this setting.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Lauge Østergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | | | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Havers-Borgersen E, Butt JH, Johansen M, Petersen OB, Ekelund CK, Rode L, Olesen JB, Køber L, Fosbøl EL. Preeclampsia and Long-Term Risk of Venous Thromboembolism. JAMA Netw Open 2023; 6:e2343804. [PMID: 37976060 PMCID: PMC10656639 DOI: 10.1001/jamanetworkopen.2023.43804] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023] Open
Abstract
Importance As venous thromboembolism (VTE) remains one of the leading causes of maternal mortality, identifying women at increased risk of VTE is of great importance. Preeclampsia is a pregnancy-induced hypertensive disorder with generalized endothelial dysfunction. Some studies suggest that preeclampsia is associated with an increased risk of VTE, but much controversy exists. Objective To examine the association between preeclampsia and the risk of VTE during pregnancy, during the puerperium, and after the puerperium. Design, Setting, and Participants This observational cohort study used Danish nationwide registries to identify all eligible primiparous women who gave birth in Denmark from January 1, 1997, to December 31, 2016. The women were followed up from primiparous pregnancy to incident VTE, emigration, death, or the end of the study (December 31, 2016). Statistical analyses were carried out from January to May 2023. Exposure Preeclampsia during primiparous pregnancy. Main Outcomes and Measure The main outcome was incident VTE, and the secondary outcome was all-cause mortality. Results A total of 522 545 primiparous women (median age, 28 years [IQR, 25-31 years]) were included, and 23 330 (4.5%) received a diagnosis of preeclampsia. Women with preeclampsia were of similar age to women without preeclampsia but had a higher burden of comorbidities. During a median follow-up of 10.2 years (IQR, 5.2-15.4 years), preeclampsia was associated with a higher incidence of VTE compared with no preeclampsia (incidence rate, 448.8 [95% CI, 399.9-503.5] vs 309.6 [95% CI, 300.6-319.9] per 1000 patient-years, corresponding to an unadjusted hazard ratio [HR] of 1.45 [95% CI, 1.29-1.63] and an adjusted HR of 1.43 [95% CI, 1.27-1.61]). When stratified according to the subcategories of VTE, preeclampsia was associated with an increased rate of deep vein thrombosis (unadjusted HR, 1.51 [95% CI, 1.32-1.72] and adjusted HR, 1.49 [95% CI, 1.31-1.70]) as well as pulmonary embolism (unadjusted HR, 1.39 [95% CI, 1.09-1.76]; adjusted HR, 1.36 [95% CI, 1.08-1.73]). These findings held true in landmark analyses during pregnancy, during the puerperium, and after the puerperium. Conclusions and Relevance This cohort study suggests that preeclampsia was associated with a significantly increased risk of VTE during pregnancy, during the puerperium, and after the puerperium, even after thorough adjustment. Future studies should address how to improve the clinical management of women with a history of preeclampsia to prevent VTE.
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Affiliation(s)
- Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jawad H. Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Johansen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav Bjørn Petersen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Kvist Ekelund
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Line Rode
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L. Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Strange JE, Christensen DM, Sindet-Pedersen C, Schou M, Falkentoft AC, Østergaard L, Butt JH, Graversen PL, Køber L, Gislason G, Olesen JB, Fosbøl EL. Frailty and Recurrent Hospitalization After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2023; 12:e029264. [PMID: 37042264 DOI: 10.1161/jaha.122.029264] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Background For frail patients with limited life expectancy, time in hospital following transcatheter aortic valve replacement is an important measure of quality of life; however, data remain scarce. Thus, we aimed to investigate frailty and its relation to time in hospital during the first year after transcatheter aortic valve replacement. Methods and Results From 2008 to 2020, all Danish patients who underwent transcatheter aortic valve replacement and were alive at discharge were included. Using the validated Hospital Frailty Risk Score, patients were categorized in the low, intermediate, and high frailty groups. Time in hospital and mortality up to 1 year are reported according to frailty groups. In total, 3437 (57.6%), 2277 (38.1%), and 257 (4.3%) were categorized in the low, intermediate, and high frailty groups, respectively. Median age was ≈81 years. Female sex and comorbidity burden were incrementally higher across frailty groups (low frailty: heart failure, 24.1%; stroke, 7.2%; and chronic kidney disease, 4.5%; versus high frailty: heart failure, 42.8%; stroke, 34.2%; and chronic kidney disease, 29.2%). In the low frailty group, 50.5% survived 1 year without a hospital admission, 10.8% were hospitalized >15 days, and 5.8% of patients died. By contrast, 26.1% of patients in the high frailty group survived 1 year without a hospital admission, 26.4% were hospitalized >15 days, and 15.6% died within 1 year. Differences persisted in models adjusted for sex, age, frailty, and comorbidity burden (excluding overlapping comorbidities). Conclusions Among patients undergoing transcatheter aortic valve replacement, frailty is strongly associated with time in hospital and mortality. Prevention strategies for frail patients to reduce hospitalization burden could be beneficial.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Hellerup Denmark
| | | | | | - Morten Schou
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Hellerup Denmark
| | | | - Lauge Østergaard
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Jawad Haider Butt
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Peter Laursen Graversen
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Gunnar Gislason
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Hellerup Denmark
- The Danish Heart Foundation Copenhagen Denmark
- Department of Clinical Medicine, Faculty of Health and Sciences University of Copenhagen Copenhagen Denmark
- The National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Hellerup Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, The Heart Center Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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8
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Juhl Madsen O, Lamberts MK, Fosboel EL, Gislason G, Olesen JB, Strange JE. Trends in percutaneous left atrial appendage occlusion and 1-year mortality: a nationwide cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2137] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Percutaneous left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in high-risk patients with atrial fibrillation and contraindication for oral anticoagulation. However, studies evaluating comorbidities and mortality remain scarce.
Objectives
The aim of this study was to evaluate changes in patient characteristic over time and 1-year risk of death.
Methods
Using Danish nationwide registers, we included all patients undergoing first-time LAAO between 2013 and 2021. To evaluate changes in patient characteristics, the study population was stratified according to calendar year of LAAO procedure: 2013–2015, 2016–2018, and 2019–2021. Baseline patient characteristics were defined from 10 years prior to date of LAAO procedure. Antithrombotic therapy was defined as claimed prescriptions within 180 days prior to LAAO procedure. Patients were then followed until either emigration, death, one year of full follow-up, or end of study period. Baseline frailty risk was estimated with The Hospital Frailty Risk Score, a validated frailty risk assessment tool based on ICD-10 codes. The 1-year unadjusted risk of death was estimated with the Aalen-Johansen method.
Results
In total, 1,306 patients underwent LAAO. The number of LAAO increased from 201 procedures in 2013–2015 to 586 in 2019–2021. During follow-up, the age of the patients remained stable (2013–2015: median age: 70 years; 2016–2018: median age 69 years; 2019–2021: median age 69 years). Fewer patients had a history of ischemic stroke (2013–2015: 44.3% vs 2019–2021: 27.6%), hemorrhagic stroke (2013–2015: 32.8% vs 2019–2021: 21.0%), and previous bleeding (2013–2015: 71.1% vs 2019–2021: 59.2%). Median CHA2DS2-VASs score decreased over time (2013–2015: 4 vs 2019–2021: 3) and same trend was found in median HAS-BLED score (2013–2015: 3 vs 2019–2021: 2).
In addition, fewer patients were categorized as high frailty risk (2013–2015: 16.9% vs 2019–2021: 8.9%). However, there was an increase in patients with a history of cancer (2013–2015: 11.9% vs 2019–2021: 18.9%). The use of antiplatelet therapy prior to LAAO decreased while the use of oral anticoagulation increased (2013–2015: 50.2% vs 2019–2021: 68.9%) due to a marked increase in non-vitamin K antagonist oral anticoagulants and a decrease in vitamin K antagonists (Figure 1).
In total, 88 (7.22%) patients died within one year of LAAO procedure. The 1-year all-cause mortality risk in each period were similar (2013–2015: 7.0%; 2016–2018: 7.1%; 2019–2021: 6.9%). [Figure 2]
Conclusion
In the years 2013–2021, the annual number of LAAO procedures increased. The age of patients remained stable. Comorbidity burden decreased and fewer patients were at high frailty risk, but the 1-year mortality risks were similar. Our real-life data suggest that profiles of patients undergoing LAAO has changed considerably over time.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
| | - M K Lamberts
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - E L Fosboel
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - G Gislason
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - J B Olesen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - J E Strange
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
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9
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Strange JE, Holt A, Christensen DM, Gislason G, Torp-Pedersen C, Hansen ML, Lamberts MK, Schou M, Olesen JB, Fosboel EL, Koeber L, Rasmussen PV. Oral fluoroquinolones and risk of aortic dissection and aortic aneurysm: a nationwide nested case-control study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2732] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Oral fluoroquinolones are commonly prescribed antibiotics. Observational studies have shown an association between fluoroquinolone-use and subsequent risk of aortic aneurysm (AA) and aortic dissection (AD) due to a potential collagen degrading effect of fluoroquinolones.
Purpose
To investigate if fluoroquinolone-use was associated with increased rates of AA or AD in patients without known aortic disease. Secondly, to investigate if fluoroquinolone-use was associated with increased all-cause mortality and aortic interventions in high-risk patients with known aortic disease.
Methods
We used a nested case-control study design in which individuals aged 30–100 years from 2003 to 2018 were included from Danish nationwide registers. Exclusion criteria were bicuspid aortic valve, coarctation of the aorta, and connective tissue disease. A main cohort and a secondary high-risk cohort were defined. The main cohort comprised patients without history of AA/AD in which two case definitions were used: 1) A broad case definition of first-time AA/AD. 2) A severe case definition of ruptured AA/AD. The high-risk cohort comprised patients surviving index AA/AD admission in which cases were defined as all-cause mortality and aortic interventions.
Cases were matched on age, sex, and year of inclusion in a 1:30 ratio with controls. For the main cohort, a potential dose-response effect was investigated using groups of cumulative defined daily doses (cDDD) of fluoroquinolones. Hazard ratios (HR) with 95% confidence intervals (CI) for fluoroquinolone-use compared with amoxicillin as an active comparator were obtained from time-dependent Cox regression models using multiple exposure windows.
Results
The main cohort comprised 4.81 million individuals with 43,280 cases. Short-term 30-day, intermediate-term 90-day, and long-term 1-year fluoroquinolone use were all not associated with AA/AD (30-day HR 1.18 [95% CI: 0.84 to 1.66]; 90-day HR 1.12 [95% CI 0.96 to 1.30]; 1-year HR 1.00 [95% CI 0.93 to 1.07]). Using a severe case definition of ruptured AA/AD yielded comparable results. For the dose-response analysis, increasing cDDD did not confer increased rates of AA/AD (1–5 cDDD: Reference group; 6–10 cDDD: HR 1.03 [95% CI: 0.87 to 1.23]; >10 cDDD: HR 1.00 [95% CI 0.83 to 1.29]) (Figure 1).
The secondary high-risk cohort included 20,195 patients surviving index admission with 9,183 cases of all-cause mortality and 1,768 cases of aortic interventions. The 30-day HR for all-cause mortality was 1.21 (95% CI 0.92 to 1.60) and the 60-day HR 1.06 (95% CI 0.89 to 1.26). No association with aortic interventions was found either (Figure 2).
Conclusion
Fluroquinolone-use was not associated with AA/AD. Furthermore, fluoroquinolone-use was not associated with all-cause mortality or aortic interventions in potentially susceptible patients with known aortic disease. These findings do not support an increased risk of AA/AD with fluoroquinolone-use.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J E Strange
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - A Holt
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | | | - G Gislason
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - C Torp-Pedersen
- Nordsjaellands Hospital, Department of Cardiology , Hilleroed , Denmark
| | - M L Hansen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - M K Lamberts
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - M Schou
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - J B Olesen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - E L Fosboel
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - L Koeber
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - P V Rasmussen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
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10
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Strange JE, Christensen DM, Sindet-Pedersen C, Gislason G, Schou M, Oestergaard L, Butt JH, Graversen PL, Koeber L, Olesen JB, Fosboel EL. Readmission after transcatheter aortic valve implantation according to frailty. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2107] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Readmissions and time spent hospitalized following transcatheter aortic valve implantation (TAVI) are important parameters of patient autonomy, particularly for frail patients with limited life-expectancy. Yet, such data remain scarce.
Purpose
To investigate actual time spent hospitalized the first year after TAVI. Secondly, to investigate time spent hospitalized according to frailty risk.
Methods
Through Danish, nationwide registries, we included all patients undergoing TAVI and alive at discharge between January 2008 and June 2020. From discharge, patients were followed until death, emigration, end of study period, or one year of follow-up, whichever came first. During follow-up, all in-patient hospital admissions were identified according to ICD-10 diagnosis codes. Length of stay was calculated, and cumulative numbers of days hospitalized was presented. Further, the proportion of patients dying within one year of follow-up was calculated.
Using The Hospital Frailty Risk Score, a validated frailty risk assessment tool, patients were categorized as low, intermediate, and high frailty risk. We then evaluated the time spent hospitalized stratified by frailty risk group.
Results
The study population comprised 5,464 patients undergoing first-time TAVI with a median age of 81 years among whom 55.2% were males. After one year, 445 (8.1%) patients had died. In total, 2,452 (44.9%) of TAVI patients survived one year and were never admitted, whereas 3,012 (55.1%) patients were admitted at least once or died within one year of TAVI. Of these, 1,200 (21.9%) patients were admitted for more than two weeks or died within one year of TAVI (Figure 1).
Regarding frailty, 3,296 (60.3%), 1,965 (36.0%), and 203 (3.7%) patients were classified as low, intermediate, and high frailty risk, respectively. In the low frailty risk group, 6.2% of patients died within one year and 50.4% survived one year without a hospital admission. By contrast, 16.7% of patients in the high frailty risk group died within one year and only 24.6% survived one year without a hospital admission. Further, 17.1% of patients in the low frailty risk group were admitted for more than two weeks or died within one year of TAVI compared with 47.3% in the high frailty risk group (Figure 2).
Conclusion
Readmissions in the first year after transcatheter aortic valve implantation were common and time spent hospitalized after transcatheter aortic valve implantation was significant. Our results were clearly related to frailty, which should be considered for future prevention strategies.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J E Strange
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | | | - C Sindet-Pedersen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - G Gislason
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - M Schou
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - L Oestergaard
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - P L Graversen
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - L Koeber
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
| | - J B Olesen
- Herlev and Gentofte Hospital, Department of Cardiology , Copenhagen , Denmark
| | - E L Fosboel
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, The Heart Center , Copenhagen , Denmark
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11
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Binding C, Olesen JB, Lee CJY, Lip GYH, Sindet-Pedersen C, Gislason G, Bonde AN. Discontinuation of direct oral anticoagulants among patients with atrial fibrillation according to gender and cohabitation status: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother 2022; 8:353-362. [PMID: 34415024 DOI: 10.1093/ehjcvp/pvab065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 08/18/2021] [Indexed: 06/13/2023]
Abstract
AIMS The aim of this study was to evaluate the risk of discontinuing treatment with direct oral anticoagulants (DOACs) among patients with atrial fibrillation (AF) according to cohabitation status and gender. METHODS AND RESULTS Using the Danish national registers, we identified 32 364 patients with AF aged 40-90 years undergoing treatment with DOACs. The study period was from 2013 to 2017, and patients were followed for 2 years, or until death, outcome, or emigration. The main outcome was discontinuation of DOAC treatment for at least 30 days. The absolute 2-year risk of DOAC discontinuation was highest among men living alone [35.7%, 95% confidence interval (CI): 37.3-34.1%]. Men living alone had a 4.6% (95% CI: 6.4-2.8%) higher absolute risk of discontinuation and a 12% [hazard ratio (HR): 1.12, 95% CI: 1.04-1.20] higher relative risk of discontinuation compared with men living with a partner. Female patients living alone likewise had a higher absolute risk of DOAC discontinuation (2.6%, 95% CI: 4.4-0.09%) compared with female patients living with a partner, yet no statistically significant difference in relative risk. In an analysis evaluating gender, we found male gender to be associated with a significantly higher relative risk of DOAC discontinuation (HR: 1.33, 95% CI: 1.26-1.40) compared with female gender (P-value for interaction with cohabitant status = 0.5996). CONCLUSION In this nationwide population study, male gender and living alone were associated with a higher risk of DOAC discontinuation among patients with AF.
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Affiliation(s)
- Casper Binding
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
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12
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Hauge SC, Abrahamsen B, Gislason G, Olesen JB, Hommel K, Hansen D. Diabetes increases the risk of bone fractures in patients on kidney replacement therapy: A Danish national cohort study. Bone 2021; 153:116158. [PMID: 34461286 DOI: 10.1016/j.bone.2021.116158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients treated with dialysis or living with a kidney transplant (kidney replacement therapy, KRT) have an increased risk of bone fracture. Patients with diabetes also have an increased risk of fracture. The aim of this study was to investigate whether the presence of diabetes in patients on KRT aggravates the risk of fracture. METHODS Nationwide Danish registries were used in this retrospective cohort study. All prevalent adult patients on hemodialysis (HD) or peritoneal dialysis (PD) on 1st of January 2000 and all incident patients starting KRT (HD, PD, kidney transplanted (KTX)) until 31st of December 2011 were included in the KRT group. Adult persons not on KRT and without diabetes on 1st of January 2000 were used as a reference group. Patients were separated in groups with and without (+/-) diabetes. They were followed until first fracture, emigration, death, or end-of-study on 31st of December 2016. RESULTS A total of 4,074,085 not on KRT +/- diabetes and 9053 patients on KRT +/- diabetes were included. Comparing the different groups with diabetes to the corresponding group without diabetes, the unadjusted HR (95% CI) for any first fracture were 1.2 (1.0-1.3) in the HD population, 1.4 (1.1-1.7) in the PD population, and 1.7 (1.4-2.2) in the KTX population. Further adjustments for age, sex, prior fractures, comorbidity and medication did not change these results significantly. CONCLUSIONS Diabetes increases the risk of fracture in patients on KRT.
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Affiliation(s)
- Sabina Chaudhary Hauge
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
| | - Bo Abrahamsen
- Department of Medicine, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.; Institute of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3. Floor, 5000 Odense C, Copenhagen, Denmark; NDORMS, Botnar Centre, Oxford University, Windmill Road, Oxford, OX3 7LD, United Kingdom
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark; The Danish Heart Foundation, Vognmagergade 7, 3. Floor, 1120 Copenhagen K, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Kristine Hommel
- Department of Medicine, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
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13
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Schelde AB, Petersen J, Jensen TB, Gromov K, Overgaard S, Olesen JB, Jimenez-Solem E. Thromboembolic and bleeding complications following primary total knee arthroplasty : a Danish nationwide cohort study. Bone Joint J 2021; 103-B:1571-1577. [PMID: 34587805 DOI: 10.1302/0301-620x.103b10.bjj-2021-0023.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS The aim of this study is to compare the effectiveness and safety of thromboprophylactic treatments in patients undergoing primary total knee arthroplasty (TKA). METHODS Using nationwide medical registries, we identified patients with a primary TKA performed in Denmark between 1 January 2013 and 31 December 2018 who received thromboprophylactic treatment. We examined the 90-day risk of venous thromboembolism (VTE), major bleeding, and all-cause mortality following surgery. We used a Cox regression model to compute hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome, pairwise comparing treatment with dalteparin or dabigatran with rivaroxaban as the reference. The HRs were both computed using a multivariable and a propensity score matched analysis. RESULTS We identified 27,736 primary TKA patients who received thromboprophylactic treatment (rivaroxaban (n = 18,846); dalteparin (n = 5,767); dabigatran (n = 1,443); tinzaparin (n = 1,372); and enoxaparin (n = 308)). In the adjusted multivariable analysis and compared with rivaroxaban, treatment with dalteparin (HR 0.68 (95% CI 0.49 to 0.92)) or dabigatran (HR 0.31 (95% CI 0.13 to 0.70)) was associated with a decreased risk of VTE. No statistically significant differences were observed for major bleeding or all-cause mortality. The propensity score matched analysis yielded similar results. CONCLUSION Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE following primary TKA surgery compared with treatment with rivaroxaban. Cite this article: Bone Joint J 2021;103-B(10):1571-1577.
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Affiliation(s)
- Astrid Blicher Schelde
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Janne Petersen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Phase 4 Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Thomas Bo Jensen
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.,The Danish Hip Arthroplasty Register, Denmark
| | - Søren Overgaard
- The Danish Hip Arthroplasty Register, Denmark.,Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Copenhagen Phase 4 Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Strange JE, Holt A, Blanche P, Gislason G, Torp-Pedersen C, Christensen DM, Hansen ML, Lamberts M, Schou M, Olesen JB, Fosbøl EL, Køber L, Rasmussen PV. Oral fluoroquinolones and risk of aortic or mitral regurgitation: a nationwide nested case-control study. Eur Heart J 2021; 42:2899-2908. [PMID: 34245252 DOI: 10.1093/eurheartj/ehab374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/09/2021] [Accepted: 06/03/2021] [Indexed: 02/01/2023] Open
Abstract
AIMS Reports have suggested an increased risk of aortic and mitral regurgitation associated with oral fluoroquinolones (FQs) resulting in a safety warning published by the European Medicines Agency (EMA). However, these findings have not yet been replicated. METHODS AND RESULTS Using Danish administrative registers, we conducted a nested case-control study in a nationwide cohort of individuals between 2005 and 2018. Cases were defined as the first occurrence of aortic or mitral regurgitation. Exposure of interest was the use of oral FQs. Hazard ratios (HRs) with 95% confidence intervals (95% CI) were obtained by fitting time-dependent Cox regression models, with penicillin V as comparator, to assess the association between FQ use and incident valvular regurgitation. We identified 38 370 cases of valvular regurgitation with 1 115 100 matched controls. FQ exposure was not significantly associated with increased rates of aortic or mitral regurgitation (HR 1.02, 95% CI 0.95-1.09) compared with penicillin V users. Investigating the cumulative defined daily doses (cDDD) of FQs yielded similar results with no significant association between increasing FQ use and valvular regurgitation (e.g. HR 1.08, 95% CI 0.95-1.23 for cDDD >10 compared with cDDD 1-5). These results were consistent across several analyses including a cohort of patients with hypertension and using a case definition based on valvular surgical interventions. CONCLUSIONS In a nationwide nested case-control study, FQs were not significantly associated with increased rates of valvular regurgitation. Our findings do not support a possible causal connection between FQ exposure and incident valvular regurgitation.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
| | - Anders Holt
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
| | - Paul Blanche
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark.,Department of Biostatistics, University of Copenhagen, Oester Farimagsgade 5, Entrance B, 2nd floor, 1014 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Noerre Alle 20, 2200 Copenhagen, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Christian- Torp-Pedersen
- Department of Clinical Research, Nordsjaellands Hospital, Kongens Vaenge 2, 3400 Hilleroed, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrobej 18-22, 9000 Aalborg, Denmark
| | | | - Morten Lock Hansen
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
| | - Morten Lamberts
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, Entrance 2, 14th floor, 2100 Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, Entrance 2, 14th floor, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, Entrance 2, 14th floor, 2100 Copenhagen, Denmark
| | - Peter Vibe Rasmussen
- Department of Cardiology, Herlev-Gentofte University Hospital, Gentofte Hospitalsvej 8, 2900 Copenhagen, Denmark
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15
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Freese Ballegaard EL, Bjerring Olesen J, Kamper AL, Feldt-Rasmussen B, Gislason G, Torp-Pedersen C, Carlson N. MO483CHA2DS2-VASC SCORE IN PATIENTS WITH EGFR<30 ML/MIN/1.73 M2 AND ATRIAL FIBRILLATION*. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab087.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) is a validated tool for evaluation of risk of stroke and systemic emboli in patients with atrial fibrillation without nephropathy. The validity of risk determination based on the CHA2DS2-VASc score in patients with severe nephropathy is untested. We investigate the validity of the CHA2DS2-VASc score in patients with eGFR<30 ml/min/1.73m2 (including dialysis treated patients) and atrial fibrillation without anticoagulation treatment.
Method
In a retrospective cohort study, all patients with atrial fibrillation and eGFR<30 ml/min/1.73 m2 were identified in nationwide Danish registers between 2008 and 2018 with subsequent exclusion of patients initiating anticoagulation treatment based on redeemed prescriptions. Cumulative incidences of stroke stratified on CHA2DS2-VASc score were computed using the Aalen-Johansen estimator, and one-year risk of stroke was calculated with comparison of CHA2DS2-VASc score based on Cox regression models adjusted for age, sex and dialysis status with G-computation of one-year risk standardized to the distribution of risk factors in the sample.
Results
From 2,452 patients with eGFR <30 ml/min/1.73 m2 and de novo atrial fibrillation, a total of 1,575 patients (64.2%) without anticoagulation treatment were included. Mean age was 78.0 years (standard deviation ±12.2), 53.3% were male, and 25.5% were on dialysis. The distribution of patients into CHA2DS2-VASc score categories of 0-1, 2, 3, 4 and ≥5 was 8.7%, 14.5%, 24.6%, 24.7% and 27.5%, respectively.
Cumulative incidence of stroke in non-dialysis dependent and dialysis-dependent patients are shown in the figure.
Overall, standardized one-year risk of stroke was 3.3% (95%CI 1.3-6.4%), 2.5% (95%CI 1.0-4.1%), 5.9% (95%CI 3.9-8.2%), 5.1% (95%CI 3.6-7.0%), and 7.3% (95%CI 5.2-10.2%) for CHA2DS2-VASc score categories of 0-1, 2, 3, 4 and ≥5, respectively. Comparably, standardized one-year risk of stroke was 2.5% (95%CI 0.3-5.7%), 1.9% (95%CI 0.0-4.7%), 7.4% (95%CI 3.2-11.5%), 4.7% (95%CI 1.0-8.3%), and 16.5% (95%CI 7.9-27.2%) for CHA2DS2-VASc score categories of 0-1, 2, 3, 4 and ≥5, respectively, in dialysis-treated patients, and 4.3% (95%CI 1.0-10.3%), 2.9% (95%CI 1.1-4.9%), 5.5% (95%CI 3.5-8.1%), 5.1% (95%CI 3.4-7.1%), and 5.9% (95%CI 3.8-8.5%) for CHA2DS2-VASc score categories of 0-1, 2, 3, 4 and ≥5, respectively, in non-dialysis-dependent patients.
Conclusion
Overall, CHA2DS2-VASc score was associated with a progressive increase in one-year risk of stroke. Although the association was most obvious in non-dialysis dependent patients, discrepancy was evident with regard to risk in patients with CHA2DS2-VASc score ≤1 in both subgroups, albeit less so in adjusted analyses.
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Affiliation(s)
| | | | - Anne Lise Kamper
- Copenhagen University Hospital Rigshospitalet, Nephrology, Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Copenhagen University Hospital Rigshospitalet, Nephrology, Copenhagen, Denmark
| | - Gunnar Gislason
- Copenhagen University Hospital Herlev and Gentofte, Cardiology, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Nicholas Carlson
- The Danish Heart Foundation, Copenhagen, Denmark
- Copenhagen University Hospital Rigshospitalet, Cardiology, Copenhagen, Denmark
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16
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Freese Ballegaard EL, Bjerring Olesen J, Kamper AL, Feldt-Rasmussen B, Gislason G, Torp-Pedersen C, Carlson N. MO503SAFETY AND EFFICACY OF ANTICOAGULATION IN PATIENTS WITH EGFR<30 ML/MIN/1.73 M2 AND ATRIAL FIBRILLATION. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab087.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Net benefit of anticoagulation in patients with eGFR <30 ml/min/1.73 m2 and atrial fibrillation remains uncertain. The aim of this study was to evaluate the use, efficacy and safety of anticoagulation therapy in patients with eGFR<30 ml/min/1.73m2 (including dialysis treated patients) and atrial fibrillation.
Method
In a retrospective cohort study, all patients with atrial fibrillation and eGFR<30 ml/min/1.73 m2 were identified in nationwide Danish registers between 2008 and 2018. Cumulative incidences of stroke and major bleeding stratified on anticoagulation treatment were computed using the Aalen-Johansen estimator. One-year risks of stroke and major bleeding were calculated with comparison of treatment vs. no treatment based on Cox regression models adjusted for age, sex and dialysis status with G-computation of one-year risks standardized to the distribution of risk factors in the sample. Major bleeding was defined as any diagnosis of bleeding leading to hospitalization.
Results
A total of 2,452 patients with eGFR <30 ml/min/1.73 m2 and de novo atrial fibrillation were identified. Mean age was 78.8 years, 51.3% were male and 20% received dialysis therapy. Anticoagulation therapy was initiated in 877 patients (35.8%), with warfarin accounting for 58.6% of all prescriptions.
Overall, one-year standardized risk of bleeding was 10.6% (95% confidence interval (CI) 8.7%-12.7%) and 8.2% (95% CI 6.9%-9.5%) in patients with and without anticoagulation, while the risks of stroke were 3.6% (95% CI 2.6%-4.5%) and 5.1% (95% CI 4.1%-6.1%), respectively.
In subgroup analyses of patients dependent vs. non-dependent on dialysis, the standardized one-year risk of bleeding was 13.3% (95% CI 9.0%-19.8%) vs. 10.4% (95% CI 8.6%-12.4%) in patients with anticoagulation and 9.0% (95% CI 6.5%-12.0%) vs. 7.8% (95% CI 6.5%-9.2%) in patients without anticoagulation. While the risk of stroke was 3.5% (95% CI 0.8%-6.7%) vs. 3.5% (95% CI 2.5%-4.9%) in patients with anticoagulation and 5.7% (95% CI 3.5%-7.8%) vs. 4.9% (95% CI 3.7% vs. 6.3%) in patients without anticoagulation. Cumulative incidences of major bleeding and stroke are shown in the figure.
Conclusion
Use of anticoagulation was associated with increased risk of bleeding and reduced risk of stroke in patients with eGFR<30 ml/min/1.73 m2 and atrial fibrillation. Randomized controlled trials are needed to establish the benefit and harm of anticoagulation in this population.
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Affiliation(s)
| | | | - Anne Lise Kamper
- Copenhagen University Hospital Rigshospitalet, Nephrology, Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Copenhagen University Hospital Rigshospitalet, Nephrology, Copenhagen, Denmark
| | - Gunnar Gislason
- Copenhagen University Hospital Herlev and Gentofte, Cardiology, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Nicholas Carlson
- Copenhagen University Hospital Rigshospitalet, Nephrology, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
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17
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Gundlund A, Olesen JB, Butt JH, Christensen MA, Gislason GH, Torp-Pedersen C, Køber L, Kümler T, Fosbøl EL. One-year outcomes in atrial fibrillation presenting during infections: a nationwide registry-based study. Eur Heart J 2021; 41:1112-1119. [PMID: 31848584 DOI: 10.1093/eurheartj/ehz873] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 06/25/2019] [Revised: 10/02/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022] Open
Abstract
AIMS Thromboprophylaxis guidelines for patients with concurrent atrial fibrillation (AF) during infections are unclear and not supported by data. We compared 1-year outcomes in patients with infection-related AF and infection without AF. METHODS AND RESULTS By crosslinking Danish nationwide registry data, AF naïve patients admitted with infection (1996-2016) were identified. Those with AF during the infection (infection-related AF) were matched 1:3 according to age, sex, type of infection, and year with patients with infection without AF. Outcomes (AF, thromboembolic events) were assessed by multivariable Cox regression. The study population comprised 30 307 patients with infection-related AF and 90 912 patients with infection without AF [median age 79 years (interquartile range 71-86), 47.6% males in both groups]. The 1-year absolute risk of AF and thromboembolic events were 36.4% and 7.6%, respectively (infection-related AF) and 1.9% and 4.4%, respectively (infection without AF). In the multivariable analyses, infection-related AF was associated with an increased long-term risk of AF and thromboembolic events compared with infection without AF: hazard ratio (HR) 25.98, 95% confidence interval (CI) 24.64-27.39 for AF and HR 2.10, 95% CI 1.98-2.22 for thromboembolic events. Further, differences in risks existed across different subtypes of infections. CONCLUSION During the first year after discharge, 36% of patients with infection-related AF had a new hospital contact with AF. Infection-related AF was associated with increased risk of thromboembolic events compared with infection without AF and our results suggest that AF related to infection may merit treatment and follow-up similar to that of AF not related to infection.
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Affiliation(s)
- Anna Gundlund
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jawad H Butt
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Mathias Aagaard Christensen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen K, Denmark.,The National Institute of Public Health, University of Southern Denmark, Øster farimagsgade 5A, 1353 Copenhagen K, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Thomas Kümler
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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18
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Sindet-Pedersen C, Olesen JB, Blanche P, Gerds TA, Strange JE, Butt JH, El-Chouli M, Phelps M, Hansen ML, Schou M, Køber L, Fosbøl E, Torp-Pedersen C, Gislason GH. Effect of government interventions to contain the COVID-19 pandemic on incidence of pulmonary embolism - A Danish nationwide register-based cohort study. Thromb Res 2021; 199:97-100. [PMID: 33485095 PMCID: PMC7787918 DOI: 10.1016/j.thromres.2020.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Caroline Sindet-Pedersen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark; The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark.
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | - Paul Blanche
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark; Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Alexander Gerds
- The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark; Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Jarl Emanuel Strange
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Matthew Phelps
- The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark
| | - Morten Lock Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark; Department of Clinical Research and Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark; The National Institute of Public Health, University of Southern Denmark, 1353 Odense, Denmark; The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark
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19
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Schelde AB, Petersen J, Jensen TB, Gromov K, Overgaard S, Olesen JB, Jimenez-Solem E. Validation of registration of pharmacological treatment in the Danish Hip and Knee Arthroplasty Registers. Basic Clin Pharmacol Toxicol 2020; 128:455-462. [PMID: 33053267 DOI: 10.1111/bcpt.13518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 11/27/2022]
Abstract
The aim of this study was to validate registration of pharmacological treatment in the Danish Hip Arthroplasty Register (DHR) and Danish Knee Arthroplasty Register (DKR). We conducted a population-based study in the Capital Region of Denmark, January 2012 to April 2016. Positive predictive value (PPV) and sensitivity were calculated with 95% confidence intervals (CI) for antithrombotic, antihemorrhagic and antibiotic treatment registered in the DHR and DKR using electronic health records as the reference standard. For the DHR, the PPV and sensitivity were 77.9% (95% CI: 77.2-78.6) and 99.6% (95% CI: 99.4-99.7) for antithrombotic treatment, 70.9% (95% CI: 70.1-71.7) and 97.4% (95% CI: 97.1-97.7) for antihemorrhagic treatment, and 82.9% (95% CI: 82.2-83.5) and 99.4% (95% CI: 99.3-99.5) for antibiotic treatment, respectively. For the DKR, the PPV and sensitivity were 80.6% (95% CI: 79.8-81.4) and 99.6% (95% CI: 99.4-99.7) for antithrombotic treatment, and 84.4% (95% CI: 83.7-85.1) and 100.0% (95% CI: 99.9-100.0) for antibiotic treatment, respectively. The PPV and sensitivity for overall pharmacological treatment registered in the DHR and DKR were generally high and acceptable for use in research.
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Affiliation(s)
- Astrid Blicher Schelde
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Janne Petersen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Thomas Bo Jensen
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.,The Danish Hip Arthroplasty Register, Denmark
| | - Søren Overgaard
- The Danish Hip Arthroplasty Register, Denmark.,Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Butt JH, Olesen JB, Gundlund A, Kümler T, Olsen PS, Havers-Borgersen E, Aagaard DT, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Left-Sided Heart Valve Surgery. JAMA Cardiol 2020; 4:1139-1147. [PMID: 31596426 DOI: 10.1001/jamacardio.2019.3649] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Indexed: 01/10/2023]
Abstract
Importance New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are conflicting. In addition, data on stroke prophylaxis in this setting are lacking. Objective To assess the long-term risk of thromboembolism in patients developing new-onset POAF after isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF). Design, Setting, and Participants This observational cohort study was conducted from January 1, 2000, through December 31, 2015, using Danish nationwide registries and the Eastern Danish Heart Surgery Database. Patients who developed POAF after isolated left-sided heart valve surgery (bioprosthetic aortic or mitral valve replacement and/or aortic or mitral valve repair) from 2000 through 2015 were included. These patients were matched with patients with nonsurgical NVAF in a 1:3 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Data analyses took place from January to March 2019. Main Outcomes and Measures Rates of thromboembolism. Results Of the 1587 patients who underwent isolated left-sided heart valve surgery, 741 patients (46.7%) developed POAF during admission. Of the 712 patients with POAF who were eligible for matching, 675 patients were matched with 2025 patients with NVAF and made up the study population. In the matched study population, the median age was 71 (interquartile range, 65-77) years, and 1600 (59.3%) were men. Oral anticoagulation therapy was initiated within 30 days postdischarge in 420 patients with POAF (62.9%) and in 1030 patients with NVAF (51.4%). The crude incidence rates of thromboembolism were 21.9 (95% CI, 17.4-27.6) and 17.7 (95% CI, 15.2-20.6) events per 1000 person-years for patients with POAF and patients with NVAF, respectively. In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio, 1.22 [95% CI, 0.88-1.68]). Oral anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (hazard ratio, 0.45 [95% CI, 0.22-0.90]) as well as patients with NVAF (hazard ratio, 0.63 [95% CI, 0.45-0.87]) compared with no anticoagulation therapy. Conclusions and Relevance New-onset POAF after isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism as NVAF. These data warrant studies addressing the role of anticoagulation therapy in POAF after left-sided heart valve surgery.
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Affiliation(s)
- Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Anna Gundlund
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Thomas Kümler
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Thein Aagaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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21
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Lee CJY, Toft-Petersen AP, Ozenne B, Phelps M, Olesen JB, Ellinor PT, Gislason G, Lip GYH, Torp-Pedersen C, Gerds TA. Assessing absolute stroke risk in patients with atrial fibrillation using a risk factor-based approach. Eur Heart J Cardiovasc Pharmacother 2020; 7:f3-f10. [PMID: 32531029 DOI: 10.1093/ehjcvp/pvaa063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/03/2020] [Indexed: 11/14/2022]
Abstract
AIM To assess the risk of stroke and thromboembolism in patients with atrial fibrillation (AF) based on risk factor combinations of the CHA2DS2-VASc score. METHODS AND RESULTS Using nationwide Danish registries, patients with AF were included from 1997 to 2015 in this retrospective observational study. A multiple logistic regression, including interactions of history of stroke with age at AF, calendar year of AF, and the CHA2DS2-VASc score risk factors (congestive heart failure, hypertension, diabetes, vascular disease, and female sex) were used to predict the personalized risks of stroke within 1 year. A total of 147 842 patients with AF were included in the study cohort (median age 76 years, range 20-100 years, 51% females). Within the first year, 6% of the cohort were diagnosed with stroke. The predicted personalized 1-year absolute risk of stroke varied widely within each CHA2DS2-VASc score. To estimate the personalized risk of stroke an online calculator was created, the Calculator of Absolute Stroke Risk (CARS), which allows calculation of all the possible combinations of the CHA2DS2-VASc score (https://hjerteforeningen.shinyapps.io/riskvisrr/). CONCLUSION Calculation of the individual risk using a risk factor-based approach as opposed to using average risk for a particular CHA2DS2-VASc score can improve risk estimates. Furthermore, CARS can assist in the communication of the stroke risk for a more evidence-based shared decision-making of whether to initiate oral anticoagulation therapy.
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Affiliation(s)
- Christina J-Y Lee
- Department of Cardiology and Clinical Research, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, 3400 Hillerød, Denmark.,Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Anne Pernille Toft-Petersen
- Department of Cardiology and Clinical Research, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | | | | | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gunnar Gislason
- The Danish Heart Foundation, Copenhagen, Denmark.,Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | | | - Thomas Alexander Gerds
- The Danish Heart Foundation, Copenhagen, Denmark.,Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
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22
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Christensen MA, Fosbøl EL, Bonde AN, Olesen JB, Gislason GH, Torp-Pedersen C, Gundlund A. Secondary stroke prophylaxis in atrial fibrillation patients with chronic kidney disease: a nationwide cohort study. Europace 2020; 22:716-723. [PMID: 31872246 DOI: 10.1093/europace/euz340] [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: 09/02/2019] [Accepted: 12/02/2019] [Indexed: 11/12/2022] Open
Abstract
AIMS Oral anticoagulation (OAC) therapy as secondary stroke prophylaxis in atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unexplored and poses a clinical treatment dilemma. We assessed the long-term risk of thromboembolic events according to post-stroke OAC therapy in AF patients with CKD after their first ischaemic stroke. METHODS AND RESULTS We identified Danish AF patients with CKD who presented with first-time ischaemic stroke from 2005 to 2014. Chronic kidney disease was defined as a diagnosis code for CKD before baseline, defined as 100 days after stroke discharge. Post-stroke antithrombotic therapy (OAC therapy and antiplatelet therapy) was identified from prescription claims from discharge to baseline. Cumulative incidences and adjusted hazard ratios (HRs) of thromboembolic events according to post-stroke OAC therapy were examined. Of 1252 AF patients with CKD presenting with ischaemic stroke, 631 (50.4%) patients were on OAC therapy and 621 (49.6%) were on antiplatelet therapy alone at baseline [median age 76 (interquartile range, IQR 71-83) and 80 (IQR 72-86), respectively]. The median follow-up period was 1.9 years (IQR 0.8-3.6). Cumulative incidence rates of thromboembolic events and bleeding showed no significant difference between those on OAC therapy and antiplatelet therapy. The results from the multivariable analysis revealed similar results: thromboembolic risk was not modified by OAC treatment [adjusted HR 0.89, 95% confidence interval (CI) 0.73-1.09] nor was the risk of bleeding (adjusted HR 0.88, 95% CI 0.67-1.17). CONCLUSION Oral anticoagulation in patients with CKD and prior stroke was not associated with a reduced risk of recurrent thromboembolic events compared with antiplatelet therapy.
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Affiliation(s)
- Mathias Aagaard Christensen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjællands Hospital, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anna Gundlund
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
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23
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Bonde AN, Martinussen T, Lee CJY, Lip GY, Staerk L, Bang CN, Bhattacharya J, Gislason G, Torp-Pedersen C, Olesen JB, Hlatky MA. Rivaroxaban Versus Apixaban for Stroke Prevention in Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e006058. [DOI: 10.1161/circoutcomes.119.006058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Indexed: 12/13/2022]
Abstract
Background:
The comparative effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) is uncertain, as they have not been compared directly in randomized trials. Previous observational comparisons of NOACs are likely to be biased by unmeasured confounders. We sought to compare the efficacy and safety of rivaroxaban and apixaban for stroke prevention in patients with atrial fibrillation (AF), using practice variation in preference for NOAC as an instrumental variable.
Methods and Results:
Patients started on apixaban or rivaroxaban after newly diagnosed AF were identified using Danish nationwide registries. Patients were categorized according to facility preferences for type of NOAC, independent of actual treatment, measured as fraction of the prior 20 patients with AF initiated on rivaroxaban in the same facility. Facility preference for NOAC was used as an instrumental variable. The occurrence of stroke/thromboembolism, major bleeding, myocardial infarction, and all-cause mortality over 2 years of follow-up were investigated using adjusted Cox regressions. We analyzed 6264 patients with AF initiated on rivaroxaban or apixaban. NOAC preference was strongly related to actual choice of treatment but not associated with any other measured baseline characteristics. Patients treated in facilities that had preference for rivaroxaban had more major bleeding: compared with patients treated in facilities that used rivaroxaban in 0% to 20% of cases, the adjusted hazard ratio for bleeding was 1.06 when treated in a facility with 25% to 40% use; 1.41 with 45% to 60% use; 1.51 with 65% to 80% use; and 1.81 with 0% to 100% use (
P
trend
=0.01). Higher facility preference for rivaroxaban was not significantly associated with increased risk of stroke/thromboembolism (
P
trend
=0.06), myocardial infarction (
P
trend
=0.65), or all-cause mortality (
P
trend
=0.89). When we used the instrumental variable to model the causal relationship between choice of NOAC and major bleeding, relative risk with rivaroxaban was 1.89 (95% CI, 1.06–2.72) compared with apixaban.
Conclusions:
Using instrumental variable estimation in a cohort of patients with AF, rivaroxaban was associated with higher risk of major bleeding compared with apixaban. No significant associations to other outcomes were found in main analyses.
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Affiliation(s)
- Anders N. Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
- Department of Health Research and Policy, Stanford University School of Medicine, CA (A.N.B., J.B., M.A.H.)
| | - Torben Martinussen
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Denmark (T.M.)
| | - Christina J.-Y. Lee
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
- Department of Health Science and Technology, Aalborg University (C.J.-Y.L.)
- Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital (C.J.-Y.L.)
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart and Chest Hospital, United Kingdom (C.J.-Y.L.)
| | | | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
| | - Casper N. Bang
- Department of Cardiology, Zealand University Hospital Roskilde, Denmark (C.N.B., C.T.-P.)
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen (C.N.B., G.G.)
| | - Jay Bhattacharya
- Department of Health Research and Policy, Stanford University School of Medicine, CA (A.N.B., J.B., M.A.H.)
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen (C.N.B., G.G.)
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
- Department of Cardiology, Zealand University Hospital Roskilde, Denmark (C.N.B., C.T.-P.)
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark (A.N.B., C.J.-Y.L., L.S., G.G., C.T.-P., J.B.O.)
| | - Mark A. Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, CA (A.N.B., J.B., M.A.H.)
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24
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25
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Strange JE, Sindet-Pedersen C, Staerk L, Grove EL, Gerds TA, Torp-Pedersen C, Gislason GH, Olesen JB. All-cause mortality, stroke, and bleeding in patients with atrial fibrillation and valvular heart disease. Eur Heart J Cardiovasc Pharmacother 2020; 7:f93-f100. [PMID: 32065652 DOI: 10.1093/ehjcvp/pvaa011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/16/2020] [Accepted: 02/11/2020] [Indexed: 12/29/2022]
Abstract
AIMS To compare the risk of all-cause mortality, stroke, and bleeding in patients with atrial fibrillation (AF) and valvular heart disease (VHD) treated with vitamin K antagonist (VKA) or factor Xa-inhibitors (FXa-I; rivaroxaban and apixaban). METHODS AND RESULTS We cross-linked data from Danish nationwide registries identifying patients with AF and VHD (aortic stenosis/insufficiency, mitral insufficiency, bioprosthetic heart valves, mitral-, and aortic valve repair) initiating VKA or FXa-I between January 2014 and June 2017. Outcomes were all-cause mortality, stroke, and bleeding. Using cause-specific Cox regression, we reported the standardized absolute 2-year risk of the outcomes and absolute risk differences (ARD). We identified 1115 (41.7%), 620 (23.1%), and 942 (35.2%) patients initiating treatment with VKA, rivaroxaban, and apixaban, respectively. The standardized absolute risk (95% confidence interval) of all-cause mortality associated with VKA treatment was 34.1% (30.4-37.8%) with corresponding ARD for FXa-I of -2.7% (-6.7% to 1.4%). The standardized absolute risk of stroke for VKA was 3.8% (2.2-5.4%) with corresponding ARD for FXa-I of -0.1% (-2.0% to 1.8%). The standardized risk of bleeding for VKA was 10.4% (7.2-12.9%) with corresponding ARD for FXa-I of -2.0% (-5.1% to 1.1%). The risk of bleeding was significantly reduced in subgroup analyses of apixaban compared with VKA [ARD: -3.9% (-7.0% to -0.9%)] and rivaroxaban [ARD: -5.6% (-9.5% to -1.7%)]. CONCLUSION In this nationwide cohort study, there were no significant differences in the risks of all-cause mortality, stroke, and bleeding in patients with AF and VHD treated with VKA compared with FXa-I.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark
| | - Thomas Alexander Gerds
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Oester Farimagsgade 5, Entrance B, 2nd floor, 1014 Copenhagen, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research, Nordsjaellands Hospital, Kongens Vaenge 2, 3400 Hilleroed, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Kildegaardsvej 28, 2900 Hellerup, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Noerre Alle 20, 2200 Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Kildegaardsvej 28, 2900 Hellerup, Denmark
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26
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Staerk L, Fosbøl EL, Lamberts M, Bonde AN, Gadsbøll K, Sindet-Pedersen C, Holm EA, Gerds TA, Ozenne B, Lip GYH, Torp-Pedersen C, Gislason GH, Olesen JB. Resumption of oral anticoagulation following traumatic injury and risk of stroke and bleeding in patients with atrial fibrillation: a nationwide cohort study. Eur Heart J 2019; 39:1698-1705a. [PMID: 29165556 DOI: 10.1093/eurheartj/ehx598] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 02/02/2017] [Accepted: 10/02/2017] [Indexed: 11/14/2022] Open
Abstract
Aims We examined the risks of all-cause mortality, stroke, major bleeding, and recurrent traumatic injury associated with resumption of vitamin K antagonists (VKAs) and non-VKAs oral anticoagulants (NOACs) following traumatic injury in atrial fibrillation (AF) patients. Methods and results This was a Danish nationwide registry-based study (2005-16), including 4541 oral anticoagulant (OAC)-treated AF patients experiencing traumatic injury (defined as traumatic brain injury, hip fracture, or traumatic torso or abdominal injury). Within 90 days following discharge from traumatic injury, 60.6% resumed VKA (median age = 80, CHA2DS2-VASc = 4, HAS-BLED = 2), 16.7% resumed NOAC (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 2), and 22.7% did not resume OAC treatment (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 3). Switch from VKA to NOAC occurred among 9.5%. Since 2009, the trend in OAC resumption increased (P-value <0.0001), in particular with NOACs (P-value <0.0001). Follow-up started 90 days after discharge, and time-varying multiple Cox regression analyses were used for comparisons. Compared with non-resumption, VKA and NOAC resumption were associated with lower hazard [95% confidence interval (CI)] of all-cause mortality [hazard ratio (HR) 0.48 (0.42-0.53) and HR 0.55 (0.47-0.66), respectively] and ischaemic stroke [HR 0.56 (0.43-0.72) and HR 0.54 (0.35-0.82), respectively], increased major bleeding hazard [HR 1.30 (1.03-1.64) and HR 1.15 (0.81-1.63), respectively], and similar hazard of recurrent traumatic injury [HR 0.93 (0.73-1.18) and HR 0.87 (0.60-1.27), respectively]. Conclusion AF patients resuming VKA and NOAC treatment following traumatic injury have lower hazard of all-cause mortality and ischaemic stroke, increased hazard of major bleeding but without additional hazards of recurrent traumatic injury. Withholding OAC following a traumatic injury in AF patients may not be warranted.
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Affiliation(s)
- Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.,The Danish Heart Association, Vognmagergade 7, 1120 Copenhagen K, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Kasper Gadsbøll
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Ellen A Holm
- Department of Internal Medicine, Nykøbing F. Hospital, Fjordvej 15, 4800 Nykøbing Falster, Denmark
| | - Thomas Alexander Gerds
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Brice Ozenne
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers vej 5, 9100 Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Epidemiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark.,Department of Health, Science and Technology, Aalborg University, Fredrik Bajers vej 5, 9100 Aalborg, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,The Danish Heart Association, Vognmagergade 7, 1120 Copenhagen K, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.,The National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
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27
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Olsen AMS, McGettigan P, Gerds TA, Fosbøl EL, Olesen JB, Sindet-Pedersen C, Staerk L, Lock Hansen M, Pallisgaard JL, Køber L, Torp-Pedersen C, Gislason GH, Lamberts M. Risk of gastrointestinal bleeding associated with oral anticoagulation and non-steroidal anti-inflammatory drugs in patients with atrial fibrillation: a nationwide study. European Heart Journal - Cardiovascular Pharmacotherapy 2019; 6:292-300. [DOI: 10.1093/ehjcvp/pvz069] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/30/2019] [Accepted: 11/18/2019] [Indexed: 11/12/2022]
Abstract
Abstract
Aims
Non-vitamin K antagonist oral anticoagulants (NOACs) are displacing vitamin K antagonists (VKAs) for stroke prophylaxis in patients with atrial fibrillation (AF). Concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs) could increase gastrointestinal bleeding (GIB) risks among these patients. The aim of this study was to examine the risk of GIB among Danish AF patients taking oral anticoagulants (OACs) and NSAIDs.
Methods and results
Using nationwide administrative registries, we determined concomitant NSAID use among anticoagulant-naïve patients with AF initiating OACs between August 2011 and June 2017. We calculated short-term absolute risks differences and hazard ratios (HRs) for GIB based on multiple adjusted cause-specific Cox regressions with time-dependent NSAID treatment. Among 41 183 patients [median age 70 years (interquartile range 64–78); 55% men], 21% of patients on NOACs and 18% on VKA were co-prescribed NSAIDs. The differences in absolute risk [95% confidence interval (CI)] of GIB within 14 days of commencing concomitant NSAID therapy (vs. no concomitant NSAID therapy) were 0.10% (0.04–0.18%) for NOACs and 0.13% (0.03–0.24%) for VKA. NOACs overall were associated with less GIB than VKA [HR 0.77 (95% CI 0.69–0.85)]. Compared with OACs alone, concomitant NSAIDs doubled the GIB risk associated with NOACs overall [HR 2.01 (95% CI 1.40–2.61)] and with VKA [HR 1.95 (95% CI 1.21–2.69)].
Conclusion
Among this nationwide AF population taking OACs, concomitant NSAID therapy increased the short-term absolute risk of GIB. Non-vitamin K antagonist oral anticoagulants alone were associated with lower GIB risks than VKA but concomitant NSAIDs abolished this advantage. The findings align with post hoc analyses from randomized studies. Physicians should exercise appropriate caution when prescribing NSAIDs for patients with AF taking NOACs or VKA.
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Affiliation(s)
- Anne-Marie Schjerning Olsen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Patricia McGettigan
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, EC1M 6BQ London, UK
| | | | - Emil Loldrup Fosbøl
- The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jannik Langtved Pallisgaard
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Institute of Health, Science and Technology, Frederik Bajersvej 7K, 9920 Aalborg University, Aalborg, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9B, 5000 Odense, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
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28
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Vinding NE, Staerk L, Gislason GH, Torp-Pedersen C, Bonde AN, Rørth R, Lee CJY, Olesen JB, Køber L, Fosbøl EL. Switching from vitamin K antagonist to dabigatran in atrial fibrillation: differences according to dose. Eur Heart J Cardiovasc Pharmacother 2019; 7:20-30. [PMID: 31730151 DOI: 10.1093/ehjcvp/pvz066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/15/2019] [Accepted: 11/02/2019] [Indexed: 11/14/2022]
Abstract
AIMS In atrial fibrillation (AF) patients 150 mg b.i.d. dabigatran is the standard dose, yet guidelines recommend 110 mg b.i.d. when bleeding risk is high. It is unknown to which extend these recommendations are followed in patients switching from vitamin K antagonist (VKA) to dabigatran. The aim of this study was to investigate if AF patients are switched from VKA to the appropriate dose of dabigatran. METHODS AND RESULTS Using nationwide registries (22 August 2011 to 31 December 2012), we identified VKA-experienced AF patients with available creatinine values who switched to dabigatran. European guidelines criteria 2012 on dabigatran dosing were examined: age ≥80 years, HAS-BLED ≥3, estimated glomerular filtration rate (eGFR)<50 mL/min/1.73 m2, or use of interacting drugs. We identified 1626 VKA-experienced AF patients who switched to dabigatran 110 mg (820 patients) or 150 mg (806 patients). Patients who switched to 110 mg compared with 150 mg were older [median age 82 years (Q1-Q3: 77-86) vs. 68 years (Q1-Q3: 64-74)], more often females (54% vs. 35%), had a higher comorbidity burden, higher proportion with CHA2DS2-VASc score ≥2 (98% vs. 80%), and more with a HAS-BLED score ≥3 (46% vs. 28%). Patients switched to 110 mg had a higher absolute risk of mortality compared with patients switched to 150 mg. Overall, 26% were inappropriately dosed and 14% were switched to 110 mg although the higher dose was indicated. Furthermore, 39% of patients switched to 150 mg fulfilled one or more criteria for 110 mg, this mostly driven by high HAS-BLED scores (28.2% of patients on 150 mg). Female sex, age ≥80 years, eGFR < 50 mL/min/1.73 m2, drugs interacting with dabigatran, and prior bleeding were associated with switch to 110 mg. Patients inappropriately dosed had similar risk of mortality as patients appropriately dosed. CONCLUSION Among VKA-experienced AF patients one in four were switched to a dabigatran dose contrary to guideline recommendations.
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Affiliation(s)
- Naja Emborg Vinding
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København 2100, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Vognmagergade 7, 3. sal, 1120 Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9900 Aalborg, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Rasmus Rørth
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København 2100, Denmark
| | - Christina J-Y Lee
- Department of Cardiology and Clinical Investigation, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9900 Aalborg, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København 2100, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København 2100, Denmark.,Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Vognmagergade 7, 3. sal, 1120 Copenhagen, Denmark
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Laugesen EK, Staerk L, Carlson N, Kamper AL, Olesen JB, Torp-Pedersen C, Gislason G, Bonde AN. Non-vitamin K antagonist oral anticoagulants vs. vitamin-K antagonists in patients with atrial fibrillation and chronic kidney disease: a nationwide cohort study. Thromb J 2019; 17:21. [PMID: 31736658 PMCID: PMC6849210 DOI: 10.1186/s12959-019-0211-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/03/2019] [Indexed: 11/30/2022] Open
Abstract
Background We aimed to compare effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin-K antagonists (VKA) in atrial fibrillation (AF) patients with chronic kidney disease (CKD) not receiving dialysis. Methods By using personal identification numbers, we cross-linked individual-level data from Danish administrative registries. We identified every citizen with a prior diagnosis of AF and CKD who initiated NOAC or VKA (2011–2017). An external analysis of 727 AF patients with CKD (no dialysis) was performed to demonstrate level of kidney function in a comparable population. Study outcomes included incidents of stroke/thromboembolisms (TEs), major bleedings, myocardial infarctions (MIs), and all-cause mortality. We used Cox proportional hazards models to determine associations between oral anticoagulant treatment and outcomes. Results Of 1560 patients included, 1008 (64.6%) initiated VKA and 552 (35.4%) initiated NOAC. In a comparable population we found that 95.3% of the patients had an estimated glomerular filtration rate (eGFR) < 59 mL/min. Patients treated with NOAC had a significantly decreased risk of major bleeding (hazard ratio (HR): 0.47, 95% confidence interval (CI): 0.26–0.84) compared to VKA. There was not found a significant association between type of anticoagulant and risk of stroke/TE (HR: 0.83, 95% CI: 0.39–1.78), MI (HR: 0.45, 95% CI: 0.18–1.11), or all-cause mortality (HR: 0.99, 95% CI: 0.77–1.26). Conclusion NOAC was associated with a lower risk of major bleeding in patients with AF and CKD compared to VKA. No difference was found in risk of stroke/TE, MI, and all-cause mortality.
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Affiliation(s)
- Emma Kirstine Laugesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Nicholas Carlson
- 3The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark.,4Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anne-Lise Kamper
- 4Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Christian Torp-Pedersen
- 5Department of Health Science and Technology, Aalborg University, Fredrik Bajers vej 5, 9100 Aalborg, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark.,3The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark.,6The National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455 Copenhagen, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Schelde AB, Eliasen A, Olesen JB, Jensen TB, Jimenez-Solem E. Real-world effectiveness and safety of pharmacological thromboprophylaxis in patients undergoing primary total hip and knee arthroplasty: A narrative review. J Orthop 2019; 19:166-173. [PMID: 32025127 DOI: 10.1016/j.jor.2019.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/14/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022] Open
Abstract
In this narrative review of the real-world effectiveness and safety of pharmacological thromboprophylaxis following primary total hip and knee arthroplasty, a total of 12 non-interventional observational studies were included. Pharmacological thromboprophylaxis included warfarin, heparins, dabigatran, rivaroxaban, apixaban, acetylsalicylic acid, and fondaparinux. The absolute risks varied across the included studies. These variations can be explained by differences in patient populations, drug exposure, follow-up time, and definition of outcomes, which makes it a challenge to compare the risk estimates. These findings emphasize the need for a large population-based real-world study to provide comparable risk estimates associated with different pharmacological thromboprophylaxis.
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Affiliation(s)
- Astrid Blicher Schelde
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | - Astrid Eliasen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Thomas Bo Jensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Denmark
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Butt JH, Olesen JB, Gundlund A, Olsen PS, Havers-Borgersen E, Aagaard DT, Gislason GH, Torp-Pedersen C, Kober L, Fosbol EL. P4799Long-term thromboembolic risk in patients with postoperative atrial fibrillation after left-sided heart valve surgery. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1175] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are sparse. In addition, data on stroke prophylaxis in this setting are lacking.
Objective
To assess the long-term risk of thromboembolism in patients developing new-onset POAF following isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF).
Methods
Using data from the Eastern Danish Heart Surgery Database and Danish nationwide registries, we identified patients who developed POAF following isolated left-sided heart valve surgery (i.e. biologic aortic/mitral valve replacement or aortic/mitral valve repair) from 2000 through 2015. These patients were matched with patients with nonsurgical NVAF in a 1:4 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Long-term risk of thromboembolism was examined by the Aalen-Johansen estimator and cause-specific Cox regression models adjusted for comorbidities, concomitant pharmacotherapy, and oral anticoagulation therapy as a time-dependent covariate.
Results
A total of 1,539 patients undergoing isolated left-sided heart valve surgery were identified. Of these, 716 (46.5%) patients developed POAF after surgery. A total of 630 patients with POAF were matched with 2,520 patients with NVAF. In the matched study population, the median age was 71 years (25th-75th percentile 66–77 years) and 59.5% were men. Oral anticoagulation therapy was initiated within 30 days post-discharge in 62.7% and 51.4% of these patients, respectively. Compared with NVAF, POAF was not associated with a significantly different 5-year absolute risk of thromboembolism (10.7% [95% confidence interval [CI], 8.0%-13.9%] versus 8.9% [95% CI, 7.6%-10.2%] in the POAF and NVAF group, respectively) (Figure). In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio [HR] 1.01 [95% CI, 0.71–1.44]). Anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (HR 0.45 [95% CI, 0.18–0.99]) as well as NVAF (HR 0.58 [95% CI, 0.42–0.80]) compared with no anticoagulation therapy.
Conclusions
New-onset POAF following isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism compared with NVAF. Future studies addressing the role of oral anticoagulation therapy in POAF after heart valve surgery are warranted to examine the efficacy and safety as well as the timing and duration of anticoagulation therapy.
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Affiliation(s)
- J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - J B Olesen
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - A Gundlund
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - P S Olsen
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - E Havers-Borgersen
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - D T Aagaard
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - G H Gislason
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology and Clinical Epidemiology, Aalborg, Denmark
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - E L Fosbol
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
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Bonde AN, Lee CY, Lip GYH, Kamper AL, Staerk LS, Torp-Pedersen C, Gislason G, Olesen JB. 3052Non-vitamin K antagonist oral anticoagulants are safe and effective alternatives to warfarin across subgroups by renal function: results from Danish registries. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
All non-vitamin K antagonist oral anticoagulants (NOACs) have some degree of renal excretion, and patients with severely reduced renal function have been excluded from randomized controlled clinical trials of stroke prevention in atrial fibrillation (AF). Influence of renal function on outcomes has not been assessed in previous real-world studies of NOACs in AF.
Purpose
To assess influence of renal function on efficacy and safety of dabigatran, rivaroxaban or apixaban vs. warfarin.
Methods
Using nationwide registries, we identified all Danish AF patients who initiated warfarin, dabigatran, rivaroxaban or apixaban between 2012 and 2016. We included patients with a plasma creatinine measurement within 14 days from drug initiation and calculated estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Hazard ratio (HR) of stroke/thromboembolism (TE) or major bleeding according to oral anticoagulation was calculated using multivariable-adjusted Cox regression analyses with warfarin as reference.
Results
We included 14,673 AF patients who started first-time oral anticoagulation within 14 days from AF diagnosis, and our study population comprised 2482 (16.9%) initiators of dabigatran (median age 72, 44.5% women), 3806 (25.9%) initiators of rivaroxaban (median age 75, 48.0% women), 5067 (34.5%) initiators of apixaban (median age 76, 48.8% women), and 3318 (22.6%) initiators of warfarin (median age 75, 45.4% women). eGFR was >50, 30–50 and 15 to <30 mL/min/1.73m2 in 10,281 (83.1%), 2079 (14.2%) and 404 (2.8%) patients at baseline. After adjustment for age, sex, year of inclusion, income, cohabitation status, eGFR, hemoglobin, medications and comorbidities, the HRs for stroke/TE compared to warfarin were 0.94 (95% confidence interval (CI) 0.74–1.20) for dabigatran, 1.06 (CI 0.84–1.34) for rivaroxaban, and 1.10 (CI 0.88–1.36) for apixaban. There were no significant heterogeneities in HRs of stroke/TE across subgroups by eGFR. Apixaban (HR 0.74, CI 0.62–0.89) was associated with lower risk of major bleeding compared to warfarin, rivaroxaban (HR 1.06, CI 0.88–1.27) with risk of major bleeding comparable to warfarin, and there were no significant heterogeneities in risk of major bleeding with rivaroxaban or apixaban across subgroups by eGFR. Dabigatran was associated with lower risk of bleeding among patients with eGFR >50 mL/min/1.73m2, but not among patients with eGFR 30–50 mL/min/1.73m2 (interaction P=0.03).
Conclusions
In a large real-world cohort, renal function had no significant influence on efficacy or safety of apixaban or rivaroxaban when compared with warfarin. Dabigatran was associated with lower risk of bleeding among patients with normal or mildly decreased renal function, but not among patients with moderately decreased renal function.
Acknowledgement/Funding
This study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research.
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Affiliation(s)
- A N Bonde
- Gentofte University Hospital, Gentofte, Denmark
| | - C Y Lee
- Aalborg University, Aalborg, Denmark
| | - G Y H Lip
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - A L Kamper
- Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - L S Staerk
- Gentofte University Hospital, Gentofte, Denmark
| | | | - G Gislason
- Gentofte University Hospital, Gentofte, Denmark
| | - J B Olesen
- Gentofte University Hospital, Gentofte, Denmark
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Strange JE, Sindet-Pedersen C, Staerk L, Grove EL, Gerds TA, Torp-Pedersen C, Gislason GH, Butt JH, Fosboel EL, Olesen JB. P4792Dabigatran versus vitamin K antagonists in patients with atrial fibrillation and valvular heart disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1168] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) and valvular heart disease (VHD) are both associated with an increased risk of stroke. Outside post-hoc analyses of randomized controlled trials, knowledge on the effectiveness and safety of dabigatran in patients with AF and VHD is scarce.
Objectives
To compare the risk of all-cause mortality, stroke, and bleeding in patients with AF and VHD treated with dabigatran or a vitamin K antagonist (VKA).
Methods
All Danish residents are provided a unique personal identification number enabling cross-linking of data from Danish nationwide registries. We identified all patients with AF and VHD initiating treatment with dabigatran or VKA between the 22nd of August 2011 and the 31st of December 2014. We defined VHD as aortic stenosis/regurgitation, mitral regurgitation, bioprosthetic heart valves, mitral-, and aortic valve repair. Outcomes were all-cause mortality, stroke, and bleeding. 2-year standardized absolute risks were calculated from cause-specific Cox regression models with death as competing risk.
Results
In total, 599 (27.3%) and 1,596 (72.7%) patients initiated treatment with dabigatran and VKA. The 2-year standardized absolute risk of all-cause mortality (95% CI) for VKA was 27.6% (25.1% to 30.1%) and 25.4% (21.8% to 29.0%) for dabigatran with a corresponding absolute risk difference of −2.2% (−6.3% to 1.9%) (Figure 1). The 2-year standardized absolute risk of stroke for VKA was 3.4% (2.3% to 4.5%) and 3.9% (2.2% to 5.5%) for dabigatran with a corresponding absolute risk difference of 0.5% (−1.6% to 2.5%). Lastly, the 2-year standardized absolute risk of bleeding for VKA was 8.2% (6.6% to 9.7%) and 7.6% (5.1% to 10.1%) for dabigatran with a corresponding absolute risk difference of −0.5% (−3.4% to 2.4%).
Figure 1
Conclusions
In this nationwide cohort study, we found no significant difference in the risk of all-cause mortality, stroke, or bleeding in patients with AF and VHD when comparing VKA to dabigatran.
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Affiliation(s)
- J E Strange
- Gentofte University Hospital, Department of cardiology, Copenhagen, Denmark
| | - C Sindet-Pedersen
- Gentofte University Hospital, Department of cardiology, Copenhagen, Denmark
| | - L Staerk
- Gentofte University Hospital, Department of cardiology, Copenhagen, Denmark
| | - E L Grove
- Aarhus University Hospital, Department of Cardiology, Aarhus, Denmark
| | - T A Gerds
- The Danish Heart Foundation, Copenhagen, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
| | - G H Gislason
- Gentofte University Hospital, Department of cardiology, Copenhagen, Denmark
| | - J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - E L Fosboel
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - J B Olesen
- Gentofte University Hospital, Department of cardiology, Copenhagen, Denmark
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Bonde AN, Martinussen T, Lee CY, Bhattacharya J, Lip GYH, Staerk L, Gislason G, Torp-Pedersen C, Olesen JB, Hlatky M. P4779High facility preference for rivaroxaban in atrial fibrillation increases risk of major bleeding compared to facility preference for apixaban. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1155] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
No randomized trial has compared efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF). Previous real-world comparisons could be biased by patient characteristics of importance for treatment selection, but instrumental variables could potentially account for measured and unmeasured confounders.
Purpose
To compare efficacy and safety of rivaroxaban and apixaban using facility preference for type of NOAC as instrumental variable.
Methods
AF patients started on apixaban or rivaroxaban were identified using nationwide registries. We categorized patients according to facility preference for type of NOAC, measured as percentage of the prior 20 AF patients started on rivaroxaban in the same facility. Occurrence of stroke/thromboembolism (TE), major bleeding, myocardial infarction and all-cause mortality during two years of follow-up were investigated using adjusted Cox regressions. To further examine general frailty according to facility preferences we also investigated occurrence of cancer, urogenital tract infection, dehydration and fracture.
Results
We analyzed 6264 AF patients initiated on rivaroxaban or apixaban. Compared with patients treated in facilities that used rivaroxaban in 0–20% of cases, the adjusted hazard ratio for bleeding was 1.05 when treated in a facility with 25–40% use; 1.40 with 45–60% use; 1.50 with 65–80% use; and 1.81 for 85–100% use (Ptrend=0.002). Higher facility level use of rivaroxaban was not associated with increased risk of stroke/TE (Ptrend=0.06), myocardial infarction (Ptrend=0.87) or all-cause mortality (Ptrend=0.91), and there was no association between facility preference for rivaroxaban and risk of cancer (Ptrend=0.83), urogenital tract infection (Ptrend=0.49), dehydration (Ptrend=0.91) or fracture (Ptrend=0.47).
Characteristics by facility preference Percent of previous AF patients from facility started on rivaroxaban P for trend 0–20% 25–40% 45–60% 65–80% 85–100% No. of patients 1406 1421 1551 930 956 Received rivaroxaban, (%) 279, (19.8) 499, (35.1) 711, (45.8) 632, (68.0) 774, (81.0) <0.001 Standard dose, (%) 1216, (86.5) 1232, (86.7%) 1366, (88.1%) 793, (85.3%) 824, (86.2%) 0.62 Median age, (interquartile range) 70, (63.3–74) 69, (63–74) 70, (64–74) 70, (64–75) 70, (63–75) 0.11 Below median income, (%) 740, (52.6) 699, (49.2) 764, (49.3) 458, (49.3) 471, (49.3) 0.31 Prior stroke, (%) 99, (7.0) 115, (8.1) 134, (8.6) 69, (7.4) 74, (7.7) 0.56 Prior bleeding, (%) 136, (9.7) 141, (9.9) 163, (10.5) 91, (9.8) 97, (10.1) 0.51 Antiplatelet therapy, (%) 445, (31.7) 465, (32.7) 491, (31.7) 303, (32.6) 317, (33.2) 0.49
Rate of events according to instrument
Conclusion
High facility preference for rivaroxaban increases risk of major bleeding compared to facility preference for apixaban.
Acknowledgement/Funding
This study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research.
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Affiliation(s)
- A N Bonde
- Gentofte University Hospital, Copenhagen, Denmark
| | - T Martinussen
- University of Copenhagen, Section of Biostatistics, Copenhagen, Denmark
| | - C Y Lee
- Aalborg University, Aalborg, Denmark
| | - J Bhattacharya
- Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - G Y H Lip
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - L Staerk
- Gentofte University Hospital, Gentofte, Denmark
| | - G Gislason
- Gentofte University Hospital, Gentofte, Denmark
| | | | - J B Olesen
- Gentofte University Hospital, Gentofte, Denmark
| | - M Hlatky
- School of Medicine, Department of Health Research and Policy, Stanford, United States of America
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Binding C, Olesen JB, Abrahamsen B, Staerk L, Gislason G, Bonde AN. P4757Vitamin k antagonists are associated with higher risk of osteoporotic fractures compared to non-vitamin k antagonist oral anticoagulants among atrial fibrillation patients: a nationwide cohort study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1133] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Osteoporotic fractures are associated with high mortality and reduced life quality in an elderly population. Several studies report an increased risk of fractures among patients treated with oral anticoagulants (OAC), however, only sparse research has been made to clarify the difference between treatment with vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOACs) regarding the risk of osteoporotic fractures.
Purpose
The purpose of this study was to evaluate the risk of osteoporotic fractures among patients with atrial fibrillation (AF) in long-term VKA or NOAC treatment.
Methods
Patients with AF were identified using Danish national registries and were included when they had undergone 180 days OAC treatment, and only if they had no prior use of osteoporosis medication. The study period was from 1 January 2013 until 30 June 2017, and patients were followed for 2 years, or until death, outcome or emigration. Outcomes were hip fracture, major osteoporotic fracture, any fracture, initiation of osteoporosis medication, and a combined endpoint. G-formula was used to determine standardized absolute risk, and multiple covariate adjusted Cox regressions were used to calculate hazard ratios (HR).
Results
Overall, 37,350 patients with AF were included; 32.6% received VKA treatment (median age 72 years, 61.8% men) and 67.4% received NOAC treatment (median age 73 years, 55.9% men). The standardized absolute 2-year risk of any fracture was low among NOAC treated patients (3.1%; 95% CI: 2.9% to 3.3%), and among VKA treated patients (3.8%; 95% CI: 3.4% to 4.2%).
NOAC was associated with a significantly lower relative risk of any fracture (HR: 0.85; 95% CI: 0.74 to 0.97), of major osteoporotic fractures (HR: 0.85; 95% CI: 0.72 to 0.99), and of initiating osteoporotic medication (HR: 0.82; 95% CI: 0.71 to 0.95). A combined endpoint showed that patients treated with NOAC had a significantly lower risk of suffering from any fracture or initiating osteoporosis medication (HR: 0.84; 95% CI: 0.76 to 0.93).
Adjusted relative two-year risks
Conclusion
In a nationwide population, the absolute risk of osteoporotic fractures was low among AF patients on OAC, but NOAC was associated with a significantly lower risk of osteoporotic fractures compared to VKA.
Acknowledgement/Funding
Scholarship from The Copenhagen University Hospital Herlev and Gentofte
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Affiliation(s)
- C Binding
- Gentofte University Hospital, Gentofte, Denmark
| | - J B Olesen
- Gentofte University Hospital, Gentofte, Denmark
| | - B Abrahamsen
- Holbaek Hospital, Department of Medicine, Holbaek, Denmark
| | - L Staerk
- Gentofte University Hospital, Gentofte, Denmark
| | - G Gislason
- Gentofte University Hospital, Gentofte, Denmark
| | - A N Bonde
- Gentofte University Hospital, Gentofte, Denmark
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Butt JH, De Backer O, Olesen JB, Havers-Borgersen E, Gislason GH, Torp-Pedersen C, Sondergaard L, Kober L, Fosbol EL. P926Comparative safety and effectiveness of vitamin K antagonist and direct oral anticoagulants in patients with atrial fibrillation undergoing transcatheter aortic valve implantation. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0521] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Data on the comparative safety and effectiveness of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) undergoing transcatheter aortic valve implantation (TAVI) are sparse.
Purpose
To examine the risk of thromboembolism, bleeding, and all-cause mortality in patients treated with DOACs versus VKAs.
Methods
Danish nationwide registries were used to identify all patients undergoing TAVI (2011–2016) with a history of AF and who were treated with oral anticoagulants. The risk of outcomes in patients treated with DOACs versus VKAs were examined by the Aalen-Johansen estimator and cause-specific Cox regression models.
Results
The study population comprised 762 patients (median age 82 [interquartile range 77–85], 52.9% men), of whom 216 (28.3%) and 546 (71.7%) patients were treated with DOACs and VKAs, respectively. The DOAC group was characterized by a higher prevalence of previous thromboembolism and a lower prevalence of chronic kidney disease compared with the VKA group. The distribution of age, sex, CHA2DS2-VASc and HAS-BLED score, and concomitant antiplatelet therapy was similar between groups. Compared with VKA, treatment with DOACs was not associated with a significantly different 3-year absolute risk of thromboembolism (9.5% [95% confidence interval [CI], 4.7%-16.2%] versus 7.7% [95% CI, 5.3%-10.8%] in the DOAC and VKA group, respectively), bleeding (5.3% [95% CI, 2.4%-10.0%] versus 6.3% [95% CI, 4.1%-9.0%]), and all-cause mortality (32.6% [95% CI, 21.9%-43.7%] versus 33.3% [95% CI, 28.3%-38.5%]). In adjusted analyses, treatment with DOACs, as compared with VKA treatment, was not associated with a significantly different risk of thromboembolism (hazard ratio [HR], 1.25 [95% CI, 0.61–2.57]), bleeding (HR, 1.22 [95% CI, 0.54–2.75]), and all-cause mortality (HR, 0.90 [95% CI, 0.60–1.35]).
Conclusions
In patients with atrial fibrillation undergoing TAVI, treatment with DOACs was not associated with a significantly different risk of thromboembolism, bleeding, and all-cause mortality compared with treatment with VKA.
Acknowledgement/Funding
None
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Affiliation(s)
- J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - O De Backer
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - J B Olesen
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - E Havers-Borgersen
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - G H Gislason
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology and Clinical Epidemiology, Aalborg, Denmark
| | - L Sondergaard
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - E L Fosbol
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
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Yaqub ZM, Sehested TSG, Bonde AN, Olesen JB, Torp-Pedersen C, Gislason G, Staerk L. 3154The incidence of atrial fibrillation continues to increase across all socioeconomic subgroups: 30-year time trends from a Nationwide cohort. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0042] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The incidence rate of atrial fibrillation (AF) has increased substantially throughout the last decades. Socioeconomic factors such as income and education are well known to be associated with the development of cardiovascular disease, however, the impact on long-term trends of AF incidence rates is yet to be described.
Purpose
This nationwide cohort study examined the temporal trends of AF incidence rates over a span of 30 years (from 1987 to 2016) in Denmark. Furthermore, the impact of income and education was outlined.
Method
Patients were identified through linkage across Danish national registries from 1987 to 2016. We extracted data on the total number of inhabitants in Denmark aged ≥18 years, and used their age, sex, civil status, income and educational level for each calendar year. Data on socio economics were available from 1994. Income was defined by the average income over the prior 5 years and grouped into low (<q1),>Q3). Educational level was divided into primary school, high school, bachelor's degree, or master's degree. We defined incident AF as all first-time in- and outpatient diagnoses of AF. The incidence rates of AF were age-standardized per 1000 person-years for each calendar year and calculated for men and women separately.
Results
A total of 6,968,997 Danish inhabitants aged ≥18 years contributed to the study population from 1987 to 2016, and 393,183 (6%) developed AF over the study period. The age-standardized incidence rates of AF per 1000 person-years increased from 1.23 (CI 1.15:1.30) to 4.05 (CI 3.93:4.17) for men and from 1.13 (CI 1.06:1.30) to 3.56 (CI 3.44:3.68) for women from 1987 to 2016. Income status and educational level influenced the age-standardized incidence rates more significantly in women than men. The incidence rate from 1994 to 2016 for women with low income increased by a factor of 2.1 from 2.0 (CI 1.89:2.21) to 4.36 (CI 4.03:4.73). However, the high income group increased by a factor of 1.6 (from 1.74 (CI 1.10:3.32) to 2.83 (CI 2.29:3.55) per 1000 person-years). Moreover, the incidence rate for women with low educational level increased from 1.60 (CI 0.95:5.97) to 4.01 (CI 3.80:4.23) per 1000 person-years. The high educational group increased only by 1.2 (from 2.55 (CI 0.77:10.38) to 3.1 (CI 3.32:4.11) per 1000 person-years).
Conclusion
In a nationwide population, the incidence rate of AF continued to increase during a 30-year period. All socioeconomic subgroups experienced an increase in AF incidence, but the impact of low socioeconomic status was more significant among women than among men. The progressive growth in AF incidence has significant public health implications.
Acknowledgement/Funding
Danish Heart Foundation
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Affiliation(s)
- Z M Yaqub
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
| | - T S G Sehested
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
| | - A N Bonde
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
| | - J B Olesen
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology and Epidemiology, Aalborg, Denmark
| | - G Gislason
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
| | - L Staerk
- Gentofte Hospital - Copenhagen University Hospital, Hellerup, Denmark
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38
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Gundlund A, Kümler T, Bonde AN, Butt JH, Gislason GH, Torp-Pedersen C, Køber L, Olesen JB, Fosbøl EL. Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant-Danish nationwide cohort study. BMJ Open 2019; 9:e028468. [PMID: 31542739 PMCID: PMC6756362 DOI: 10.1136/bmjopen-2018-028468] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES We compared long-term outcomes in patients with atrial fibrillation (AF) with and without a secondary precipitant. DESIGN AND SETTING Retrospective cohort study based on Danish nationwide registries. PARTICIPANTS Patients with AF with and without secondary precipitants (1996-2015) were matched 1:1 according to age, sex, calendar year, CHA2DS2-VASc score and oral anticoagulation therapy (OAC), resulting in a cohort of 39 723 patients with AF with a secondary precipitant and the same number of patients with AF without a secondary precipitant. Secondary precipitants included alcohol intoxication, thyrotoxicosis, myocardial infarction, surgery and infection in conjunction with AF. PRIMARY AND SECONDARY OUTCOMES The primary outcome in this study was thromboembolic events. Secondary outcomes included AF rehospitalisation and death. Long-term risks of outcomes were examined by multivariable Cox regression analysis. RESULTS The most common precipitants were infection (55.0%), surgery (13.2%) and myocardial infarction (12.0%). The 5-year absolute risk of thromboembolic events (taking death into account as a competing risk) in patients with AF grouped according to secondary precipitants were 8.3% (alcohol intoxication), 8.5% (thyrotoxicosis), 12.1% (myocardial infarction), 11.6% (surgery), 12.2% (infection), 10.1% (>1 precipitant) and 12.3% (no secondary precipitant). In the multivariable analyses, AF with a secondary precipitant was associated with the same or an even higher thromboembolic risk than AF without a secondary precipitant. One exception was patients with AF and thyrotoxicosis: those not initiated on OAC therapy carried a lower thromboembolic risk the first year of follow-up than matched patients with AF without a secondary precipitant and no OAC therapy. CONCLUSIONS In general, AF with a secondary precipitant was associated with the same thromboembolic risk as AF without a secondary precipitant. Consequently, this study highlights the need for more research regarding the long-term management of patients with AF associated with a secondary precipitant.
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Affiliation(s)
- A Gundlund
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Thomas Kümler
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | | | | | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University, Aalborg East, Denmark
- Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Bonde AN, Staerk L, Lee CJY, Vinding NE, Bang CN, Torp-Pedersen C, Gislason G, Lip GYH, Olesen JB. Outcomes Among Patients With Atrial Fibrillation and Appropriate Anticoagulation Control. J Am Coll Cardiol 2019; 72:1357-1365. [PMID: 30213328 DOI: 10.1016/j.jacc.2018.06.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) patients on a vitamin K antagonist (VKA) with time in therapeutic range (TTR) ≥70% are not recommended to switch to a direct oral anticoagulant according to guidelines. OBJECTIVES This study sought to assess future TTR and risk of stroke/thromboembolism and major bleeding among AF patients on VKA with TTR ≥70%. METHODS The authors used Danish nationwide registries to identify AF patients on VKA from 1997 to 2011 with available international normalized ratio values. Patients were included 6 months after VKA initiation, divided according to TTR, and followed for 12 months after inclusion. Cox proportional hazard models estimated hazard ratios (HRs). TTR was examined both as a baseline variable and as a time-dependent covariate in the Cox models. RESULTS Of the 4,772 included AF patients still on VKA 6 months after initiation, 1,691 (35.4%) had a TTR ≥70%, and 3,081 (65.6%) had a TTR <70%. Among patients with prior TTR ≥70% still on treatment 12 months after inclusion, only 513 (55.7%) still had a TTR ≥70%. Compared with prior TTR ≥70%, prior TTR <70% was not associated with a higher risk of stroke/thromboembolism (HR: 1.14; 95% confidence interval [CI]: 0.77 to 1.70) or major bleeding (HR: 1.12; 95% CI: 0.84 to 1.49). When the authors estimated TTR time-dependently during follow-up, TTR <70% was associated with an increased risk of stroke/thromboembolism (HR: 1.91; 95% CI: 1.30 to 2.82) and major bleeding (HR: 1.34; 95% CI: 1.02 to 1.76). CONCLUSIONS Among AF patients on VKA, almost one-half of patients with prior TTR ≥70% had TTR <70% during the following year. Prior TTR ≥70% per se had limited long-term prognostic value.
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Affiliation(s)
| | - Laila Staerk
- Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Christina J-Y Lee
- Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
| | | | - Casper N Bang
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark; Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar Gislason
- Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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Lee CJY, Gerds TA, Carlson N, Bonde AN, Gislason GH, Lamberts M, Olesen JB, Pallisgaard JL, Hansen ML, Torp-Pedersen C. Risk of Myocardial Infarction in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2019; 72:17-26. [PMID: 29957227 DOI: 10.1016/j.jacc.2018.04.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 02/21/2018] [Revised: 03/11/2018] [Accepted: 04/03/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Evidence is conflicting as to the efficacy of direct oral anticoagulation (DOAC) and vitamin K antagonist (VKA) for prevention of myocardial infarction (MI). OBJECTIVES This study aimed to investigate the risk of MI associated with the use of apixaban, dabigatran, rivaroxaban, and VKA in patients with atrial fibrillation. METHODS Patients with atrial fibrillation were identified using Danish health care registers and stratified by initial oral anticoagulant treatment. Standardized absolute 1-year risks were estimated based on Cox regression for hazard rates of MI hospitalizations and mortality. Reported were absolute risks separately for the oral anticoagulation treatments and standardized to the characteristics of the study population. RESULTS Of the 31,739 patients included (median age, 74 years; 47% females), the standardized 1-year risk of MI for VKA was 1.6% (95% confidence interval [CI]: 1.3 to 1.8), apixaban was 1.2% (95% CI: 0.9 to 1.4), dabigatran was 1.2% (95% CI: 1.0 to 1.5), and rivaroxaban was 1.1% (95% CI: 0.8 to 1.3). No significant risk differences were observed in the standardized 1-year risks of MI among the DOACs: dabigatran versus apixaban (0.04%; 95% CI: -0.3 to 0.4), rivaroxaban versus apixaban (0.1%; 95% CI: -0.4 to 0.3), and rivaroxaban versus dabigatran (-0.1%; 95% CI: -0.5 to 0.2). The risk differences for DOACs versus VKA were all significant: -0.4% (95% CI: -0.7 to -0.1) for apixaban, -0.4% (95% CI: -0.7 to -0.03) for dabigatran, and -0.5% (95% CI: -0.8 to -0.2) for rivaroxaban. CONCLUSIONS No significant risk differences of MI were found in the direct comparisons of DOACs, and DOACs were all associated with a significant risk reduction of MI compared with VKA.
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Affiliation(s)
- Christina Ji-Young Lee
- Department of Health Science and Technology, Aalborg University and Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark.
| | - Thomas Alexander Gerds
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Internal Medicine, Holbaek Hospital, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Morten Lamberts
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | | | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University and Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
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Hauge SC, Abrahamsen B, Gislason G, Bjerring Olesen J, Hommel K, Hansen D. SaO028BONE FRACTURES IN PATIENTS ON RENAL REPLACEMENT THERAPY: DOES DIABETES INCREASE THE RISK? Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz101.sao028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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42
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Vinding NE, Bonde AN, Rørth R, Lamberts M, Olesen JB, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. The importance of time in therapeutic range in switching from vitamin K antagonist to non-vitamin K antagonist oral anticoagulants in atrial fibrillation. Europace 2018; 21:572-580. [DOI: 10.1093/europace/euy262] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/14/2018] [Indexed: 01/18/2023] Open
Affiliation(s)
- Naja Emborg Vinding
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København Ø, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, Hellerup, Denmark
| | - Rasmus Rørth
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København Ø, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København Ø, Denmark
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, Hellerup, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Kildegaardsvej 28, Hellerup, Denmark
- The Danish Heart Foundation, Vognmagergade 7, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Institute of Health, Science and Technology, Aalborg University, Niels Jernes Vej 12, Aalborg Ø, Denmark
- Aalborg University Hospital, Unit of Epidemiology and Biostatistics, Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København Ø, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, København Ø, Denmark
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Pallisgaard JL, Lindhardt TB, Staerk L, Olesen JB, Torp-Pedersen C, Hansen ML, Gislason GH. Thiazolidinediones are associated with a decreased risk of atrial fibrillation compared with other antidiabetic treatment: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother 2018; 3:140-146. [PMID: 28028073 DOI: 10.1093/ehjcvp/pvw036] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/01/2016] [Indexed: 12/20/2022]
Abstract
Aim The aim of this study was to investigate the association between thiazolidinediones (TZDs) vs. other antidiabetic drugs and risk of atrial fibrillation (AF) in diabetic patients. Method and results Diabetes mellitus (diabetes) increases the risk of AF by approximately 34%. TZD is an insulin sensitizer that also has anti-inflammatory effects, which might decrease the risk of AF compared with other antidiabetic drugs. We used data from the Danish nationwide registries to study 108 624 patients with diabetes and without prior AF who were treated with metformin or sulfonylurea as first-line drugs. The incidence of AF was significantly lower with TZD as the second-line antidiabetic treatment compared with other second-line antidiabetic drugs (P < 0.001). The 10 year cumulative incidence [95% confidence interval (95% CI)] of AF was 6.2% (3.1-9.3%) with TZD vs. 10.2% (9.8-10.6%) with other antidiabetic drugs. The decreased risk of AF remained significant after adjusting for age, sex, and comorbidities with a hazard ratio (95% CI) of 0.76 (0.57-1.00), P = 0.047 associated with TZD treatment compared with other antidiabetic drugs. Conclusion Use of a TZD to treat diabetes was associated with reduced risk of developing AF compared with other antidiabetic drugs as second-line treatment.
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Affiliation(s)
- Jannik Langtved Pallisgaard
- University Hospital Gentofte and Herlev, Kildegaardsvej 28, 2900 Hellerup, Copenhagen, Denmark.,Faculty of Health and Medical Sciences Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Tommi Bo Lindhardt
- University Hospital Gentofte and Herlev, Kildegaardsvej 28, 2900 Hellerup, Copenhagen, Denmark.,Faculty of Health and Medical Sciences Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Laila Staerk
- University Hospital Gentofte and Herlev, Kildegaardsvej 28, 2900 Hellerup, Copenhagen, Denmark.,Faculty of Health and Medical Sciences Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- University Hospital Gentofte and Herlev, Kildegaardsvej 28, 2900 Hellerup, Copenhagen, Denmark
| | | | - Morten Lock Hansen
- Zealand University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Gunnar Hilmar Gislason
- University Hospital Gentofte and Herlev, Kildegaardsvej 28, 2900 Hellerup, Copenhagen, Denmark.,Faculty of Health and Medical Sciences Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Danish Heart Foundation, Vognmagergade 7, 3. sal, 1120 Copenhagen, Denmark.,National Institute of Public Health University of Southern Denmark, Oster Farimagsgade 5 A, 1353 Copenhagen, Denmark
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44
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Gundlund A, Kümler T, Olesen JB, Bonde AN, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Comparative thromboembolic risk in atrial fibrillation patients with and without a concurrent infection. Am Heart J 2018; 204:43-51. [PMID: 30075325 DOI: 10.1016/j.ahj.2018.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to compare long-term thromboembolic risk in infection-related and non-infection-related atrial fibrillation (AF). METHODS Using Danish nationwide registries, we identified patients with first-time AF from 1996-2015 and performed a retrospective cohort study. We did a 1:1 match (upon sex, age, calendar year, and oral anticoagulation (OAC) status at the beginning of follow-up) of patients with infection-related (concurrent discharge diagnosis code for infection) and non-infection-related AF. Long-term outcomes were examined using multivariable Cox regression analyses. RESULTS Our study population comprised 48,644 patients equally distributed on infection-related and non-infection-related AF. In both groups, those initiated on OAC therapy were younger than those not initiated on OAC therapy (median age 77 years, interquartile range 69-83 versus median age 79 years, interquartile range 71-86). During the 1st year of follow up, infection-related AF was associated with an increased risk of thromboembolic events compared with non-infection-related AF: adjusted hazard ratio (HR) 1.44 (95% confidence interval (CI) 1.16-1.78) for those initiated on OAC therapy and HR 1.17 (95% CI 1.06-1.28) for those not initiated on OAC therapy. In both groups, OAC therapy was associated with better outcomes than no OAC therapy (HR of thromboembolic events 0.75 (95% CI 0.68-0.83) and HR 0.70 (95% CI 0.63-0.78) for patients with infection-related and non-infection-related AF, respectively). CONCLUSION Infection was associated with an increased thromboembolic risk in patients with first-time AF. OAC therapy was associated with a similar risk-reduction in AF patients with and without a concurrent infection.
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45
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Gundlund A, Fosbøl EL, Gislason GH, Olesen JB. Reply: Oral anticoagulation and hip fracture risk: a common misconception? J Intern Med 2018; 284:323-324. [PMID: 29797617 DOI: 10.1111/joim.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A Gundlund
- Department of Cardiology S, University Hospital of Copenhagen, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - E L Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - G H Gislason
- Department of Cardiology S, University Hospital of Copenhagen, Herlev-Gentofte Hospital, Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen K, Denmark.,The National Institute of Public Health, University of Southern, Denmark
| | - J B Olesen
- Department of Cardiology S, University Hospital of Copenhagen, Herlev-Gentofte Hospital, Hellerup, Denmark
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46
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Nissen Bonde A, Lip GYH, Kamper AL, Gislason G, Torp-Pedersen C, Hlatky M, Olesen JB. P3845Use of oral anticoagulation and association to outcomes in atrial fibrillation patients who develop chronic kidney disease: a nationwide cohort study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - G Y H Lip
- Birmingham City Hospital, Birmingham, United Kingdom
| | - A L Kamper
- Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - G Gislason
- Gentofte University Hospital, Gentofte, Denmark
| | | | - M Hlatky
- School of Medicine, Stanford, United States of America
| | - J B Olesen
- Gentofte University Hospital, Gentofte, Denmark
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47
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Strange JE, Sindet-Pedersen C, Staerk L, Gislason GH, Torp-Pedersen C, Olesen JB. P6076Oral anticoagulants in patients with atrial fibrillation and non-mechanical heart valve disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J E Strange
- Gentofte University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - C Sindet-Pedersen
- Gentofte University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - L Staerk
- Gentofte University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - G H Gislason
- Gentofte University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
| | - J B Olesen
- Gentofte University Hospital, Department of Cardiology, Copenhagen, Denmark
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48
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Kamil S, Olesen JB, Hansen ML, Gislason GH, Dominguez MH. P3843Closure of left atrial appendage in patients with atrial fibrillation undergoing first-time coronary bypass graft surgery is associated with lower risk of stroke. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S Kamil
- Gentofte University Hospital, Department of Cardiology, Hellerup, Denmark
| | - J B Olesen
- Gentofte University Hospital, Department of Cardiology, Hellerup, Denmark
| | - M L Hansen
- Gentofte University Hospital, Department of Cardiology, Hellerup, Denmark
| | - G H Gislason
- Gentofte University Hospital, Department of Cardiology, Hellerup, Denmark
| | - M H Dominguez
- Bispebjerg University Hospital, Department of Cardiology, Frederiksberg, Copenhagen, Denmark
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Butt JH, Olesen JB, Havers-Borgeren E, Gundlund A, Andersson C, Gislason GH, Torp-Pedersen C, Kober L, Fosbol EL. P2912New-onset postoperative atrial fibrillation following non-cardiac surgery is associated with a long-term thromboembolic risk similar to non-valvular atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - J B Olesen
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - E Havers-Borgeren
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - A Gundlund
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - C Andersson
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - G H Gislason
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - C Torp-Pedersen
- Aalborg University Hospital, Department of Cardiology and Clinical Epidemiology, Aalborg, Denmark
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
| | - E L Fosbol
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology, Copenhagen, Denmark
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50
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Tahir SN, Dalgaard F, Ruwald M, Olesen JB, Madelaire C, Gislason GH, Bonde AN. P5769Digoxin overdosage is associated with increased mortality in long-term digoxin users with atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- S N Tahir
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - F Dalgaard
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - M Ruwald
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - J B Olesen
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - C Madelaire
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - G H Gislason
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
| | - A N Bonde
- Gentofte Hospital - Copenhagen University Hospital, Cardiology department, Hellerup, Denmark
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