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Hewage SA, Noviyani R, Brain D, Sharma P, Parsonage W, McPhail SM, Barnett A, Kularatna S. Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality. Cost Eff Resour Alloc 2023; 21:76. [PMID: 37872572 PMCID: PMC10591401 DOI: 10.1186/s12962-023-00486-0] [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: 03/23/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations. METHODS We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively. RESULTS In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common. CONCLUSIONS While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.
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Affiliation(s)
- Sumudu A Hewage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia.
| | - Rini Noviyani
- Department of Pharmacy, Udayana University, Bali, Indonesia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Cardiology department, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, QLD, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
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Sidhu V, Badge H, Churches T, Maree Naylor J, Adie S, A Harris I. Comparative effectiveness of aspirin for symptomatic venous thromboembolism prophylaxis in patients undergoing total joint arthroplasty, a cohort study. BMC Musculoskelet Disord 2023; 24:629. [PMID: 37537580 PMCID: PMC10401792 DOI: 10.1186/s12891-023-06750-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA). METHODS Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student's t and Fisher's exact tests (unadjusted) and multivariable regression (adjusted). RESULTS There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration < 14 days (OR = 6.7, 95% CI 3.5-13.1, p < 0.001) and history of previous VTE (OR = 2.4, 95% CI 1.1-5.8, p = 0.05). There were no significant differences in the primary or secondary outcomes between prophylaxis groups. CONCLUSIONS Aspirin may be suitable for VTE prophylaxis following THA and TKA. The comparatively low unadjusted 90-day VTE rate in the aspirin group may have been due to selective use in lower-risk patients. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov, trial number NCT01899443 (15/07/2013).
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Affiliation(s)
- Verinder Sidhu
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia.
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia.
| | - Helen Badge
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Timothy Churches
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Justine Maree Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Juneja D, Nasa P, Jain R. Liver injury from direct oral anticoagulants. World J Hepatol 2023; 15:841-849. [PMID: 37397936 PMCID: PMC10308284 DOI: 10.4254/wjh.v15.i6.841] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/23/2023] [Accepted: 05/15/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Drug-induced liver injury (DILI) can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs. Direct-acting oral anticoagulants (DOACs) are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions. A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs. However, it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.
AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.
METHODS A systematic search was conducted on multiple databases including PubMed, Science Direct, Reference Citation Analysis, and Google Scholar. The search terms included “Acute Liver Failure” OR “Acute-On-Chronic Liver Failure” OR “Acute Chemical and Drug Induced Liver Injury” OR “Chronic Chemical and Drug Induced Liver Injury” AND “Factor Xa Inhibitors” OR “Dabigatran” OR “Rivaroxaban” OR “apixaban” OR “betrixaban” OR “edoxaban” OR “Otamixaban”. The results were filtered for literature published in English and on adult patients. Only case reports and case studies reporting cases of DILI secondary to DOACs were included. Data on demographics, comorbidities, medication history, laboratory investigations, imaging, histology, management, and outcomes were extracted.
RESULTS A total of 15 studies (13 case reports and 2 case series) were included in the analysis, comprising 27 patients who developed DILI secondary to DOACs. Rivaroxaban was the most commonly implicated DOAC (n = 20, 74.1%). The mean time to onset of DILI was 40.6 d. The most common symptoms were jaundice (n = 15, 55.6%), malaise (n = 9, 33.3%), and vomiting (n = 9, 33.3%). Laboratory investigations showed elevated liver enzymes and bilirubin levels. Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury. Most patients had a favourable outcome, and only 1 patient (3.7%) died due to liver failure.
CONCLUSION DOACs are increasingly used for various clinical conditions, and DILI secondary to DOACs is a rare but potentially serious complication. Prompt identification and cessation of the offending drug are crucial for the management of DILI. Most patients with DILI secondary to DOACs have a favourable outcome, but a small proportion may progress to liver failure and death. Further research, including post-marketing population-based studies, is needed to better understand the incidence and risk factors for DILI secondary to DOACs.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
| | - Prashant Nasa
- Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, United Arab Emirates
| | - Ravi Jain
- Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302001, Rajasthan, India
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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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Samarai D, Isma N, Lindstedt S, Hlebowicz J. Novel oral anticoagulant use in adults with congenital heart disease: a single-center experience report. Egypt Heart J 2023; 75:3. [PMID: 36624331 PMCID: PMC9829939 DOI: 10.1186/s43044-022-00326-1] [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: 07/07/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) are a group with an increased risk of thromboembolic complications and arrhythmias. Vitamin K antagonists are the most commonly used thromboprophylaxis therapy in this population. Studies on the efficacy and safety of novel oral anticoagulants (NOAC) are scare in ACHD. A retrospective study on ACHD patients on NOAC treatment registered in the National Quality Registry for Congenital Heart Disease, SWEDCON, and National Quality Registry for Atrial fibrillation and Anticoagulation, AuriculA, from Southern Sweden. RESULTS Thirty patients who had been taking NOAC treatment for a minimum of 3 months were included. Their median age was 55 years (SD 17 years) and 57% were male. Median follow-up was 17 months (IQR: 10-41). Eliquis was the most used NOAC (47%). Median CHA2DS2-VASc score was 2 (IQR: 0-3) and HAS-BLED was 1 (IQR: 0-2). Complex ACHD was prevalent in 27% of the patients. No thromboembolic events were recorded; however, one major bleeding, unspecified, was reported during the total cumulative patient follow-up time of 64 years. CONCLUSIONS The results of our study, although limited in size, suggest that NOAC appear safe and effective in ACHD patients. Further and larger studies on NOAC in ACHD patients are warranted.
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Affiliation(s)
- Daniel Samarai
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden
| | - Nazim Isma
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiology, Skåne University Hospital, Lund University, Entrégatan 7, 221 85 Lund, Sweden
| | - Sandra Lindstedt
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiothoracic Surgery, Lund University, Lund University Hospital, Lund, Sweden
| | - Joanna Hlebowicz
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiology, Skåne University Hospital, Lund University, Entrégatan 7, 221 85 Lund, Sweden
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Ripoll JG, Klompas AM, Smith BB, Smith MM. Contemporary Perioperative Management of Direct Oral Anticoagulants. Adv Anesth 2022; 40:93-109. [PMID: 36333054 DOI: 10.1016/j.aan.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
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Hamdy MMA, Korany MA, Ebied SA, Haggag RS. Stability-indicating RP-HPLC assay of three novel oral anticoagulants binary mixtures with rosuvastatin calcium: Application to pharmaceutical preparations and human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1193:123160. [PMID: 35189581 DOI: 10.1016/j.jchromb.2022.123160] [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: 11/01/2021] [Revised: 01/18/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
The binary mixtures of the novel oral anticoagulants (NOACs); Apixaban (APX), Edoxaban tosylate (EDX) and Rivaroxaban (RIV) with the lipid lowering statin; Rosuvastatin calcium were analyzed using a validated HPLC-DAD method. This method was suitable for the quantitative assay of the targeted mixtures in tablets and human plasma. The analysis in dosage form was a stability indicating one where the drugs were separated from possible degradation products arising from applying different stress conditions. For analysis in human plasma, EDX was used as internal standard in APX/ROS and RIV/ROS mixtures, while APX was used as internal standard in EDX/ROS mixture and the method was validated according to FDA regulation for analysis in biological fluids. A ZORBAX Eclipse column C18 (4.6 × 150 mm × 5 µm) was used as stationary phase with a gradient eluting mobile phase composed of acidified water and acetonitrile. The method selectivity was demonstrated by its ability to simultaneously analyze the drugs in presence of possible forced degradation products and dosage form excipients and in presence of plasma interferences (analysis in biological fluid) at a single wavelength (291 nm) with the use of the internal standard. The simplicity of the method emphasizes its capability to analyze the drugs in pharmaceutical preparations and human plasma. This is very important in regular clinical monitoring of the drugs plasma concentrations for cardiovascular patients medicated with either of these combinations, as prophylaxis from stroke, in order to prevent severe bleeding and to achieve optimum dose adjustment.
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Affiliation(s)
- Mohamed M A Hamdy
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt.
| | - Mohamed A Korany
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Shaza A Ebied
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Rim S Haggag
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt; Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
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Sayed A, Ghonim M, Ghonim M, Awad AK, Saleh Y, Abdelfattah OM. Are direct oral anticoagulants preferable to warfarin for the treatment of left ventricular thrombi? A Bayesian meta-analysis of randomized controlled trials. Am Heart J Plus 2021; 12:100066. [PMID: 38559599 PMCID: PMC10978137 DOI: 10.1016/j.ahjo.2021.100066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 04/04/2024]
Abstract
Background There is no clear consensus on the optimal choice of anticoagulant in patients with left ventricular thrombi (LVT). Given the potentially fatal complications associated with this disease entity, we performed a systematic review and meta-analysis of recent randomized clinical trials (RCTs) to synthesize the latest evidence on this topic. Methods We performed a comprehensive search of electronic databases to identify RCTs comparing warfarin to direct oral anticoagulants (DOACs) in patients with LVT. A random-effects Bayesian analysis using a binomial-normal hierarchical model was performed to compare the two treatment options with regards to the risk of mortality, stroke, LVT resolution, and major bleeding. Results In an analysis comprising 3 RCTs (N = 139), there were no statistically significant differences regarding mortality (OR: 0.68; 95% CrI: 0.10 to 4.43), stroke (OR: 0.14; 95% CrI: 0.01 to 1.27), or LVT resolution (OR: 1.17; 95% CrI: 0.37 to 3.45). Major bleeding was significantly lower in the DOAC group (OR: 0.16; 95% CrI: 0.02 to 0.82). Conclusion In patients with LVT, the currently available evidence from RCTs supports the use of DOACs rather than warfarin due to lower major bleeding risks and no evidence of inferiority with respect to mortality, stroke or LVT resolution.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | - Ahmed K. Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Yehia Saleh
- Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
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Wang Y, Zhang K, Yin L, Fu G, Liu Z. Dabigatran Use after Argatroban for Heparin-induced Thrombocytopenia with Thrombosis: A Case Series and Literature Review. Ann Vasc Surg 2021; 80:392.e1-392.e7. [PMID: 34656708 DOI: 10.1016/j.avsg.2021.08.022] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/14/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is immune-mediated thrombotic thrombocytopenia following the use of heparin, which contributes to a high limb-amputation rate and mortality if not appropriately handled. There is growing evidence suggesting that novel oral anticoagulants (NOACs) may be effective for treating HIT. METHODS We described five rare cases of patients with HIT associated with deep vein thrombosis treated with dabigatran, a member of NOACs. We also reviewed representative cases and literature investigating the use of NOACs to treat patients with HIT to further discuss the efficacy and safety. RESULTS AND CONCLUSIONS Following the treatment of dabigatran after argatroban, the platelet count of patients with HIT gradually elevated and reached the normal range eventually. There was no incidence of new symptomatic, objectively-confirmed arteriovenous thromboembolism observed within the 90-day-period follow up. The patient in case 3 presented with gastric bleeding after dabigatran treatment and died in the end. The results suggested that dabigatran use after argatroban may be effective in the treatment of patients with HIT. However, safety should be reconsidered since severe complications were observed in case 3.
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Affiliation(s)
- Yue Wang
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China.; Department of Cardiac Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Kaijie Zhang
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Li Yin
- Department of Vascular Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Guosheng Fu
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China..
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Xie S, Chen J, Xiong G, Li J, Wan J, Liu Y, Xu R, Zhang W. The efficacy and safety of rivaroxaban in coronary artery disease patients with heart failure and sinus rhythm: a systematic review and meta-analysis. Eur J Clin Pharmacol 2021. [PMID: 34345970 DOI: 10.1007/s00228-021-03195-w] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To explore the efficacy and safety of rivaroxaban in patients with coronary artery disease (CAD), heart failure (HF) and sinus rhythm (SR). METHODS Comprehensive literature searches were conducted using the PubMed, Cochrane Library, Embase, CNKI and Wanfang databases from inception to February 2021. Randomized controlled trials (RCTs) focusing on the efficacy and safety of new oral anticoagulant (NOAC) therapy in CAD and HF patients in SR were eligible. Statistical analyses were performed using R Programming Language. RESULTS Three RCTs included 10,658 adult patients treated with antiplatelet drugs with or without rivaroxaban were ultimately analysed. The average follow-up period was 20.4-24 months. Rivaroxaban had a favourable point estimate in myocardial infarction (MI) and stroke (MI rivaroxaban group (3.83%, 203/5306) vs. APT group (4.52%, 214/4731), RR = 0.78, 95% CI 0.65-0.94, P < 0.01, I2 = 0%), (stroke: rivaroxaban group (1.60%, 85/5306) vs. APT group (2.52%, 119/4731), RR = 0.64, 95% CI 0.49-0.85, P < 0.01, I2 = 12%) compared with the placebo. Rivaroxaban was comparable to the placebo for all-cause death and major bleeding (all-cause death: rivaroxaban group (12.27%, 688/5606) vs. APT group (14.59%, 737/5052), RR = 0.73, 95% CI 0.49-1.06, P > 0.05, I2 = 87%), (major bleeding: rivaroxaban group (1.52%, 85/5586) vs. APT group (1.37%, 69/5043), RR = 1.18, 95% CI 0.86-1.62, P > 0.05, I2 = 0%). CONCLUSIONS In SR patients with CAD and HF, the rates of MI and stroke associated with rivaroxaban combined with APT were lower than those associated with APT alone, and the two treatments had similar rates of all-cause death and major bleeding.
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Osho AA, Vlahakes GJ. Commentary: Moving the Dial on DOAC use Early After Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 34:960-961. [PMID: 34139348 DOI: 10.1053/j.semtcvs.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Asishana A Osho
- Fellow in Cardiothoracic Surgery, Harvard Medical School and Massachusetts General Hospital, Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Gus J Vlahakes
- Professor of Surgery, Harvard Medical School. Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Krupa P, Kanta M, Hosszu T, Soukup J, Ryska P, Dulicek P, Cesak T. A rare case of non-traumatic spinal epidural hematoma in lumbar region associated with apixaban therapy. J Thromb Thrombolysis 2021; 52:1215-1219. [PMID: 33956281 DOI: 10.1007/s11239-021-02462-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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a very rare clinical entity with potential diagnostic difficulties and which can result in severe neurological deficit. The etiology of this rare condition is largely not known, but with potential predisposition in patients on anticoagulation medication. This includes the novel anticoagulants with direct inhibition of the factor Xa mechanism (DOACs). These medications are supposed to have more predictable pharmacokinetics with fewer severe haemorrhagic adverse events in comparison with standard warfarin therapy. However, in the last few years, an increasing number of case reports have been published of haemorrhage into the central nervous system. We present a case of non-traumatic spinal epidural hematoma in the lumbar region in a patient on chronic apixaban therapy. To the best of our knowledge, it is the first described SSEH in the lumbar region associated with apixaban therapy.
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Affiliation(s)
- Petr Krupa
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic. .,Department of Neuroregeneration, Institute of Experimental Medicine, Czech Academy of Sciences, Prague, Czech Republic.
| | - Martin Kanta
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
| | - Tomas Hosszu
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
| | - Jiri Soukup
- The Fingerland Department of Pathology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Pavel Ryska
- Department of Radiology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Petr Dulicek
- Fourth Department of Internal Medicine and Hematology, Charles University Medical Faculty and Faculty Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Charles University Medical Faculty and Faculty Hospital, Hradec Králové, Czech Republic
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Abstract
Excessive bleeding is an important cause of morbidity and mortality after cardiac surgery. Bleeding after cardiac surgery is multifactorial. Adherence to the proverbial 6 Ps remains the cornerstone of any strategy for management of postoperative bleeding after cardiac surgery. Recent years have seen a surge in the number of patients who have been prescribed novel oral anticoagulants (NOACs) for the prevention and treatment of thromboembolic events. This phenomenon has significant repercussions particularly for patients presenting for emergency cardiac surgery. The published evidence guiding management of such patients is limited and in the form of expert consensus. Plasma levels of NOAC >30 ng/ml necessitate specific therapeutic interventions to tackle excessive bleeding attributed to NOAC intake. Current recommendation is to consider using specific reversal agent if available. Otherwise, use of prothrombin complex concentrates is recommended.
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Affiliation(s)
- Shehani Alwis
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
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Sachs B, Misrai V, Tabatabaei S, Woo HH. Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants. Asian J Urol 2020; 7:340-344. [PMID: 32995278 PMCID: PMC7498936 DOI: 10.1016/j.ajur.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/16/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022] Open
Abstract
Objective Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity. Methods A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification. Results There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77±6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94±56 mL, 301±211 kJ, and 35±21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2±2.4 days and 2.4±2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions. Conclusions This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.
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Affiliation(s)
| | | | | | - Henry H Woo
- The Chris O'Brien Lifehouse Hospital, Sydney, Australia
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Bukhari MA, Al-Theaby A, Tawhari M, Al-Shaggag A, Pyrke R, Gangji A, Treleaven D, Ribic C. Efficacy and safety of non-vitamin K antagonist oral anticoagulants post-kidney transplantation. World J Transplant 2019; 9:134-144. [PMID: 31750090 PMCID: PMC6851500 DOI: 10.5500/wjt.v9.i6.134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 07/18/2019] [Revised: 09/17/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) were developed as alternatives to vitamin K antagonists, primarily warfarin, as they do not require routine monitoring and have limited drug-drug and drug-food interactions. However, the efficacy and safety of these agents in kidney transplantation are not well studied.
AIM To assess the profile and safety of NOACs for patients who had kidney transplantation, and to provide recommendations and guidelines on therapeutic strategies in these patients.
METHODS This was a retrospective study carried out among adult patients who were actively on the following NOACs (apixaban, rivaroxaban or dabigatran) in our renal transplantation program from December 2015 to December 2016. The patients were identified primarily through electronic medical record system (patient data linkage). Data on the clinical and laboratory profile of the patients were retrieved and analyzed with SPSS 22.0.
RESULTS Complete data on 42 renal transplant patients were retrieved: 59.5% males, 90.5% were whites and 66.7% were older than 60 years old. The mean duration since renal transplantation of the patients was 8.8 ± 7.4 years. The most common risk factors for the development of end-stage renal disease in the subjects were hypertension (19.0%), polycystic kidney disease (19.0%), followed by diabetic nephropathy (16.7%) and chronic glomerulonephritis (16.7%). The main indications for NOACs use in the cohort were atrial fibrillation in 25 patients (59.5%) and venous thromboembolism in 10 patients (23.8%). Overall, 29 patients (69%) were treated with apixaban, 10 patients (23.8%) with rivaroxaban and 3 patients (7.14%) with dabigatran. No (0%) thromboembolic events were observed during the one-year period, but 3 (7.1%) bleeding events occurred in the cohort consisting of 1 patient treated with rivaroxaban 15 mg daily and 2 patients who received apixaban 2.5 mg twice daily. There were no significant changes in serum tacrolimus level three days after the initiation of NOACs among patients treated with tacrolimus (pre- and post-NOACs tacrolimus levels were 7.2516 and 7.8867 ng/mL, P = 0.55, respectively). Also, after one-year of treatment with NOACs there were no significant changes in the pre- and post-NOACs serum creatinine level (P = 0.772) and estimated glomerular filtration rates (P = 0.232).
CONCLUSION No thromboembolic events or significant changes in renal profile were observed in our cohort of kidney transplant recipients who were treated with NOACs for at least a year. However, a few bleeding events were observed. This calls for further well-planned randomized controlled trials to assess the efficacy and safety of NOACs among renal transplant recipients.
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Affiliation(s)
| | - Abdulrahman Al-Theaby
- Department of Transplantation, King Abdulaziz Medical City, Riyadh 11159, Saudi Arabia
| | - Mohammed Tawhari
- Department of Transplantation, King Abdulaziz Medical City, Riyadh 11159, Saudi Arabia
| | - Ali Al-Shaggag
- Department of Nephrology and Transplantation King Fahad Specialist Hospital, Dammam 15215, Saudi Arabia
| | - Ryan Pyrke
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Azim Gangji
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Darin Treleaven
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Christine Ribic
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
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Markou M, Pleger B, Grözinger M, Pintea B, Hamsen U, Könen S, Schildhauer TA, Martínez R, Gousias K. Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury. Eur J Trauma Emerg Surg 2021; 47:565-71. [PMID: 31529164 DOI: 10.1007/s00068-019-01228-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/03/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited. METHODS We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants. RESULTS 71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation. CONCLUSIONS Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.
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Youn SH, Lim H, Ju Y, Soh JS, Park JW, Kang HS, Kim SE, Moon SH, Kim JH, Park CK, Seo SI, Shin WG. Effect of gastroprotective agents on upper gastrointestinal bleeding in patients receiving direct oral anticoagulants. Scand J Gastroenterol 2018; 53:1490-1495. [PMID: 30509124 DOI: 10.1080/00365521.2018.1541478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Direct oral anticoagulants (DOACs) are effective in the prevention and treatment of thromboembolism; however, they are associated with upper gastrointestinal bleeding (UGIB). In this study, we evaluated the efficacy of gastroprotective agents (GPAs) in reducing the risk of UGIB in patients receiving DOACs. METHODS We retrospectively reviewed the medical records of 2076 patients who received DOACs for the prevention or treatment of thromboembolic events between January 2008 and July 2016. A cumulative incidence analysis using the Kaplan-Meier method was performed to determine the rate of UGIB and its association with GPAs administration. RESULTS Of the 2076 patients, 360 received GPAs. Over the follow-up period (1160 person-years), one patient in the GPA group (0.7 per 100 person-years) and 29 patients in the non-GPA group (2.8 per 100 person-years) developed UGIB (p = .189). In the multivariate analysis, UGIB was associated with older age (hazard ratio (HR), 1.041; p = .048), a history of peptic ulcer or UGIB (HR, 5.931; p < .001), and concomitant use of antiplatelet agents (HR, 3.121; p = .014). GPAs administration did not reduce the risk of UGIB (p = .289). However, based on the subgroup analysis of 225 patients with concomitant use of antiplatelet agents or a history of peptic ulcer or UGIB, the GPA group (0 per 100 person-years) showed reduced incidence of UGIB compared with the non-GPA group (11.3 per 100 person-years) (p = .065). CONCLUSIONS The prophylactic use of GPAs could reduce the risk of UGIB in patients receiving DOACs who have risk factors, such as concomitant use of antiplatelet agents or a history of peptic ulcer or UGIB.
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Affiliation(s)
- Sung Hee Youn
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Hyun Lim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Yeonmi Ju
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Jae Seung Soh
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Ji Won Park
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Ho Suk Kang
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Sung Eun Kim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Sung Hoon Moon
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Jong Hyeok Kim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Choong Kee Park
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Seung In Seo
- b Department of Internal Medicine, Kangdong Sacred Heart Hospital , University of Hallym College of Medicine , Seoul , Republic of Korea
| | - Woon Geon Shin
- b Department of Internal Medicine, Kangdong Sacred Heart Hospital , University of Hallym College of Medicine , Seoul , Republic of Korea
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Berton F, Costantinides F, Rizzo R, Franco A, Contarin J, Stacchi C, Maglione M, Visintini E, Di Lenarda A, Di Lenarda R. Should we fear direct oral anticoagulants more than vitamin K antagonists in simple single tooth extraction? A prospective comparative study. Clin Oral Investig 2018; 23:3183-3192. [PMID: 30392079 DOI: 10.1007/s00784-018-2739-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 08/30/2018] [Accepted: 10/24/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The aim of this prospective comparative clinical study was to evaluate the effect of oral anticoagulants on peri- and post-operative bleeding during simple single tooth extractions, comparing patients in treatment with vitamin K antagonists (VKAs) and patients assuming direct oral anticoagulants (DOACs). MATERIALS AND METHODS Patients under oral anticoagulant therapy needing dental extraction were eligible for entering the study; patients were enrolled following inclusion and exclusion criteria and divided into VKAs and DOAC group according to the anticoagulation therapy. Included patients underwent a simple single dental extraction with elevators and forceps with a maximum surgical time of 15 minutes, without anticoagulation therapy discontinuation. All participants were assessed pre-operatively, during surgery, 30 min minutes and 7 days after surgery. Biological complications were registered and post-extraction bleeding was clinically defined according to Iwabuchi classification. Parametric and non-parametric tests were used to evaluate the variables between the groups. RESULTS Sixty-five patients per group were enrolled and 130 teeth were extracted. The two groups were comparable for pre-, peri-, and post-operative variables. Only 1 patient of DOAC group and 2 patients for VKA group needed medical evaluation for post-extractive bleeding. No statistically significant difference resulted in post-operative bleeding events between the groups (p = 0.425). CONCLUSIONS DOAC and VKA patients showed the same incidence of bleeding complications after simple single tooth extraction. Bleeding events were not statistically significant and not clinically relevant. CLINICAL RELEVANCE Patients assuming DOACs can be treated similarly to patients in VKAs therapy with INR index between 2 and 3. Non-ceasing of DOAC therapy seems to be appropriate for simple single dental extractions.
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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
| | - Roberto Rizzo
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Anna Franco
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Jenny Contarin
- 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
| | - Michele Maglione
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Erika Visintini
- Maxillofacial and Dental Surgical Clinic, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Department of Medical, Surgical and Health Sciences, University of Trieste, 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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Schwill S, Krug K, Peters-Klimm F, van Lieshout J, Laux G, Szecsenyi J, Wensing M. Novel oral anticoagulants in primary care in patients with atrial fibrillation: a cross-sectional comparison before and after their introduction. BMC Fam Pract 2018; 19:115. [PMID: 30021509 PMCID: PMC6052679 DOI: 10.1186/s12875-018-0796-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 06/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Novel oral anticoagulation (NOAC) has been introduced in recent years, but data on use in atrial fibrillation (AF) in primary care setting is scarce. In Germany, General Practitioners are free to choose type of oral anticoagulation (OAC) in AF. Our aim was to explore changes in prescription-rates of OAC in German primary care before and after introduction of NOAC on the market. METHODS Data of a representative morbidity registration project in primary care in Germany (CONTENT) were analysed. Patients with AF in 2011 or 2014 were included (before and after broad market authorization of NOAC, respectively). We defined three independent groups: patients from 2011 without follow-up (group A), patients from 2014 but without previous record in 2011 (group B) and patients with AF and records in 2011 and 2014 (group C). RESULTS 2642 patients were included. Group A (n = 804) and B (n = 755) were comparable regarding patient characteristics. 87.3% of group A and 84.8% of group B had CHA2DS2-VASc-Score ≥ 2, indicating a need for oral anticoagulation (OAC). Prescription of OAC increased from 23.1% (n = 186) to 42.8% (n = 323, p < .01) with stable use of vitamin-k-antagonist (22.6-24.9%). NOAC increased from 0.6 to 19.2% (p < .01). Monotherapy with Acetylsalicylic acid (ASA) decreased from 15.3% (n = 123) to 8.2% (n = 62, p < .01). In group C (n = 1083), OAC increased from 35.3 to 55.4% (p < .01), with stable prescription rate of vitamin-k-antagonist (34.4-35.7%). NOAC increased from 0.9 to 21.5% (p < .01). CONCLUSIONS In summary, our study showed a significant increase of OAC over time, which is fostered by the use of NOAC but with a stable rate of VKA and a sharp decrease of ASA. Patients on VKA are rarely switched to NOAC, but new patients with AF are more likely to receive NOAC.
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Affiliation(s)
- Simon Schwill
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Katja Krug
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Frank Peters-Klimm
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan van Lieshout
- Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Gunter Laux
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Kolb JM, Flack KF, Chatterjee-Murphy P, Desai J, Wallentin LC, Ezekowitz M, Connolly S, Reilly P, Brueckmann M, Ilgenfritz J, Aisenberg J. Locations and Mucosal Lesions Responsible for Major Gastrointestinal Bleeding in Patients on Warfarin or Dabigatran. Dig Dis Sci 2018; 63:1878-1889. [PMID: 29582237 DOI: 10.1007/s10620-018-5007-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Different oral anticoagulants may be associated with gastrointestinal bleeding (GIB) from different locations or mucosal lesions. We aimed to test this hypothesis. METHODS Two blinded gastroenterologists independently analyzed source documents from the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial of dabigatran 150 mg BID (D150), dabigatran 110 mg BID (D110) versus warfarin in non-valvular atrial fibrillation (NVAF). RESULTS Major GIB events (total n = 546) and life-threatening GIB events (n = 258) were more common with D150 versus warfarin (RR 1.57 [1.28-1.92] and RR 1.62 [1.20-2.18], respectively) and similar for D110 compared to warfarin (RR 1.11 [0.89-1.38] and RR 1.16 [0.84-1.61], respectively). Fatal bleeding was similarly rare across treatment groups. Lower GI major bleeding and life-threatening bleeding were more common with D150 compared to warfarin (RR 2.23 [1.47, 3.38] and RR 2.64 [1.36, 5.13], respectively) and with D110 compared to warfarin (RR 1.78 [1.16, 2.75] and RR 2.00 [1.00, 4.00], respectively). MGIB from colonic angiodysplasia was increased with dabigatran versus warfarin (P < 0.01 for both dose comparisons). Subacute and chronic MGIB events were more common with D150 than with warfarin (RR 1.72 [1.06, 2.78] and RR 1.66 [1.12, 2.45], respectively), as were hematochezia or melena (RR 1.67 [1.18, 2.36] and RR 1.72 [1.20, 2.47], respectively). CONCLUSIONS In a chronic NVAF population, D150 but not D110 is associated with increased major and life-threatening GI bleeding in comparison with warfarin. At both dabigatran doses, increased bleeding from the colorectum, in particular from angiodysplasia, is seen.
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Affiliation(s)
- Jennifer M Kolb
- Department of Gastroenterology and Hepatology, University of Colorado Hospital, Denver, CO, USA
| | - Kathryn Friedman Flack
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jay Desai
- Department of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lars C Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Michael Ezekowitz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Paul Reilly
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - James Aisenberg
- Department of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Yanagisawa N, Nagata N, Watanabe K, Iida T, Hamada M, Kobayashi S, Shimbo T, Akiyama J, Uemura N. Post-polypectomy bleeding and thromboembolism risks associated with warfarin vs direct oral anticoagulants. World J Gastroenterol 2018; 24:1540-1549. [PMID: 29662292 PMCID: PMC5897858 DOI: 10.3748/wjg.v24.i14.1540] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/15/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants (DOAC). METHODS We collected data from 218 patients receiving oral anticoagulants (73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics (age- and sex-matched controls) who underwent polypectomy. (1) We evaluated post-polypectomy bleeding (PPB) risk in patients receiving warfarin or DOAC compared with controls; (2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge (HPB) (endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB. RESULTS PPB rate was significantly higher in warfarin users and DOAC users compared with controls (13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban (13.2%), dabigatran (11.1%), and apixaban (13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group (guideline recommendation) had a higher PPB rate (10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant group. CONCLUSION PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.
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Affiliation(s)
- Naohiro Yanagisawa
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Tatsuhiro Iida
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Mariko Hamada
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Sakurako Kobayashi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takuro Shimbo
- Ohta Nishinouchi Hospital, Fukushima 963-8022, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba 272-8516, Japan
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Sun C, Qin F, Liu C, Bai F, Tu T, Wu Z, Liu Q. Are NOACs safer than phenprocoumon in patients undergoing pulmonary vein isolation with the cryoballoon technique using purse-string suture closure? Int J Cardiol 2018; 254:173. [PMID: 29407086 DOI: 10.1016/j.ijcard.2017.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Chao Sun
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China
| | - Fen Qin
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China
| | - Chaoshuo Liu
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China
| | - Fan Bai
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China
| | - Tao Tu
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China
| | - Zhihong Wu
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China.
| | - Qiming Liu
- Department of Cardiology/Cardiac Catheterisation Lab, Second Xiangya Hospital, Central South University, Changsha City, Hunan Province 410011, China.
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Rowe MK, Lollback N, Slater L, Hill J, Gould PA, Kaye GC. Elective Cardioversion in the Era of Novel Oral Anticoagulants - Does a Nurse Administered Verbal Questionnaire for Compliance Negate the Need for Routine Transoesophageal Echocardiography? Heart Lung Circ 2017; 27:989-994. [PMID: 28966115 DOI: 10.1016/j.hlc.2017.08.013] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 07/31/2017] [Accepted: 08/13/2017] [Indexed: 09/30/2022]
Abstract
BACKGROUND Anticoagulation prior to elective external direct current cardioversion (EDCCV) is mandatory. The inability to monitor compliance with novel oral anticoagulants (NOACs) raises a potential safety issue. We aimed to evaluate whether a structured, nurse-led assessment of compliance prior to EDCCV ensures safety without the need for routine transoesophageal echocardiography (TOE). METHODS Data was prospectively collected on consecutive patients undergoing EDCCV during 2014-2015. All procedures were supervised by an electrophysiology clinical nurse consultant (EPCNC). Drug compliance was verbally assessed using a standardised questionnaire by the EPCNC. Novel oral anticoagulants compliance was required for a continuous period of 3 weeks prior to EDCCV; otherwise a TOE-guided EDDCV was performed. All patients had follow-up 30 days post-procedure. RESULTS Three hundred and eleven cardioversions were performed on 256 patients in whom 154 (49.5%) were prescribed a NOAC (rivaroxaban (n=105; 68.2%), dabigatran (n=38; 24.7%), apixaban (n=11; 7.1%)). Median age was 63 years (24-94 yrs), mean CHADS2-Vasc score was 2.0±1.5 and 138 (89.6%) were outpatients. One hundred and twenty-nine (83.8%) EDCCV were for atrial fibrillation and 25 (16.2%) for atrial flutter. Sinus rhythm was achieved in 90.3% of cases. Fourteen patients (9%) assessed as non-compliant underwent TOE. 129 (83.8%) EDCCV were performed without prior TOE. No stroke or systemic embolism was identified in any patient treated with either warfarin or a NOAC. CONCLUSIONS A standardised, verbal questionnaire can be administered to detect NOAC non-compliance in patients undergoing EDCCV. With appropriate compliance assessment a nurse-led EDCCV without routine TOE did not significantly compromise safety in this study group.
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Affiliation(s)
- Matthew K Rowe
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia
| | - Naomi Lollback
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Leanne Slater
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - John Hill
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia
| | - Paul A Gould
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia
| | - Gerald C Kaye
- Department of Cardiology Princess Alexandra Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia.
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24
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Abstract
An increasing number of oral anticoagulants have become available over the past decade. Each of these agents has differing implications on both regional and neuraxial anesthetic techniques. This article describes the pharmacology, pharmacokinetics, and pharmacodynamics of the most commonly used novel oral anticoagulants (NOACs). It also outlines recent guidelines for the use of NOACs in the perioperative setting, especially with regard to neuraxial anesthesia.
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25
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Kawada T. Effect and risk of novel oral anticoagulants versus warfarin in patients with non-valvular atrial fibrillation. J Cardiol 2017; 70:99. [PMID: 28209462 DOI: 10.1016/j.jjcc.2016.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoyuki Kawada
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan.
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26
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Kepplinger J, Prakapenia A, Barlinn K, Siegert G, Gehrisch S, Zerna C, Beyer-Westendorf J, Puetz V, Reichmann H, Siepmann T, Bodechtel U. Standardized use of novel oral anticoagulants plasma level thresholds in a new thrombolysis decision making protocol. J Thromb Thrombolysis 2016; 41:293-300. [PMID: 26001908 DOI: 10.1007/s11239-015-1229-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) patients receiving non-vitamin-K antagonist oral anticoagulants (NOAC) are commonly excluded from thrombolytic therapy, as interpretation of coagulation tests remains unclear. We aimed to investigate the applicability of a novel institutional protocol for thrombolysis based on current expert recommendations and NOAC specific coagulation assessment. We included hospitalized AIS patients receiving NOAC for at least 24 h and consecutive AIS patients not receiving NOAC into a prospective study. We performed standard coagulation tests and specific tests for dabigatran, rivaroxaban and apixaban plasma levels. We studied 65 patients: mean age 72 ± 13 years, 30 (46 %) male, median NIHSS score 3 (IQR 6). Fifteen (23 %) were on NOAC treatment (5 dabigatran, 5 rivaroxaban, and 5 apixaban, respectively) and 50 (77 %) were not. In patients without NOAC, dabigatran was not detectable (0 ng/ml), and plasma levels of rivaroxaban (median: 10.0 ng/ml, IQR 7.0) and apixaban (7.2 ng/ml, IQR 6.7) were below our lower thresholds that allow thrombolysis. In patients with dabigatran pre-treatment, trough levels (58.0 ng/ml, IQR 143.0) were below our upper threshold that would allow thrombolysis in 3/5 patients. In patients receiving rivaroxaban, trough level (68.0 ng/ml, IQR 64.0) was below our predefined upper thresholds that would allow thrombolysis in 4/5 patients. In all patients on apixaban, trough level was above our predefined threshold of 40 ng/ml that precludes thrombolysis (98.2 ng/ml, IQR 84.3). Predefined thresholds of NOAC plasma levels in the decision of thrombolysis in NOAC treated AIS patients might supplement routine coagulation tests and should be validated in a larger study population.
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Affiliation(s)
- Jessica Kepplinger
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Alexandra Prakapenia
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Gabriele Siegert
- Institute of Clinical Chemistry and Laboratory Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Siegmund Gehrisch
- Institute of Clinical Chemistry and Laboratory Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Charlotte Zerna
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Internal Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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27
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Garkina SV, Vavilova TV, Lebedev DS, Mikhaylov EN. Compliance and adherence to oral anticoagulation therapy in elderly patients with atrial fibrillation in the era of direct oral anticoagulants. J Geriatr Cardiol 2016; 13:807-810. [PMID: 27899946 PMCID: PMC5122507 DOI: 10.11909/j.issn.1671-5411.2016.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Affiliation(s)
- Svetlana V Garkina
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
- Neuromodulation unit, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
- *Correspondence to:
| | - Tatiana V Vavilova
- Department of Clinical Laboratory Diagnostics and Genetics, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Dmitry S Lebedev
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Evgeny N Mikhaylov
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
- Neuromodulation unit, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
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Abstract
Edoxaban, a direct factor Xa inhibitor, was extensively studied in the prevention and treatment of venous thromboembolism and in patients with nonvalvular atrial fibrillation (AF). The aim of this review is to focus specifically on the efficacy and safety profile of edoxaban in patients with AF from preclinical development through the phase III trial that led to regulatory approval.
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Affiliation(s)
- Alon Eisen
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- Brigham and Women's Hospital and Harvard Medical School Boston, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA
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29
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Pinho-Gomes AC, Hague A, Ghosh J. Management of novel oral anticoagulants in emergency and trauma surgery. Surgeon 2016; 14:234-9. [PMID: 27107730 DOI: 10.1016/j.surge.2016.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/15/2016] [Accepted: 03/19/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND The compelling safety, efficacy and predictable effect of novel oral anticoagulants (NOACs) is driving a rapid expansion in their therapeutic indications. Management of the increasing number of patients on those new agents in the setting of emergency or trauma surgery can be challenging and the absence of specific reversal agents has been a matter of concern. This review summarises the key principles that underpin the management of those patients with a particular emphasis on the recent development of specific antidotes. FINDINGS As of 2015, a new line of antidotes, specific for these drugs, are at different stages of their development with their release imminent. However, as NOACs are innately reversible due to their short half-life, the use of reversal agents will probably be restricted to a few exceptional cases. Post-marketing surveillance will be paramount to better clarify the role of these promising drugs. CONCLUSIONS Management of patients on NOACs in the context of emergency or trauma surgery relies on best supportive care in combination with the blood products and/or specific antidotes as required. Familiarity with the new reversal agents is essential but further evidence on their indications, safety and efficacy as well as consensus guidelines are warranted prior to widespread adoption.
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Affiliation(s)
| | - Adam Hague
- Department of Vascular Surgery, University Hospital of South Manchester, UK
| | - Jonathan Ghosh
- Department of Vascular Surgery, University Hospital of South Manchester, UK.
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30
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Abstract
Novel oral anticoagulants (NOACs) have emerged as a good alternative to warfarin in the prevention of stroke for patients with atrial fibrillation. NOAC use is increasing rapidly; therefore, greater understanding of their use in the perioperative period is important for optimal care. Studies and reviews that reported on the use of NOACs were identified, with particular focus on the perioperative period. PubMed was searched for relevant articles published between January 2000 and August 2015. The inevitable rise in the use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™), edoxaban (Lixiana™) and dabigatran (Pradaxa™) may present a simplified approach to perioperative anticoagulant management due to fewer drug interactions, rapidity of onset of action and relatively short half-lives. Coagulation status, however, cannot reliably be monitored and no antidotes are currently available. When planning for discontinuation of NOACs, special consideration of renal function is required. Advice regarding the management of bleeding complications is provided for consideration in emergency surgery. In extreme circumstances, haemodialysis may be considered for bleeding with the use of dabigatran. NOACs will increasingly affect operative planning in plastic surgery. In order to reduce the incidence of complications associated with anticoagulation, the management of NOACs in the perioperative period requires knowledge of the time of last dose, renal function and the bleeding risk of the planned procedure. Consideration of these factors will allow appropriate interpretation of the current guidelines.
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Affiliation(s)
- C F Munson
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK.
| | - A J Reid
- Blond McIndoe Laboratories, Institute of Inflammation and Repair, University of Manchester, Manchester, UK; Department of Plastic Surgery & Burns, University Hospital of South Manchester, Manchester, UK
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31
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Abstract
Background: Novel oral anticoagulants (NOACs) are considered to be at least as effective and safe as warfarin with several advantages such as predictable pharmacokinetics, allowing for standardized dosing without monitoring, a lack of food interactions and fewer drug interactions; however, their misuse could potentially result in patient harm. Objective: To evaluate the appropriate use of the NOACs within a community teaching hospital. Setting: A community teaching hospital in the United States. Method: A retrospective chart review of patients that were prescribed dabigatran, rivaroxaban, or apixaban at our institution from October 2012 through November 2014 was conducted. Main outcome measure: The primary objective was to determine the percentage of patients that were appropriately prescribed NOACs. Secondary objectives were to determine the number of patients who were inappropriately transitioned from warfarin or parenteral anticoagulants to a NOAC or vice versa, the number of incidents when a NOAC was held or discontinued inappropriately before a procedure and the number of bleeding or thrombotic events while taking a NOAC. Results: Of the 113 patients receiving therapy with an NOAC, appropriate prescribing was observed in 79.7%. Dabigatran, rivaroxaban, and apixaban were appropriately prescribed in 73.8%, 88.3%, and 85.8% of patients respectively. Lack of renal dose-adjustment in patients with reduced renal function was the most common reason for inappropriate use (8.8%). Ten out of 38 patients (26%) were inappropriately transitioned from/to other anticoagulants. Two out of six patients underwent a procedure without holding NOACs as recommended prior to surgery. Of all patients receiving NOACs, a total of 3 bleeding incidents were observed, one with each NOAC. Conclusion: The NOACs were appropriately prescribed for the majority of patients within our institution. Future efforts however should focus on ensuring appropriate dose adjustments for renal impairment, procedures for transitioning between NOACs and parenteral anticoagulants, and adequate withholding times for NOACs prior to surgery in order to optimize the management of NOACs usage within our institution.
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Affiliation(s)
- Sultan Alghadeer
- Columbus Regional Health in Columbus, GA, United States; Teaching Faculty, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Lori Hornsby
- Outpatient Clinic, Columbus Regional Health, Midtown Medical Center, Columbus, GA 31901, United States; Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, United States
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Otsui K, Gorog DA, Yamamoto J, Yoshioka T, Iwata S, Suzuki A, Ozawa T, Takei A, Inoue N. Global Thrombosis Test - a possible monitoring system for the effects and safety of dabigatran. Thromb J 2015; 13:39. [PMID: 26648789 PMCID: PMC4672538 DOI: 10.1186/s12959-015-0069-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 09/08/2015] [Indexed: 01/17/2023] Open
Abstract
Background Dabigatran is an alternative to warfarin (WF) for the thromboprophylaxis of stroke in patients with non-valvular atrial fibrillation (NVAF). The advantage of dabigatran over WF is that monitoring is not required; however, a method to monitor the effect and the safety of dabigatran is not currently available. The Global Thrombosis Test (GTT) is a novel method to assess both clot formation and lysis activities under physiological conditions. Objective The aim of this study was to evaluate whether treatment with dabigatran might affect shear-induced thrombi (occlusion time [OT], sec) by the GTT, and to investigate the possibility that the GTT could be useful as a monitoring system for dabigatran. Patients/Methods The study population consisted of 50 volunteers and 43 NVAF patients on WF therapy, who were subsequently switched to dabigatran. Using the GTT, the thrombotic status was assessed one day before and 1 month after switching anticoagulation from WF to dabigatran. Results The OT was 524.9 ± 17.0 sec in volunteers whereas that of NVAF patients on WF therapy was 581.7 ± 26.3 sec. The switch from WF to dabigatran significantly prolonged OT (784.5 ± 19.3 sec). One patient on WF therapy and 12 patients on dabigatran therapy were shown to have OT > 900 sec. Conclusion The GTT could be used to assess the risk of dabigatran-related bleeding complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nobutaka Inoue
- Kobe Rosai Hospital, Kobe, Japan ; Department of Cardiovascular Medicine, Kobe Rosai Hospital, 4-1-23, Kagoike Touri, Chuo-Ku, Kobe, 651-0053 Japan
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Affiliation(s)
- Paolo Prandoni
- a Department of Cardiothoracic and Vascular Sciences , Vascular Medicine Unit, University Hospital of Padua , Padua , Italy
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Preblick R, Kwong WJ, White RH, Goldhaber SZ. Cost-effectiveness of edoxaban for the treatment of venous thromboembolism based on the Hokusai-VTE study. Hosp Pract (1995) 2015; 43:249-57. [PMID: 26549305 DOI: 10.1080/21548331.2015.1099412] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 10/22/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is associated with almost 300,000 deaths per year in the United States. Novel oral anticoagulants (NOACs) offer an alternative to warfarin-based therapy without monitoring requirements and with fewer drug and food interactions. Edoxaban, a direct Xa inhibitor, is approved by the Food and Drug Administration (FDA), based upon results of the Hokusai-VTE Phase 3 trial. The trial demonstrated that edoxaban administered once daily after initial treatment with heparin was non-inferior in reducing the risk of VTE recurrence and caused significantly less major and clinically relevant non-major (CRNM) bleeding compared to warfarin. The objective of this study was to evaluate the cost-effectiveness of edoxaban versus warfarin for the treatment of adults with VTE. METHODS A cost-effectiveness model was developed using patient-level data from the Hokusai-VTE trial, clinical event costs from real-world databases, and drug acquisition costs for warfarin of $0.36 and edoxaban of $9.24 per tablet. RESULTS From a U.S. health-care delivery system perspective, the incremental cost-effectiveness ratio (ICER) was $22,057 per quality adjusted life year (QALY) gained. Probabilistic sensitivity analysis showed that edoxaban had an ICER <$50,000 per QALY gained relative to warfarin in 67% of model simulations. The result was robust to variation in key model parameters including the cost and disutility of warfarin monitoring. CONCLUSION Despite its higher drug acquisition cost, edoxaban is a cost-effective alternative to warfarin for the treatment of VTE.
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Affiliation(s)
- Ronald Preblick
- a Health Economics and Outcomes Research, Daiichi Sankyo, Inc ., Parsippany , NJ , USA
| | - W Jacqueline Kwong
- a Health Economics and Outcomes Research, Daiichi Sankyo, Inc ., Parsippany , NJ , USA
| | - Richard H White
- b Division of General Medicine, Anticoagulation Service , University of California Davis Health System , Sacramento , CA , USA
| | - Samuel Z Goldhaber
- c Cardiovascular Division , Brigham and Women's Hospital , Boston , MA , USA
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Lu D, Zhang Q, Liu Q, Wang K, Wang S, Shan Q. Bleeding risks with novel oral anticoagulants during catheter ablation of atrial fibrillation: a systematic review and network meta-analysis. J Interv Card Electrophysiol 2015; 44:105-11. [PMID: 26342485 DOI: 10.1007/s10840-015-0053-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 04/21/2015] [Accepted: 08/26/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Comprehensive comparisons of safety (measured by bleeding risk) between multiple novel oral anticoagulants (NOACs and warfarin) in the peri-procedural period of catheter ablation (CA) for atrial fibrillation (AF) are rare. METHODS AND RESULTS MEDLINE, EMBASE, and COCHRANE LIBRARY were searched up to February 2015 by two reviewers independently. Predefined inclusion criteria identified 24 studies which were included in the analysis. Data were extracted by two researchers, and a network meta-analysis was conducted in R with R2WinBugS package, within Bayesian framework. Pooled odds ratios (OR) and 95% confidence intervals (CI) were summarized to evaluate the bleeding risks of three novel anticoagulants (dabigatran, rivaroxaban, apixaban) in AF patients undergoing catheter ablation (CA). With respect to total bleeding risk, no significant difference was observed between dabigatran, rivaroxaban, apixaban, and vitamin K antagonists (VKAs) by mixed-treatment comparison. The similar results were seen in the direct comparison. While dabigatran was associated with a lower rate of minor bleeding in comparison to VKAs (OR = 0.67 with 95%CI 0.49-0.93). CONCLUSIONS Risks of bleeding with dabigatran, rivaroxaban, apixaban, and VKAs were similar in peri-procedural period of CA for AF.
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Maas AH, Euler Mv, Bongers MY, Rolden HJ, Grutters JP, Ulrich L, Schenck-Gustafsson K. Practice points in gynecardiology: Abnormal uterine bleeding in premenopausal women taking oral anticoagulant or antiplatelet therapy. Maturitas 2015; 82:355-9. [PMID: 26358933 DOI: 10.1016/j.maturitas.2015.08.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 08/26/2015] [Accepted: 08/27/2015] [Indexed: 11/20/2022]
Abstract
A growing number of premenopausal women are currently using antithrombotic and/or (dual) antiplatelet therapy for various cardiovascular indications. These may induce or exacerbate abnormal uterine bleeding and more awareness and knowledge among prescribers is required. Heavy and irregular menstrual bleeding is common in women in their forties and may have a variety of underlying causes that require different treatment options. Thus using anticoagulants in premenopausal women demands specific expertise and close collaboration between cardiovascular physicians and gynecologists. In this article we summarize the scope of the problem and provide practical recommendations for the care for young women taking anticoagulants and/or (dual) antiplatelet therapy. We also recommend that more safety data on uterine bleeding with novel anticoagulants in premenopausal women should be obtained.
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Morimoto T, Crawford B, Wada K, Ueda S. Comparative efficacy and safety of novel oral anticoagulants in patients with atrial fibrillation: A network meta-analysis with the adjustment for the possible bias from open label studies. J Cardiol 2015; 66:466-74. [PMID: 26162944 DOI: 10.1016/j.jjcc.2015.05.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/07/2015] [Accepted: 05/13/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study was designed to compare efficacy and safety among novel oral anticoagulants (NOACs), which have not been directly compared in randomized control trials to date. METHOD We performed network meta-analyses of randomized control trials in preventing thromboembolic events and major bleeding in patients with atrial fibrillation. PubMed, Embase, and the Cochrane Database of Systematic Reviews for published studies and various registries of clinical trials for unpublished studies were searched for 2002-2013. All phase III randomized controlled trials (RCTs) of NOACs (apixaban, edoxaban, dabigatran, rivaroxaban), idraparinux, and ximelagatran were reviewed. RESULTS A systematic literature search identified nine phase III RCTs for primary analyses. The efficacy of each NOAC was similar with respect to our primary composite endpoint following adjustment for open label designs [odds ratios (ORs) versus vitamin K antagonists: apixaban 0.79; dabigatran 150mg 0.77; edoxaban 60mg 0.87; rivaroxaban 0.86] except for dabigatran 110mg and edoxaban 30mg. Apixaban and edoxaban 30mg and 60mg had significantly fewer major bleeding events than dabigatran 150mg, ricvaroxaban, and vitamin K antagonists. All NOACs were similar in reducing secondary endpoints with the exception of dabigatran 110mg and 150mg which were associated with a significantly greater incidence of myocardial infarction compared to apixaban, edoxaban 60mg, and rivaroxaban. CONCLUSIONS Our indirect comparison with adjustment for study design suggests that the efficacy of the examined NOACs is similar across drugs, but that some differences in safety and risk of myocardial infarction exist, and that open label study designs appear to overestimate safety and treatment efficacy. Differences in study design should be taken into account in the interpretation of results from RCTs of NOACs.
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Affiliation(s)
- Takeshi Morimoto
- Division of General Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | | | | | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus School of Medicine, Okinawa, Japan.
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Abstract
Based on efficacy, safety, and ease of use, novel oral anticoagulants will likely replace VKAs for many if not most patients with atrial fibrillation. Novel anticoagulants have a lower rate of intracranial hemorrhage compared with vitamin K antagonists. The incidence of other life-threatening bleeds is similar if not lower. Dose adjustments need to be made based on renal function and advanced age. There is at present a need for an antidote for these new drugs.
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Affiliation(s)
- Sunita J Ferns
- Department of Pediatrics, University of North Carolina, College of Medicine, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Gerald V Naccarelli
- Penn State Hershey heart and Vascular Institute, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
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Ferreira J, Mirco A. Systematic review of cost-effectiveness analyses of novel oral anticoagulants for stroke prevention in atrial fibrillation. Rev Port Cardiol 2015; 34:179-91. [PMID: 25727748 DOI: 10.1016/j.repc.2014.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 07/11/2014] [Accepted: 08/16/2014] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Novel oral anticoagulants are emerging options for the prevention and treatment of thromboembolic diseases. They are increasingly used in clinical practice due to their simplicity of use and clinical benefits, but an important step is to evaluate their cost-effectiveness. The aim of the AFFORD study (A Review of Cost EFFectiveness of Novel ORal Anticoagulant Drugs) was to perform a systematic review of cost-effectiveness studies of novel oral anticoagulants for stroke prevention in non-valvular atrial fibrillation (AF). METHODS A systematic review of the literature was conducted by searching the PubMed, Embase, Scopus, Cochrane and Web of Knowledge databases to identify all cost-effectiveness studies of novel oral anticoagulants for stroke prevention in AF. RESULTS The search identified 27 studies, 18 with dabigatran, three with apixaban, two with rivaroxaban and four with at least two of these drugs. The incremental cost-effectiveness ratios were 30 405 ± 16 101 euros per quality-adjusted life-year (QALY) for dabigatran 110 mg, 17 566 ± 16 902 euros/QALY for dabigatran 150 mg, 8102 ± 3252 euros/QALY for age-adjusted dabigatran, 11 897 ± 3341 euros/QALY for apixaban and 17 960 ± 12 005 euros/QALY for rivaroxaban. CONCLUSION The present systematic review demonstrates that novel oral anticoagulants are cost-effective for stroke prevention in AF.
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Affiliation(s)
| | - Ana Mirco
- Serviços Farmacêuticos, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
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40
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Jo HE, Barnes DJ. Role of novel oral anticoagulants in the management and prevention of venous thromboembolism. World J Hematol 2015; 4:1-9. [DOI: 10.5315/wjh.v4.i1.1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/11/2014] [Accepted: 12/17/2014] [Indexed: 02/05/2023] Open
Abstract
Venous thromboembolism (VTE) encompasses deep vein thrombosis and pulmonary embolism and is a major health burden, both medically and economically. Anticoagulation is the primary treatment and can be divided into three stages: initial, long term and extended treatment. Initial anticoagulation is given to reduce the risk of complications including fatal pulmonary embolism, while long term and extended treatment are aimed at prevention of recurrent VTE. Until recently, initial anticoagulation has only been achievable with administration of parental agents such as unfractionated or low molecular weight heparin, while vitamin K antagonists such as warfarin, have been the mainstay of long term and extended treatment. Factor-Xa inhibitors and direct thrombin inhibitors are oral anticoagulants that are being increasingly utilized as an alternative form of anticoagulation. This article aims to review the current guidelines in the management of VTE, the recent literature regarding novel anticoagulants in VTE, suggested treatment regimes and limitations.
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Ohyagi M, Nakamura K, Watanabe M, Fujigasaki H. Embolic stroke during apixaban therapy for left atrial appendage thrombus. J Stroke Cerebrovasc Dis 2015; 24:e101-2. [PMID: 25620711 DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 11/26/2014] [Accepted: 11/28/2014] [Indexed: 01/11/2023] Open
Abstract
Left atrial appendage (LAA) thrombus is associated with atrial fibrillation (AF) and is a powerful predictor of cardiogenic thromboembolism. Warfarin is an established anticoagulant therapy for patients with LAA thrombus to prevent thromboembolic complications. Apixaban is superior to warfarin in the prevention of thromboembolic complications in patients with AF, and there are case reports showing apixaban-associated resolution of LAA thrombus; however, the efficacy and safety of apixaban for the treatment of LAA thrombus remains unproven. Here we report a patient who experienced embolic stroke while taking apixaban for the treatment of LAA thrombus. Thrombolysis therapy was initiated at the onset of stroke and the patient recovered remarkably. Apixaban is known to make thrombi mobile and/or fragile by shifting the coagulation/fibrinolysis balance to a relative predominance of fibrinolytic activity; therefore, it is necessary to monitor for thromboembolic complications after the initiation of apixaban for the treatment of pre-existing LAA thrombus.
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Labaf A, Carlwe M, Svensson PJ. Efficacy and safety of novel oral anticoagulants in clinical practice: a report from three centers in Sweden. Thromb J 2014; 12:29. [PMID: 25506268 PMCID: PMC4265344 DOI: 10.1186/s12959-014-0029-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 08/05/2014] [Accepted: 11/04/2014] [Indexed: 12/27/2022] Open
Abstract
Introduction In clinical trials new oral anticoagulants (NOAC) have proved to be
as effective as warfarin for thromboprophylaxis in atrial fibrillation. The aim of
this study was to evaluate the efficacy and safety of these drugs in clinical
practise. Methods and results All patients treated with new oral anticoagulants at Skåne
University hospital and Halland County Hospital Halmstad between 2009 and
September 2013 was identified in the Swedish national quality registry for atrial
fibrillation and anticoagulation (AuriculA). Medical records were reviewed to
identify thromboembolism and major bleeding and compared to a warfarin cohort with
a time in therapeutic range (TTR) of 76%. There were 826 patients, mean age 70.6,
follow up 591 years, with atrial fibrillation treated with NOAC. Dabigatran was
the initial drug in 79% of the cohort. The incidences of ischemic stroke/ TIA and
major bleeding were 1.9 (95% CI; 1.0-3.2) and 2.0 (95% CI; 1.1-3.5) per 100
patient-years respectively. The corresponding incidences for warfarin were 1.5
(95% CI; 1.0-2.2) and 2.5 (95% CI; 1.8-3.3), with no statistical significance
between the groups. Two subdural hematomas occurred 0.4 (95% CI; 0.06-1.1) per 100
patient-years. Mean age of patients with complications was 77.9 (±5.9) and 69.3
(±11.3) for those without (p < 0.001). The discontinuation rate was 6.5% and
1.7% was due to dyspepsia for dabigatran, lower than the RE-LY trial. Conclusion This study, largely based on dabigatran shows that treatment is
efficient and safe in everyday clinical practice and not significantly different
compared to a warfarin cohort with tight anticoagulation control. Electronic supplementary material The online version of this article (doi:10.1186/s12959-014-0029-6) contains supplementary material, which is available to authorized
users.
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Affiliation(s)
- Ashkan Labaf
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Martin Carlwe
- Department of Medicine, Hallands Hospital, Halmstad, Sweden
| | - Peter J Svensson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Coagulation disorders, Skåne University Hospital, 205 02 Malmö, Sweden
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Fujii S. Editorial: Resolution of left atrial thrombus with novel oral anticoagulants. J Cardiol Cases 2014; 10:241-242. [PMID: 30534253 PMCID: PMC6279654 DOI: 10.1016/j.jccase.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Geldhof V, Vandenbriele C, Verhamme P, Vanassche T. Venous thromboembolism in the elderly: efficacy and safety of non-VKA oral anticoagulants. Thromb J 2014; 12:21. [PMID: 25650285 PMCID: PMC4314657 DOI: 10.1186/1477-9560-12-21] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
Increasing age and renal impairment are risk factors for venous thrombosis but also for anticoagulant-induced bleeding. In large-scale phase III trials, non-VKA oral anticoagulants (NOACs) were at least as effective and safe for the treatment of acute venous thromboembolism as warfarin. Here, we review the efficacy and safety of dabigatran, rivaroxaban, apixaban and edoxaban in the subgroups of elderly patients (≥75 years) and patients with impaired renal function (creatinine clearance ≤50 ml/min). In all phase III trials, the efficacy of NOACs in the prevention of recurrent VTE was conserved both in the elderly subgroup and in the subgroup with impaired renal function. In a meta-analysis of the pooled results, NOACs reduced VTE recurrence compared with warfarin in elderly patients. In elderly patients and patients with impaired renal function, the safety of NOACs was in line with the results of the overall study. NOACs may offer an effective, safer and more convenient alternative for VKAs also in the elderly. However, the efficacy/safety profile of NOACs in the aged population needs to be confirmed in real-life.
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Affiliation(s)
- Vincent Geldhof
- Division of Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium
| | - Christophe Vandenbriele
- Vascular Medicine and Haemostasis, Division of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, Division of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium
| | - Thomas Vanassche
- Vascular Medicine and Haemostasis, Division of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium ; Center for Molecular and Vascular Biology (CMVB), Department of Cardiovascular Sciences, University of Leuven, Herestraat 49, Leuven B3000, Belgium
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Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.
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Affiliation(s)
- Anja Käberich
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Simone Wärntges
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany ; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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Riley MP. Anticoagulation Issues in Atrial Fibrillation Ablation. Card Electrophysiol Clin 2014; 6:95-100. [PMID: 27063824 DOI: 10.1016/j.ccep.2013.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Patients undergoing atrial fibrillation ablation are anticoagulated before, during, and following their procedure to reduce the serious risk of a thromboembolic complication. Despite this well established recommendation, there remains debate about the optimal nature of anticoagulation and a continuing evolution in practice patterns. This article addresses issues related to anticoagulation in atrial fibrillation ablation focusing on the preprocedural, intraprocedural, and postprocedural periods.
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Affiliation(s)
- Michael P Riley
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Albert NM. Use of novel oral anticoagulants for patients with atrial fibrillation: systematic review and clinical implications. Heart Lung 2013; 43:48-59. [PMID: 24373340 DOI: 10.1016/j.hrtlng.2013.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [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: 07/16/2013] [Revised: 10/26/2013] [Accepted: 10/29/2013] [Indexed: 10/26/2022]
Abstract
Atrial fibrillation (AF), a common arrhythmia, increases the risk of ischemic stroke. Stroke and bleeding scores for patients with AF can help to stratify risk and determine the need for antithrombotic therapy, for which warfarin has been the gold standard. Although highly effective, warfarin has several limitations that can lead to its underuse. Data from randomized, Phase III clinical trials of the novel oral anticoagulants, dabigatran, a direct thrombin inhibitor, and rivaroxaban and apixaban, both factor Xa inhibitors, indicate these drugs are at least noninferior to warfarin for the prevention of stroke and systemic embolism. They are easier to administer, and have an equivalent or lower risk of bleeding versus warfarin. A better understanding of the risks and benefits of the novel oral anticoagulants, and their use in clinical practice, will prepare clinicians to anticipate and address educational and clinical needs of AF patients and their families, and promote evidence-based prescription of appropriate and safe anticoagulation therapy.
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Key Words
- AF
- Atrial fibrillation
- CHA(2)DS(2)-VASc
- CHADS(2)
- CI
- CrCl
- Dabigatran
- GI
- HAS-BLED
- ICH
- INR
- MI
- Novel oral anticoagulants
- RR
- Rivaroxaban
- TTR
- Warfarin
- atrial fibrillation
- cardiac failure, hypertension, age, diabetes, stroke (doubled)
- confidence interval
- congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, previous stroke or transient ischemic attack (doubled), vascular disease, sex category
- creatinine clearance
- gastrointestinal
- hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol
- international normalized ratio
- intracranial hemorrhage
- myocardial infarction
- relative risk
- time in therapeutic range
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Affiliation(s)
- Nancy M Albert
- Research and Innovation, Cleveland Clinic Health System, USA; George M and Linda H Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue J3-4, Cleveland, OH 44195, USA.
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Alotaibi GS, Almodaimegh H, McMurtry MS, Wu C. Do women bleed more than men when prescribed novel oral anticoagulants for venous thromboembolism? A sex-based meta-analysis. Thromb Res 2013; 132:185-9. [PMID: 23932014 DOI: 10.1016/j.thromres.2013.07.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/01/2013] [Accepted: 07/19/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Bleeding complications occur more frequently in women than men in clinical trials of warfarin and thrombolytics. It is unknown whether these sex-related differences exist for new oral anticoagulants, including dabigatran, rivaroxaban, and apixaban. To determine whether women suffer more bleeding complications with these agents, we conducted a systematic review and meta-analysis of randomized controlled trials on new oral anticoagulants for venous thromboembolism (VTE). MATERIALS AND METHODS Medline, Embase, and the Cochrane-controlled trial register on the Cochrane library were searched to identify studies that evaluated novel oral anticoagulants versus any comparator, and reported outcomes, including major bleeding and recurrent VTE, stratified by sex. No language restrictions were applied. Studies were evaluated according to a priori inclusion criteria and critically appraised using established internal validity criteria. Pooled relative risk was estimated using a random effects model. RESULTS Eight studies were eligible, comprising 9417 patients. There was no difference in the primary efficacy outcome of recurrent VTE between men and women [Relative Risk (RR) 1.02, 95% confidence interval (CI) 0.74-1.39]. However, men had less major bleeding with novel oral anticoagulants compared to women [RR 0.79, 95% CI 0.66-0.97, p=0.03]. All-cause mortality was not reported by sex in any of the studies. CONCLUSION Women suffer more bleeding complications than men when receiving novel oral anticoagulants for VTE. Future clinical trials should report outcomes stratified by sex, and further studies are needed to investigate the clinical impact of this sex-related safety difference.
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