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Du Z, Jiang W, Yu C, Zhang M, Xia W. Asymmetric dimethylarginine correlates with indicators of prethrombotic state in patients with nonvalvular atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 38563722 DOI: 10.1111/pace.14952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/24/2024] [Accepted: 02/03/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The mechanism of asymmetric dimethylarginine (ADMA) in thrombosis in patients with nonvalvular atrial fibrillation (NVAF) is still unclear. Our aim was to investigate the relationship between ADMA and indicators of prethrombotic state in NVAF patients and to analyze the predictive role of ADMA in NVAF thrombosis. METHODS A total of 192 NVAF patients were continuously selected from January 2023 to October 2023. Plasma ADMA levels were measured by high-performance liquid chromatography. P-selectin (P-sel), von Willebrand factor (vWF), D-dimer (D-D), and plasminogen activator inhibitor-1 (PAI-1) levels were measured by enzyme-linked immunosorbent assay (ELISA). Nitric oxide (NO) levels were measured by the nitrate reductase assay for plasma nitrite/nitrate, then the Griess method (Shanghai Hailian Biotechnology Co., Shanghai, China) was used to calculate plasma NO levels. RESULTS In our study, ADMA levels were significantly elevated and positively correlated with P-sel, vWF, D-D, and PAI-1, whereas NO levels were significantly negatively correlated with these prethrombotic factors in NVAF. Furthermore, multifactorial logistic regression analysis showed that ADMA and LA diameter were independent predictors of high thrombosis risk (CHA2DS2-VASc ≥2 score) in patients with NVAF. CONCLUSIONS Our findings suggested that ADMA correlated with the prethrombotic state in NVAF and that reduction of ADMA levels in NVAF patients may be a novel therapeutic strategy for thrombosis risk reduction.
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Affiliation(s)
- Zhaona Du
- School of Clinical Medicine, Shandong Second Medical University, Weifang, China
| | - Wenbo Jiang
- Department of Neurosurgery, Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Chengyun Yu
- School of Clinical Medicine, Shandong Second Medical University, Weifang, China
| | - Ming Zhang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, China
| | - Wei Xia
- Department of Cardiology, Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
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Yu M, Li X, Zong L, Wang Z, Lv Q. A Novel Body Mass Index-Based Thromboembolic Risk Score for Overweight Patients with Nonvalvular Atrial Fibrillation. Anatol J Cardiol 2024; 28:35-43. [PMID: 37961898 PMCID: PMC10796238 DOI: 10.14744/anatoljcardiol.2023.3373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/15/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND A novel risk prediction model appears to be urgently required to improve the assessment of thrombotic risk in overweight patients with nonvalvular atrial fibrillation (NVAF). We developed a novel body mass index (BMI)-based thromboembolic risk score (namely AB2S score) for these patients. METHODS A total of 952 overweight patients with NVAF were retrospectively enrolled in this study with a 12-month follow-up. The primary endpoint was 1-year systemic thromboembolism and the time to thrombosis (TTT). The candidate risk variables identified by logistic regression analysis were included in the final nomogram model to construct AB2S score. The measures of model fit were evaluated using area under the curve (AUC), C-statistic, and calibration curve. The performance comparison of the AB2S score to the CHADS2 and CHA2DS2-VASc score was performed in terms of the AUC and decision analysis curve (DAC). RESULTS The AB2S score was constructed using 7 candidate risk variables, including a 3-category BMI (25 to 30, 30 to 34, or ≥35 kg/m2). It yielded a c-index of 0.885 (95% CI, 0.814-0.954) and an AUC of 0.885 (95% CI, 0.815-0.955) for predicting 1-year systemic thromboembolism in patients with NVAF. Compared to the CHADS2 score and CHA2DS2-VASc score, the AB2S score had greater AUC and DAC values in predicting the thromboembolic risk and better risk stratification in TTT (P <.0001, P =.082, respectively). CONCLUSION Our results highlighted the importance of a BMI-based AB2S score in determining systemic thromboembolism risk in overweight patients with NVAF, which may aid in decision-making for these patients to balance the effectiveness of anticoagulation from the underlying thrombotic risk.
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Affiliation(s)
- Meixiang Yu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liuliu Zong
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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Ruan ZB, Li W, Jin K, Ding XW, Chen GC, Zhu JG, Ren Y, Zhu L. A preliminary study of minimal left atrial appendage occlusion using Watchman under the guidance of fluoroscopy. Catheter Cardiovasc Interv 2024; 103:119-128. [PMID: 37681962 DOI: 10.1002/ccd.30838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) has been considered an alternative treatment to prevent embolic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it carries a risk of general anesthesia or esophageal injury if guided by transesophageal echocardiography (TEE). AIMS We aimed to investigate the feasibility and safety of minimal LAAO (MLAAO) using Watchman under fluoroscopy guidance alone in patients with NVAF. METHODS A total of 249 consecutive patients with NVAF who underwent LAAO using the WATCHMAN device were divided into two groups: the Standard LAAO (SLAAO) group and the MLAAO group. Procedural characteristics and follow-up results were compared between the two groups. RESULTS There was no statistically significant difference in the rate of successful device implantation (p > 0.05). Fluoroscopy time, radiation exposure dose, and contrast medium usage in the MLAAO group were higher than those in the SLAAO group (p < 0.001). The procedure time and hospitalization duration were significantly lower in the MLAAO group than those in the SLAAO group (p < 0.001). The occluder compression ratio, measured with fluoroscopy, was lower than that measured with TEE (17.63 ± 3.75% vs. 21.69 ± 4.26%, p < 0.001). Significant differences were observed between the SLAAO group and the MLAAO group (p < 0.05) in terms of oropharyngeal/esophageal injury, hypotension, and dysphagia. At 3 months after LAAO, the MLAAO group had a higher incidence of residual flow within 1-5 mm compared to the SLAAO group, although the difference was not statistically significant. CONCLUSION MLAAO guided by fluoroscopy, instead of TEE, without general anesthesia simplifies the operational process and may be considered safe, effective, and feasible, especially for individuals who are unable to tolerate or unwilling to undergo TEE or general anesthesia.
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Affiliation(s)
- Zhong-Bao Ruan
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Wei Li
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Kai Jin
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Xiang-Wei Ding
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Ge-Cai Chen
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Jun-Guo Zhu
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Yi Ren
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
| | - Li Zhu
- Department of Cardiology, The affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, P.R. China
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Zheng XY, Feng GW, Guo J, Xie F, Li X, Zhang MZ, Zhang XF, Wu XF, Ding YJ. A cross-sectional study of appropriateness evaluation of anticoagulation therapy for inpatients with nonvalvular atrial fibrillation. Front Pharmacol 2023; 14:1286559. [PMID: 38116077 PMCID: PMC10728771 DOI: 10.3389/fphar.2023.1286559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
Background: Oral anticoagulants (OACs) are essential for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the appropriateness of anticoagulation treatment in locally practice remains unclear. This study evaluated compliance with anticoagulation therapy concerning the guidelines and drug labels in patients with NVAF. Methods: Hospitalized patients diagnosed with NVAF between 1 November 2020, and 31 December 2021, were retrospectively enrolled. The appropriateness of anticoagulation regimens at discharge was evaluated based on a flowchart designed according to atrial fibrillation (AF) guidelines and medication labels. Furthermore, we explored factors potentially influencing the "no-use of OACs" using binary logistic regression and verified anticoagulation-related issues through a physician questionnaire. Results: A total of 536 patients were enrolled in this study, including 254 patients (47.4%) with inappropriate anticoagulation regimens. 112 patients (20.9%) were categorized as "underdosing-use of OACs," 134 (25%) who needed anticoagulation therapy were "no-use of OACs" and eight (1.5%) were "over-use of OACs." The results of a binary logistic regression analysis showed that paroxysmal AF (odds ratio [OR], 7.74; 95% confidence interval [CI], 4.57-13.10), increased blood creatinine levels (OR, 1.88; 95% CI, 1.11-3.16), hospitalized pacemaker implantation (OR, 6.76; 95% CI, 2.67-17.11), percutaneous coronary intervention (OR, 3.35; 95% CI, 1.44-7.80), and an increased HAS-BLED score (OR, 1.62; 95% CI, 1.11-2.35) were associated with "no-use of OACs" in patients with NVAF who had indications for anticoagulation therapy. Conclusion: For patients with NVAF with severe renal dysfunction and paroxysmal AF, anticoagulation therapy was inadequate. The underdosing-use of OACs in patients with NVAF was frequently observed. We recommend an anticoagulation management team to tailor anticoagulation regimens to suit each patient's needs.
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Affiliation(s)
- Xiao-Yuan Zheng
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Guang-Wei Feng
- Department of Pharmacy, Dahua Hospital, Xuhui District, Shanghai, China
| | - Jing Guo
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Fen Xie
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xia Li
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Ming-Zhu Zhang
- Department of Pharmacy, Shandong Provincial Third Hospital, Jinan, China
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, China
| | - Xiu-Fen Zhang
- Oncology Institute, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xiu-Feng Wu
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yong-Juan Ding
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
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Xue S, Na R, Dong J, Wei M, Kong Q, Wang Q, Qiu X, Li F, Song H. Characteristics and Mechanism of Acute Ischemic Stroke in NAVF Patients With Prior Oral Anticoagulant Therapy. Neurologist 2023; 28:379-385. [PMID: 37582631 PMCID: PMC10627545 DOI: 10.1097/nrl.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVES We aimed to analyze the characteristics and mechanisms of acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) who received prior anticoagulant therapy. METHODS We retrospectively analyzed the data of patients with NVAF and AIS between January 2016 and December 2021. Patients were divided into non-anticoagulant, adequate anticoagulant, and insufficient anticoagulant groups according to their prior anticoagulant status. Patients with prior anticoagulant therapy were further divided into warfarin and direct oral anticoagulant groups. RESULTS A total of 749 patients (661 without anticoagulants, 33 with adequate anticoagulants, and 55 with insufficient anticoagulants) were included. Patients with adequate anticoagulant had a milder National Institute of Health Stroke Scale at presentation ( P =0.001) and discharge ( P =0.003), a higher proportion of Modified Rankin Scale (mRS) ≤2 at discharge ( P =0.011), and lower rates of massive infarction ( P =0.008) than patients without anticoagulant. Compared with the non-anticoagulant group, the proportion of intravenous thrombolysis was significantly lower in the adequate anticoagulant ( P <0.001) and insufficient anticoagulant ( P =0.009) groups. Patients in the adequate anticoagulant group had higher rates of responsible cerebral atherosclerotic stenosis ( P =0.001 and 0.006, respectively) and competing large artery atherosclerotic mechanisms ( P =0.006 and 0.009, respectively) than those in the other 2 groups. Compared with warfarin, direct oral anticoagulant was associated with higher rates of Modified Rankin Scale ≤2 at discharge ( P =0.003). CONCLUSIONS Adequate anticoagulant therapy may be associated with milder stroke severity and better outcomes at discharge in patients with NVAF. Competing large artery atherosclerotic mechanisms may be associated with anticoagulant failure in patients with NAVF with prior adequate anticoagulant therapy.
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Affiliation(s)
- Sufang Xue
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Risu Na
- Department of Neurology, Tongliao City Hospital, Tongliao, China
| | - Jing Dong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qi Kong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qiujia Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xue Qiu
- Department of Neurology, Shuangqiao Hospital, Beijing, China
| | - Fangyu Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
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Shiozawa M, Koga M, Inoue H, Yamashita T, Yasaka M, Suzuki S, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Hirayama A, Nakahara J, Teramukai S, Kimura T, Morishima Y, Takita A, Yamaguchi T, Toyoda K. Risk of both intracranial hemorrhage and ischemic stroke in elderly individuals with nonvalvular atrial fibrillation taking direct oral anticoagulants compared with warfarin: Analysis of the ANAFIE registry. Int J Stroke 2023; 18:986-995. [PMID: 37154598 PMCID: PMC10507992 DOI: 10.1177/17474930231175807] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Elderly patients with nonvalvular atrial fibrillation (NVAF) might have a higher risk of intracerebral hemorrhage. To investigate this, we compared the incidence of intracranial hemorrhage (ICH) and its subtypes, as well as ischemic stroke, in patients taking direct oral anticoagulants (DOACs) compared with warfarin in a real-world setting. We also determined the baseline characteristics associated with both ICH and ischemic stroke. METHODS Patients aged ⩾ 75 years with documented NVAF enrolled in the prospective, multicenter, observational All Nippon Atrial Fibrillation in the Elderly Registry between October 2016 and January 2018 were evaluated. The co-primary endpoints were the incidence of ischemic stroke and ICH. Secondary endpoints included subtypes of ICH. RESULTS Of 32,275 patients (13,793 women; median age, 81.0 years) analyzed, 21,585 (66.9%) were taking DOACs and 8233 (25.5%) were taking warfarin. During the median 1.88-year follow-up, 743 patients (1.24/100 person-years) developed ischemic stroke and 453 (0.75/100 person-years) developed ICH (intracerebral hemorrhage, 189; subarachnoid hemorrhage, 72; subdural/epidural hemorrhage, 190; unknown subtype, 2). The incidence of ischemic stroke (adjusted hazard ratio (aHR) 0.82, 95% confidence interval (CI) 0.70-0.97), ICH (aHR 0.68, 95% CI 0.55-0.83), and subdural/epidural hemorrhage (aHR 0.53, 95% CI 0.39-0.72) was lower in DOAC users versus warfarin users. The incidence of fatal ICH and fatal subarachnoid hemorrhage was also lower in DOAC users versus warfarin users. Several baseline characteristics other than anticoagulants were also associated with the incidence of the endpoints. Of these, history of cerebrovascular disease (aHR 2.39, 95% CI 2.05-2.78), persistent NVAF, (aHR 1.90, 95% CI 1.53-2.36), and long-standing persistent/permanent NVAF (aHR 1.92, 95% CI 1.60-2.30) was strongly associated with ischemic stroke; severe hepatic disease (aHR 2.67, 95% CI 1.46-4.88) was strongly associated with overall ICH; and history of fall within 1 year was strongly associated with both overall ICH (aHR 2.29, 95% CI 1.76-2.97) and subdural/epidural hemorrhage (aHR 2.90, 95% CI 1.99-4.23). CONCLUSION Patients aged ⩾ 75 years with NVAF taking DOACs had lower risks of ischemic stroke, ICH, and subdural/epidural hemorrhage than those taking warfarin. Fall was strongly associated with the risks of intracranial and subdural/epidural hemorrhage. DATA ACCESS STATEMENT The individual de-identified participant data and study protocol will be shared for up to 36 months after the publication of the article. Access criteria for data sharing (including requests) will be decided on by a committee led by Daiichi Sankyo. To gain access, those requesting data access will need to sign a data access agreement. Requests should be directed to yamt-tky@umin.ac.jp.
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Affiliation(s)
- Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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Burnham KT, Yang T, Wooster J. A Real-World Comparison of Apixaban and Rivaroxaban in Obese and Morbidly Obese Patients With Nonvalvular Atrial Fibrillation. J Pharm Pract 2023:8971900231202643. [PMID: 37713139 DOI: 10.1177/08971900231202643] [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: 09/16/2023]
Abstract
Background: Contemporary guidelines for managing nonvalvular atrial fibrillation (NVAF) include apixaban and rivaroxaban as first-line anticoagulation treatment options. Minimal guidance is available regarding selecting anticoagulants for patients with class I-III obesity. Objective: This study aims to evaluate the comparative effectiveness and safety of apixaban and rivaroxaban in both obese and morbidly obese patients with NVAF. Methods: A retrospective cohort study was conducted at an outpatient cardiovascular clinic after Institutional Review Board approval. Patients were eligible if they were ≥18 years of age, had a BMI ≥30 kg/m2, and took apixaban or rivaroxaban for NVAF for ≥3 months. The primary endpoint was the composite rate of stroke, transient ischemic attack (TIA), myocardial infarction (MI), or presence of atrial thrombosis. Bleeding events were evaluated as the primary safety endpoint. Results: Combined, the cohorts consisted of 303 obese or morbidly obese patients. The primary composite endpoint occurred in 3.8% of patients taking apixaban and 1.7% of patients taking rivaroxaban (P = .28). Both clinically relevant, non-major and major bleeding occurred more often in the apixaban arm, but this difference was not statistically significant; however, bleeding risk may have been skewed due to differences in baseline characteristics. Conclusion and Relevance: For obese and morbidly obese patients prescribed either apixaban or rivaroxaban for NVAF, rates of stroke, TIA, MI, and atrial thrombosis did not differ. The preferred DOAC for patients with class I-III obesity remains elusive, but current data points to a patient-centered approach for anticoagulant selection.
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Affiliation(s)
- Kevin T Burnham
- Department of Pharmacy, Methodist Health System, Dallas, TX, USA
| | - Tianrui Yang
- Fisch College of Pharmacy, The University of Texas at Tyler, Dallas, TX, USA
| | - Jessica Wooster
- Fisch College of Pharmacy, The University of Texas at Tyler, Dallas, TX, USA
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Alshibani M. Appropriateness of rivaroxaban and apixaban dosing in hospitalized patients with a newly diagnosed nonvalvular atrial fibrillation at a single tertiary hospital. Medicine (Baltimore) 2023; 102:e35058. [PMID: 37682197 PMCID: PMC10489303 DOI: 10.1097/md.0000000000035058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/11/2023] [Indexed: 09/09/2023] Open
Abstract
Possible challenges in dosing non-vitamin K antagonist oral anticoagulants in nonvalvular atrial fibrillation (NVAF) and limited evidence in Saudi Arabia make it difficult to assess their appropriateness. This study aimed to assess the appropriateness of prescribing rivaroxaban and apixaban in hospitalized patients with newly diagnosed NVAF. This single-center, descriptive, retrospective study was conducted at a tertiary hospital in Saudi Arabia between December 2018 and December 2019. The included patients were aged 18 years and older with newly diagnosed NVAF who received either rivaroxaban or apixaban during hospitalization. The primary outcome was the dosing appropriateness of rivaroxaban and apixaban in NVAF based on recent food and drug administration prescribing guidelines. Descriptive statistics including frequencies and percentages as well as mean ± standard deviation was used to summarize the data. Pearson Chi-square was used to test for significant difference in proportions of appropriate and inappropriate dosing. Pearson Correlation was used to test for associations between underdosing and overdosing with other patients characteristics. A priori P value < .05 was considered significant throughout. A total of 203 patients were included in our analysis. Majority of the patients {125 (61.6%), P = .001} received rivaroxaban. Overall, the dosing appropriateness observed in 143 (70.5%) of the patients who received the rivaroxaban and apixaban was significantly higher than the dosing inappropriateness observed in 60 (29.5%) of the patients who received the same drugs, P < .001. Apixaban had the highest proportion of patients, 45 (57.7%) with dosing inappropriateness. Overall, underdosing was the most common dosing inappropriateness observed in 53 (26.1%) of the patients. There was a significant negative correlation between the drugs underdosing and creatinine clearance, r = -0.223, P = .001. The findings in our present study showed that majority of the patients received appropriate dosing of rivaroxaban and apixaban in hospitalized patients with NVAF. Healthcare providers should update themselves with the recent dosing recommendations for the non-vitamin K-antagonist oral anticoagulants in NVAF to further improve the dosing appropriateness in hospitalized patients with NVAF.
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Affiliation(s)
- Mohannad Alshibani
- Faculty of Pharmacy, Department of Pharmacy Practice, King Abdulaziz University, Jeddah, Saudi Arabia
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9
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Alberts MJ, Zhdanava M, Pilon D, Caron-Lapointe G, Lefebvre P, Bookhart B, Kharat A. Ischemic stroke and systemic embolism among patients with non-valvular atrial fibrillation who abandon oral anticoagulant therapy. Curr Med Res Opin 2023; 39:1279-1286. [PMID: 37589313 DOI: 10.1080/03007995.2023.2247967] [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: 06/12/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To compare the risk of stroke and systemic embolism (SE) among patients with nonvalvular atrial fibrillation (NVAF) who abandoned their first direct oral anticoagulant (DOAC) fill ("abandoners") relative to patients who continued DOACs beyond the first fill ("continuers"). METHODS In this retrospective longitudinal study, adults with NVAF prescribed DOACs were selected from Symphony Health, an ICON plc Company, PatientSource, 1 April 2017 to 31 October 2020. A 90-day landmark period following the first DOAC fill was used to classify patients as abandoners or continuers. Inverse probability of treatment weighting was used to balance baseline characteristics between cohorts. Time to ischemic stroke/SE was described and compared between cohorts using weighted Kaplan-Meier and Cox proportional hazard models from the end of the landmark period until end of clinical activity or data. RESULTS After weighting, 200,398 and 211,352 patients comprised the abandoner and continuer cohorts, respectively. The mean duration of follow-up was 14.9 and 15.7 months, respectively. At 12 months of follow-up, the probability of ischemic stroke/SE was 1.34% in the abandoner cohort and 1.00% in the continuer cohort; the risk of ischemic stroke/SE was 35% higher in the abandoner versus continuer cohort (hazard ratio [95% confidence interval] = 1.35 [1.20, 1.51]; p < 0.0001). CONCLUSIONS Patients with NVAF who abandoned the first DOAC fill had significantly higher risk of ischemic stroke/SE compared to patients who continued therapy beyond the first fill. There is an unmet need for better access to DOACs so that the long-term risk of poor outcomes may be minimized.
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Affiliation(s)
| | | | | | | | | | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Gong X, Hua R, Bai J, Wu T, Wang Q, Zhang J, Zhang W, Ying L, Ke Y, Wang X, Zhang X, Liu K, Chen Y, Zhang B, Dong P, Xiao J, Li C, Zhu L, Li C. Rationale and design of the optimal antithrombotic treatment for acute coronary syndrome patients with concomitant atrial fibrillation and implanted with new-generation drug-eluting stent: OPtimal management of anTIthroMbotic Agents (OPTIMA)-4 trial. Clin Cardiol 2023. [PMID: 37191146 DOI: 10.1002/clc.24025] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND About 5%-15% of acute coronary syndrome (ACS) patients undergoing stent implantation have concomitant atrial fibrillation and need both antiplatelet and anticoagulant therapies. The optimal antithrombotic regimen remains uncertain in this scenario. HYPOTHESIS A multicenter randomized controlled trial (OPtimal management of anTIthroMbotic Agents [OPTIMA]-4) is designed to test the hypothesis that, for ACS patients with concomitant nonvalvular atrial fibrillation (NVAF) and having low-to-moderate risk of bleeding, clopidogrel is comparable in efficacy but superior in safety compared to ticagrelor while being used in combination with dabigatran after new-generation drug-eluting stent (DES) implantation. METHODS ACS patients who have low-to-moderate risk of bleeding (e.g., HAS-BLED score ≤ 2) and require anticoagulation therapy (CHA2 DS2 -VASc score ≥ 2) will be recruited after implantation of new-generation DES. A total of 1472 eligible patients will be randomly assigned to receive a 12-month dual antithrombotic treatment of either clopidogrel 75 mg daily or ticagrelor 90 mg twice daily in combination with dabigatran 110 mg twice daily. Participants will be followed up for 12 months after randomization. The primary efficacy endpoint is a composite of cardiovascular death, myocardial infarction, unplanned revascularization, ischemic stroke, and systemic thromboembolism. The primary safety endpoint is set as major bleeding or clinically relevant nonmajor bleeding defined by the International Society of Thrombosis and Hemostasis. The enrollment and follow-up have been launched. RESULTS The first enrollment occurred on March 12, 2018. The recruitment is anticipated to be completed before December 31, 2024. CONCLUSIONS The OPTIMA-4 trial offers an opportunity to assess the optimal dual antithrombotic regimen in ACS patients with concomitant NVAF after the implantation of new-generation DES.
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Affiliation(s)
- Xiaoxuan Gong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianling Bai
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Tianyu Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qin Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinhua Zhang
- The Pharmaceutical Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenhao Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lianghong Ying
- Department of Cardiology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an Second People's Hospital, Huai'an, China
| | - Yongsheng Ke
- Department of Cardiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xiaoyan Wang
- Department of Cardiology, The Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xiwen Zhang
- Department of Cardiology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Kun Liu
- Department of Cardiology, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Yan Chen
- Department of Cardiology, Taishan People's Hospital, Taishan, China
| | - Boqing Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Peng Dong
- Department of Cardiology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Jianqiang Xiao
- Department of Cardiology, Changzhou Wujin People's Hospital, Changzhou, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Taizhou, China
| | - Chunjian Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Asami M, Naganuma T, Ohno Y, Tani T, Okamatsu H, Mizutani K, Watanabe Y, Izumo M, Saji M, Mizuno S, Ueno H, Kubo S, Shirai S, Nakashima M, Yamamoto M, Hayashida K. Initial Japanese Multicenter Experience and Age-Related Outcomes Following Left Atrial Appendage Closure: The OCEAN-LAAC Registry. JACC Asia 2023; 3:272-284. [PMID: 37181391 PMCID: PMC10167511 DOI: 10.1016/j.jacasi.2022.11.003] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/17/2022] [Accepted: 11/07/2022] [Indexed: 05/16/2023]
Abstract
Background Limited data are available describing left atrial appendage closure (LAAC) and age-related outcomes in Asians. Objectives This study summarizes the initial experience with LAAC in Japan and determines age-related clinical outcomes in patients with nonvalvular atrial fibrillation undergoing percutaneous LAAC. Methods In an ongoing, prospective, investigator-initiated, multicenter, observational registry of patients undergoing LAAC in Japan, we analyzed short-term clinical outcomes in patients with nonvalvular atrial fibrillation who underwent LAAC. Patients were classified into younger, middle-aged, and elderly groups (≤70, 70 to 80, and >80 years of age, respectively) to determine age-related outcomes. Results Patients (n = 548; mean age, 76.4 ± 8.1 years; male, 70.3%) who underwent LAAC at 19 Japanese centers between September 2019 and June 2021 were enrolled in the study, including 104, 271, and 173 patients in the younger, middle-aged, and elderly groups, respectively. Participants had a high-risk of bleeding and thromboembolism with a mean CHADS2 score of 3.1 ± 1.3, a mean CHA2DS2-VASc score of 4.7 ± 1.5, and a mean HAS-BLED score of 3.2 ± 1.0. Device success rates were 96.5% and anticoagulants discontinuation at the 45-day follow-up was achieved in 89.9%. In-hospital outcomes were not significantly different, but major bleeding events during the 45-day follow-up were significantly higher in the elderly group compared to the other groups (younger vs middle-aged vs elderly, 1.0% vs 3.7% vs 6.9%, respectively; P = 0.047) despite the same postoperative drug regimens. Conclusions The initial Japanese experience with LAAC demonstrated safety and efficacy; however, perioperative bleeding events were more common in the elderly and postoperative drug regimens must be tailored (OCEAN-LAAC [Optimized Catheter Valvular Intervention-Left Atrial Appendage Closure] registry; UMIN000038498).
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Affiliation(s)
- Masahiko Asami
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tomoyuki Tani
- Department of Cardiology, Sapporo East Tokushukai Hospital, Hokkaido, Japan
| | - Hideharu Okamatsu
- Department of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kazuki Mizutani
- Department of Cardiology, Kinki University School of Medicine, Osaka, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masaki Izumo
- Department of Cardiology, St Marianna University School of Medicine, Kanagawa, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Hiroshi Ueno
- Department of Cardiology, Toyama University Hospital, Toyama, Japan
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | | | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center, Aichi, Japan
- Department of Cardiology, Nagoya Heart Center, Aichi, Japan
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - OCEAN-LAAC Investigators
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
- Department of Cardiology, Tokai University School of Medicine, Kanagawa, Japan
- Department of Cardiology, Sapporo East Tokushukai Hospital, Hokkaido, Japan
- Department of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Department of Cardiology, Kinki University School of Medicine, Osaka, Japan
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
- Department of Cardiology, St Marianna University School of Medicine, Kanagawa, Japan
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan
- Department of Cardiology, Toyama University Hospital, Toyama, Japan
- Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
- Department of Cardiology, Sendai Kousei Hospital, Miyagi, Japan
- Department of Cardiology, Toyohashi Heart Center, Aichi, Japan
- Department of Cardiology, Nagoya Heart Center, Aichi, Japan
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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12
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Mohanty S, Banerjee A, Kumar A, Deb P, Samantray H, Das D. Non-Valvular Atrial Fibrillation in Young Adults in Eastern India: A Clinico-Aetiological Retrospective Analysis in a Tertiary Care Hospital. Cureus 2023; 15:e36918. [PMID: 37128533 PMCID: PMC10148691 DOI: 10.7759/cureus.36918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The development of atrial fibrillation adds a lot to the morbidity and mortality of individual patients. The spectrum of non-valvular atrial fibrillation among young adults is less known. The present observational study aims to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults between 18 and 40 years of age. METHODS A retrospective observational study was carried out to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults less than 40 years of age attending the cardiac outpatient department in a tertiary care hospital in Eastern India over a period of two years. Patients with any form of organic valvular heart disease and patients more than 40 years of age were excluded from the study. One hundred and seventeen patients under 40 years of age were analysed with respect to demographic, aetiological, and clinical profiles. RESULTS Most common aetiologies behind non-valvular atrial fibrillation in young adults (<40 years) were hypertension (40%) and the presence of left ventricular systolic dysfunction (31%). Thyrotoxicosis, obesity, obstructive sleep apnoea, the presence of congenital heart disease, coronary artery disease, myopericarditis, chronic kidney disease, dyselectronemia, diabetes mellitus, and the presence of chronic obstructive pulmonary disease contributed towards the development of non-valvular atrial fibrillation in the young population in less proportion of cases. Most of the cases were symptomatic with palpitation, shortness of breath, or diaphoresis. Less number of cases (17%) had left atrial thrombus which may be due to early clinical attention with the proper therapeutic anticoagulation regimen. CONCLUSIONS Hypertension and the presence of left ventricular systolic dysfunction contribute to the majority towards the development of non-valvular atrial fibrillation among young adults. Accurate measurement and monitoring of blood pressure among young adults and careful assessment of left ventricular systolic dysfunction with subsequent appropriate management of hypertension and left ventricular systolic dysfunction in young can decrease the burden of non-valvular atrial fibrillation among the young population.
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Affiliation(s)
- Satyapriya Mohanty
- Cardiothoracic Surgery, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
| | - Anindya Banerjee
- Cardiology, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
| | - Abhinav Kumar
- Cardiology, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
| | - Pranjit Deb
- Cardiology, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
| | - Humshika Samantray
- Cardiothoracic Surgery, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
| | - Debasish Das
- Cardiology, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, IND
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13
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Bing S, Chen RR. Clinical efficacy and safety comparison of Watchman device versus ACP/Amulet device for percutaneous left atrial appendage closure in patients with nonvalvular atrial fibrillation: A study-level meta-analysis of clinical trials. Clin Cardiol 2022; 46:117-125. [PMID: 36448417 PMCID: PMC9933112 DOI: 10.1002/clc.23956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022] Open
Abstract
Left atrial appendage occlusion is not inferior to oral anticoagulants in the prevention of stroke in several randomized controlled trials. However, the clinical efficacy and safety comparison of the Watchman and amplatzer cardiac plug (ACP)/Amulet devices for percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation was controversial. A database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared Watchman device vs ACP/Amulet device. The effective outcomes were stroke and systemic embolism. Safety outcomes were all-cause death, cardiovascular death, and major bleeding. Device-related complications included device-related thrombus (DRT), peri-device leaks (PDL > 5 mm). A total of 19 articles involving 6224 patients were included in the present study. The Watchman and ACP/Amulet groups comprised 3267 and 2957 patients, respectively. No statistically significant differences were detected in the stroke (odd ratio [OR]:1.24, 95% confidence interval [CI]: 0.92-1.67, p = .17, I2 = 0), systemic embolism (OR:1.10, 95% CI: 0.51-2.35, p = .81, I2 = 0%), all-cause death (OR:0.97, 95% CI: 0.80-1.18, p = .77, I2 = 1%), cardiogenic death (OR:0.99, 95% CI: 0.77-1.29, p = .96, I2 = 0%), major bleeding (OR:1.18, 95% CI: 0.98-1.43, p = .08, I2 = 25%). DRT (OR:1.48, 95% CI: 1.06-2.06, p = .02, I2 = 0%) and PDL > 5 mm (OR:2.57, 95% CI: 1.63-4.04, p < .0001, I2 = 0%) were significantly lower in ACP/Amulet group compared to Watchman group. The effective and safety outcomes were comparable between two groups. ACP/Amulet group had significantly lower rates of DRT and PDL > 5 mm than Watchman group.
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Affiliation(s)
- Sun Bing
- Department of Cardiology, Tang du HospitalAir Force Medical UniversityXi'anShaanxiChina
| | - Rui Rui Chen
- Department of Cardiology, Tang du HospitalAir Force Medical UniversityXi'anShaanxiChina
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14
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Shen Z, Chen D, Cheng H, Tan F, Yan J, Deng H, Fang W, Wang S, Zhu J. N-terminal pro-B-type natriuretic peptide and D-dimer combined with left atrial diameter to predict the risk of ischemic stroke in nonvalvular atrial fibrillation. Clin Cardiol 2022; 46:41-48. [PMID: 36208092 PMCID: PMC9849441 DOI: 10.1002/clc.23933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES We aimed to explore the potential role of N-terminal pro-B-type natriuretic peptide (NT-proBNP), d-dimer, and the echocardiographic parameter left atrial diameter (LAD) in identifying and predicting the occurrence of ischemic stroke (IS) in patients with nonvalvular atrial fibrillation (NVAF). METHODS We conducted a retrospective study of 445 patients with NVAF in the First Affiliated Hospital of Nanchang University. They were divided into the NVAF (309 cases) and NVAF with stroke (136 cases) groups according to whether acute ischemic stroke (AIS) occurred at admission. Multivariate logistic regression was used to analyze the odds ratio (OR) of NT-proBNP, d-dimer, and LAD for IS. The predictive value of NT-proBNP, d-dimer, and LAD in identifying the occurrence of IS in NVAF was determined by plotting the receiver operating characteristic (ROC) curves. RESULTS NT-proBNP, d-dimer, and LAD levels were significantly higher in the NVAF with stroke group than in the NVAF group (p < .05). NT-ProBNP, d-dimer, and LAD were independently associated with IS in NVAF patients (odds ratio [OR] = 1.12, 95% confidence interval [CI]: 1.08-1.16; OR = 1.87, 95% CI: 1.37-2.55; OR = 1.21, 95% CI: 1.13-1.28, p < .01). The optimal cutoff points for NT-ProBNP, d-dimer, and LAD levels to distinguish the NVAF group from the NVAF with stroke group were 715.0 pg/ml, 0.515 ng/ml, and 38.5 mm, respectively, with the area under the curve (AUC) being [0.801 (95% CI: 0.76-0.84); 0.770 (95% CI: 0.72-0.85); 0.752 (95% CI: 0.71-0.80), p < .01]. The combined score of NT-proBNP, d-dimer, and LAD improved the predictive efficacy of the single index, with an AUC of 0.846 (95% CI: 0.81-0.88, p < .01), sensitivity of 77.2%, and specificity of 76.4%. CONCLUSION NT-proBNP, d-dimer, and the echocardiographic parameter LAD have outstanding value in predicting the risk of IS in patients with NVAF.
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Affiliation(s)
- Zican Shen
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Dong Chen
- Beijing Hospital of Traditional Chinese MedicineCapital Medical UniversityBeijingChina
| | - Hao Cheng
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Feng Tan
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Jianwei Yan
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Haiming Deng
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Wei Fang
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Sunan Wang
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
| | - Jianbing Zhu
- Department of CardiologyThe First Affiliated Hospital of Nanchang UniversityNanchangChina,Jiangxi Hypertension Research InstituteNanchangChina
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15
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Krittayaphong R, Pumprueg S, Sairat P. Soluble ST2 in the prediction of heart failure and death in patients with atrial fibrillation. Clin Cardiol 2022; 45:447-456. [PMID: 35188278 PMCID: PMC9019881 DOI: 10.1002/clc.23799] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/21/2022] [Accepted: 02/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background Biomarkers may be a useful marker for predicting heart failure (HF) or death in patients with atrial fibrillation (AF). Hypothesis Soluble ST2 (sST2) may be a good biomarker for the prediction of HF or death in patients with AF. Methods This is a prospective study of patients with nonvalvular AF. Clinical outcomes were HF or death. Clinical and laboratory data were compared between those with and without clinical outcomes. Univariate and multivariate analysis was performed to determine whether sST2 is an independent predictor for heart failure or death in patients with nonvalvular AF. Results A total of 185 patients (mean age: 68.9 ± 11.0 years) were included, 116 (62.7%) were male. The average sST2 and N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) levels were 31.3 ± 19.7 ng/ml and 2399.5 ± 6853.0 pg/ml, respectively. Best receiver operating characteristic (ROC) cut off of sST2 for predicting HF or death was 30.14 ng/ml. Seventy‐three (39.5%) patients had an sST2 level ≥30.14 ng/ml, and 112 (60.5%) had an sST2 level <30.14 ng/dl. The average follow‐up was 33.1 ± 6.6 months. Twenty‐nine (15.7%) patients died, and 33 (17.8%) developed HF during follow‐up. Multivariate analysis revealed that high sST2 to be an independent risk factor for death or HF with a HR and 95% CI of 2.60 (1.41–4.78). The predictive value of sST2 is better than NT‐proBNP, and it remained significant in AF patients irrespective of history of HF, and NT‐proBNP levels. Conclusions sST2 is an independent predictor of death or HF in patients with AF irrespective of history of HF or NT‐proBNP levels.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satchana Pumprueg
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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16
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Bodega F, Russi A, Melillo F, Blunda F, Rubino C, Leo G, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Castiglioni A, Alfieri O, De Bonis M, Montorfano M, Tresoldi M, Filippi M, Salerno A, Cera M, Zangrillo A, Alberto M, Godino C. Direct oral anticoagulants in patients with nonvalvular atrial fibrillation and extreme body weight. Eur J Clin Invest 2022; 52:e13658. [PMID: 34310688 DOI: 10.1111/eci.13658] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited clinical data exist describing the use of direct oral anticoagulants (DOACs) in patient with extreme body weight. Thus, the International Society of Thrombosis and Haemostasis (ISTH) recommends avoiding DOACs in patients with weight >120 Kg, and on the contrary, no restrictions exist for underweight patients. OBJECTIVE To evaluate the effects of extreme body weight on DOAC activity and to compare the clinical outcomes of patients with an extreme body weight versus patients with a normal weight (61-119 Kg) treated with DOACs. METHODS Single tertiary care Italian centre multidisciplinary registry including nonvalvular atrial fibrillation (NVAF) patients treated with DOACs. Based on weight, three subcohorts were defined: (i) underweight patients (≤60 Kg); (ii) patients with a normal weight (61-119 Kg, as control group); and (iii) overweight patients (≥120 Kg). Primary efficacy endpoint was 2-year rate of thromboembolic events. Primary safety endpoint was 2-year rate of major bleeding. Event-free survival curves among groups were compared using Cox-Mantel test. RESULTS 812 NVAF patients were included, 108 patients weighed ≤60 Kg (13%, underweight), 688 weighed between 61 and 119 Kg (85%, normal weight), and 16 weighed ≥120 Kg (2%, overweight). In particular, among underweight patients, dabigatran was prescribed in 26% patients, apixaban in 27%, rivaroxaban in 28% and edoxaban in 22% ones. Instead, among overweight patients, 44% were treated with dabigatran, 25% with apixaban, 25% with rivaroxaban and 4% with edoxaban. Underweight patients were older, more frequently women, with lower creatinine clearance and a history of previous strokes, resulting in higher CHA2DS2-VASc score than in both remaining groups. Up to 2 years, no statistically significant difference was observed between the three groups of weight for thromboembolic events (P = .765) and for overall bleeding (P = .125), but a trend towards decreased overall bleeding rates was noticed as weight increased (24.1% vs 16.7% vs 12.5%, respectively). CONCLUSION In this tertiary care centre registry, 15% of patients treated with DOACs presented an extreme weight. Compared to patients with a normal weight, no significant rates of thromboembolic events were observed for underweight or overweight patients. A trend towards decreased overall bleeding frequency as weight increased was highlighted up to 2 years. The present results should be considered as preliminary and hypothesis generating.
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Affiliation(s)
| | - Anita Russi
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Fabiana Blunda
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Claudia Rubino
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giulio Leo
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Mattiello
- Information Systems Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Ottavio Alfieri
- Cardiac Surgery Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Matteo Montorfano
- Interventional Cardiovascular Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Anna Salerno
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michela Cera
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Cosmo Godino
- Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
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Coleman CI, Bunz TJ, Ashton V. Adherence and persistence to rivaroxaban in non-valvular atrial fibrillation patients receiving 30- or 90-day supply prescription fills. Curr Med Res Opin 2022; 38:19-26. [PMID: 34581258 DOI: 10.1080/03007995.2021.1985987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND It is unclear whether 90-day supply fills with rivaroxaban result in better adherence and persistence compared to 30-day supply fills. We assessed patients' adherence and persistence to rivaroxaban at 12- and 24-months in nonvalvular atrial fibrillation (NVAF) patients whose rivaroxaban prescriptions were filled every 30- vs. 90-days. METHODS Using the IBM MarketScan Commercial and Medicare Supplemental data sets, we identified adult NVAF patients with ≥12-months of continuous insurance coverage who filled a prescription in May 2018 and their immediate subsequent prescription for rivaroxaban for the same days' supply. We propensity score-matched 30- and 90-day rivaroxaban interval fill patients and compared the percentage with a proportion of days covered (PDC) ≥80%, mean PDC, and percentage persistent to rivaroxaban therapy over 12- and 24-months of follow-up. RESULTS Following propensity score matching, 2237 patients were included in the rivaroxaban 30- and 90-day supply fill cohorts. The proportion of patients with a PDC ≥80% was greater in the 90-day vs. 30-day cohort at both 12-months (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.54-1.97) and 24-months (OR = 1.78, 95%CI = 1.58-2.00), as were mean PDC values (absolute difference in mean PDC = 9.4%, 95%CI = 8.2-10.7% at 12-months and 11.2%, 95%CI = 9.5-12.9% higher at 24-months, respectively). Persistence to rivaroxaban was not found to significantly differ between the 30- and 90-day supply cohorts at 12- or 24-months (assuming a 30-day permissible gap); however, greater persistence was observed with 90-day fills at both time points when a 14-day gap was utilized (HR = 1.22, 95%CI = 1.10-1.36 at 12-months and HR = 1.12, 95%CI = 1.02-1.22 at 24-months). CONCLUSIONS Dispensing 90-day supply fills with rivaroxaban appears to increase the proportion of patients achieving acceptable (PDC ≥80%) adherence as well as mean adherence compared to 30-day supply fills. Ninety-day rivaroxaban fills may also result in improved persistence vs. 30-day fills.
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Affiliation(s)
- Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, CT, USA
| | - Thomas J Bunz
- Pharmacoepidemiology Group, New England Health Analytics LLC, Granby, CT, USA
| | - Veronica Ashton
- Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, NJ, USA
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18
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Deitelzweig S, Keshishian AV, Zhang Y, Kang A, Dhamane AD, Luo X, Klem C, Ferri M, Jiang J, Yuce H, Lip GY. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients With Active Cancer. JACC CardioOncol 2021; 3:411-424. [PMID: 34604802 PMCID: PMC8463723 DOI: 10.1016/j.jaccao.2021.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 12/16/2020] [Accepted: 06/13/2021] [Indexed: 01/01/2023]
Abstract
Background Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer. Objectives This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin. Methods A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score–matched cohorts. Results A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% CI: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, while consistent treatment effects were seen for all treatment comparisons across key cancer types. Conclusions Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types.
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Key Words
- AF, atrial fibrillation
- GI, gastrointestinal
- GU, genitourinary
- ICH, intracranial hemorrhage
- MB, major bleeding
- NOAC, non–vitamin K antagonist oral anticoagulant
- NVAF, nonvalvular atrial fibrillation
- PSM, propensity score matching
- SE, systemic embolism
- VTE, venous thromboembolism
- active cancer
- anticoagulants
- bleeding
- nonvalvular atrial fibrillation
- stroke
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, Louisiana, USA
- University of Queensland School of Medicine—Ochsner Clinical School, New Orleans, Louisiana, USA
- Address for correspondence: Dr Steven Deitelzweig, Ochsner Health 1514 Jefferson Highway, 11th floor, Hospital Medicine, New Orleans, Louisiana 70121, USA. @statinmedresearch
| | - Allison V. Keshishian
- STATinMED Research, Ann Arbor, Michigan, USA
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Yan Zhang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amiee Kang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amol D. Dhamane
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | | | - Christian Klem
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Mauricio Ferri
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Jenny Jiang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Kim SM, Jeon ET, Jung JM, Lee JS. Real-world oral anticoagulants for Asian patients with non-valvular atrial fibrillation: A PRISMA-compliant article. Medicine (Baltimore) 2021; 100:e26883. [PMID: 34397907 PMCID: PMC8360482 DOI: 10.1097/md.0000000000026883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate the comparative efficacy and safety of 4 non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in Asians with non-valvular atrial fibrillation in real-world practice through a network meta-analysis of observational studies. METHODS We searched multiple comprehensive databases (PubMed, Embase, and Cochrane library) for studies published until August 2020. Hazard ratios and 95% confidence intervals were used for the pooled estimates. Efficacy outcomes included ischemic stroke (IS), stroke/systemic embolism (SSE), myocardial infarction (MI), and all-cause mortality, and safety outcomes included major bleeding, gastrointestinal (GI) bleeding, and intracerebral hemorrhage (ICH). The P score was calculated for ranking probabilities. Subgroup analyses were separately performed in accordance with the dosage range of NOACs ("standard-" and "low-dose"). RESULTS A total of 11, 6, and 8 studies were allocated to the total population, standard-dose group, and low-dose group, respectively. In the total study population, edoxaban ranked the best in terms of IS and ICH prevention and apixaban ranked the best for SSE, major bleeding, and GI bleeding. In the standard-dose regimen, apixaban ranked the best in terms of IS and SSE prevention. For major bleeding, GI bleeding, and ICH, edoxaban ranked the best. In the low-dose regimen, edoxaban ranked the best for IS, SSE, GI bleeding, and ICH prevention. For major bleeding prevention, apixaban ranked best. CONCLUSIONS All 4 NOACs had different efficacy and safety outcomes according to their type and dosage. Apixaban and edoxaban might be relatively better and more well-balanced treatment for Asian patients with non-valvular atrial fibrillation.
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Affiliation(s)
- Seung Min Kim
- Department of Neurology, Veterans Health Service Medical Center, Seoul
| | - Eun-Tae Jeon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
- Korea University Zebrafish Translational Medical Research Center, Ansan
| | - Ji-Sung Lee
- Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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20
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Laliberté F, Ashton V, Kharat A, Lejeune D, Moore KT, Jung Y, Lefebvre P, Berger JS. Economic burden of rivaroxaban and warfarin among nonvalvular atrial fibrillation patients with obesity and polypharmacy. J Comp Eff Res 2021; 10:1235-1250. [PMID: 34378989 DOI: 10.2217/cer-2021-0150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Evaluate healthcare resource utilization (HRU) and costs associated with rivaroxaban and warfarin among nonvalvular atrial fibrillation (NVAF) patients with obesity and polypharmacy. Materials & methods: IQVIA PharMetrics® Plus (January 2010-September 2019) data were used to identify NVAF patients with obesity (BMI ≥30 kg/m2) and polypharmacy (≥5 medications) initiated on rivaroxaban or warfarin. Weighted rate ratios and cost differences were evaluated post-treatment initiation. Results: Rivaroxaban was associated with significantly lower rates of HRU, including hospitalization (rate ratio [95% CI]: 0.83 [0.77, 0.92]). Medical costs were reduced in rivaroxaban users (difference [95% CI]: -US$6868 [-US$10,628, -US$2954]), resulting in significantly lower total healthcare costs compared with warfarin users (difference [95% CI]: -US$4433 [-US$8136, -US$582]). Conclusion: Rivaroxaban was associated with lower HRU and costs compared with warfarin among NVAF patients with obesity and polypharmacy in commercially insured US patients.
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Affiliation(s)
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ 08560, USA
| | | | | | - Young Jung
- Groupe d'analyse Ltée, Montréal, QC H3B 0G7, Canada
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21
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Lenart-Migdalska A, Drabik L, Kaźnica-Wiatr M, Tomkiewicz-Pająk L, Podolec P, Olszowska M. Flow Cytometric Assessment of Endothelial and Platelet Microparticles in Patients With Atrial Fibrillation Treated With Dabigatran. Clin Appl Thromb Hemost 2021; 26:1076029620972467. [PMID: 33237804 PMCID: PMC7787695 DOI: 10.1177/1076029620972467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The prothrombotic state in patients with atrial fibrillation (AF) is related to
endothelial injury, the activation of platelets and the coagulation cascade. We
evaluated the levels of platelet- (CD42b) and endothelial-derived (CD144)
microparticles in the plasma patients with non-valvular AF treated with
dabigatran at the time of expected minimum and maximum drug plasma
concentrations. Following that, we determined the peak dabigatran plasma
concentration (cpeak ). CD42b increased after taking dabigatran
(median [IQR] 36.7 [29.4-53.3] vs. 45.6 [32.3-59.5] cells/µL; p = 0.025). The
concentration of dabigatran correlated negatively with the post-dabigatran
change in CD42b (ΔCD42b, r = -0.47, p = 0.021). In the multivariate model, the
independent predictors of ΔCD42b were: cpeak (HR -0.55; with a 95%
confidence interval, CI [-0.93, -0.16]; p = 0.007), coronary artery disease
(CAD) (HR -0.41; 95% CI [-0.79, -0.02]; p = 0.037) and peripheral artery disease
(PAD) (HR 0.42; 95% CI [0.07, 0.74]; p = 0.019). CD144 did not increase after
dabigatran administration. These data suggest that low concentrations of
dabigatran may be associated with platelet activation. PAD and CAD have distinct
effects on CD42b levels during dabigatran treatment.
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Affiliation(s)
- Aleksandra Lenart-Migdalska
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland
| | - Leszek Drabik
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland.,Department of Pharmacology, Jagiellonian University Medical College, Cracow, Poland
| | - Magdalena Kaźnica-Wiatr
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland
| | - Maria Olszowska
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland
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22
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Chen IC, Chang WT, Hsu PC, Yeh YL, Zheng S, Huang YC, Lin CH, Tsai LM, Lin LJ, Liu PY, Liu YW. Off-label reduced-dose apixaban does not reduce hemorrhagic risk in Taiwanese patients with nonvalvular atrial fibrillation: A retrospective, observational study. Medicine (Baltimore) 2021; 100:e26272. [PMID: 34115024 PMCID: PMC8202542 DOI: 10.1097/md.0000000000026272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT East Asians are reportedly at high risk of anticoagulant-related bleeding; therefore, some physicians prefer to prescribe low-dose direct oral anticoagulants (DOACs). Little is known about the therapeutic effectiveness and safety of off-label reduced-dose apixaban in East Asians with nonvalvular atrial fibrillation (AF). We aimed to investigate the effectiveness and safety of off-label reduced-dose apixaban in Taiwanese patients with nonvalvular AF.This retrospective cohort study enrolled 1073 patients with nonvalvular AF who took apixaban between July 2014 and October 2018 from 4 medical centers in southern Taiwan. The primary outcomes included thromboembolic events (stroke/transient ischemic attack or systemic embolism), major bleeding, and all-cause mortality.Among all patients, 826 (77%) patients were classified as the "per-label adequate-dose" treatment group (i.e., consistent with the Food and Drug Administration label recommendations) while 247 (23%) patients were the "off-label reduced-dose" treatment group. The mean follow-up period was 17.5 ± 13 months. The "off-label reduced-dose" group did not have a lower major bleeding rate than the "per-label adequate-dose" group (4.8% vs 3.8%, adjusted hazard ratio [HR] 1.20, 95% confidence interval [CI] 0.69-2.09), but had a nonsignificantly higher incidence of thromboembolic events (4.23% vs 3.05%, adjusted HR: 1.29, 95% CI: 0.71-2.34).An off-label reduced-dose apixaban treatment strategy may not provide incremental benefits or safety for Taiwanese patients with nonvalvular AF.
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Affiliation(s)
- I-Chih Chen
- Department of Internal Medicine, Division of Cardiology, Tainan Municipal Hospital
- Department of Pharmacy, Chia Nan University of Pharmacy and Science
| | - Wei-Ting Chang
- Department of Internal Medicine, Division of Cardiology, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan
| | - Po-Chao Hsu
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Ya-Lan Yeh
- Department of Internal Medicine, Division of Cardiology, Tainan Municipal Hospital
- Chang Gung University of Science and Technology, Chiayi Campus
| | | | | | - Chih-Hsien Lin
- Department of Internal Medicine, Division of Cardiology, Chi-Mei Medical Center
| | - Liang-Miin Tsai
- Department of Internal Medicine, Division of Cardiology, Tainan Municipal Hospital
| | - Li-Jen Lin
- Department of Internal Medicine, Division of Cardiology, Tainan Municipal Hospital
| | - Ping-Yen Liu
- Department of Internal Medicine, Division of Cardiology, National Cheng Kung University Hospital
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Wen Liu
- Department of Internal Medicine, Division of Cardiology, National Cheng Kung University Hospital
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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23
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Gabilondo M, Loza J, Pereda A, Caballero O, Zamora N, Gorostiza A, Mar J. Quality of life in patients with nonvalvular atrial fibrillation treated with oral anticoagulants. ACTA ACUST UNITED AC 2021; 26:277-283. [PMID: 33631081 DOI: 10.1080/16078454.2021.1892329] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Health-related quality of life (HRQL) is a key factor in making anticoagulant treatment decisions. The objective of this study was to assess the HRQL of patients with nonvalvular atrial fibrillation by treatment type: direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). METHODS We carried out a cross-sectional observational study with clinical practice data, gathering demographic and clinical variables. HRQL was measured using the 5-level 5-dimension EuroQol questionnaire (EQ-5D-5L). Differences between the study groups in HRQL as measured by the EQ-5D-5L were analyzed using two-part multivariate regression models. First, using logistic regression, the adjusted probability, p(x), of having perfect health was estimated in each subgroup. Secondly, generalized linear models were used to estimate mean disutility values, w(x), in a population that does not have perfect health, i.e. utility less than 1 or 1-w(x). RESULTS We recruited 333 patients, of whom 126 were on DOACs and 207 on VKAs. A significant difference was observed in the EQ-5D-5L anxiety/depression dimension, with a higher percentage of patients classified in the 'no problems' category in the DOAC group. The same type of analysis did not identify significant differences in any of the other dimensions (mobility, self-care, usual activities or pain/discomfort). DISCUSSION In the multivariate model, utility was significantly higher in the DOAC group than in the VKA group, although the difference was small (0.0121). This difference is attributable to patients on DOACs having less anxiety/depression. CONCLUSION Patients treated with DOACs report a slightly better quality of life than those treated with VKAs.
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Affiliation(s)
- Miren Gabilondo
- Department of Haematology, Basque Health Service (Osakidetza), Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Jesús Loza
- Department of Haematology, Basque Health Service (Osakidetza), Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Angel Pereda
- Department of Haematology, Basque Health Service (Osakidetza), Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Ohiane Caballero
- Nursing Unit, Basque Health Service (Osakidetza), Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Nerea Zamora
- Nursing Unit, Basque Health Service (Osakidetza), Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Ania Gorostiza
- Research Unit, Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Arrasate-Mondragón, Spain.,Economic Evaluation Unit, Kronikgune Institute for Health Service Research, Barakaldo, Spain
| | - Javier Mar
- Research Unit, Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Arrasate-Mondragón, Spain.,Economic Evaluation Unit, Kronikgune Institute for Health Service Research, Barakaldo, Spain.,Economic Evaluation Unit, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
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24
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Lenart-Migdalska A, Drabik L, Kaźnica-Wiatr M, Tomkiewicz-Pająk L, Podolec P, Olszowska M. Increased Levels of Platelets and Endothelial-Derived Microparticles in Patients With Non-Valvular Atrial Fibrillation During Rivaroxaban Therapy. Clin Appl Thromb Hemost 2021; 27:10760296211019465. [PMID: 34032122 PMCID: PMC8155766 DOI: 10.1177/10760296211019465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
It is known that atrial fibrillation (AF) is associated with the procoagulant
state. Several studies have reported an increase of circulating microparticles
in AF, which may be linked to a hypercoagulable state, atrial thrombosis and
thromboembolism. We evaluated in our study alterations in both platelet (PMP,
CD42b) and endothelial-derived (EMP, CD144) microparticle levels on
anticoagulant therapy with rivaroxaban in nonvalvular AF. After administration
of rivaroxaban, PMP levels were increased (median, [IQR] 35.7 [28.8-47.3] vs.
48.4 [30.9-82.8] cells/µL; P = 0.012), along with an increase
in EMP levels (14.6 [10.0-18.6] vs. 18.3 [12.9-37.1] cells/µL,
P < 0.001). In the multivariable regression analysis,
the independent predictor of post-dose change in PMPs was statin therapy (HR
−0.43; 95% CI −0.75,−0.10, P = 0.011). The post-dose change in
EMPs was also predicted by statin therapy (HR −0.34; 95% CI −0.69, −0.01,
P = 0.046). This study showed an increase in both EMPs and
PMPs at the peak plasma concentration of rivaroxaban. Statins have promising
potential in the prevention of rivaroxaban-related PMP and EMP release. The
pro-thrombotic role of PMPs and EMPs during rivaroxaban therapy requires further
study.
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Affiliation(s)
- Aleksandra Lenart-Migdalska
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland
| | - Leszek Drabik
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland.,Department of Pharmacology, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Kaźnica-Wiatr
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland
| | - Maria Olszowska
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland
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25
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Ingrasciotta Y, Fontana A, Mancuso A, Ientile V, Sultana J, Uomo I, Pastorello M, Calabrò P, Andò G, Trifirò G. Comparison of Direct Oral Anticoagulant Use for the Treatment of Non-Valvular Atrial Fibrillation in Pivotal Clinical Trials vs. the Real-World Setting: A Population-Based Study from Southern Italy. Pharmaceuticals (Basel) 2021; 14:ph14040290. [PMID: 33805899 PMCID: PMC8064382 DOI: 10.3390/ph14040290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
Patients enrolled into pivotal randomized controlled trials (RCTs) may differ substantially from those treated in a real-world (RW) setting, which may result in a different benefit–risk profile. The aim of the study was to assess the external validity of pivotal RCT findings concerning direct oral anticoagulants (DOACs) for the treatment of nonvalvular atrial fibrillation (NVAF) by comparing patients recruited in RCTs to those treated with DOACs registered in a southern Italian local health unit (LHU) in the years 2013–2017. The Palermo LHU claims database was used to describe the baseline characteristics of incident DOAC users (washout > 1 year) with NVAF compared with those of enrolled patients in DOAC pivotal RCTs. In the RW, DOAC treatment discontinuation was calculated during the follow-up and compared with DOAC treatment discontinuation of enrolled patients in DOAC pivotal RCTs. Rates of effectiveness and safety outcomes during the follow-up were calculated in an unmatched and in a simulated RCT population, by matching individual incidental RW and RCT DOAC users (excluding edoxaban users) on age, sex, and CHADS2 score. Overall, 42,336 and 7092 incident DOAC users with NVAF were identified from pivotal RCTs and from the RW setting, respectively. In RCTs, DOAC use was more common among males (62.6%) compared with an almost equal sex distribution in the RW. RCT patients were younger (mean age ± standard deviation: 70.7 ± 9.2 years) than RW patients (76.0 ± 8.6 years). Compared with RCTs, a higher proportion of RW dabigatran users (30.4% vs. 19.6%) and a lower proportion of RW apixaban (15.9% vs. 25.3%) and rivaroxaban (20.4% vs. 23.7%) users discontinued the treatment during the follow-up (p-value < 0.001). The rate of ischemic stroke was lower in RW high-dose dabigatran users (unmatched/-matched population: 0.40–0.11% per year) than in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) population (0.93% per year). Major bleeding rates were lower in RW users than in RCT users. In conclusion, except for dabigatran, a lower proportion of DOAC discontinuers was observed in the real-world than in pivotal RCT settings. This study provides reassurance to practicing physicians that DOAC use appears to be effective in stroke prevention and is likely safer in RW patients than in RCT enrolled patients. These results may be related to a lower burden of comorbidities despite more advanced age in the RW population compared to the pivotal RCT population.
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Affiliation(s)
- Ylenia Ingrasciotta
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
- Correspondence: ; Tel.: +39-0902213877
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Anna Mancuso
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Valentina Ientile
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98158 Messina, Italy; (A.M.); (V.I.); (J.S.)
| | - Ilaria Uomo
- Department of Pharmacy, Palermo Local Health Unit, 90100 Palermo, Italy; (I.U.); (M.P.)
| | - Maurizio Pastorello
- Department of Pharmacy, Palermo Local Health Unit, 90100 Palermo, Italy; (I.U.); (M.P.)
| | - Paolo Calabrò
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, 98158 Messina, Italy;
| | - Gianluca Trifirò
- Department of Diagnostic Public Health, University of Verona, 37129 Verona, Italy;
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Zhang L, Kong YH, Wang DW, Li KT, Yu HP. Anticoagulant management by low-dose of low molecular weight heparin in patients with nonvalvular atrial fibrillation following hemorrhagic transformation and complicated with venous thrombosis: Five case reports and literature review. Medicine (Baltimore) 2021; 100:e24189. [PMID: 33607764 PMCID: PMC7899910 DOI: 10.1097/md.0000000000024189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/12/2020] [Indexed: 01/05/2023] Open
Abstract
For patients with nonvalvular atrial fibrillation (NVAF) following hemorrhagic infarction (HI)/hemorrhage transformation (HT) and complicated with venous thrombosis, the management of anticoagulation is controversial. Our study intends to explore the safety and effectiveness of using low-dose of low molecular weight heparin (LMWH) to treat NVAF patients with HI (or HT) and complicated with venous thrombosis.Between January 2018 and January 2019, NVAF related acute ischemic stroke patients with HT/HI, hospitalized in the department of neurology or rehabilitation in our hospital, are enrolled retrospectively. Among them, those who were found to have venous thrombosis and undergo anticoagulation (LMWH) during the treatment were extracted. We investigate the efficacy and safety in those patients who have been treated with anticoagulant of LMWH.Five cases accepted LMWH within 3 weeks attributed to the appearance of venous thrombosis, and all of them did not display new symptomatic bleeding or recurrent stroke. However, based on the results of a head computed tomography scan, there were 2 cases of slightly increased intracranial hemorrhage, and then we reduced the dose of anticoagulant. In addition, color ultrasound showed that venous thrombosis disappeared or became stable.Patients with NVAF following HI/HT have a higher risk of thromboembolism. Early acceptance of low-dose LMWH as an anticoagulant is relatively safe and may gain benefit. However, in the process of anticoagulant therapy, we should follow-up head computed tomography/magnetic resonance imaging frequently, as well as D-dimer values, limb vascular ultrasound. Besides, the changes of symptoms and signs should be focused to judge the symptomatic bleeding or recurrent stroke. Furthermore, it is better to adjust anticoagulant drug dosage according to specific conditions.
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Song CG, Bi LJ, Zhao JJ, Wang X, Li W, Yang F, Jiang W. The efficacy and safety of Hirudin plus Aspirin versus Warfarin in the secondary prevention of Cardioembolic Stroke due to Nonvalvular Atrial Fibrillation: A multicenter prospective cohort study. Int J Med Sci 2021; 18:1167-1178. [PMID: 33526977 PMCID: PMC7847633 DOI: 10.7150/ijms.52752] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 11/05/2022] Open
Abstract
Background: To investigate the efficacy and safety of hirudin plus aspirin therapy compared with warfarin in the secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation (NVAF). Methods: Patients with cardioembolic stroke due to NVAF were prospectively enrolled from 18 collaborating hospitals from Dec 2011 to June 2015. Fourteen days after stroke onset, eligible patients were assigned to the hirudin plus aspirin group (natural hirudin prescribed as the traditional Chinese medicine Maixuekang capsule, 0.75 g, three times daily, combined with aspirin 100 mg, once daily) or the warfarin group (dose-adjusted warfarin targeting international normalized ratio (INR) 2-3, with an initial daily dose of 1.25 mg). Patients were followed up at 1, 2, 3, 6, 9, and 12 months after stroke onset. Time in therapeutic range (TTR) was calculated according to Rosendaal methodology to evaluate the quality of INR management in the warfarin group. The primary efficacy endpoint was the recurrence of stroke within 12 months after stroke onset. Safety was assessed as the occurrence of the composite event "intracranial hemorrhage and other bleeding events, death, and other serious adverse events". The Cox proportional hazard model and Kaplan-Meier curve were used to analyze the efficacy and safety events. Results: A total of 221 patients entered final analysis with 112 patients in the hirudin plus aspirin group and 109 in the warfarin group. Over the whole duration of our study, TTR for patients taking warfarin was 66.5 % ± 21.5%. A significant difference was not observed in the recurrence of stroke between the two groups (3.57% vs. 2.75%; P = 0.728). The occurrence of safety events was significantly lower in the hirudin plus aspirin group (2.68% vs.10.09%; P = 0.024). The risk for efficacy event was similar between the two groups (hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.29-5.80). The safety risk was significantly lower in the hirudin plus aspirin group (HR, 0.27; 95% CI, 0.07-0.95). Kaplan-Meier analysis revealed significant difference in the temporal distribution in safety events (P = 0.023) but not in stroke recurrence (P = 0.726). Conclusion: Significant difference in efficacy was not detected between warfarin group and hirudin plus aspirin group. Compared with warfarin, hirudin plus aspirin therapy had lower safety risk in the secondary prevention of cardioembolic stroke due to NVAF.
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Affiliation(s)
- Chang-Geng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Li-Jie Bi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing-Jing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Mailhot T, McManus DD, Waring ME, Lessard D, Goldberg R, Bamgbade BA, Saczynski JS. Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation. J Am Geriatr Soc 2020; 68:2778-2786. [PMID: 32780497 PMCID: PMC8567309 DOI: 10.1111/jgs.16756] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 07/21/2023]
Abstract
BACKGROUND/OBJECTIVES Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016-2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). RESULTS Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59-8.26), older age (OR = 1.56; 95% CI = 1.29-1.88), lower education (OR = 3.81; 95%CI = 2.13-6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34-14.55), bleeding risk (OR = 1.43; 95% CI = 1.12-1.81), and stroke risk (OR = 1.35; 95% CI = 1.13-1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01-2.80). Having both impairments (OR = 1.87; 95% CI = 1.08-3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09-2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Machado-Alba JE, Gaviria-Mendoza A, Machado-Duque ME, Tovar-Yepes C, Ruigómez A, García Rodríguez LA. Use of non-vitamin K antagonist oral anticoagulants in Colombia: A descriptive study using a national administrative healthcare database. Pharmacoepidemiol Drug Saf 2020; 30:426-434. [PMID: 33063370 PMCID: PMC7983923 DOI: 10.1002/pds.5124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/26/2020] [Accepted: 08/25/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE We aimed to describe time-trends in the use of NOACs among a group of ambulatory patients with nonvalvular atrial fibrillation (NVAF) in Colombia and to describe treatment patterns and user characteristics. METHODS Using the Audifarma S.A administrative healthcare database in Colombia, we identified 10 528 patients with NVAF aged at least 18 years between July 2009 and June 2017 with a first prescription (index date) for apixaban, dabigatran or rivaroxaban (index NOAC) and followed them for at least year (max, 8.0 years, mean 2.2 years). We described patient characteristics, NOAC use over time, and the dose of the first NOAC prescription. RESULTS A total of 2153 (20.5%) patients started on apixaban, 3089 (29.3%) on dabigatran and 5286 (50.2%) on rivaroxaban. The incidence of new users of apixaban and rivaroxaban increased over study years while for dabigatran it decreased. Mean age at the index date was: 78.5 years (apixaban), 76.5 years (dabigatran), 76.0 years (rivaroxaban). The percentage of patients started NOAC therapy on the standard dose was: apixaban 38.0%, dabigatran 30.9%, rivaroxaban 56.9%. The percentage still prescribed their index NOAC at 6 months was apixaban 44.6%, dabigatran 51.4%, rivaroxaban 52.7%. Hypertension was the most common comorbidity (>80% in each NOAC cohort). CONCLUSION During the last decade, the incidence of NOAC use in patients with NVAF affiliated with a private healthcare regime in Colombia has markedly increased. Future studies should evaluate whether the large number of patients with NVAF starting NOAC treatment on a reduced dose are done so appropriately.
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Affiliation(s)
- Jorge E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Manuel E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Carlos Tovar-Yepes
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica (CEIFE), Madrid, Spain
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Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
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Okuno T, Hagemeyer D, Brugger N, Ryffel C, Heg D, Lanz J, Praz F, Stortecky S, Räber L, Roten L, Reichlin T, Windecker S, Pilgrim T. Valvular and Nonvalvular Atrial Fibrillation in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020; 13:2124-2133. [PMID: 32972574 DOI: 10.1016/j.jcin.2020.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the impact of valvular and nonvalvular atrial fibrillation (AF) in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND AF has been associated with adverse clinical outcomes after TAVR. However, the differential impact of valvular as opposed to nonvalvular AF has not been investigated. METHODS In a retrospective analysis of a prospective registry, valvular AF was defined as AF in the setting of concomitant mitral stenosis or the presence of a mitral valve prosthesis. The presence of mitral stenosis was determined by pre-procedural echocardiography. The primary endpoint was a composite of cardiovascular death or disabling stroke at 1 year after TAVR. RESULTS Among 1,472 patients undergoing TAVR between August 2007 and June 2018, AF was recorded in 465 patients (31.6%) and categorized as nonvalvular in 376 (25.5%) and valvular in 89 (6.0%). AF scores including HAS-BLED, CHADS2, and CHA2DS2-VASc were comparable between patients with nonvalvular and valvular AF. The primary endpoint occurred in 9.3% of patients with no AF, in 14.5% of patients with nonvalvular AF (hazard ratio: 1.57; 95% confidence interval: 1.12 to 2.20; p = 0.009), and in 24.2% of patients with valvular AF (hazard ratio: 2.75; 95% confidence interval: 1.71 to 4.41; p < 0.001). Valvular AF conferred an increased risk for cardiovascular death or disabling stroke compared with nonvalvular AF (hazard ratio: 1.77; 95% confidence interval: 1.07 to 2.94; p = 0.027). CONCLUSIONS The presence of valvular AF in patients undergoing TAVR increased the risk for cardiovascular death or disabling stroke compared with both no AF and nonvalvular AF. (SWISS TAVI Registry; NCT01368250).
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Daniel Hagemeyer
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Ryffel
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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Cen Z, Meng Q, Cui K. New oral anticoagulants for nonvalvular atrial fibrillation with stable coronary artery disease: A meta-analysis. Pacing Clin Electrophysiol 2020; 43:1393-1400. [PMID: 32975310 DOI: 10.1111/pace.14081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND New oral anticoagulants (NOACs) are effective and safe in patients with nonvalvular atrial fibrillation (NVAF). Limited evidence is available regarding outcomes for NVAF patients with stable coronary artery disease (CAD). METHODS A systematic search of Medline, Embase, and the Cochrane Register was performed. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration risk-of-bias assessment tool. We evaluated all primary publications and secondary analyses comparing NOACs with any other OAC agent for preventing stroke in patients with both NVAF and stable CAD from phase III clinical randomized control trials. The primary outcomes were stroke, systemic embolism (SE), major bleeding, and intracranial hemorrhage (ICH), and the secondary outcomes were cardiovascular (CV) death, all-cause death, and myocardial infarction (MI). RESULTS Four articles with a total of 19 266 patients were included in this study. The pooled results showed a relative risk for stroke/SE with NOACs of 0.83 (95% confidence interval [CI]: 0.71-0.97), for major bleeding 0.85 (95% CI: 0.63-1.14), for ICH 0.36 (95% CI: 0.19-0.54), for MI 1.00 (95% CI: 0.82-1.20), for CV death 0.94 (95% CI: 0.83-1.06), and for all-cause death 0.95 (95% CI: 0.85-1.07). CONCLUSION NOACs were effective in preventing stroke/SE and reducing the risk of ICH in patients with both NVAF and CAD.
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Affiliation(s)
- Zhifu Cen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiuyu Meng
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Sychev D, Mirzaev K, Cherniaeva M, Kulikova M, Bochkov P, Shevchenko R, Gorbatenkova S, Golovina O, Ostroumova O, Bahteeva D, Rytkin E. Drug-drug interaction of rivaroxaban and calcium channel blockers in patients aged 80 years and older with nonvalvular atrial fibrillation. Drug Metab Pers Ther 2020; 0:/j/dmdi.ahead-of-print/dmdi-2020-0127/dmdi-2020-0127.xml. [PMID: 32887180 DOI: 10.1515/dmdi-2020-0127] [Citation(s) in RCA: 4] [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: 05/31/2020] [Accepted: 06/22/2020] [Indexed: 01/06/2023]
Abstract
Objectives For revealing the peculiarities of the drug-drug interaction of rivaroxaban (substrate CYP3A4 and P-gp) and calcium channel blockers (CCBs) (verapamil - inhibitor CYP3A4 and P-gp and amlodipine - substrate CYP3A4) in patients 80 years and older with nonvalvular atrial fibrillation (NAF) we studied 128 patients. Methods All patients were divided into groups depending on the therapy taken: the 1st - rivaroxaban + amlodipine (n=51), the 2nd - rivaroxaban + verapamil (n=30), the control group - rivaroxaban without CCBs (n=47). A trough steady-state plasma concentration (C min,ss) of rivaroxaban, prothrombin time (PT) in the blood plasma and the event of clinically relevant non-major (CRNM) bleeding were assessed for each patient. Results Patient in group 2 had higher C min,ss of rivaroxaban, PT and CRNM than subjects in the control group (Me 73.8 [50.6-108.8] ng/mL vs. 40.5 [25.6-74.3] ng/mL; Me 14.8 [13.4-17.3] s vs. 13.8 [12.6-14.4] s; 34% vs. 13%, respectively, p<0.05 for all). When compared, the PT and complication rate in group 1 with the control group C min,ss of rivaroxaban were practically the same (p>0.05 for all). Conclusions In patients ≥80 years with NAF, the use of rivaroxaban in combination with verapamil may not be safe and can lead to CRNM bleeding.
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Affiliation(s)
- Dmitry Sychev
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Karin Mirzaev
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation,Moscow, Russia
| | - Marina Cherniaeva
- Department of Internal and Preventive Medicine of Federal State Budgetary Institution of Higher Professional Education "Central State Medical Academy of the Presidential Administration of the Russian Federation", Marshal Timoshenko street,19, building 1A, 121359,Moscow, Russia
- State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradsky prospect, Moscow, Russia
| | - Maria Kulikova
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Pavel Bochkov
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation,Moscow, Russia
| | - Roman Shevchenko
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation,Moscow, Russia
| | - Svetlana Gorbatenkova
- State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradsky prospect, Moscow, Russia
| | - Olga Golovina
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Olga Ostroumova
- Department of Therapy and Polymorbid Pathology of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Damirya Bahteeva
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Eric Rytkin
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
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Sychev D, Mirzaev K, Cherniaeva M, Kulikova M, Bochkov P, Shevchenko R, Gorbatenkova S, Golovina O, Ostroumova O, Bahteeva D, Rytkin E. Drug-drug interaction of rivaroxaban and calcium channel blockers in patients aged 80 years and older with nonvalvular atrial fibrillation. Drug Metab Pers Ther 2020; 35:dmpt-2020-0127. [PMID: 32975202 DOI: 10.1515/dmpt-2020-0127] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/22/2020] [Indexed: 11/15/2022]
Abstract
Objectives For revealing the peculiarities of the drug-drug interaction of rivaroxaban (substrate CYP3A4 and P-gp) and calcium channel blockers (CCBs) (verapamil - inhibitor CYP3A4 and P-gp and amlodipine - substrate CYP3A4) in patients 80 years and older with nonvalvular atrial fibrillation (NAF) we studied 128 patients. Methods All patients were divided into groups depending on the therapy taken: the 1st - rivaroxaban + amlodipine (n=51), the 2nd - rivaroxaban + verapamil (n=30), the control group - rivaroxaban without CCBs (n=47). A trough steady-state plasma concentration (C min,ss) of rivaroxaban, prothrombin time (PT) in the blood plasma and the event of clinically relevant non-major (CRNM) bleeding were assessed for each patient. Results Patient in group 2 had higher C min,ss of rivaroxaban, PT and CRNM than subjects in the control group (Me 73.8 [50.6-108.8] ng/mL vs. 40.5 [25.6-74.3] ng/mL; Me 14.8 [13.4-17.3] s vs. 13.8 [12.6-14.4] s; 34% vs. 13%, respectively, p<0.05 for all). When compared, the PT and complication rate in group 1 with the control group C min,ss of rivaroxaban were practically the same (p>0.05 for all). Conclusions In patients ≥80 years with NAF, the use of rivaroxaban in combination with verapamil may not be safe and can lead to CRNM bleeding.
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Affiliation(s)
- Dmitry Sychev
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Karin Mirzaev
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Marina Cherniaeva
- Department of Internal and Preventive Medicine of Federal State Budgetary Institution of Higher Professional Education "Central State Medical Academy of the Presidential Administration of the Russian Federation", Marshal Timoshenko street,19, building 1A, 121359, Moscow, Russia.,State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradsky prospect, Moscow, Russia
| | - Maria Kulikova
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Pavel Bochkov
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Roman Shevchenko
- Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Svetlana Gorbatenkova
- State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradsky prospect, Moscow, Russia
| | - Olga Golovina
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Olga Ostroumova
- Department of Therapy and Polymorbid Pathology of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Damirya Bahteeva
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Eric Rytkin
- Department of Clinical Pharmacology and Therapy of Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
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Li X, Zuo C, Lu W, Zou Y, Xu Q, Li X, Lv Q. Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic. Front Pharmacol 2020; 11:1275. [PMID: 32973511 PMCID: PMC7472570 DOI: 10.3389/fphar.2020.01275] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/31/2020] [Indexed: 12/30/2022] Open
Abstract
Objective This study was designed to evaluate the efficacy of remote medication management of rivaroxaban by pharmacists for geriatric patients with nonvalvular atrial fibrillation during the COVID-19 pandemic. Methods A single-site, prospective cohort study was conducted among patients with non-valvular atrial fibrillation who received rivaroxaban therapy from July 2019 to December 2019. Patients in the pharmacist-led education and follow-up service (PEFS) group were managed remotely by a pharmacist. In contrast, those in the usual care (UC) group were managed by other providers. Data of routine blood tests, coagulation function tests, which also included cardiac function parameters were collected. The number and type of provider encounters, interventions related to rivaroxaban therapy, the occurrence of thromboembolism or bleeding, and the time of the first outpatient visit after discharge were recorded. Results A total of 600 patients were recruited, and results of 381 patients were analyzed in the end, of which 179 patients were from the PEFS group and 202 were from the UC group. There was no significant difference between the two groups in terms of the occurrence ratio of systemic thrombosis, heart failure (LVEF < 40%), and left atrial dilation, which was defined as enlargement of left atrial diameter (LAD) > 40 mm. The cumulative incidences of bleeding complications, such as gastrointestinal tract and skin ecchymosis, were significantly higher in the UC group (12.4% vs. 6.1%, P=0.038; 4.5% vs. 0.6%, P=0.018). There was no significant difference after pharmacist intervention in terms of thrombosis occurrence ratio between the two groups (P = 0.338, HR: 0.722, 95% CI: 0.372-1.405). Remote instruction by a pharmacist reduced outpatient service frequency within the first 30 days after discharge (23.7% vs. 1.1%, P < 0.001). However, more patients in the PEFS group presented for the first outpatient revisit later than 40 days post-discharge (12.8% vs. 21.3%, P < 0.001). Conclusion Remote pharmacist-led medication instruction of rivaroxaban could reduce bleeding complications of the gastrointestinal tract and skin ecchymosis and postpone the first outpatient revisit after discharge.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chengchun Zuo
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenjing Lu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Zou
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing Xu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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Sonaglioni A, Vincenti A, Lombardo M, Anzà C. Left Atrial Cavity Thrombus and Fatal Systemic Embolization in a Stroke Patient with Nonvalvular Atrial Fibrillation: A Caveat against Left Atrial Appendage Closure for Stroke Prevention. J Cardiovasc Echogr 2020; 30:41-43. [PMID: 32766107 PMCID: PMC7307615 DOI: 10.4103/jcecho.jcecho_46_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 11/28/2022] Open
Abstract
An 88-year-old male with nonvalvular atrial fibrillation (NVAF) and severe congestive heart failure (HF), was admitted to the Neurological Intensive Care Unit because of the acute onset of aphasia and left hemiplegia. Transthoracic echocardiography revealed a left atrial (LA) cavity thrombus. Its “fatal” distal embolization to abdominal aorta occurred in a few days. These observations should lead to a cautious approach in proposing a percutaneous closure of LA appendage in older NVAF patients, with HF and/or left ventricular dysfunction and larger LA volumes, who are not adequately anticoagulated.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Antonio Vincenti
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Claudio Anzà
- Department of Cardiovascular, Multimedica IRCCS, Milano, Italy
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Hill NR, Sandler B, Bergrath E, Milenković D, Ashaye AO, Farooqui U, Cohen AT. A Systematic Review of Network Meta-Analyses and Real-World Evidence Comparing Apixaban and Rivaroxaban in Nonvalvular Atrial Fibrillation. Clin Appl Thromb Hemost 2020; 26:1076029619898764. [PMID: 31918558 PMCID: PMC7098208 DOI: 10.1177/1076029619898764] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
There is no direct evidence comparing the 2 most commonly prescribed direct oral anticoagulants, apixaban and rivaroxaban, used for stroke prevention in nonvalvular atrial fibrillation (NVAF). A number of network meta-analyses (NMAs) of randomized control trials and real-world evidence (RWE) studies comparing the efficacy, effectiveness, and safety of apixaban and rivaroxaban have been published; however, a comprehensive evidence review across the available body of evidence is lacking. In this study, we aimed to systematically review and evaluate the clinical outcomes of apixaban and rivaroxaban using a combination of data gleaned from both NMAs and RWE studies. The review identified 21 NMAs and 5 RWE studies. The data demonstrated that apixaban was associated with fewer major bleeding events compared to rivaroxaban. There was no difference in the efficacy/effectiveness profiles between these treatments. Bleeding is a serious complication of anticoagulation therapy for the management of NVAF, and is associated with increased rates of hospitalization, morbidity, mortality, and health-care expenditure. The majority of studies in this comprehensive evidence review suggests that apixaban has a lower risk of major bleeding events compared to rivaroxaban in patients with NVAF.
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Affiliation(s)
- Nathan R Hill
- Bristol-Myers Squibb Company, Uxbridge, London, United Kingdom
| | | | | | | | | | - Usman Farooqui
- Bristol-Myers Squibb Company, Lawrence Township, NJ, USA
| | - Alexander T Cohen
- Guy's and St. Thomas' Hospitals, King's College, London, United Kingdom
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Santoso A, Raharjo SB. Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians. Int J Angiol 2020; 29:88-97. [PMID: 32499669 DOI: 10.1055/s-0040-1708477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)-vascular disease, age 65 to 74 years, sex category (female; CHA 2 DS 2 -VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, "triple therapy" comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for "triple therapy" would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.
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Affiliation(s)
- Anwar Santoso
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
| | - Sunu B Raharjo
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
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He J, Fu Z, Yang L, Liu W, Tian Y, Liu Q, Jiang Z, Tian L, Huang J, Tian S, Zhao Y. The predictive value of a concise classification of left atrial appendage morphology to thrombosis in non-valvular atrial fibrillation patients. Clin Cardiol 2020; 43:789-795. [PMID: 32406558 PMCID: PMC7368353 DOI: 10.1002/clc.23381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/28/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023] Open
Abstract
Background The complexity of left atrial appendage (LAA) in patients with nonvalvular atrial fibrillation (NVAF) is closely related to LAA thrombosis and stroke incidence. But the classification of LAA morphology is not uniform and controversial. Hypothesis This study divided the LAA into two categories according to the LAA morphology to investigate the risk of thrombosis related to the LAA structural complexity in NVAF patients. Methods A total of 336 NVAF patients were enrolled continuously in this study. The patients were divided into thrombosis group and non‐thrombosis group according to whether the thrombus presence in LAA. Through computer LAA three‐dimensional reconstruction, LAA morphology was divided into the complex type and simple type according to with or without the clearly lobulated structure judged by imaging experts. The relationship between LAA thrombosis and various potential risk factors was analyzed. Results A total of 19 potential risk factors for LAA thrombosis in NVAF patients were enrolled into statistical analysis. The coincidence rate of LAA morphology classification was 96.4% (324/336) between two imaging experts. Multivariate logistic regression analysis showed that complex LAA morphology (OR 4.168, 95% CI 1.871‐9.288, P < .001) was associated with the presence of LAA thrombus, independently of other enrolled risks. Conclusions It is a concise and reliable method to divide the LAA morphology into complex type and simple type according to whether with the clearly lobulated structure. The complex LAA is an independent risk factor for LAA thrombosis in NVAF patients.
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Affiliation(s)
- Jionghong He
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Zenan Fu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China.,Department of Respiratory, The Third Affiliated Hospital of Zunyi Medical University, Zunyi City, Guizhou Province, China
| | - Long Yang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Wei Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Ye Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Qifang Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Zhi Jiang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Longhai Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Jing Huang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Shui Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Yidong Zhao
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
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Dhamane AD, Baker CL, Rajpura J, Mardekian J, Dina O, Russ C, Rosenblatt L, Lingohr-Smith M, Lin J. Continuation with apixaban treatment is associated with lower risk for hospitalization and medical costs among elderly patients. Curr Med Res Opin 2019; 35:1769-1776. [PMID: 31120309 DOI: 10.1080/03007995.2019.1623187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: To compare the risk of hospitalization and costs associated with major bleeding (MB) or stroke/systemic embolism (SE) among elderly patients with nonvalvular atrial fibrillation (NVAF) who initiated apixaban then switched to another oral anticoagulant (OAC) vs. those who continued with apixaban treatment. Methods: NVAF patients (≥65 years) initiating apixaban were identified from the Humana database (1 January 2013-30 September 2017) and grouped into switcher and continuer cohorts. For switchers, the earliest switch from apixaban to another OAC was defined as the index event/date. A random date during apixaban treatment was selected as the index date for continuers. Patients were followed from index date to health plan disenrollment or 31 December 2017, whichever was earlier. Multivariable regression analyses were used to examine the association of switchers vs. continuers with risk of MB-related or stroke/SE-related hospitalization and healthcare costs during follow-up. Results: Of 7858 elderly NVAF patients included in the study, 14% (N = 1110; mean age: 78 years) were switchers; 86% (N = 6748; mean age: 79 years) were continuers. Apixaban switchers vs. continuers had significantly greater risk of MB-related hospitalization (hazard ratio [HR]: 2.00; 95% CI: 1.52-2.64; p < .001) during follow-up; risk of stroke/SE hospitalization did not differ significantly (HR: 1.36, 95% CI: 0.89-2.06, p = .154). MB- and stroke/SE-related medical costs were higher for switchers vs. continuers, although total all-cause healthcare costs were similar. Conclusion: Elderly patients with NVAF in the US who continued with apixaban treatment had a lower risk of MB-related hospitalization and lower MB- and stroke/SE-related medical costs compared to patients who switched to another OAC.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jay Lin
- Novosys Health , Green Brook , NJ , USA
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41
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Sukumar S, Gulilat M, Linton B, Gryn SE, Dresser GK, Alfonsi JE, Schwarz UI, Kim RB, Schwartz JB. Apixaban Concentrations with Lower than Recommended Dosing in Older Adults with Atrial Fibrillation. J Am Geriatr Soc 2019; 67:1902-1906. [PMID: 31112620 DOI: 10.1111/jgs.15982] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Lower than recommended doses of direct-acting oral anticoagulants are often prescribed to older adults with nonvalvular atrial fibrillation (NVAF). Our goal was to determine the consequences of lower than recommended dosing on plasma apixaban concentrations during the clinical care of older adults with NVAF. DESIGN Convenience sample of patients receiving anticoagulation during 2017. SETTING Academic medical center. PARTICIPANTS Stable adults older than 65 years with NVAF receiving apixaban on a chronic basis. MEASUREMENTS Patient age, weight, creatinine, co-medications, and apixaban concentrations. RESULTS A total of 110 older adults with NVAF (mean age = 80.4 y; range = 66-100 y with 45% women) were studied. Overall, 48 patients received recommended dosing of 5 mg twice/day, and 42 received lower than recommended dosing. One patient in each category had concentrations below the expected 5% to 95% range at time of peak concentrations. Differences in proportion of apixaban concentrations within or outside expected ranges were not significant between patients receiving lower than recommended doses and those dosed as recommended at 5 mg twice/day (P = .35). However, in patients dosed as recommended with 5 mg twice/day, four had concentrations above the 5% to 95% range for peak levels expected at 3 to 4 hours after dosing; in two, this occurred around the midpoint of the dosing interval. Twenty patients received 2.5 mg twice/day as recommended. One-third had apixaban concentrations higher than expected peak concentrations compared with the clinical trials, and more than two-thirds had levels above the reported median for peak concentrations. CONCLUSIONS Apixaban concentrations in older adults with NVAF seen clinically were higher than expected based on clinical trial data. The findings raise questions about the optimal dosing of apixaban in older adults with NVAF encountered outside of clinical trials and suggest a role for the monitoring of apixaban concentrations during care of patients that differ from those in randomized trials or when considering dosing outside of published guidelines. J Am Geriatr Soc 67:1902-1906, 2019.
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Affiliation(s)
- Smrithi Sukumar
- School of Medicine, University of California, San Francisco, California
| | - Markus Gulilat
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Bradley Linton
- Pharmacy Services, London Health Sciences Centre, London, Ontario, Canada
| | - Steven E Gryn
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - George K Dresser
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeffrey E Alfonsi
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ute I Schwarz
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Richard B Kim
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Janice B Schwartz
- School of Medicine, University of California, San Francisco, California
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
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42
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Baker CL, Dhamane AD, Rajpura J, Mardekian J, Dina O, Russ C, Rosenblatt L, Lingohr-Smith M, Lin J. Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2019; 25:1076029619870249. [PMID: 31418293 PMCID: PMC6829636 DOI: 10.1177/1076029619870249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We compared the risks of switching to another oral anticoagulant (OAC) and discontinuation of direct oral anticoagulants (DOACs) among elderly patients with nonvalvular atrial fibrillation (NVAF) who were prescribed rivaroxaban or dabigatran versus apixaban. Patients (≥65 years of age) with NVAF prescribed DOACs (January 1, 2013 to September 30, 2017) were identified from the Humana research database and grouped into DOAC cohorts. Cox regression analyses were used to evaluate whether the risk for switching to another OAC or discontinuing index DOACs differed among cohorts. Of the study population (N = 38 250), 55.9% were prescribed apixaban (mean age: 78.6 years; 49.8% female), 37.3% rivaroxaban (mean age: 77.4 years; 46.7% female), and 6.8% dabigatran (mean age: 77.0 years; 44.0% female). Compared to patients prescribed apixaban, patients prescribed rivaroxaban (hazard ratio [HR]: 2.08; 95% confidence interval [CI], 1.92-2.25; P < .001) or dabigatran (HR: 3.74; 95% CI, 3.35-4.18, P < .001) had a significantly higher risk of switching to another OAC during the follow-up; compared to patients prescribed apixaban, the risks of discontinuation were also higher for patients treated with rivaroxaban (HR: 1.10; 95% CI, 1.07-1.13, P < .001) or dabigatran (HR: 1.29; 95% CI, 1.23-1.35, P < .001).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jay Lin
- 3 Novosys Health, Green Brook, NJ, USA
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43
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Allan V, Sammon CJ, McDonald L, Mehmud F, Alikhan R, Ramagopalan SV. Impact of atrial fibrillation awareness campaigns: interrupted time series using the Clinical Practice Research Datalink. Future Cardiol 2019; 15:311-318. [PMID: 31241353 DOI: 10.2217/fca-2019-0025] [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: 11/21/2022] Open
Abstract
Aim: This study investigated whether the rates of atrial fibrillation (AF) consultations changed following AF awareness campaigns in England. Materials & methods: Among adults in the Clinical Practice Research Datalink, Poisson regression was used to model weekly rates of AF-related consultations over time. The models were used to assess whether rates changed in the 8 weeks following World Heart Rhythm Week (WHRW) and Global AF aware week. Results: A higher incidence of pulse checks was observed following WHRW (IRR 1.16 [95% CI 1.08-1.24]). No difference in the incidence of AF diagnoses was noted following WHRW (IRR: 1.03 [95% CI: 0.97-1.09]) or Global AF aware week (IRR: 0.94 [95% CI: 0.88-1.00]). Conclusion: The results suggest AF campaigns may increase awareness but do not bring about short-term increases in the rates of AF diagnoses.
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Affiliation(s)
- Victoria Allan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Cormac J Sammon
- PHMR Ltd, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| | - Laura McDonald
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | | | - Raza Alikhan
- Department of Haematology, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, Wales, UK
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
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Yamashita T, Koretsune Y, Ishikawa M, Shiosakai K, Kogure S. Postmarketing surveillance on clinical use of edoxaban in patients with nonvalvular atrial fibrillation (ETNA-AF-Japan): Three-month interim analysis results. J Arrhythm 2019; 35:121-129. [PMID: 30805052 PMCID: PMC6373660 DOI: 10.1002/joa3.12149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants are the first-line drugs for anticoagulation therapy in nonvalvular atrial fibrillation (NVAF). However, a real-world, large-scale, clinical study on edoxaban has not been performed. Our ongoing postmarketing surveillance, ETNA-AF-Japan (Edoxaban Treatment in routiNe clinical prActice in patients with non-valvular Atrial Fibrillation; UMIN000017011), was designed to collect such data. METHODS Enrollment started on 13 April 2015 and ended on 30 September 2017. Eligible patients were those diagnosed with NVAF who were to receive edoxaban for the first time and provided written consent for study participation. Baseline patient characteristics and adverse events (AEs) were collected. RESULTS A total of 11 569 patients were enrolled. Data for 8157 patients in the first 3 months were analyzed. Mean age, body weight, creatinine clearance (CLcr), and CHADS 2 score were 74.2 ± 10.0 years, 60.0 ± 12.6 kg, 64.0 ± 25.6 mL/min, and 2.2 ± 1.3, respectively. Female patients, and patients with age ≥75 years, body weight ≤60 kg, and CLcr <30 mL/min constituted 40.7%, 52.4%, 54.6%, and 4.7%, respectively. Patients with paroxysmal, persistent, and permanent AF constituted 46.1%, 38.7%, and 15.1%, respectively. Most patients (85.3%) received dosages according to the prescribing information, and 90.8% continued the medication for 3 months. Bleeding AEs occurred in 3.29%, including major bleeding in 0.29%. CONCLUSIONS The majority (90.8%) of patients continued medication and no significant safety concerns related to edoxaban were reported during the first 3 months of treatment. Clearer safety and efficacy profiles of edoxaban await data analyses after the 2-year follow-up period.
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Affiliation(s)
| | | | - Mayumi Ishikawa
- Post Marketing Study DepartmentDaiichi Sankyo Co. Ltd.TokyoJapan
| | - Kazuhito Shiosakai
- Biostatistics & Data Management DepartmentDaiichi Sankyo Co. Ltd.TokyoJapan
| | - Seiji Kogure
- Post Marketing Study DepartmentDaiichi Sankyo Co. Ltd.TokyoJapan
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Yan S, Li Q, Xia Z, Yan S, Wei Y, Hong K, Wu Y, Li J, Cheng X. Risk factors of thromboembolism in nonvalvular atrial fibrillation patients with low CHA2DS2-VASc score. Medicine (Baltimore) 2019; 98:e14549. [PMID: 30813164 PMCID: PMC6408143 DOI: 10.1097/md.0000000000014549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The risk of thromboembolism in patients with CHA2DS2-VASc score of 0 to 1 was low, and the anticoagulant therapy was not recommended. Although the CHA2DS2-VASc score was low, there were still many patients suffered from thrombotic events and stroke. We aim to investigate the risk factors of thrombotic events in nonvalvular atrial fibrillation (NVAF) patients with low CHA2DS2-VASc score.We retrospectively enrolled 595 consecutive NVAF patients with low CHA2DS2-VASc score (male: CHA2DS2-VASc = 0, female: CHA2DS2-VASc = 1). The general clinical data, blood biochemical data, and echocardiography results of the 595 patients were collected. Multivariate logistic regression models were used to evaluate risk factors of thrombosis. Receiver operating characteristic curve was used to identify the optimal cut-off value of the independent risk factors. A P value of <.05 (2-sided) was considered to be statistically significant.In multivariate analysis, lipoprotein (a) (Lp(a)) plasma level and left atrium diameter (LAD) were positively related to thromboembolism in NVAF patients with CHA2DS2-VASc score of 0 to 1 after adjustment for age, gender, and other variables (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.01-1.03; OR = 1.13, 95% CI: 1.06-1.18). Lp(a) exerted a significant predictive value with area under the curve (AUC) of 0.62 (95% CI: 0.55-0.68, P < .01). The optimal cut-off value for Lp(a) predicting thrombotic events was 27.2 mg/dL (sensitivity 45.7%, specificity 73.4%). LAD showed a significant predictive value with AUC of 0.71 (95% CI: 0.64-0.78, P < .01). The optimal cut-off point for LAD predicting thrombotic events was 43.5 mm (sensitivity 47.1%, specificity 85.8%).High Lp(a) plasma level and left atrial dilatation might be independent risk factors of thrombotic events for NVAF patients with low CHA2DS2-VASc score.
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Esposti LD, Briere JB, Bowrin K, Diego S, Perrone V, Pasquale GD. Antithrombotic treatment patterns in patients with atrial fibrillation in Italy pre- and post-DOACs: the REPAIR study. Future Cardiol 2019; 15:109-118. [PMID: 30663889 PMCID: PMC6462838 DOI: 10.2217/fca-2018-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
AIM To evaluate antithrombotic treatment patterns in patients in Italy with nonvalvular atrial fibrillation (NVAF) before and after direct oral anticoagulants (DOACs) were approved. METHODS This analysis included patients with a discharge diagnosis of NVAF in 2010 and 2014, which constituted the pre- and post-DOACs populations, respectively. RESULTS Approximately 90% of patients were eligible for oral anticoagulant (OAC) therapy. Overall use of OACs increased from 38% in 2010 to 45% in 2014; use of antiplatelet therapy decreased from 36 to 25%. Approximately 14% of eligible patients remained untreated. CONCLUSION Although an improvement in OAC prescription was observed post-DOACs launch, treatment patterns in Italy suggest that a proportion of patients with NVAF are still undertreated or do not receive appropriate therapy.
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Affiliation(s)
- Luca D Esposti
- CliCon Srl, Health Economics and Outcomes Research, Ravenna, Italy
| | | | | | - Sangiorgi Diego
- CliCon Srl, Health Economics and Outcomes Research, Ravenna, Italy
| | | | - Giuseppe Di Pasquale
- Dipartimento Medico Azienda USL di Bologna. Unità Operativa di Cardiologia Ospedale Maggiore, Bologna, Italy
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Zhou LY, Yang SF, Zhang Z, Zhang C, Shen L, Gu ZC, Zuo XC. A Renal Function Based Trade-Off Analysis of Non-vitamin K Antagonist Oral Anticoagulants in Nonvalvular Atrial Fibrillation. Front Physiol 2018; 9:1644. [PMID: 30524307 PMCID: PMC6256743 DOI: 10.3389/fphys.2018.01644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/31/2018] [Indexed: 12/27/2022] Open
Abstract
Background: Non-vitamin K antagonist oral anticoagulants (NOACs) depend on some degree of renal excretion, and no head-to-head comparisons based on renal function is available. This study mainly investigated the trade-off property of NOACs in nonvalvular atrial fibrillation (NVAF) with varying degrees of renal function. Methods: A comprehensive search of Medline, Embase, Cochrane Library, and Clinical Trials.gov Website was performed for eligible randomized controlled trials (RCTs) that reported the efficacy and safety outcomes according to renal function of NOACs. Primary efficacy outcome was any Stroke or systemic embolism (S/SE). Major bleeding was considered as a primary safety outcome. Risk ratios (RRs) with their confidence intervals (CIs), the surface under the cumulative ranking curve (SUCRA), and trade-off analysis were conducted by renal function. Results: Finally, 5 phase III Clinical Trials (72961 NVAF patients) comparing NOACs with warfarin in NVAF patients were included. In terms of normal renal function, dabigatran-150 mg was ranked first for efficacy (SUCRA: 90.3), and edoxaban-30 mg was ranked first for safety (SUCRA: 93.3). Dabigatran-110 mg/150 mg, and apixaban-5 mg were regarded as the most effective and reasonably safe interventions in the trade-off analysis. Regarding mild renal impairment, edoxaban-60 mg was ranked first for efficacy (SUCRA: 97.8), and edoxaban-30 mg was ranked first for safety (SUCRA: 99.5). Edoxaban-60 mg and dabigatran-150 mg were accounted as the most effective and reasonably safe interventions. With regards to moderate renal impairment, dabigatran-150 mg was ranked first for efficacy (SUCRA: 95.1), and edoxaban-15 mg was ranked first for safety (SUCRA: 98.2). Apixaban-2.5 mg and Edoxaban-30 mg was considered as the reasonably effective and the safest interventions. Conclusions: Dabigatran-150 mg seems the most effective therapy in patients with normal renal function and moderate renal impairment, and edoxaban-60 mg in patients with mild renal impairment. Low dose edoxaban (15 and 30 mg) seems the safest intervention. Apixaban-2.5 mg and edoxaban-30 mg might be the best trade-off property in moderate renal insufficiency. HIGHLIGHTS STUDY REGISTRATION: PROSPERO Identifier, CRD42017054235.
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Affiliation(s)
- Ling-Yun Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Shuo-Fei Yang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhen Zhang
- Pharmacy Department, Memorial Healthcare System, Hollywood, FL, United States
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Cong Zuo
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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Deguchi I, Takao M. Reduced Doses of Direct Oral Anticoagulants in Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation. J Stroke Cerebrovasc Dis 2019; 28:354-9. [PMID: 30401611 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/22/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The choice of standard or reduced doses of direct oral anticoagulants (DOACs) depends on patients' age, body weight, and renal function based on package instructions. Our aim was to conduct a simulation of DOAC dose using patients' data obtained on admission. METHODS This retrospective study included 314 ischemic stroke patients with nonvalvular atrial fibrillation admitted to our hospital between September 2014 and February 2018. Data on age, body weight, creatinine, and creatinine clearance were collected for each subject, and simulation was conducted for the dose of each DOAC. RESULTS The mean age of 314 subjects was 77.2 years; those aged 75 years or older accounted for 61.5% (193 patients). It was suggested that a standard dose of rivaroxaban could be used in 67.5% of patients and that of apixaban in 65.9%. By contrast, a standard dose of dabigatran could be used in only 16.9% of patients and that of edoxaban in only 32.5%. The simulation analysis for patients aged 75 years or older showed that a standard dose of rivaroxaban could be used in 54.9% of patients and that of apixaban in 44.6%, while that of edoxaban could be used in only 19.7% of patients. CONCLUSIONS When DOACs are prescribed for secondary prevention of cerebral infarction in patients with nonvalvular atrial fibrillation, the rate of standard or reduced dose varies depending on the kind of DOAC. Further analysis is required to clarify whether a standard dose of one DOAC or reduced dose of another DOAC yields the best result for each patient.
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Stacy ZA, Richter SK. Direct oral anticoagulants for stroke prevention in atrial fibrillation: treatment outcomes and dosing in special populations. Ther Adv Cardiovasc Dis 2018; 12:247-262. [PMID: 30081727 DOI: 10.1177/1753944718787384] [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: 01/21/2023] Open
Abstract
BACKGROUND To review data from the pivotal phase III trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) versus warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), and to summarize the major findings with regards to patient subgroups that are at an increased risk for stroke or bleeding. METHODS A PubMed literature search (January 2009 to January 2017) was performed using the terms 'dabigatran', 'rivaroxaban', 'apixaban', 'edoxaban', 'atrial fibrillation', 'RE-LY', 'ROCKET AF', 'ARISTOTLE', and 'ENGAGE AF-TIMI 48'. All primary publications and secondary analyses in special populations at increased risk of stroke or bleeding from the pivotal phase III clinical trials were evaluated. RESULTS Available secondary analyses indicate no treatment interactions with regards to stroke or systemic embolic event (SEE) prevention for any of the DOACs in the patient subgroups, including patients with advanced age, impaired renal function, diabetes, prior stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD). Although higher bleeding incidence was reported with dabigatran and rivaroxaban in patients aged 75 years and over with apixaban in patients with diabetes, and with rivaroxaban in patients with previous MI or PAD, no changes in dosing are recommended. CONCLUSIONS Overall, results of secondary analyses indicate that the recommended dosing strategy for each of the DOACs produces a consistent anticoagulant effect across a diverse patient population, including those at increased risk of stroke or bleeding.
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Affiliation(s)
- Zachary A Stacy
- Division of Acute Care Pharmacy, Pharmacy Practice Department, St Louis College of Pharmacy, 4588 Parkview Place, St Louis, MO 63110-1088, USA
| | - Sara K Richter
- Division of Acute Care Pharmacy, Pharmacy Practice Department, St Louis College of Pharmacy, St Louis, MO, USA
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Abstract
This study aimed to explore the relationship of D-dimer level with the risk stratification of ischemic stroke, and determine whether high D-dimer levels could be used as a risk factor of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF).This single-center, retrospective study recruited NVAF patients who did not undergo anticoagulant therapy. These patients were divided into 2 groups: ischemic stroke group and no-stroke group. The medical records of each patient were reviewed, demographic and clinical analyses were performed, and the laboratory results were summarized.A total of 323 eligible in-patients with NVAF, who did not receive anticoagulant therapy, were recruited (206 male and 117 female patients, median age was 75.18 ± 10.46 years old). Among these patients, 78 patients suffered from acute ischemic stroke. D-dimer level increased with age, and was positively correlated with the risk stratification of stroke, CHADS2 score (rs = 0.441, P < .001), and CHA2DS2-VASC score (rs = 0.412, P < .001), even after adjustment for age and gender (rs = 0.422, P < .001). The difference in baseline D-dimer level between these 2 groups was not statistically significant (0.70 vs 0.66 mg/L, P = .330), but this significantly increased when patients suffered from stroke (1.34 vs 0.70 mg/L, P < .001). The D-dimer level after stroke (≥6 months) was also higher than the baseline (1.16 vs 0.68 mg/L, P = .514) in 6 months, and this level nearly returned to baseline level after one year (0.69 vs 0.68 mg/L, P = .158). However, logistic regression revealed that only the D-dimer level at stroke onset and OMI were independent risk factors for ischemic stroke (P < .001), while the increase from baseline D-dimer levels was not an independent risk factor (P = .125).D-dimer level is positively correlated with the risk stratification of ischemic stroke, but has no predictive value on the occurrence of ischemic stroke in patients with NVAF.
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Affiliation(s)
- Li-Rui You
- Department of Geriatric, Medical Care Centre, Beijing Friendship Hospital, Captial Medical University
- Department of Internal Medicine, Beijing Norther Hospital, Beijing, China
| | - Mei Tang
- Department of Geriatric, Medical Care Centre, Beijing Friendship Hospital, Captial Medical University
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