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Lin C, Ge Q, Wang L, Zeng P, Huang M, Li D. Predictors, prevalence and prognostic role of pulmonary hypertension in patients with chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2024; 46:2368082. [PMID: 38938193 PMCID: PMC11216249 DOI: 10.1080/0886022x.2024.2368082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/08/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND To estimate the predictors, prevalence and prognostic role of pulmonary hypertension (PH) in patients with chronic kidney disease (CKD) using meta-analysis. METHODS The PubMed, EmBase, and the Cochrane library were systematically searched for eligible studies from inception till May 2024. All of pooled analyses were performed using the random-effects model. RESULTS Fifty observational studies involving 17,558 CKD patients were selected. The prevalence of PH in CKD patients was 38% (95% confidence interval [CI]: 33%-43%), and the prevalence according to CKD status were 31% (95% CI: 20%-42%) for CKD (I-V), 39% (95% CI: 25%-54%) for end stage kidney disease (ESKD) (predialysis), 42% (95% CI: 35%-50%) for ESKD (hemodialysis), and 26% (95% CI: 19%-34%) for renal transplant. We noted the risk factors for PH in CKD included Black individuals (relative risk [RR]: 1.39; 95% CI: 1.18-1.63; p < 0.001), chronic obstructive pulmonary disease (RR: 1.48; 95% CI: 1.21-1.82; p < 0.001), cardiovascular disease history (RR: 1.62; 95% CI: 1.05-2.51; p = 0.030), longer dialysis (RR: 1.70; 95% CI: 1.18-2.46; p = 0.005), diastolic dysfunction (RR: 1.88; 95% CI: 1.38-2.55; p < 0.001), systolic dysfunction (RR: 3.75; 95% CI: 2.88-4.87; p < 0.001), and grade 5 CKD (RR: 5.64; 95% CI: 3.18-9.98; p < 0.001). Moreover, PH in CKD patients is also associated with poor prognosis, including all-cause mortality, major cardiovascular events, and cardiac death. CONCLUSION This study systematically identified risk factors for PH in CKD patients, and PH were associated with poor prognosis. Therefore, patients with high prevalence of PH should be identified for treatment.
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Affiliation(s)
- Chunlong Lin
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
| | - Qilong Ge
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
| | - Lei Wang
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
| | - Pan Zeng
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
| | - Mingmin Huang
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
| | - Dan Li
- Department of Respiratory and Critical Care Medicine, Yueyang municipal Hospital of Hunan Normal University, Hunan, China
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Botto GL, Capranzano P, Colonna P, Fornasari DMM, Sciatti E, Riva L. Use of DOACs in frail elderly patients in light of class genericization. Int J Cardiol 2024; 411:132276. [PMID: 38880419 DOI: 10.1016/j.ijcard.2024.132276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Frailty and comorbidity influence the therapeutic approach in everyday clinical practice. The DOACs genericization opens a reflection on their differences from a pharmacological and bioavailability point of view, particularly in elderly frail patients. The aim of this project was to create a national Delphi consensus on the topic of the use of DOACs for atrial fibrillation (AF) in such patients, in light of the genericization of the class. METHODS AND RESULTS The consensus dealt with 3 main topics: a) efficacy and safety of DOACs in elderly and/or frail patients; b) therapeutic choice in specific frailty scenarios; c) DOACs genericization. 56 cardiologists, two internists and two neurologists from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: uncertain, 4: agree, 5: strongly agree). A positive consensus was reached if the percentage of agreement (vote 1-2, positive consensus) or disagreement (votes 4-5, negative consensus) was >66%; otherwise, no consensus was reached. Results are displayed accordingly. CONCLUSIONS After 10 years of everyday clinical management of DOACs for AF, specific elements differentiating a molecule from another, either for efficacy or for safety, are consolidated. However, some uncertainties still exist in particular contexts, such as chronic kidney disease or cancer patients. Clinicians have an unsure attitude towards generic drugs, because clinical practice is lacking as well as a proper knowledge of the topic. Albeit being an alternative, the choice of the generic drug must remain the responsibility of the clinician.
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Affiliation(s)
- Giovanni Luca Botto
- Cardiology and Electrophysiology, Department of Medicine, ASST Rhodense, Rho & Garbagnate Hospitals, Italy.
| | - Piera Capranzano
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Italy
| | | | | | | | - Letizia Riva
- Cardiology Department, Maggiore Hospital, Bologna, Italy
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Diener HC, Grosse GM, Hüsing A, Stang A, Kuklik N, Brinkmann M, Maurer GD, Soda H, Pohlmann C, Hilker-Roggendorf R, Popovic N, Kraft P, Mackert BM, Eschenfelder CC, Weimar C. Efficacy and safety of oral factor Xa inhibitors versus vitamin-K antagonists in the early phase after acute ischemic stroke or TIA in the real-world setting: The PRODAST study. Eur Stroke J 2024; 9:696-703. [PMID: 38567789 DOI: 10.1177/23969873241242239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
INTRODUCTION Factor Xa (FXa) inhibitors are superior to vitamin K antagonists (VKAs) in terms of avoiding hemorrhagic complications. However, no robust data are available to date as to whether this also applies to the early phase after stroke. In this prospective registry study, we aimed to investigate whether anticoagulation with FXa inhibitors in the early phase after acute ischemic stroke or transient ischemic attack (TIA) is associated with a lower risk of major bleeding events compared with VKAs. MATERIALS AND METHODS The Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) study is a prospective, multicenter, observational, post-authorization safety study at 86 German stroke units between July 2015 and November 2020. Primary outcome was a major bleeding event during hospital stay. Secondary endpoints were recurrent strokes, recurrent ischemic strokes, TIA, systemic/pulmonary embolism, myocardial infarction, death and the composite endpoint of stroke, systemic embolism, life-threatening bleeding and death. RESULTS In total, 10,039 patients have been recruited. 5,874 patients were treated with FXa inhibitors and 1,050 patients received VKAs and were eligible for this analysis. Overall, event rates were low. We observed 49 major bleeding complications during 33,297 treatment days with FXa-inhibitors (rate of 14.7 cases per 10,000 treatment days) and 16 cases during 7,714 treatment days with VKAs (rate of 20.7 events per 10,000 treatment days), translating into an adjusted hazard ratio (aHR) of 0.70 (95% confidence interval (95% CI): 0.37-1.32) in favor of FXa inhibitors. Hazards for ischemic endpoints (63 vs 17 strokes, aHR: 0.96 (95% CI: 0.53-1.74), mortality (33 vs 6 deaths, aHR: 0.87 (95% CI: 0.33-2.34)) and the combined endpoint (154 vs 39 events, aHR: 0.99 (95% CI: 0.65-1.41) were not substantially different. DISCUSSION AND CONCLUSION This large real-world study shows that FXa inhibitors appear to be similarly effective in terms of bleeding events and ischemic endpoints compared to VKAs in the early post-stroke phase of hospitalization. However, the results need to be interpreted with caution due to the low precision of the estimates.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Gerrit M Grosse
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Anika Hüsing
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
- School of Public Health, Department of Epidemiology Boston University, Boston, MA, United States of America
| | - Nils Kuklik
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Marcus Brinkmann
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
- Center for Clinical Trials Essen, University Hospital Essen, Essen, Germany
| | - Gabriele D Maurer
- Department of Neurology, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Hassan Soda
- Klinik für Akutneurologie mit Überregionaler Stroke Unit, Klinischer Neurophysiologie und Intensivmedizin, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt, Germany
| | - Carsten Pohlmann
- Department of Neurology, Asklepios Klinik Barmbek, Hamburg, Germany
| | | | - Nikola Popovic
- Department of Neurology, Evangelisches Krankenhaus Hattingen, Hattingen, Germany
| | | | | | | | - Christian Weimar
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
- BDH Clinic Elzach, Elzach, Germany
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024; 21:e31-e149. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Parks AL, Stevens SM, Woller SC. Anticoagulant therapy in renal insufficiency theme: Anticoagulation in complex situations. Thromb Res 2024; 241:109097. [PMID: 39094333 DOI: 10.1016/j.thromres.2024.109097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/12/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024]
Abstract
Many patients with impaired renal function have concurrent indications for anticoagulant therapy, including atrial fibrillation and venous thromboembolism. For mild chronic kidney disease, data from clinical trials and existing guidelines can be applied to clinical management. The benefits and harms of anticoagulation therapy in patients with more advanced renal impairment are nuanced, as both thrombotic and bleeding risk are increased. Until recently, data regarding anticoagulants in severe renal impairment were primarily observational, but emerging evidence includes a few small clinical trials and the emergence of novel agents hypothesized to have improved efficacy and safety in this population. In this review, we summarize existing data on anticoagulation in patients with chronic kidney disease. We suggest a framework for anticoagulation decision-making in the burgeoning worldwide population of patients with chronic kidney disease.
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Affiliation(s)
- Anna L Parks
- Division of Hematology & Hematologic Malignancies, Department of Internal Medicine, University of Utah, United States of America.
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Intermountain Health, United States of America; Division of General Internal Medicine, Department of Internal Medicine, University of Utah, United States of America
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Intermountain Health, United States of America; Division of General Internal Medicine, Department of Internal Medicine, University of Utah, United States of America
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6
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Hämmerle P, Aeschbacher S, Schlageter V, Coslovsky M, Hennings E, Krisai P, Coduri F, Blum MR, Rodondi N, Reichlin T, Müller A, Stauber A, Moschovitis G, Rigamonti E, Beer J, Ammann P, Bonati LH, Conen D, Osswald S, Kühne M, Zuern CS. Heart rate variability and stroke or systemic embolism in patients with atrial fibrillation. Heart Rhythm 2024; 21:1509-1516. [PMID: 38762133 DOI: 10.1016/j.hrthm.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/22/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Stroke remains one of the most serious complications in atrial fibrillation (AF) patients and has been linked to disturbances of the autonomic nervous system. OBJECTIVE The purpose of this study was to test the hypothesis that impaired cardiac autonomic function might be associated with an enhanced stroke risk in AF patients. METHODS A total of 1922 AF patients who were in either sinus rhythm (SR group; n = 1121) or AF (AF group; n = 801) on a 5-minute resting electrocardiographic (ECG) recording were enrolled in the study. Heart rate variability triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-minute total power, and power in the high-frequency, low-frequency, and very-low-frequency ranges were calculated. Cox regression models were constructed to examine the association of heart rate variability (HRV) parameters with the composite endpoint of stroke or systemic embolism. RESULTS Mean age was 71 ± 8 years in the SR group and 75 ± 8 years in the AF group. Thirty-seven patients in the SR group (3.4%) and 60 patients in the AF group (8.0%) experienced a stroke or systemic embolism during follow-up of 5 years. In patients with SR, HRVI <15 was the strongest HRV parameter to be associated with stroke or systemic embolism (hazard ratio 3.04; 95% confidence interval 1.3-7.0; P = .009) after adjustment for multiple confounders. In the AF group, no HRV parameter was found to be associated with the composite endpoint. CONCLUSION HRVI measured during SR on a single 5-minute ECG recording is independently associated with stroke or systemic embolism in AF patients. HRV analysis in SR may help to improve risk stratification in AF patients.
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Affiliation(s)
- Peter Hämmerle
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Vincent Schlageter
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Coslovsky
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department Clinical Research, University of Basel, University Hospital Basel, Basel, Switzerland
| | - Elisa Hennings
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philipp Krisai
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Federica Coduri
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University Bern, Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University Bern, Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Müller
- Department of Cardiology, Triemli Hospital Zürich, Zürich, Switzerland
| | - Annina Stauber
- Department of Cardiology, Triemli Hospital Zürich, Zürich, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Regional Hospital of Lugano, Lugano, Switzerland
| | - Elia Rigamonti
- Division of Cardiology, Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Regional Hospital of Lugano, Lugano, Switzerland
| | - Jürg Beer
- Department of Medicine, Cantonal Hospital of Baden and Molecular Cardiology, University Hospital of Zürich, Zürich, Switzerland
| | - Peter Ammann
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Leo H Bonati
- Rheinfelden Rehabilitation Clinic, Rheinfelden, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | - Stefan Osswald
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christine S Zuern
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.
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7
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Yamashita T, Igawa Y, Fukuzawa M, Hayashi T, Hennig S, Okumura K. Pharmacokinetics of Edoxaban 15 mg in Very Elderly Patients with Nonvalvular Atrial Fibrillation: A Subanalysis of the ELDERCARE-AF Study. Thromb Haemost 2024; 124:874-882. [PMID: 38641335 PMCID: PMC11349424 DOI: 10.1055/s-0044-1785511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 02/26/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We evaluated the pharmacokinetics (PK) of low-dose (15 mg) edoxaban in very elderly patients (≥80 years) with nonvalvular atrial fibrillation (NVAF) and high bleeding risk. METHODS This subanalysis of the phase 3, randomized, double-blind, placebo-controlled, multicenter ELDERCARE-AF study evaluated edoxaban plasma concentrations and compared them with the Japanese population of the ENGAGE AF-TIMI 48 and Japanese severe renal impairment (SRI) studies. RESULTS The PK analysis population included 451 patients, 53.8% of whom concomitantly used antiplatelet drugs, 41.0% had SRI, and 38.0% had low body weight. Edoxaban plasma concentrations at trough and 1 to 3 hours post-dose in ELDERCARE-AF were 17.3 ± 13.9 (n = 427) and 93.3 ± 57.8 ng/mL (n = 447), respectively. These values were slightly higher than the 15 mg group in ENGAGE AF-TIMI 48 (n = 79; 12.4 ± 12.1 and n = 115; 78.7 ± 45.0 ng/mL, respectively), lower than the ENGAGE AF-TIMI 48 high-dose reduced to 30 mg group (n = 83; 25.1 ± 36.6 and n = 111; 150 ± 91.6 ng/mL, respectively), but similar to the Japanese SRI study (n = 39; 18.4 ± 11.2 and n = 40; 96.8 ± 48.3 ng/mL, respectively). ELDERCARE-AF patients with SRI and low body weight (≤45 kg) had higher concentrations than those without, and those taking antiplatelet drugs had lower concentrations than those who were not. CONCLUSION PK data support edoxaban 15 mg once daily for very elderly NVAF patients with high bleeding risk, with caution for patients with SRI and/or low body weight.
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Affiliation(s)
- Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Masayuki Fukuzawa
- Japan Business Unit, Primary Medical Science Department, Cardiovascular Group, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takuya Hayashi
- Data Analysis Group, Data Intelligence Department, Global DX, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
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8
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Yasaka M, Shimizu F, Niwa Y, Kiyonaga A, Terasaka N. Safety and Effectiveness of Four-Factor Prothrombin Complex Concentrate in Special Populations with INR Below 2: A Post-Marketing Surveillance Study. Cardiol Ther 2024; 13:603-614. [PMID: 39096439 PMCID: PMC11333383 DOI: 10.1007/s40119-024-00380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024] Open
Abstract
INTRODUCTION We previously conducted a prospective, observational post-marketing surveillance study to assess the safety and effectiveness of four-factor prothrombin complex concentrate (4F-PCC) for rapid vitamin K antagonist (VKA) reversal in Japanese patients. METHODS This subgroup analysis compared the safety, especially thromboembolic events (TEEs), and effectiveness of 4F-PCC by stratifying patients into two subgroups according to baseline international normalized ratio (INR) levels with < 2.0 and ≥ 2.0. RESULTS Of 1271 eligible patients, 215 (17.9%) had INR < 2.0 and 987 (82.1%) had INR ≥ 2.0. Overall baseline characteristics were similar between groups; age (74.0 years vs 74.0 years), body mass index (22.1 kg/m2 vs 21.9 kg/m2), ratio of inpatients (90.2% vs 88.7%), manifested atrial fibrillation (46.0% vs 48.8%). Median INRs at baseline were 1.72 (minimum 0.92, maximum 1.99) in the INR < 2.0 group and 2.95 (2.00, 27.11) in the INR ≥ 2.0 group. The most common reason for 4F-PCC administration was intracranial hemorrhage (67.0% vs 59.5%), and lesser gastrointestinal bleeding (0.9% vs 7.5%). After 4F-PCC administration (average doses 24.5 IU/kg [INR < 2.0 group] and 29.2 IU/kg [INR ≥ 2.0 group]), INRs were significantly reduced to 1.21 (- 28%) and 1.31 (- 68%), respectively, and resulted in hemostasis in a similarly rapid manner. The incidences of adverse drug reactions were 3.7% in each group. TEEs occurred in 4 (1.9%) patients in the INR < 2.0 group and 11 (1.1%) patients in the INR ≥ 2.0 group and were predominantly composed of stroke, while similar rates (67.0% vs 62.9%) of bleeding events post-anticoagulant resumption were observed between groups. CONCLUSION This study supports the favorable tolerability and efficacy of 4F-PCC regardless of baseline INR (< 2.0 or ≥ 2.0), with a prompt reduction of INR and substantial hemostatic effectiveness in the real-world setting for patients requiring urgent VKA reversal, although no indicated 4F-PCC dose for VKA reversal exists for INR < 2.0 to date.
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Affiliation(s)
- Masahiro Yasaka
- Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Fumihiko Shimizu
- Medical Affairs, CSL Behring K.K, 1-2-3 Kita-Aoyama Minato-ku, Tokyo, 107-0061, Japan
| | - Yuki Niwa
- Medical Affairs, CSL Behring K.K, 1-2-3 Kita-Aoyama Minato-ku, Tokyo, 107-0061, Japan
| | - Ayako Kiyonaga
- Medical Affairs, CSL Behring K.K, 1-2-3 Kita-Aoyama Minato-ku, Tokyo, 107-0061, Japan
| | - Naoki Terasaka
- Medical Affairs, CSL Behring K.K, 1-2-3 Kita-Aoyama Minato-ku, Tokyo, 107-0061, Japan.
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9
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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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10
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Forbes N, Yi Q, Moayyedi P, Bosch J, Bhatt DL, Fox KAA, Eikelboom JW. Incidence and predictors of major gastrointestinal bleeding in patients on aspirin, low-dose rivaroxaban, or the combination: Secondary analysis of the COMPASS randomised controlled trial. Aliment Pharmacol Ther 2024; 60:737-748. [PMID: 38952045 DOI: 10.1111/apt.18139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/02/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND The incidence of major gastrointestinal bleeding (GIB) in patients on low-dose direct-acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking. AIMS To assess GIB incidence and predictors from RCT data of patients on aspirin, low-dose rivaroxaban, or both. METHODS This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures. RESULTS Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53-6.82 for ≥75 vs. 55-64), peptic ulcer disease (PUD, OR 1.57, 1.01-2.44), liver disease (OR 2.09, 1.01-4.33), hypertension (OR 1.42, 1.04-1.94), and smoking (OR 1.85, 1.26-2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12-2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88-7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64-4.84) than upper GIB (OR 1.86, 1.18-2.92). CONCLUSIONS We established incidences and identified risk factors for GIB in users of low-dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors.
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Affiliation(s)
- Nauzer Forbes
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Keith A A Fox
- Division of Cardiology, University of Edinburgh, Edinburgh, UK
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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11
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Piqueras-Sanchez C, Esteve-Pastor MA, Moreno-Fernandez J, Soler-Espejo E, Rivera-Caravaca JM, Roldán V, Marín F. Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation. Expert Rev Neurother 2024; 24:913-928. [PMID: 39039686 DOI: 10.1080/14737175.2024.2379413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.
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Affiliation(s)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
| | - Jorge Moreno-Fernandez
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Eva Soler-Espejo
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | | | - Vanessa Roldán
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
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12
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Johnson LS, Benz AP, Shoamanesh A, Eikelboom JW, Ezekowitz M, Giugliano RP, Wallentin L, Ruff CT, Lopes RD, Jolly S, Whitlock R, Granger CB, Connolly S, Healey JS. Residual Stroke Risk Among Patients With Atrial Fibrillation Prescribed Oral Anticoagulants: A Patient-Level Meta-Analysis From COMBINE AF. J Am Heart Assoc 2024:e034758. [PMID: 39190578 DOI: 10.1161/jaha.123.034758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/10/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Despite oral anticoagulation, patients with atrial fibrillation (AF) remain at risk of ischemic stroke and systemic embolism (SE) events. For patients whose residual risk is sufficiently high, additional therapies might be useful to mitigate stroke risk. METHODS AND RESULTS Individual patient data from 5 landmark trials testing oral anticoagulation in AF were pooled in A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in AF (COMBINE AF). We calculated the rate of ischemic stroke/SE among oral anticoagulation-treated patients with a CHA2DS2-VASc score≥2, across strata of CHA2DS2-VASc score, stroke history, and AF type, as either paroxysmal or nonparoxysmal. We included 71 794 patients with AF (median age 72 years, interquartile range, 13 years, 61.3% male) randomized to a direct oral anticoagulant or vitamin K antagonist, and followed for a mean of 2.1 (±0.8) years. The median CHA2DS2-VASc score was 4 (interquartile range, 3-5), 18.8% had a prior stroke, and 76.4% had nonparoxysmal AF. The overall rate of stroke/SE was 1.33%/y (95% CI, 1.27-1.39); 1.38%/y (95% CI, 1.31-1.45) for nonparoxysmal AF, and 1.15%/y (95% CI, 1.05-1.27) for paroxysmal AF. The rate of ischemic stroke/SE increased by a rate ratio of 1.36 (95% CI, 1.32-1.41) per 1-point increase in CHA2DS2-VASc, reaching 1.67%/y (95% CI, 1.59-1.75) ≥4 CHA2DS2-VASc points. Patients with both nonparoxysmal AF and CHA2DS2-VASc ≥4 had a stroke/SE rate of 1.75%/y (95% CI, 1.66-1.85). In patients with a prior stroke, the risk was 2.51%/y (95% CI, 2.33-2.71). CONCLUSIONS AF type, CHA2DS2-VASc score, and stroke history can identify patients with AF, who despite oral anticoagulation have a residual stroke/SE risk of 1.5% to 2.5% per year. Evaluation of additional stroke/SE prevention strategies in high-risk patients is warranted.
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Affiliation(s)
- Linda S Johnson
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Clinical Sciences Lund University Malmö Sweden
| | - Alexander P Benz
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Cardiology University Medical Center Mainz, Johannes Gutenberg-University Mainz Germany
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University Hamilton Canada
- Division of Neurology McMaster University Hamilton ON Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University Hamilton Canada
| | - Michael Ezekowitz
- Sydney Kimmel Medical School Thomas Jefferson University Philadelphia PA USA
- Cardiology Department, Lankenau Medical Center Bryn Mawr Hospital/Mainline Health Wynnewood PA USA
| | - Robert P Giugliano
- Division of Cardiovascular Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA USA
- Thrombolysis in Myocardial Infarction Study Group Boston MA USA
| | - Lars Wallentin
- Uppsala Clinical Research Centre Uppsala University Uppsala Sweden
- Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Christian T Ruff
- Division of Cardiovascular Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA USA
- Thrombolysis in Myocardial Infarction Study Group Boston MA USA
| | - Renato D Lopes
- Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
- Duke Clinical Research Institute, Duke University Durham NC USA
| | - Sanjit Jolly
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
| | - Christopher B Granger
- Division of Cardiology Duke University Durham NC USA
- Duke Clinical Research Institute, Duke University Durham NC USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University Hamilton Canada
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
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13
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Palareti G, Testa S, Legnani C, Paoletti O, Cini M, Antonucci E, Pengo V, Poli D, Ageno W, Prandoni P, Prisco D, Tosetto A. The use of reduced DOAC doses in atrial fibrillation patients does not always lead to good anticoagulation levels and avoid adverse events. Int J Cardiol 2024:132484. [PMID: 39187070 DOI: 10.1016/j.ijcard.2024.132484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/08/2024] [Accepted: 08/23/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND The MAS study (Blood Advances 2024) showed that a high proportion of Italian AF patients treated with direct oral anticoagulants (DOACs) receive reduced doses. This sub-analysis of MAS data aimed to analyze the effects of reduced (appropriate or not)- or standard-dose use on DOAC activity assessed at baseline and the occurrence of thrombotic or bleeding complications during follow-up. METHODS The MAS study design, the methods for DOAC measurement, the results, and the adverse events during follow-up, are described in detail elsewhere. RESULTS Seven hundred AF patients (42 % of the total 1657) received a reduced dose (considered inappropriate in 140 [20 %]). They were older, more frequently women, with lower body mass index (BMI), hemoglobin levels, and creatinine clearance. They more often had cerebral or cardiovascular diseases, were taking more medications, with higher scores for thrombotic or bleeding risk. Despite the use of low doses, 133 (19.0 %) patients had high standardized C-trough DOAC levels and experienced a high proportion of bleeding events (8.3 % per year). Conversely, some patients (4.7 %) had very low levels, resulting in a high incidence of thrombotic events (6.7 % per year). No difference was detected if the reduced dose was appropriate or not. CONCLUSION The unpredictable, highly variable inter-individual anticoagulant effect of DOACs may lead to either too low or too high anticoagulant levels, increasing the risk of thrombotic or bleeding events. This is particularly relevant for patients with high-risk conditions, such as those chosen for reduced-dose treatment. Further studies are needed to investigate this important clinical issue.
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Affiliation(s)
| | - Sophie Testa
- Centro Emostasi e Trombosi, Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | | | - Oriana Paoletti
- Centro Emostasi e Trombosi, Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Michela Cini
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | | | - Vittorio Pengo
- Clinica Cardiologica, Centro Trombosi, Dipartimento di Scienze Cardio-Toraco-Vascolare, Università di Padova, Italy
| | - Daniela Poli
- Malattie Aterotrombotiche, AOU Careggi, Firenze, Italy
| | - Walter Ageno
- Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Domenico Prisco
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze
| | - Alberto Tosetto
- UOC Ematologia, Centro Malattie Emorragiche e Trombotiche (CMET), AULSS 8 Berica Ospedale S. Bortolo, Vicenza, Italy
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14
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Ardeshna N, Feldeisen T, Kong X, Haymart B, Kaatz S, Ali M, Barnes GD, Froehlich JB. Comparing DOAC and warfarin outcomes in an obese population using the 'real-world' Michigan Anticoagulation Quality Improvement Initiative (MAQI 2) registry. Vasc Med 2024:1358863X241264478. [PMID: 39177515 DOI: 10.1177/1358863x241264478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken warfarin in the treatment of nonvalvular atrial fibrillation (AF) and venous thromboembolism (VTE). Limited data explore the safety of DOACs in obesity. METHODS This multicenter retrospective study between June 2015 and September 2019 uses the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry to compare DOACs and warfarin across weight classes (not obese: body mass index (BMI) ⩾ 18.5 and < 30; obese: BMI ⩾ 30 and < 40; severely obese: BMI ⩾ 40). Primary outcomes include major, clinically relevant nonmajor (CRNM), and minor bleeding events per 100 patient-years. Secondary outcomes include stroke, recurrent VTE, and all-cause mortality. RESULTS DOACs were prescribed to 49% of the 4089 patients with AF and 46% of the 3162 patients with VTE. Compared to patients treated with warfarin, those treated with DOACs had a higher estimated glomerular filtration rate across BMI categories regardless of indication. In the AF population, severely obese patients treated with DOACs had more major (3.4 vs 1.8, p = 0.004), CRNM (8.6 vs 5.9, p = 0.019), and minor bleeding (11.4 vs 9.9, p = 0.001). There was no difference in stroke or all-cause mortality. In the VTE population, both CRNM (7.5 vs 6.7, p = 0.042) and minor bleeding (19.3 vs 10.5, p < 0.001) events occurred at higher rates in patients treated with DOACs. There was no difference in recurrent pulmonary embolism, stroke, or all-cause mortality. CONCLUSION There is a higher rate of bleeding in severely obese patients with VTE and AF treated with DOACs compared to warfarin, without a difference in secondary outcomes. Further studies to compare the anticoagulant classes and understand bleeding drivers in this population are needed.
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Affiliation(s)
- Nelish Ardeshna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Current: Department of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Thane Feldeisen
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Xiaowen Kong
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
| | - Brian Haymart
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott Kaatz
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Mona Ali
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
- Department of Pharmaceutical Service, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Geoffrey D Barnes
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James B Froehlich
- Michigan Anticoagulation Quality Improvement Initiative, MI, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
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15
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Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024; 45:2914-2932. [PMID: 39027946 PMCID: PMC11335376 DOI: 10.1093/eurheartj/ehae398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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16
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Oliva A, Ioppolo AM, Chiarito M, Cremonesi A, Azzano A, Miccichè E, Mangiameli A, Ariano F, Ferrante G, Reimers B, Garot P, Amabile N, Mehran R, Condorelli G, Stefanini G, Cao D. Left Atrial Appendage Closure Compared With Oral Anticoagulants for Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e034815. [PMID: 39119987 DOI: 10.1161/jaha.124.034815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been suggested as an alternative to long-term oral anticoagulation for nonvalvular atrial fibrillation, but comparative data remain scarce. We aimed to assess ischemic and bleeding outcomes of LAAC compared with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for the prevention of cardioembolic events in patients with atrial fibrillation. METHODS AND RESULTS Embase and MEDLINE were searched for randomized trials comparing LAAC, VKAs, and DOACs. The primary efficacy end point was any stroke or systemic embolism. Treatment effects were calculated from a network meta-analysis and ranked according to the surface under the cumulative ranking curve. Seven trials and 73 199 patients were included. The risk of the primary end point was not statistically different between LAAC versus VKAs (odds ratio [OR], 0.92 [95% CI, 0.62-1.50]) and LAAC versus DOACs (OR, 1.11 [95% CI, 0.71-1.73]). LAAC and DOACs resulted in similar risk of major or minor (OR, 0.93 [95% CI, 0.61-1.42]) and major bleeding (OR, 0.92 [95% CI, 0.58-1.46]); however, after exclusion of procedural bleeding, bleeding risk was significantly lower in those undergoing LAAC. Both LAAC and DOACs reduced the risk of all-cause death compared with VKAs (LAAC versus VKAs: OR, 0.70 [95% CI, 0.53-0.91]; DOACs versus VKAs: OR, 0.90 [95% CI, 0.85-0.95], respectively). DOACs ranked as the best treatment for stroke or systemic embolism prevention (66.9%) and LAAC for reducing major bleeding (63.9%) and death (96.4%). CONCLUSIONS As a nonpharmacological alternative to oral anticoagulation for atrial fibrillation, LAAC showed similar efficacy and safety compared with VKAs or DOACs. Prospective confirmation from larger studies is warranted.
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Affiliation(s)
- Angelo Oliva
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | | | - Mauro Chiarito
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Alberto Cremonesi
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
| | - Alessia Azzano
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Eligio Miccichè
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Andrea Mangiameli
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Francesco Ariano
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Giuseppe Ferrante
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
| | - Nicolas Amabile
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Gianluigi Condorelli
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Davide Cao
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
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17
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Liu L, Yan W, Xu X, Wan C, Liu F, Yao Q, Song L, Wang B, Song Z, Li H. Safety and effectiveness of left atrial appendage closure in atrial fibrillation patients with different types of heart failure. BMC Cardiovasc Disord 2024; 24:430. [PMID: 39148039 PMCID: PMC11328490 DOI: 10.1186/s12872-024-04094-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 08/02/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Both atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases. If the two exist together, the risk of stroke, hospitalization for HF and all-cause death is increased. Currently, research on left atrial appendage closure (LAAC) in patients with AF and HF is limited and controversial. This study was designed to investigate the safety and effectiveness of LAAC in AF patients with different types of HF. METHODS Patients with non-valvular atrial fibrillation (NVAF) and HF who underwent LAAC in the First Affiliated Hospital of Army Medical University from August 2014 to July 2021 were enrolled. According to left ventricular ejection fraction (LVEF), the study divided into HF with reduced ejection fraction (LVEF < 50%, HFrEF) group and HF with preserved ejection fraction (LVEF ≥ 50%, HFpEF) group. The data we collected from patients included: gender, age, comorbid diseases, CHA2DS2-VASc score, HAS-BLED score, NT-proBNP level, residual shunt, cardiac catheterization results, occluder size, postoperative medication regimen, transthoracic echocardiography (TTE) results and transesophageal echocardiography (TEE) results, etc. Patients were followed up for stroke, bleeding, device related thrombus (DRT), pericardial tamponade, hospitalization for HF, and all-cause death within 2 years after surgery. Statistical methods were used to compare the differences in clinical outcome of LAAC in AF patients with different types of HF. RESULTS Overall, 288 NVAF patients with HF were enrolled in this study, including 142 males and 146 females. There were 74 patients in the HFrEF group and 214 patients in the HFpEF group. All patients successfully underwent LAAC. The CHA2DS2-VASc score and HAS-BLED score of HFrEF group were lower than those of HFpEF group. A total of 288 LAAC devices were implanted. The average diameter of the occluders was 27.2 ± 3.5 mm in the HFrEF group and 26.8 ± 3.3 mm in the HFpEF group, and there was no statistical difference between the two groups (P = 0.470). Also, there was no statistically significant difference in the occurrence of residual shunts between the two groups as detected by TEE after surgery (P = 0.341). LVEF was significantly higher in HFrEF group at 3 days, 3 months and 1 year after operation than before (P < 0.001). At 45-60 days after surgery, we found DRT in 9 patients and there were 4 patients (5.4%) in HFrEF group and 5 patients (2.3%) in HFpEF group, with no significant difference between the two groups (P = 0.357). One patient with DRT had stroke. The incidence of stroke was 11.1% in patients with DRT and 0.7% in patients without DRT (P = 0.670). There was one case of postoperative pericardial tamponade, which was improved by pericardiocentesis at 24 h after surgery in the HFpEF group, and there was no significant difference between the two groups (P = 1.000). During a mean follow-up period of 49.7 ± 22.4 months, there were no significant differences in the incidence of stroke, bleeding, DRT and HF exacerbation between the two groups. We found a statistical difference in the improvement of HF between HFrEF group and HFpEF group (P < 0.05). CONCLUSIONS LAAC is safe and effective in AF patients with different types of HF. The improvement of cardiac function after LAAC is more pronounced in HFrEF group than in HFpEF group.
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Affiliation(s)
- Liping Liu
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Wen Yan
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Xiang Xu
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Chen Wan
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Feng Liu
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Qing Yao
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Ling Song
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Binbin Wang
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Zhiyuan Song
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China
| | - Huakang Li
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Army Medical University, Chongqing, 400038, China.
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18
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Spruit JR, de Vries TAC, Hemels MEW, Pisters R, de Groot JR, Jansen RWMM. Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Decade of Experience. Drugs Aging 2024:10.1007/s40266-024-01138-5. [PMID: 39141209 DOI: 10.1007/s40266-024-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Both the prevalence of atrial fibrillation (AF) and its subsequent use of direct oral anticoagulants (DOACs) are rapidly increasing in patients of older age. In the absence of contra-indications, guidelines advocate anticoagulation based on the CHA2DS2-VASc score for all AF patients aged 75 and above. However, some practitioners are hesitant to prescribe anticoagulants to older and frail patients due to perceived elevated bleeding risks. This review delves into the comparative treatment outcomes of DOACs versus vitamin K antagonists (VKAs) in older patients with AF, particularly focusing on those of advanced age, frailty, increased risk of falling, chronic kidney disease (CKD), or with a history of major bleeding. Additionally, considerations on the use of off-label DOAC doses, the role of left atrial appendage (LAA) closure and future developments in factor XIa-inhibitors will be discussed. RESULTS While strong evidence supports the use of DOACs in the vital older patients with nonvalvular AF, it remains scant in frail patient groups. There is some evidence from non-randomized studies suggesting that the effect of DOACs compared with VKAs is consistent between frail and nonfrail patients. However, recent findings from a single randomized trial showed increased bleeding risks but comparable thromboembolic outcomes in frail individuals switching from VKAs to DOACs. In patients with an increased risk of falling, data suggest no relevant interaction of increased risk of falling on the effectiveness and safety of DOACs compared with warfarin. Resuming oral anticoagulants in patients with Af after major bleeding seems to be beneficial. Off-label low-dose DOAC is often prescribed to patients who were underrepresented in larger randomized trails because of an elevated risk of bleeding or overexposure to DOACs, but its effect on clinical outcomes remains uncertain. CONCLUSIONS DOACs are the recommended oral anticoagulant for vital older patients with AF. The scarcity of data backing DOAC use in frail individuals, those with renal impairments, or significant bleeding history underscores the necessity for further investigation. However, existing evidence suggests at least similar effectiveness and safety and potential benefits for DOACs in these patient subsets. Therefore, there is no reason to suggest these patients should be treated differently than the established guidelines regarding anticoagulation.
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Affiliation(s)
- Jocelyn R Spruit
- Department of Geriatric Medicine, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands.
| | - Tim A C de Vries
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - René W M M Jansen
- Department of Geriatric Medicine, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
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19
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Chen KH, Hsu YY, Chou CY, Hsu CC, Chang SL, Yu WC, Chang YL. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in low-weight patients with atrial fibrillation. J Thromb Thrombolysis 2024:10.1007/s11239-024-03016-8. [PMID: 39143401 DOI: 10.1007/s11239-024-03016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 08/16/2024]
Abstract
It remains unclear whether non-vitamin K antagonist oral anticoagulants (NOACs) are more effective and safer than warfarin in low-weight patients with atrial fibrillation (AF). Here, we retrospectively compared the effectiveness and safety of NOACs with those of warfarin in low-weight patients with AF. We extracted the July 2011-September 2022 data of patients with AF treated with a NOAC (dabigatran, rivaroxaban, apixaban, or edoxaban) or warfarin at a tertiary hospital. The patients were divided into low-weight (body weight ≤ 60 kg) and non-low-weight (body weight = 60-100 kg) groups. The primary outcomes were hospitalization for ischemic stroke (IS) or systemic embolism (SE) and major bleeding, whereas the secondary outcomes were any ischemic and bleeding events. We used the inverse probability of treatment weighting to balance the baseline characteristics between the groups. In total, 5,044 patients (mean age = 73.7 years, mean CHA2DS2-VASc score = 3.0, mean HAS-BLED score = 2.3) were enrolled and divided into low-weight and non-low-weight groups-containing 1,666 (1,406 NOAC users, 260 warfarin users) and 3,378 (2,978 NOAC users, 400 warfarin users) patients, respectively. NOACs were associated with a lower risk of any bleeding event in the low-weight group (adjusted hazard ratio = 0.61, 95% confidence interval = 0.51-0.73). The between-group differences in the risks of IS/SE, any ischemic event, major bleeding, and any bleeding event were nonsignificant. Thus, the use of NOACs (specifically dabigatran or edoxaban) is associated with a lower risk of any bleeding event than warfarin use in low-weight patients with AF.
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Affiliation(s)
- Kuan-Hsuan Chen
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan.
| | - Yeh-Yun Hsu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Chian-Ying Chou
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Chung Yu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Divison of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taipei City, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Pharmacy, Veterans General Hospital, Taipei, Taipei City, Taiwan.
- Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
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20
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Clapham RE, Speed V, Byrne R, Roberts LN, Czuprynska J, Gee E, Duffy S, Patel R, Patel RK, Arya R, Patel JP. Can edoxaban be used at extremes of bodyweight and in patients with a creatinine clearance ≥95 ml/min? - A population pharmacokinetic analysis. Thromb Res 2024; 242:109118. [PMID: 39180817 DOI: 10.1016/j.thromres.2024.109118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/23/2024] [Accepted: 08/10/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Clinical evidence surrounding edoxaban use in patients weighing <50 kg and >120 kg is lacking. The International Society of Thrombosis and Haemostasis Scientific and Standardisation Committee suggests avoiding edoxaban in patients >120 kg. Additionally, concerns exist regarding decreased efficacy in patients prescribed edoxaban for atrial fibrillation with a creatinine clearance (CrCl) >95 ml/min, a finding of the ENGAGE AF-TIMI 48 trial when edoxaban was compared to warfarin. OBJECTIVE To derive a population pharmacokinetic (PopPK) model using clinical practice data, to understand the impact of bodyweight and renal function on edoxaban pharmacokinetics. METHOD Edoxaban plasma concentrations and patient characteristics were collated from King's College Hospital anticoagulation clinics between 11/2016 and 08/2022. A PopPK model was developed using non-linear mixed effects modelling and used to simulate edoxaban concentrations at the extremes of bodyweight and with varying renal function. RESULTS Data from 409 patients (46 < 50 kg, 34 > 120 kg and 123 with a CrCl > 95 ml/min) provided 455 edoxaban plasma concentrations. A one-compartment model with between-subject variability on clearance with a proportional error model best described the data. The most significant covariates impacting on edoxaban exposure were CrCl and bodyweight. Our work suggests that edoxaban exposure in patients weighing up to 140 kg is comparable to those weighing 75 kg. Edoxaban exposure is reduced in patients weighing <50 kg due to the recommended dose reductions. There is also a reduction in AUCss when CrCl > 95 ml/min compared to CrCl 80 ml/min. CONCLUSIONS Our population PK model for edoxaban suggests that renal function is a key driver for overall edoxaban exposure. Further clinical outcome data is required to understand clinical effectiveness and adverse outcomes.
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Affiliation(s)
- Rachel E Clapham
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK; Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King's College London, UK.
| | - Victoria Speed
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK; Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Rosalind Byrne
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Julia Czuprynska
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Emma Gee
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Sinead Duffy
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Rachna Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Raj K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK
| | - Jignesh P Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK; Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King's College London, UK
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21
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Diaz AB, Chow J, Hoo FK, Keong GLC, Venketasubramanian N, Rey N, Rogelio G, Mehta R. Risk of gastrointestinal bleeding in Asian patients receiving oral anticoagulants for stroke prevention in atrial fibrillation. Drugs Context 2024; 13:2024-5-5. [PMID: 39165614 PMCID: PMC11335362 DOI: 10.7573/dic.2024-5-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/02/2024] [Indexed: 08/22/2024] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in atrial fibrillation. At the Asia Pacific Advancing Patient care with EdoXaban 2023 meeting, experts shared insights on gastrointestinal bleeding with NOACs for stroke prevention in atrial fibrillation in Asian clinical practice, where NOACs have gained widespread acceptance due to their favourable profiles. Gastrointestinal bleeding risk varies amongst NOACs, emphasizing the importance of diligent patient assessment, dosage selection and vigilant monitoring. Edoxaban emerged as a viable option with a low gastrointestinal bleeding risk profile in Asian compared with non-Asian patients, supporting its continued clinical utilization for appropriate patients.
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Affiliation(s)
| | - Jeremy Chow
- Asian Heart & Vascular Centre,
Singapore,
Singapore
| | - Fan Kee Hoo
- University Putra
Malaysia, Serdang,
Malaysia
| | | | | | - Nannette Rey
- de La Salle Medical and Health Sciences Institute, Dasmarinas Cavite,
Philippines
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22
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Arcoraci V, Rottura M, Gianguzzo VM, Pallio G, Imbalzano E, Nobili A, Natoli G, Argano C, Squadrito G, Irrera N, Corrao S. Atrial fibrillation management in older hospitalized patients: Evidence of a poor oral anticoagulants prescriptive attitude from the Italian REPOSI registry. Arch Gerontol Geriatr 2024; 128:105602. [PMID: 39163746 DOI: 10.1016/j.archger.2024.105602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/31/2024] [Accepted: 08/11/2024] [Indexed: 08/22/2024]
Abstract
Atrial fibrillation (AF) prevalence increases in older patients which also show a high thromboembolic risk. Oral anticoagulants (OACs) are recommended to prevent cardioembolic events and direct oral anticoagulants (DOACs) improved anti-thrombotic treatment. However, the benefits/risks of anticoagulant in older patients still need to be completely defined. This retrospective observational study aimed to describe the treatment with OACs in older AF hospitalized patients, and to identify factors influencing OAC therapy or discontinuation using the REgistro Politerapie SIMI. Univariate and multivariate logistic regression models were applied to identify predictors of OACs treatment and discontinuation. Cox proportional hazards models were performed to evaluate one-year mortality by treatment groups. AF patients were 1,128(26.5 %) at discharge and 1,098(97.3 %) required OAC treatment; about half of them (N = 528;48.1 %) were no-OACs users; 236(21.5 %) and 334(30.4 %) used DOACs and VKA, respectively. Increasing DOACs use was observed during the study period. Predictors of OACs treatment were: BMI (OR:1.04; 95 %CI:1.01-1.07), Barthel index (OR:1.01; 95 %CI:1.01-1.02), medications number (OR:1.07; 95 %CI:1.01-1.13). Conversely, a lower probability was found in patients with a high CIR.S (OR:0.59; 95 %CI:0.36-0.97) and neoplasm (OR:0.57; 95 %CI:0.37-0.88). Hospital stay (OR:1.02; 95 %CI:1.01-1.05), neoplasm (OR:2.25; 95 %CI:1.07-4.70) and INR (OR:1.21; 95 %CI:1.05-1.40) increased OACs discontinuation. A lower discontinuation was observed in dyslipidemic patients (OR:0.18; 95 %CI:0.04-0.82) and heart failure (OR:0.38; 95 %CI:0.21-0.70). Among AF patients, 157(14.3 %) died during the follow-up year. Age (HR = 1.05; 95 %CI = 1.03-1.08) and CIR.S (HR = 2.54; 95 %CI = 1.53-4.21) were associated with a greater mortality risk. In conclusion, critical issues related to the underuse and discontinuation of OACs therapy in hospitalized older patients were highlighted.
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Affiliation(s)
- Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Viviana Maria Gianguzzo
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Giovanni Pallio
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Giuseppe Natoli
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy
| | - Christiano Argano
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Salvatore Corrao
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy; Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
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23
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Antar SA, Ashour NA, Hamouda AO, Noreddin AM, Al-Karmalawy AA. Recent advances in COVID-19-induced liver injury: causes, diagnosis, and management. Inflammopharmacology 2024:10.1007/s10787-024-01535-7. [PMID: 39126569 DOI: 10.1007/s10787-024-01535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 03/29/2024] [Indexed: 08/12/2024]
Abstract
Since the start of the pandemic, considerable advancements have been made in our understanding of the effects of SARS-CoV-2 infection and the associated COVID-19 on the hepatic system. There is a broad range of clinical symptoms for COVID-19. It affects multiple systems and has a dominant lung illness depending on complications. The progression of COVID-19 in people with pre-existing chronic liver disease (CLD) has also been studied in large multinational groups. Notably, SARS-CoV-2 infection is associated with a higher risk of hepatic decompensation and death in patients with cirrhosis. In this review, the source, composition, mechanisms, transmission characteristics, clinical characteristics, therapy, and prevention of SARS-CoV-2 were clarified and discussed, as well as the evolution and variations of the virus. This review briefly discusses the causes and effects of SARS-CoV-2 infection in patients with CLD. As part of COVID-19, In addition, we assess the potential of liver biochemistry as a diagnostic tool examine the data on direct viral infection of liver cells, and investigate potential pathways driving SARS-CoV-2-related liver damage. Finally, we explore how the pandemic has had a significant impact on patient behaviors and hepatology services, which may increase the prevalence and severity of liver disease in the future. The topics encompassed in this review encompass the intricate relationships between SARS-CoV-2, liver health, and broader health management strategies, providing valuable insights for both current clinical practice and future research directions.
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Affiliation(s)
- Samar A Antar
- Center for Vascular and Heart Research, Fralin Biomedical Research Institute, Virginia Tech, Roanoke, VA, 24016, USA
- Department of Pharmacology, Faculty of Pharmacy, Horus University-Egypt, New Damietta, 34518, Egypt
| | - Nada A Ashour
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tanta University, Tanta, 31527, Egypt
| | - Amir O Hamouda
- Department of Biochemistry, Faculty of Pharmacy, Horus University-Egypt, New Damietta, 34518, Egypt
| | - Ayman M Noreddin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ahram Canadian University, 6Th of October City, Giza, 12566, Egypt
- Department of Internal Medicine, School of Medicine, University of California -Irvine, Irvine, USA
| | - Ahmed A Al-Karmalawy
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Horus University-Egypt, New Damietta, New Damietta, 34518, Egypt.
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Ahram Canadian University, 6Th of October City, Giza, 12566, Egypt.
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Montomoli M, Candía BG, Barrios AA, Bernat EP. Anticoagulation in Chronic Kidney Disease. Drugs 2024:10.1007/s40265-024-02077-6. [PMID: 39120783 DOI: 10.1007/s40265-024-02077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 08/10/2024]
Abstract
The nuanced landscape of anticoagulation therapy in patients with chronic kidney disease (CKD) presents a formidable challenge, intricately balancing the dual hazards of hemorrhage and thrombosis. These patients find themselves in a precarious position, teetering on the edge of these risks due to compromised platelet functionality and systemic disturbances within their coagulation frameworks. The management of such patients necessitates a meticulous approach to dosing adjustments and vigilant monitoring to navigate the perilous waters of anticoagulant therapy. This is especially critical considering the altered pharmacokinetics in CKD, where the clearance of drugs is significantly impeded, heightening the risk of accumulation and adverse effects. In the evolving narrative of anticoagulation therapy, the introduction of direct oral anticoagulants (DOACs) has heralded a new era, offering a glimmer of hope for those navigating the complexities of CKD. These agents, with their promise of easier management and a reduced need for monitoring, have begun to reshape the contours of care, particularly for patients not yet on dialysis. However, this is not without its caveats. The application of DOACs in the context of advanced CKD remains a largely uncharted territory, necessitating a cautious exploration to unearth their true potential and limitations. Moreover, the advent of innovative strategies such as left atrial appendage occlusion (LAAO) underscores the dynamic nature of anticoagulation therapy, potentially offering a tailored solution for those at the intersection of CKD and elevated stroke risk. Yet the journey toward integrating such advancements into standard practice is laden with unanswered questions, demanding rigorous investigation to illuminate their efficacy and safety across the spectrum of kidney disease. In summary, the management of anticoagulation in CKD is a delicate dance, requiring a harmonious blend of precision, caution, and innovation. As we venture further into this complex domain, we must build upon our current understanding, embracing both emerging therapies and the need for ongoing research. Only then can we hope to offer our patients a path that navigates the narrow strait between bleeding and clotting, toward safer and more effective care.
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Affiliation(s)
- Marco Montomoli
- Nephrology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain.
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Alsoudi AF, Koo E, Wai K, Mruthyunjaya P, Rahimy E. Risk of ocular neovascular conversion and systemic bleeding complications in patients with AMD on DOACs or Warfarin. Ophthalmology 2024:S0161-6420(24)00459-7. [PMID: 39116948 DOI: 10.1016/j.ophtha.2024.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024] Open
Abstract
PURPOSE Conversion to neovascular disease in patients with non-neovascular age-related macular degeneration (AMD) initiated on direct oral anticoagulants (DOAC) compared to matched patients treated with warfarin. DESIGN Retrospective cohort study. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS The study included 20,300 patients and 13,387 patients with non-neovascular AMD initiated on DOACs or warfarin, respectively, before propensity score matching (PSM). METHODS, INTERVENTION, OR TESTING TriNetX (Cambridge, MA, USA), was used to identify patients diagnosed with non-neovascular AMD stratified by treatment with DOACs or warfarin with at least six months of follow-up. Propensity score matching was performed to control for baseline demographics and medical comorbidities. MAIN OUTCOME MEASURES Relative risk (RR) of developing neovascular AMD, macular hemorrhage (MH), vitreous hemorrhage (VH), and requiring an ocular intervention (intravitreal anti-vascular endothelial growth factor (VEGF) therapy or pars plana vitrectomy (PPV)) within six months and one year. Patients with chronic atrial fibrillation (AF) on anticoagulation were separately evaluated for the same measures within 5 years after initiating therapy. RESULTS Treatment with warfarin was associated with higher risk of developing neovascular AMD at six months (RR,1.24, 95% CI, 1.12 - 1.39; P<.001) and one year (RR, 1.26, 95% CI, 1.14 - 1.40; P<.001) when compared to matched patients treated with DOACs. There was an increased risk of requiring intravitreal anti-VEGF therapy (6 months: RR, 1.30; 95% CI, 1.13-1.49; P<.001; 1 year: RR, 1.31, 95% CI, 0.72 - 2.05; P<.001) and PPV (6 months: RR, 1.16; 95% CI, 1.16-3.94; P = .01; 1 year: RR, 2.29, 95% CI, 1.30 - 4.05; P=.003). Among patients with AMD and AF treated with warfarin, there was an increased risk of ocular complications (neovascular AMD: RR, 1.25; 95% CI, 1.14-1.38; P<.001; MH: RR, 1.86; 95% CI, 1.47-2.35; P<.001; VH: RR, 2.22; 95% CI, 1.51-3.26; P<.001) and need for intravitreal anti-VEGF therapy (RR, 1.34; 95% CI, 1.18-1.52; P<.001) over an extended 5-year period. There was no significant difference in the development of major systemic hemorrhagic events between the two cohorts over five years. CONCLUSIONS Patients with non-neovascular AMD treated with warfarin were more likely to develop neovascular disease and require ocular intervention for hemorrhagic complications when compared to matched patients initiated on DOACs.
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Affiliation(s)
- Amer F Alsoudi
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - Euna Koo
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Karen Wai
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Prithvi Mruthyunjaya
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ehsan Rahimy
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA; Department of Ophthalmology, Palo Alto Medical Foundation, Palo Alto, CA, USA.
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Marston NA, Pirruccello JP, Melloni GEM, Kamanu F, Bonaca MP, Giugliano RP, Scirica BM, Wiviott SD, Bhatt DL, Steg PG, Raz I, Braunwald E, Libby P, Ellinor PT, Bick AG, Sabatine MS, Ruff CT. Clonal hematopoiesis, cardiovascular events and treatment benefit in 63,700 individuals from five TIMI randomized trials. Nat Med 2024:10.1038/s41591-024-03188-z. [PMID: 39107561 DOI: 10.1038/s41591-024-03188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 07/11/2024] [Indexed: 08/15/2024]
Abstract
Clonal hematopoiesis of indeterminate potential (CHIP) has been associated with an increased risk of cardiovascular (CV) disease in the general population. Currently, it is unclear whether this association is observed in large clinical trial cohorts with a high burden of existing CV disease or whether CV therapies can mitigate CHIP-associated CV risk. To address these questions, we studied 63,700 patients from five randomized trials that tested established therapies for CV disease, including treatments targeting the proteins PCSK9, SGLT2, P2Y12 and FXa. During a median follow-up of 2.5 years, 7,453 patients had at least one CV event (CV death, myocardial infarction (MI), ischemic stroke or coronary revascularization). The adjusted hazard ratio (aHR) for CV events for CHIP+ patients was 1.07 (95% CI: 0.99-1.16, P = 0.08), with consistent risk estimates across each component of CV risk. Significant heterogeneity in the risk of MI was observed, such that CHIP+ patients had a 30% increased risk of first MI (aHR = 1.31 (1.05-1.64), P = 0.02) but no increased risk of recurrent MI (aHR = 0.94 (0.79-1.13), Pint = 0.008), as compared to CHIP- patients. Moreover, no significant heterogeneity in treatment effect between individuals with and without CHIP was observed for any of the therapies studied in the five trials. These results indicate that in clinical trial populations, CHIP is associated with incident but not recurrent coronary events and that the presence of CHIP does not appear to identify patients who will derive greater benefit from commonly used CV therapies.
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Affiliation(s)
- Nicholas A Marston
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - James P Pirruccello
- Division of Cardiology, Institute for Human Genetics and Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Giorgio E M Melloni
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frederick Kamanu
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Robert P Giugliano
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, USA
| | - Philippe Gabriel Steg
- Division of Cardiology, Assistance Publique-Hopitaux de Paris, Universite de Paris, Paris, France
| | - Itamar Raz
- Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Eugene Braunwald
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Libby
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander G Bick
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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27
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Moser N, Omar MA, Koshman SL, Lin M, Youngson E, Kent W, Harten C. Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement. J Thorac Cardiovasc Surg 2024; 168:523-532.e3. [PMID: 37061910 DOI: 10.1016/j.jtcvs.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 03/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.
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Affiliation(s)
- Nils Moser
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - William Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Cheryl Harten
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
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28
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Dinshaw L, Steffel J, Götte A, Weiss TW, Waltenberger J, Kirchhof P. [Oral anticoagulation with Edoxaban for stroke prevention in patients with atrial fibrillation: Analysis of 1-year follow-up data of routine clinical practice in Germany, Austria and Switzerland (DACH) from the ETNA-AF registry]. Dtsch Med Wochenschr 2024; 149:e58-e66. [PMID: 38959945 PMCID: PMC11251752 DOI: 10.1055/a-2328-7240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Hintergrund Orale Nicht-Vitamin-K-Antikoagulanzien (NOAKs) sind sicher und wirksam in der Schlaganfallprävention bei Patienten mit Vorhofflimmern (AF). Es gibt jedoch nur wenige Daten zur Sicherheit und Wirksamkeit der oralen Antikoagulation mit Edoxaban im deutschsprachigen Raum in der Routineversorgung. Wir berichten über die Ein-Jahres-Ergebnisse der Patienten, die in Deutschland, Österreich und der Schweiz (DACH) im Rahmen der ETNA-AF-Europa-Studie mit Edoxaban zur Schlaganfallprävention behandelt wurden. Methoden Die ETNA-AF-Europa-Studie (Clinicaltrials.gov:NCT02 944 019) ist eine multizentrische, prospektive Beobachtungsstudie, in die mit Edoxaban zur Schlaganfallprävention bei AF behandelte Patienten (n = 13 092) aus 852 Zentren in 10 europäischen Ländern aufgenommen wurden. Die DACH-Kohorte besteht aus 5457 (41,7 %) Patienten aus Zentren in Deutschland, Österreich und der Schweiz. Resultate Die Patienten (74 Jahre, 2384 [44 %] Frauen) hatten im Mittel einen CHA 2 DS 2 -VASc-Score von 3,2 ± 1,4 – und eine labelkonforme Dosierung von Edoxaban wurde von 4309 Patienten (78,9 %) eingenommen. Nach einem Beobachtungszeitraum von einem Jahr traten bei 42 Patienten (0,8 %/Jahr) ein Schlaganfall oder ein systemisch embolisches Ereignis auf, und bei 36 Patienten (0,7 %/Jahr) kam es zu einem schweren Blutungsereignis, was bei 10 Patienten (0,2 %/Jahr) auf eine intrakranielle Blutung und bei 13 Patienten (0,3 %/Jahr) auf eine schwere gastrointestinale (GI) Blutung zurückzuführen war. Schwere und klinisch relevante, nicht schwere Blutungen zusammengenommen ereigneten sich bei insgesamt 72 Patienten (1,4 %/Jahr) über den Beobachtungszeitraum. Die Gesamtmortalität lag bei 179 Patienten (3,4 %/Jahr), wobei 85 (1,6 %/Jahr) an einer kardiovaskulären Todesursache verstarben. Bei Patienten mit einem erhöhten Lebensalter, einem gebrechlichen Allgemeinzustand, einem CHA 2 DS 2 -VASc-Score ≥ 4 zeigten sich eine höhere Gesamtmortalität und eine höhere Rate von Schlaganfällen sowie schweren Blutungsereignissen. Schlussfolgerung In Deutschland, Österreich und der Schweiz ist die Ereignisrate der Schlaganfälle und schweren Blutungen bei Patienten, die zur Schlaganfallprävention bei AF mit Edoxaban behandelt wurden, niedrig. Eine zunehmende Morbidität geht mit einer höheren Rate der relevanten klinischen Endpunkte einher.
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Affiliation(s)
- Leon Dinshaw
- Universitäres Herz- und Gefäßzentrum UKE Hamburg, Klinik und Poliklinik für Kardiologie, Hamburg
- Sana Hanse-Klinkum Wismar, Klinik für Innere Medizin und Kardiologie, Wismar
| | - Jan Steffel
- Swiss EP AG, Zürich, und Universität Zürich, Schweiz
| | - Andreas Götte
- Medizinische Klinik II, Kardiologie, St. Vincenz-Krankenhaus GmbH, Paderborn
| | - Thomas W. Weiss
- Institut für Kardiometabolik, Karl-Landsteiner-Gesellschaft, St. Pölten und Medizinische Fakultät, Sigmund-Freud-Privatuniversität, Wien
| | | | - Paulus Kirchhof
- Universitäres Herz- und Gefäßzentrum UKE Hamburg, Klinik und Poliklinik für Kardiologie, Hamburg
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Jangir R, Kumar M, Berwal A, Muzahid M, Tailor RR, Dulhanani M. Dorsal Scapular Osteochondroma in a Young Male: A Case Report and Literature Review. J Orthop Case Rep 2024; 14:10-15. [PMID: 39157478 PMCID: PMC11327675 DOI: 10.13107/jocr.2024.v14.i08.4628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/11/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction Osteochondromas are a unique group of benign bone tumors that are characterized by bony outgrowth covered by Cartilage. It has a peculiar micro-architecture as its cortices are extensions of those of parent bone and there is a continuity of medullary cavity; this is akin to branching in plants, rightly earning the name "Exostosis." Case Report We report a case of a 21-year-old male who presented with complaints of swelling on the upper back associated with mild discomfort. Examination confirmed a bony mass on the dorsal aspect of the scapula without any restricted range of motion of the shoulder joint. On the confirmation of diagnosis, en bloc excision was performed. Conclusion In conclusion, dorsal scapular osteochondromas are a rarity, and excision of the lesion is an effective management for symptomatic lesions.
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Affiliation(s)
- Rajat Jangir
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mohit Kumar
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Ayush Berwal
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mohammed Muzahid
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Rajat Raj Tailor
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mohit Dulhanani
- Department of Orthopaedics, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
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30
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Lenard A, Hermann SA, Stoll F, Burhenne J, Foerster KI, Mikus G, Meid AD, Haefeli WE, Blank A. Effect of Clarithromycin, a Strong CYP3A and P-glycoprotein Inhibitor, on the Pharmacokinetics of Edoxaban in Healthy Volunteers and the Evaluation of the Drug Interaction with Other Oral Factor Xa Inhibitors by a Microdose Cocktail Approach. Cardiovasc Drugs Ther 2024; 38:747-756. [PMID: 36870039 PMCID: PMC11266212 DOI: 10.1007/s10557-023-07443-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE We assessed the differential effect of clarithromycin, a strong inhibitor of cytochrome P450 (CYP) 3A4 and P-glycoprotein, on the pharmacokinetics of a regular dose of edoxaban and on a microdose cocktail of factor Xa inhibitors (FXaI). Concurrently, CYP3A activity was determined with a midazolam microdose. METHODS In an open-label fixed-sequence trial in 12 healthy volunteers, the pharmacokinetics of a microdosed FXaI cocktail (μ-FXaI; 25 μg apixaban, 50 μg edoxaban, and 25 μg rivaroxaban) and of 60 mg edoxaban before and during clarithromycin (2 x 500 mg/d) dosed to steady-state was evaluated. Plasma concentrations of study drugs were quantified using validated ultra-performance liquid chromatography-tandem mass spectrometry methods. RESULTS Therapeutic clarithromycin doses increased the exposure of a therapeutic 60 mg dose of edoxaban with a geometric mean ratio (GMR) of the area under the plasma concentration-time curve (AUC) of 1.53 (90 % CI: 1.37-1.70; p < 0.0001). Clarithromycin also increased the GMR (90% CI) of the exposure of microdosed FXaI apixaban to 1.38 (1.26-1.51), edoxaban to 2.03 (1.84-2.24), and rivaroxaban to 1.44 (1.27-1.63). AUC changes observed for the therapeutic edoxaban dose were significantly smaller than those observed with the microdose (p < 0.001). CONCLUSION Clarithromycin increases FXaI exposure. However, the magnitude of this drug interaction is not expected to be clinically relevant. The edoxaban microdose overestimates the extent of the drug interaction with the therapeutic dose, whereas AUC ratios for apixaban and rivaroxaban were comparable to the interaction with therapeutic doses as reported in the literature. TRIAL REGISTRATION EudraCT Number: 2018-002490-22.
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Affiliation(s)
- Alexander Lenard
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Simon A Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Juergen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany.
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Kirchhof P, Bakhai A, de Asmundis C, de Groot JR, Deharo JC, Kelly P, Lopez-de-Sa E, Monteiro P, Fronk EM, Lamparter M, Laeis P, Smolnik R, Steffel J, Waltenberger J, Weiss TW, De Caterina R. Long-term effectiveness and safety of edoxaban in patients with atrial fibrillation: 4-year data from the ETNA-AF-Europe study. Int J Cardiol 2024; 408:132118. [PMID: 38697397 DOI: 10.1016/j.ijcard.2024.132118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/28/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND To assess long-term effectiveness and safety of edoxaban in Europe. METHODS AND RESULTS ETNA-AF-Europe, a prospective, multinational, multi-centre, post-authorisation, observational study was conducted in agreement with the European Medicines Agency. The primary and secondary objectives assessed real-world safety (including bleeding and deaths) and effectiveness (including stroke, systemic embolic events and clinical edoxaban use), respectively. Median (interquartile range) age of the 13,164 patients was 75.0 (68.0-80.0) years; CHA2DS2-VASc and HAS-BLED scores were 3.0 (2.0-4.0) and 2.0 (1.0-2.0), respectively. Follow-up duration was 3.98 (3.21-4.05) years. Patients on edoxaban 30 mg (n = 3042) at baseline were older (80.0 vs 73.0 years), more likely assessed as frail by investigators (27.0% vs 6.6%) and had more comorbidities than those on edoxaban 60 mg (n = 9617; missing dosing information for n = 505). Annualised event rates of all-cause and cardiovascular death in the overall population, edoxaban 60 mg and edoxaban 30 mg groups were 4.1%, 2.8% and 8.4%, and 1.0%, 0.7% and 2.0%, respectively. Annualised rates of stroke were relatively constant throughout the follow-up, transient ischaemic attack and systemic embolism were < 1% in the overall population. Rates of any major and major gastrointestinal bleeding were low, with slightly higher rates for edoxaban 30 vs 60 mg group. Intracranial haemorrhage was uncommon (0.2%). CONCLUSIONS In European patients with AF, long-term therapy with edoxaban is associated with low and relatively constant annualised rates of stroke and major bleeding. Differences in outcomes between the two approved doses are attributable to differences in clinical characteristics.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK; Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Martinistraße 52, Hamburg 20246, Germany; German Center for Cardiovascular Sciences (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Ameet Bakhai
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, Belgium
| | - Joris R de Groot
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam 1105 AZ, the Netherlands
| | - Jean Claude Deharo
- AP-HM, Aix Marseille University, Hospital Timone, Cardiologie, Rythmologie, 264 rue Saint-Pierre, Marseille 13005, France
| | - Peter Kelly
- Department of Neurology, HRB Stroke Clinical Trials Network Ireland, University College Dublin/Mater Misericordiae University Hospital, Eccles St, Northside, Dublin, Ireland
| | - Esteban Lopez-de-Sa
- Cardiology Department, Hospital Universitario La Paz, IDIPAZ, Madrid 28046, Spain
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitario de Coimbra, Praceta Mota Pinto 3000-075, Coimbra, Portugal
| | - Eva-Maria Fronk
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | | | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | - Rüdiger Smolnik
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, Munich 81379, Germany
| | | | - Johannes Waltenberger
- Chair of Cardiology and Vascular Medicine, University of Münster, Schlossplatz 2, Münster 48149, Germany; Diagnostic and Therapeutic Heart Center, Kappelistr. 35, Zurich 8002, Switzerland
| | - Thomas W Weiss
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Polten, Austria
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa, and Cardiology Division, Pisa University Hospital, 56124 Pisa, Italy; and Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy.
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Simon TG, Singer DE, Zhang Y, Mastrorilli JM, Cervone A, DiCesare E, Lin KJ. Comparative Effectiveness and Safety of Apixaban, Rivaroxaban, and Warfarin in Patients With Cirrhosis and Atrial Fibrillation : A Nationwide Cohort Study. Ann Intern Med 2024; 177:1028-1038. [PMID: 38976880 DOI: 10.7326/m23-3067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events, albeit with increased bleeding risk, among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. OBJECTIVE To compare the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. DESIGN Population-based cohort study. SETTING Two U.S. claims data sets (Medicare and Optum's de-identified Clinformatics Data Mart Database [2013 to 2022]). PARTICIPANTS 1:1 propensity score (PS)-matched patients with cirrhosis and nonvalvular AF initiating use of apixaban, rivaroxaban, or warfarin. MEASUREMENTS Primary outcomes included ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). Database-specific and pooled PS-matched rate differences (RDs) per 1000 person-years (PY) and Cox proportional hazard ratios (HRs) with 95% CIs were estimated, controlling for 104 preexposure covariates. RESULTS Rivaroxaban initiators had significantly higher rates of major hemorrhagic events than apixaban initiators (RD, 33.1 per 1000 PY [95% CI, 12.9 to 53.2 per 1000 PY]; HR, 1.47 [CI, 1.11 to 1.94]) but no significant differences in rates of ischemic events or death. Consistently higher rates of major hemorrhage were found with rivaroxaban across subgroup and sensitivity analyses. Warfarin initiators also had significantly higher rates of major hemorrhage than apixaban initiators (RD, 26.1 per 1000 PY [CI, 6.8 to 45.3 per 1000 PY]; HR, 1.38 [CI, 1.03 to 1.84]), particularly hemorrhagic stroke (RD, 9.7 per 1000 PY [CI, 2.2 to 17.2 per 1000 PY]; HR, 2.85 [CI, 1.24 to 6.59]). LIMITATION Nonrandomized treatment selection. CONCLUSION Among patients with cirrhosis and nonvalvular AF, initiators of rivaroxaban versus apixaban had significantly higher rates of major hemorrhage and similar rates of ischemic events and death. Initiation of warfarin versus apixaban also contributed to significantly higher rates of major hemorrhagic events, including hemorrhagic stroke. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Tracey G Simon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School; Division of Gastroenterology and Hepatology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School; and Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, Massachusetts (T.G.S.)
| | - Daniel E Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.E.S.)
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Julianna M Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Elyse DiCesare
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Y.Z., J.M.M., A.C., E.D.)
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, and Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (K.J.L.)
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Alikhan R, Nour M, Yasaka M, Ofori-Asenso R, Axelsson-Chéramy S, Chen H, Seghal V, Yokobori S, Koch B, Tiede A, Cash BD, Maegele M, Singer AJ. Design and rationale for REVERXaL: A real-world study of patients with factor Xa inhibitor-associated major bleeds. Thromb Res 2024; 240:109046. [PMID: 38905928 DOI: 10.1016/j.thromres.2024.109046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND The prevalence of anticoagulation treatment is increasing as an aging global population faces a high burden of cardiovascular comorbidities. Direct oral anticoagulants, including factor Xa inhibitors (FXai), are replacing vitamin K antagonists as the most commonly prescribed treatment for reducing risk of thrombotic events. While the risk of FXai-associated spontaneous bleeds is established, less is understood about their management and the effect of treatment on clinical and patient-reported outcomes. The primary objectives of the REVERXaL study are to describe patient characteristics, health care interventions during the acute-care phase, in-hospital outcomes, and associations between timing of reversal/replacement agent administration and in-hospital outcomes. Secondary/exploratory objectives focus on clinical assessments and patient-reported outcome measures (PROMs) at 30 and 90 days. METHODS REVERXaL is a multinational, observational study of hospitalized patients with FXai-associated major bleeds in Germany, Japan, the United Kingdom, and the United States. The study includes 2 cohorts of approximately 2000 patients each. Cohort A is a historic cohort for whom medical chart data will be collected from hospitalization to discharge for patients admitted for major bleeds during FXai use within 2 years prior to enrollment of Cohort B. Cohort B will prospectively enroll patients administered any reversal/replacement agent during hospitalization to manage FXai-associated major bleeds and will include the collection of clinical outcomes and PROMs data over 3 months. CONCLUSIONS REVERXaL will generate insights on patient characteristics, treatment approaches, and associated outcomes in patients hospitalized with FXai-associated major bleeds. These data may inform clinical practice and streamline treatment pathways in this population. REGISTRATION URL: https://www. CLINICALTRIALS gov; unique identifier: NCT06147830.
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Affiliation(s)
- Raza Alikhan
- University Hospital of Wales and Cardiff University School of Medicine, Cardiff, Wales, United Kingdom.
| | - May Nour
- University of California, Los Angeles, California, United States
| | | | | | | | - Hungta Chen
- AstraZeneca, Wilmington, Delaware, United States
| | - Vinay Seghal
- University College London Hospital, London, United Kingdom
| | | | - Bruce Koch
- AstraZeneca, Wilmington, Delaware, United States
| | | | - Brooks D Cash
- University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Marc Maegele
- Cologne-Merheim Medical Center, Cologne, Germany
| | - Adam J Singer
- Stony Brook University, New York, New York, United States
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Ezekowitz MD, Alameh I, Kamareddine M. The ATHERO-AF Study: A Need to Optimize AF Management in an Environment of Medical Advancement. JACC. ADVANCES 2024; 3:101118. [PMID: 39105111 PMCID: PMC11299570 DOI: 10.1016/j.jacadv.2024.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Affiliation(s)
- Michael D. Ezekowitz
- Sydney Kimmel Medical School, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Cardiology Department, Lankenau Medical Centre, Bryn Mawr Hospital/Mainline Health, Wynnewood, Pennsylvania, USA
| | - Ibrahim Alameh
- Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
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Ding WY, Calvert P, Lip GYH, Gupta D. Novel stroke prevention strategies following catheter ablation for atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:690-696. [PMID: 38428582 DOI: 10.1016/j.rec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Negri S, Mazzuca E, Lococo F, Mondoni M, Covino M, Kuzmych K, Agati S, Amata M, Arcoleo G, Gabbrielli L, Pancani R, Tedeschi E, Baiamonte P, Sassu A, Patrucco F, Foci V, Marchetti G, Vernuccio F, Zanardi E, Gaccione AT, Sorino C. Pneumomediastinum in COVID-19: Risk factors and outcomes from a multicentre case-control study. Respir Med 2024; 230:107684. [PMID: 38823564 DOI: 10.1016/j.rmed.2024.107684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND An increased incidence of pneumomediastinum has been observed among patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. The study aimed to identify risk factors for COVID-19-associated pneumomediastinum and investigate the impact of pneumomediastinum on clinical outcomes. METHODS In this multicentre retrospective case-control study, we included consecutive patients with COVID-19 pneumonia and pneumomediastinum hospitalized from March 2020 to July 2020 at ten centres; then, we identified a similarly sized control group of consecutive patients hospitalized with COVID-19 pneumonia and respiratory failure who did not develop pneumomediastinum during the same period. Clinical, laboratory, and radiological characteristics, as well as respiratory support and outcomes, were collected and compared between the two groups. Risk factors of pneumomediastinum were assessed by multivariable logistic analysis. RESULTS Overall 139 patients with pneumomediastinum and 153 without pneumomediastinum were analysed. Lung involvement ≥75 %, consolidations, body mass index (BMI) < 22 kg/m2, C-reactive protein (CRP) > 150 mg/L, D-dimer >3000 ng/mL FEUs, and smoking exposure >20 pack-year were all independently correlated with the occurrence of pneumomediastinum. Patients with pneumomediastinum had a longer hospital stay (mean ± SD 31.2 ± 20.2 days vs 19.6 ± 14.2, p < 0.001), higher intubation rate (73/139, 52.5 % vs 27/153, 17.6 %, p < 0.001), and in-hospital mortality (68/139, 48.9 % vs 36/153, 23.5 %, p < 0.001) compared to controls. CONCLUSIONS Extensive lung parenchyma involvement, consolidations, low BMI, high inflammatory markers, and tobacco exposure are associated with a greater risk of pneumomediastinum in COVID-19 pneumonia. This complication significantly worsens the outcomes.
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Affiliation(s)
- Stefano Negri
- Department of Pulmonology, Sant'Anna Hospital of Como, Italy
| | - Emilia Mazzuca
- Pulmonology, A.O.O.R. Villa Sofia-Cervello, Palermo, Italy
| | - Filippo Lococo
- Department of Thoracic Surgery, Fondazione Policlinico Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy; Department of Thoracic Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Marcello Covino
- Emergency Department - Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Khrystyna Kuzmych
- Department of Thoracic Surgery, Fondazione Policlinico Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy; Department of Thoracic Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sergio Agati
- Department of Pulmonology, Sant'Anna Hospital of Como, Italy
| | - Marta Amata
- Pulmonology, A.O.O.R. Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ersilia Tedeschi
- Pulmonology, Ente Ecclesiastico Ospedale "F. Miulli" Acquaviva delle Fonti-Bari, Italy
| | | | - Alessandro Sassu
- Pulmonology and Semintensive Respiratory Unit, Ospedale Santissima Trinità, Cagliari, Italy
| | - Filippo Patrucco
- Pulmonology, Dipartimento Medico, AOU Maggiore della Carità di Novara, Italy
| | - Valentina Foci
- Pulmonology, Ospedali Riuniti di Livorno, Azienda Usl Toscana Nord-Ovest, Italy
| | | | - Federica Vernuccio
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Italy
| | - Erika Zanardi
- Pulmonology, Ospedale di Cittadella, AULSS6-Euganea, Padova, Italy
| | | | - Claudio Sorino
- Department of Pulmonology, Sant'Anna Hospital of Como, Italy; Faculty of Medicine and Surgery, University of Insubria, Varese, Italy.
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Bertici NS, Tudoran C, Bertici RA, Fira-Mladinescu O, Jianu DC, Streian CG, Staicu RE, Manzur AR, Lascu A. Concomitance of Pericardial Tamponade and Pulmonary Embolism in an Invasive Mucinous Lung Adenocarcinoma with Atypical Presentation: Diagnostic and Therapeutic Pitfalls-Case Report and Literature Review. Int J Mol Sci 2024; 25:8413. [PMID: 39125981 PMCID: PMC11313361 DOI: 10.3390/ijms25158413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
The invasive mucinous adenocarcinoma of the lungs (LIMA) is an uncommon histological subtype of the mucinous adenocarcinoma. In this article, we present the case of a patient with a very high cardiovascular risk profile, diagnosed with LIMA, pericardial tamponade due to secondary dissemination, and pulmonary embolism, whose management rouses many challenges. Despite receiving the correct anticoagulant and antiaggregant therapy, our patient developed repeated acute major cardiovascular events leading to a fatal outcome. To gather additional information on LIMA and the above cluster of pathologies, we performed the first research of the international medical literature for scientific articles published in the last eight years on PubMed, ResearchGate, Clarivate, and Google Scholar. As the first literature research failed to identify any case similar to our patient, we performed a second study of the same databases for subjects with lung adenocarcinoma instead of LIMA and the same comorbidities, and we found 10 cases. LIMA is a less frequent type of adenocarcinoma, with polymorphic radiologic appearances on the chest computed tomography, frequently mimicking pneumonia, and thus delaying the diagnosis and therapy. It has a worse prognosis and higher mortality than the common adenocarcinoma, but information on its secondary dissemination and complications is still required.
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Affiliation(s)
- Nicoleta Sorina Bertici
- Department XIII, Pulmonology University Clinic, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania; (N.S.B.); (O.F.-M.)
- Center for Research and Innovation in Personalised Medicine of Respiratory Diseases, Pulmonology University Clinic, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania;
- IInd Pulmonology Ward, Clinical Hospital of Infectious Diseases and Pulmonology “Victor Babeș” Timișoara, Gheorghe Adam Street 13, 300310 Timișoara, Romania
| | - Cristina Tudoran
- Department VII, Internal Medicine II, Discipline of Cardiology, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
- Center of Molecular Research in Nephrology and Vascular Disease, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
- Cardiology Clinic, County Emergency Hospital “Pius Brinzeu”, Liviu Rebreanu, No. 156, 300723 Timișoara, Romania
| | - Razvan Adrian Bertici
- Center for Research and Innovation in Personalised Medicine of Respiratory Diseases, Pulmonology University Clinic, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania;
- Doctoral School Medicine-Pharmacy, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania; (R.E.S.); (A.R.M.)
| | - Ovidiu Fira-Mladinescu
- Department XIII, Pulmonology University Clinic, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania; (N.S.B.); (O.F.-M.)
- Center for Research and Innovation in Personalised Medicine of Respiratory Diseases, Pulmonology University Clinic, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania;
- IInd Pulmonology Ward, Clinical Hospital of Infectious Diseases and Pulmonology “Victor Babeș” Timișoara, Gheorghe Adam Street 13, 300310 Timișoara, Romania
| | - Dragos Catalin Jianu
- Department VIII, Clinic of Neurology I, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania;
- Centre for Cognitive Research in Neuropsychiatric Pathology (Neuropsy-Cog), Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
| | - Caius Glad Streian
- Department VI Cardiology-Cardiovascular Surgery, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania;
- Advanced Research Center of the Institute for Cardiovascular Diseases, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
- Institute for Cardiovascular Diseases of Timișoara, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Gheorghe Adam Street, No. 13A, 300310 Timișoara, Romania;
| | - Raluca Elisabeta Staicu
- Doctoral School Medicine-Pharmacy, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania; (R.E.S.); (A.R.M.)
- Institute for Cardiovascular Diseases of Timișoara, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Gheorghe Adam Street, No. 13A, 300310 Timișoara, Romania;
| | - Andrei Raul Manzur
- Doctoral School Medicine-Pharmacy, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania; (R.E.S.); (A.R.M.)
- Institute for Cardiovascular Diseases of Timișoara, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Gheorghe Adam Street, No. 13A, 300310 Timișoara, Romania;
| | - Ana Lascu
- Institute for Cardiovascular Diseases of Timișoara, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Gheorghe Adam Street, No. 13A, 300310 Timișoara, Romania;
- Department III Functional Sciences—Pathophysiology, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
- Centre for Translational Research and Systems Medicine, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2, 300041 Timișoara, Romania
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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40
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Huang X, Xu W, Wu G, Li R, Gu P, Zheng Q, Liu X, Dai H, Lin X, Liu Y, Du X, Su J, Zhang W, Zhang M, Zhu Z, Huang X, Huang N, Zhang J. Efficacy and safety of dabigatran and rivaroxaban in atrial fibrillation patients with impaired liver function: a multicenter retrospective cohort study. Eur J Clin Pharmacol 2024; 80:1141-1150. [PMID: 38605248 DOI: 10.1007/s00228-024-03689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with impaired liver function (ILF) have not been sufficiently studied. The aim of this study was to evaluate the efficacy and safety of DOACs for stroke prevention in patients with AF and ILF. METHOD This study was based on data from 15 centers in China, including 4,982 AF patients. The patients were divided into 2 subgroups based on their liver function status: patients with normal liver function (NLF)(n = 4213) and patients with ILF (n = 769). Logistic regression analysis was used to investigate the risk of total bleeding, major bleeding, thromboembolism, and all-cause deaths in AF patients with NLF and ILF after taking dabigatran or rivaroxaban, respectively. RESULTS Among AF patients treated with dabigatran or rivaroxaban, patients with ILF were associated with significantly higher major bleeding, compared with NLF patients (aOR: 4.797; 95% CI: 2.224-10.256; P < 0.001). In patients with NLF, dabigatran (n = 2011) had considerably lower risk of total bleeding than rivaroxaban (n = 2202) (aOR: 1.23; 95% CI: 1.002-1.513; P = 0.049). In patients with ILF, dabigatran (n = 321) significantly favored lower risks of major bleeding compared with rivaroxaban(n = 448) (aOR: 5.484; 95% CI: 1.508-35.269; P = 0.026). CONCLUSION After using dabigatran or rivaroxaban, patients with ILF had remarkably increased risk of major bleeding compared with patients with NLF. In AF patients with NLF, dabigatran had the distinct strength of significantly reduced risk of total bleeding compared with rivaroxaban. In patients with AF and ILF, dabigatran use was associated with lower risk for major bleeding compared with rivaroxaban.
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Affiliation(s)
- Xinhai Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Wenlin Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Guilan Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Ruijuan Li
- Department of Pharmacy, Tongji Shanxi Hospital, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Ping Gu
- Department of Pharmacy, Suining Central Hospital, Suining, Sichuan, 629000, China
| | - Qiaowei Zheng
- Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiumei Liu
- Department of Pharmacy, People's Hospital of He'nan University of Chinese Medicine, People's Hospital of Zhengzhou), Zhengzhou, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Xiangsheng Lin
- Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fujian, China
| | - Yuxin Liu
- Department of Pharmacy, Huaihe Hospital of Henan University, kaifeng, China
| | - Xiaoming Du
- Department of Pharmacy, Shengjing hospital of China Medical University, Shenyang, China
| | - Jun Su
- Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
| | - Wang Zhang
- Department of Pharmacy, The first people's Hospital of Changde City, Changde, Hunan, China
| | - Min Zhang
- Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Qingdao, Shandong, China
| | - Zhu Zhu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, China
| | - Xiaohong Huang
- Department of Pharmacy, Zhangzhou affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji(Wuhan) Hospital, Wuhan, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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Genovesi S, Camm AJ, Covic A, Burlacu A, Meijers B, Franssen C, Luyckx V, Liakopoulos V, Alfano G, Combe C, Basile C. Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation. Nephrol Dial Transplant 2024; 39:1248-1257. [PMID: 38816212 PMCID: PMC11288792 DOI: 10.1093/ndt/gfae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Indexed: 06/01/2024] Open
Abstract
The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25-30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - A John Camm
- St. George's University of London, London, UK
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Alexandru Burlacu
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Björn Meijers
- Nephrology Unit, University Hospitals Leuven and Department of Microbiology, Immunology and Organ Transplantation, KU Leuven, Leuven, Belgium
| | - Casper Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Valerie Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Vassilios Liakopoulos
- Second Department of Nephrology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Christian Combe
- Department of Nephrology, CHU de Bordeaux and INSERM U1026, University of Bordeaux, Bordeaux, France
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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42
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Nayak T, Lohrmann G, Passman R. Controversies in Diagnosis and Management of Atrial Fibrillation. Cardiol Rev 2024:00045415-990000000-00308. [PMID: 39072621 DOI: 10.1097/crd.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Early detection of atrial fibrillation (AF) plays an important role in decreasing adverse cardiovascular outcomes. It is estimated, however, that one-third of those with AF are asymptomatic and may experience the adverse effects of the arrhythmia prior to being detected clinically. In the past, AF was diagnosed on 12-lead electrocardiogram or medically prescribed external monitors. The development of device-monitoring technologies capable of recording AF or AF-surrogates such as atrial high-rate episodes on cardiovascular implantable electronic devices or photoplethysmography/electrocardiogram on consumer-grade wearable devices, has resulted in increased recognition of device-detected, subclinical, AF. Recent studies reveal information about the stroke risk associated with these subclinical events and the response to anticoagulation and raise important questions about the use of both medical and direct-to-consumer AF detection devices for screening purposes. In addition to screening and detection of AF, emerging studies are also being conducted on different strategies for maintenance of sinus rhythm and stroke prevention including catheter ablation and left atrial appendage occlusion. This review aims to highlight recent developments and future studies in these areas.
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Affiliation(s)
- Tanvi Nayak
- From the Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Graham Lohrmann
- Cardiology Division, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rod Passman
- Cardiology Division, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL
- Northwestern University Center for Arrhythmia Research, Chicago, IL
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43
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Escobar C, Palacios B, Villarreal M, Gutiérrez M, Capel M, Aranda U, Hernández I, García M, Lledó L, Arenillas JF. Clinical and Economic Consequences of a First Major Bleeding Event in Patients Treated with Direct Factor Xa Inhibitors in Spain: A Long-Term Observational Study. J Clin Med 2024; 13:4253. [PMID: 39064293 PMCID: PMC11278163 DOI: 10.3390/jcm13144253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
Aims: Our aims were to describe the clinical characteristics, adverse clinical events, healthcare resource utilization (HCRU) and costs of patients with major bleeding during direct Factor Xa inhibitor (FXai) use. Methods: This is a retrospective cohort study that included secondary data from computerized health records of seven Spanish Autonomous Communities. Patients with a first major bleeding during treatment with a direct FXai were analyzed during a 3-year period. Results: Of 8972 patients taking a direct FXai, 470 (5.24%) had major bleeding (mean age (SD) 77.93 (9.71) years, 61.06% women). The most frequent indications for using FXais were atrial fibrillation (78.09%) and venous thromboembolism (17.66%). Among those with major bleeding, 88.94% presented with gastrointestinal bleeding, 6.81% intracranial bleeding, 2.13% trauma-related bleeding and 4.26% other major bleeding. Prothrombin complex concentrates were used in 63.19%, followed by transfusion of blood products (20.21%) and Factor VIIa (7.66%). In total, 4.26% of patients died in the hospital due to the first major bleeding. At the study end (after 3-year follow-up), 28.94% of the patients had died, 12.34% had a myocardial infarction and 9.15% an ischemic stroke. At year 3, overall bleeding cost was EUR 5,816,930.5, of which 79.74% accounted for in-hospital costs to treat the bleeding episode. Conclusions: Despite the use of replacement agents being high, major events were common, with a 29% mortality at the end of the follow up, and HCRU and costs were high, evidencing the need for new reversal treatment strategies.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain
| | - Beatriz Palacios
- BioPharmaceuticals Medical, AstraZeneca, 28050 Madrid, Spain; (B.P.); (M.V.); (M.G.)
| | - Miriam Villarreal
- BioPharmaceuticals Medical, AstraZeneca, 28050 Madrid, Spain; (B.P.); (M.V.); (M.G.)
| | - Martín Gutiérrez
- BioPharmaceuticals Medical, AstraZeneca, 28050 Madrid, Spain; (B.P.); (M.V.); (M.G.)
| | - Margarita Capel
- BioPharmaceuticals Corporate Affairs & Market Access, AstraZeneca, 28050 Madrid, Spain;
| | - Unai Aranda
- Global Medical Affairs, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD 20878, USA;
| | | | - María García
- Atrys Health, 28002 Madrid, Spain; (I.H.); (M.G.); (L.L.)
| | - Laura Lledó
- Atrys Health, 28002 Madrid, Spain; (I.H.); (M.G.); (L.L.)
| | - Juan F. Arenillas
- Neurology Department, Comprehensive Stroke Center, Hospital Clínico Universitario, 47003 Valladolid, Spain;
- Clinical Neurosciences Research Group, Department of Medicine, University of Valladolid, 47003 Valladolid, Spain
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Nanji K, Xie J, Hatamnejad A, Pur DR, Phillips M, Zeraatkar D, Wong TY, Guymer RH, Kaiser PK, Sivaprasad S, Bhandari M, Steel DH, Wykoff CC, Chaudhary V. Exploring the fragility of meta-analyses in ophthalmology: a systematic review. Eye (Lond) 2024:10.1038/s41433-024-03255-2. [PMID: 39033242 DOI: 10.1038/s41433-024-03255-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 06/13/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024] Open
Abstract
OBJECTIVE The fragility index (FI) of a meta-analysis evaluates the extent that the statistical significance can be changed by modifying the event status of individuals from included trials. Understanding the FI improves the interpretation of the results of meta-analyses and can help to inform changes to clinical practice. This review determined the fragility of ophthalmology-related meta-analyses. METHODS Meta-analyses of randomized controlled trials with binary outcomes published in a journal classified as 'Ophthalmology' according to the Journal Citation Report or an Ophthalmology-related Cochrane Review were included. An iterative process determined the FI of each meta-analysis. Multivariable linear regression modeling evaluated the relationship between the FI and potential predictive factors in statistically significant and non-significant meta-analyses. RESULTS 175 meta-analyses were included. The median FI was 6 (Q1-Q3: 3-12). This meant that moving 6 outcomes from one group to another would reverse the study's findings. The FI was 1 for 18 (10.2%) of the included meta-analyses and was ≤5 for 75 (42.4%) of the included meta-analyses. The number of events (p < 0.001) and the p-value (p < 0.001) were the best predictors of the FI in both significant and non-significant meta-analyses. CONCLUSION The statistical significance of meta-analyses in ophthalmology often hinges on the outcome of a few patients. The number of events and the p-value are the most important factors in determining the fragility of the evidence. The FI is an easily interpretable measure that can supplement the reader's understanding of the strength of the evidence being presented. PROSPERO REGISTRATION CRD42022377589.
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Affiliation(s)
- Keean Nanji
- Department of Surgery, Division of Ophthalmology, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jim Xie
- Department of Surgery, Division of Ophthalmology, McMaster University, Hamilton, ON, Canada
| | - Amin Hatamnejad
- Department of Surgery, Division of Ophthalmology, McMaster University, Hamilton, ON, Canada
| | - Daiana R Pur
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mark Phillips
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Robyn H Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Department of Surgery (Ophthalmology), The University of Melbourne, Melbourne, Australia
| | - Peter K Kaiser
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - David H Steel
- Bioscience Institute, Newcastle University, Newcastle Upon Tyne, UK
- Sunderland Eye Infirmary, Sunderland, UK
| | - Charles C Wykoff
- Retina Consultants of Texas, Houston, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Varun Chaudhary
- Department of Surgery, Division of Ophthalmology, McMaster University, Hamilton, ON, Canada.
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Chen Q, Baek J, Goldberg R, Tjia J, Lapane K, Alcusky M. To treat or not to treat: a comparative effectiveness analysis of oral anticoagulant outcomes among U.S. nursing home residents with atrial fibrillation. BMC Geriatr 2024; 24:619. [PMID: 39030486 PMCID: PMC11264888 DOI: 10.1186/s12877-024-05186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/28/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Nursing home residents with atrial fibrillation are at high risk for ischemic stroke, but most are not treated with anticoagulants. This study compared the effectiveness and safety between oral anticoagulant (OAC) users and non-users. METHODS We conducted a new-user retrospective cohort study by using Minimum Data Set 3.0 assessments linked with Medicare claims. The participants were Medicare fee-for-service beneficiaries with atrial fibrillation residing in US nursing homes between 2011 and 2016, aged ≥ 65 years. The primary outcomes were occurrence of an ischemic stroke or systemic embolism (effectiveness), occurrence of intracranial or extracranial bleeding (safety) and net clinical outcome (effectiveness or safety outcomes). Secondary outcomes included total mortality and a net clinical and mortality outcome. Cox proportional hazards and Fine and Grey models estimated multivariable adjusted hazard ratios (aHRs) and sub-distribution hazard ratios (sHRs). RESULTS Outcome rates were low (effectiveness: OAC: 0.86; non-users: 1.73; safety: OAC: 2.26; non-users: 1.75 (per 100 person-years)). OAC use was associated with a lower rate of the effectiveness outcome (sHR: 0.69; 95% Confidence Interval (CI): 0.61-0.77), higher rates of the safety (sHR: 1.70; 95% CI: 1.58-1.84) and net clinical outcomes (sHR: 1.20; 95% CI: 1.13-1.28) lower rate of all-cause mortality outcome (sHR: 0.60; 95% CI: 0.59-0.61), and lower rate of the net clinical and mortality outcome (sHR: 0.60; 95% CI: 0.59-0.61). Warfarin users, but not DOAC users, had a higher rate of the net clinical outcome versus OAC non-users. CONCLUSIONS Our results support the benefits of treatment with OACs to prevent ischemic strokes and increase longevity, while highlighting the need to weigh apparent benefits against elevated risk for bleeding. Results were consistent with net favorability of DOACs versus warfarin.
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Affiliation(s)
- Qiaoxi Chen
- Population Health Sciences Program, Morningside Graduate School of Biomedical Sciences, University of Massachusetts Chan Medical School, Worcester, MA, 01655, USA.
| | - Jonggyu Baek
- Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Robert Goldberg
- Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Kate Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Matthew Alcusky
- Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA.
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Vontetsianos A, Chynkiamis N, Gounaridi MI, Anagnostopoulou C, Lekka C, Zaneli S, Anagnostopoulos N, Oikonomou E, Vavuranakis M, Rovina N, Papaioannou AI, Kaltsakas G, Koulouris N, Vogiatzis I. Exercise Intolerance Is Associated with Cardiovascular Dysfunction in Long COVID-19 Syndrome. J Clin Med 2024; 13:4144. [PMID: 39064183 PMCID: PMC11278210 DOI: 10.3390/jcm13144144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Cardiorespiratory complications are commonly reported among patients with long COVID-19 syndrome. However, their effects on exercise capacity remain inconclusive. We investigated the impact of long COVID-19 on exercise tolerance combining cardiopulmonary exercise testing (CPET) with resting echocardiographic data. Methods: Forty-two patients (55 ± 13 years), 149 ± 92 days post-hospital discharge, and ten healthy age-matched participants underwent resting echocardiography and an incremental CPET to the limit of tolerance. Left ventricular global longitudinal strain (LV-GLS) and the left ventricular ejection fraction (LVEF) were calculated to assess left ventricular systolic function. The E/e' ratio was estimated as a surrogate of left ventricular end-diastolic filling pressures. Tricuspid annular systolic velocity (SRV) was used to assess right ventricular systolic performance. Through tricuspid regurgitation velocity and inferior vena cava diameter, end-respiratory variations in systolic pulmonary artery pressure (PASP) were estimated. Peak work rate (WRpeak) and peak oxygen uptake (VO2peak) were measured via a ramp incremental symptom-limited CPET. Results: Compared to healthy participants, patients had a significantly (p < 0.05) lower LVEF (59 ± 4% versus 49 ± 5%) and greater left ventricular end-diastolic diameter (48 ± 2 versus 54 ± 5 cm). In patients, there was a significant association of E/e' with WRpeak (r = -0.325) and VO2peak (r = -0.341). SRV was significantly associated with WRpeak (r = 0.432) and VO2peak (r = 0.556). LV-GLS and PASP were significantly correlated with VO2peak (r = -0.358 and r = -0.345, respectively). Conclusions: In patients with long COVID-19 syndrome, exercise intolerance is associated with left ventricular diastolic performance, left ventricular end-diastolic pressure, PASP and SRV. These findings highlight the interrelationship of exercise intolerance with left and right ventricular performance in long COVID-19 syndrome.
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Affiliation(s)
- Angelos Vontetsianos
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Nikolaos Chynkiamis
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
- Thorax Research Foundation, 11521 Athens, Greece
| | - Maria Ioanna Gounaridi
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.I.G.); (E.O.); (M.V.)
| | - Christina Anagnostopoulou
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Christiana Lekka
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Stavroula Zaneli
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Nektarios Anagnostopoulos
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.I.G.); (E.O.); (M.V.)
| | - Manolis Vavuranakis
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.I.G.); (E.O.); (M.V.)
| | - Nikoletta Rovina
- 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Andriana I. Papaioannou
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Georgios Kaltsakas
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
- Lane Fox Respiratory Service, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- Centre of Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE1 1UL, UK
| | - Nikolaos Koulouris
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
| | - Ioannis Vogiatzis
- Rehabilitation Unit, 1st Respiratory Medicine Department, “Sotiria” Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.V.); (C.A.); (C.L.); (S.Z.); (N.A.); (A.I.P.); (G.K.); (N.K.); (I.V.)
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle upon Tyne NE1 8ST, UK
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Chobanov JD, Wang Z, Man KKC, Dayib E, Lip GYH, Hingorani AD, Leung WK, Wong ICK, Mongkhon P, Lau WCY. Sex-specific comparative outcomes between oral anticoagulants in patients with atrial fibrillation: a systematic review and meta-analysis. Open Heart 2024; 11:e002792. [PMID: 39019498 PMCID: PMC11253745 DOI: 10.1136/openhrt-2024-002792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/02/2024] [Indexed: 07/19/2024] Open
Abstract
AIMS Women with atrial fibrillation (AF) are under-represented in randomised controlled trials (RCTs) of direct oral anticoagulants (DOACs). This systematic review and meta-analysis of RCTs and observational studies examined sex-specific outcomes of DOACs in AF. METHODS PubMed, Embase, Web of Science and Cochrane Library were searched from January 2008 to November 2022. Sex-specific comparative outcomes of stroke/systemic embolism (SE), major bleeding, intracranial haemorrhage (ICH) and gastrointestinal bleeding (GIB) between oral anticoagulants were pooled using random effects models. P values for interaction were calculated to examine differences in results between sexes. RCTs and observational studies were meta-analysed separately. RESULTS 5 RCTs and 33 observational studies were included, totalling 1 085 931 women and 1 387 123 men. Meta-analyses showed that for both sexes, DOAC versus warfarin was generally associated with lower risk of stroke/SE, major bleeding and ICH; in DOAC-DOAC comparisons, rivaroxaban versus dabigatran had higher GIB risk. The only sex-specific difference observed was that when compared with warfarin, women had higher GIB risk with rivaroxaban (women: pooled risk ratio (pRR)=1.34, 95% CI=1.18 to 1.51; men: pRR=0.97, 95% CI=0.85 to 1.10; p value for interaction (p for interaction)<0.001) and possibly dabigatran (women: pRR=1.25, 95% CI=0.92 to 1.70; men: pRR=0.83, 95% CI=0.72 to 0.97; p-for-interaction=0.02). The sex difference in GIB remained for rivaroxaban when a Bonferroni-corrected significance level was used (α=0.003). No sex-specific GIB data for apixaban and edoxaban was available for the meta-analysis. CONCLUSIONS For both sexes, DOACs generally demonstrated favourable effectiveness and safety over warfarin. However, observational data suggested that women may have higher GIB risk with rivaroxaban and possibly dabigatran than warfarin. Further studies are warranted to verify our findings and elucidate sex-specific GIB risk with apixaban and edoxaban, of which the data is currently lacking. PROSPERO REGISTRATION NUMBER CRD42022325027.
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Affiliation(s)
- Jan D Chobanov
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Zixuan Wang
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicines, London, UK
- School of Pharmacy, Institute of Clinical Sciences, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, Hong Kong
| | - Kenneth K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, Hong Kong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Edil Dayib
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Aroon D Hingorani
- Institute of Cardiovascular Sciences, University College London and University College London British Heart Foundation Research Accelerator, London, UK
| | - Wai K Leung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, Hong Kong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Aston School of Pharmacy, Aston University, Birmingham, UK
| | - Pajaree Mongkhon
- Unit of Excellence on Cardiovascular Archive Research and Clinical Epidemiology, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Pharmacoepidemiology, Social and Administrative Pharmacy (P-SAP) Research Unit, Division of Social and Administrative Pharmacy (SAP), Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Wallis C Y Lau
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, Hong Kong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
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Tekin A, Devarajan A, Sakata KK, Qamar S, Sharma M, Valencia Morales DJ, Malinchoc M, Talaei F, Welle S, Taji J, Khosa S, Sharma N, Brown M, Lal A, Bansal V, Khan SA, La Nou AT, Sanghavi D, Cartin-Ceba R, Kashyap R, Gajic O, Domecq JP, Azadeh N. Pneumomediastinum and pneumothorax in coronavirus disease-2019: Description of a case series and a matched cohort study. Heliyon 2024; 10:e33679. [PMID: 39055836 PMCID: PMC11269848 DOI: 10.1016/j.heliyon.2024.e33679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
Objective To describe the characteristics of COVID-19 patients with pneumothorax and pneumomediastinum (PTX/PM) and their association with patient outcomes. Patients and methods Adults admitted to five Mayo Clinic hospitals with COVID-19 between 03/2020-01/2022 were evaluated. PTX/PM was defined by imaging. Descriptive analyses and a matched (age, sex, admission month, COVID-19 severity) cohort comparison was performed. Hospital mortality, length of stay (LOS), and predisposing factors were assessed. Results Among 6663 patients, 197 had PTX/PM (3 %) (75 PM, 40 PTX, 82 both). The median age was 59, with 71 % males. Exposure to invasive and non-invasive mechanical ventilation and high-flow nasal cannula before PTX/PM were 42 %, 17 %, and 20 %, respectively. Among isolated PTX and PM/PTX patients 70 % and 53.7 % underwent an intervention, respectively, while 96 % of the PM-only group was followed conservatively.A total of 171 patients with PTX/PM were compared to 171 matched controls. PTX/PM patients had more underlying lung disease (40.9 vs. 23.4 %, p < 0.001) and lower median body mass index (BMI) (29.5 vs. 31.3 kg/m2, p = .007) than controls. Among patients with available data, PTX/PM patients had higher median positive end-expiratory and plateau pressures than controls; however, differences were not significant (10 vs. 8 cmH2O; p = 0.38 and 28 vs. 22 cmH2O; p = 0.11, respectively). PTX/PM patients had a higher odds of mortality (adjusted odds ratio [95%CI]: 3.37 [1.61-7.07]) and longer mean LOS (percent change [95%CI]: 39 [9-77]) than controls. Conclusion In COVID-19 patients with similar severity, PTX/PM patients had more underlying lung disease and lower BMI. They had significantly increased mortality and LOS.
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Affiliation(s)
- Aysun Tekin
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anusha Devarajan
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Kenneth K. Sakata
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Shahraz Qamar
- Post-Baccalaureate Research Education Program, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mayank Sharma
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Fahimeh Talaei
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Stephanie Welle
- Division of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Jamil Taji
- Division of Pulmonary Medicine, Division of Critical Care Medicine, Mayo Clinic Health Systems, Mankato, MN, USA
| | - Sandeep Khosa
- Division of Pulmonary Medicine, Division of Critical Care Medicine, Mayo Clinic Health Systems, Mankato, MN, USA
| | - Nikhil Sharma
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Meghan Brown
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amos Lal
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vikas Bansal
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Syed Anjum Khan
- Division of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Abigail T. La Nou
- Division of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Research, WellSpan Health, York, PA, USA
| | - Ognjen Gajic
- Division of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Juan P. Domecq
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Natalya Azadeh
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Parmentier S, Koschmieder S, Henze L, Griesshammer M, Matzdorff A, Bakchoul T, Langer F, Alesci RS, Duerschmied D, Thomalla G, Riess H. Antithrombotic Therapy in Cancer Patients with Cardiovascular Diseases: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society for Thrombosis and Hemostasis Research (GTH e.V.). Hamostaseologie 2024. [PMID: 39009011 DOI: 10.1055/a-2337-4025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Active cancer by itself but also chemotherapy is associated with an increased risk of cardiovascular disease (CVD) and especially coronary artery disease (CAD) and atrial fibrillation (AF). The frequency of CVD, CAD, and AF varies depending on comorbidities (particularly in older patients), cancer type, and stage, as well as the anticancer therapeutic being taken. Many reports exist for anticancer drugs being associated with CVD, CAD, and AF, but robust data are often lacking. Because of this, each patient needs an individual structured approach concerning thromboembolic and bleeding risk, drug-drug interactions, as well as patient preferences to evaluate the need for anticoagulation therapy and targeting optimal symptom control. Interruption of specific cancer therapy should be avoided to reduce the potential risk of cancer progression. Nevertheless, additional factors like thrombocytopenia and anticoagulation in the elderly and frail patient with cancer cause additional challenges which need to be addressed in daily clinical management. Therefore, the aim of these recommendations is to summarize the available scientific data on antithrombotic therapy (both antiplatelet and anticoagulant therapy) in cancer patients with CVD and in cases of missing data providing guidance for optimal careful decision-making in daily routine.
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Affiliation(s)
- Stefani Parmentier
- Tumorzentrum, St. Claraspital Tumorzentrum, St. Claraspital, Basel, Basel-Stadt, Switzerland
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Larissa Henze
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Internal Medicine II, Hematology, Oncology and Palliative Medicine, Asklepios Hospital Harz, Goslar, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Langer
- Center for Oncology, University Cancer Center Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Center Eppendorf, Hamburg, Germany
| | - Rosa Sonja Alesci
- IMD Blood Coagulation Center, Hochtaunus/Frankfurt, Bad Homburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Hemostaseology, Angiology and Medical Intensive Care, Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Riess
- Division of Hematology, Oncology and Tumorimmunology, Department of Medical, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
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Dankowski R, Sacharczuk W, Fedorowicz J, Małek-Elikowska M, Ożegowski S, Baszko A. Myocardial Work Indices in Patients Recently Recovered from Mild-to-Moderate COVID-19. J Clin Med 2024; 13:4090. [PMID: 39064130 PMCID: PMC11278412 DOI: 10.3390/jcm13144090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/22/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Persistent cardiovascular issues are common in COVID-19 survivors, making the detection of subtle myocardial injuries critical. This study evaluates myocardial work (MW) indices in patients recently recovering from mild-to-moderate COVID-19. Methods: A total of 105 recently recovered COVID-19 patients (who had a mean age of 52 years) underwent comprehensive laboratory testing and advanced echocardiographic assessments. The median time since their COVID-19 infections was 56 days (IQR: 42-71). The cohort was stratified based on high-sensitive troponin I (hs-TnI) levels: undetectable versus detectable. The echocardiographic analysis utilized pressure-strain loops to evaluate MW indices. Results: Detectable hs-TnI levels were observed in 42% of patients. The median values of MW indices for the entire group were slightly below normal values: global work index (GWI)-1834 mmHg% (IQR 1168-2054 mmHg%), global constructive work (GCW)-2130 mmHg% (IQR 2010-2398 mmHg%), global wasted work (GWW)-119 mmHg% (IQR 78-175 mmHg%), and global work efficiency (GWE)-94% (IQR 92-96%). Patients with detectable hs-TnI had higher GWW (168 vs. 97 mmHg%, p < 0.005) and lower GWE (93% vs. 95%, p < 0.005). In multiple regression analysis, strain dispersion (PSD) was the sole predictor for GWW (β = 0.67, p < 0.001), while for GWE, PSD (β = -0.67, p < 0.001) and LVEF (β = 0.16, p = 0.05) were significant predictors. Conclusions: Among patients recently recovering from mild-to-moderate COVID-19, elevated hs-TnI levels are linked with a reduction in GWE and an increase in GWW. PSD is an important predictor of myocardial inefficiency and wasted work. In this group, disruptions in the timing and coordination of cardiac muscle contractions may play a key pathophysiological role in reducing the efficiency of the heart's performance.
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Affiliation(s)
- Rafał Dankowski
- 2nd Department of Cardiology, Poznan University of Medical Sciences, 60-485 Poznan, Poland; (W.S.); (J.F.); (A.B.)
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