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Farzat M, Wagenlehner FM. On the relationship between various anticoagulants and robot-assisted radical prostatectomy: a single-surgeon serial analysis. J Robot Surg 2024; 18:174. [PMID: 38613654 PMCID: PMC11016122 DOI: 10.1007/s11701-024-01933-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
Prostate cancer patients often have other health conditions and take anticoagulants. It was believed that surgery under anticoagulants could worsen surgical results. This study aims to explore the safety of robot-assisted prostatectomy in anticoagulated patients, without any exclusion criteria. The study included 500 patients who underwent RARP by a single surgeon between April 2019 and August 2022. Patients were divided into two groups: Group 1, consisting of 376 men (75.2%), did not receive any anticoagulation, while Group 2, with 124 patients (24.8%), received different forms of anticoagulation. Then, the anticoagulation group was divided into 4 subgroups according to their definite anticoagulation: the aspirin 15.6%, new oral anticoagulants (NOAC) 5.4%, Vitamin K antagonist (VKA) 2%, and dual-antiplatelet therapy (DAPT) 1.8% subgroup. Postoperative complications and readmission rates were compared between the two study groups and subgroups. Patients in the combined group 2 were older and they also carried more comorbidities compared to men in group 1 (p = 0.03, p = 0.001).The study groups had similar oncological results, with 40.4% of patients having locally advanced cancers. Catheter days were longer in the anticoagulation group (4.5 vs 4 days, p = 0.001). No significant differences were observed between study groups for overall, minor, and major complications (p = 0.160, 0.100, and 0.915, respectively). In addition, readmissions were low (5.6%) and similar between the study groups (p = 0.635). Under cautious management, RARP under diverse anticoagulation regimes is safe and has comparable results to men with no medications. Further prospective studies must be conducted to confirm our findings.
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Affiliation(s)
- Mahmoud Farzat
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Wichernstraße 40, 57074, Siegen, Germany.
- Department of Urology and Robotic Urology, Diakonie Klinikum, Siegen, Germany.
| | - Florian M Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Wichernstraße 40, 57074, Siegen, Germany
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Tittl L, Marten S, Naue C, Beyer-Westendorf J. Patterns of atrial fibrillation anticoagulation with rivaroxaban - 7-year follow-up from the Dresden NOAC registry. Thromb Res 2024; 236:61-67. [PMID: 38394987 DOI: 10.1016/j.thromres.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Data on long-term effectiveness and safety of rivaroxaban for stroke prevention in atrial fibrillation (SPAF) are scarce and not available from randomized clinical trials. METHODS We used data from the prospective, non-interventional DRESDEN NOAC REGISTRY to evaluate rates of stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and ISTH major bleeding, in general and changes of event patterns over time. RESULTS Between 1st October 2011 and 31st December 2022, 1204 SPAF patients receiving rivaroxaban were followed for 6.7 ± 3.4 years with a mean rivaroxaban exposure of 4.9 ± 3.5 years. During follow up, intention-to treat rates of stroke/TIA/SE were 3.5/100 pt. years (95 % CI 2.5-4.7) in the first year and fell to 1.6/100 pt. years (95 % CI 1.2-2.0) in years 2-5 and 2.1/100 pt. years (95 % CI 1.6-2.7) after 5 years. Similarly, on-treatment event rates fell from 2.4/100 pt. years (95 % CI 1.5-3.5) to 1.1 (95 % CI 0.7-1.5) and 1.6 (95 % CI 1.0-2.3), respectively. Major bleeding rates on treatment were 3.5/100 pt. years in the first treatment year (95 % CI 2.5-4.8) and 2.7 (95 % CI 2.2-3.4) and 3.5 (95 % CI 2.7-4.6) in the periods 2-5 and > 5 years, respectively. Of note, rates of fatal bleeding were low throughout follow-up (0.2 vs. 0.2 vs. 0.1/100 pt. years). CONCLUSIONS Our results demonstrate the long-term effectiveness and safety of rivaroxaban therapy in unselected SPAF patients in daily care. Our data indicate that patterns of cardiovascular events remain constant over many years. In contrast, bleeding patterns change over time, possibly due to effects of co-morbidities in an ageing population.
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Affiliation(s)
- Luise Tittl
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Sandra Marten
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Christiane Naue
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany.
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Tsai CT, Chan YH, Liao JN, Chen TJ, Lip GYH, Chen SA, Chao TF. The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery stenosis-a nationwide cohort study. BMC Med 2024; 22:113. [PMID: 38475752 DOI: 10.1186/s12916-024-03338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND In post-stroke atrial fibrillation (AF) patients who have indications for both oral anticoagulant (OAC) and antiplatelet agent (AP), e.g., those with carotid artery stenosis, there is debate over the best antithrombotic strategy. We aimed to compare the risks of ischemic stroke, composite of ischemic stroke/major bleeding and composite of ischemic stroke/intracranial hemorrhage (ICH) between different antithrombotic strategies. METHODS This study included post-stroke AF patients with and without extracranial artery stenosis (ECAS) (n = 6390 and 28,093, respectively) identified from the Taiwan National Health Insurance Research Database. Risks of clinical outcomes and net clinical benefit (NCB) with different antithrombotic strategies were compared to AP alone. RESULTS The risk of recurrent ischemic stroke was higher for patients with ECAS than those without (12.72%/yr versus 10.60/yr; adjusted hazard ratio [aHR] 1.104, 95% confidence interval [CI] 1.052-1.158, p < 0.001). For patients with ECAS, when compared to AP only, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy was associated with lower risks for ischaemic stroke (aHR 0.551, 95% CI 0.454-0.669), the composite of ischaemic stroke/major bleeding (aHR 0.626, 95% CI 0.529-0.741) and the composite of ischaemic stroke/ICH (aHR 0.577, 95% CI 0.478-0.697), with non-significant difference for major bleeding and ICH. When compared to AP only, warfarin monotherapy was associated with higher risks of major bleeding (aHR 1.521, 95% CI 1.231-1.880), ICH (aHR 2.045, 95% CI 1.329-3.148), and the composite of ischaemic stroke and major bleeding. With combination of AP plus warfarin, there was an increase in ischaemic stroke, major bleeding, and the composite outcomes, when compared to AP only. NOAC monotherapy was the only approach associated with a positive NCB, while all other options (warfarin, combination of AP-OAC) were associated with negative NCB. CONCLUSIONS For post-stroke AF patients with ECAS, NOAC monotherapy was associated with lower risks of adverse outcomes and a positive NCB. Combination of AP with NOAC or warfarin did not offer any benefit, but more bleeding especially with AP-warfarin combination therapy.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Durand E, Verrez T, Gillibert A, Levesque T, Barbe T, Koning R, Motreff P, Eltchaninoff H, Collet JP, Rangé G. Safety and efficacy of NOAC vs. VKA in patients treated by PCI: a retrospective study of the FRANCE PCI registry. Front Cardiovasc Med 2024; 10:1320001. [PMID: 38292452 PMCID: PMC10824844 DOI: 10.3389/fcvm.2023.1320001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Dual antithrombotic therapy (DAT) combining oral anticoagulation (OAC), preferentially Non-vitamin K antagonist OAC (NOAC) and single antiplatelet therapy (SAPT) for a period of 6-12 months is recommended after percutaneous coronary intervention (PCI) in patients with an indication for OAC. Objective To compare outcomes between vitamin K antagonist (VKA) and NOAC-treated patients in the nation-wide France PCI registry. Methods All consecutive patients from the France PCI registry treated by PCI and discharged with OAC between 2014 and 2020 were included and followed one-year. Major bleeding was defined as Bleeding Academic Research Consortium (BARC) classification ≥3 and major adverse cardiac events (MACE) as the composite of all-cause mortality, myocardial infarction (MI), and ischemic stroke. A propensity-score analysis was used. Results Of the 7,277 eligible participants, 2,432 (33.4%) were discharged on VKA and 4,845 (66.6%) on NOAC. After propensity-score adjustment, one-year major bleeding was less frequent in NOAC vs. VKA-treated participants [3.1% vs. 5.2%, -2.1% (-3.6% to -0.6%), p = 0.005 as well as the rate of MACE [9.2% vs. 11.9%, -2.7% (-5.0% to -0.4%), p = 0.02]. One-year mortality was also significantly decreased in NOAC vs. VKA-treated participants [7.4% vs. 9.9%, -2.6% (-4.7% to -0.5%), p = 0.02]. The area under ROC curves of the anticoagulant treatment propensity score was estimated at 0.93, suggesting potential indication bias. Conclusions NOAC seems to have a better efficacy and safety profile than VKA. However, potential indication bias were found.
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Affiliation(s)
- Eric Durand
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, Rouen, France
| | - Thibault Verrez
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, Rouen, France
| | - Andre Gillibert
- Department of Biostatistics, Normandie Univ, CHU Rouen, Rouen, France
| | - Thomas Levesque
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, Rouen, France
| | - Thomas Barbe
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, Rouen, France
| | - René Koning
- Department of Cardiology, Clinique Saint Hilaire, Rouen, France
| | - Pascal Motreff
- Department of Cardiology, Clermont Ferrand University Hospital, Clermont-Ferrand, France
| | - Hélène Eltchaninoff
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, Rouen, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris, France
| | - Gregoire Rangé
- Department of Cardiology, Hôpital de Chartres, Chartres, France
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Yau CE, Low CE, Ong NY, Rana S, Chew LJR, Tyebally SM, Chai P, Yeo TC, Chan MY, Lee MX, Tan LL, Koo CY, Lee ARYB, Sia CH. Non-Vitamin K Antagonist Oral Anticoagulants versus Low Molecular Weight Heparin for Cancer-Related Venous Thromboembolic Events: Individual Patient Data Meta-Analysis. Cancers (Basel) 2023; 15:5887. [PMID: 38136433 PMCID: PMC10741613 DOI: 10.3390/cancers15245887] [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: 11/06/2023] [Revised: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. Low molecular weight heparin (LMWH) has been the standard of care but new guidelines have approved the use of non-vitamin K antagonist oral anticoagulants (NOAC). By conducting an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) comparing the outcomes of NOAC versus LMWH in cancer patients, we aim to determine an ideal strategy for the prophylaxis of VTE and prevention of VTE recurrence. Three databases were searched from inception until 19 October 2022. IPD was reconstructed from Kaplan-Meier curves. Shared frailty, stratified Cox and Royston-Parmar models were fit to compare the outcomes of venous thromboembolism recurrence and major bleeding. For studies without Kaplan-Meier curves, aggregate data meta-analysis was conducted using random-effects models. Eleven RCTs involving 4844 patients were included. Aggregate data meta-analysis showed that administering NOACs led to a significantly lower risk of recurrent VTE (RR = 0.65; 95%CI: 0.50-0.84) and deep vein thrombosis (DVT) (RR = 0.60; 95%CI: 0.40-0.90). In the IPD meta-analysis, NOAC when compared with LMWH has an HR of 0.65 (95%CI: 0.49-0.86) for VTE recurrence. Stratified Cox and Royston-Parmar models demonstrated similar results. In reducing risks of recurrent VTE and DVT among cancer patients, NOACs are superior to LMWHs without increased major bleeding.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Natasha Yixuan Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sounak Rana
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Lucas Jun Rong Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sara Moiz Tyebally
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Ping Chai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Mark Y. Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore;
| | - Li-Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Ainsley Ryan Yan Bin Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
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Grymonprez M, Carnoy L, Capiau A, Boussery K, Mehuys E, De Backer TL, Steurbaut S, Lahousse L. Impact of P-glycoprotein and CYP3A4-interacting drugs on clinical outcomes in patients with atrial fibrillation using non-vitamin K antagonist oral anticoagulants: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother 2023; 9:722-730. [PMID: 37791408 DOI: 10.1093/ehjcvp/pvad070] [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] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/03/2023] [Accepted: 10/02/2023] [Indexed: 10/05/2023]
Abstract
AIMS The clinical relevance of common pharmacokinetic interactions with non-vitamin K antagonist oral anticoagulants (NOACs) often remains unclear. Therefore, the impact of P-glycoprotein (P-gp) and CYP3A4 inhibitors and inducers on clinical outcomes in NOAC-treated patients with atrial fibrillation (AF) was investigated. METHODS AND RESULTS AF patients were included between 2013 and 2019 using Belgian nationwide data. Concomitant use of P-gp/CYP3A4-interacting drugs at the time of NOAC initiation was identified. Among 193 072 NOAC-treated AF patients, 46 194 (23.9%) and 2903 (1.5%) subjects concomitantly used a P-gp/CYP3A4 inhibitor or inducer, respectively. After multivariable adjustment, concomitant use of P-gp/CYP3A4 inhibitors was associated with significantly higher major bleeding [adjusted hazard ratio (aHR) 1.24, 95% confidence interval (CI) (1.18-1.30)] and all-cause mortality risks [aHR 1.07, 95% CI (1.02-1.11)], but not with thromboembolism in NOAC-treated AF patients. A significantly increased risk of major bleeding was observed with amiodarone [aHR 1.27, 95% CI (1.21-1.34)], diltiazem [aHR 1.28, 95% CI (1.13-1.46)], verapamil [aHR 1.36, 95% CI (1.03-1.80)], ticagrelor [aHR 1.50, 95% CI (1.20-1.87)], and clarithromycin [aHR 1.55, 95% CI (1.14-2.11)]; and in edoxaban [aHR 1.24, 95% CI (1.06-1.45)], rivaroxaban [aHR 1.25, 95% CI (1.16-1.34)], and apixaban users [aHR 1.27, 95% CI (1.16-1.39)], but not in dabigatran users [aHR 1.07, 95% CI (0.94-1.23)]. Concomitant use of P-gp/CYP3A4 inducers (e.g. antiepileptic drugs like levetiracetam) was associated with a significantly higher stroke risk [aHR 1.31, 95% CI (1.03-1.68)], but not with bleeding or all-cause mortality. CONCLUSION Concomitant use of P-gp/CYP3A4 inhibitors was associated with higher bleeding and all-cause mortality risks in NOAC users, whereas the use of P-gp/CYP3A4 inducers was associated with higher stroke risks.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Laura Carnoy
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, Rotterdam 3000, CA, The Netherlands
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Sulzgruber P, Hammer A, Niessner A. Rivaroxaban After Transcatheter Aortic Valve Replacement: A Critical Appraisal of the GALILEO Trial. Cardiovasc Drugs Ther 2023; 37:1239-1241. [PMID: 35699869 PMCID: PMC10721672 DOI: 10.1007/s10557-022-07350-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The anti-thrombotic approach in individuals undergoing transcatheter aortic valve replacement (TAVR) mirrors a controversial field in clinical practice. METHODS/RESULTS The aim of this article was to critically appraise the randomized controlled GALILEO trial, where two different antithrombotic regimes (10 mg rivaroxaban + 3 months aspirin vs. aspirin + 3 months clopidogrel) were compared in patients who underwent TAVR as well as available evidence in literature in this field. CONCLUSION The GALILEO trial was prematurely terminated as a consequence of increased risk of both death or thromboembolic complications and a higher risk of bleeding in the anticoagulation arm, compared to the antiplatelet-based strategy. Various concerns have been raised that the negative results of the GALILEO trial need to be regarded with caution. A routine use of oral anticoagulation (OAC) for the prevention of atherothrombotic events and valve thrombosis after TAVR in individuals who do not have an indication for oral anticoagulation, can currently not be recommended when considering the evidence base of available literature. However, the negative results of the GALILEO trial need to be interpreted with caution - especially in terms of dose of rivaroxaban - and should not discourage from performing further trials investigating safety and efficacy of this therapeutic approach. Additionally, further dose-finding trials for rivaroxaban should be considered.
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Affiliation(s)
- Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Andreas Hammer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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9
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Macherey-Meyer S, Braumann S, Heyne S, Meertens MM, Tichelbäcker T, Baldus S, Lee S, Adler C. [Preclinical loading in patients with acute chest pain and acute coronary syndrome - PRELOAD survey]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01087-8. [PMID: 38032364 DOI: 10.1007/s00063-023-01087-8] [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: 05/05/2023] [Revised: 10/05/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Guidelines on myocardial infarction (MI) recommend antithrombotic and anticoagulatory treatment at time of diagnosis. MI with ST segment elevation (STEMI) is mostly a certain diagnosis. Acute coronary syndrome without ST segment elevation (NSTE-ACS) has diagnostic uncertainty and remains a working diagnosis in the prehospital setting. OBJECTIVE Assessment of prehospital loading with aspirin and heparin depending on ACS subtype and pretreatment with oral anticoagulants. METHODS The PRELOAD survey was a nationwide German study. STEMI/NSTE-ACS scenarios were designed and varied in pretreatment: I) no pretreatment, II) new oral anticoagulants (NOAC), III) vitamin K antagonist (VKA). Loading strategy was assessed and included: a) aspirin (ASA), b) unfractionated heparin (UFH), c) ASA + UFH, d) no loading. RESULTS A total of 708 emergency physicians were included. In NSTE-ACS without pretreatment, 79% chose loading (p < 0.001). ASA + UFH (71.4%) was the preferred option. In corresponding STEMI scenario, 100% chose loading and 98.6% preferred ASA + UFH (p < 0.001). In NSTE-ACS with NOAC pretreatment, 69.8% favored loading (p < 0.001); in VKA pretreatment the corresponding rate was 72.3% (p < 0.001). In each scenario, ASA was the preferred option. In STEMI with NOAC pretreatment, 97.5% chose loading (p < 0.001); analogous rate was 96.8% in STEMI with VKA pretreatment (p < 0.001). ASA was the preferred option again. CONCLUSIONS Prehospital loading was the preferred treatment strategy despite the diagnostic uncertainty in NSTE-ACS and guidelines recommending loading at time of diagnosis. Pretreatment with oral anticoagulants resulted in a strategy shift to loading with only aspirin. In STEMI patients, this indicates potential undertreatment.
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Affiliation(s)
- Sascha Macherey-Meyer
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Simon Braumann
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Sebastian Heyne
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Max Maria Meertens
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Tobias Tichelbäcker
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Stephan Baldus
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Samuel Lee
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Christoph Adler
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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10
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Grymonprez M, Capiau A, Steurbaut S, Boussery K, Mehuys E, Somers A, Petrovic M, De Backer TL, Lahousse L. Pharmacodynamic Drug-Drug Interactions and Bleeding Outcomes in Patients with Atrial Fibrillation Using Non-Vitamin K Antagonist Oral Anticoagulants: a Nationwide Cohort Study. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07521-5. [PMID: 37930588 DOI: 10.1007/s10557-023-07521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE Pharmacodynamic drug-drug interactions (PD DDIs) may influence the safety of non-vitamin K antagonist oral anticoagulants (NOACs), but the extent to which PD DDIs increase bleeding risks, remains unclear. Therefore, the impact of PD DDIs on bleeding outcomes in NOAC-treated patients with atrial fibrillation (AF) was investigated. METHODS Using Belgian nationwide data, NOAC-treated AF patients were included between 2013-2019. Concomitant use of PD interacting drugs when initiating NOAC treatment was identified. RESULTS Among 193,072 patients, PD DDIs were identified in 114,122 (59.1%) subjects. After multivariable adjustment, concomitant use of PD interacting drugs was associated with significantly higher risks of major or clinically-relevant non-major bleeding (adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) (1.13-1.24)), gastrointestinal (aHR 1.12, 95%CI (1.03-1.22)), urogenital (aHR 1.21, 95%CI (1.09-1.35)) and other bleeding (aHR 1.28, 95%CI (1.20-1.36)), compared to NOAC-treated AF patients without PD interacting drug use. Increased bleeding risks were most pronounced with P2Y12 inhibitors (aHR 1.62, 95%CI (1.48-1.77)) and corticosteroids (aHR 1.53, 95%CI (1.42-1.66)), followed by selective serotonin or serotonin and norepinephrine reuptake inhibitors (SSRI/SNRI, aHR 1.26, 95%CI (1.17-1.35)), low-dose aspirin (aHR 1.14, 95%CI (1.08-1.20)) and non-steroidal anti-inflammatory drugs (NSAID, aHR 1.10, 95%CI (1.01-1.21)). Significantly higher intracranial bleeding risks in NOAC users were observed with SSRI/SNRIs (aHR 1.50, 95%CI (1.25-1.81)) and corticosteroids (aHR 1.49, 95%CI (1.21-1.84)). CONCLUSION Concomitant use of PD interacting drugs, especially P2Y12 inhibitors and corticosteroids, was associated with higher major, gastrointestinal, urogenital, and other bleeding risks in NOAC-treated AF patients. Remarkably, higher intracranial bleeding risks were observed with SSRI/SNRIs and corticosteroids.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Annemie Somers
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, Rotterdam, 3000, CA, the Netherlands.
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11
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Faisaluddin M, Alwifati N, Naeem N, Balasubramanian S, Narasimhan B, Iqbal U, Dani SS. Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation in End-Stage Renal Disease on Hemodialysis: A Meta-Analysis of Randomized Control Trials. Am J Cardiol 2023; 206:309-311. [PMID: 37722229 DOI: 10.1016/j.amjcard.2023.08.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
End-stage renal disease (ESRD) and atrial fibrillation (AF) are commonly encountered, with ESRD itself serving as a well-established risk factor for AF.1 The 2018 AF guidelines have recommended apixaban across all the spectrums of renal impairment, including patients on hemodialysis (HD), and the 2019 American Heart Association/American College of Cardiology/Heart Rhythm Society updated guidelines have suggested careful consideration of reduced dose of direct oral anticoagulants (DOACs) in patients with ESRD.2,3 The current data on the safety and efficacy of warfarin versus DOACs in patients with AF with ESRD and HD is variable. This study aimed to perform a study-level meta-analysis to evaluate the effectiveness and safety of warfarin and DOACs in patients with AF who require dialysis.
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Affiliation(s)
- Mohammed Faisaluddin
- Department Of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Nader Alwifati
- Department Of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Nauman Naeem
- Department Of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Senthil Balasubramanian
- Division of Cardiovascular Medicine, NorthShore University Health System-Metro Chicago, Evanston, Illinois
| | - Bharat Narasimhan
- Department of Cardiology, Houston Methodist Hospital, Houston, Texas
| | - Uzma Iqbal
- Department of Cardiovascular Medicine, Rochester General Hospital, New York, New York
| | - Sourbha S Dani
- Department of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts.
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12
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Tiosano S, Banai A, Mulla W, Goldenberg I, Bayshtok G, Amit U, Shlomo N, Nof E, Rosso R, Glikson M, Guetta V, Barbash I, Beinart R. Left Atrial Appendage Occlusion versus Novel Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation-One-Year Survival. J Clin Med 2023; 12:6693. [PMID: 37892833 PMCID: PMC10607551 DOI: 10.3390/jcm12206693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/29/2023] Open
Abstract
Aim To compare the 1-year survival rate of patients with atrial fibrillation (AF) following left atrial appendage occluder (LAAO) implantation vs. treatment with novel oral anticoagulants (NOACs). METHODS We have conducted an indirect, retrospective comparison between LAAO and NOAC registries. The LAAO registry is a national prospective cohort of 419 AF patients who underwent percutaneous LAAO between January 2008 and October 2015. The NOACs registry is a multicenter prospective cohort of 3138 AF patients treated with NOACs between November 2015 and August 2018. Baseline patient characteristics were retrospectively collected from coded diagnoses of hospitalization and outpatient clinic notes. Follow-up data was sorted from coded diagnoses and the national civil registry. Subjects were matched according to propensity score. Baseline characteristics were compared using Chi-Square and student's t-test. Survival analysis was performed using Kaplan-Meier survival curves, log-rank test, and multivariable Cox regression, adjusting for possible confounding variables. RESULTS This study included 114 subjects who underwent LAAO implantation and 342 subjects treated with NOACs. The mean age of participants was 77.9 ± 7.44 and 77.1 ± 11.2 years in the LAAO and NOAC groups, respectively (p = 0.4). The LAAO group had 70 (61%) men compared to 202 (59%) men in the NOAC group (p = 0.74). No significant differences were found in baseline comorbidities, renal function, or CHA2DS2-VASc score. One-year mortality was observed in 5 (4%) patients and 32 (9%) patients of the LAAO and NOAC groups, respectively. After adjusting for confounders, LAAO was significantly associated with a lower risk for 1-year mortality (HR 0.38, 95%CI 0.14-0.99). In patients with impaired renal function, this difference was even more prominent (HR 0.21 for creatinine clearance (CrCl) < 60 mL/min). CONCLUSIONS In a pooled analysis of two registries, we found a significantly lower risk for 1-year mortality in patients with AF who were implanted with LAAO than those treated with NOACs. This finding was more prominent in patients with impaired renal function. Future prospective direct studies should further investigate the efficacy and adverse effects of both treatment strategies.
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Affiliation(s)
- Shmuel Tiosano
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Ariel Banai
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Wesam Mulla
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Surgeon General Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Ido Goldenberg
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Gabriella Bayshtok
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Arrow Program, Sheba Medical Center, Ramat Gan 5266202, Israel
| | - Uri Amit
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Nir Shlomo
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Eyal Nof
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Raphael Rosso
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9574425, Israel
| | - Victor Guetta
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Israel Barbash
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Roy Beinart
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
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13
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Bachorski W, Bychowski J, Gruchała M, Jaguszewski M. Two Approaches to Triple Antithrombotic Therapy in Patients with Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Treated with Percutaneous Coronary Intervention: Which Is More Efficient and Safer? Diagnostics (Basel) 2023; 13:3055. [PMID: 37835798 PMCID: PMC10572308 DOI: 10.3390/diagnostics13193055] [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: 08/15/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding and thromboembolic events. Thus, optimal treatment strategies in this challenging subset have been controversial. Herein, we aim to investigate different triple antithrombotic treatment (TAT) strategies in patients with ACS and AF after PCI. METHODS This was a retrospective, single-center study based on all consecutive patients with the diagnosis of ACS and AF treated with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus dual antiplatelet therapy using a P2Y12 inhibitor (clopidogrel) and aspirin (for 1 to 3 months) and observed for 12 months for major adverse cardiac events (MACE) and major or clinically relevant non-major bleeding incidents. RESULTS MACE occurred in 26.6% of patients treated with the VKA and 30.9% with NOAC (p = 0.659). Bleeding occurred in 7.8% of patients treated with VKA and 7.4% with NOAC (ns). CONCLUSIONS Among patients with ACS and AF who had undergone PCI, there was no significant difference in the risk of bleeding and ischemic events among those who received TAT with NOAC and VKA.
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Affiliation(s)
- Witold Bachorski
- Department of Cardiology, Medical University of Gdansk, M. Skłodowskiej-Curie 3a, 80-210 Gdansk, Poland
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14
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Grymonprez M, Steurbaut S, Capiau A, Vauterin D, Van Vaerenbergh F, Mehuys E, Boussery K, De Backer TL, Lahousse L. Minimal Adherence Threshold to Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation to Reduce the Risk of Thromboembolism and Death: A Nationwide Cohort Study. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07507-3. [PMID: 37707648 DOI: 10.1007/s10557-023-07507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Poor adherence to non-vitamin K antagonist oral anticoagulants (NOACs) may raise thromboembolic risks in patients with atrial fibrillation (AF). However, the minimal adherence to maintain the protective effect of NOACs is currently unknown. Therefore, we investigated thresholds of NOAC adherence in association with thromboembolic and mortality risks. METHODS Patients with AF initiating NOACs between 2013 and 2019 were identified in Belgian nationwide data. Adherence was measured using the proportion of days covered (PDC) after one year of treatment. Inverse probability of treatment weighted Cox regression was used to investigate outcomes. RESULTS 92,111 persons were included (250,750 person-years). Compared to NOAC users with a one-year PDC of 100%, significantly higher risks of stroke or systemic embolism were observed among NOAC users with PDCs of 85-89% (adjusted hazard ratio (aHR) 1.35, 95% confidence interval (CI) (1.19-1.54)), 80-84% (aHR 1.31, 95%CI (1.08-1.58)) and < 80% (aHR 1.64, 95%CI (1.34-2.01)), while no significant differences were observed among NOAC users with one-year PDCs of 95-99% (aHR 1.02, 95%CI (0.94-1.12)) or 90-94% (aHR 1.06, 95%CI (0.95-1.18)). Significantly higher risks of all-cause mortality were observed with decreasing levels of NOAC adherence, which were already higher among NOAC users with a one-year PDC of 90-94% versus 100% (aHR 1.09, 95%CI (1.01-1.17)). Findings were similar with once-daily and twice-daily dosed NOACs. CONCLUSION Poor adherence to NOACs is associated with increased risks of thromboembolism and all-cause mortality. The minimal adherence threshold should be ≥ 90%, preferably even ≥ 95%.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, Jette, 1090, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Frauke Van Vaerenbergh
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, Ghent, 9000, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium.
- Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, Rotterdam, 3015, The Netherlands.
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15
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Rottura M, Drago SFA, Molonia A, Irrera N, Marino S, Scoglio R, Orlando L, Gigliotti De Fazio M, Squadrito F, Arcoraci V, Imbalzano E. Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice. Biomed Pharmacother 2023; 165:115020. [PMID: 37352701 DOI: 10.1016/j.biopha.2023.115020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.
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Affiliation(s)
- M Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S F A Drago
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - A Molonia
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - N Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S Marino
- Italian Society of General Practice (SIMG), Messina, Italy
| | - R Scoglio
- Italian Society of General Practice (SIMG), Messina, Italy
| | - L Orlando
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - M Gigliotti De Fazio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - F Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - V Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy.
| | - E Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
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Bozic D, Alicic D, Martinovic D, Zaja I, Bilandzic-Ivisic J, Sodan R, Kresic B, Bratanic A, Puljiz Z, Ardalic Z, Bozic J. Plasma Drug Values of DOACs in Patients Presenting with Gastrointestinal Bleeding: A Prospective Observational Study. Medicina (Kaunas) 2023; 59:1466. [PMID: 37629757 PMCID: PMC10456420 DOI: 10.3390/medicina59081466] [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] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Anticoagulants are a well-known risk factor for gastrointestinal bleeding (GIB). In recent years, direct oral anticoagulants (DOACs) have taken a leading role in the treatment and prevention of thromboembolic incidents. The aim of this study was to investigate the prevalence of DOAC-treated patients with GIB whose plasma drug concentrations exceeded the cut-off values reported in the literature and to evaluate their clinical characteristics. Materials and Methods: Patients who were admitted to the Intensive Care Unit in the period 2/2020-3/2022 due to GIB were prospectively included in the study and classified into three groups according to the prescribed type of DOAC (apixaban, rivaroxaban, and dabigatran). For all participants, it was determined if the measured plasma drug levels exceeded the maximum serum concentration (Cmax) or trough serum concentration (Ctrough) obtained from the available data. A comparison of clinical parameters between the patients with and without excess drug values was performed. Results: There were 90 patients (54.4% men) included in the study, of whom 27 were treated with dabigatran, 24 with apixaban, and 39 with rivaroxaban. According to Cmax, there were 34 (37.8%), and according to Ctrough, there were 28 (31.1%) patients with excess plasma drug values. A statistically significant difference regarding excess plasma drug values was demonstrated between DOACs according to both Cmax (p = 0.048) and Ctrough (p < 0.001), with the highest rate in the group treated with dabigatran (55.6% for Cmax and 59.3% for Ctrough). Multivariate logistic regression showed that age (OR 1.177, p = 0.049) is a significant positive and glomerular filtration rate (OR 0.909, p = 0.016) is a negative predictive factor for excess plasma drug values. A total of six (6.7%) patients had fatal outcomes. Conclusions: Plasma drug concentrations exceed cut-off values reported in the literature in more than one-third of patients with GIB taking DOAC, with the highest rate in the dabigatran group. Clinicians should be more judicious when prescribing dabigatran to the elderly and patients with renal failure. In these patients, dose adjustment, plasma drug monitoring, or substitution with other, more appropriate DOACs should be considered.
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Affiliation(s)
- Dorotea Bozic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Damir Alicic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Ivan Zaja
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Josipa Bilandzic-Ivisic
- Department of Gastroenterology, General Hospital of Sibenik-Knin County, Stjepana Radica 83, 22000 Sibenik, Croatia
| | - Rosana Sodan
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Branka Kresic
- Department of Medical Laboratory Diagnostics, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Andre Bratanic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
- Department of Internal medicine, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
| | - Zeljko Puljiz
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
- Department of Internal medicine, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
| | - Zarko Ardalic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia;
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Grymonprez M, Vanspranghe K, Steurbaut S, De Backer TL, Lahousse L. Non-vitamin K Antagonist Oral Anticoagulants ( NOACs) Versus Warfarin in Patients with Atrial Fibrillation Using P-gp and/or CYP450-Interacting Drugs: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2023; 37:781-791. [PMID: 34637052 DOI: 10.1007/s10557-021-07279-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Non-vitamin K antagonist oral anticoagulants (NOACs) are excreted by P-glycoprotein (P-gp) and some are metabolized by CYP450 enzymes such as CYP3A4. Although fewer drug interactions are present with NOACs, it is unclear whether NOACs should also be preferred over vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) using pharmacokinetically interacting drugs. Therefore, the benefit-risk profile of NOACs versus VKAs was investigated in AF patients treated with P-gp and/or CYP450-interacting drugs. METHODS Using PubMed and Embase, randomized controlled trials and observational studies on the effectiveness and safety of NOACs versus VKAs in AF patients using P-gp and/or CYP450-interacting drugs were included. A meta-analysis was performed, calculating relative risks (RR) and 95% confidence intervals (CI) with the Mantel-Haenszel method. RESULTS Twelve studies were included, investigating 10,793 NOAC and 10,096 VKA users treated with P-gp/CYP3A4 inhibitors, whereas no studies on P-gp and/or CYP450-inducing drugs were identified. Compared to VKAs, NOACs were associated with a borderline non-significantly lower stroke or systemic embolism (stroke/SE) risk (RR 0.85, 95%CI (0.72-1.01)), significantly lower intracranial bleeding (RR 0.47, 95%CI (0.34-0.65)) and all-cause mortality risks (RR 0.87, 95%CI (0.79-0.95), but significantly higher gastrointestinal bleeding risk (RR 1.74, 95%CI (1.06-2.86)). Among AF patients using amiodarone, NOACs were associated with significantly lower stroke/SE (RR 0.71, 95%CI (0.54-0.93)) and intracranial bleeding risks (RR 0.51, 95%CI (0.29-0.88)), but significantly higher gastrointestinal bleeding risk (RR 2.15, 95%CI (1.24-3.72)) than VKAs. CONCLUSION The benefit-risk profile of NOACs compared to VKAs was preserved in AF patients using P-gp/CYP3A4 inhibitors, including amiodarone.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
| | - Kevin Vanspranghe
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015, Rotterdam, The Netherlands
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Berton F, Costantinides F, Stacchi C, Corradini A, Di Lenarda A, Di Lenarda R. Is L-PRF an effective hemostatic agent in single tooth extractions? A cohort study on VKA and DOAC patients. Clin Oral Investig 2023; 27:2865-2874. [PMID: 36707441 PMCID: PMC10264503 DOI: 10.1007/s00784-023-04880-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/23/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The aim of this clinical observational study was to assess the efficacy of L-PRF as a hemostatic agent in patients under treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). MATERIALS AND METHODS Patients under oral anticoagulant therapy (VKA or DOACs) who needed a single simple tooth extraction were enrolled. L-PRF plug was positioned inside the alveolus and secured with non-absorbable sutures. Surgical time, pain-VAS, paracetamol intake, intra-operative, post-operative biological complications, and bleeding events have been registered. RESULTS A total of 112 patients (59 patients for DOAC and 53 for VKA group) were enrolled. Post-operative bleeding was recorded in nine patients (17%) for VKA group and nine patients (15.3%) for DOACs group. None of the patients needed a medical support for managing of bleeding. Seven days after surgery, no cases of post-extractive complications occurred. CONCLUSIONS The use of L-PRF resulted in limited mild late post-operative bleedings without the need of medical intervention. CLINICAL RELEVANCE The use of L-PRF can be adopted for an uneventful post-operative curse in anticoagulated patients without chasing their therapy for single tooth extraction.
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Affiliation(s)
- Federico Berton
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Fulvia Costantinides
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Claudio Stacchi
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Ambra Corradini
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services, Trieste, Italy
| | - Roberto Di Lenarda
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Laterra G, Dattilo G, Correale M, Brunetti ND, Artale C, Sacchetta G, Pistelli L, Borgi M, Campanella F, Cocuzza F, Lo Nigro MC, Contarini M. Imaging Modality to Guide Left Atrial Appendage Closure: Current Status and Future Perspectives. J Clin Med 2023; 12:jcm12113756. [PMID: 37297950 DOI: 10.3390/jcm12113756] [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] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. The left atrial appendage (LAA) is the most likely source of thrombus formation in patients with non-valvular atrial fibrillation (NVAF). Left atrial appendage closure (LAAC) represents an effective alternative to NOAC in patients with NVAF. Expert consensus documents recommend intraprocedural imaging by means of either transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in addition to standard fluoroscopy to guide LAAC. TEE-guided LAAC usually requires general anesthesia. The ICE technique is a "minimalist approach", without general anesthesia, but ICE imaging techniques are not yet simplified and standardize, and the ICE may result in inferior image quality compared with that of TEE. Another "minimalist approach" can be the use of ICE via the esophageal route (ICE-TEE), that jet is validated to identify the presence of LAA thrombi in patients and to perform other procedures. In our cath laboratory ICE-TEE to guide LAAC is used in some complex patients. Indeed, our single center experience suggests that ICE-TEE could be a good alternative imaging technique to guide LAAC procedure without general anesthesia.
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Affiliation(s)
- Giulia Laterra
- Cardiology Unit, Department of Emergency, Umberto Primo Hospital, 94100 Enna, Italy
| | - Giuseppe Dattilo
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Michele Correale
- Cardiothoracic Department, Policlinico Riuniti University Hospital, 71122 Foggia, Italy
| | | | - Claudia Artale
- Cardiology Unit, Department of Emergency, Umberto Primo Hospital, 96100 Siracusa, Italy
| | - Giorgio Sacchetta
- Cardiology Unit, Department of Emergency, Umberto Primo Hospital, 96100 Siracusa, Italy
| | - Lorenzo Pistelli
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Marco Borgi
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Francesca Campanella
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Federica Cocuzza
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Maria Claudia Lo Nigro
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy
| | - Marco Contarini
- Cardiology Unit, Department of Emergency, Umberto Primo Hospital, 96100 Siracusa, Italy
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20
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Fiedler L, Motloch LJ, Dieplinger AM, Jirak P, Davtyan P, Gareeva D, Badykova E, Badykov M, Lakman I, Agapitov A, Sadikova L, Pavlov V, Föttinger F, Mirna M, Kopp K, Hoppe UC, Pistulli R, Cai B, Yang B, Zagidullin N. Prophylactic rivaroxaban in the early post-discharge period reduces the rates of hospitalization for atrial fibrillation and incidence of sudden cardiac death during long-term follow-up in hospitalized COVID-19 survivors. Front Pharmacol 2023; 14:1093396. [PMID: 37324463 PMCID: PMC10266094 DOI: 10.3389/fphar.2023.1093396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction: While acute Coronavirus disease 2019 (COVID-19) affects the cardiovascular (CV) system according to recent data, an increased CV risk has been reported also during long-term follow-up (FU). In addition to other CV pathologies in COVID-19 survivors, an enhanced risk for arrhythmic events and sudden cardiac death (SCD) has been observed. While recommendations on post-discharge thromboprophylaxis are conflicting in this population, prophylactic short-term rivaroxaban therapy after hospital discharge showed promising results. However, the impact of this regimen on the incidence of cardiac arrhythmias has not been evaluated to date. Methods: To investigate the efficacy of this therapy, we conducted a single center, retrospective analysis of 1804 consecutive, hospitalized COVID-19 survivors between April and December 2020. Patients received either a 30-day post-discharge thromboprophylaxis treatment regimen using rivaroxaban 10 mg every day (QD) (Rivaroxaban group (Riva); n = 996) or no thromboprophylaxis (Control group (Ctrl); n = 808). Hospitalization for new atrial fibrillation (AF), new higher-degree Atrioventricular-block (AVB) as well as incidence of SCD were investigated in 12-month FU [FU: 347 (310/449) days]. Results: No differences in baseline characteristics (Ctrl vs Riva: age: 59.0 (48.9/66.8) vs 57 (46.5/64.9) years, p = n.s.; male: 41.5% vs 43.7%, p = n.s.) and in the history of relevant CV-disease were observed between the two groups. While hospitalizations for AVB were not reported in either group, relevant rates of hospitalizations for new AF (0.99%, n = 8/808) as well as a high rate of SCD events (2.35%, n = 19/808) were seen in the Ctrl. These cardiac events were attenuated by early post-discharge prophylactic rivaroxaban therapy (AF: n = 2/996, 0.20%, p = 0.026 and SCD: n = 3/996, 0.30%, p < 0.001) which was also observed after applying a logistic regression model for propensity score matching (AF: χ 2-statistics = 6.45, p = 0.013 and SCD: χ 2-statistics = 9.33, p = 0.002). Of note, no major bleeding complications were observed in either group. Conclusion: Atrial arrhythmic and SCD events are present during the first 12 months after hospitalization for COVID-19. Extended prophylactic Rivaroxaban therapy after hospital discharge could reduce new onset of AF and SCD in hospitalized COVID-19 survivors.
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Affiliation(s)
- Lukas Fiedler
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Department of Internal Medicine, Nephrology and Intensive Care Medicine, Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Lukas J. Motloch
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Anna-Maria Dieplinger
- Nursing Science Program, Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Peter Jirak
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Paruir Davtyan
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Diana Gareeva
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Elena Badykova
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Marat Badykov
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Irina Lakman
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
- Scientific Laboratory for the Socio-Economic Region Problems Investigation, Ufa University of Science and Technology, Ufa, Russia
| | - Aleksandr Agapitov
- Scientific Laboratory for the Socio-Economic Region Problems Investigation, Ufa University of Science and Technology, Ufa, Russia
| | - Liana Sadikova
- Scientific Laboratory for the Socio-Economic Region Problems Investigation, Ufa University of Science and Technology, Ufa, Russia
| | - Valentin Pavlov
- Department of Urology, Bashkir State Medical University, Ufa, Russia
| | - Fabian Föttinger
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Moritz Mirna
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Kristen Kopp
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Uta C. Hoppe
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Rudin Pistulli
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Benzhi Cai
- Department of Pharmacology (The Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Baofeng Yang
- Department of Pharmacology (The Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Naufal Zagidullin
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
- Department of Biomedical Engineering, Ufa University of Science and Technology, Ufa, Russia
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Yoon M, Park JJ, Hur T, Hua CH, Shim CY, Yoo BS, Cho HJ, Lee S, Kim HM, Kim JH, Lee S, Choi DJ. The ReInforcement of adherence via self-monitoring app orchestrating biosignals and medication of RivaroXaban in patients with atrial fibrillation and co-morbidities: a study protocol for a randomized controlled trial (RIVOX-AF). Front Cardiovasc Med 2023; 10:1130216. [PMID: 37324622 PMCID: PMC10263056 DOI: 10.3389/fcvm.2023.1130216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/05/2023] [Indexed: 06/17/2023] Open
Abstract
Background Because of the short half-life of non-vitamin K antagonist oral anticoagulants (NOACs), consistent drug adherence is crucial to maintain the effect of anticoagulants for stroke prevention in atrial fibrillation (AF). Considering the low adherence to NOACs in practice, we developed a mobile health platform that provides an alert for drug intake, visual confirmation of drug administration, and a list of medication intake history. This study aims to evaluate whether this smartphone app-based intervention will increase drug adherence compared with usual care in patients with AF requiring NOACs in a large population. Methods This prospective, randomized, open-label, multicenter trial (RIVOX-AF study) will include a total of 1,042 patients (521 patients in the intervention group and 521 patients in the control group) from 13 tertiary hospitals in South Korea. Patients with AF aged ≥19 years with one or more comorbidities, including heart failure, myocardial infarction, stable angina, hypertension, or diabetes mellitus, will be included in this study. Participants will be randomly assigned to either the intervention group (MEDI-app) or the conventional treatment group in a 1:1 ratio using a web-based randomization service. The intervention group will use a smartphone app that includes an alarm for drug intake, visual confirmation of drug administration through a camera check, and presentation of a list of medication intake history. The primary endpoint is adherence to rivaroxaban by pill count measurements at 12 and 24 weeks. The key secondary endpoints are clinical composite endpoints, including systemic embolic events, stroke, major bleeding requiring transfusion or hospitalization, or death during the 24 weeks of follow-up. Discussion This randomized controlled trial will investigate the feasibility and efficacy of smartphone apps and mobile health platforms in improving adherence to NOACs. Trial registration The study design has been registered in ClinicalTrial.gov (NCT05557123).
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Affiliation(s)
- Minjae Yoon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin Joo Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Taeho Hur
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Cam-Hao Hua
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seonhwa Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Sungyoung Lee
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Republic of Korea
| | - Dong-Ju Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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22
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Grymonprez M, De Backer TL, Capiau A, Vauterin D, Mehuys E, Boussery K, Steurbaut S, Lahousse L. Trends in oral anticoagulant use in patients with atrial fibrillation in Belgium from 2013 to 2019: A nationwide cohort study. Br J Clin Pharmacol 2023; 89:1360-1373. [PMID: 36321924 DOI: 10.1111/bcp.15582] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/03/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
AIM Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly preferred over vitamin K antagonists (VKAs) in atrial fibrillation (AF) management. However, differences in oral anticoagulant (OAC) prescribing according to patient's age, sex and physician's specialty may be present. Therefore, incident and prevalent use of OACs, NOACs and VKAs, stratified by age, sex and prescriber, and factors associated with the choice of OAC were investigated. METHODS Using two Belgian nationwide healthcare databases, AF patients ≥45 years old with ≥1 OAC prescription claim between 2013 and 2019 were identified. OAC use was investigated per half-year. Factors influencing NOAC vs. VKA initiation were identified by multivariable logistic regression. RESULTS Among 448 661 included OAC-treated AF patients, 297 818 were newly treated. Incident OAC use ranged from 45-49 to 42-44 users/10 000 persons between 2013 and 2019, whereas prevalent OAC use increased from 337 to 435 users/10 000 persons. Incident and prevalent NOAC use exceeded VKA use since 2013 and 2015, respectively, and NOACs represented 92% of incident and 81% of prevalent OAC users in 2019. Apixaban was the most frequently used NOAC since 2016. NOACs were significantly more prescribed by cardiologists and to older patients, whereas VKAs were more initiated in patients with cardiovascular, renal and hepatic comorbidities. Prevalent OAC use increased less in women than men (25.3% vs. 33.0% between 2013 and 2019) and female subjects had 5% significantly lower odds of NOAC vs. VKA initiation than men. CONCLUSION Since 2013, prevalent anticoagulant use increased almost one third in Belgium, while incident use was stable. Potential (N)OAC underuse in women requires further exploration.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.,Department of Hospital Pharmacy, UZ Brussel, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Hughes JM, Teh BM, Hart CJ, Gibbs HH, Aung AK. Risk factors and management outcomes in epistaxis: a tertiary centre experience. ANZ J Surg 2023; 93:555-560. [PMID: 36539988 DOI: 10.1111/ans.18179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes. METHODS This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity. RESULTS A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations. CONCLUSION Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.
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Affiliation(s)
- Jed M Hughes
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Bing Mei Teh
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
- Department of Otolaryngology, Head and Neck Surgery, Monash Health; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Cameron J Hart
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Harry H Gibbs
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Grymonprez M, De Backer TL, Bertels X, Steurbaut S, Lahousse L. Long-term comparative effectiveness and safety of dabigatran, rivaroxaban, apixaban and edoxaban in patients with atrial fibrillation: A nationwide cohort study. Front Pharmacol 2023; 14:1125576. [PMID: 36817122 PMCID: PMC9932194 DOI: 10.3389/fphar.2023.1125576] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Background: Although non-vitamin K antagonist oral anticoagulants (NOACs) are recommended over vitamin K antagonists (VKAs) in atrial fibrillation (AF) management, direct long-term head-to-head comparisons are lacking. Therefore, their risk-benefit profiles were investigated compared to VKAs and between NOACs. Methods: AF patients initiating anticoagulation between 2013-2019 were identified in Belgian nationwide data. Inverse probability of treatment weighted Cox regression was used to investigate effectiveness and safety outcomes and were additionally stratified by NOAC dose. Results: Among 254,478 AF patients (328,796 person-years of follow-up), NOACs were associated with significantly lower risks of stroke or systemic embolism (stroke/SE) (hazard ratio (HR) 0.68, 95% confidence interval (CI) (0.64-0.72)), all-cause mortality (HR 0.76, 95%CI (0.74-0.79)), major or clinically relevant non-major bleeding (MB/CRNMB) (HR 0.94, 95%CI (0.91-0.98)) and intracranial hemorrhage (HR 0.73, 95%CI (0.66-0.79)), but non-significantly different risks of myocardial infarction, gastrointestinal and urogenital bleeding compared to VKAs. Despite similar stroke/SE risks, dabigatran and apixaban were associated with significantly lower MB/CRNMB risks compared to rivaroxaban (HR 0.86, 95%CI (0.83-0.90); HR 0.86, 95%CI (0.83-0.89), respectively) and edoxaban (HR 0.91, 95%CI (0.83-0.99); HR 0.86, 95%CI (0.81-0.91), respectively), and apixaban with significantly lower major bleeding risks compared to dabigatran (HR 0.86, 95%CI (0.80-0.92)) and edoxaban (HR 0.79, 95%CI (0.72-0.86)). However, higher mortality risks were observed in some risk groups including with apixaban in patients with diabetes or concomitantly using digoxin compared to dabigatran and edoxaban, respectively. Conclusion: NOACs had better long-term risk-benefit profiles than VKAs. While effectiveness was comparable, apixaban was overall associated with a more favorable safety profile followed by dabigatran.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Xander Bertels
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.,Department of Hospital Pharmacy, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
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25
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Lee H, Hong JH, Seo KD. Long-term stroke and major bleeding risk in patients with non-valvular atrial fibrillation: A comparative analysis between non-vitamin K antagonist oral anticoagulants and warfarin using a clinical data warehouse. Front Neurol 2023; 14:1058781. [PMID: 36793489 PMCID: PMC9923348 DOI: 10.3389/fneur.2023.1058781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Non-vitamin K antagonist oral anticoagulants (NOACs) has been the drug of choice for preventing ischemic stroke in patients with atrial fibrillation (AF) since 2014. Many studies based on claim data revealed that NOACs had comparable effect to warfarin in preventing ischemic stroke with fewer hemorrhagic side effects. We analyzed the difference in clinical outcomes according to the drugs in patients with AF based on the clinical data warehouse (CDW). Methods We extracted data of patients with AF from our hospital's CDW and obtained clinical information including test results. All claim data of the patients were extracted from National Health Insurance Service, and dataset was constructed by combining it with CDW data. Separately, another dataset was constructed with patients who could obtain sufficient clinical information from the CDW. The patients were divided NOAC and warfarin groups. The occurrence of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and death were confirmed as clinical outcome. The factors influencing the risk of clinical outcomes were analyzed. Results The patients who were diagnosed AF between 2009 and 2020 were included in the dataset construction. In the combined dataset, 858 patients were treated with warfarin, 2,343 patients were treated with NOACs. After the diagnosis of AF, the incidence of ischemic stroke during follow-up was 199 (23.2%) in the warfarin group, 209 (8.9%) in the NOAC group. Intracranial hemorrhage occurred in 70 patients (8.2%) among the warfarin group, 61 (2.6%) of the NOAC group. Gastrointestinal bleeding occurred in 69 patients (8.0%) in the warfarin group, 78 patients (3.3%) in the NOAC group. NOAC's hazard ratio (HR) of ischemic stroke was 0.479 (95% CI 0.39-0.589, p < 0.0001), HR of intracranial hemorrhage was 0.453 (95% CI 0.31-0.664, p < 0.0001), and HR of gastrointestinal bleeding was 0.579 (95% CI 0.406-0.824, p = 0.0024). In the dataset constructed using only CDW, the NOAC group also had a lower risk of ischemic stroke and intracranial hemorrhage than warfarin group. Conclusions In this CDW based study, NOACs are more effective and safer than warfarin in patients with AF even with long-term follow-up. NOACs should be used to prevent ischemic stroke in patients with AF.
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Affiliation(s)
- Hancheol Lee
- Department of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Jung Hwa Hong
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea,Department of Neurology, Graduate School of Medicine, Kangwon National University, Chuncheon, Republic of Korea,*Correspondence: Kwon-Duk Seo ✉
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26
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Polzin A, Helten C, Metzen D, Zako S, Veulemans V, Kelm M, Zeus T. TAVR: nemesis of NOACs? J Thromb Thrombolysis 2023; 55:181-184. [PMID: 36318378 PMCID: PMC9925602 DOI: 10.1007/s11239-022-02721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
Data on non-vitamin K antagonist oral anticoagulants (NOACs) in transcatheter aortic valve replacement (TAVR) patients are controversial. In patients without atrial fibrillation (AF), rivaroxaban showed enhanced ischemia and bleeding as compared to standard of care. ENVISAGE showed enhanced bleeding in AF patients as compared to vitamin K antagonist (VKA). Only apixaban was non-inferior but failed superiority regarding bleeding in AF patients after TAVR. One could hypothesize that this might be due to pharmacokinetics of NOACs. Therefore, we compared outcome in rivaroxaban/edoxaban (once-daily) and apixaban (twice-daily) treated patients. 568 patients with indication for permanent oral anticoagulation due to AF undergoing TAVR were analyzed via inverse probability of treatment weighting. Valve academic research consortium complications during 30-day follow-up were assessed. Bleeding complications were similar in once-daily and twice-daily NOACs (major: 22 (7.5%) vs. 14 (5.3%), p = 0.285; minor: 66 (22.4%) vs. 46 (17.4%), p = 0.133). Complications did not change when splitting the cohort in the different agents apixaban, rivaroxaban and edoxaban. These findings remained robust after multivariate analysis. In summary, twice-daily and once-daily NOACs did not differ regarding bleeding complications in a hypothesis generating real-world cohort of TAVR patients with AF.
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Affiliation(s)
- Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany.
| | - Carolin Helten
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Daniel Metzen
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Saif Zako
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, University Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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27
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Mitrovic D, Veeger N, van Roon E. Impact of minor bleeds on confidence in anticoagulation therapy, adherence to treatment and quality of life in patients using a non-vitamin K antagonist oral anticoagulant for atrial fibrillation. Curr Med Res Opin 2022; 38:1485-1488. [PMID: 35656940 DOI: 10.1080/03007995.2022.2085963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE In a previous study on the reasons for discontinuation of novel oral anticoagulation therapy (NOAC) in patients with atrial fibrillation, we showed that minor bleeding was the second most important reason for NOAC discontinuation. This finding suggest that the impact of minor bleeds on the patient's perspective on NOACs cannot be ignored, especially those minor bleeds for which the patient searched medical care. We therefore performed a study in which we explored the impact of minor bleed (clinically relevant non-major bleeds) on patient confidence in therapy, adherence to treatment and quality of life in AF patients using NOAC's. METHODS Details on NOAC therapy, level of confidence, adherence and quality of life were assessed using a semi-structured telephone interview. Questions related to annoyance, concern and trust were scored on a scale of 1-10, with score 10 representing the highest level of impact or trust. For the adherence to treatment before and after a minor bleed the Medication Adherence Rating Scale (MARS-5) questionnaire was used. The total MARS-5 score ranges from 5 to 25; score 5 is indicative of poor adherence and 25 suggest perfect adherence. Furthermore, the impact (restrictions) of a bleed on physical activities and daily life was assessed using a VAS score ranging from 1 to 10; score 10 representing the highest level of restriction. RESULTS A total of 142 patients were included. During NOAC treatment, minor bleeds were reported by 87 patients (61%) of whom 16 (11%) suffered from a CRNMB. All patients that suffered from a CRNMB contacted their treating physician and 13 received treatment. The most frequently reported CRNMBs were epistaxis (n = 6), a bleed after injury (n = 3), rectal bleed (n = 2) and an eye bleed (n = 2). With regard to the impact of a CRNMB, the median level of annoyance was 8 (min-max 2-10)) and the level of concern 4 (min-max 1-10). The MARS-5 score for adherence to treatment was only marginally influenced. Also the level of trust remained high after the CRNMB. Out of 12 patients, only 2 patients reported a reduction of 1 and 8 points, respectively. Ten patients scored no change and one patient scored a 1 point increase in the level of trust. The mean reduction in trust was 0.7 (95%CI -0.8 to 2.2). With regard to the reported restrictions on physical activities, 8 out of 12 patients reported no (score 1) or only marginal impact (score 2), 2 patients reported a moderate impact (score 5 and 6) and 2 patients reported a high impact score 7 (mean score 2.9 (95%CI 1.3-4.5). For the daily life impact question, 5 out of 9 patients reported no or only marginal impact, 3 patients reported a moderate impact (scores 4 and 5) and 1 patient reported maximal impact (score 10) (mean score 3.2 (95%CI 0.9-5.5)). CONCLUSION In our study the level of trust, annoyance and concern were not significantly impacted by the CRNMB, nor the adherence to treatment and impact on daily life and physical activities. However, on an individual basis, there were patients that reported a high impact. We hope that future data on impact of this type of minor bleeds will help us identify and guide suboptimaly adherent NOAC patients in shared decision manner.
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Affiliation(s)
- Darko Mitrovic
- Department of Hospital Pharmacy Tjongerschans, Heerenveen, The Netherlands
| | - Nic Veeger
- Department of Pharmacotherapy, Epidemiology and Economy, Faculty Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Eric van Roon
- Department of Pharmacotherapy, Epidemiology and Economy, Faculty Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy Medical Centre Leeuwarden, Leeuwarden, the Netherlands
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28
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC Asia 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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30
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Holt A, Strange JE, Rasmussen PV, Blanche P, Nouhravesh N, Jensen MH, Schjerning AM, Schou M, Torp-Pedersen C, Gislason GH, Hansen ML, McGettigan P, Lamberts M. Bleeding Risk Following Systemic Fluconazole or Topical Azoles in Patients with Atrial Fibrillation on Apixaban, Rivaroxaban, or Dabigatran. Am J Med 2022; 135:595-602.e5. [PMID: 34861201 DOI: 10.1016/j.amjmed.2021.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bleeding safety in relation to use of systemic fluconazole and topical azoles among patients with atrial fibrillation treated with apixaban, rivaroxaban, or dabigatran is insufficiently explored, despite clinical relevance and several reports suggesting associations. METHODS Using nationwide Danish registers, we identified patients with atrial fibrillation initiated on apixaban, rivaroxaban, or dabigatran from 2012-2018. We investigated associations between bleeding incidents and systemic fluconazole or topical azole treatment using a case-crossover design with 30-day exposure windows and reported odds ratios (OR) with 95% confidence intervals (CI). RESULTS We included 32,340 (36%), 32,409 (36%), and 24,940 (28%) patients initiated on apixaban, rivaroxaban, and dabigatran, respectively. Patients on apixaban were older (median age: 77 years; interquartile range [IQR] 70-84) compared with rivaroxaban users (median age: 75 years; IQR 68-82) and patients on dabigatran (median age: 73 years; IQR 66-80). Apixaban users had a significantly increased risk of bleeding following exposure to systemic fluconazole: odds ratio (OR) 3.5; 95% confidence interval (CI), 1.4-10.6. No increased risk was found among rivaroxaban and dabigatran users: ORs of 0.9 (95% CI, 0.2-3.0) and 1.7 (95% CI, 0.5-5.6), respectively. As to bleeding risk pertaining to topical azole exposure among apixaban, rivaroxaban, and dabigatran users, no association was found, with corresponding ORs of 0.8 (95% CI, 0.5-1.3); 1.3 (95% CI, 0.9-2.1); and 1.2 (95% CI 0.8-1.8), respectively. CONCLUSION In patients with atrial fibrillation on either apixaban, rivaroxaban, or dabigatran, an association between an elevated bleeding risk and use of systemic fluconazole was found among patients on apixaban. We found no increased risk of bleeding following co-exposure to topical azoles.
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Affiliation(s)
- Anders Holt
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark.
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | - Peter Vibe Rasmussen
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | - Paul Blanche
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark; Section of Biostatistics, University of Copenhagen, Denmark
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | - Mads Hashiba Jensen
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | | | - Morten Schou
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Departments of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark; Danish Heart Foundation, Copenhagen, Denmark
| | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
| | - Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hosptial - Herlev and Gentofte, Copenhagen, Denmark
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31
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Galvain T, Hill R, Donegan S, Lisboa P, Lip GYH, Czanner G. The management of anticoagulants in patients with atrial fibrillation and history of falls or risk of falls: protocol for a systematic review and meta-analysis. Syst Rev 2022; 11:63. [PMID: 35395931 PMCID: PMC8991693 DOI: 10.1186/s13643-022-01937-0] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 03/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation affects an estimated 33 million individuals worldwide and is a major cause of stroke, heart failure, and death. Anticoagulants substantially reduce the risk of stroke but are also associated with an increased risk of bleeding and especially intracranial hemorrhage which is the most concerning complication. Because of this, many patients are not offered anticoagulants, particularly patients at risk of falls or with a history of falls. It is unclear what anticoagulant treatment these patients should be offered. The Liverpool AF-Falls project aims to investigate this area, and this protocol for a systematic review and meta-analysis aims to define what is the most appropriate anticoagulant treatment option for the management of atrial fibrillation patients at risk of falls or with a history of falls. METHODS This systematic review and meta-analysis will include randomized and non-randomized studies evaluating the safety and efficacy of different anticoagulant treatments (vitamin K antagonist and non-vitamin K antagonist oral anti-coagulant). Bibliographic databases (Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov , Embase, MEDLINE, Scopus and Web of Science) will be searched according to a pre-specified search strategy. Titles, abstracts, and full texts will be assessed by two independent reviewers and disagreements resolved with a third independent reviewer. The Cochrane Risk of Bias tool 2 (RoB 2) will be used to assess the risk of bias in randomized trials, and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool will be used for non-randomized studies. A pairwise meta-analysis based on the fixed and random-effects models will be conducted. Publication bias will be evaluated with a funnel plot and Egger's test. Heterogeneity will be assessed with the I2 statistic. If conditions for indirect comparison are met and sufficient data are available, a network meta-analysis will be conducted using frequentist and Bayesian methodologies. DISCUSSION This review will be the first to summarize direct and indirect evidence on the safety and efficacy of anticoagulant treatments in atrial fibrillation patients at risk of falls or with a history of falls. The findings will be important to patients, clinicians, and health policy-makers to inform best practices in the use of these treatments. SYSTEMATIC REVIEW REGISTRATION PROSPERO registry number: CRD42020201086.
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Affiliation(s)
- Thibaut Galvain
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, UK.
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals, Liverpool Health Partners, Liverpool, UK
| | - Sarah Donegan
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Paulo Lisboa
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gabriela Czanner
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, UK
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Al-Jabi SW, Dalu AA, Koni AA, Khdour MR, Taha AA, Amer R, Zyoud SH. The relationship between self-efficacy and treatment satisfaction among patients with anticoagulant therapy: a cross-sectional study from a developing country. Thromb J 2022; 20:15. [PMID: 35379235 PMCID: PMC8978358 DOI: 10.1186/s12959-022-00374-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/23/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Thromboembolic events are a common complicated health problem. Although anticoagulants have several positive effects on these conditions, they also have several characteristics that strongly affect compliance and satisfaction. The purpose of this investigation is to explore the association between treatment satisfaction and self-efficacy in a sample of patients using anticoagulation therapy and determine the influence of sociodemographic and clinical factors on both aspects. METHODS This was a cross-sectional exploratory study carried out in Palestine. The Arabic version of the Anti-Coagulant Treatment Satisfaction Scale (ACTS) assessed treatment satisfaction. In addition, the Arabic version of the 6-Item Self-Efficacy for Managing Chronic Diseases (SES6C) was used to assess self-efficacy. RESULTS A total of 300 patients using anticoagulants (average age 51.95 and SD 17.98) were included. There is a modest correlation between treatment satisfaction and self-efficacy (r = 0.345; p < 0.001). The mean and median self-efficacy scores were 38.41 ± 9.88 and 39.00 (interquartile range: 33.00-46.00), respectively. Overall, patients reported a moderate burden and benefit score. The mean and median of the acting burden were 43.30 ± 10.45, and 43.30 (interquartile range: 36.00 to 51.00), respectively. The results showed that young age, higher education, employment, use of fewer medications, and having fewer diseases were significantly associated with higher self-efficacy behaviors. The results also showed that new oral anti-coagulants (NOACs) had a higher degree of self-efficacy and ACTS benefit scores (41.00 (33.75-47.00), p = 0.002; 13.00 (12.00-15.00), p < 0.001, respectively), than vitamin k antagonists (VKA). CONCLUSIONS The results demonstrated a significant relationship between treatment satisfaction and self-efficacy, and certain sociodemographic and clinical characteristics influence both. We found that there is a higher degree of self-efficacy and treatment satisfaction among patients who use NOACs than those who use UFH / VKA. Therefore, patients should be motivated to increase their knowledge about anticoagulant therapy. Healthcare providers should play an active role in educating patients, increasing their self-esteem, and awareness about anticoagulant drugs. Importantly, this study was an explanatory one, and it includes a low proportion of patients with venous thromboembolism. This encourages future research on a large scale of patients, considering the indications of anticoagulant therapy.
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Affiliation(s)
- Samah W. Al-Jabi
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Amal Abu Dalu
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Amer A. Koni
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Division of Clinical Pharmacy, Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Maher R. Khdour
- grid.16662.350000 0001 2298 706XFaculty of Pharmacy, Al-Quds University, Abu Deis, Jerusalem, 51000 Palestine
| | - Adham Abu Taha
- grid.11942.3f0000 0004 0631 5695Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Pathology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Riad Amer
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Sa’ed H. Zyoud
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Clinical Research Center, An-Najah National University Hospital, Nablus, 44839 Palestine
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Biller K, Biller B, Findeisen H, Eckardt L, Wedekind H. Resolution of left atrial appendage thrombi: No difference between phenprocoumon and non-vitamin K-dependent oral antagonists. Clin Cardiol 2022; 45:650-656. [PMID: 35373849 PMCID: PMC9175243 DOI: 10.1002/clc.23823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/13/2022] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation is the most important risk factor for left atrial appendage (LAA) thrombi, a potentially life‐threatening condition. Thrombus resolution may prevent embolic events and allow rhythm‐control strategies, which have been shown to reduce cardiovascular complications. Hypothesis There is no significant difference between phenprocoumon and non‐Vitamin K‐dependent oral anticoagulants (NOACs) in the resolution of LAA‐thrombi in a real‐world setting. Methods Consecutive patients with LAA‐thrombi from June 2013 to June 2017 were included in an observational single‐center analysis. The primary endpoint was defined as the resolution of the thrombus. The observational period was 1 year. Resolutions rates in patients on phenprocoumon or NOACs were compared and the time to resolution was analyzed. Results We identified 114 patients with LAA‐thrombi. There was no significant difference in the efficacy of resolution between phenprocoumon and NOACs (p = .499) at the time of first control which took place after a mean of 58 ± 42.2 (median 48) days. At first control most thrombi were dissolved (74.6%). The analysis after set‐time intervals revealed a resolution rate of 2/3 of LAA‐thrombi after 8–10 weeks in the phenprocoumon and NOAC groups. After 12 weeks a higher number of thrombi had resolved in the presence of NOAC (89.3%) whereas in the presence of phenprocoumon 68.3% had resolved (p = .046). Conclusion In this large observational study NOACs were found to be potent drugs for the resolution of LAA‐thrombi. In addition, the resolution of LAA‐thrombi was found to be faster in the presence of NOAC as compared to phenprocoumon.
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Affiliation(s)
- Katharina Biller
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital, Münster, Germany
| | - Benedikt Biller
- Department of Cardiology II-Electrophysiology, University Hospital, Münster, Germany
| | - Hannes Findeisen
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II-Electrophysiology, University Hospital, Münster, Germany
| | - Horst Wedekind
- Department of Cardiology, St. Franziskus-Hospital, Münster, Germany
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Cheung ZB, Xiao R, Forsh DA. Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review. Arch Orthop Trauma Surg 2022; 142:633-40. [PMID: 33417028 DOI: 10.1007/s00402-020-03701-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early surgery has been consistently demonstrated to reduce complications and mortality in hip fracture patients. There remains no general consensus, however, regarding the optimal time to surgery for hip fracture patients who are on novel oral anticoagulants (NOAC) on admission and its effect on clinical outcomes after surgery. The objective of this review was to assess the effect of preoperative NOAC therapy on time to surgery and postoperative complications in hip fracture patients. METHODS We performed a systematic review of the literature using the PubMed, Embase, and Cochrane Library electronic databases. Relevant articles were identified and included if they: (i) included patients on NOAC therapy on admission who did not undergo reversal; (ii) included a control group of patients not on any anticoagulation; (iii) included time from admission to surgery; and (iv) included one of the following outcomes: blood transfusion, venous thromboembolism (VTE), stroke, readmission, and mortality. RESULTS Nine studies were included with a total of 4,419 patients. There were 414 NOAC patients and 4,005 non-anticoagulated patients. Six of the nine studies found a significant increase in time to surgery for patients on NOAC therapy. Three of the seven studies that reported rates of blood transfusion found a significantly higher incidence of transfusion in patients on NOACs. None of the studies found a significant difference in VTE and stroke. One of the two studies that reported readmissions showed a higher risk of readmission for patients on NOACs. Eight of the nine included studies found no significant difference in postoperative mortality rates between the NOAC and control groups, with the remaining study finding a higher mortality rate only in patients on NOAC therapy who underwent fixation and not those who underwent arthroplasty. CONCLUSIONS These mixed findings suggest that delay to surgery may not be warranted in the urgent surgical setting of patients on NOAC therapy who sustain hip fractures.
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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Joosten LPT, de Boer AR, van Eerde EJB, van Doorn S, Hoes AW, Bots ML, Rutten FH, Geersing GJ. Atrial fibrillation: trends in prevalence and antithrombotic prescriptions in the community. Neth Heart J 2022. [PMID: 35230637 DOI: 10.1007/s12471-022-01667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction In the past decade, the atrial fibrillation (AF) landscape, including the treatment modalities, has drastically changed. This raises the question how AF prevalence and choices in antithrombotic therapy prescription have developed in the community over time. Methods Routine care data from the Julius General Practitioners’ Network (JGPN) were used to calculate the yearly prevalence of AF and to quantify the percentage of all patients who were prescribed a platelet inhibitor, vitamin K antagonist (VKA), non-VKA oral anticoagulant (NOAC) or no antithrombotic medication. To explore whether certain patient characteristics are associated with selective prescription of oral anticoagulants (OAC), we applied logistic regression analyses. Results From 2008 through 2017, the JGPN database included 7459 unique AF patients. During this period, the prevalence of AF increased from 0.4% to 1.4%. The percentage of patients prescribed a VKA declined from 47% to 41%, whereas the percentage of patients prescribed a NOAC rose from 0% to 20%. In patients with new-onset AF, older age, heart failure, diabetes mellitus, vascular disease and dementia were independently associated with a higher likelihood of VKA rather than NOAC prescription. In 2017, 25% of all patients with AF and a CHA2DS2-VASc score ≥ 2 were not prescribed OAC therapy (i.e. 8% with platelet inhibitor monotherapy and 17% without any antithrombotic therapy). Conclusion Between 2008 and 2017, AF prevalence in the community more than tripled. Prescription patterns showed possible ‘channelling’ of VKAs over NOACs in frailer, elderly patients, whereas still about one in every four AF patients with a CHA2DS2-VASc score ≥ 2 was not prescribed any prophylactic OAC therapy. Supplementary Information The online version of this article (10.1007/s12471-022-01667-x) contains supplementary material, which is available to authorized users.
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Liao JN, Chan YH, Kuo L, Tsai CT, Lim SS, Chao TF. Optimal anticoagulation in elderly patients with atrial fibrillation: Which drug at which dose? Kardiol Pol 2022; 80:128-136. [PMID: 35167115 DOI: 10.33963/kp.a2022.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
Aging is an important risk factor for adverse events in elderly patients with atrial fibrillation (AF) and complicates the management of anticoagulation. Underuse of oral anticoagulants (OACs) is common in elderly patients because of comorbidities, the altered physiological function of multiple organs, frailty, risk of falls, and the lack of randomized controlled trials (RCTs) specifically for elderly patients. Nevertheless, current data still support OACs use for reducing ischemic stroke with positive net clinical benefits. Sub-analyses of RCTs and real-world cohort studies showed that non-vitamin K antagonist OACs (NOACs) would be more favorable choices compared to warfarin for stroke prevention in the elderly. This review will discuss important data on stroke prevention and the use of NOACs in elderly AF patients.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Su-Shen Lim
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. .,Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Grajek S, Kałużna-Oleksy M. Do non-vitamin K antagonist oral anticoagulants increase the risk of myocardial infarction? Kardiol Pol 2022; 80:16-24. [PMID: 35137946 DOI: 10.33963/kp.a2022.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 11/23/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs), compared with warfarin, have a favorable risk-benefit profile. However, in the RE-LY study in patients with atrial fibrillation (AF), the number of patients with MI was higher in the dabigatran group as compared to the warfarin group. Many meta-analyses showed that dabigatran treatment led to an increased risk of myocardial infarction (MI). Large real-world data (RWD) did not confirm an increase in the risk of MI during dabigatran treatment. In our meta-analysis we excluded RWD, and each of the four drugs was evaluated in two key-phase III randomized controlled trials: in patients with AF and patients with AF and chronic coronary syndrome or acute coronary syndrome treated with percutaneous coronary interventions. In each study, warfarin was the comparator for NOACs. In this homogeneous group of patients, dabigatran, in direct comparison with warfarin, significantly increased the risk of MI by about 30%. Moreover, the risk of MI was also significantly higher than the opposite effect of activated factor (F) X inhibitors (FXa inhibitors) vs. warfarin. In our network meta-analysis, considering individual NOACs in recommended doses, we found an increased risk of MI compared to warfarin only in patients treated with dabigatran 150 mg twice a day and, in particular, 110 mg twice a day. In this review we present evidence supporting our opinion that in patients with AF and coronary stenting, the choice of NOACs (direct FXa vs. thrombin inhibitors) is equally as important as choosing the optimal antiplatelet therapy (single or dual antiplatelet therapy).
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Affiliation(s)
- Stefan Grajek
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland.
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Grymonprez M, Vanspranghe K, Capiau A, Boussery K, Steurbaut S, Lahousse L. Impact of P-glycoprotein and/or CYP3A4-interacting drugs on effectiveness and safety of NOACs in patients with atrial fibrillation: a meta-analysis. Br J Clin Pharmacol 2022; 88:3039-3051. [PMID: 35132677 DOI: 10.1111/bcp.15265] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/24/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022] Open
Abstract
AIM P-glycoprotein (P-gp) and CYP3A4-interacting drugs influence plasma levels of non-vitamin K antagonist oral anticoagulants (NOACs). However, the clinical relevance is questioned. Therefore, the impact of pharmacokinetically-interacting drugs on the effectiveness and safety of NOACs in patients with atrial fibrillation (AF) was investigated. METHODS A meta-analysis was performed based on randomized controlled trials and observational studies retrieved from Pubmed and Embase, that investigated the impact of concomitantly used P-gp/CYP3A4-interacting drugs on the risk-benefit profile of NOACs in AF patients. RESULTS Fifteen studies were included, investigating 21,711 and 306,421 NOAC-treated AF patients with and without P-gp/CYP3A4 inhibitor use respectively, while only one study included P-gp/CYP3A4 inducers. In NOAC-treated AF patients, concomitant use of P-gp/CYP3A4 inhibitors was associated with significantly higher major bleeding (relative risk (RR) 1.10, 95% confidence interval (CI) (1.01-1.19)) and all-cause mortality risks (RR 1.14, 95%CI (1.05-1.23)) compared to not using P-gp/CYP3A4 inhibitors, while the risks of stroke/SE (RR 0.88, 95%CI (0.77-1.01)), intracranial bleeding (RR 0.89, 95%CI (0.68-1.15)) and gastro-intestinal bleeding (RR 1.09, 95%CI (0.91-1.30)) were not significantly different. Concomitant use of amiodarone with NOACs was associated with lower thromboembolic (RR 0.75, 95%CI (0.61-0.92)), similar major bleeding (RR 0.92, 95%CI (0.80-1.07)), but higher mortality risks (RR 1.21, 95%CI (1.05-1.39)). Co-administration of verapamil or diltiazem was associated with higher major bleeding risks (RR 1.64, 95%CI (1.31-2.06)), but comparable thromboembolic (RR 1.10, 95%CI (0.75-1.61)) and mortality risks (RR 1.01, 95%CI (0.77-1.33)). CONCLUSION Given the higher bleeding and mortality risks in NOAC-treated AF patients concomitantly using P-gp/CYP3A4 inhibitors, close monitoring is warranted.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Kevin Vanspranghe
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.,Department of Hospital Pharmacy, UZ Brussel, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Martha JW, Pranata R, Raffaelo WM, Wibowo A, Akbar MR. Direct Acting Oral Anticoagulant vs. Warfarin in the Prevention of Thromboembolism in Patients With Non-valvular Atrial Fibrillation With Valvular Heart Disease-A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:764356. [PMID: 35096994 PMCID: PMC8797143 DOI: 10.3389/fcvm.2021.764356] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/04/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose: There is uncertainty as to which anticoagulant should be used in non-valvular atrial fibrillation (AF) with valvular heart disease. This systematic review and meta-analysis aimed to assess the efficacy and safety of direct-acting oral anticoagulants (DOACs) compared with warfarin in patients with non-valvular AF with valvular heart disease. Methods: We performed a comprehensive literature search using PubMed, Scopus, Embase, and Clinicaltrials.gov from the inception of databases up until August 2, 2021, and the search was updated and finalized on October 17, 2021. The intervention group was DOACs and the control group was warfarin. The primary outcome was systemic embolism and stroke (SSE), and the secondary outcome was major bleeding and intracranial hemorrhage. The pooled effect estimate was reported as the hazard ratio (HR) and odds ratio (OR). Results: There were 21,185 patients from seven studies included in this systematic review and meta-analysis. Stroke and systemic embolism were lower in patients receiving DOACs [HR 0.76 (95% CI 0.67, 0.87), p < 0.001; I2: 5%] compared with warfarin. The subgroup analysis on RCTs showed the significant reduction of SSE in the DOACs group [HR 0.73 (95% CI 0.60, 0.89), p = 0.002; I2: 16%]. There was no significant difference in terms of major bleeding [HR 0.89 (95% CI 0.75, 1.05), p = 0.18; I2: 69%]. Intracranial hemorrhage [HR 0.42 (95% CI 0.22, 0.80), p = 0.008; I2: 73%] were lower in the DOAC group. Conclusion: This meta-analysis indicates that DOACs were associated with a lower risk of SSE and intracranial hemorrhage compared with patients receiving warfarin. There was no significant difference between the two groups in terms of major bleeding.
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Affiliation(s)
- Januar Wibawa Martha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | | | - Arief Wibowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
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Guise PA, Wang K. Haemorrhagic complications following cataract and vitreoretinal surgery with sub-Tenon's block in patients receiving non-vitamin K oral anticoagulant agents: A prospective audit. Anaesth Intensive Care 2022; 50:289-294. [PMID: 35078342 DOI: 10.1177/0310057x211057136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is a lack of data to support either continuation or interruption of non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery. A prospective audit was undertaken of 291 patients undergoing cataract surgery or vitreoretinal surgery, predominantly under sub-Tenon's block, while continuing these agents. The median time from last non-vitamin K oral anticoagulant dose to the insertion of sub-Tenon's block was five hours. No patient required emergency reversal of anticoagulation. There were no sight-threatening complications in the immediate perioperative period, although two vitreoretinal patients (3.8%) had a moderate haemorrhagic complication on day five, and two cataract patients (0.8%) had a minor haemorrhagic complication on days one and 14 postoperatively. Despite continuing their non-vitamin K oral anticoagulants, three (1%) cataract patients had a moderate thromboembolic complication within the 30-day postoperative period. The risk of haemorrhagic complications associated with continuation of anticoagulation with non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery is low, and this audit supports the continuation of non-vitamin K oral anticoagulants for our patients having cataract and vitreoretinal surgery.
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Affiliation(s)
- Philip A Guise
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Kailun Wang
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Tütüncü S, Olma M, Kunze C, Dietzel J, Schurig J, Fiessler C, Malsch C, Haas TE, Dimitrijeski B, Doehner W, Hagemann G, Hamilton F, Honermann M, Jungehulsing GJ, Kauert A, Koennecke HC, Mackert BM, Nabavi D, Nolte CH, Reis JM, Schmehl I, Sparenberg P, Stingele R, Völzke E, Waldschmidt C, Zeise-Wehry D, Heuschmann PU, Endress M, Haeusler KG. Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry. J Neurol 2022; 269:470-480. [PMID: 34718884 PMCID: PMC8739306 DOI: 10.1007/s00415-021-10866-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022]
Abstract
AIMS We aimed to analyze prevalence and predictors of NOAC off-label under-dosing in AF patients before and after the index stroke. METHODS The post hoc analysis included 1080 patients of the investigator-initiated, multicenter prospective Berlin Atrial Fibrillation Registry, designed to analyze medical stroke prevention in AF patients after acute ischemic stroke. RESULTS At stroke onset, an off-label daily dose was prescribed in 61 (25.5%) of 239 NOAC patients with known AF and CHA2DS2-VASc score ≥ 1, of which 52 (21.8%) patients were under-dosed. Under-dosing was associated with age ≥ 80 years in patients on rivaroxaban [OR 2.90, 95% CI 1.05-7.9, P = 0.04; n = 29] or apixaban [OR 3.24, 95% CI 1.04-10.1, P = 0.04; n = 22]. At hospital discharge after the index stroke, NOAC off-label dose on admission was continued in 30 (49.2%) of 61 patients. Overall, 79 (13.7%) of 708 patients prescribed a NOAC at hospital discharge received an off-label dose, of whom 75 (10.6%) patients were under-dosed. Rivaroxaban under-dosing at discharge was associated with age ≥ 80 years [OR 3.49, 95% CI 1.24-9.84, P = 0.02; n = 19]; apixaban under-dosing with body weight ≤ 60 kg [OR 0.06, 95% CI 0.01-0.47, P < 0.01; n = 56], CHA2DS2-VASc score [OR per point 1.47, 95% CI 1.08-2.00, P = 0.01], and HAS-BLED score [OR per point 1.91, 95% CI 1.28-2.84, P < 0.01]. CONCLUSION At stroke onset, off-label dosing was present in one out of four, and under-dosing in one out of five NOAC patients. Under-dosing of rivaroxaban or apixaban was related to old age. In-hospital treatment after stroke reduced off-label NOAC dosing, but one out of ten NOAC patients was under-dosed at discharge. CLINICAL TRIAL REGISTRATION NCT02306824.
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Affiliation(s)
- Serdar Tütüncü
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel Olma
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joanna Dietzel
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelia Fiessler
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Eberhard Haas
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | | | - Wolfram Doehner
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- BCRT-Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Georg Hagemann
- Department of Neurology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Martin Honermann
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | | | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | | | | | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Joschua Mirko Reis
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Ingo Schmehl
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Robert Stingele
- Department of Neurology, German Red Cross Hospital Berlin Köpenick, Berlin, Germany
| | - Enrico Völzke
- Department of Neurology, Schlosspark-Klinik Berlin, Berlin, Germany
| | | | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, Clinical Trial Centre Würzburg, University of Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Endress
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner site Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
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Nepal G, Kharel S, Bhagat R, Ka Shing Y, Ariel Coghlan M, Poudyal P, Ojha R, Sunder Shrestha G. Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis. Acta Neurol Scand 2022; 145:10-23. [PMID: 34287841 DOI: 10.1111/ane.13506] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 05/11/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Megan Ariel Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Prasanta Poudyal
- Department of Otorhinolaryngology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Gentle Sunder Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
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Valery JR, Marar A, Pujalte G, Ward C, Abdelmoneim YM, Fitzgerald PJ, Mwakyanjala E, Harris DM, Murray L, Heckman MG, White LJ, Stancampiano F. Assessment of Knowledge Regarding Risks and Benefits of the Use of Non-Vitamin K Antagonist Oral Anticoagulants. J Prim Care Community Health 2022; 13:21501319221118806. [PMID: 36000450 PMCID: PMC9424872 DOI: 10.1177/21501319221118806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOAC) have replaced vitamin K antagonist (VKA) oral anticoagulants as the first-line treatment option for stroke prevention in high-risk patients with atrial fibrillation. With VKA therapy, disease and treatment-related knowledge is associated with improved adherence and outcomes. There is concern that due to the lack of need for ongoing visits for laboratory monitoring in patients on NOACs, there is less opportunity for education, leading to poor disease- and treatment-related knowledge in this patient group. METHODS One hundred ninety-nine (199) patients presenting to 2 primary care clinics on NOAC therapy were surveyed regarding atrial fibrillation and their knowledge regarding NOACs. Chart review was completed to determine patient characteristics and data obtained was compared with survey results to determine the accuracy of the survey responses. RESULTS Patients with a lower degree of NOAC knowledge tended to be older (P < .001), have higher Charlson Comorbidity Index scores (P = .001), use apixaban more often (P = .008), and have been on NOACs for a shorter time period (P = .007). CONCLUSIONS There is an opportunity to improve NOAC-related knowledge in patients with atrial fibrillation. When developing educational interventions, patient characteristics associated with poor knowledge should be considered. Based on our results, these are patients who are older, more medically complex, are on apixaban, and have been on NOAC therapy for a shorter duration.
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Affiliation(s)
- Jose Raul Valery
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ahmad Marar
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | - George Pujalte
- Division of Family Medicine, and Orthopedics, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Cynthia Ward
- Primary Care Pharmacy, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Yousif M Abdelmoneim
- Division of Laboratory Medicine and Pathology Mayo Clinic Florida, Jacksonville, FL, USA
| | - Patrick J Fitzgerald
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Edson Mwakyanjala
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dana M Harris
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Loren Murray
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Michael G Heckman
- Division of Clinical Trials and Biostatistics, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Launia J White
- Division of Clinical Trials and Biostatistics, Mayo Clinic Florida, Jacksonville, FL, USA
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Honan KA, Jogimahanti A, Khair T. An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus. Am J Med 2022; 135:17-23. [PMID: 34469758 DOI: 10.1016/j.amjmed.2021.07.023] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022]
Abstract
Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy-specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020-by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.
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Affiliation(s)
- Kevin A Honan
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston.
| | - Arjun Jogimahanti
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
| | - Tarif Khair
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
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46
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Aguilar F, Lo KB, Quintero EE, Torres RJ, Hung WA, Albano JC, Alviz I, Rodriguez C, Garcia MJ, Romero J, Slipczuk L. Off-label direct oral anticoagulants dosing in atrial fibrillation and venous thromboembolism is associated with higher mortality. Expert Rev Cardiovasc Ther 2021; 19:1119-1126. [PMID: 34879208 DOI: 10.1080/14779072.2021.2013816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) off-label use data is lacking. Our study aimed to assess the clinical outcomes in a racially mixed population treated for atrial fibrillation (AF) and venous thromboembolism (VTE). METHODS We retrospectively evaluated six months of DOAC prescriptions for AF or VTE treatment. Prescriptions were classified as off-label or appropriate following FDA labeling. The off-label group was sub-classified as under or overdosing. RESULTS Of the 1,087 DOAC prescriptions, 67% were for AF. African Americans and Caucasians were equally represented. There were 171 (16%) inappropriate prescriptions, with 106 (62%), being underdosed. The off-label group had a higher 30-day readmissions risk (OR = 1.69, 95% CI:1.11-2.54, p = 0.012) and 1-year all-cause mortality (OR = 1.90, 95% CI:1.02-3.37, p = 0.032). There was no difference in major bleeding (OR = 1.27, 95% CI:0.63-2.37, p = 0.480) or new thromboembolism (OR = 1.27, 95% CI:0.73-2.13, p = 0.369) between the groups. Underdosing carried a higher risk of new thromboembolism (OR = 3.15, 95% CI:1.09-9.15, p = 0.024). CONCLUSIONS One in every six patients received off-label DOACs dosing. Off-label use had increased 30-day readmissions and 1-year all-cause mortality. Underdosing was associated with a higher risk of new thromboembolism.
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Affiliation(s)
- Francisco Aguilar
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Kevin B Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | - Ricardo J Torres
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Wikien A Hung
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Jeri C Albano
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Isabella Alviz
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Carlos Rodriguez
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Jorge Romero
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
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Mone P, Trimarco B, Santulli G. Aspirin, NOACs, warfarin: which is the best choice to tackle cognitive decline in elderly patients? Insights from the GIRAF and ASCEND-Dementia trials presented at the AHA 2021. Eur Heart J Cardiovasc Pharmacother 2021; 8:E7-E8. [PMID: 34849683 PMCID: PMC9890627 DOI: 10.1093/ehjcvp/pvab081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Pasquale Mone
- Departments of Medicine and Molecular Pharmacology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, New York, NY, USA,ASL (Azienda Sanitaria Locale–Local Health Unit) AV, Avellino, Italy,Department of Preventive Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Gaetano Santulli
- Corresponding author. Departments of Medicine and Molecular Pharmacology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, New York City, NY, USA. Tel: 00171843033370;
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Angelini F, Bocchino PP, Peyracchia M, Saglietto A, Magnano M, Patanè N, D’Ascenzo F, Giustetto C, Anselmino M, Gaita F, Toso E. Prevalence and predictors of left atrial thrombosis in atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants. Acta Cardiol 2021; 78:290-297. [PMID: 34821203 DOI: 10.1080/00015385.2021.2005307] [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] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure. RESULTS A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA2DS2-VASc score > 3 (OR 4.54, 95% CI 1.50 - 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 - 18.50, p value = .001). CONCLUSIONS Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA2DS2-VASc score > 3 and obesity.
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Affiliation(s)
- Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Mattia Peyracchia
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Massimo Magnano
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Nicolò Patanè
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Carla Giustetto
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
| | - Elisabetta Toso
- Division of Cardiology, Cardiovascular and Thoracic Department of Medical Sciences, University of Turin and ‘Città della Salute e della Scienza’ Hospital, Turin, Italy
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Manfredini M, Poli PP, Creminelli L, Porro A, Maiorana C, Beretta M. Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery. J Clin Med 2021; 10:5526. [PMID: 34884228 PMCID: PMC8658703 DOI: 10.3390/jcm10235526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. MATERIALS AND METHODS A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. RESULTS 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. CONCLUSIONS No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. CLINICAL RELEVANCE direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.
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Affiliation(s)
| | | | | | - Alberto Porro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Odontostomatology Unit, University of Milan, Via della Commenda 10, 20122 Milan, Italy; (M.M.); (P.P.P.); (L.C.); (C.M.); (M.B.)
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AlSheef M, Gray J, AlShammari A. Risk of postoperative bleeding following dental extractions in patients on antithrombotic treatment. Saudi Dent J 2021; 33:511-7. [PMID: 34803294 DOI: 10.1016/j.sdentj.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/02/2020] [Accepted: 09/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The risk of bleeding after dental extractions in patients taking antithrombotic medication is not well known. This study aims to investigate the incidence of postoperative bleeding following dental extractions in adult patients taking antithrombotic medication in Saudi Arabia. Methods This retrospective study included 539 patients aged 18–93 years who attended 840 appointments for dental extractions from January 2012 to June 2016 at a tertiary care hospital in Saudi Arabia. Patients who returned with a complaint of bleeding were treated with local hemostatic measures as outpatients. Results and Conclusion: Only 1.7% of extraction appointments were associated with postoperative bleeding. The highest risk of bleeding was noted in patients receiving warfarin (3.88%), whereas those on clopidogrel had no significant risk of bleeding. Women were found to have the highest rate of bleeding, particularly those on newer oral anticoagulant medications. Dental extractions can be safely done in adults receiving antithrombotic treatment, provided established guidelines are followed; therefore, dental professionals must exercise caution when planning invasive dental treatment for patients on continued antithrombotic therapy.
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