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Mihm AE, Hicklin HE, Cunha AL, Nisly SA, Davis KA. Direct oral anticoagulants versus warfarin for the treatment of left ventricular thrombosis. Intern Emerg Med 2021; 16:2313-2317. [PMID: 34165680 DOI: 10.1007/s11739-021-02788-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alexandra Evaun Mihm
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Harry Eugene Hicklin
- Department of Internal Medicine, Atrium Health, Wake Forest School of Medicine, Winston Salem, NC, 27157, USA
| | - Alexandra Lee Cunha
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, 27268, USA
| | - Sarah Anne Nisly
- Department of Pharmacy, Atrium Health, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- School of Pharmacy, Wingate University, Wingate, NC, 28174, USA
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Garigan TP, Earwood JS, Poplawski M. Monotherapy for nonvalvular A-fib with stable CAD? J Fam Pract 2021; 70:403-407. [PMID: 34818177 PMCID: PMC8619808 DOI: 10.12788/jfp.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A meta-analysis found oral anticoagulant (OAC) monotherapy provided efficacy comparable to OAC plus single antiplatelet therapy-with lower bleeding risk.
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Affiliation(s)
- Thomas P Garigan
- Department of Soldier and Family Medicine, Eisenhower Army Medical Center, Fort Gordon, GA
| | - John S Earwood
- Department of Soldier and Family Medicine, Eisenhower Army Medical Center, Fort Gordon, GA
| | - Michal Poplawski
- Department of Soldier and Family Medicine, Eisenhower Army Medical Center, Fort Gordon, GA
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Yue D, Jiang Y, Yang Z, Cao L, Huo L, Wang J. Comparison of the effects of left atrial appendage closure and oral anticoagulants in preventing stroke in patients with non-valvular atrial fibrillation: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27251. [PMID: 34664871 PMCID: PMC8447996 DOI: 10.1097/md.0000000000027251] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aims to analyze and evaluate the difference in efficacy between left atrial appendage closure (LAAC) and oral anticoagulants (OA) in preventing stroke in patients with non-valvular atrial fibrillation (NVAF) through the method of meta-analysis. The purpose is to provide for the prevention of stroke in patients with NVAF valuable treatment guidance. METHODS This study is a comprehensive collection of randomized controlled studies of LAAC and OA in the prevention of stroke in patients with NVAF, and searches PubMed, Embase, the Cochrane Library, Web of Science, CNKI, SinoMed, VIP Database, WANFANG Database, and other Chinese and English databases by combining subject words with free words, and the retrieval time is from the establishment of each database to June 1, 2021. At the same time, searching the included literature and literature of related reviews by manual. Two researchers independently conduct literature screening and quality evaluation. Statistical software RevMan 5.3 and Stata 12.0 were used for meta-analysis. RESULTS This study evaluating the difference in efficacy between LAAC and OA in preventing stroke in patients with NVAF will be published in high-quality medical academic journals. CONCLUSION This study will give the best treatment strategy to prevent stroke in patients with NVAF, and provide some reference for clinical medical staff.OSF registration number: DOI 10.17605/OSF.IO/2UXPA (https://osf.io/2uxpa).
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Affiliation(s)
- Deyong Yue
- Department of Pharmacy, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 25 Nanmen Road, Chengqiao Town, Chongming District, Shanghai, China
| | - Yunda Jiang
- Department of Pharmacy, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 25 Nanmen Road, Chengqiao Town, Chongming District, Shanghai, China
| | - Zhongying Yang
- Department of Pharmacy, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 25 Nanmen Road, Chengqiao Town, Chongming District, Shanghai, China
| | - Liang Cao
- Department of Information, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 25 Nanmen Road, Chengqiao Town, Chongming District, Shanghai, China
| | - Long Huo
- Department of Spleen and Stomach Diseases, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 725 South Wanping Road, Xuhui District, Shanghai, China
| | - Jing Wang
- Department of Internal Medicine of Traditional Chinese Medicine, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 25 Nanmen Road, Chengqiao Town, Chongming District, Shanghai, China
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Descamps R, Moussa MD, Besnier E, Fischer MO, Preau S, Tamion F, Daubin C, Cousin N, Vincentelli A, Goutay J, Du Cheyron D. Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study. Crit Care 2021; 25:127. [PMID: 33810800 PMCID: PMC8019180 DOI: 10.1186/s13054-021-03554-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/26/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring. METHODS We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding. RESULTS Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29-0.67] vs 0.33 [0.22-0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47-1.46] vs 0.66 [0.36-0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan-Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006). CONCLUSION In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.
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Affiliation(s)
- Richard Descamps
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France.
| | - Mouhamed D Moussa
- Inserm, CHU Lille, Surgical Critical Care, Department of Anesthesiology and Critical Care, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76000, Rouen, France
| | - Marc-Olivier Fischer
- Department of Anesthesiology and Critical Care, Caen University Hospital, 14000, Caen, France
| | - Sébastien Preau
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Fabienne Tamion
- UNIROUEN, Inserm U1096, FHU- REMOD-VHF, Normandie Univ, 76000, Rouen, France
- Department of Medical Intensive Care, Rouen University Hospital, 76000, Rouen, France
| | - Cédric Daubin
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
| | - Nicolas Cousin
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - André Vincentelli
- Inserm, CHU Lille, Department of Cardiac Surgery, Institut Pasteur de Lille, UMR1011-EGID, Univ. Lille, 59000, Lille, France
| | - Julien Goutay
- Department of Medical Intensive Care, Lille University Hospital, 59000, Lille, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
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Turcato G, Bonora A, Zorzi E, Zaboli A, Zannoni M, Ricci G, Pfeifer N, Maccagnani A, Tenci A. Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users. Intern Emerg Med 2020; 15:311-318. [PMID: 31754969 DOI: 10.1007/s11739-019-02229-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/02/2019] [Indexed: 02/07/2023]
Abstract
More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified. The objective of this study was to assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB. This was a multicentre retrospective study conducted over 2 years. The study included patients evaluated at three different EDs for GIB. The baseline characteristics were included. Subsequently, we assessed the differences in past medical history and clinical data between the two study groups (DOAC and warfarin users). Differences between the two groups were evaluated using Kaplan-Meier curves. Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs and 60.6% (172/284) were treated with warfarin. Overall, 8.1% (23/284) of patients died within 30 days. Among the 172 warfarin-treated patients, 8.7% (15/172) died within 30 days from ED evaluation. In the 112 DOAC-treated patients, the mortality rate was 7.1% (8/112). The Cox regression analysis, adjusted for possible clinical confounders, and the Kaplan-Meier curves did not outline differences between the two treatment groups. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.
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Affiliation(s)
- Gianni Turcato
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy.
| | - Antonio Bonora
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Arian Zaboli
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Giorgio Ricci
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | | | - Andrea Tenci
- Department of Emergency Medicine, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
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Godino C, Melillo F, Rubino F, Arrigoni L, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Colombo A, Salerno A, Cera M, Margonato A. Real-world 2-year outcome of atrial fibrillation treatment with dabigatran, apixaban, and rivaroxaban in patients with and without chronic kidney disease. Intern Emerg Med 2019; 14:1259-1270. [PMID: 31073827 DOI: 10.1007/s11739-019-02100-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 01/05/2023]
Abstract
Patients with non-valvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) are at increased risk of stroke and bleeding. Although direct oral anticoagulant (DOAC) trials excluded patients with severe CKD, a growing portion of CKD patients have been starting DOACs and limited data from real-world outcome in this high-risk setting are available. The INSigHT registry included 632 consecutive NVAF patients that started apixaban (256 patients, 41%), dabigatran (245, 39%) and rivaroxaban (131, 20%) between 2012 and 2015. Based on creatinine clearance, two sub-cohorts were defined: (1) non-CKD group (CrCl 60-89 mL/min, 413 patients) and (2) CKD group (15-59 ml/min, 219). Compared to non-CKD patients, those with CKD, were at higher ischemic (CHA2DS2-VASc 4.5 vs 2.9, p < 0.001) and hemorrhagic risk (HAS-BLED 2.4 vs 1.8, p < 0.001). At 2-year follow-up, the overall ISTH-major bleeding and thromboembolic event rates were 5.2% and 2.3% and no significant difference between non-CKD and CKD patients for both efficacy and safety endpoints were observed. In non-CKD patients, the 2-year ISTH-major bleeding rates were higher in rivaroxaban group (HR 2.9, 95% CI 1.1-7.3; p = 0.047) while dabigatran showed non-significant excess in thromboembolic events (HR 4.3, 95% CI 0.9-20.8; p = 0.068). In CKD patients, a significantly higher rate of thromboembolic events was observed in rivaroxaban (HR 6.3, 95% CI 1.1-38.1; p = 0.044). This real-world, non-insurance database registry shows remarkable 2-year safety and efficacy profile of DOACs even in patients with moderate to severe CKD. Head to head differences between DOACs are exploratory, hypothesis generating and warrant further investigation in larger studies.
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Affiliation(s)
- Cosmo Godino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Francesco Melillo
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Rubino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Arrigoni
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Cappelletti
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Mattiello
- Information Systems Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiovascular Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Michela Cera
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Chi G, Gibson CM, Kalayci A, Cohen AT, Hernandez AF, Hull RD, Kahe F, Jafarizade M, Sharfaei S, Liu Y, Harrington RA, Goldhaber SZ. Extended-duration betrixaban versus shorter-duration enoxaparin for venous thromboembolism prophylaxis in critically ill medical patients: an APEX trial substudy. Intensive Care Med 2019; 45:477-487. [PMID: 30778649 DOI: 10.1007/s00134-019-05565-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/05/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the efficacy and safety of betrixaban for venous thromboembolism (VTE) prophylaxis among critically ill patients. METHODS The APEX trial randomized 7513 acutely ill hospitalized patients to betrixaban for 35-42 days or enoxaparin for 10 ± 4 days. Among those, 703 critically ill patients admitted to the intensive care unit were included in the analysis, and 547 patients who had no severe renal insufficiency or P-glycoprotein inhibitor use were included in the full-dose stratum. The risk of VTE, bleeding, net clinical benefit (composite of VTE and major bleeding), and mortality was compared at 35-42 days and at 77 days. RESULTS At 35-42 days, extended betrixaban reduced the risk of VTE (4.27% vs 7.95%, P = 0.042) without causing excess major bleeding (1.14% vs 3.13%, P = 0.07). Both VTE (3.32% vs 8.33%, P = 0.013) and major bleeding (0.00% vs 3.26%, P = 0.003) were decreased in the full-dose stratum. Patients who received betrixaban had more non-major bleeding than enoxaparin (overall population: 2.56% vs 0.28%, P = 0.011; full-dose stratum: 3.32% vs 0.36%, P = 0.010). Mortality was similar at the end of study (overall population: 13.39% vs 16.19%, P = 0.30; full-dose stratum: 13.65% vs 16.30%, P = 0.39). CONCLUSIONS Compared with shorter-duration enoxaparin, critically ill medical patients who received extended-duration betrixaban had fewer VTE without more major bleeding events. The benefit of betrixaban was driven by preventing asymptomatic thrombosis and offset by an elevated risk of non-major bleeding. The APEX trial did not stratify by intensive care unit admission and the present study included a highly selected population of critically ill patients. These hypothesis-generating findings need to be validated in future studies. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov . Unique identifier: NCT01583218.
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Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | | | - Arzu Kalayci
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College London, London, UK
| | | | - Russell D Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Farima Kahe
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mehrian Jafarizade
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sadaf Sharfaei
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yuyin Liu
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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