501
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Kozieł M, Merino JL, De Caterina R, Huber K, Jin J, Melino M, Goette A, Lip GYH. Comparing TEE- vs Non-TEE-guided cardioversion of atrial fibrillation: The ENSURE-AF trial. Eur J Clin Invest 2020; 50:e13221. [PMID: 32150758 DOI: 10.1111/eci.13221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/16/2020] [Accepted: 03/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND ENSURE-AF (NCT02072434) assessed therapy with edoxaban vs enoxaparin-warfarin in patients with nonvalvular atrial fibrillation (AF) undergoing elective electrical cardioversion (ECV). OBJECTIVES To evaluate clinical features and primary efficacy (composite of stroke, systemic embolic events, myocardial infarction and cardiovascular mortality during study period) and safety endpoints (composite of major and clinically relevant nonmajor bleeding during on-treatment period) in patients awaiting ECV of AF with a transesophageal echocardiography (TEE)-guided vs a non-TEE-guided strategy. METHODS In this prospective, randomized, open-label, blinded endpoint study, 2199 patients were randomized to edoxaban 60 mg once-daily (30 mg for creatinine clearance 15-50 mL/min, weight ≤60 kg and/or concomitant use of P-glycoprotein inhibitor) or enoxaparin-warfarin. Primary efficacy endpoint and safety endpoint were reported. Associates of TEE use, efficacy endpoint and safety endpoint were explored using multivariable logistic regression. RESULTS In total, 589 patients from the edoxaban stratum and 594 from the enoxaparin-warfarin stratum were allocated to the TEE-guided strategy. Primary efficacy was similar regardless of TEE approach (P = .575). There were no significant differences in bleeding rates, regardless of TEE approach (P = .677). Independent predictors of TEE use were as follows: history of ischaemic stroke/ transient ischaemic attack, hypertension and valvular heart disease. Mean CHA2 DS2 VASc and HAS-BLED score were independent predictors of the efficacy endpoint whilst mean age was an independent predictor of the safety endpoint. CONCLUSIONS Thromboembolic and bleeding events were not different between patients undergoing TEE-guided strategy and in those undergoing an optimized conventional anticoagulation approach for ECV of AF.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Division of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Jose L Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, Universidad Europea, Madrid, Spain
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Medical School, Sigmund Freud University, Vienna, Austria
| | - James Jin
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | | | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Paderborn, Germany and Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Division of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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502
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van Miert JHA, Veeger NJGM, Meijer K. Is the time in therapeutic range on coumarins predicted by previous time in therapeutic range? Res Pract Thromb Haemost 2020; 4:604-609. [PMID: 32548559 PMCID: PMC7292664 DOI: 10.1002/rth2.12328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/01/2020] [Accepted: 02/25/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The benefit of vitamin K antagonists depends on the time within the therapeutic range (TTR). A patient's previous TTR could be a factor in the decision to change the anticoagulation regimen. However, the predictive value of a previous TTR for a future TTR is not well established, nor is it clear which TTR should prompt action. OBJECTIVES To investigate the predictive performance of a TTR and identify a threshold below which no recovery of TTR should be expected. PATIENTS/METHODS From 18 031 patients who used acenocoumarol in a first-line anticoagulation clinic, a TTR was calculated over multiple periods of 90, 180, and 365 days each. We assessed the correlation between baseline and later TTR and the separation between groups by quintile of baseline TTR. We describe the proportion of patients who obtain a TTR≥ 70% conditional on baseline TTR. RESULTS The correlation between baseline and later TTR was 0.25 (95% confidence interval [CI], 0.24-0.26), 0.27 (95% CI, 0.26-0.28) and 0.34 (95% CI, 0.32-0.35) for analyses over 90, 180, and 365 days. Corresponding c statistics for discrimination by baseline group were 0.60, 0.61, and 0.63. The probability to obtain a TTR ≥70% increased with baseline TTR: from 42% with a baseline TTR of 50%-65% when TTR was 100% (TTR calculated over 180 days). CONCLUSIONS We conclude that a current TTR hardly predicts a future TTR. Physicians and patients should deliberate together which probabilities to accept, take measures to improve TTR, and consider potential alternatives.
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Affiliation(s)
- Jasper H. A. van Miert
- Department of HematologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- Certe Thrombosis Service GroningenGroningenThe Netherlands
| | - Nic J. G. M. Veeger
- Department of EpidemiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Karina Meijer
- Department of HematologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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503
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Schwab K, Smith R, Wager E, Kaur S, Alvarez L, Wagner J, Leung H. Identification and early anticoagulation in patients with atrial fibrillation in the emergency department. Am J Emerg Med 2020; 44:315-322. [PMID: 32331958 DOI: 10.1016/j.ajem.2020.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Emergency departments (ED) in the United States see more than half a million atrial fibrillation visits a year, however guideline recommended anticoagulation is prescribed in <55% of eligible patients. OBJECTIVE The purpose of this study was to measure guideline recommended anticoagulation prescribing in patients with nonvalvular atrial fibrillation (NVAF) presenting to the ED, with the goal of closing any treatment gap established. METHODS We conducted an observational, prospective cohort study in consecutive patients presenting to the ED with a diagnosis of NVAF. CHA2DS2-VASc and HAS-BLED scores were calculated and used as predefined criteria to establish guideline-based oral anticoagulation compliance in comparing routine care (baseline cohort) versus a multidisciplinary team approach. Transition of Care (TOC) services and follow-up were also provided in the multidisciplinary cohort. The primary endpoint was to compare the proportion of patients on guideline based oral anticoagulant (OAC) therapy at admission and discharge between the groups. RESULTS In the Baseline Cohort (BC) (n = 99), 62.3% of patients with a moderate-high risk of stroke (CHA2DS2-VASc score ≥ 2) were discharged on guideline-based OAC therapy versus 87.8% in the Multidisciplinary Team Cohort (MTC) (n = 131), a 25.5% overall improvement for appropriate anticoagulation (p-value <.001, 95% CI (0.14-0.37)). CONCLUSIONS A multidisciplinary team approach with TOC services for the identification and early intervention of NVAF patients at risk of stroke in the ED can significantly improve the percentage of moderate to high-risk patients that are discharged home with guideline based OAC.
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Affiliation(s)
- Kim Schwab
- Sharp Chula Vista Medical Center, Chula Vista, CA, United States of America.
| | - Richard Smith
- Pfizer, Inc., New York, NY, United States of America
| | - Eric Wager
- Keck Graduate Institute, Claremont, CA, United States of America
| | - Sukhjit Kaur
- Keck Graduate Institute, Claremont, CA, United States of America
| | - Lisa Alvarez
- Sharp Chula Vista Medical Center, Chula Vista, CA, United States of America
| | - Jordan Wagner
- Sharp Chula Vista Medical Center, Chula Vista, CA, United States of America
| | - Helen Leung
- Touro University, Vallejo, CA, United States of America
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504
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Fernández CS, Gullón A, Formiga F. The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. J Comp Eff Res 2020; 9:509-523. [PMID: 32329353 DOI: 10.2217/cer-2019-0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.
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Affiliation(s)
| | - Alejandra Gullón
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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505
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Nagaraj TA, Snider MJ, Davidson E, Weiss R, Li J, Afzal M. Risk Versus Benefit of Combined Aspirin and Warfarin Therapy in Patients With Atrial Fibrillation. J Pharm Pract 2020; 34:766-773. [PMID: 32292101 DOI: 10.1177/0897190020916638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Guidelines have differing recommendations for aspirin use in patients with an indication for anticoagulation. The purpose of this study was to evaluate the incidence of major bleeding and thromboembolic events (TEs) in patients with atrial fibrillation (AF) receiving warfarin alone (monotherapy group) versus warfarin plus aspirin (combination therapy group). METHODS This was a retrospective, cohort study including patients from a pharmacist-run anticoagulation clinic. Inclusion criteria were patients with AF receiving anticoagulation between January 2013 and January 2014 observed over 5 years. RESULTS One hundred forty-two patients were included in the combination group versus 89 in monotherapy group. In the combination group, 60 (42.3%) patients were on aspirin for no apparent indication, 19 (13.4%) had stable coronary artery disease and diabetes, and 26 (18.3%) had diabetes alone. Major bleeding occurred in 21 (14.9%) patients in the combination group versus 7 (7.9%) patients in the monotherapy group (odds ratio [OR] = 2.02, 95% confidence interval [CI]: 0.78-5.91; P = .17). TE occurred in 10 (7%) patients in the combination group versus 4 (4.5%) in the monotherapy group (OR = 1.61, 95% CI: 0.44-7.24; P = .57). There was no significant difference in bleeding (P = .85) or TE (P = .37) rates between aspirin indications in the combination group. CONCLUSION Combination therapy versus monotherapy may increase bleeding risk with little benefit in decreasing AF-related stroke or cardiovascular events.
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Affiliation(s)
| | | | - Erica Davidson
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raul Weiss
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Junan Li
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Muhammad Afzal
- Ohio State University Wexner Medical Center, Columbus, OH, USA
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506
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Patil T, Lebrecht M. A single center retrospective cohort study evaluating use of direct oral anticoagulants (DOACs) in morbidly obese veteran population. Thromb Res 2020; 192:124-130. [PMID: 32473496 DOI: 10.1016/j.thromres.2020.04.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are preferred over warfarin for the treatment of venous thromboembolism (VTE) as well as atrial fibrillation (AF). The efficacy and safety of fixed dose regimen of DOACs remains unclear in morbidly obese patient population and are currently not recommended for use in patients with a body mass index (BMI) > 40 kg/m2 or a weight of >120 kg. OBJECTIVE The goal of this study is to evaluate the use of DOACs in morbidly obese veteran population as compared to warfarin. METHODS This retrospective single center cohort study included morbidly obese patients weighing >120 kg or BMI > 40 kg/m2 who were prescribed DOACs or warfarin for AF or VTE between January 1st, 2015 to May 31st, 2018. Data was extracted from the computerized patient record system (CPRS) and the Salem Veterans Affairs Medical Center (SVAMC) data warehouse. The primary outcome was combined incidence of stroke/transient ischemic attack (TIA) and VTE. Secondary outcomes included all-cause mortality, ISTH major bleed and clinically relevant non major bleed as well as primary outcome and ISTH major bleeding analyses in the subgroups of AF and VTE patients. RESULTS The study included 190 patients in warfarin group and 214 in DOACs group. Baseline characteristics were mostly well matched except for the follow up duration which was significantly longer in the warfarin group as compared to DOAC (p > 0.001). The annual incidence rate of primary outcome was similar between warfarin and DOACs (3.91% vs.1.61%; RR:2.436; 95% CI 0.85-8.54; p = 0.1543). CONCLUSION This hypothesis generating study suggests that DOAC use may be feasible in morbidly obese patients. Additional studies are necessary to confirm this finding and further guide clinical practice in this area.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affair Medical Center, 3512 Sunchase lane, apt 802, Roanoke, VA 24018, United States of America.
| | - Morgan Lebrecht
- Salem Veterans Affair Medical Center, 3512 Sunchase lane, apt 802, Roanoke, VA 24018, United States of America
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507
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Obi AT, Thompson JR, Beaulieu RJ, Sutzko DC, Osborne N, Albright J, Gallagher KA, Henke PK. Bleeding and thrombotic outcomes associated with postoperative use of direct oral anticoagulants after open peripheral artery bypass procedures. J Vasc Surg 2020; 72:1996-2005.e4. [PMID: 32278573 DOI: 10.1016/j.jvs.2020.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 02/10/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Widespread adoption of direct oral anticoagulants (DOACs) for atrial fibrillation and venous thromboembolism treatment has resulted in peripheral bypass patients receiving therapeutic anticoagulation with DOACs postoperatively. This study was undertaken to evaluate patient outcomes after open peripheral bypass based on anticoagulation treatment. METHODS Postoperative treatment and outcomes of patients undergoing peripheral bypass operations between January 2012 and December 2017 from a statewide multicenter quality improvement registry were examined. Surgeons participating in the registry were surveyed on practice patterns regarding DOACs in bypass patients. Multivariate logistic regression was performed for 30-day transfusion outcomes, and multiple linear regression was performed for length of stay. RESULTS Among 9682 patients, 7685 patients received no anticoagulation, whereas 1379 received a vitamin K antagonist (VKA) and 618 received a DOAC postoperatively. Patients receiving anticoagulation compared with no anticoagulation had a higher body mass index and were more likely to have preoperative anemia, congestive heart failure, and atrial fibrillation (all P < .001). Compared with patients receiving VKAs, patients receiving DOACs were less likely to have chronic kidney disease (P = .002) and more likely to have atrial fibrillation (P < .001). The shortest length of stay was among patients receiving no anticoagulation (median, 5 days; interquartile range, 3-9 days; P < .001), followed by DOACs (median, 6 days; interquartile range 3-11 days; P < .001) and VKAs (median, 8 days; interquartile range, 5-13 days; P < .001). Compared with patients receiving VKAs postoperatively, there was no difference in readmission for anticoagulation complications, bypass thrombectomy or thrombolysis, major amputation, or graft patency at 1 year among patients receiving DOACs. On multivariate logistic regression, patients receiving a DOAC (odds ratio, 0.743; confidence interval, 0.59-0.94; P = .011) or no anticoagulation (odds ratio, 0.792; confidence interval, 0.69-0.91; P = .001) were less likely to require transfusion within 30 days than patients taking VKAs. Approximately 70% of the surveyed surgeons reported that they "sometimes" or "always" use DOACs instead of VKAs for protection of a high-risk bypass. CONCLUSIONS Among patients undergoing lower extremity surgical bypass, those receiving a DOAC postoperatively had a shorter length of stay and were less likely to receive a transfusion in 30 days without compromising graft patency and readmission for anticoagulation complications, thrombectomy, or thrombolysis or affecting amputation rate compared with those receiving a VKA. A majority of surgeons within the quality collaborative have adopted the use of DOACs after peripheral bypass, suggesting the need for a prospective trial evaluating DOAC safety and efficacy in patients requiring anticoagulation for high-risk bypass grafts.
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Affiliation(s)
- Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Jonathan R Thompson
- Section of Vascular Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Neb
| | - Robert J Beaulieu
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Danielle C Sutzko
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Nicholas Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | | | - Katherine A Gallagher
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich.
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508
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Guo Y, Lip GYH, Lane DA. Lifestyle and risk factor modification for reduction of atrial fibrillation: We could do more. Trends Cardiovasc Med 2020; 30:387-388. [PMID: 32276083 DOI: 10.1016/j.tcm.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Yutao Guo
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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509
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Wojakowski E, Cheruvil C, Hassan A, Holsen MR, Chen L, Rossi M, Wilcox N, Woodruff AE. Albumin and bleed risk in rivaroxaban treated patients. J Thromb Thrombolysis 2020; 50:1004-1011. [DOI: 10.1007/s11239-020-02092-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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510
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Abstract
RATIONALE Dabigatran is an anticoagulant medication that has been widely used to prevent strokes caused by atrial fibrillation, deep vein thrombosis, and pulmonary embolism. However, the potential adverse effect of dabigatran of gastrointestinal mucosal injury is often neglected, and even induces esophagitis. PATIENT CONCERNS A 77-year-old woman was admitted to the hospital with symptoms of progressive retrosternal pain, upper abdominal discomfort, and dysphagia. DIAGNOSIS Esophagogastroduodenoscopy showed longitudinal sloughing mucosal casts in the distal esophagus. Histological examination showed squamous epithelium with neutrophil infiltration, partial epithelial degeneration, and Helicobacter pylori. Based on a literature review, medical history, and imaging examination, the patient was diagnosed with dabigatran-induced esophagitis. INTERVENTIONS The patient recovered with standard H. pylori eradication therapy and proton pump inhibitor without discontinuing dabigatran. OUTCOMES After 2 weeks, the retrosternal pain and dysphagia were relieved and upper abdominal discomfort was attenuated. LESSONS Our case highlights the importance of physicians' awareness of the clinical and endoscopic characteristics of dabigatran-induced esophagitis and the importance of H. pylori-associated tests and eradication if necessary for patients with long-term dabigatran treatment.
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Affiliation(s)
- Yi Zhou
- Department of Gastroenterology, Shanghai Hospital of Integrated Traditional Chinese and Western Medicine
| | - Yancheng Dai
- Department of Gastroenterology, Shanghai Hospital of Integrated Traditional Chinese and Western Medicine
- Institute of Digestive Diseases, LongHua Hospital
| | - Lei Lu
- Department of Pathology, Shanghai Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhiquan Fu
- Department of Gastroenterology, Shanghai Hospital of Integrated Traditional Chinese and Western Medicine
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511
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Ding WY, Harrison SL, Lane DA, Lip GYH. Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation. J Thromb Haemost 2020; 18:788-790. [PMID: 32233026 DOI: 10.1111/jth.14738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/12/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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512
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Li X, Liu L, Xu B, Xiang Q, Li Y, Zhang P, Wang Y, Xie Q, Mao Y, Cui Y. Bioequivalence and pharmacodynamics of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. Pharmacol Res Perspect 2020; 8:e00593. [PMID: 32338459 PMCID: PMC7184321 DOI: 10.1002/prp2.593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
To assess bioequivalence of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. This was an open-label, single-center, randomized four-period crossover study with a 7-day washout period. A single oral dose of 150 mg generic dabigatran etexilate capsule (test drug) or a commercial dabigatran etexilate capsule (Pradaxa® , reference drug) was given to healthy volunteers under the fasting and fed conditions. Plasma concentrations of total and free dabigatran were detected using a validated HPLC-MS/MS method. A noncompartmental method was used for pharmacokinetic analysis and established coagulation assays were applied for pharmacodynamic analysis. The 90% CIs of the test/reference ratios of Cmax , AUC0-t , and AUC0-∞ for the total dabigatran concentration were 92.57%-106.58%, 91.63%-106.32%, and 92.54%-106.17%, respectively, under fasting condition, and 99.30%-110.74%, 98.58%-105.37%, and 97.75%-103.99%, respectively, under fed conditions. The 90% CIs of the ratios of the parameters for the free dabigatran were 93.18%-106.98%, 92.13%-107.10%, 92.89%-106.48%, respectively, under fasting condition, and 100.05%-110.89%, 99.37%-106.23%, 97.59%-103.98%, respectively, under the fed condition. Additionally, the upper limit of the 90% CIs for σWT/σWR was below 2.5. There were no significant differences in the coagulation parameters including thrombin clotting time, activated partial thromboplastin time, and anti-IIa activity between the two preparations. The generic dabigatran etexilate capsule is bioequivalent to the brand-named product in healthy Chinese volunteers under fasting and fed conditions. The two products have comparable pharmacodynamic parameters, with a good safety profile. In addition, food intake influences absorption of both products in a similar way.
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Affiliation(s)
- Xin Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Lihua Liu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Bing Xu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qian Xiang
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yuan Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Ping Zhang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Yangyang Wang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qiufen Xie
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yong Mao
- Chengdu Brilliant Pharmaceutical Co. LtdChengduThe People’s Republic of China
| | - Yimin Cui
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
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513
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Vazquez SR. Vascular Disease Patient Information Page: Direct oral anticoagulants – 2020 update. Vasc Med 2020; 25:196-199. [DOI: 10.1177/1358863x19898262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sara R Vazquez
- University of Utah Health Thrombosis Center, Salt Lake City, UT, USA
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514
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Bernaitis N, Bowden M, La Caze A. A clinical audit of oral anticoagulant therapy in aged care residents with atrial fibrillation. Int J Clin Pharm 2020; 42:474-481. [DOI: 10.1007/s11096-020-01025-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/30/2022]
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515
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Fernando SM, Mok G, Castellucci LA, Dowlatshahi D, Rochwerg B, McIsaac DI, Carrier M, Wells PS, Bagshaw SM, Fergusson DA, Tanuseputro P, Kyeremanteng K. Impact of Anticoagulation on Mortality and Resource Utilization Among Critically Ill Patients With Major Bleeding. Crit Care Med 2020; 48:515-524. [PMID: 32205598 DOI: 10.1097/ccm.0000000000004206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants. DESIGN Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria). SETTING Two hospitals within a single tertiary care level hospital system. PATIENTS We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding. CONCLUSIONS Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Garrick Mok
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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516
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Effect of Lesion Complexity and Clinical Risk Factors on the Efficacy and Safety of Dabigatran Dual Therapy Versus Warfarin Triple Therapy in Atrial Fibrillation After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2020; 13:e008349. [DOI: 10.1161/circinterventions.119.008349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The REDUAL PCI trial (Evaluation of Dual Therapy With Dabigatran vs Triple Therapy With Warfarin in Patients With AF That Undergo a PCI With Stenting) demonstrated that, in patients with atrial fibrillation following percutaneous coronary intervention, bleeding risk was lower with dabigatran plus clopidogrel or ticagrelor (dual therapy) than warfarin plus clopidogrel or ticagrelor and aspirin (triple therapy). Dual therapy was noninferior for risk of thromboembolic events. Whether these results apply equally to patients at higher risk of ischemic events due to lesion complexity or clinical risk factors is unclear.
Methods:
The primary end point was time to first major or clinically relevant nonmajor bleeding event. The composite efficacy end point was death, thromboembolic event, or unplanned revascularization. Our prespecified subgroup analysis categorized patients by presence of procedural complexity and/or clinical complexity factors at baseline. A modified dual antiplatelet therapy score categorized patients according to degree of clinical risk.
Results:
Of 2725 patients, 43.1% had clinical complexity factors alone, 9.9% procedural factors alone, 10.0% both, and 37.0% neither. Risk of the primary bleeding end point was lower in both dabigatran dual therapy groups than warfarin triple therapy groups, regardless of procedural and/or clinical lesion complexity (interaction
P
values: 0.90 and 0.37, respectively). Importantly, a similar risk of the efficacy end point was observed between dabigatran dual and warfarin triple therapy, regardless of the presence of clinical or procedural complexity factors (interaction
P
values: 0.67 and 0.54, dabigatran 110 and 150 mg dual therapy, respectively). Similar benefit was seen for each dose of dabigatran dual therapy for bleeding events regardless of dual antiplatelet therapy score (interaction
P
values: 0.53 and 0.54, respectively), with similar risk of thromboembolic events (interaction
P
values: 0.20 and 0.08, respectively).
Conclusions:
In patients with atrial fibrillation undergoing percutaneous coronary intervention, dabigatran 110 and 150 mg dual therapy reduced bleeding risk compared with warfarin triple therapy, with a similar risk of thromboembolic outcomes, irrespective of procedural and/or clinical complexity and modified dual antiplatelet therapy score.
Registration:
URL:
https://clinicaltrials.gov/
; Unique identifier: NCT02164864.
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517
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Tinkham TT, Vazquez SR, Jones AE, Witt DM. Direct oral anticoagulant plus antiplatelet therapy: prescribing practices and bleeding outcomes. J Thromb Thrombolysis 2020; 49:492-496. [PMID: 31776847 DOI: 10.1007/s11239-019-01999-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Concurrent antiplatelet therapy (APT) is common during warfarin therapy but is less well-documented during direct oral anticoagulant (DOAC) therapy. Combined anticoagulant and APT use has been associated with increased bleeding risk without providing additional protection against thrombosis. This study aimed to describe single-center prescribing rates of DOAC + APT as well as compare bleeding rates between DOAC monotherapy and DOAC + APT cohorts. Patients receiving DOAC therapy were evaluated for APT use at the time of hospital discharge. Patients were categorized into DOAC monotherapy and DOAC + APT cohorts. Primary outcomes included DOAC + APT prescribing rate as well as rates of major bleeding and clinically relevant non-major bleeding (CRNMB) within six months after hospital discharge. Secondary outcomes included rates of thromboembolism and all-cause mortality. Of 407 patients receiving DOAC therapy, 78 (19.2%) also received APT at hospital discharge. Common indications for APT included secondary cardiovascular event prevention (57.7%) and primary cardiovascular event prevention (29.5%). The indication for APT could not be determined in 12.8% of patients. The major bleeding rate was 1.3% for DOAC + APT and 1.2% for DOAC monotherapy (p = 0.95). The CRNMB rate was 10.2% for DOAC + APT and 6.4% for DOAC monotherapy (p = 0.23). Thromboembolism and mortality were infrequent in both cohorts. DOAC + APT was documented in approximately 1 of 5 patients. Adding APT to DOAC therapy did not significantly increase the major bleeding or CRNMB rates compared to DOAC monotherapy but the sample size limits drawing conclusions about the safety of these regimens. Targeting primary prevention or unclear indications for APT could be a focus of future interventions.
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Affiliation(s)
- Tyler T Tinkham
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Sara R Vazquez
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA.
- University of Utah Health Thrombosis Center, Salt Lake City, UT, USA.
- University of Utah Health Thrombosis Center, 50 N Medical Drive Room 1R211, Salt Lake City, UT, 84132, USA.
| | - Aubrey E Jones
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
- University of Utah Health Thrombosis Center, Salt Lake City, UT, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
- University of Utah Health Thrombosis Center, Salt Lake City, UT, USA
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518
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Kezerle L, Tsadok MA, Berliner Senderey A, Hoshen M, Leventer‐Roberts M, Reges O, Leibowitz M, Haim M. Use of oral anticoagulation therapy in the first 3 months after the diagnosis of atrial fibrillation in Israel: A population‐based study. J Cardiovasc Electrophysiol 2020; 31:1356-1363. [DOI: 10.1111/jce.14452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
| | - Meytal A. Tsadok
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Adi Berliner Senderey
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moshe Hoshen
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Maya Leventer‐Roberts
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Orna Reges
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
- Department of Health Systems ManagementAriel University Israel
| | - Morton Leibowitz
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
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519
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Glycemic status and risks of thromboembolism and major bleeding in patients with atrial fibrillation. Cardiovasc Diabetol 2020; 19:30. [PMID: 32156277 PMCID: PMC7063754 DOI: 10.1186/s12933-020-01005-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 02/24/2020] [Indexed: 12/17/2022] Open
Abstract
Background Studies specifically examining the association between glycated hemoglobin A1c (HbA1c) levels and ischemic stroke/systemic thromboembolism (IS/SE) risk in atrial fibrillation (AF) patients are limited. Here, we investigated the association between HbA1c levels and the risk of IS/SE, as well as major bleeding, among AF patients with or without oral anticoagulants (OACs). We also compared the effectiveness and safety of warfarin and direct oral anticoagulants (DOACs) in different HbA1c categories. Methods We utilized medical data from a multi-center healthcare provider in Taiwan, which included 34,036 AF patients with serum HbA1c data available within 3 months after AF being diagnosed. Patients were divided into seven study groups according to their HbA1c levels: < 5.4%, 5.4%–5.6%, 5.7%–5.9%, 6.0%–6.4%, 6.5%–6.9%, 7.0%–7.9%, and ≥ 8.0%. The risks of IS/SE and major bleeding were compared among the groups after adjusting for baseline stroke and bleeding risk factors. Results Compared with the patients with HbA1c level < 5.4%, IS/SE risk significantly increased at HbA1c levels higher than 6.5% [adjusted hazard ratio (HR): 1.20, 95% confidence interval (CI): 1.00–1.43 for HbA1c level 6.5%–6.9%; 1.32, (95% CI 1.11–1.57) for HbA1c level 7.0%–7.9%; and 1.48 (95% CI 1.25–1.76) for HbA1c level ≥ 8.0%]. These results were generally consistent in AF patients without OACs (n = 24,931). However, among 9105 patients receiving OACs, IS/SE risk was not higher for patients having higher HbA1c levels. The risk of major bleeding was comparable across all HbA1c categories. Compared with warfarin, DOACs were associated with lower risks of IS/SE (adjusted HR: 0.61, 95% CI 0.49–0.75) and major bleeding (adjusted HR: 0.30, 95% CI 0.21–0.42) without interactions across different HbA1c categories (all P interactions > 0.05). Conclusion For AF patients, IS/SE risk significantly increased once HbA1c levels exceeded 6.5%, and OACs may attenuate these associations. Compared with warfarin, DOACs were more effective and safer across broad HbA1c categories. Therefore, in addition to prescribing DOACs when indicated, more aggressive glycemic control to achieve an HbA1c level < 6.5% may be considered for eligible AF patients and should be tested in further prospective studies.
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520
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Prescribing and Safety of Direct-Acting Oral Anticoagulants Compared to Warfarin in Patients with Atrial Fibrillation on Chronic Hemodialysis. PHARMACY 2020; 8:pharmacy8010037. [PMID: 32164234 PMCID: PMC7151654 DOI: 10.3390/pharmacy8010037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 11/20/2022] Open
Abstract
ESRD patients receiving hemodialysis (HD) were excluded from landmark trials evaluating direct-acting oral anticoagulants (DOACs) in atrial fibrillation (AF). The objective was to evaluate prescribing and bleeding with DOACs compared to warfarin in AF patients with chronic HD. A retrospective, observational study of patients receiving warfarin or DOAC from April 2010-April 2016 from area health system hospitals and Dialysis Clinics, Inc. records. Data was analyzed using descriptive statistics, ANOVA, and chi-square. Ninety-one patients were included with warfarin as the initial OAC in most patients (n = 76) at average dose of 29 mg/week. Fifteen patients were initially prescribed apixaban (n = 12) or dabigatran (n = 3). Most switches in OAC therapy were to apixaban. When the initial OAC was a DOAC, it was not dosed appropriately in five with one bleed, two dosed appropriately had bleeds. When initial warfarin was switched to a DOAC, it was not dosed appropriately in seven with five bleeds. More bleeds occurred with warfarin alone (n = 18) vs. those on warfarin switched to DOAC (n = 5) vs. DOAC alone (n = 3), p = 0.022. All but four patients that bled had HAS-BLED scores three or higher. Warfarin was most often prescribed and associated with a higher incidence of bleeding compared to DOACs in this population of patients at high risk for bleeding. Larger studies should be conducted to analyze the impact of DOAC dose appropriateness on safety and clinical outcomes.
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521
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Luo CF, Mo P, Li GQ, Liu SM. Aspirin-omitted dual antithrombotic therapy in non-valvular atrial fibrillation patients presenting with acute coronary syndrome or undergoing percutaneous coronary intervention: results of a meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:218-224. [PMID: 32129850 DOI: 10.1093/ehjcvp/pvaa016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/31/2020] [Accepted: 02/27/2020] [Indexed: 11/12/2022]
Abstract
AIMS To investigate the effects of aspirin-omitted dual antithrombotic therapy (DAT) on myocardial infarction and stent thrombosis in non-valvular atrial fibrillation (NVAF) patients presenting with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS A systematic review and meta-analysis were performed using PubMed to search for randomized clinical trials comparing DAT with triple antithrombotic therapy (TAT) in this setting. Three trials involving 8845 patients were included (4802 and 4043 patients treated with DAT and TAT, respectively). There were no significant differences in all-cause death and stroke between the aspirin-omitted DAT group and TAT group. Otherwise, the incidence of myocardial infarction was significantly higher with aspirin-omitted DAT vs. TAT [odds ratio (OR): 1.29, 95% confidence interval (CI): 1.02-1.63; P = 0.04; I2 = 0%]. Similarly, the incidence of stent thrombosis increased in patients treated with aspirin-omitted DAT vs. TAT (OR: 1.61, 95% CI: 1.02-2.53; P = 0.04; I2 = 0%). The occurrence of major bleeding and clinically relevant non-major bleeding events, as defined by the International Society on Thrombosis and Haemostasis, was significantly lower with aspirin-omitted DAT vs. TAT (OR: 0.61, 95% CI: 0.48-0.78; P = 0.02; I2 = 76%). Similar results were found according to the International Society on Thrombosis and Haemostasis major bleeding, Thrombolysis in Myocardial Infarction major or minor bleeding, and Thrombolysis in Myocardial Infarction major bleeding scales. CONCLUSION Aspirin-omitted DAT reduces the occurrence of bleeding episodes, with a higher rate of myocardial infarction and stent thrombosis in NVAF patients presenting with ACS or undergoing PCI.
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Affiliation(s)
- Cheng-Feng Luo
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, the Second Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Changgangdong Road, 250, Guangzhou, China
| | - Pei Mo
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, the Second Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Changgangdong Road, 250, Guangzhou, China
| | - Guo-Qiang Li
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, the Second Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Changgangdong Road, 250, Guangzhou, China
| | - Shi-Ming Liu
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, the Second Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, Changgangdong Road, 250, Guangzhou, China
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522
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Kozieł M, Potpara TS, Lip GYH. Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting. Res Pract Thromb Haemost 2020; 4:357-365. [PMID: 32211570 PMCID: PMC7086461 DOI: 10.1002/rth2.12319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/25/2022] Open
Abstract
Patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) are at high risk of stroke, recurrent coronary ischemic events, and cardiovascular mortality. The composition of antithrombotic therapy including an oral anticoagulant and antiplatelet drug(s) should be tailored according to the individual patient's risk profile, to reduce the bleeding risk and maintain antithrombotic effect. There is no single antithrombotic treatment regimen that would fit to all patients with AF and ACS. However, available data promote the use of full-dose direct oral anticoagulants (DOACs) (dabigatran 150 mg twice daily or apixaban 5 mg twice daily) or rivaroxaban 15 mg once daily in patients with AF and ACS or percutaneous coronary intervention (PCI). For many patients, a DOAC plus P2Y12 inhibitor early after ACS and/or PCI would be optimal, whereas a longer course of triple therapy should be used in patients at high thrombotic risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
| | - Tatjana S. Potpara
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
- School of MedicineBelgrade UniversityBelgradeSerbia
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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523
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Mahat U, Ahuja S, Talati R. Shunt thrombosis in pediatric patients undergoing staged cardiac reconstruction for cyanotic congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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524
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Lee SR, Choi EK, Kwon S, Jung JH, Han KD, Cha MJ, Oh S, Lip GY. Effectiveness and Safety of Direct Oral Anticoagulants in Relation to Temporal Changes in Their Use. Circ Cardiovasc Qual Outcomes 2020; 13:e005894. [DOI: 10.1161/circoutcomes.119.005894] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background:
Since the direct oral anticoagulants (DOAC) were introduced, oral anticoagulant (OAC) prescription patterns have rapidly changed in patients with atrial fibrillation (AF). We aimed to evaluate the evolving trends of OAC use in a large nationwide cohort and specifically examine the changes in patient profiles treated with warfarin or DOAC and whether the time trends in OAC use affected clinical outcomes.
Methods and Results:
Using the Korean Health Insurance Review and Assessment database, we divided OAC naive patients with AF into 3 groups according to the enrollment period between January 2015 and December 2017 (n=35 353 in cohort 1, n=36 631 in cohort 2, and n=44 819 in cohort 3). DOAC use increased from 59% to 89%, whereas warfarin use has decreased from 41% to 11% during the study period. Patients treated with warfarin were increasingly younger from cohort 1 to cohort 3 (mean age 68–65 years,
P
<0.001) with lower mean CHA
2
DS
2
-VASc scores (3.3–2.9,
P
<0.001), whereas those with DOAC did not show a significant difference in clinical characteristics over the study period. Warfarin group had improved clinical outcomes over time, reflecting dynamic changes in patient characteristics. Compared with warfarin group, unadjusted hazard ratios of composite outcome for DOAC group have changed over time (hazard ratio 0.77 [95% CI, 0.69–0.85] in cohort 1, hazard ratio 0.84 [95% CI, 0.73–0.97] in cohort 2, and hazard ratio 1.00 [95% CI, 0.78–1.25] in cohort 3). After propensity score weighting between warfarin and DOAC groups in each cohort, DOAC showed consistently lower risks of the composite outcome by approximately 23% to 25% compared with warfarin across 3 different periods.
Conclusions:
In contemporary clinical practice, OAC prescription patterns and characteristics of patients treated warfarin or DOAC have dynamically changed. Despite these changes, DOAC showed a consistent better net clinical benefit compared with warfarin across different periods.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.)
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.)
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.)
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Republic of Korea (J.-H.J., K.-D.H.)
| | - Kyung-Do Han
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Republic of Korea (J.-H.J., K.-D.H.)
| | - Myung-Jin Cha
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.)
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.)
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom (G.Y.H.L.)
- Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.)
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525
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Boriani G, Colella J, Imberti J, Fantecchi E, Vitolo M. Female sex and stroke in atrial fibrillation: an intriguing relationship. Intern Emerg Med 2020; 15:175-179. [PMID: 31396922 DOI: 10.1007/s11739-019-02169-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Cardiology Division, Policlinico di Modena, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125, Modena, Italy.
| | - Jacopo Colella
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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526
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Wiegmann AL, Khalid SI, Coogan AC, Xu TQ, DeCesare LA, Skertich NJ, Velasco J, Myers JA. Antithrombotic prescriptions for many general surgery patients significantly increases the likelihood of post-operative bleeding complications. Am J Surg 2020; 219:453-459. [DOI: 10.1016/j.amjsurg.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 12/23/2022]
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527
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Negreva M, Zarkova A, Prodanova K, Petrov P. Paroxysmal Atrial Fibrillation: Insight Into the Intimate Mechanisms of Coagulation. Cardiol Res 2020; 11:22-32. [PMID: 32095193 PMCID: PMC7011925 DOI: 10.14740/cr972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/10/2020] [Indexed: 11/11/2022] Open
Abstract
Background Atrial fibrillation (AF) is a hypercoagulable state. However, the intimate mechanisms leading to impaired coagulation and the timing of their activation are unclear. The aim of the study was to investigate the factors that initiate the coagulation cascade in the early hours (up to 48 h) of clinical manifestation of paroxysmal atrial fibrillation (PAF). Methods Tissue factor (TF) level, coagulation activity of factor VII (FVIIa), factor XII (FXIIa) and factor XI (FXIa) were measured in plasma of 51 non-anticoagulated patients (26 men and 25 women, aged 59.84 ± 11.42 years) and 52 controls (26 men and 26 women, aged 59.50 ± 10.53 years) by enzyme-linked immunoassays and kinetic assays. Results TF was higher in the PAF group (268.63 ± 90.62 pg/mL vs. 170.21 ± 66.19 pg/mL, P < 0.001) as well as FVIIa (170.82±59.39% vs. 95.17±37.90%, P < 0.001), FXIIa (218.31±84.04% vs. 148.41±53.94%, P < 0.001) and FXIa (178.41±55.94% vs. 111.75±37.33%, P < 0.001). Regression analysis showed that in the first 6 h of the disease, increase in time led to increase in FXIIa (r = 0.25, P < 0.05), FXIa (r = 0.75, P < 0.05), TF level (r = 0.25, P < 0.05) and FVIIa (r = 0.25, P < 0.05). Conclusion Hemocoagulation changes were observed even < 6 h after the onset of the disease. They suggest that PAF has an early tendency for hypercoagulability, with the involvement of the intrinsic and extrinsic pathways of coagulation.
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Affiliation(s)
- Mariya Negreva
- Department of Cardiology, Medical University of Varna, Varna, Bulgaria
| | - Ana Zarkova
- National Specialized Hospital for Active Treatment of Hematologic Diseases, Sofia, Bulgaria
| | - Krasimira Prodanova
- Faculty of Applied Mathematics and Informatics, Technical University of Sofia, Sofia, Bulgaria
| | - Petar Petrov
- Department of Cardiology, Medical University of Varna, Varna, Bulgaria
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528
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Peled H, Dau NQ. Prothrombin Complex Concentrate or Coagulation Factor Xa (Recombinant), Inactivated-zhzo. Chest 2020; 155:1308. [PMID: 31174650 DOI: 10.1016/j.chest.2019.02.335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Harry Peled
- In-Patient Cardiology/Non-invasive Lab and Critical Care, St. Jude Medical Center, Fullerton, CA.
| | - Nhu Quyen Dau
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
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529
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Ding WY, Harrison S, Gupta D, Lip GYH, Lane DA. Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies. Front Med (Lausanne) 2020; 7:54. [PMID: 32154260 PMCID: PMC7047213 DOI: 10.3389/fmed.2020.00054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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530
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Lacoste JL, Hansen CL. Antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting. Am J Health Syst Pharm 2020; 76:1395-1402. [PMID: 31505555 DOI: 10.1093/ajhp/zxz152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Updates to the primary literature and clinical practice guidelines on use of antithrombotic combinations for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and stenting are reviewed. SUMMARY Up to 8% of patients undergoing PCI have AF and thus require both antiplatelet and anticoagulation therapies, which put them at increased risk for bleeding. Current literature suggests that using a single antiplatelet agent in combination with oral anticoagulation with a direct-acting oral anticoagulant (i.e., dual therapy) is effective and associated with less bleeding risk than triple therapy (dual antiplatelet therapy plus an oral anticoagulant) in patients with AF undergoing PCI with stent placement. The most recently studied dual therapy regimens consist of clopidogrel in combination with apixaban, rivaroxaban, or dabigatran. Guidelines recommend use of an oral anticoagulant plus clopidogrel and aspirin for a short period of time. In general, aspirin should be discontinued in most patients at discharge. In patients with a high risk of thrombosis, aspirin can be continued for up to 1 month. Dual therapy should be continued for 12 months, with oral anticoagulant monotherapy continued thereafter. CONCLUSION A review of current literature on antithrombotic therapy in patients with AF undergoing PCI and subsequent coronary artery stenting indicates that the favored regimen is dual therapy consisting of clopidogrel with rivaroxaban, apixaban, dabigatran, or a vitamin K antagonist. Aspirin may be used in the periprocedural period but should be discontinued thereafter to reduce the risk of bleeding. Decisions regarding specific agents and duration of treatment should be based on thrombotic risk, bleeding risk, and patient preference.
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Affiliation(s)
| | - Cory L Hansen
- BCPS AQ-Cardiology, Intermountain Healthcare-Utah Valley Hospital, Provo, UT
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531
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Kaide CG, Gulseth MP. Current Strategies for the Management of Bleeding Associated with Direct Oral Anticoagulants and a Review of Investigational Reversal Agents. J Emerg Med 2020; 58:217-233. [DOI: 10.1016/j.jemermed.2019.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/30/2019] [Accepted: 10/13/2019] [Indexed: 01/19/2023]
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532
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Abstract
Heart failure (HF) and atrial fibrillation (AF), increasingly common in the aging population, are closely related and commonly found together. This article explores the relationship between AF and HF and the thromboembolic effect of these diseases. Morbidity and mortality are increased when the 2 conditions are seen together. Stroke risks are significant with AF and all subtypes of HF. This article suggests that all patients with AF and HF should be considered for anticoagulation. Current evidence suggests that non-vitamin K antagonist oral anticoagulants are effective and safe in AF and HF in comparison with warfarin.
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533
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Gorenek (Chair) B, Halvorsen S, Kudaiberdieva G, Bueno H, Van Gelder IC, Lettino M, Marin F, Masip J, Mueller C, Okutucu S, Poess J, Potpara TS, Price S, Lip (Co-chair) GYH. Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:348-357. [DOI: 10.1177/2048872619894255] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.
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Affiliation(s)
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Norway
| | - Gulmira Kudaiberdieva
- Adana, Turkey
- Scientific Research Institute of Heart Surgery and Organ Transplantation, Kyrgyzstan
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
| | | | | | - Francisco Marin
- Hospital Clínico, Universitario Virgen de la Arrixaca, Spain
| | - Josep Masip
- Cardiology Department, Hospital Sanitas CIMA, University of Barcelona, Spain
| | - Christian Mueller
- Cardiovascular Research Institute, University Hospital of Basel, Switzerland
| | - Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Turkey
| | - Janine Poess
- Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Germany
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | | | - Gregory YH Lip (Co-chair)
- Liverpool Centre for Cardiovascular Science, University of Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
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534
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Favaloro EJ, Gilmore G, Bonar R, Dean E, Arunachalam S, Mohammed S, Baker R. Reducing the effect of DOAC interference in laboratory testing for factor VIII and factor IX: A comparative study using DOAC Stop and andexanet alfa to neutralize rivaroxaban effects. Haemophilia 2020; 26:354-362. [PMID: 31962376 DOI: 10.1111/hae.13930] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/20/2019] [Accepted: 01/01/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Investigation of factors (F) VIII and IX is common, with testing important for diagnosis or exclusion of haemophilia A or B, associated acquired conditions and factor inhibitors. Rivaroxaban, a common direct anti-Xa agent, causes significant interference in clotting assays, including substantial false reduction of factor levels. AIM To assess whether rivaroxaban-induced interference of FVIII and FIX testing could be neutralized. MATERIALS AND METHODS An international, cross-laboratory exercise for FVIII (n = 84) and FIX (n = 74), using four samples: (A) pool of normal plasma; (B) pool spiked with rivaroxaban (200 ng/mL); (C) rivaroxaban sample subsequently treated with 'DOAC Stop' and; (D) rivaroxaban sample treated with andexanet alfa (200 μg/mL). Testing performed blind to sample type. RESULTS All laboratories reported normal FIX and 94% reported normal FVIII in the pool sample. Instead, 55% and 95%, respectively, reported abnormal FIX and FVIII levels for the rivaroxaban sample. DOAC Stop treatment evidenced a correction in most laboratories (100% reported normal FIX and 86% normal FVIII). Andexanet alfa provided intermediate results, with many laboratories still reporting abnormal results (59% for FVIII, 18% for FIX). We also identified reagent-specific issues. CONCLUSIONS As expected, rivaroxaban caused false low values of FVIII and FIX. This might lead to increased testing to identify the cause of low factor levels and potentially lead to false identification of (mild) haemophilia A or B if unrecognized by clinicians/laboratories. DOAC Stop effectively neutralized the rivaroxaban effect, but andexanet alfa less so, with reagent-related effects evident, and thus, false low values sometimes persisted.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Laboratory Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
| | - Grace Gilmore
- Western Australian Centre for Thrombosis and Haemostasis (WACTH), Murdoch University, Perth, WA, Australia
| | - Roslyn Bonar
- Royal College of Pathologists of Australasia Quality Assurance Program (RCPAQAP), St Leonards, NSW, Australia
| | - Elysse Dean
- Royal College of Pathologists of Australasia Quality Assurance Program (RCPAQAP), St Leonards, NSW, Australia
| | - Sandya Arunachalam
- Royal College of Pathologists of Australasia Quality Assurance Program (RCPAQAP), St Leonards, NSW, Australia
| | - Soma Mohammed
- Department of Laboratory Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ross Baker
- Western Australian Centre for Thrombosis and Haemostasis (WACTH), Murdoch University, Perth, WA, Australia
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535
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Potpara TS, Ferro C, Lip GYH, Dan GA, Lenarczyk R, Mallamaci F, Ortiz A, Sarafidis P, Ekart R, Dagres N. Management of atrial fibrillation in patients with chronic kidney disease in clinical practice: a joint European Heart Rhythm Association (EHRA) and European Renal Association/European Dialysis and Transplantation Association (ERA/EDTA) physician-based survey. Europace 2020; 22:496-505. [DOI: 10.1093/europace/euz358] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/13/2019] [Indexed: 01/09/2023] Open
Abstract
Abstract
The European Heart Rhythm Association (EHRA) and European Renal Association/European Dialysis and Transplantation Association (ERA/EDTA) jointly conducted a physician-based survey to gain insight into the management of atrial fibrillation (AF) in patients with chronic kidney disease (CKD) and adherence to current European Society of Cardiology AF Guidelines in contemporary clinical practice. Physician-based survey conducted during an 8-week period using an internet-based questionnaire sent to all EHRA and ERA/EDTA members, with voluntary and anonymous responses. Among 306 physicians (160 EHRA and 146 ERA/EDTA members; 56 countries), a multidisciplinary team for management of AF-CKD patients was available to only 20/300 respondents (6.7%) and 132/295 (44.7%) routinely screened CKD patients for AF. Oral anticoagulation (OAC) use was based on individual stroke risk in mild/moderate CKD but on shared decision-making in advanced CKD. The CHA2DS2-VASc score-based decisions were more common among cardiologists, with substantial intra- and inter-specialty heterogeneity in the use and dosing of specific OAC drugs across CKD stages, heterogeneous strategies for OAC monitoring (especially among nephrologists) and a modest impact of CKD on rate and rhythm control treatment decisions. The HAS-BLED score was generally not a determinant of OAC prescribing. Our survey provided important insights into contemporary management of AF patients with CKD in clinical practice, revealing certain differences between nephrologists and cardiologists and highlighting shared and specific knowledge gaps and unmet needs. These findings emphasize the need for streamlining the care for AF patients across different specialties and may inform development of tailored education interventions.
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Affiliation(s)
- Tatjana S Potpara
- School of Medicine, Belgrade University, Visegradska 26, 11000 Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Charles Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool, UK
| | - George A Dan
- Medicine University ‘Carol Davila’, Colentina University Hospital, Bucharest, Romania
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Curie-Sklodowskiej Str 9, 41-800 Zabrze, Poland
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robert Ekart
- Faculty of Medicine, Maribor University, Maribor, Slovenia
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany
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536
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Kozieł M, Al-Saady N, Hjortshøj SP, Goudev A, Huber K, Cohen A, Jin J, Melino M, Winters SM, Goette A, Lip GYH. Edoxaban versus warfarin in vitamin K antagonist experienced and naïve patients from the edoxaban versus warfarin in subjects undergoing cardioversion of atrial fibrillation (ENSURE-AF) randomised trial. Clin Res Cardiol 2020; 109:1018-1024. [PMID: 31915996 PMCID: PMC7376082 DOI: 10.1007/s00392-019-01594-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/23/2019] [Indexed: 12/01/2022]
Abstract
Background In ENSURE-AF study, edoxaban had similar efficacy and safety profile versus enoxaparin–warfarin (enox–warf) in patients undergoing electrical cardioversion of non-valvular atrial fibrillation. Objectives To evaluate the efficacy and safety of edoxaban versus enox–warf in patients who were vitamin K antagonists (VKA) naïve or experienced at time of randomisation into ENSURE-AF trial. Methods The primary efficacy endpoint was a composite of stroke, systemic embolic event, myocardial infarction, and cardiovascular death during the overall study period, 28 days on study drug after cardioversion and 30 days follow-up. The primary safety endpoint was the composite of major and clinically relevant nonmajor bleeding during the on-medication period from time of first dose to last dose of study drug taken + 3 days. Results Of 2199 patients enrolled in ENSURE-AF, 1095 were randomised to edoxaban and 1104 to enox–warf. There were numerically fewer primary efficacy endpoint events with edoxaban than enox–warf irrespective of whether VKA experienced or naïve (0.5% vs. 0.9%, 0.3% vs. 1.4%, respectively). There were no significant differences in the primary safety endpoint [odds ratio (OR) 2.09, 95% confidence interval (CI) 0.72–6.81 in anticoagulant experienced patients, OR 0.77, 95% CI 0.15–3.60 in anticoagulant naïve patients] and in major bleeding rates regardless of treatment or VKA experience (OR 0.69, 95%CI 0.06–6.04, OR 0.48, 95% CI 0.01–9.25, respectively). Conclusions Edoxaban had comparable efficacy and safety to optimized anticoagulation with enox–warf. The primary efficacy and safety endpoint outcomes were broadly similar between VKA experienced or naïve patients.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L78TX, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Naab Al-Saady
- Covance Inc, Cardiovascular/Metabolic, Maidenshead, UK
| | - Søren P Hjortshøj
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Assen Goudev
- Queen Giovanna University Hospital, Sofia, Bulgaria
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Medcial School, Wilhelminenhospital, and Sigmund Freud University, Vienna, Austria
| | - Ariel Cohen
- Hôpital Saint Antoine, Hôpital Tenon; Université Pierre Et Marie Curie (Paris VI), Paris, France
| | - James Jin
- Daiichi Sankyo Pharma Development, Basking Ridge, New York, USA
| | | | | | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Germany.,Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L78TX, UK. .,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland. .,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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537
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Safety outcomes of apixaban in patients with nonvalvular atrial fibrillation and severe renal impairment. J Thromb Thrombolysis 2020; 50:330-336. [DOI: 10.1007/s11239-019-02028-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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538
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539
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Geller AI, Shehab N, Lovegrove MC, Rose KO, Weidle NJ, Goring SK, Budnitz DS. Emergency Visits for Oral Anticoagulant Bleeding. J Gen Intern Med 2020; 35:371-373. [PMID: 31664597 PMCID: PMC6957602 DOI: 10.1007/s11606-019-05391-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew I Geller
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Kathleen O Rose
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
- Northrup Grumman Corporation, Atlanta, GA, USA
| | - Nina J Weidle
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
- Eagle Global Scientific LLC, Atlanta, GA, USA
| | - Sandra K Goring
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
- Northrup Grumman Corporation, Atlanta, GA, USA
| | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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540
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Kozieł M, Simovic S, Pavlovic N, Nedeljkovic M, Paparisto V, Music L, Goshev E, Dan AR, Manola S, Kusljugic Z, Trendafilova E, Dobrev D, Dan GA, Lip GY, Potpara TS. Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey. IJC HEART & VASCULATURE 2019; 26:100461. [PMID: 32140551 PMCID: PMC7046541 DOI: 10.1016/j.ijcha.2019.100461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
23.6% of patients in the survey had newly-diagnosed atrial fibrillation (AF). Those patients had different risk profiles than those with a history of AF. The specificity of the management of first-diagnosed AF patients was presented.
Background BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice. Methods Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey. Results Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA2DS2-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use. Conclusions In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Stefan Simovic
- Cardiology Clinic, University Clinical Center of Kragujevac, Kragujevac, Serbia
| | | | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Vilma Paparisto
- Clinic of Cardiology, University Hospital Center Mother Theresa, Tirana, Albania
| | - Ljilja Music
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty, Podgorica, Montenegro
| | - Evgenii Goshev
- National Heart Hospital, Coronary Care Unit, Sofia, Bulgaria
| | - Anca Rodica Dan
- Colentina University Hospital, Cardiology Department, Bucharest, Romania
| | - Sime Manola
- Clinical Center Sestre Milosrdnice, Zagreb, Croatia
| | - Zumreta Kusljugic
- Clinic of Internal Medicine, Cardiology Department, University Clinical Center Tuzla, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | | | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Gheorghe-Andrei Dan
- Medicine University “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
- School of Medicine, Belgrade University, Belgrade, Serbia
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tatjana S. Potpara
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
- Corresponding author at: Cardiology Clinic, Clinical Center of Serbia, Visegradska 26, 11000 Belgrade, Serbia.
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541
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Effectiveness and Safety of Direct Oral Anticoagulant for Secondary Prevention in Asians with Atrial Fibrillation. J Clin Med 2019; 8:jcm8122228. [PMID: 31861095 PMCID: PMC6947173 DOI: 10.3390/jcm8122228] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022] Open
Abstract
We investigated the effectiveness and safety of direct oral anticoagulants (DOACs) for secondary prevention in patients with atrial fibrillation (AF), particularly focusing on subgroups of patients with severe, disabling, and recent stroke. Using the Korean National Health Insurance Service claims database between January 2010 and April 2018, we selected OAC-naïve patients with non-valvular AF and a history of stroke. Cumulative risks for recurrent stroke, major bleeding, composite outcome (recurrent stroke + major bleeding), and mortality were compared between DOAC and warfarin groups. Among 61,568 patients, 28,839 and 32,729 received warfarin and DOACs, respectively. Compared with warfarin, DOACs were associated with lower risks of recurrent stroke (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.62-0.72), major bleeding (HR 0.73, 95% CI 0.66-0.80), composite outcome (HR 0.69, 95% CI 0.65-0.73), and mortality. DOAC use resulted in a consistent trend of improved outcomes in the subgroups of patients with severe, disabling, and recent stroke. In conclusion, DOACs were associated with lower risks of recurrent stroke, major bleeding, composite clinical outcomes, and mortality in patients with AF and a history of stroke. These results were consistent across all types of DOACs and subgroups of patients with severe, disabling, and recent stroke.
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542
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Perreault S, Denus S, White‐Guay B, Côté R, Schnitzer ME, Dubé M, Dorais M, Tardif J. Oral Anticoagulant Prescription Trends, Profile Use, and Determinants of Adherence in Patients with Atrial Fibrillation. Pharmacotherapy 2019; 40:40-54. [DOI: 10.1002/phar.2350] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
| | - Simon Denus
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
- Montreal Heart Institute Montreal Quebec Canada
| | - Brian White‐Guay
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | | | - Marie‐Pierre Dubé
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | - Marc Dorais
- StatSciences Inc. Notre‐Dame‐de‐l’Île‐Perrot Quebec Canada
| | - Jean‐Claude Tardif
- Montreal Heart Institute Montreal Quebec Canada
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
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543
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Rivera-Caravaca JM, Marín F, Esteve-Pastor MA, Gálvez J, Lip GYH, Vicente V, Roldán V. Murcia atrial fibrillation project II: protocol for a prospective observational study in patients with atrial fibrillation. BMJ Open 2019; 9:e033712. [PMID: 31843852 PMCID: PMC6924708 DOI: 10.1136/bmjopen-2019-033712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is characterised by a high stroke risk. Vitamin K antagonists (VKAs) are the most commonly used oral anticoagulants (OACs) in Spain, but their efficacy and safety depend on the time in therapeutic range of International Normalized Ratio (INR) 2.0-3.0 over 65%-70%. Unfortunately, the difficulties of maintaining an optimal level of anticoagulation and the complications of VKAs (particularly haemorrhagic ones), frequently lead to cessation of this therapy, which has been associated with higher risk of adverse events (AEs), including ischaemic stroke. Our aims are as follows: (1) to evaluate the quality of oral anticoagulation with VKAs, the prevalence of poor quality of anticoagulation, and to identify factors predisposing to poor quality anticoagulation; and (2) to identify patients who will stop OAC and to investigate what factors influence the decision of OAC withdrawal. METHODS AND ANALYSIS Prospective observational cohort study including outpatients newly diagnosed with AF and naïve for OACs from July 2016 to June 2018 in an anticoagulation clinic. Patients with prosthetic heart valves, rheumatic mitral valves or valvular AF will be excluded. Follow-up will extend for up to 3 years. During this period, the INR results and changes in the anticoagulant therapy will be recorded, as well as all AEs, or any other information that would be relevant to the proper conduct of research. ETHICS AND DISSEMINATION All patients were informed about the nature and purpose of the study, and the protocol was approved by the Ethics Committee of Hospital General Universitario Morales Meseguer (reference: EST:20/16). This is an observational study focusing on 'real life' practice and therefore all treatments and follow-up will be performed in accordance to the routine clinical practice with no specific interventions or visits. The results of our study will be disseminated by presentations at national and international meetings, and publications in peer-reviewed journals.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Deparment of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Francisco Marín
- Deparment of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Deparment of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Josefa Gálvez
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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544
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Ding Y, Niu J, Fan J, Liu Y. Repeated mechanical thrombectomy for acute ischemic stroke in a dialysis patient: A case report and literature review. Hemodial Int 2019; 24:E13-E19. [PMID: 31830373 DOI: 10.1111/hdi.12811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/25/2019] [Accepted: 11/28/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Yun‐Long Ding
- Department of Neurology, Jingjiang People's HospitalThe Seventh Affiliated Hospital of Yangzhou University Jiangsu China
| | - Jia‐Li Niu
- Department of Clinical Pharmacy, Jingjiang People's HospitalThe Seventh Affiliated Hospital of Yangzhou University Jiangsu China
| | - Jiao‐Xin Fan
- Department Nephrology, Jingjiang People's HospitalThe Seventh Affiliated Hospital of Yangzhou University Jiangsu China
| | - Yan Liu
- Department of Neurology, Jingjiang People's HospitalThe Seventh Affiliated Hospital of Yangzhou University Jiangsu China
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545
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Harrison SL, Lane DA, Lip GYH. Reducing risk of adverse cardiovascular and renal outcomes for patients with atrial fibrillation and type 2 diabetes. Eur J Heart Fail 2019; 22:136-138. [PMID: 31820530 DOI: 10.1002/ejhf.1685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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546
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Tran NT, Lin CH, Do NN, Muradian IK, Lu QD, Henderson SO. The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility. J Pharm Pract 2019; 34:631-634. [PMID: 31818177 DOI: 10.1177/0897190019892120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.
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Affiliation(s)
| | - Cindy H Lin
- 436102Correctional Health Services, Los Angeles, CA, USA
| | - Nguyen N Do
- 436102Correctional Health Services, Los Angeles, CA, USA
| | | | - Quyen D Lu
- 436102Correctional Health Services, Los Angeles, CA, USA
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547
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Review of the 2019 European Society of Cardiology Guidelines for the management of patients with supraventricular tachycardia: What is new, and what has changed? Anatol J Cardiol 2019; 22:282-286. [PMID: 31789617 PMCID: PMC6955050 DOI: 10.14744/anatoljcardiol.2019.93507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Supraventricular arrhythmias are frequent, and symptomatic patients often need medical therapy or catheter ablation. The recently published 2019 European Society of Cardiology (ESC) Guidelines for the management of patients with supraventricular tachycardia (SVT) give a comprehensive overview of current developments in the field and provides recommendations for the management of adults with SVT. In this paper, we briefly summarized major new recommendations and significant changes from the former ESC guideline published 16 years ago.
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548
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Smythe MA, Parker D, Garwood CL, Cuker A, Messé SR. Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation. Pharmacotherapy 2019; 40:55-71. [PMID: 31698510 DOI: 10.1002/phar.2345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with atrial fibrillation (AF) who suffer an acute ischemic stroke are at risk for both hemorrhagic transformation and recurrent ischemic stroke in the acute post-stroke period. Oral anticoagulants are recommended for secondary stroke prevention in patients with AF. The optimal time to initiate anticoagulant therapy after acute ischemic stroke in patients with AF is uncertain. There is concern that early initiation increases the risk of hemorrhagic transformation, whereas delayed initiation leaves the patient at risk for recurrent ischemic stroke. In this article, we provide a review of the risk of hemorrhagic transformation of acute ischemic stroke as well as review the literature and major guidelines addressing the timing of anticoagulation initiation after an acute ischemic stroke in patients with AF. Relevant articles published from 1990 to the present were identified using the PubMed and Embase databases. The majority of available literature is observational data. Large ischemic lesions, cerebral microbleeds, thrombolytic therapy, and other clinical factors may increase the risk of hemorrhagic transformation of an acute ischemic stroke. Parenteral anticoagulation within 48 hours is associated with an increased risk of hemorrhagic transformation and is not recommended. Insufficient data exist to support the safety of routine oral anticoagulant (direct oral anticoagulants or warfarin) initiation within 48 hours of an acute ischemic stroke. Direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation. Infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation and should guide decisions when available. A recommended framework for patient decision making is provided. Randomized controlled trials in this area are needed to identify the optimal timing of anticoagulation initiation, and such trials are under way.
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Affiliation(s)
- Maureen A Smythe
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.,Department of Pharmacy Services, Beaumont Hospital, Royal Oak, Michigan
| | - Dennis Parker
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.,Department of Pharmacy, Detroit Medical Center, Detroit Receiving Hospital, Detroit, Michigan
| | - Candice L Garwood
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.,Department of Pharmacy, Detroit Medical Center, Harper University Hospital, Detroit, Michigan
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve R Messé
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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549
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Comparing the Effectiveness and Safety of Nonvitamin K Antagonist Oral Anticoagulants and Warfarin in Elderly Asian Patients With Atrial Fibrillation: A Nationwide Cohort Study. Chest 2019; 157:1266-1277. [PMID: 31809694 DOI: 10.1016/j.chest.2019.11.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/19/2019] [Accepted: 11/09/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Stroke prevention in elderly patients with atrial fibrillation (AF) can be challenging, requiring a balance between thromboembolism prevention and serious bleeding. Comparisons of nonvitamin K antagonist oral anticoagulants (NOACs) and warfarin in older adults at different age strata (65-74, 75-89, and ≥ 90 years of age) in the daily practice have not been well described, particularly in Asians. We aimed to assess the clinical outcomes of NOACs compared with warfarin for stroke prevention in elderly patients with AF. METHODS From 2012 to 2015, 64,169 patients ≥ 65 years of age with AF who received at least one NOAC (dabigatran, rivaroxaban, or apixaban) or warfarin prescription were identified from the Taiwan National Health Insurance Research Database. The risks of ischemic stroke, intracranial hemorrhage (ICH), major bleeding, mortality, and composite adverse events were compared between NOACs and warfarin in all patients ≥ 65 years of age and, specifically, with different age strata (ie, 65-74, 75-89, ≥ 90 years). RESULTS Overall, NOACs were associated with a significantly lower risk of ischemic stroke (adjusted hazard ratio [aHR], 0.869; 95% CI, 0.812-0.931), ICH (aHR, 0.524; 95% CI, 0.456-0.601), major bleeding (aHR, 0.824; 95% CI, 0.776-0.875), mortality (aHR, 0.511; 95% CI, 0.491-0.532), and composite adverse events (aHR, 0.646; 95% CI, 0.625-0.667) than warfarin. There was heterogeneity in treatment effect for NOACs vs warfarin in different age strata, but the results still favored NOACs even among very older adults (≥ 90 years). The results were generally consistent with propensity matching analysis. The absolute risk difference and reductions in ICH and composite adverse events with NOAC use were even greater among older adults than warfarin. CONCLUSIONS Compared with warfarin, NOACs were associated with a significantly lower risk of adverse events, with heterogeneity in treatment effects among different age strata. Overall, the clear safety signal in favor of NOACs over warfarin was evident irrespective of age strata, being most marked in very older adults.
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550
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Dobesh PP, Bhatt SH, Trujillo TC, Glaubius K. Antidotes for reversal of direct oral anticoagulants. Pharmacol Ther 2019; 204:107405. [DOI: 10.1016/j.pharmthera.2019.107405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 12/26/2022]
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