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Renda G, Bucciarelli V, Barbieri G, Lanuti P, Berteotti M, Malatesta G, Cesari F, Salvatore T, Giusti B, Gori AM, Marcucci R, De Caterina R. Ex Vivo Antiplatelet Effects of Oral Anticoagulants. J Cardiovasc Dev Dis 2024; 11:111. [PMID: 38667729 PMCID: PMC11049965 DOI: 10.3390/jcdd11040111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on platelet function is still unclear. We conducted a comprehensive ex vivo study aimed at assessing the effect of the four currently marketed NOACs on platelet function. METHODS We incubated blood samples from healthy donors with concentrations of NOACs (50, 150 and 250 ng/mL), in the range of those achieved in the plasma of patients during therapy. We evaluated generation of thrombin; light transmittance platelet aggregation (LTA) in response to adenosine diphosphate (ADP), thrombin receptor-activating peptide (TRAP), human γ-thrombin (THR) and tissue factor (TF); generation of thromboxane (TX)B2; and expression of protease-activated receptor (PAR)-1 and P-selectin on the platelet surface. RESULTS All NOACs concentration-dependently reduced thrombin generation compared with control. THR-induced LTA was suppressed by the addition of dabigatran at any concentration, while TF-induced LTA was reduced by factor-Xa inhibitors. ADP- and TRAP-induced LTA was not modified by NOACs. TXB2 generation was reduced by all NOACs, particularly at the highest concentrations. We found a concentration-dependent increase in PAR-1 expression after incubation with dabigatran, mainly at the highest concentrations, but not with FXa inhibitors; P-selectin expression was not changed by any drugs. CONCLUSIONS Treatment with the NOACs is associated with measurable ex vivo changes in platelet function, arguing for antiplatelet effects beyond the well-known anticoagulant activities of these drugs. There are differences, however, among the NOACs, especially between dabigatran and the FXa inhibitors.
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Affiliation(s)
- Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Valentina Bucciarelli
- Cardiovascular Sciences Department, Azienda Ospedaliero-Universitaria delle Marche, 60121 Ancona, Italy;
| | - Giulia Barbieri
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Paola Lanuti
- Department of Medicine and Aging Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Gelsomina Malatesta
- Cardiology Unit, National Institute of Health and Science on Aging (INRCA), 64125 Ancona, Italy;
| | - Francesca Cesari
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Tanya Salvatore
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Raffaele De Caterina
- Cardiology Division 1-Pisa University Hospital, University of Pisa, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, 37011 Città Sant’Angelo, Italy
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Kazimierczyk E, Dąbrowska M, Gierlotka M, Kapica-Topczewska K, Karaszewski B, Kobayashi A, Krasiński Z, Kubica J, Kułakowska A, Kurek K, Ładny R, Pleban E, Rejdak K, Rydzewska G, Słowik A, Szopiński P, Woźniak A, Tycińska A. The use of andexanet alpha in the Polish setting: An interdisciplinary protocol. Expert consensus statement of the Polish Cardiac Society. Kardiol Pol 2024; 82:123-139. [PMID: 38230495 DOI: 10.33963/v.kp.98059] [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: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 01/18/2024]
Abstract
Andexanet alfa (AA) is a recombinant inactive analog of human activated factor X (FXa), effectively reversing the effects of its inhibitors - rivaroxaban and apixaban, which are available in Poland. The drug was approved for clinical use registration after the publication of the results of the ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors 4), in which its efficacy in restoring hemostasis in life-threatening hemorrhages in patients receiving using the aforementioned anticoagulants was demonstrated. Hence, AA is now recommended for patients on apixaban or rivaroxaban therapy with massive and uncontrollable hemorrhages, including hemorrhagic strokes (HS) and gastrointestinal bleeding. Drug-specific chromogenic anti-Xa assays are generally best suited for estimating rivaroxaban and apixaban plasma levels, aside from direct assessment of their concentrations. The absence of anti-Xa activity, determined using these assays, allows us to rule out the presence of clinically relevant plasma concentrations of any FXa inhibitor. On the other hand, the dose of AA should not be modified based on the results of coagulation tests, as it depends solely on the time that elapsed since the last dose of FXa inhibitor and oon the dose and type of FXa inhibitor. AA is administered as an intravenous (i.v.) bolus, followed by an i.v. infusion of the drug. The maximum reversal of anti-Xa activity occurs within two minutes of the end of the bolus treatment, with the continuation of the continuous i.v. infusion allowing the effect to be maintained for up to two hours afterwards. Because anticoagulant activity can reappear after the infusion is completed, it is currently unclear at what point after AA administration FXa inhibitors or heparin should be re-administered. In Poland AA is starting to become available and its urgent need to administer it to patients with severe bleeding on apixaban or rivaroxaban.
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Affiliation(s)
- Ewelina Kazimierczyk
- Department of Cardiology, University Clinical Hospital in Bialystok, Białystok, Poland.
| | - Milena Dąbrowska
- Department of Hematology Diagnostic, University Clinical Hospital in Bialystok, Białystok, Poland
| | - Marek Gierlotka
- Department of Cardiology, University Clinical Hospital in Opole, Opole, Poland
| | | | | | - Adam Kobayashi
- Department of Pharmacology and Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine - Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, Warszawa, Poland
| | - Zbigniew Krasiński
- Department of Vascular, Endovascular, Angiology and Phlebology Surgery (CNWA), Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Alina Kułakowska
- Department of Neurology and Stroke Unit, University Clinical Hospital in Bialystok, Białystok, Poland
| | - Krzysztof Kurek
- Department of Gastroenterology and Internal Medicine, University Clinical Hospital in Bialystok, Białystok, Poland
| | - Robert Ładny
- 1st Clinic of General and Endocrine Surgery, University Clinical Hospital in Bialystok, Białystok, Poland
| | - Eliza Pleban
- Vascular Surgery Clinic, Cardinal Stefan Wyszynski National Institute of Cardiology in Warsaw, Warszawa, Poland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Grażyna Rydzewska
- Department of Internal Medicine and Gastroenterology and Subdivision of Inflammatory Bowel Diseases of the Ministry of Internal Affairs and Administration in Warsaw, Warszawa, Poland
| | - Agnieszka Słowik
- Clinical Department of Neurology, University Hospital in Krakow, Kraków, Poland
| | - Piotr Szopiński
- Vascular Surgery Clinic, Cardinal Stefan Wyszynski National Institute of Cardiology in Warsaw, Warszawa, Poland
| | - Arkadiusz Woźniak
- Department of Vascular Surgery, University Clinical Hospital in Bialystok, Białystok, Poland
| | - Agnieszka Tycińska
- Department of Cardiology, University Clinical Hospital in Bialystok, Białystok, Poland
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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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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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Verma LA, Penson PE, Akpan A, Lip GYH, Lane DA. Managing older people with atrial fibrillation and preventing stroke: a review of anticoagulation approaches. Expert Rev Cardiovasc Ther 2023; 21:963-983. [PMID: 38088256 DOI: 10.1080/14779072.2023.2276892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/25/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Oral anticoagulants (OACs) are the cornerstone of stroke prevention in atrial fibrillation (AF), but prescribing decisions in older people are complicated. Clinicians must assess the net clinical benefit of OAC in the context of multiple chronic conditions, polypharmacy, frailty and life expectancy. The under-representation of high-risk, older adult sub-populations in clinical trials presents the challenge of choosing the right OAC, where a 'one-size-fits-all' approach cannot be taken. AREAS COVERED This review discusses OAC approaches for stroke prevention in older people with AF and presents a prescribing aid to support clinicians' decision-making. High-risk older adults with multiple chronic conditions, specifically chronic kidney disease, dementia/cognitive impairment, previous stroke/transient ischemic attack or intracranial hemorrhage, polypharmacy, frailty, low body weight, high falls risk, and those aged ≥75 years are considered. EXPERT OPINION Non-vitamin K antagonist OACs are the preferred first-line OAC in older adults with AF, including high-risk subpopulations, after individual assessment of stroke and bleeding risk, except those with mechanical heart valves and moderate-to-severe mitral stenosis. Head-to-head comparisons of NOACs are not available, therefore the choice of drug (and dose) should be based on an individual's risk (stroke and bleeding) and incorporate their treatment preferences. Treatment decisions must be person-centered and principles of shared decision-making applied.
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Affiliation(s)
- Leona A Verma
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Peter E Penson
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Asangaedem Akpan
- Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Medicine for Older People, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Bielecka B, Gorczyca-Głowacka I, Ciba-Stemplewska A, Wożakowska-Kapłon B. Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre. Int J Environ Res Public Health 2023; 20:6145. [PMID: 37372735 PMCID: PMC10298142 DOI: 10.3390/ijerph20126145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be 'tailored' in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004-2011 and beyond (years 2012-2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients' sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004-2011 and 2012-2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012-2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.
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Affiliation(s)
- Bernadetta Bielecka
- 1st Clinic of Cardiology and Electrotherapy, Świętokrzyskie Cardiology Centre, 25-736 Kielce, Poland; (B.B.); (B.W.-K.)
| | | | - Agnieszka Ciba-Stemplewska
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland;
- Clinic of Internal Medicine, 25-736 Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Świętokrzyskie Cardiology Centre, 25-736 Kielce, Poland; (B.B.); (B.W.-K.)
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland;
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Chao TF, Unverdorben M, Kirchhof P, Koretsune Y, Yamashita T, Crozier RA, Pecen L, Chen C, Borrow AP, De Caterina R. Prescribing Patterns and Outcomes of Edoxaban in Atrial Fibrillation: One-Year Data from the Global ETNA-AF Program. J Clin Med 2023; 12:jcm12051870. [PMID: 36902656 PMCID: PMC10003604 DOI: 10.3390/jcm12051870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 03/02/2023] Open
Abstract
Non-recommended dosing occurs in ~25-50% of non-vitamin K antagonist oral anticoagulant prescriptions, with limited data for edoxaban. We analyzed edoxaban dosing patterns in atrial fibrillation patients from the Global ETNA-AF program, relating patterns to baseline characteristics and 1-year clinical outcomes. The following dosing groups were compared: non-recommended 60 mg ("overdosed") vs. recommended 30 mg; non-recommended 30 mg ("underdosed") vs. recommended 60 mg. Most (22,166/26,823; 82.6%) patients received recommended doses. Non-recommended dosing was more frequent near label-specified dose-reduction thresholds. Ischemic stroke (IS; HR 0.85, 95% CI 0.50-1.47; p = 0.6) and major bleeding (MB; HR 1.47, 95% CI 0.97-2.71; p = 0.07) did not differ between recommended 60 mg and "underdosed" groups, whereas all-cause (HR 1.61, 95% CI 1.23-2.08; p = 0.0003) and cardiovascular deaths (HR 1.61, 95% CI 1.11-2.38; p = 0.01) were higher in the "underdosed" group. Compared with recommended 30 mg, the "overdosed" group had lower IS (HR 0.51, 95% CI 0.28-0.98; p = 0.04) and all-cause death (HR 0.74, 95% CI 0.55-0.98; p = 0.03) without higher MB (HR 0.74, 95% CI 0.46-1.22; p = 0.2). In conclusion: non-recommended dosing was infrequent, but more common near dose-reduction thresholds. "Underdosing" was not associated with better clinical outcomes. The "overdosed" group had lower IS and all-cause death without higher MB.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11220, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
| | - Martin Unverdorben
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, NJ 07920, USA
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK
| | - Yukihiro Koretsune
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka 540-0006, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan
| | - Robert A. Crozier
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, NJ 07920, USA
| | - Ladislav Pecen
- Institute of Computer Science, Academy of Sciences of the Czech Republic, 18207 Prague, Czech Republic
| | - Cathy Chen
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, NJ 07920, USA
| | - Amanda P. Borrow
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, NJ 07920, USA
| | - Raffaele De Caterina
- Pisa University Hospital, University of Pisa, 56126 Pisa, Italy
- Fondazione VillaSerena per la Ricerca, 65013 Città Sant’Angelo, Italy
- Correspondence: ; Tel.: +39-050-315-2714; Fax: +39-050-315-2684
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Díez-Villanueva P, Cosín-Sales J, Roldán-Schilling V, Barrios V, Riba-Artés D, Gavín-Sebastián O; RE_BELD Spanish Investigator’s Group. Use of Direct Acting Oral Anticoagulants in Elderly Patients with Atrial Fibrillation: A Multicenter, Cross-Sectional Study in Spain. J Clin Med 2023; 12. [PMID: 36769872 DOI: 10.3390/jcm12031224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have substantially improved anticoagulation. However, data on NOAC use among elderly patients are scarce. We sought to describe NOAC use among elderly AF patients in Spain. We performed a non-interventional, multicenter, multispecialty, cross-sectional study in elderly (≥75 years) AF patients treated with NOACs for stroke prevention. Patients' characteristics by NOAC treatment were compared using standardized differences (SDD). NOAC dosing was classified according to the Spanish summary of products characteristics (SmPC) into appropriate (recommended dose) and inappropriate (under and overdosed). Multivariate logistic regression analyses were used to explore factors associated with inappropriate dosing. 500 patients were included. Mean (SD) age was 81.5 (4.7) years, and 50% were women. Mean (SD) creatinine clearance was 57.4 mL/min (18.8), and 23.6% were frail. Dabigatran treatment totaled 38.4%, rivaroxaban 15.2%, apixaban 33.2%, and edoxaban 13.2%. Almost one-fourth of elderly patients treated with NOACs in Spain were inappropriately dosed (underdosing 14.4% and overdosing 9.6%). Underdosing was significantly associated with weight (OR = 1.03, 95%CI = 1.0-1.1), while higher a EHRA score decreased the risk of underdosing (OR = 0.47, 95%CI = 0.2-1.0). Overdosing was significantly associated with a history of ischemic stroke (OR = 2.95, 95%CI = 1.1-7.7). Addressing incorrect dosing among elderly AF patients is relevant to improve patient outcomes.
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van den Dries CJ, Pajouheshnia R, van den Ham HA, Souverein P, Moons KGM, Hoes AW, Geersing GJ, van Doorn S. Safety of off-label dose reduction of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Br J Clin Pharmacol 2023; 89:751-761. [PMID: 36102068 PMCID: PMC10091743 DOI: 10.1111/bcp.15534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023] Open
Abstract
AIM To investigate the effects of off-label non-vitamin K oral anticoagulant (NOAC) dose reduction compared with on-label standard dosing in atrial fibrillation (AF) patients in routine care. METHODS Population-based cohort study using data from the United Kingdom Clinical Practice Research Datalink, comparing adults with non-valvular AF receiving an off-label reduced NOAC dose to patients receiving an on-label standard dose. Outcomes were ischaemic stroke, major/non-major bleeding and mortality. Inverse probability of treatment weighting and inverse probability of censoring weighting on the propensity score were applied to adjust for confounding and informative censoring. RESULTS Off-label dose reduction occurred in 2466 patients (8.0%), compared with 18 108 (58.5%) on-label standard-dose users. Median age was 80 years (interquartile range [IQR] 73.0-86.0) versus 72 years (IQR 66-78), respectively. Incidence rates were higher in the off-label dose reduction group compared to the on-label standard dose group, for ischaemic stroke (0.94 vs 0.70 per 100 person years), major bleeding (1.48 vs 0.83), non-major bleeding (6.78 vs 6.16) and mortality (10.12 vs 3.72). Adjusted analyses resulted in a hazard ratio of 0.95 (95% confidence interval [CI] 0.57-1.60) for ischaemic stroke, 0.88 (95% CI 0.57-1.35) for major bleeding, 0.81 (95% CI 0.67-0.98) for non-major bleeding and 1.34 (95% CI 1.12-1.61) for mortality. CONCLUSION In this large population-based study, the hazards for ischaemic stroke and major bleeding were low, and similar in AF patients receiving an off-label reduced NOAC dose compared with on-label standard dose users, while non-major bleeding risk appeared to be lower and mortality risk higher. Caution towards prescribing an off-label reduced NOAC dose is therefore required.
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Affiliation(s)
- Carline J van den Dries
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Romin Pajouheshnia
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Yang S, Zhang Y, Chen N, Shi J, Ju W, Chen H, Yang G, Wang Z, Liu H, Jiang X, Cui C, Chen M, Li M. Characteristics, Thrombus Resolution, and Long-Term Outcomes in Patients with Nonvalvular Atrial Fibrillation and Atrial Thrombus. Clin Appl Thromb Hemost 2023; 29:10760296231168097. [PMID: 37079758 PMCID: PMC10126607 DOI: 10.1177/10760296231168097] [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: 04/22/2023] Open
Abstract
To assess the prevalence and management of atrial thrombus in patients with nonvalvular atrial fibrillation (NVAF) and identify the risk factors of the nonresolution of atrial thrombus. This single-center retrospective observational study consecutively enrolled patients with NVAF and atrial thrombus detected using transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CTA) from January 2012 to December 2020. Patients with prior left atrial appendage (LAA) intervention were excluded. The primary endpoint was the presence of atrial thrombus, while the secondary endpoint was the complete resolution of atrial thrombus. The prevalence of atrial thrombus in patients with NVAF was 1.4%. Ninety patients with atrial thrombus (mean age 62.8 ± 11.9 years and 61.1% men) were finally analyzed. Atrial thrombus was in the LAA in 82 (91.1%) patients. During follow up, 60% of the patients showed complete resolution of atrial thrombus. Congestive heart failure (odds ratio [OR]: 8.94; 95% confidence interval [CI]: 1.67-47.80) and a history of ischemic stroke (OR: 8.28; 95% CI: 1.48-46.42) were independently associated with the risk of the nonresolution of atrial thrombus. The presence of atrial thrombus in patients with NVAF who received anticoagulation therapy is non-negligible. Even in anticoagulated patients, TEE or cardiac CTA might still be needed. Congestive heart failure and a history of ischemic stroke are risk factors of the nonresolution of atrial thrombus.
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Affiliation(s)
- Shu Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yanjuan Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ning Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiaojiao Shi
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongwu Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zidun Wang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hailei Liu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaohong Jiang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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11
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Shim CY, Seo J, Kim YJ, Lee SH, De Caterina R, Lee S, Hong GR. Efficacy and safety of edoxaban in patients early after surgical bioprosthetic valve implantation or valve repair: A randomized clinical trial. J Thorac Cardiovasc Surg 2023; 165:58-67.e4. [PMID: 33726903 DOI: 10.1016/j.jtcvs.2021.01.127] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early warfarin anticoagulation is recommended in patients undergoing surgical bioprosthetic valve implantation or valve repair. It is unclear whether non-vitamin K antagonist oral anticoagulants can be a full alternative to warfarin. This study aimed to compare efficacy and safety of edoxaban with warfarin in patients early after surgical bioprosthetic valve implantation or valve repair. METHODS The Explore the Efficacy and Safety of Edoxaban in Patients after Heart Valve Repair or Bioprosthetic Valve Replacement study was a prospective, randomized (1:1), open-label, clinical trial conducted from December 2017 to September 2019. Patients were randomly assigned to receive edoxaban (60 mg or 30 mg once daily) or warfarin for the first 3 months after surgical bioprosthetic valve implantation or valve repair. The primary efficacy outcome was a composite of death, clinical thromboembolic events, or asymptomatic intracardiac thrombosis. The primary safety outcome was the occurrence of major bleeding. RESULTS Of 220 participants, 218 (109 per group) were included in the modified intention-to-treat analysis. The primary efficacy outcome occurred in 4 patients (3.7%) taking warfarin and none taking edoxaban (risk difference, -0.0367; 95% confidence interval, -0.0720 to -0.0014; P < .001 for noninferiority). The primary safety outcome occurred in 1 patient (0.9%) taking warfarin and 3 patients (2.8%) taking edoxaban (risk difference, 0.0183; 95% confidence interval, -0.0172 to 0.0539; P = .013 for noninferiority). CONCLUSIONS Edoxaban is noninferior to warfarin for preventing thromboembolism and is potentially comparable for risk of major bleeding during the first 3 months after surgical bioprosthetic valve implantation or valve repair.
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Affiliation(s)
- Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Raffaele De Caterina
- Cardio-Thoracic and Vascular Department, Pisa University Hospital and University of Pisa, Pisa, Italy
| | - Sak Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Bielecka B, Gorczyca-Głowacka I, Wożakowska-Kapłon B. Nine-Year Trends in Prevention of Thromboembolic Complications in Elderly Patients with Atrial Fibrillation Treated with NOACs. Int J Environ Res Public Health 2022; 19:ijerph191911938. [PMID: 36231248 PMCID: PMC9565553 DOI: 10.3390/ijerph191911938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common disease in elderly patients and thromboembolic complication prophylaxis significantly improves the prognosis in these patients. The study assessed the frequency of individual non-vitamin K antagonist oral anticoagulant (NOAC) use among patients ≥75 years and attempted to identify factors predisposing to their prescription. METHODS The data of patients with non-valvular AF hospitalized in the reference cardiology center between 2011 and 2019 were analyzed. RESULTS Out of 1443 analyzed patients, 329 (22.8%) received apixaban, 618 (42.8%) dabigatran, and 496 (34.4%) rivaroxaban. The entire population mean age was 82.3 ± 5 years, and 57.9% were females. Independent predictors of apixaban use were age, and bleeding history. Hospitalization for the implantation/reimplantation of a cardiac implantable electronic device (CIED) reduced the chance of apixaban use. Hypertension was a predictor of dabigatran prescription. The chance of using dabigatran decreased with age. Hypertension and bleeding history decreased the chance of rivaroxaban application. CONCLUSIONS In hospitalized AF patients ≥75 years, dabigatran was the most frequently used NOAC. Age, comorbidities and bleeding risk determined the selection of individual NOACs.
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Affiliation(s)
- Bernadetta Bielecka
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Iwona Gorczyca-Głowacka
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland
- Correspondence: ; Tel.: +48-604-407-956
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
- Collegium Medicum, Jan Kochanowski University, 25-369 Kielce, Poland
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13
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Karwowski J, Rekosz J, Mączyńska-Mazuruk R, Wiktorska A, Wrzosek K, Loska W, Szmarowska K, Solecki M, Sumińska-Syska J, Dłużniewski M. Left atrial appendage thrombus in patients with atrial fibrillation who underwent oral anticoagulation. Cardiol J 2022:VM/OJS/J/88275. [PMID: 35703043 DOI: 10.5603/cj.a2022.0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/07/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Electric cardioversion of atrial fibrillation (AF) is associated with an increased risk of embolism, with embolic material existing in the heart cavities. The initiation of oral anticoagulation therapy reduces the risk of thromboembolic events. The aims of this study were to evaluate the prevalence of left atrial appendage (LAA) thrombi in non-valvular AF, to compare vitamin K antagonists (VKAs) and non-vitamin K oral anticoagulants (NOACs) with respect to thrombus prevalence, and to evaluate the rate of LAA thrombus persistence on repeat transesophageal echocardiography (TEE) after treatment change. METHODS We enrolled 160 consecutive AF patients who presented with an AF duration > 48 h and had undergone TEE before cardioversion. RESULTS Left atrial appendage thrombus was observed in 12 (7.5%) patients, and spontaneous echo contrast 4 was observed in 19 (11.8%) patients; the incidence was similar between the NOAC and VKA groups (8.9% vs. 3.6% and 12.4% vs. 18.5 %, respectively). Among patients on NOAC, thrombus prevalence was detected in 8.4% of users of rivaroxaban, 8% of users of dabigatran, and 12.5% of users of apixaban. CONCLUSIONS The LAA thrombus developed in 7.5% of patients despite anticoagulation therapy, demonstrating similar prevalence rates among patients either on NOAC or VKA. Lower mean LAA flow velocity and a history of vascular disease were independent predictors of embolic material in the LAA. It seems that in the case of embolic materials in LAA under NOAC treatment, switching to VKA provides additional clinical benefit to the patients.
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Affiliation(s)
- Jarosław Karwowski
- Department of Heart Diseases, Medical Center of Postgraduate Education, Warsaw, Poland.
| | - Jerzy Rekosz
- 2nd Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | | | - Anna Wiktorska
- 2nd Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | - Karol Wrzosek
- Department of Heart Diseases, Medical Center of Postgraduate Education, Warsaw, Poland
| | - Wioletta Loska
- 2nd Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | | | - Mateusz Solecki
- 2nd Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | - Joanna Sumińska-Syska
- Department of Heart Diseases, Medical Center of Postgraduate Education, Warsaw, Poland
| | - Mirosław Dłużniewski
- Department of Heart Diseases, Medical Center of Postgraduate Education, Warsaw, Poland
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14
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Tsai SHL, Hu CW, Shao SC, Tischler EH, Obisesan OH, Vervoort D, Chen WC, Hu JR, Kuo LT. Comparative Risks of Fracture Among Direct Oral Anticoagulants and Warfarin: A Systematic Review and Network Meta-Analysis. Front Cardiovasc Med 2022; 9:896952. [PMID: 35677694 PMCID: PMC9168033 DOI: 10.3389/fcvm.2022.896952] [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: 03/15/2022] [Accepted: 04/21/2022] [Indexed: 12/02/2022] Open
Abstract
Importance Previous studies have shown the effectiveness and safety of direct oral anticoagulants (DOACs), including lower fracture risks, compared to warfarin. However, direct or indirect comparisons between different DOACs are scarce in the literature. Objective This study aims to compare fracture risks among different DOACs and warfarin, including apixaban, rivaroxaban, dabigatran, and edoxaban, in patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). Methods We searched PubMed/MEDLINE, Embase, Cochrane CENTRAL, and Web of Science for randomized controlled trials and cohort studies comparing the fracture risks among patients who used warfarin or DOACs, up to March 2021. Two authors extracted data and appraised the risk of bias of included studies. The primary outcome was fracture risk. We performed pairwise meta-analyses to compare differences between medications and network meta-analyses using frequentist random-effects models to compare through indirect evidence. We used surface under the cumulative ranking curve (SUCRA) and mean ranks to determine the probability of a DOAC ranking best in terms of fracture risk. Results Thirty-one studies were included in the final analysis. Twenty-four randomized controlled trials and seven cohort studies with 455,343 patients were included in the systematic review and network meta-analysis. Compared to warfarin, the risk of any fractures was lowest with apixaban [relative risk (RR) = 0.59; 95% confidence interval (CI): 0.48-0.73], followed by rivaroxaban (RR: 0.72; 95% CI: 0.60-0.86), edoxaban (RR: 0.88; 95% CI: 0.62-1.23), and dabigatran (RR = 0.90; 95% CI: 0.75-1.07). No substantial inconsistency between direct and indirect evidence was detected for all outcomes. Conclusions All DOACs were safer than warfarin concerning the risk of fracture; however, apixaban had the lowest relative risk of fracture within the class of DOACs. Further head-to-head prospective studies should confirm the comparative safety profiles of DOACs regarding fractures.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Department of Orthopaedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Hu
- Department of Orthopaedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
| | - Eric H. Tischler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York, New York, NY, United States
| | - Olufunmilayo H. Obisesan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dominique Vervoort
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Wei Cheng Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiun-Ruey Hu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Liang-Tseng Kuo
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Sports Medicine, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
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15
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Gorczyca-Głowacka I, Bielecka B, Wałek P, Chrapek M, Ciba-Stemplewska A, Jelonek O, Kot A, Czyżyk A, Pióro M, Major A, Wożakowska-Kapłon B. Temporal Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients between 2004 and 2019. Int J Environ Res Public Health 2022; 19:5584. [PMID: 35564979 DOI: 10.3390/ijerph19095584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the recent years, antithrombotic prophylaxis in patients with atrial fibrillation (AF) has changed significantly. The main aim of this study is to assess the temporal trends of antithrombotic therapy and identify factors predisposing oral anticoagulant (OAC) use in stroke prevention in AF patients. METHODS The present study is a retrospective, observational, single-center study, which includes consecutively hospitalized patients in the reference cardiology center from January 2004 to December 2019. RESULTS A total of 9656 patients (43.7% female, mean age 71.2 years) with AF between 2004-2019 are included. Among the total study population, in most of the patients (81.1%), OAC therapy was used, antiplatelet (APT) therapy was prescribed for 13.5% patients, heparins for 2.1% patients and 3.3% of patients did not receive any stroke prevention. OAC prescription significantly increased from 61.6% in 2004 to 97.4% in 2019. The independent predictors of OAC prescription were: the period of hospitalization, non-paroxysmal AF, age, hypertension, diabetes mellitus, previous thromboembolism, hospitalization due to electrical cardioversion, ablation or AF without any procedures. CONCLUSIONS In hospitalized patients with AF, during sixteen years of the study period, a significant increase in OAC use and a decrease in APT use were noted. Factors other than these included in the CHA2DS2-VASc score were independent predictors of OAC use.
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16
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Yang Q, Chen X, Zhai J, Dang Y. Comparison of major bleeding events of uninterrupted non-vitamin K antagonist oral anticoagulants versus uninterrupted vitamin K antagonist during catheter ablation of atrial fibrillation: a meta-analysis of randomised controlled trials. Acta Cardiol 2022; 77:257-263. [PMID: 33871328 DOI: 10.1080/00015385.2021.1915603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous meta-analyses comparing major bleeding of uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) versus uninterrupted vitamin K antagonist (VKA) during catheter ablation (CA) of atrial fibrillation (AF) had no consensus. This meta-analysis was performed to comprehensively evaluate the risk of major bleeding events of these two anticoagulant strategies. METHODS We searched online databases for randomised controlled trials that compared major bleeding events of uninterrupted NOACs and VKA during CA of AF. A fixed-effect model was used if P-value was > 0.10 and I2 was < 50%, otherwise a random- effect model was used. RESULTS Six studies including 2392 patients were included in the analysis. The incidence of major bleeding was lower in the NOACs group than in the VKA group (OR = 0.56, 95% CI = 0.34 - 0.93, I2 = 38%, p = 0.15). Subgroup analyses showed that the incidence of severe puncture site complications was lower in the NOACs group than in the VKA group (OR = 0.53, 95% CI = 0.30 - 0.96, I2 = 16%, p = 0.32). But the incidence of cardiac tamponade (OR = 0.53, 95% CI = 0.23 - 1.26, I2 = 0%, p = 0.46), intracranial (OR = 0.25, 95% CI = 0.03 - 2.23, I2 = 0%, p = 0.82) and gastrointestinal bleeding (OR = 0.98, 95% CI = 0.18 - 5.39, I2 = 0%, p = 0.43) had no statistically differences between the two groups. CONCLUSION This meta-analysis suggests that compared to uninterrupted VKA, uninterrupted NOACs are superior in major bleeding during CA of AF, but this superiority existed only in the aspect of severe puncture site complications.
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Affiliation(s)
- Qian Yang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Xuefeng Chen
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Jianlong Zhai
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
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17
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Shin JY, Choe JC, Ahn JH, Lee HW, Oh JH, Choi JH, Lee HC, Cha KS, Hong TJ, Park JS. Clinical outcomes of patients who received a lower dose of non-vitamin K antagonist oral anticoagulants for the medical management of acute pulmonary embolism. Acta Cardiol 2022; 77:122-129. [PMID: 33678134 DOI: 10.1080/00015385.2021.1878424] [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: 10/22/2022]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are used to treat acute pulmonary embolism (PE). However, lower NOAC doses are often prescribed because of increased risk of NOAC complications. OBJECTIVE We sought to determine the incidence and clinical outcomes of patients with acute provoked PE receiving lower NOAC doses. METHOD 140 patients with acute PE with only NOACs used for medical management was enrolled and were followed up for 6 months. The composite primary endpoint was all-cause death, venous thromboembolism recurrence, and residual thrombus on follow-up computed tomography. RESULTS Of the 140 patients, 99 (70.7%) received the standard NOAC dose and 41 (29.3%) received the lower dose. The crude incidences of the primary endpoint were 19 (19.2%) in patients who received the standard NOAC dose and 13 (31.7%) in those who received the lower dose. Compared with patients who received the standard dose, those who received the lower dose had no differences in the rate of primary endpoints (hazard ratio 1.140, 95% confidence interval 0.536-2.423, p = 0.733) during a median of 185 days. CONCLUSION We found that up to 30% of patients received the lower dose of NOACs for acute PE in clinical practice. Clinical outcomes with appropriate underdoing of NOAC treated in acute PE might not increase compared to the standard NOAC doses.
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Affiliation(s)
- Ji Yeon Shin
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jeong Cheon Choe
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jin Hee Ahn
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Hye Won Lee
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jun-Hyok Oh
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jung Hyun Choi
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Han Cheol Lee
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Kwang Soo Cha
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Taek Jong Hong
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jin Sup Park
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea
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Deitelzweig S, Bergrath E, di Fusco M, Kang A, Savone M, Cappelleri JC, Russ C, Betts M, Cichewicz A, Schaible K, Tarpey J, Fahrbach K. Real-world evidence comparing oral anticoagulants in non-valvular atrial fibrillation: a systematic review and network meta-analysis. Future Cardiol 2022; 18:393-405. [PMID: 35360925 DOI: 10.2217/fca-2021-0120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare real-world effectiveness/safety of non-vitamin K antagonist oral anticoagulants and vitamin K antagonists among patients with non-valvular atrial fibrillation. Materials & methods: A systematic review of electronic databases yielded 7661 citations published from January 2013 to January 2020. Fifty-five studies were included in Bayesian network meta-analyses of hazard ratios. Results & conclusion: In comparison with vitamin K antagonists, apixaban, dabigatran and rivaroxaban were associated with a reduced risk of stroke or systemic embolism, ischemic stroke, intracranial hemorrhage and all-cause mortality. Apixaban, dabigatran and edoxaban, but not rivaroxaban, were associated with a reduced risk of major bleeding. This study confirmed the effectiveness and safety of non-vitamin K antagonist oral anticoagulants for the treatment of non-valvular atrial fibrillation in real-world settings, consistent with clinical trial evidence.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Health System, Department of Hospital Medicine, New Orleans, LA 70121, USA
| | - Evelien Bergrath
- Regeneron Pharmaceuticals, Inc., Health Economics and Outcomes Research, Tarrytown, NY 10591, USA
| | - Manuela di Fusco
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Amiee Kang
- Bristol Myers Squibb Company, Health Economics and Outcomes Research, Lawrenceville, NJ 08648, USA
| | - Mirko Savone
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Joseph C Cappelleri
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Cristina Russ
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Marissa Betts
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Allie Cichewicz
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Kassandra Schaible
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Jialu Tarpey
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Kyle Fahrbach
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
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Patti G, Parato VM, Cavallari I, Calabrò P, Russo V, Renda G, Gragnano F, Pengo V, D'Onofrio A, Grimaldi M, De Caterina R. A Prospective Study to Evaluate the Effectiveness of Edoxaban for the Resolution of Left Atrial Thrombosis in Patients with Atrial Fibrillation. J Clin Med 2022; 11. [PMID: 35407553 DOI: 10.3390/jcm11071945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Available evidence on left atrial (LA) thrombus dissolution in patients with atrial fibrillation (AF) largely refers to the use of vitamin K antagonist oral anticoagulants (VKAs), showing >50% thrombus resolution over a 4-week to 12-month treatment period. Available data on non-vitamin K antagonist anticoagulants (NOACs) in this setting are limited and derive from isolated case reports or observational small-sized investigations with dabigatran, rivaroxaban or apixaban. The aim of this study was to investigate the extent of thrombus resolution with edoxaban therapy in patients with AF and LA thrombosis. We conducted a prospective, observational, open-label pilot study in seven Italian institutions. We included a total of 25 patients with non-valvular AF and LA (or left atrial appendage (LAA)) thrombosis, documented by transesophageal echocardiography (TEE). All patients received edoxaban OD treatment (n = 23 on 60 mg daily; n = 2 on 30 mg daily) and underwent TEE examination after 4 weeks. The primary endpoint was the percentage of patients with complete thrombus resolution by TEE imaging at 4 weeks. The mean age of the study population was 68.3 ± 10.8 years with a female population of 16%. AF was permanent in all cases, with a mean arrhythmia duration of 4.3 ± 1.7 years. CHA2DS2-VASc and HAS-BLED scores were 3.2 ± 1.5 and 1.9 ± 1.1, respectively. We were able to demonstrate a complete thrombus resolution in 14 patients (56%) at 4 weeks. In patients with residual atrial thrombosis (n = 11), we observed a 15.4 ± 14.9% reduction in the thrombus area from baseline. As compared with patients without thrombus dissolution, those with thrombus resolution had a numerically lower-indexed LA diameter (27.9 ± 9.3 vs 34.8 ± 16.1 mm/m2), a smaller maximum thrombus area at baseline (45.5 ± 44.6 vs 63.9 ± 43.5 mm2), a higher left ventricular ejection fraction (47.4 ± 21.0% vs 38.4 ± 20.6%) and higher maximum LAA flow velocities (26.3 ± 15.2 vs 19.3 ± 10.0 cm/s). Figures on the percentage of thrombus resolution in this study are comparable to those reported in the literature for the other OACs. We conclude that, in patients with AF, the use of edoxaban is associated with a >50% resolution of atrial thrombus at 4 weeks, similar to studies using VKAs and the other NOACs (ClinicalTrials.gov identifier number: NCT034899395).
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20
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Mazur P, Kopytek M, Ząbczyk M, Undas A, Natorska J. Towards Personalized Therapy of Aortic Stenosis. J Pers Med 2021; 11:1292. [PMID: 34945764 DOI: 10.3390/jpm11121292] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 12/18/2022] Open
Abstract
Calcific aortic stenosis (CAS) is the most common cause of acquired valvular heart disease in adults with no available pharmacological treatment to inhibit the disease progression to date. This review provides an up-to-date overview of current knowledge of molecular mechanisms underlying CAS pathobiology and the related treatment pathways. Particular attention is paid to current randomized trials investigating medical treatment of CAS, including strategies based on lipid-lowering and antihypertensive therapies, phosphate and calcium metabolism, and novel therapeutic targets such as valvular oxidative stress, coagulation proteins, matrix metalloproteinases, and accumulation of advanced glycation end products.
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21
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Luijkx J, Winkler P, van 't Hof A. Clopidogrel or ticagrelor alongside dabigatran in acute coronary syndrome and indication for NOAC: a study rationale. Future Cardiol 2021; 18:265-274. [PMID: 34821510 DOI: 10.2217/fca-2021-0085] [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
The combination of oral anticoagulants with platelet inhibitors has been widely investigated in patients with coronary stenting and concomitant atrial fibrillation. In these patients, default therapy after percutaneous coronary intervention in acute coronary syndrome is clopidogrel plus non-vitamin K antagonist oral anticoagulant, omitting aspirin. However, in view of the high thromboembolic risk associated with acute coronary syndrome and the number of poor metabolizers for clopidogrel, investigation of alternative P2Y12-inhibitors is mandatory. This prospective, multicenter, open-label, registry-based, randomized, controlled trial aims to show the non-inferiority of dabigatran plus ticagrelor versus dabigatran plus clopidogrel in patients on chronic anticoagulants who undergo percutaneous coronary intervention in acute coronary syndrome. The primary end point is major bleeding as defined by the Bleeding Academic Research Consortium bleeding definition. Trial registration number: NL75644.096.21.
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Affiliation(s)
- Jasper Luijkx
- Department of Cardiology, Zuyderland Medical Center, 6419 PC Heerlen, The Netherlands
| | - Patty Winkler
- Department of Cardiology, Zuyderland Medical Center, 6419 PC Heerlen, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, 6229 HX, Maastricht, The Netherlands
| | - Arnoud van 't Hof
- Department of Cardiology, Zuyderland Medical Center, 6419 PC Heerlen, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, 6229 HX, Maastricht, The Netherlands
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22
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Jin H, Zhu K, Wang L, Zhi H. A network meta-analysis of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and diabetes mellitus. Acta Cardiol 2021; 76:960-969. [PMID: 33432890 DOI: 10.1080/00015385.2020.1869671] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE With the aim of recommending proper anticoagulation for patients with atrial fibrillation (AF) and diabetes mellitus, we performed the network meta-analysis comparing the non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in terms of efficacy (stroke or systemic embolism) and safety (major bleeding) outcome. METHODS A systematic search of PubMed, EMBASE, Web of Science and Cochrane Library was performed with the items "dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, AF and diabetes mellitus". On the basis of R (version 3.5.1, R Foundation for Statistical Computing) and JAGS (version 4.3.0) to perform the network meta-analysis, our work was also conducted with the help of NetMetaXL (version1.6.1) and winBUGS (version1.4.3) to obtain the cumulative ranking curve (SUCRA) of treatments. RESULTS With respect to the most effective drug for preventing systemic embolism or stroke, there was a high probability that dabigatran150 (SUCRA 0.88) would ranked first, followed by apixaban (SUCRA 0.63), dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.51). In comparison, probability of ranking the safest drug for preventing major bleeding was edoxaban (SUCRA 0.94), followed by dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.52). CONCLUSION In patients suffering from AF and diabetes, dabigatran 110 mg (bid) was more likely to become the choice for its performance on preventing systemic embolism or stroke and major bleeding, followed by rivaroxaban 20 mg (QD).
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Affiliation(s)
- Hao Jin
- School of Medicine, Southeast University, Nanjing, China
| | - Kongbo Zhu
- Department of Cardiology, Affiliated ZhongDa Hospital of Southeast University (HZ), Nanjing, China
| | - Lina Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University, Nanjing, China
| | - Hong Zhi
- Department of Cardiology, Affiliated ZhongDa Hospital of Southeast University (HZ), Nanjing, China
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23
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Cepas-Guillen PL, Flores-Umanzor E, Regueiro A, Brugaletta S, Ibañez C, Sanchis L, Sitges M, Rodés-Cabau J, Sabaté M, Freixa X. Low Dose of Direct Oral Anticoagulants after Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 2021; 8:jcdd8110142. [PMID: 34821695 PMCID: PMC8623304 DOI: 10.3390/jcdd8110142] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 08/30/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal antithrombotic strategy following left atrial appendage occlusion (LAAO) is not yet clearly established. Low-dose non-vitamin K antagonist oral anticoagulants (NOAC) might represent a valid alternative, but data regarding their usage is scarce. The aim of this study was to examine the efficacy and safety of low-dose NOAC compared to single (SAPT) or dual antiplatelet therapies (DAPT) after LAAO. We included consecutive patients with non-valvular atrial fibrillation who underwent LAAO and received low-dose apixaban, SAPT, or DAPT at discharge. The primary objective of this study included an efficacy endpoint (thromboembolic events and device related thrombosis (DRT)) and a safety endpoint (incidence of major bleeding) within the first three months after LAAO. A total of 139 patients were included. This group involved SAPT in 26 (18%), DAPT in 73 (53%), and apixaban in 40 (29%) patients. Follow-up at three-months showed no significant differences in the primary efficacy endpoint (2 (8%) SAPT, 3 (4%) DAPT and 0 (0%) apixaban; p value = 0.25). In contrast, the primary safety endpoint occurred more frequently in DAPT patients (7 (10%) DAPT, 0 (0%), SAPT and 0 with apixaban; p value = 0.03). Combining both efficacy and safety outcomes, low dose apixaban had a lower rate of events (2 (8%) with SAPT, 9 (12%) with DAPT and 0 (0%) with apixaban; p = 0.046). Low-dose apixaban after LAAO may be a valid alternative to DAPT and SAPT as depicted by the reduction in the occurrence of major bleedings and combined DRT/major bleedings respectively. Randomized data will be necessary to validate this strategy.
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Affiliation(s)
- Pedro Luis Cepas-Guillen
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Eduardo Flores-Umanzor
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Ander Regueiro
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Salvatore Brugaletta
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Cristina Ibañez
- Anesthesiology Department, Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Laura Sanchis
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Marta Sitges
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Josep Rodés-Cabau
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Quebec Heart and Lung Institute, Quebec City, QC G1V 4G5, Canada
| | - Manel Sabaté
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Correspondence: ; Tel.: +34-932275519
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Szpotowicz A, Gorczyca I, Jelonek O, Uziębło-Życzkowska B, Maciorowska M, Wójcik M, Błaszczyk R, Kapłon-Cieślicka A, Gawałko M, Budnik M, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Bednarski J, Bakuła-Ostalska E, Tomaszuk-Kazberuk A, Szyszkowska A, Wełnicki M, Mamcarz A, Krzciuk M, Wożakowska-Kapłon B. Why Did All Patients with Atrial Fibrillation and High Risk of Stroke Not Receive Oral Anticoagulants? Results of the Polish Atrial Fibrillation (POL-AF) Registry. J Clin Med 2021; 10:4611. [PMID: 34640629 DOI: 10.3390/jcm10194611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Most atrial fibrillation (AF) patients are at high risk of thromboembolic, and the use of oral anticoagulants (OACs) is advised in such cases. The aim of the study was to evaluate the frequency at which OACs were used in patients with AF and high risk thromboembolic complications, and identify factors that result in OACs not being used in the researched group of patients. Methods: The prospective, multicenter and non-interventional POL-AF registry is a study that includes AF patients from ten Polish cardiology centers. They were consecutively hospitalized between January and December of 2019. All the patients in the study were of high stroke risk. Results: A total of 3614 patients with AF and high stroke risk were included. Among the total study population, 91.5% received OAC therapy; antiplatelet therapy was prescribed for 3.7% of patients, heparin for 2.7%, and 2.1% of patients did not receive any stroke prevention therapy. Independent predictors of no OAC prescription were intracranial bleeding (OR 0.15, 95%CI 0.07–0.35, p < 0.001), gastrointestinal bleeding (OR 0.25, 95%CI 0.17–0.37, p < 0.001), cancer (OR 0.37, 95%CI 0.25–0.55, p < 0.001), hospitalization due to acute coronary syndrome (OR 0.48, 95%CI 0.33–0.69, p < 0.001), and anemia (OR 0.62, 95%CI 0.48–0.81, p < 0.001). Conclusions: Most AF patients with a high thromboembolic risk received OACs. The factors predisposing a lack of OAC use in these patients were conditions that significantly increased the risk of bleeding complications.
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Park S, Je NK. Factors Influencing the Selection of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients With Non-Valvular Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2021; 26:656-664. [PMID: 34558337 DOI: 10.1177/10742484211049919] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Major atrial fibrillation (AF) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, except in rare clinical circumstances based on 4 randomized controlled trials comparing each NOAC with warfarin. We aimed to investigate the current NOAC prescription behaviors in alignment with the recent clinical evidence available. METHOD We conducted a cross-sectional analysis of NOAC-using patients with non-valvular atrial fibrillation (NVAF) who were aged ≥65 years on the index date (July 1, 2018) based on nationwide claims data. The types of NOACs being taken were analyzed using chi-squared tests, and factors influencing NOAC selection were identified using multinomial logistic regression analysis. RESULTS A total of 6,061 patients were included. Among the 4 NOACs, rivaroxaban was the most used NOAC. Patients aged ≥75 years (odds ratio [OR] = 1.270, confidence interval [CI] = 1.089-1.450) and women (OR = 1.148, CI = 1.011-1.284) were more likely to use apixaban relative to rivaroxaban. Patients with prior stroke/transient ischemic attack/thromboembolism had higher odds of using dabigatran (OR = 1.508, CI = 1.312-1.704) and apixaban (OR = 1.186, CI = 1.026-1.346). Patients with renal disease had higher odds of using apixaban (OR = 1.466, 95% CI = 1.238-1.693). These findings are consistent with the efficacy and safety profiles reported in pivotal trials and observational studies comparing individual NOACs. CONCLUSION Among the 4 NOACs, rivaroxaban was the most commonly used NOAC. Apixaban was preferred for patients aged ≥75 years, females, and patients with renal disease.
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Affiliation(s)
- Susin Park
- College of Pharmacy, 34996Pusan National University, Busan, Republic of Korea
| | - Nam Kyung Je
- College of Pharmacy, 34996Pusan National University, Busan, Republic of Korea
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26
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Lin YS, Kuan FC, Chao TF, Wu M, Chen SW, Chen MC, Chung CM, Chu PH, Lip GYH, Wu VCC. Mortality associated with the use of non-vitamin K antagonist oral anticoagulants in cancer patients: Dabigatran versus rivaroxaban. Cancer Med 2021; 10:7079-7088. [PMID: 34464520 PMCID: PMC8525135 DOI: 10.1002/cam4.4241] [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] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
Objective This study assesses the mortality outcomes of non‐vitamin K antagonist oral anticoagulants (NOACs) in cancer patients with venous thromboembolism (VTE) and atrial fibrillation (AF). Methods Medical records of cancer patients receiving NOACs for VTE or AF between January 1, 2011, and December 31, 2016, were retrieved from Taiwan's National Health Institute Research Database. NOACs were compared using the inverse probability of treatment weighting (IPTW) method. The primary outcome was cancer‐related death. Secondary outcomes were all‐cause mortality, major bleeding, and gastrointestinal (GI) bleeding. Results Among 202,754 patients who received anticoagulants, 3591 patients (dabigatran: 907; rivaroxaban: 2684) with active cancers were studied. Patients who received dabigatran were associated with lower risks of cancer‐related death at one year (HR = 0.71, 95% CI = 0.54–0.93) and at the end of follow‐ups (HR = 0.79, 95% CI = 0.64–0.98) compared with rivaroxaban. Patients who received dabigatran were also associated with lower risks of all‐cause mortality (HR = 0.81, 95% CI = 0.67–0.97), major bleeding (HR = 0.64, 95% CI = 0.47–0.88), and GI bleeding (HR = 0.57, 95% CI = 0.39–0.84) at the end of follow‐ups compared with rivaroxaban. Conclusion Compared with rivaroxaban, the use of dabigatran may be associated with a lower risk of cancer‐related death and all‐cause mortality.
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Affiliation(s)
- Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Feng-Che Kuan
- Department of Hematology and Oncology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Michael Wu
- Divison of Cardiovascular Medicine, Miriam and Rhode Island Hospital, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Chang-Ming Chung
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Victor Chien-Chia Wu
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
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Huang S, Safavi-Naeini P, Rasekh A. Medical and Device Therapy for Stroke Prevention in Patients With Atrial Fibrillation. Tex Heart Inst J 2021; 48:472193. [PMID: 34669950 DOI: 10.14503/thij-21-7549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sophia Huang
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | | | - Abdi Rasekh
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
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28
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Wu X, Hu L, Liu J, Gu Q. Association of Direct Oral Anticoagulants vs. Vitamin K Antagonists With Fractures in Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:713187. [PMID: 34368263 PMCID: PMC8339256 DOI: 10.3389/fcvm.2021.713187] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Current evidence regarding the application of direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs) on the fracture risk is inconsistent. Therefore, we conducted a meta-analysis to evaluate the fracture risk of DOACs vs. VKAs in patients with atrial fibrillation (AF). Methods: The PubMed and Embase databases were systematically searched until June 2021 for all the studies that reported oral anticoagulants in AF patients. The random-effect model with an inverse variance method was selected to pool the risk ratios (RRs) and 95% confidence intervals (CIs). Results: A total of 10 studies were included in this meta-analysis. Among AF patients receiving anticoagulants, DOAC users showed a reduced risk of any fracture compared to those with VKAs (RR = 0.80; 95% CI: 0.70–0.91) regardless of gender [males (RR = 0.79; 95% CI: 0.67–0.92) and females (RR = 0.71; 95% CI: 0.57–0.89)]. Apixaban (RR = 0.75; 95% CI: 0.60–0.92) and rivaroxaban (RR = 0.73; 95% CI: 0.61–0.88), but not dabigatran and edoxaban, were associated with a decreased risk of any fracture compared with VKAs. DOAC users had decreased risks of osteoporotic fractures (RR = 0.63; 95% CI: 0.47–0.84) and hip/pelvic fractures (RR = 0.88; 95% CI: 0.79–0.97) compared to those treated with VKAs. Conclusions: Our meta-analysis suggested that the use of DOACs was associated with a reduced risk of any fracture compared with VKAs. Further studies should confirm our findings.
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Affiliation(s)
- Xiaojuan Wu
- Department of Gastroenterology, Ganzhou People's Hospital, Ganzhou, China
| | - Linyan Hu
- Hengshui Health School, Hengshui, China
| | - Jinjin Liu
- Department of Oncology, Ganzhou People's Hospital, Ganzhou, China
| | - Qiuping Gu
- Department of Gastroenterology, Ganzhou People's Hospital, Ganzhou, China
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29
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Lucà F, Giubilato S, Di Fusco SA, Piccioni L, Rao CM, Iorio A, Cipolletta L, D’Elia E, Gelsomino S, Rossini R, Colivicchi F, Gulizia MM. Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account. J Clin Med 2021; 10:jcm10153212. [PMID: 34361996 PMCID: PMC8348761 DOI: 10.3390/jcm10153212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/15/2022] Open
Abstract
The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.
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Affiliation(s)
- Fabiana Lucà
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
- Correspondence: (F.L.); (L.P.)
| | - Simona Giubilato
- Division of Cardiology, Cannizzaro Hospital, 95121 Catania, Italy;
| | | | - Laura Piccioni
- Division of Cardiology, Cardiovascular Departiment, Civile Giuseppe Mazzini Hospital, 64100 Teramo, Italy
- Correspondence: (F.L.); (L.P.)
| | - Carmelo Massimiliano Rao
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Annamaria Iorio
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Laura Cipolletta
- Division of Cardiology, Department of Cardiovascular Sciences, Ancona University Hospital, 60126 Ancona, Italy;
| | - Emilia D’Elia
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6202 AZ Maastricht, The Netherlands;
| | - Roberta Rossini
- Division of Cardiology, S. Croce e Carle Hospital, 12100 Cuneo, Italy;
| | - Furio Colivicchi
- Division of Cardiology, S. Filippo Neri Hospital, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, 95123 Catania, Italy;
- Heart Care Foundation, 50121 Florence, Italy
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30
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Albertsen IE, Jensen M, Abdelgawwad K, Søgaard M, Larsen TB, Nielsen PB. Characteristics of patients receiving extended treatment after incident venous thromboembolism. Basic Clin Pharmacol Toxicol 2021; 129:332-342. [PMID: 34245119 DOI: 10.1111/bcpt.13637] [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] [Received: 04/23/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/20/2022]
Abstract
Given high recurrence risk after venous thromboembolism (VTE), guidelines recommend extended dose rivaroxaban (10 mg OD) or apixaban (2.5 mg BID) to be considered after 6 months of initial treatment. This study aimed to provide insight into clinical practice regarding the use of extended preventive treatment and to describe duration of the initial treatment. Linkage of nationwide health registers identified all in- and outpatients with VTE from April 2017 through 2018. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated adjusting for other VTE-related factors. The study included 6030 patients with VTE. Among rivaroxaban users, 2.2% (n = 113) received the extended 10-mg dose after mean 9.4 (SD 3.1) months of standard treatment. For apixaban, 4.7% (n = 40) received extended 2.5-mg dose after mean 8.0 months (SD 3.9). After adjustments, incident pulmonary embolism (HR 1.81 95% CI 1.12;2.91) and trauma/fracture (HR 1.42 95% CI 0.46;4.43) were associated with switching to extended dose, whereas patients with unprovoked VTE were less likely to receive the extended dose (HR 0.68 95% CI 0.30;1.55). Less than 3% of patients with incident VTE received extended treatment after initial standard treatment. Even though international guidelines suggest that the risk-benefit balance is in favour of extended VTE treatment, this was yet to be translated into clinical practice as of 2018. Studies using contemporary data are warranted to investigate routine clinical practice of extended treatment for VTE recurrence.
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Affiliation(s)
- Ida Ehlers Albertsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | | | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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31
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Natorska J, Kopytek M, Undas A. Aortic valvular stenosis: Novel therapeutic strategies. Eur J Clin Invest 2021; 51:e13527. [PMID: 33621361 DOI: 10.1111/eci.13527] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Aortic stenosis (AS) prevalence is estimated to reach 4.5 million cases worldwide by the year 2030. AS is a progressive disease without a pharmacological treatment. In the current review, we aimed to investigate novel therapeutic approaches for non-surgical AS treatment, at least in patients with mild-to-moderate AS. MATERIALS AND METHODS The most recent and relevant papers concerned with novel molecular pathways that have potential as therapeutic targets in AS were selected from searches of PubMed and Web of Science up to February 2021. RESULTS Growing evidence indicates that therapies using proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, simvastatin/ezetimibe combination, cholesteryl ester transfer protein inhibitors or antisense oligonucleotides targeting apolipoprotein(a) reduce the risk of AS progression. It has been shown that enhanced valvular lipid oxidation may drive AS development by leading to the activation of valvular interstitial cells (VICs), the most abundant valvular cells having a major contribution to valve calcification. Since VICs are able to release pro-inflammatory cytokines, clotting factors and proteins involved in calcification, strategies targeting these cell activations seem promising as therapeutic interventions. Recently, non-vitamin K antagonist oral anticoagulants (NOACs) have been shown to inhibit activation of VICs. CONCLUSION Several novel molecular pathways of AS development have been identified over the past few years. Therapies using PCSK9 inhibitors, simvastatin/ezetimibe combination, lipoprotein(a)-lowering therapy are highly promising candidates as therapeutics in the prevention of mild AS progression, while preclinical studies show that NOACs may inhibit valvular inflammation and coagulation activation and slower the rate of AS progression.
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Affiliation(s)
- Joanna Natorska
- John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Kopytek
- John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
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Boriani G, De Caterina R, Manu MC, Souza J, Pecen L, Kirchhof P. Impact of Weight on Clinical Outcomes of Edoxaban Therapy in Atrial Fibrillation Patients Included in the ETNA-AF-Europe Registry. J Clin Med 2021; 10:jcm10132879. [PMID: 34209595 PMCID: PMC8269173 DOI: 10.3390/jcm10132879] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/11/2021] [Accepted: 06/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Extremes of body weight may alter exposure to non-vitamin K antagonist oral anticoagulants and thereby impact clinical outcomes. This ETNA-AF-Europe sub-analysis assessed 1-year outcomes in routine care patients with atrial fibrillation across a range of body weight groups treated with edoxaban. Methods: ETNA-AF-Europe is a multinational, multicentre, observational study conducted in 825 sites in 10 European countries. Overall, 1310, 5565, 4346 and 1446 enrolled patients were categorised into ≤60 kg, >60–≤80 kg (reference weight group), >80–≤100 kg and >100 kg groups. Results: Patients weighing ≤60 kg were older, more frail and had a higher CHA2DS2-VASc score vs. the other weight groups. The rates of stroke/systemic embolism, major bleeding and ICH were low at 1 year (0.82, 1.05 and 0.24%/year), with no significant differences among weight groups. The annualised event rates of all-cause death were 3.50%/year in the overall population. After adjustment for eGFR and CHA2DS2-VASc score, the risk of all-cause death was significantly higher in extreme weight groups vs. the reference group. Conclusions: Low rates of stroke and bleeding were reported with edoxaban, independent of weight. The risk of all-cause death was higher in extremes of weight vs. the reference group after adjustment for important risk modifiers, thus no obesity paradox was observed.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41100 Modena, Italy
- Correspondence:
| | - Raffaele De Caterina
- Chair of Cardiology, Cardiology Division, Pisa University Hospital, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo, 65013 Pescara, Italy
| | | | - José Souza
- Daiichi Sankyo Europe GmbH, Zielstattstraße 48, 81379 Munich, Germany; (M.C.M.); (J.S.)
| | - Ladislav Pecen
- Institute of Computer Science of the Czech Academy of Sciences, 18207 Prague, Czech Republic;
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Centre UKE Hamburg, 20246 Hamburg, Germany;
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham B152TT, UK
- The Atrial Fibrillation NETwork (AFNET), 48149 Münster, Germany
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33
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Zhao S, Hong X, Cai H, Liu M, Li B, Ma P. Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update. Front Cardiovasc Med 2021; 8:660986. [PMID: 34262952 PMCID: PMC8273244 DOI: 10.3389/fcvm.2021.660986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Xuejiao Hong
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Mingzhou Liu
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Bing Li
- Department of General Practice, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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34
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Chong DT, Andreotti F, Verhamme P, Dalal J, Uaprasert N, Wang CC, On YK, Li YH, Jiang J, Hasegawa K, Almuti K, Bai R, Lo ST, Krittayaphong R, Lee LH, Quek DK, Johar S, Seow SC, Hammett CJ, Tan JW. Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management. Eur Cardiol 2021; 16:e23. [PMID: 34135993 PMCID: PMC8201470 DOI: 10.15420/ecr.2020.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 10/23/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022] Open
Abstract
The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.
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Affiliation(s)
| | | | | | | | - Noppacharn Uaprasert
- Chulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok, Thailand
| | - Chun-Chieh Wang
- Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine Taoyuan City, Taiwan
| | - Young Keun On
- Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul, South Korea
| | - Yi-Heng Li
- National Cheng King University Hospital Taiwan
| | - Jun Jiang
- Second Affiliated Hospital Zhejiang University School of Medicine Zhejiang, China
| | - Koji Hasegawa
- Translational Research, National Hospital Organization Kyoto Medical Center Kyoto, Japan
| | | | - Rong Bai
- Beijing Anzhen Hospital, Capital Medical University Beijing, China
| | | | | | | | | | | | | | | | - Jack Wc Tan
- National Heart Centre Singapore.,Singapore General Hospital Singapore.,Sengkang General Hospital Singapore
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35
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Zhuang Y, Dai LF, Chen MQ. Efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism: a meta-analysis. JRSM Open 2021; 12:20542704211010686. [PMID: 34178359 PMCID: PMC8207293 DOI: 10.1177/20542704211010686] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Several trials had compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin for acute venous thromboembolism, but the results were incomplete. This updated review comprehensively assessed the efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism. Design Meta-analysis of randomised control trials. Six databases were searched from January 2000 to December 2018. Setting Adult patients had got non-vitamin K antagonist oral anticoagulants or warfarin for venous thromboembolism. Participants Randomised control trials that compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin. Main outcome measures The efficacy and safety of non-vitamin K antagonist oral anticoagulants . Results Seven studies involving 29,879 cases were included, among which 14,943 cases were assigned to non-vitamin K antagonist oral anticoagulants group and 14,936 cases to warfarin group. Meta-analysis showed that compared with warfarin, recurrent venous thromboembolism (odds ratio 0.94 [95% confidence interval 0.81 to 1.11]), death related to venous thromboembolism or fatal pulmonary embolism (odds ratio 1.00 [95% confidence interval 0.63 to 1.60]), symptomatic deep-vein thrombosis (odds ratio 0.88 [95% confidence interval 0.72 to 1.09]), symptomatic nonfatal pulmonary embolism (odds ratio 1.03 [(95% confidence interval 0.82 to 1.30]) and all deaths (odds ratio 0.92 [95% confidence interval 0.76 to 1.12]) are similar in non-vitamin K antagonist oral anticoagulants group, but major bleeding event (odds ratio 0.61 [95% confidence interval 0.50 to 0.75]) and clinically relevant non-major bleeding event (odds ratio [95% confidence interval 0.53 to 0.85]) are less in non-vitamin K antagonist oral anticoagulants group. . Conclusions For the treatment of venous thromboembolism, non-vitamin K antagonist oral anticoagulants is as effective as warfarin, and has a better safety profile than warfarin.
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Affiliation(s)
- Yan Zhuang
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Lin-Feng Dai
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Ming-Qi Chen
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
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36
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Rago A, Pezzullo E, Malvezzi Caracciolo d'Aquino M, Scognamiglio G, Caso VM, Martone F, Attena E, Parisi V, D'Onofrio A, Golino P, Nigro G, Russo V. Non Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients Scheduled for Electrical Cardioversion: A Real-Life Propensity Score Matched Study. J Blood Med 2021; 12:413-420. [PMID: 34113202 PMCID: PMC8187032 DOI: 10.2147/jbm.s299265] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Aim The aim of the present study was to assess the safety and effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients undergoing electrical cardioversion (EC). Methods A propensity score-matched analysis was performed in order to identify two homogeneous groups including AF patients on NOACs and VKAs treatment scheduled for EC. The primary safety endpoint was major bleeding. The composite of stroke, transient ischemic attack (TIA) and systemic embolism (SE) was the primary effectiveness endpoint. The discontinuation rate of anticoagulant therapy was assessed. Results A total of 495 AF patients on NOACs therapy and scheduled for EC were compared to 495 VKAs recipients. No statistically significant differences in the incidence of both major bleeding (1.01% versus 1.4%; P= 0.5) and thromboembolic events (0.6% versus 0.8%; P= 0.7) were observed during a mean follow-up of 15 ± 3 months. The discontinuation rate of NOACs was significantly lower compared to VKAs (1.6% versus 3.6%, P=0.04). Conclusion We showed a safe and effective clinical profile of NOACs among AF patients scheduled for electrical cardioversion in real-life setting. Patients on NOACs therapy showed a lower discontinuation rate compared to those on VKAs.
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Affiliation(s)
- Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | | | | | - Valentina Maria Caso
- Department of Medical Translational Sciences, University of the Study of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Emilio Attena
- Departmental Unit of Electrophysiology, Monaldi Hospital, Naples, Italy
| | - Valentina Parisi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio D'Onofrio
- Departmental Unit of Electrophysiology, Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Department of Cardiology, Monaldi Hospital, Naples, Italy
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Abstract
Mitral regurgitation is the most prevalent form of moderate or severe valve disease in developed countries. Surgery represents the standard of care for symptomatic patients with severe mitral regurgitation, but up to 50% of patients are denied surgery because of high surgical risk. In this context, different transcatheter options have been developed to address this unmet need. Transcatheter mitral valve replacement (TMVR) is an emergent field representing an alternative option in high complex contexts when transcatheter mitral valve repair is not feasible or suboptimal due to anatomical issues. However, TMVR is burdened by some device-specific issues (device malposition, migration or embolization, left ventricular outflow tract obstruction, hemolysis, thrombosis, stroke). Here we discuss the thrombotic risk of TMVR and current evidence about anticoagulation therapy after TMVR.
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Affiliation(s)
- Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Denti
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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38
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Lin SY, Peng YF, Huang CF, Kuo CH, Tang SC, Jeng JS. Measurement of Dabigatran Concentration Using Finger Prick Dried Blood Spot Sample Collection. Front Pharmacol 2021; 12:679431. [PMID: 34122105 PMCID: PMC8187780 DOI: 10.3389/fphar.2021.679431] [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: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose: Real-world laboratory monitoring of dabigatran activity is challenging. The purpose of the present study was to demonstrate the feasibility and accuracy of finger prick sampling with dried blood spot (fpDBS) cards in measuring the dabigatran concentration. Material and Methods: Patients >20 years of age with atrial fibrillation and receiving dabigatran therapy for more than 7 days were included in the study. Peak and trough dabigatran concentrations were collected by simultaneous finger prick and venous puncture. The dabigatran concentration was measured by ultra-high performance liquid chromatography with tandem mass spectrometry. Our previously developed post-column infused internal standard (PCI-IS) method was applied to estimate the blood spot volume on fpDBS and to calibrate the drug concentration. Deming regression was used to analyze the correlation between dabigatran concentration on fpDBS cards and in plasma samples, followed by Bland–Altman analysis to compare the bias between two sampling techniques. Results: A total of 33 patients were enrolled and contributed 66 plasma and 55 fpDBS dabigatran samples. The average patient age was 74.6 ± 7.9 years, mean creatinine clearance 58.1 ± 18.3 mL/min, and CHA2DS2-VASc score 3.5 ± 1.6 points. The dabigatran concentration ranged from 41.8–1421.7 ng/mL. The plasma and DBS dabigatran concentrations correlated well (r = 0.98), and the conversion factor for fpDBS to plasma dabigatran concentration was 1.28. The Bland–Altman analysis showed that 94.5% of the fpDBS-predicted concentration fell within 20% of bias. Conclusions: The study showed that fpDBS measurement of dabigatran concentration is reliable and can be applied in clinical scenarios.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Fong Peng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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39
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Li HJ, Lin SY, Lin FJ, Hung CS, Wang CC. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation and valvular heart disease. Curr Med Res Opin 2021; 37:535-542. [PMID: 33538623 DOI: 10.1080/03007995.2021.1885365] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We compared the effectiveness and safety outcomes of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in patients with AF and VHD, as these patients have been partially excluded from clinical trials. METHODS This retrospective cohort study was conducted using the National Health Insurance Research Database in Taiwan. Patients with AF and VHD and above 20 years of age, who were prescribed oral anticoagulants such as warfarin, dabigatran, rivaroxaban, and apixaban, were included. Propensity score matching was performed to balance intergroup differences. The Cox proportional hazards model was used to compare the effectiveness and safety of warfarin and NOACs. RESULTS We included 5833 NOAC-warfarin pairs, 3001 dabigatran-warfarin pairs and 2595 rivaroxaban-warfarin pairs. Warfarin and NOACs had similar risk of ischemic stroke (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.79-1.06; p = .25) and bleeding events (HR, 0.90; 95% CI, 0.78-1.02; p = .10). NOACs showed reduced risk of venous thromboembolism, intracranial hemorrhage, and mortality (HR and 95% CI, 0.39 [0.20-0.77], p = .01; 0.62 [0.45-0.84], p < .01; and 0.47 [0.41-0.53], p < .01, respectively). The benefit of NOACs in reducing the risk of venous thromboembolism was mainly driven by dabigatran, and the benefit of reducing the risk of intracranial hemorrhage and mortality was observed in both dabigatran and rivaroxaban users. CONCLUSIONS NOACs had a comparable risk of ischemic stroke and bleeding in patients with AF and VHD, and reduced the risk of venous thromboembolism, intracranial hemorrhage, and mortality, compared to warfarin. Therefore, NOAC is an effective and safe alternative to warfarin in these patients.
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Affiliation(s)
- Hsing-Jung Li
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Yi Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Ju Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Sheng Hung
- Department of Internal Medicine, Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 4777] [Impact Index Per Article: 1592.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Song T, Xin X, Cui P, Zong M, Li X. Factors Associated with Anticoagulation Adherence in Chinese Patients with Non-Valvular Atrial Fibrillation. Patient Prefer Adherence 2021; 15:493-500. [PMID: 33688171 PMCID: PMC7935330 DOI: 10.2147/ppa.s285020] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/25/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Inadequate medication adherence among patients with non-valvular atrial fibrillation (NVAF) will directly affect the efficacy and safety of anticoagulation therapy, leading to a considerable increase in the risk of ischemic stroke and death. In this study, we aim to investigate medication adherence and identify the influencing factors, including social-demographic, disease-related information and self-efficacy. PATIENTS AND METHODS We recruited 170 patients with NVAF from a tertiary hospital atrial fibrillation outpatient clinics and cardiology ward from June 2020 to September 2020. Patients who had been taking oral anticoagulation medication for at least 3 months were included. And Morisky medication adherence scale (MGL) was used to assess the adherence to anticoagulants, which scores <4 were considered as low adherence. RESULTS Fifty (29.4%) NVAF patients had a MGL score<4. Monthly income, types of comorbidities, number of drugs, and self-efficacy were determinants of anticoagulation adherence. Binomial logistic regression showed that patients had been prescribed more durgs (OR: 3.51, p=0.002), had high monthly income (OR: 7.87, p=0.001), without other diseases (OR: 8.00, p=0.005), and with higher self-efficacy (OR: 1.42, p=0.001) showed high adherence. CONCLUSION Number of drugs, types of comorbidities, monthly income, and self-efficacy were associated with the adherence of non-vitamin K antagonist oral anticoagulants (NOACs).
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Affiliation(s)
- Ting Song
- School of Nursing, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Xiao Xin
- Department of Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People’s Republic of China
| | - Peirong Cui
- School of Nursing, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Mingcan Zong
- School of Nursing, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Xianhua Li
- Department of Outpatient Office, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People’s Republic of China
- Correspondence: Xianhua Li Department of Outpatient Office, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People’s Republic of ChinaTel +86 18917762081 Email
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Ajam T, Cumpian TL, Tilkens BL, Jahangir IA, Frost J, Ceretto C, Jahangir A. Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly. Expert Rev Clin Pharmacol 2020; 13:1309-1327. [PMID: 33107345 DOI: 10.1080/17512433.2020.1842191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population. AREAS COVERED We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database. EXPERT OPINION NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.
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Affiliation(s)
- Tarek Ajam
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | - Tabitha L Cumpian
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Blair L Tilkens
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | | | - Jared Frost
- Pharmacy Services, Advocate Aurora Health , Milwaukee, WI, USA
| | - Cheryl Ceretto
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Arshad Jahangir
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
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Gorczyca I, Jelonek O, Uziębło-Życzkowska B, Chrapek M, Maciorowska M, Wójcik M, Błaszczyk R, Kapłon-Cieślicka A, Gawałko M, Budnik M, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Szpotowicz A, Bednarski J, Bakuła-Ostalska E, Tomaszuk-Kazberuk A, Szyszkowska A, Wełnicki M, Mamcarz A, Wożakowska-Kapłon B. Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry. J Clin Med 2020; 9:jcm9113565. [PMID: 33167503 PMCID: PMC7694480 DOI: 10.3390/jcm9113565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration. Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs. Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban. Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.
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Affiliation(s)
- Iwona Gorczyca
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Olga Jelonek
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
- Correspondence: ; Tel.: +48-261-816-376
| | - Magdalena Chrapek
- Faculty of Natural Sciences, The Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Małgorzata Maciorowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Agnieszka Kapłon-Cieślicka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Tomasz Tokarek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Michał Wojewódzki
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Anna Szpotowicz
- Department of Cardiology, Regional Hospital, 27-400 Ostrowiec Swiętokrzyski, Poland;
| | - Janusz Bednarski
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Elwira Bakuła-Ostalska
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Anna Tomaszuk-Kazberuk
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Anna Szyszkowska
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Marcin Wełnicki
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Artur Mamcarz
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Beata Wożakowska-Kapłon
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
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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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Overvad TF, Larsen TB, Søgaard M, Albertsen IE, Ording AG, Noble S, Højen AA, Nielsen PB. Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives. Expert Rev Cardiovasc Ther 2020; 18:791-800. [PMID: 32909840 DOI: 10.1080/14779072.2020.1822167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections. AREAS COVERED This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives. EXPERT OPINION Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient's preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.
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Affiliation(s)
- Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Oncology, Aalborg University Hospital , Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Anne Gulbech Ording
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University , Cardiff, UK
| | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
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Romiti GF, Corica B, Proietti M. A comprehensive appraisal of dabigatran etexilate clinical evidence and applications: a 10-year-long story. Future Cardiol 2020; 17:215-226. [PMID: 32883107 DOI: 10.2217/fca-2020-0084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
During the last decade, non-vitamin K antagonist oral anticoagulants (NOACs) revolutionized the thromboprophylaxis management of several medical conditions, including atrial fibrillation and venous thromboembolism. Dabigatran etexilate was the first NOAC widely available worldwide, and it is currently the only one that directly inhibits thrombin. More recently, the availability of idarucizumab, a specific reversal agent, has increased the safety of dabigatran use in clinical practice, especially for those patients with severe and life-threatening bleeding. This review aims to summarize current evidence on dabigatran, starting from its pharmacological characteristics, and providing an updated overview of pivotal randomized controlled trials and real-world data on its efficacy and safety.
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Affiliation(s)
- Giulio Francesco Romiti
- Department of Translational & Precision Medicine, Sapienza - University of Rome, 00161 Rome, Italy
| | - Bernadette Corica
- Department of Translational & Precision Medicine, Sapienza - University of Rome, 00161 Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences & Community Health, University of Milan, 20122 Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L14 3PE, UK
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Zhao S, Hong X, Cao J, Cai H, Du S, Ma P. Appropriate Dosing Regimens of Non-Vitamin K Antagonist Oral Anticoagulants for Treatment of Patients With Non-Valvular Atrial Fibrillation: An Evidence-Based Consideration. Front Pharmacol 2020; 11:1293. [PMID: 32973522 PMCID: PMC7468491 DOI: 10.3389/fphar.2020.01293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/04/2020] [Indexed: 01/29/2023] Open
Abstract
Patients with non-valvular atrial fibrillation (NVAF) exhibit a high risk of stroke, which is associated with high mortality. Thus, stroke prevention is crucial for the overall management of NVAF. Two categories of drugs, vitamin K antagonist warfarin and non-vitamin K antagonist oral anticoagulants (NOACs), are clinically used to prevent NVAF-related stroke. In some circumstances, NOACs are superior to warfarin. However, NOACs selection for NVAF patients is affected by many factors, including individual patient characteristics, comorbidities, risk factors, or laboratory variables. This article summarizes the discrepancy in NOACs management with emphasis on the dosing regimens and influencing factors, such as stroke risk, age, body weight, renal function, gastrointestinal bleeding (GIB) risk, and combination of antiplatelet therapy, in order to identify individual groups with particular clinical characteristics who may obtain more benefit from a certain dosing regimen of NOACs. Determination of a particular subset of patient populations for the appropriate dose regimen of NOACs will help to achieve desired clinical outcomes. Furthermore, to compensate clinical evidence, we should place more emphasis on the findings of current clinical trials and supplement real-world data.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Xuejiao Hong
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Jingjing Cao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Song Du
- Department of Cardiovascular Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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49
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Souverein PC, van den Ham HA, Huerta C, Merino EM, Montero D, León-Muñoz LM, Schmiedl S, Heeke A, Rottenkolber M, Andersen M, Aakjaer M, De Bruin ML, Klungel OH, Gardarsdottir H. Comparing risk of major bleeding between users of different oral anticoagulants in patients with nonvalvular atrial fibrillation. Br J Clin Pharmacol 2020; 87:988-1000. [PMID: 32627222 PMCID: PMC9328267 DOI: 10.1111/bcp.14450] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/11/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS The introduction of direct oral anticoagulants (DOACs) has broadened the treatment arsenal for nonvalvular atrial fibrillation, but observational studies on the benefit-risk balance of DOACs compared to vitamin K antagonists (VKAs) are needed. The aim of this study was to characterize the risk of major bleeding in DOAC users using longitudinal data collected from electronic health care databases from 4 different EU-countries analysed with a common study protocol. METHODS A cohort study was conducted among new users (≥18 years) of DOACs or VKAs with nonvalvular atrial fibrillation using data from the UK, Spain, Germany and Denmark. The incidence of major bleeding events (overall and by bleeding site) was compared between current use of DOACs and VKAs. Cox regression analysis was used to calculate hazard ratios and 95% confidence intervals (CI) and adjust for confounders. RESULTS/CONCLUSION Overall, 251 719 patients were included across the 4 study cohorts (mean age ~75 years, % females between 41.3 and 54.3%), with overall hazard ratios of major bleeding risk for DOACs vs VKAs ranging between 0.84 (95% CI: 0.79-0.90) in Denmark and 1.13 (95% CI 1.02-1.25) in the UK. When stratifying according to the bleeding site, risk of gastrointestinal bleeding was increased by 48-67% in dabigatran users and 30-50% for rivaroxaban users compared to VKA users in all data sources except Denmark. Compared to VKAs, apixaban was not associated with an increased risk of gastrointestinal bleeding in all data sources and seemed to be associated with the lowest risk of major bleeding events compared to dabigatran and rivaroxaban.
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Affiliation(s)
- Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Consuelo Huerta
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Elisa Martín Merino
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Luz M León-Muñoz
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany.,Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | | | - Marietta Rottenkolber
- Diabetic Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universitaet Muenchen, Munich, Germany
| | - Morten Andersen
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Mia Aakjaer
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Marie L De Bruin
- Copenhagen Centre of Regulatory Science, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
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50
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Kozieł M, Mazurek M, Teutsch C, Diener HC, Dubner SJ, Halperin JL, Ma CS, Rothman KJ, Brandes A, Paquette M, Zint K, França LR, Lu S, Bartels DB, Huisman MV, Lip GYH. Persistence with Anticoagulation for Atrial Fibrillation: Report from the GLORIA-AF Phase III 1-Year Follow-up. J Clin Med 2020; 9:E1969. [PMID: 32586056 DOI: 10.3390/jcm9061969] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 01/25/2023] Open
Abstract
Background: We aimed to assess the extent to which drug persistence is better with non-vitamin K antagonist oral anticoagulants (NOACs) than vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients and to estimate the difference in therapy persistence depending on NOAC dosing regimen (once daily (QD) vs. twice daily (BID)). Methods: Consecutive patients were followed for 1 year in phase III of the GLORIA-AF registry. Drug persistence was defined as the use of OAC without any discontinuation in >30 days or switching to alternative therapy. Results: Among 21,109 eligible patients in phase III, 17,266 patients who were prescribed OAC at baseline and those who took ≥1 OAC dose were included. The 1-year proportion of patients receiving NOAC and VKA who persisted on treatment was 80% and 75%, respectively. The 1-year persistence with NOACs BID and NOACs QD was 81% and 80%, respectively. Female gender, hypertension, older age, alcohol use, permanent, asymptomatic, and minimally symptomatic AF were associated with better OAC persistence. Region, medication usage predisposing to bleeding, being a current smoker, treatment reimbursement, and proton pump inhibitors were associated with lower OAC persistence. Conclusions: Drug persistence was higher with NOACs (1-year persistence was 80%) than with VKAs (75%). There was little difference in 1-year persistence between NOAC dosing regimens.
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