501
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Di Lullo L, Ronco C, Cozzolino M, Russo D, Russo L, Di Iorio B, De Pascalis A, Barbera V, Galliani M, Vitaliano E, Campana C, Santoboni F, Bellasi A. Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation. Thromb Res 2017; 155:38-47. [PMID: 28482261 DOI: 10.1016/j.thromres.2017.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49ml/min) and those on dialysis.
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Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy.
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, S. Paolo Hospital, Milano, Italy
| | - D Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - L Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - B Di Iorio
- Department of Nephrology and Dialysis, Landolfi Hospital, Solofra, Italy
| | - A De Pascalis
- Department of Nephrology and Dialysis, V. Fazzi Hospital, Lecce, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - M Galliani
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - E Vitaliano
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - C Campana
- Cardiology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
| | - F Santoboni
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - A Bellasi
- Nephrology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
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502
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Nardi F, Gulizia MM, Colivicchi F, Abrignani MG, Di Fusco SA, Di Lenarda A, Di Tano G, Geraci G, Moschini L, Riccio C, Verdecchia P, Enea I. ANMCO Position Paper: direct oral anticoagulants for stroke prevention in atrial fibrillation: clinical scenarios and future perspectives. Eur Heart J Suppl 2017; 19:D70-D88. [PMID: 28751836 PMCID: PMC5526472 DOI: 10.1093/eurheartj/sux007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thrombo-embolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.
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Affiliation(s)
- Federico Nardi
- Cardiology Department, S.O.C. Cardiologia, Ospedale Castelli, ASL VCO, Via Fiume 18, 28922, Verbania, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Furio Colivicchi
- CCU-Cardiology Department, Presidio Ospedaliero San Filippo Neri, Rome, Italy
| | | | | | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Giuseppe Di Tano
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello Palermo, Italy
| | - Giovanna Geraci
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello Palermo, Italy
| | | | - Carmine Riccio
- Prevention and cardiac rehabilitation Department, A.O. Sant'Anna e San Sebastiano, Caserta, Italy
| | - Paolo Verdecchia
- Internal Medicine Unit, Ospedale di Assisi, Assisi, Perugia, Italy
| | - Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Caserta, Italy
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503
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Ofek F, Bar Chaim S, Kronenfeld N, Ziv-Baran T, Berkovitch M. International Normalized Ratio Is Significantly Elevated With Rivaroxaban and Apixaban Drug Therapies: A Retrospective Study. Clin Ther 2017; 39:1003-1010. [DOI: 10.1016/j.clinthera.2017.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 11/17/2022]
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504
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Koscielny J, Rosenthal C, von Heymann C. Nicht-Vitamin-K-abhängige orale Antikoagulanzien. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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505
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Qué hacer ante una cirugía urgente en pacientes tratados con anticoagulantes orales de acción directa. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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506
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Caporale R, Geraci G, Gulizia MM, Borzi M, Colivicchi F, Menozzi A, Musumeci G, Scherillo M, Ledda A, Tarantini G, Gerometta P, Casolo G, Formigli D, Romeo F, Di Bartolomeo R. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Association of Interventional Cardiology (SICI-GISE) and Italian Society of Cardiac Surgery (SICCH): clinical approach to pharmacologic pre-treatment for patients undergoing myocardial revascularization procedures. Eur Heart J Suppl 2017; 19:D151-D162. [PMID: 28751841 PMCID: PMC5520758 DOI: 10.1093/eurheartj/sux010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The wide availability of effective drugs in reducing cardiovascular events together with the use of myocardial revascularization has greatly improved the prognosis of patients with coronary artery disease. The combination of antithrombotic drugs to be administered before the knowledge of the coronary anatomy and before the consequent therapeutic strategies, can allow to anticipate optimal treatment, but can also expose the patients at risk of bleeding that, especially in acute coronary syndromes, can significantly weigh on their prognosis, even more than the expected theoretical benefit. In non ST-elevation acute coronary syndromes patients in particular, we propose a 'selective pre-treatment' with P2Y12 inhibitors, based on the ischaemic risk, on the bleeding risk and on the time scheduled for the execution of coronary angiography. Much of the problems concerning this issue would be resolved by an early access to coronary angiography, particularly for patients at higher ischaemic and bleeding risk.
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Affiliation(s)
- Roberto Caporale
- Interventional Cardiology Department, Ospedale Civile dell'Annunziata, Via Migliori 1, 87100 Cosenza, Italy
| | - Giovanna Geraci
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Mauro Borzi
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
| | | | - A. Menozzi
- Cardiology Unit, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | | | - Antonietta Ledda
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Giuseppe Tarantini
- Cardiological Sciences, Thoracic and Vascular Department, Università degli Studi, Padova, Italy
| | | | - Giancarlo Casolo
- Cardiology Department, Nuovo Ospedale Versilia, Lido di Camaiore, Lucca, Italy
| | - Dario Formigli
- Interventional Cardiology, A.O. G. Rummo, Benevento, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
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507
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Enea I, Roncon L, Gulizia MM, Azzarito M, Becattini C, Bongarzoni A, Casazza F, Cuccia C, D’Agostino C, Rugolotto M, Vatrano M, Vinci E, Fenaroli P, Formigli D, Silvestri P, Nardi F, Vedovati MC, Scherillo M. ANMCO Position Paper: the use of non-vitamin K dependent new oral anticoagulant(s) in pulmonary embolism therapy and prevention. Eur Heart J Suppl 2017; 19:D293-D308. [PMID: 28751847 PMCID: PMC5526474 DOI: 10.1093/eurheartj/sux026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including (i) their mechanism of action, pharmacodynamics, and pharmacokinetics; (ii) the use in the acute phase with the 'double drug single dose' approach or with 'single drug double dose'; (iii) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; (iv) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance > 30 mL/min), the elderly (>75 years); (v) they propose a possible laboratory clinical pathway for follow-up; and (vi) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.
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Affiliation(s)
- Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Via G. Tescione, 1. 81100 Casert, Italy
| | - Loris Roncon
- Cardiology Department, S. Maria della Misericordia Hospital, Rovigo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi-Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializazione “Garibaldi”, Catania, Italy
| | | | - Cecilia Becattini
- Department of Internal and Vascular Medicine, Perugia General Hospital, Perugia, Italy
| | | | | | - Claudio Cuccia
- Cardiology Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | | | - Marco Vatrano
- CCU-Hemodynamics and Interventional Cardiology Department, Civil Pugliese Hospital, Catanzaro, Italy
| | - Eugenio Vinci
- Cardiology-CCU Department, Umberto I Hospital, Siracusa, Italy
| | - Paride Fenaroli
- Nephrology and Dialysis Unit, Salvatore Maugeri Foundation, University of Pavia, Pavia, Italy
| | - Dario Formigli
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Paolo Silvestri
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Federico Nardi
- Cardiology Department, Castelli Hospital, Verbania, Italy
| | - Maria Cristina Vedovati
- Department of Internale and Vascular Medicine, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Marino Scherillo
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
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508
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Chan NC, Eikelboom JW, Weitz JI. Evolving Treatments for Arterial and Venous Thrombosis: Role of the Direct Oral Anticoagulants. Circ Res 2017; 118:1409-24. [PMID: 27126650 DOI: 10.1161/circresaha.116.306925] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
The direct oral anticoagulants (DOACs) represent a major advance in oral anticoagulant therapy and have replaced the vitamin K antagonists as the preferred treatment for many indications. By simplifying long-term anticoagulant therapy and improving its safety, the DOACs have the potential to reduce the global burden of thrombosis. Postmarketing studies suggest that the favorable results achieved with DOACs in the randomized controlled trials can be readily translated into practice, but highlight the need for appropriate patient, drug and dose selection, and careful follow-up. Leveraging on their success to date, ongoing studies are assessing the utility of DOACs for the prevention of thrombosis in patients with embolic stroke of unknown source, heart failure, coronary artery disease, peripheral artery disease, antiphospholipid syndrome, and cancer. The purpose of this article is to (1) review the pharmacology of the DOACs, (2) describe the advantages of the DOACs over vitamin K antagonists, (3) summarize the experience with the DOACs in established indications, (4) highlight current challenges and limitations, (5) highlight potential new indications; and (6) identify future directions for anticoagulant therapy.
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Affiliation(s)
- Noel C Chan
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.).
| | - John W Eikelboom
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
| | - Jeffrey I Weitz
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
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509
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Ronco F, Mazzone P, Hosseinian L, Genovesi S. Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease. Cardiorenal Med 2017; 7:207-217. [PMID: 28736561 DOI: 10.1159/000470856] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/07/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in this population the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. SUMMARY In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared to VKA. Limited data from post hoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate, eGFR, between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR <30 mL/min, since there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacological alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared to patients with normal renal function. KEY MESSAGES Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.
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Affiliation(s)
- Federico Ronco
- Interventional Cardiology, Cardiovascular Department, ULSS-12 Veneziana, Venice and Mestre, Italy
| | - Patrizio Mazzone
- Arrhythmology and Cardiac Pacing Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Leila Hosseinian
- Department of Anesthesiology, Mount Sinai Hospital, New York, NY, USA
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Nephrology Unit, S. Gerardo Hospital, Monza, Italy
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510
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Abe M, Ogawa H, Ishii M, Masunaga N, Esato M, Chun YH, Tsuji H, Wada H, Hasegawa K, Lip GY, Akao M. Relation of Stroke and Major Bleeding to Creatinine Clearance in Patients With Atrial Fibrillation (from the Fushimi AF Registry). Am J Cardiol 2017; 119:1229-1237. [PMID: 28219663 DOI: 10.1016/j.amjcard.2017.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
Abstract
Creatinine clearance (CrCl) has been widely used to adjust the dosage of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation (AF) and exclude contraindicated patients. However, there are few available real-world data on the relation between CrCl and adverse clinical outcomes in patients with AF. Therefore, we evaluated the clinical characteristics and adverse events in Japanese patients with AF stratified by CrCl. We categorized patients in the Fushimi AF Registry, a large prospective community-based Japanese cohort of patients with AF, into 3 groups as follows: (1) CrCl <30 ml/min, (2) CrCl 30 to 49 ml/min, and (3) CrCl ≥50 ml/min. We evaluated 3,080 patients after a median follow-up of 1,076 days. Comparing with patients with CrCl ≥50 ml/min, patients with AF with CrCl <30 ml/min showed increased risks of stroke/systemic embolism (SE) (hazard ratio [HR] 1.68; 95% confidence interval [CI] 1.04 to 2.65; p = 0.04) and major bleeding (HR, 2.08; 95% CI 1.23 to 3.39; p = 0.008) after adjustment for prespecified factors. Patients with AF with CrCl <30 ml/min were also associated with higher risks of all-cause death, hospitalization for heart failure, myocardial infarction, or the composite of all-cause death and stroke/SE. However, no excess risk of stroke/SE (HR 1.10; 95% CI 0.76 to 1.58; p = 0.6) or major bleeding (HR 0.98; 95% CI 0.63 to 1.48; p = 0.9) was noted for patients with CrCl 30 to 49 ml/min. In conclusion, Japanese patients with AF with CrCl <30 ml/min were closely associated with adverse clinical events including stroke/SE and major bleeding.
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511
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Başaran Ö, Dogan V, Beton O, Tekinalp M, Aykan AÇ, Kalaycıoğlu E, Bolat I, Taşar O, Şafak Ö, Kalçık M, Yaman M, İnci S, Altıntaş B, Kalkan S, Kırma C, Biteker M. Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study. J Thromb Thrombolysis 2017; 43:157-165. [PMID: 27848065 DOI: 10.1007/s11239-016-1445-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA2DS2VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA2DS2VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.
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Affiliation(s)
- Özcan Başaran
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
| | - Volkan Dogan
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
| | - Osman Beton
- Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Mehmet Tekinalp
- Department of Cardiology, Kahramanmaraş Necip Fazıl State Hospital, Kahramanmaraş, Turkey
| | - Ahmet Çağrı Aykan
- Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ezgi Kalaycıoğlu
- Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ismail Bolat
- Department of Cardiology, Fethiye State Hospital, Muğla, Turkey
| | - Onur Taşar
- Department of Cardiology, Elazığ Education and Research Hospital, Elazig, Turkey
| | - Özgen Şafak
- Department of Cardiology, Burdur State Hospital, Burdur, Turkey
| | - Macit Kalçık
- Department of Cardiology, İskilip Atıf Hoca State Hospital, Iskilip, Turkey
| | - Mehmet Yaman
- Department of Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Sinan İnci
- Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey
| | - Bernas Altıntaş
- Department of Cardiology, Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Sedat Kalkan
- Department of Cardiology, Gönen State Hospital, Gönen, Turkey
| | - Cevat Kırma
- Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Murat Biteker
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
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512
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Vosko MR, Bocksrucker C, Drwiła R, Dulíček P, Hauer T, Mutzenbach J, Schlimp CJ, Špinler D, Wolf T, Zugwitz D. Real-life experience with the specific reversal agent idarucizumab for the management of emergency situations in dabigatran-treated patients: a series of 11 cases. J Thromb Thrombolysis 2017; 43:306-317. [PMID: 28210988 PMCID: PMC5337234 DOI: 10.1007/s11239-017-1476-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have a favorable benefit-risk profile compared with vitamin K antagonists. However, the lack of specific reversal agents has made the management of some patients receiving long-term treatment with NOACs problematic in emergency situations such as major bleeding events or urgent procedures. Idarucizumab, a fully humanized Fab antibody fragment that binds specifically and with high affinity to dabigatran, was recently approved for use in adult patients treated with dabigatran when rapid reversal of its anticoagulant effect is required. Clinical experience with idarucizumab is currently limited. We report 11 real-life clinical cases in which idarucizumab was used after multidisciplinary consultation in a variety of emergency situations including severe postoperative bleeding, emergency high-bleeding-risk surgery (hip/spine surgery and neurosurgery), invasive diagnostic testing (lumbar puncture), intracranial bleeding (pre-pontine subarachnoid hemorrhage and lobar intracerebral hemorrhage) and thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. This case series illustrates the role of idarucizumab in improving patient safety in rare emergency situations requiring rapid reversal of the anticoagulant effect of dabigatran, while highlighting the importance of information and education about the availability and appropriate use of this recently approved specific reversal agent.
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Affiliation(s)
- Milan R Vosko
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria.
| | | | - Rafał Drwiła
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - Petr Dulíček
- Fourth Department of Internal Medicine, Hematology, Hradec Králové Faculty of Medicine, Hradec Králové University Hospital, Hradec Králové, Czech Republic
| | - Tomas Hauer
- Department of Internal Medicine, České Budějovice Regional Hospital, and Faculty of Health and Science, University of South Bohemia, České Budějovice, Czech Republic
| | - Johannes Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Schlimp
- Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital, Klagenfurt, Austria
| | - David Špinler
- Department of Internal Medicine, Ústí nad Orlicí Hospital, Ústí nad Labem, Czech Republic
- Department of Cardiology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | - Thomas Wolf
- Department of Neurology, Wiener Neustadt Regional Hospital, Wiener Neustadt, Austria
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Delanaye P, Bouquegneau A, Dubois BE, Sprynger M, Mariat C, Krzesinski JM, Lancellotti P. Fibrillation auriculaire et anticoagulation chez le patient hémodialysé : une décision difficile. Nephrol Ther 2017; 13:59-66. [DOI: 10.1016/j.nephro.2016.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/17/2016] [Accepted: 09/18/2016] [Indexed: 10/20/2022]
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514
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Prisco D, Ageno W, Becattini C, D'Angelo A, Davì G, De Cristofaro R, Dentali F, Di Minno G, Falanga A, Gussoni G, Masotti L, Palareti G, Pignatelli P, Santi RM, Santilli F, Silingardi M, Tufano A, Violi F. Italian intersociety consensus on DOAC use in internal medicine. Intern Emerg Med 2017; 12:387-406. [PMID: 28191610 DOI: 10.1007/s11739-017-1628-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/02/2017] [Indexed: 12/15/2022]
Abstract
The direct oral anticoagulants (DOACs) are drugs used in clinical practice since 2009 for the prevention of stroke or systemic embolism in non-valvular atrial fibrillation, and for the treatment and secondary prevention of venous thromboembolism. The four DOACs, including the three factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and one direct thrombin inhibitor (dabigatran) provide oral anticoagulation therapy alternatives to Vitamin K antagonists (VKAs). Despite their clear advantages, the DOACs require on the part of the internist a thorough knowledge of their pharmacokinetic and pharmacodynamic characteristics to ensure their correct use, laboratory monitoring and the appropriate management of adverse events. This document represents a consensus paper on the use of DOACs by representatives of three Italian scientific societies: the Italian Society of Internal Medicine (SIMI), the Federation of the Associations of Hospital Managers (FADOI), and the Society for the Study of Haemostasis and Thrombosis (SISET). This document formulates expert opinion guidance for pragmatic managing, monitoring and reversing the anticoagulant effect of DOACs in both chronic and emergency settings. This practical guidance may help the internist to create adequate protocols for patients hospitalized ion internal medicine wards, where patients are often elderly subjects affected by poly-morbidities and renal insufficiency, and, thus, require particular attention to drug-drug interactions and peri-procedural protocols.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Giovanni Davì
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Raimondo De Cristofaro
- Institute of Internal Medicine and Geriatrics, Center for Haemorrhagic and Thrombotic Diseases, Haematology, Foundation Policlinico universitario "Agostino Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giovanni Di Minno
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, and the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto M Santi
- Haemostasis and Thrombosis Unit, Haematology, Az. Osp. "SS.Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | - Francesca Santilli
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Mauro Silingardi
- Internal Medicine Unit A - Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Antonella Tufano
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
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515
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Del Re M, Fogli S, Derosa L, Massari F, De Souza P, Crucitta S, Bracarda S, Santini D, Danesi R. The role of drug-drug interactions in prostate cancer treatment: Focus on abiraterone acetate/prednisone and enzalutamide. Cancer Treat Rev 2017; 55:71-82. [DOI: 10.1016/j.ctrv.2017.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 12/15/2022]
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517
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Bertoletti L, Ollier E, Duvillard C, Delavenne X, Beyens MN, De Magalhaes E, Bellet F, Basset T, Mismetti P, Laporte S. Direct oral anticoagulants: Current indications and unmet needs in the treatment of venous thromboembolism. Pharmacol Res 2017; 118:33-42. [DOI: 10.1016/j.phrs.2016.06.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 12/11/2022]
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Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:365-379. [PMID: 27896543 PMCID: PMC5337242 DOI: 10.1007/s11239-016-1446-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.
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Affiliation(s)
- Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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519
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Milling TJ, Frontera J. Exploring indications for the Use of direct oral anticoagulants and the associated risks of major bleeding. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:S67-S80. [PMID: 28581331 PMCID: PMC5568002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thrombosis is a leading cause of morbidity and mortality in the United States. Arterial and venous thromboses are implicated in the pathogenesis of major disorders, including myocardial infarction, ischemic stroke, and venous thromboembolism. Over the past decade, direct oral anticoagulants (DOACs) (eg, direct thrombin inhibitor and factor Xa [FXa] inhibitors) have been adopted as alternatives to warfarin due to their clinical advantages and efficacy for the treatment of thrombosis. As with all anticoagulants, treatment with DOACs is associated with a risk of major bleeding, including life-threatening gastrointestinal bleeds and intracranial hemorrhages (ICHs). In turn, the burden of bleeding associated with DOAC treatment is itself associated with substantial healthcare costs that are amplified by an increased risk of thromboembolic events and mortality following major bleeding events, especially in patients with ICHs. Given the rapid adoption of the DOACs and projected usage in the large patient population affected by thromboembolic conditions, clinicians are increasingly likely to encounter patients with major bleeding events due to DOAC therapy. Unlike warfarin, effective strategies to manage these bleeds are limited. There is an unmet need for reversal agents for use in the management of patients who receive FXa inhibitors and experience life-threatening bleeding or need emergency surgery. Andexanet alfa and ciraparantag are being evaluated as potential antidotes for both direct and indirect FXa inhibitors.
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520
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Fairman KA, Davis LE, Kruse CR, Sclar DA. Financial Impact of Direct-Acting Oral Anticoagulants in Medicaid: Budgetary Assessment Based on Number Needed to Treat. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:203-214. [PMID: 27896681 DOI: 10.1007/s40258-016-0295-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Faced with rising healthcare costs, state Medicaid programs need short-term, easily calculated budgetary estimates for new drugs, accounting for medical cost offsets due to clinical advantages. OBJECTIVE To estimate the budgetary impact of direct-acting oral anticoagulants (DOACs) compared with warfarin, an older, lower-cost vitamin K antagonist, on 12-month Medicaid expenditures for nonvalvular atrial fibrillation (NVAF) using number needed to treat (NNT). METHOD Medicaid utilization files, 2009 through second quarter 2015, were used to estimate OAC cost accounting for generic/brand statutory minimum (13/23%) and assumed maximum (13/50%) manufacturer rebates. NNTs were calculated from clinical trial reports to estimate avoided medical events for a hypothetical population of 500,000 enrollees (approximate NVAF prevalence × Medicaid enrollment) under two DOAC market share scenarios: 2015 actual and 50% increase. Medical service costs were based on published sources. Costs were inflation-adjusted (2015 US$). RESULTS From 2009-2015, OAC reimbursement per claim increased by 173 and 279% under maximum and minimum rebate scenarios, respectively, while DOAC market share increased from 0 to 21%. Compared with a warfarin-only counterfactual, counts of ischemic strokes, intracranial hemorrhages, and systemic embolisms declined by 36, 280, and 111, respectively; counts of gastrointestinal hemorrhages increased by 794. Avoided events and reduced monitoring, respectively, offset 3-5% and 15-24% of increased drug cost. Net of offsets, DOAC-related cost increases were US$258-US$464 per patient per year (PPPY) in 2015 and US$309-US$579 PPPY after market share increase. CONCLUSIONS Avoided medical events offset a small portion of DOAC-related drug cost increase. NNT-based calculations provide a transparent source of budgetary-impact information for new medications.
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Affiliation(s)
- Kathleen A Fairman
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA.
| | - Lindsay E Davis
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
| | - Courtney R Kruse
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
| | - David A Sclar
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
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521
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Raschi E, Bianchin M, De Ponti R, De Ponti F, Ageno W. Emerging therapeutic uses of direct-acting oral anticoagulants: An evidence-based perspective. Pharmacol Res 2017; 120:206-218. [PMID: 28366835 DOI: 10.1016/j.phrs.2017.03.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/22/2017] [Accepted: 03/29/2017] [Indexed: 12/24/2022]
Abstract
Direct-acting oral anticoagulants (DOACs) were claimed to cause a potential paradigm shift in the therapeutic scenario of patients requiring short- and long-term anticoagulation, by virtue of their pharmacological properties, perceived as innovative. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirmed that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy and effectiveness and unequivocally documented a consistent and clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Interestingly, two parallel paths can be identified in the current research scenario: A) in the aforementioned consolidated therapeutic indications, an innovative approach is directed towards tailored treatment strategies, to identify patients most likely to benefit from one of the different anticoagulant drugs, in particular subpopulations at increased risk of adverse events (e.g., bleeding); B) in unconventional settings, DOACs are gaining interest for potential use in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is less defined. The aim of this review is to critically assess the body of evidence underlying emerging therapeutic uses of DOACs (e.g., heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome), including evolving issues in special populations (e.g., patients with VTE and cancer or cirrhosis). This will be achieved by analyzing the strength (i.e., systematic reviews, randomized clinical trials, observational studies, case report/series) and consistency (i.e., concordance) of both published and unpublished evidence registered in major public repositories.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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522
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Barón-Esquivias G, Marín F, Sanmartín Fernandez M. Rivaroxaban in patients with atrial fibrillation: from ROCKET AF to everyday practice. Expert Rev Cardiovasc Ther 2017; 15:403-413. [DOI: 10.1080/14779072.2017.1309293] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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523
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Yoong D, Naccarato M, Gough K. Extensive Bruising and Elevated Rivaroxaban Plasma Concentration in a Patient Receiving Cobicistat-Boosted Elvitegravir. Ann Pharmacother 2017; 51:713-714. [PMID: 28351160 DOI: 10.1177/1060028017702677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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524
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Abstract
The standard of care for oral anticoagulation therapy has primarily been warfarin, which is limited by its indirect mechanism-of-action, variable kinetics, tolerability, and routine monitoring concerns. The direct-acting oral anticoagulants (DOACs) have predictable pharmacokinetics and pharmacodynamics, and improved safety and efficacy compared to warfarin for the prevention of stroke in patients with nonvalvular atrial fibrillation and prevention or management of venous thromboembolism. Consequential bleeding is a concern with all anticoagulants. Vitamin K is not a rapid reversal agent for warfarin; rather it facilitates synthesis of new vitamin K-dependent clotting factors, which can take longer than 24 h. Other nonspecific agents, including recombinant activated factor VII, three- and four-factor prothrombin complex concentrates (PCC), and activated PCC or Factor Eight Inhibitor Bypassing Activity (FEIBA®), are options based on clinical need. Specific agents to quickly reverse the effects of DOACs have been under development, and idarucizumab, a monoclonal antibody fragment that rapidly binds dabigatran, has been approved for clinical use in cases of dabigatran-related life-threatening bleeding, or if a dabigatran-treated patient needs emergency surgery or an invasive procedure. Idarucizumab specifically and rapidly reverses dabigatran-induced anticoagulation as measured by established coagulation assays. However, this does not guarantee complete hemostasis, especially if a patient has underlying comorbidities such as renal or liver disease, or has experienced recent trauma that requires urgent surgery. In these cases, concomitant supportive therapy and/or administration of concentrated clotting factors may be considered. Emerging data from ongoing trials and clinical experience will further inform providers regarding optimal approaches for anticoagulation reversal.
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Affiliation(s)
- William E Dager
- a Department of Pharmaceutical Services , University of California, Davis Medical Center , Sacramento , CA , US
| | - Linda Banares
- b Department of Clinical Sciences , Touro University California, College of Pharmacy , Vallejo , CA , US
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525
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Kermer P, Eschenfelder CC, Diener HC, Grond M, Abdalla Y, Althaus K, Berrouschot J, Cangür H, Daffertshofer M, Edelbusch S, Gröschel K, Haase CG, Harloff A, Held V, Kauert A, Kraft P, Lenz A, Müllges W, Obermann M, Partowi S, Purrucker J, Ringleb PA, Röther J, Rossi R, Schäfer N, Schneider A, Schuppner R, Seitz RJ, Szabo K, Wruck R. Antagonizing dabigatran by idarucizumab in cases of ischemic stroke or intracranial hemorrhage in Germany – A national case collection. Int J Stroke 2017; 12:383-391. [DOI: 10.1177/1747493017701944] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Idarucizumab is a monoclonal antibody fragment with high affinity for dabigatran that reverses its anticoagulant effects within minutes. It may exhibit the potential for patients under dabigatran therapy suffering ischemic stroke to regain eligibility for thrombolysis with rt-PA and may inhibit lesion growth in patients with intracerebral hemorrhage on dabigatran. Aims To provide insights into the clinical use of idarucizumab in patients under effective dabigatran anticoagulation presenting with signs of ischemic stroke or intracranial hemorrhage. Methods Retrospective data collected from German neurological/neurosurgical departments administering idarucizumab following product launch from January to August 2016 were used. Results Thirty-one patients presenting with signs of stroke received idarucizumab in 22 stroke centers. Nineteen patients treated with dabigatran presented with ischemic stroke and 12 patients suffered from intracranial bleeding. In patients receiving rt-PA thrombolysis following idarucizumab, 79% benefitted from i.v. thrombolysis with a median improvement of five points in NIHSS. No bleeding complications occurred. Hematoma growth was observed in 2 out of 12 patients with intracranial hemorrhage. The outcome was favorable with a median NIHSS improvement of 5.5 points and mRS 0–3 in 67%. Overall, mortality was low with 6.5% (one patient in each group). Conclusion Administration of rt-PA after reversing dabigatran activity with idarucizumab in case of ischemic stroke is feasible, easy to manage, effective, and appears to be safe. In dabigatran-associated intracranial hemorrhage, idarucizumab has the potential to prevent hematoma growth and improve outcome. Idarucizumab represents a new therapeutic option for patients under dabigatran treatment presenting with ischemic stroke or intracranial hemorrhage.
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Affiliation(s)
- Pawel Kermer
- Department of Neurology, Nordwestkrankenhaus Sanderbusch, Sande, Germany
| | | | | | - Martin Grond
- Department of Neurology, Kreiskrankenhaus Siegen, Germany
| | - Yasser Abdalla
- Department of Neurosurgery, Nordwestkrankenhaus Sanderbusch, Sande, Germany
| | | | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land GmbH, Altenburg, Germany
| | - Hakan Cangür
- Department of Neurology, Klinikum Wolfsburg, Germany
| | | | | | - Klaus Gröschel
- Department of Neurology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Claus G Haase
- Department of Neurology and Clinical Neurophysiology, Evangelische Kliniken Gelsenkirchen, Gelsenkirchen, Germany
| | - Andreas Harloff
- Department of Neurology, University Medical Centre, Freiburg, Germany
| | - Valentin Held
- Department of Neurology, University Hospital Mannheim, Mannheim, Germany
| | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | - Peter Kraft
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Arne Lenz
- Department of Neurology, Sozialstiftung Bamberg, Bamberg, Germany
| | - Wolfgang Müllges
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Mark Obermann
- Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany
| | - Someieh Partowi
- Stroke Unit, Marienhaus Klinikum, Kreis Ahrweiler, Bad Neuenahr-Ahrweiler, Germany
| | - Jan Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Raluca Rossi
- Department of Neurology, Main-Kinzig-Kliniken, Gelnhausen, Germany
| | - Niklas Schäfer
- Department of Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Andreas Schneider
- Department of Neurology and Clinical Neurophysiology, Evangelische Kliniken Gelsenkirchen, Gelsenkirchen, Germany
| | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Rüdiger J Seitz
- Department of Neurology, Centre of Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Germany
| | - Kristina Szabo
- Department of Neurology, University Hospital Mannheim, Mannheim, Germany
| | - Robert Wruck
- Department of Neurology, Klinikum Mittelbaden, Rastatt, Germany
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526
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Rieser KN, Rosenberg EI, Vogel Anderson K. Evaluation of the Appropriateness of Direct Oral Anticoagulant Selection and Monitoring in the Outpatient Setting. J Pharm Technol 2017. [DOI: 10.1177/8755122517698976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Direct oral anticoagulants (DOACs) share many indications with warfarin but require less frequent follow-up and monitoring. There is limited data available on the prescribing of DOACs and appropriate laboratory monitoring in a real-world clinical setting. Objective: To determine if patients receiving care at 2 University of Florida (UF) Health Internal Medicine clinics are prescribed DOACs according to Food and Drug Administration (FDA)–approved labeling. Secondary objectives were to determine the percentage of patients receiving appropriate baseline laboratory tests prior to DOAC initiation and the frequency of laboratory monitoring. Methods: This retrospective chart review evaluated patients enrolled at 2 UF Health Internal Medicine practices within the UF Health system who were prescribed a DOAC between April 2014 and April 2015. Adherence to FDA-approved dosing recommendations and baseline laboratory tests were compared to previously published data. This study was approved by the UF Institutional Review Board. Results: A total of 194 patients met inclusion criteria. Ninety-six patients (49.5%) were on a DOAC prior to data collection; 98 patients (50.5%) started a DOAC during data collection. Of the 194 patients, 155 (79.9%) were prescribed DOACs per FDA-approved labeling ( P = .0005); 79 (40.8%) obtained a complete blood count, serum creatinine, and liver function tests prior to DOAC initiation. Conclusions: Prescribing practices were significantly better than published data; however, 1 in 5 patients were not prescribed a DOAC according to FDA-approved labeling. Less than half of the patients started on a DOAC obtained the recommended labs prior to medication initiation.
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Affiliation(s)
| | | | - Katherine Vogel Anderson
- The University of Florida College of Pharmacy, Gainesville, FL, USA
- The University of Florida College of Medicine, Gainesville, FL, USA
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527
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Cheung KS, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management. World J Gastroenterol 2017; 23:1954-1963. [PMID: 28373761 PMCID: PMC5360636 DOI: 10.3748/wjg.v23.i11.1954] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/18/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
Novel oral anticoagulants (NOACs), which include direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding (GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran (150 mg b.i.d), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.
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528
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Early secondary prevention after initially ineffective revascularization treatments for acute ischemic stroke due to tandem occlusion. Blood Coagul Fibrinolysis 2017; 28:493-495. [PMID: 28319471 DOI: 10.1097/mbc.0000000000000631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: The most effective treatment of patients with stroke due to tandem occlusion is still unclear. We report the case of a man with stroke due to tandem internal carotid artery/middle cerebral artery occlusion, who underwent initially ineffective intravenous thrombolysis (IVT) and endovascular treatment. Early anticoagulation with apixaban was started after 48 h of IVT, given a newly diagnosed nonvalvular atrial fibrillation. Spontaneous partial recanalization of the cervical internal carotid artery was noted, and carotid endarterectomy was performed 72 h after IVT and 8 h after the last dose of apixaban. Surgery was conducted without any complication and the patient was discharged 7 days after onset with a residual mild hemiparesis. This is the first report of urgent carotid endarterectomy in an anticoagulated patient receiving a direct oral anticoagulant. This case highlights the importance of an early multidisciplinary approach to achieve a successful treatment of stroke due to tandem occlusion.
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529
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Papadopoulos DV, Kostas-Agnantis I, Gkiatas I, Tsantes AG, Ziara P, Korompilias AV. The role of new oral anticoagulants in orthopaedics: an update of recent evidence. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:573-582. [DOI: 10.1007/s00590-017-1940-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/05/2017] [Indexed: 12/27/2022]
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530
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Rose MFLDS. Pharmacological profile of non-vitamin K antagonist oral anticoagulants. ACTA ACUST UNITED AC 2017. [DOI: 10.5897/ajpp2017.4744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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531
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Hellfritzsch M, Hyllested LMR, Meegaard L, Wiberg-Hansen A, Grove EL, Pottegård A. Switching, Adverse Effects and Use of Over-the-Counter Analgesics among Users of Oral Anticoagulants: A Pharmacy-based Survey. Basic Clin Pharmacol Toxicol 2017; 121:37-43. [PMID: 28132418 DOI: 10.1111/bcpt.12762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/23/2017] [Indexed: 11/26/2022]
Abstract
Oral anticoagulants are widely used but information on important aspects in that respect is not available from medical registers or clinical databases. Therefore, we conducted a survey including patients filling a prescription for oral anticoagulants at two large Danish community pharmacies. We collected information concerning the patients' knowledge of their anticoagulant treatment including prior drug switching. Further, patients were asked about use of over-the-counter analgesics, adverse effects and how the treatment affected their everyday life. Among 335 eligible patients, 301 (90%) agreed to participate. Atrial fibrillation was the most common indication (65%), and most patients filled a prescription for a non-vitamin K antagonist oral anticoagulant (NOAC) (58%). Among the 12% (n = 35) of participants who had switched oral anticoagulant treatment, 69% had switched from a vitamin K antagonist (VKA) to a NOAC. Switching was most frequently caused by inconvenience (34%) and adverse effects (23%). Although half of all patients had recently bought over-the-counter analgesics, purchase of ibuprofen and aspirin was rare (6%). More VKA users than NOAC users felt limited in their everyday life because of anticoagulant treatment (18% versus 9%). Among non-incident NOAC users, 21% had experienced adverse effects during their current treatment. Based on first-hand information from a large sample of anticoagulant users, we conclude that the main drug-related issues leading to anticoagulant switching and perceived limitations in everyday life were inconvenience and adverse effects. This varied between drug groups. Further, use of NSAIDs obtained over the counter was rare.
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Affiliation(s)
- Maja Hellfritzsch
- Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | | | | | | | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anton Pottegård
- Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark.,Copenhagen Sønderbro Pharmacy, Copenhagen, Denmark
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532
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Proietti M, Lip GYH. Reply: Apixaban Dosing in Chronic Kidney Disease: Differences Between U.S. and E.U. Labeling. J Am Coll Cardiol 2017; 69:1212. [PMID: 28254191 DOI: 10.1016/j.jacc.2016.11.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/17/2016] [Indexed: 11/19/2022]
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533
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Sánchez Fuentes D, Budiño Sánchez M, López Sánchez M. Use of oral anticoagulation for patients who undergo invasive procedures. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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534
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Management of radial artery perforation during transradial catheterization using a polytetrafluoroethylene-covered coronary stent. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:133-135. [DOI: 10.1016/j.carrev.2016.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/01/2016] [Accepted: 08/10/2016] [Indexed: 12/28/2022]
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535
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Voukalis C, Shantsila E, Lip GY. Clinical Stroke prevention in atrial fibrillation. J R Coll Physicians Edinb 2017; 47:13-23. [PMID: 28569277 DOI: 10.4997/jrcpe.2017.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Oral anticoagulation therapy has reduced the risk of ischaemic stroke and improved the outcomes for patients with atrial fibrillation considerably. The emergence of the non-vitamin K oral anticoagulants as alternatives to vitamin K antagonists has significantly changed the practice of stroke prevention in atrial fibrillation. As the main complication with antithrombotic therapy is bleeding, physicians should always balance the risk of ischaemic stroke against intracranial haemorrhage and intervene where appropriate to reduce both risks. Individual approach is often mandatory due to heterogeneity of the risks and patient preferences. The purpose of this review is to summarise the current knowledge of the oral anticoagulation therapy in atrial fibrillation patients and guide physicians with the management of anticoagulants based on data from clinical trials and systematic reviews.
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Affiliation(s)
- C Voukalis
- GYH Lip, University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK.
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536
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Edoxaban in Atrial Fibrillation and Venous Thromboembolism-Ten Key Questions and Answers: A Practical Guide. Adv Ther 2017; 34:620-637. [PMID: 28194578 PMCID: PMC5350200 DOI: 10.1007/s12325-017-0488-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Indexed: 12/13/2022]
Abstract
Edoxaban is the fourth non-vitamin K antagonist oral anticoagulant now available for clinical use in the prevention of stroke/systemic embolism in atrial fibrillation (AF) and in the treatment of venous thromboembolism (VTE), after the completion of large-scale randomized comparative clinical trials with the vitamin K antagonist warfarin. Edoxaban has some peculiar pharmacological properties and outcome data. Here a group of experts in AF and VTE answers a set of questions on its practical use, trying to define the profile of patients that would be most appropriate for its use.
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537
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Oral anticoagulation for stroke prevention amongst atrial fibrillation patients with valvular heart disease. Curr Opin Cardiol 2017; 32:174-180. [DOI: 10.1097/hco.0000000000000365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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538
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Vrijens B, Antoniou S, Burnier M, de la Sierra A, Volpe M. Current Situation of Medication Adherence in Hypertension. Front Pharmacol 2017; 8:100. [PMID: 28298894 PMCID: PMC5331678 DOI: 10.3389/fphar.2017.00100] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/16/2017] [Indexed: 12/02/2022] Open
Abstract
Despite increased awareness, poor adherence to treatments for chronic diseases remains a global problem. Adherence issues are common in patients taking antihypertensive therapy and associated with increased risks of coronary and cerebrovascular events. Whilst there has been a gradual trend toward improved control of hypertension, the number of patients with blood pressure values above goal has remained constant. This has both personal and economic consequences. Medication adherence is a multifaceted issue and consists of three components: initiation, implementation, and persistence. A combination of methods is recommended to measure adherence, with electronic monitoring and drug measurement being the most accurate. Pill burden, resulting from free combinations of blood pressure lowering treatments, makes the daily routine of medication taking complex, which can be a barrier to optimal adherence. Single-pill fixed-dose combinations simplify the habit of medication taking and improve medication adherence. Re-packing of medication is also being utilized as a method of improving adherence. This paper presents the outcomes of discussions by a European group of experts on the current situation of medication adherence in hypertension.
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Affiliation(s)
- Bernard Vrijens
- WestRock HealthcareVisé, Belgium; Department of Public Health, University of LiègeLiège, Belgium
| | | | - Michel Burnier
- Department of Nephrology and Hypertension, University Hospital Lausanne Lausanne, Switzerland
| | - Alejandro de la Sierra
- Internal Medicine Department, Hospital Mutua Terrassa, University of Barcelona Barcelona, Spain
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "La Sapienza"Rome, Italy; IRCCS NeuromedPozzilli, Italy
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539
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Monagle S, Eikelboom JW, Ng KH, Bhagirath VC. Clinical implications of reversal agents for direct oral anticoagulants. Future Cardiol 2017; 13:153-159. [DOI: 10.2217/fca-2016-0070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are effective in preventing and treating venous thromboembolism, and preventing stroke in atrial fibrillation. Until recently, there has been no specific reversal agent for DOACs. Now, a specific antidote for the direct thrombin inhibitor, dabigatran has been approved for use, and antidotes for factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) are being developed. We review the evidence for currently used and emerging reversal strategies, and discuss possible clinical implications, including increased prescription of DOACs, use of DOACs in clinical situations previously felt to pose too great a risk of bleeding, and use of reversal agents beyond currently approved indications.
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Affiliation(s)
- Sarah Monagle
- Population Health Research Institute, Hamilton, Canada
- Monash University, Melbourne, Australia
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kuan H Ng
- Population Health Research Institute, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Vinai C Bhagirath
- Population Health Research Institute, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
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540
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Atas H, Sahin AA, Barutçu Atas D, Sunbul M, Kepez A, Agirbasli M. Potential Causes and Implications of Low Target Therapeutic Ratio in Warfarin-Treated Patients for Thrombosis Prophylaxis: A Single-Center Experience. Clin Appl Thromb Hemost 2017; 24:536-541. [PMID: 28301912 DOI: 10.1177/1076029617695484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Time in therapeutic range (TTR) of international normalized ratio is crucial for the safety and efficacy of anticoagulation with warfarin and it is influenced by many factors. There are limited data about the quality of warfarin therapy and its effects on clinical outcomes in Turkey. The aim of this study is to demonstrate the quality of anticoagulant therapy with warfarin and evaluate the parameters that affect the quality of warfarin therapy. A total of 170 patients with atrial fibrillation (AF; mean age: 62.2 ± 13.3; 69.2% female) treated with warfarin were included in this study. The mean follow-up period was 20 ± 8.4 months. The mean TTR levels of all patients were found to be 54.2% ± 21.4%. The TTR levels were similar in patients with valvular AF (VAF) and nonvalvular AF (NVAF). Logistic regression analysis revealed that elderly, heart failure (HF), and renal dysfunction were independent predictors of lower TTR. There were no significant differences between the VAF and NVAF subgroups regarding the incidence of mortality, stroke, and myocardial infarction. Cox regression analysis revealed that HF, coronary artery disease, and renal dysfunction were independent predictors of clinical outcomes in addition to lower TTR. Our results provide data regarding the quality of anticoagulation with warfarin from a single tertiary center in Istanbul, Turkey. The questions remain in seeking quality improvement in anticoagulation.
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Affiliation(s)
- Halil Atas
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Ahmet Anıl Sahin
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Dilek Barutçu Atas
- 2 Division of Nephrology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Murat Sunbul
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Alper Kepez
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Agirbasli
- 3 Department of Cardiology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
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541
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Koscielny J, von Heymann C, Bauersachs R, Mouret P, Antz M. [Perioperative anticoagulation with NOAC using the example of rivaroxaban]. MMW Fortschr Med 2017; 159:18-23. [PMID: 28244023 DOI: 10.1007/s15006-017-9295-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC). METHOD The present position paper summarises the outcomes of an expert panel discussion. RESULTS AND CONCLUSIONS Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.
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Affiliation(s)
- Jürgen Koscielny
- Gerinnungsambulanz mit Hämophiliezentrum im ambulanten Gesundheitszentrum (AGZ), Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, Durchgang Luisenstr. 13, 10117, Berlin, Deutschland.
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
| | - Rupert Bauersachs
- Klinikum Darmstadt GmbH, Klinik für Gefäßmedizin - Angiologie, Gefäßzentrum Darmstadt, Darmstadt, Deutschland
| | | | - Matthias Antz
- Klinik für Kardiologie, Herzzentrum Klinikum Oldenburg, Oldenburg, Deutschland
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542
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Barysienė J, Žebrauskaitė A, Petrikonytė D, Marinskis G, Aidietienė S, Aidietis A. Findings of transoesophageal echocardiogram in appropriately anticoagulated patients with persistent atrial fibrillation prior to planned cardioversion. BMC Cardiovasc Disord 2017; 17:67. [PMID: 28228120 PMCID: PMC5322653 DOI: 10.1186/s12872-017-0503-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/16/2017] [Indexed: 12/28/2022] Open
Abstract
Background To evaluate a diagnostic value of transoesophageal echocardiogram (TEE) in appropriately anticoagulated patients with a non-valvular atrial fibrillation (AF) and to establish possible additional indications for TEE; to evaluate the incidence of left atrial (LA) thrombi in appropriately anticoagulated patients in daily clinical practice. Methods This retrospective study analyses data of 432 patients who had been anticoagulated by means of oral anticoagulants (OACs) prior to planned cardioversion during the period from 2012 to 2015. Thromboembolic (TE) and bleeding risks were assessed using CHA2DS2-VASc and HAS-BLED scores. Transthoracic and transoesophageal echocardiograms were evaluated. TE complications during 30 days after discharge were assessed. Results 432 patients were selected, aged from 22 to 89 years (mean 65.0 ±11.5), 277 (64.1%) males and 155 (35.9%) females, 306 (70.8%) on warfarin and 126 (29.2%) on non-vitamin K antagonist oral anticoagulants (NOAC). Mean CHA2DS2-VASc score was 3.5 ±1.5. TEE was performed for 120 (27.8%) patients, more frequently for patients on NOACs and for ones with III° LA enlargement. TEE revealed LA thrombi in seven (5.8%) of the patients. In warfarin and NOACs groups thrombi were revealed in five (7.0%) and two (4.1%) patients, respectively. TEE did not reveal any thrombi in patients with normal left ventricular (LV) function; however, thrombi were found in two (6.1%) patients with slightly decreased LV function, and in five (17.9%) patients with markedly decreased LV function. In patients with decreased left ventricular ejection fraction (LVEF) thrombi in LA were found more frequently than in patients with normal and slightly decreased LVEF (17.9% vs 2.2%, p=0.008). CHA2DS2-VASc score of all 7 patients was ≥5. None of the patients after cardioversion had TE complications 30 days after discharge. Conclusions The risk of LA thrombi in patients prepared for scheduled cardioversion in line with the guidelines is low. Higher risk of thrombi was present in patients with decreased LVEF (≤40%), CHA2DS2-VASc ≥5. In order to assess more accurately indications to perform TEE for appropriately anticoagulated patients prior to scheduled cardioversion a study with larger number of patients is required.
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Affiliation(s)
- Jūratė Barysienė
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania.,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania
| | - Aistė Žebrauskaitė
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania. .,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania.
| | - Dovilė Petrikonytė
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania.,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania
| | - Germanas Marinskis
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania.,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania
| | - Sigita Aidietienė
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania.,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania
| | - Audrius Aidietis
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, 2 Santariškių St., LT -08661, Vilnius, Lithuania.,Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 21 Čiurlionio St., LT-03101, Vilnius, Lithuania
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543
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ENRIQUEZ ALAND, CHURCHILL TIMOTHY, GAUTAM SANDEEP, CHINITZ JASONS, BARBHAIYA CHIRAGR, KUMAR SAURABH, JOHN ROYM, TEDROW USHAB, KOPLAN BRUCEA, STEVENSON WILLIAMG, MICHAUD GREGORYF. Determinants of Heparin Dosing and Complications in Patients Undergoing Left Atrial Ablation on Uninterrupted Rivaroxaban. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:183-190. [DOI: 10.1111/pace.13013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 11/26/2022]
Affiliation(s)
- ALAN D. ENRIQUEZ
- Section of Cardiovascular Medicine; Yale University School of Medicine; New Haven Connecticut
| | - TIMOTHY CHURCHILL
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | - SANDEEP GAUTAM
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri
| | - JASON S. CHINITZ
- Southside Hospital; North Shore Long Island Jewish; Bayshore New York
| | | | - SAURABH KUMAR
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | - ROY M. JOHN
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | - USHA B. TEDROW
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | - BRUCE A. KOPLAN
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | | | - GREGORY F. MICHAUD
- Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
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544
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Nielsen PB, Skjøth F, Søgaard M, Kjældgaard JN, Lip GYH, Larsen TB. Effectiveness and safety of reduced dose non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ 2017; 356:j510. [PMID: 28188243 PMCID: PMC5421446 DOI: 10.1136/bmj.j510] [Citation(s) in RCA: 237] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective To examine clinical effectiveness and safety of apixaban 2.5 mg, dabigatran 110 mg, and rivaroxaban 15 mg compared with warfarin among patients with atrial fibrillation who had not previously taken an oral anticoagulant.Design Propensity weighted (inverse probability of treatment weighted) nationwide cohort study.Setting Individual linked data from three nationwide registries in Denmark.Participants Patients with non-valvular atrial fibrillation filling a first prescription for an oral anticoagulant from August 2011 to February 2016. Patients who filled a prescription for a standard dose non-vitamin K antagonist oral anticoagulant (novel oral anticoagulants, NOACs) were excluded. To control for baseline differences in the population, a propensity score for receipt of either of the four treatment alternatives was calculated to apply an inverse probability treatment weight.Intervention Initiated anticoagulant treatment (dabigatran 110 mg, rivaroxaban 15 mg, apixaban 2.5 mg, and warfarin).Main outcome measures Patients were followed in the registries from onset of treatment for the primary effectiveness outcome of ischaemic stroke/systemic embolism and for the principal safety outcome of any bleeding events.Results Among 55 644 patients with atrial fibrillation who met inclusion criteria, the cohort was distributed according to treatment: apixaban n=4400; dabigatran n=8875; rivaroxaban n=3476; warfarin n=38 893. The overall mean age was 73.9 (SD 12.7), ranging from a mean of 71.0 (warfarin) to 83.9 (apixaban). During one year of follow-up, apixaban was associated with higher (weighted) event rate of ischaemic stroke/systemic embolism (4.8%), while dabigatran, rivaroxaban, and warfarin had event rates of 3.3%, 3.5%, and 3.7%, respectively. In the comparison between a non-vitamin K antagonist oral anticoagulant and warfarin in the inverse probability of treatment weighted analyses and investigation of the effectiveness outcome, the hazard ratios were 1.19 (95% confidence interval 0.95 to 1.49) for apixaban, 0.89 (0.77 to 1.03) for dabigatran, and 0.89 (0.69 to 1.16) for rivaroxaban. For the principal safety outcome versus warfarin, the hazard ratios were 0.96 (0.73 to 1.27) for apixaban, 0.80 (0.70 to 0.92) for dabigatran, and 1.06 (0.87 to 1.29) for rivaroxaban.Conclusion In this propensity weighted nationwide study of reduced dose non-vitamin K antagonist oral anticoagulant regimens, apixaban 2.5 mg twice a day was associated with a trend towards higher rates of ischaemic stroke/systemic embolism compared with warfarin, while rivaroxaban 15 mg once a day and dabigatran 110 mg twice a day showed a trend towards lower thromboembolic rates. The results were not significantly different. Rates of bleeding (the principal safety outcome) were significantly lower for dabigatran, but not significantly different for apixaban and rivaroxaban compared with warfarin.
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Affiliation(s)
- Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Unit of Clinical Biostatistics, Aalborg University Hospital, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, DK-9000, Denmark
| | - Jette Nordstrøm Kjældgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, DK-9000, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, DK-9000, Denmark
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545
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Cappellari M, Bovi P. Early use of direct oral anticoagulants after TIA/stroke in patients with atrial fibrillation: a 2016 update. J Thromb Thrombolysis 2017; 43:302-305. [PMID: 28168541 DOI: 10.1007/s11239-017-1475-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Manuel Cappellari
- USD Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy.
| | - Paolo Bovi
- USD Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy
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546
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Conway SE, Hwang AY, Ponte CD, Gums JG. Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know. Pharmacotherapy 2017; 37:236-248. [DOI: 10.1002/phar.1884] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Susan E. Conway
- Department of Pharmacy: Clinical and Administrative Sciences; University of Oklahoma College of Pharmacy; Oklahoma City Oklahoma
| | - Andrew Y. Hwang
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
| | - Charles D. Ponte
- Departments of Clinical Pharmacy and Family Medicine; West Virginia University Schools of Pharmacy and Medicine; Morgantown West Virginia
| | - John G. Gums
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
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547
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Escobar C, Arceluz M, Montes de Oca R, Mori R, López-Sendón JL, Merino JL. Administración simultánea de rivaroxabán y dronedarona en pacientes con fibrilación auricular no valvular. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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548
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Fanola CL, Mooney D, Cowan AJ, Ko D, Sisson EK, Henault LE, Tripodis Y, Hylek EM. Incidence of severe renal dysfunction among individuals taking warfarin and implications for non-vitamin K oral anticoagulants. Am Heart J 2017; 184:150-155. [PMID: 28224930 PMCID: PMC6594157 DOI: 10.1016/j.ahj.2016.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study is to assess incidence and risk factors for severe renal dysfunction in patients requiring oral anticoagulation to help guide initial drug choice and provide a rational basis for interval monitoring of renal function for patients prescribed non-vitamin K oral anticoagulants. METHODS Patients on warfarin for atrial fibrillation or venous thromboembolism were consecutively enrolled from January 2007 to December 2010. Baseline kidney function was assessed, and patients were followed to their first decline of kidney function to creatinine clearance<30 mL/min. Multivariate regression assessed independent risk factors for the primary outcome. Severe renal impairment based on baseline kidney function was assessed by Kaplan-Meier analyses. RESULTS Of 787 patients identified, 34 were excluded for baseline CrCl <30 mL/min. The mean age was 71 years, and 74% and 31% had hypertension and diabetes mellitus, respectively. At baseline, 23% (n=174) had moderate chronic kidney disease (CKD) (CrCl 30-59mL/min), whereas 31% had mild CKD (CrCl 60-89mL/min). Severe renal impairment occurred in 92 patients (12%), 25% of which was seen within 5.3 months. Of those with baseline stage 3 CKD, 37% developed severe renal impairment. Stage 3 CKD conferred a 14-fold increased risk in the development of severe renal dysfunction (odds ratio 14.5, 95% CI 6.7-31.3, P<.001). Coronary artery disease was also associated with severe renal impairment (odds ratio 2.2, 95% CI 1.3-3.8, P=.004). CONCLUSIONS Acute and chronic renal dysfunction is common among individuals requiring long-term anticoagulant therapy. Patients with moderate chronic kidney disease and coronary artery disease are at the highest short-term risk of developing severe renal impairment. More frequent monitoring of these patients is warranted.
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Affiliation(s)
- Christina L Fanola
- Department of Cardiology and Vascular Medicine, Boston University School of Medicine, Boston, MA.
| | - Deirdre Mooney
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Andrew J Cowan
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Darae Ko
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Emily K Sisson
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Lori E Henault
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Elaine M Hylek
- Department of Medicine, Boston University School of Medicine, Boston, MA
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549
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Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL, Saxonhouse SJ, Spinler SA. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2017; 69:871-898. [DOI: 10.1016/j.jacc.2016.11.024] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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550
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Escobar C, Arceluz M, Montes de Oca R, Mori R, López-Sendón JL, Merino JL. Concomitant Rivaroxaban and Dronedarone Administration in Patients With Nonvalvular Atrial Fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:121-122. [PMID: 27693025 DOI: 10.1016/j.rec.2016.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 06/06/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Martín Arceluz
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Rosa Montes de Oca
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Ricardo Mori
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - José Luis López-Sendón
- Unidad de Electrofisiología Robotizada, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - José Luis Merino
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
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