851
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PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: Executive Summary. Heart Rhythm 2014. [DOI: 10.1016/j.hrthm.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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852
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Arioli F, D'Arbela PG, Aloi F, Nsubuga MM, Grimaldi A, Ammirati E. Prosthetic thrombosis and pregnancy on warfarin: Debate on mechanical mitral valve replacement in sub-Saharan Africa based on a case report. Int J Cardiol 2014; 176:e86-8. [DOI: 10.1016/j.ijcard.2014.07.162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
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853
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Hirsch R. Should we offer a bioprosthetic valve to women of child-bearing age who need valve replacement? Interv Cardiol 2014. [DOI: 10.2217/ica.14.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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854
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855
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Affiliation(s)
- Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, G. D'Annunzio University - Chieti, and G. Monasterio Foundation, Pisa, Italy
| | - A John Camm
- Division of Clinical Sciences, St George's University of London, London, UK
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856
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Barnes GD, Eagle KA, Froehlich JB. Perioperative management of oral anticoagulants: a focus on target-specific oral anticoagulants. Hosp Pract (1995) 2014; 42:62-7. [PMID: 25255407 DOI: 10.3810/hp.2014.08.1118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although warfarin has historically been the dominant oral anticoagulant, newer target-specific oral anticoagulants (TSOACs) have been introduced in the marketplace in the past few years. Dabigatran, rivaroxaban, and apixaban, collectively referred to as TSOACs, have undergone extensive testing in comparison with warfarin and other anticoagulants for a variety of conditions. Compared with warfarin, the shorter time to peak effect, shorter half-life, and fewer drug-drug interactions have helped make the TSOACs attractive alternatives to warfarin for the prevention and treatment of thromboembolic disease associated with orthopedic surgery and atrial fibrillation as well as for the treatment of venous thromboembolism. However, their unique properties pose a challenge for their management in the perioperative period. This article reviews the current guideline-based approach to perioperative management of anticoagulants, the clinical data, and the recommendations supporting use of the TSOACs in the perioperative period. The article also addresses common pitfalls in their perioperative management. By understanding a few key properties of the new oral anticoagulants and with careful perioperative planning, physicians can ensure that their patients will safely undergo most surgical procedures with minimal disruption of their chronic anticoagulation.
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857
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Salem JE, Sabouret P, Funck-Brentano C, Hulot JS. Pharmacology and mechanisms of action of new oral anticoagulants. Fundam Clin Pharmacol 2014; 29:10-20. [DOI: 10.1111/fcp.12091] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/26/2014] [Accepted: 07/15/2014] [Indexed: 12/23/2022]
Affiliation(s)
- Joe-Elie Salem
- Department of Pharmacology and UMR ICAN 1166; Faculty of Medicine; Institute of Cardiometabolism and Nutrition (ICAN); Sorbonne Universités; UPMC Univ Paris 06 F-75013 Paris France
- Department of Pharmacology and CIC-1421; Institute of Cardiometabolism and Nutrition (ICAN); AP-HP; Pitié-Salpêtrière Hospital; F-75013 Paris France
- INSERM; Institute of Cardiometabolism and Nutrition (ICAN); CIC-1421 and UMR ICAN 1166; F-75013 Paris France
| | - Pierre Sabouret
- Department of Cardiology; AP-HP; Pitié-Salpêtrière Hospital; F-75013 Paris France
| | - Christian Funck-Brentano
- Department of Pharmacology and UMR ICAN 1166; Faculty of Medicine; Institute of Cardiometabolism and Nutrition (ICAN); Sorbonne Universités; UPMC Univ Paris 06 F-75013 Paris France
- Department of Pharmacology and CIC-1421; Institute of Cardiometabolism and Nutrition (ICAN); AP-HP; Pitié-Salpêtrière Hospital; F-75013 Paris France
- INSERM; Institute of Cardiometabolism and Nutrition (ICAN); CIC-1421 and UMR ICAN 1166; F-75013 Paris France
| | - Jean-Sebastien Hulot
- Department of Pharmacology and UMR ICAN 1166; Faculty of Medicine; Institute of Cardiometabolism and Nutrition (ICAN); Sorbonne Universités; UPMC Univ Paris 06 F-75013 Paris France
- Department of Pharmacology and CIC-1421; Institute of Cardiometabolism and Nutrition (ICAN); AP-HP; Pitié-Salpêtrière Hospital; F-75013 Paris France
- INSERM; Institute of Cardiometabolism and Nutrition (ICAN); CIC-1421 and UMR ICAN 1166; F-75013 Paris France
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858
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Koertke H, Zittermann A, Wagner O, Secer S, Sciangula A, Saggau W, Sack FU, Ennker J, Cremer J, Musumeci F, Gummert JF. Telemedicine-guided, very low-dose international normalized ratio self-control in patients with mechanical heart valve implants. Eur Heart J 2014; 36:1297-305. [DOI: 10.1093/eurheartj/ehu330] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 07/28/2014] [Indexed: 11/13/2022] Open
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859
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Iung B, Rodes-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J 2014; 35:2942-9. [DOI: 10.1093/eurheartj/ehu365] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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860
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Hess PL, Mirro MJ, Diener HC, Eikelboom JW, Al-Khatib SM, Hylek EM, Bosworth HB, Gersh BJ, Singer DE, Flaker G, Mega JL, Peterson ED, Rumsfeld JS, Steinberg BA, Kakkar AK, Califf RM, Granger CB. Addressing barriers to optimal oral anticoagulation use and persistence among patients with atrial fibrillation: Proceedings, Washington, DC, December 3-4, 2012. Am Heart J 2014; 168:239-247.e1. [PMID: 25173533 PMCID: PMC4269555 DOI: 10.1016/j.ahj.2014.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/16/2014] [Indexed: 11/22/2022]
Abstract
Approximately half of patients with atrial fibrillation and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs (NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3-4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.
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Affiliation(s)
- Paul L Hess
- Duke Clinical Research Institute, Durham, NC.
| | | | | | | | | | | | - Hayden B Bosworth
- Duke Clinical Research Institute, Durham, NC; Durham Veterans Affairs Medical Center, Durham, NC
| | | | | | | | | | | | | | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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861
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Sairaku A, Nakano Y, Kihara Y. Does dabigatran interfere with intraablation heparinization? Thromb Res 2014; 134:742-3. [DOI: 10.1016/j.thromres.2014.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
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862
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Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi S, Smith SC, Darbar D, Wee JO, Waddell TK, Amar D, Adler D. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014; 148:e153-93. [PMID: 25129609 PMCID: PMC4454633 DOI: 10.1016/j.jtcvs.2014.06.036] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Gyorgy Frendl
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
| | - Alissa C Sodickson
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Department of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University Cleveland Clinic, Cleveland, Ohio
| | - Albert L Waldo
- Division of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Bernard J Gersh
- Division of Cardiovascular Diseases and Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - James E Tisdale
- Department of Pharmacy Practice, College of Pharmacy, Purdue University and Indiana University School of Medicine, Indianapolis, Ind
| | - Hugh Calkins
- Department of Medicine, Cardiac Arrhythmia Service, Johns Hopkins University, Baltimore, Md
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Stephen Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Sidney C Smith
- Center for Heart and Vascular Care, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Dawood Darbar
- Division of Cardiovascular Medicine, Department of Medicine, Arrhythmia Service, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Jon O Wee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Thomas K Waddell
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Amar
- Memorial Sloan-Kettering Cancer Center, Department of Anesthesiology and Critical Care Medicine, New York, NY
| | - Dale Adler
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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863
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2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. Executive summary. J Thorac Cardiovasc Surg 2014; 148:772-91. [DOI: 10.1016/j.jtcvs.2014.06.037] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 11/23/2022]
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864
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Lip GY, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, Haeusler KG, Boriani G, Capodanno D, Gilard M, Zeymer U, Lane D, Storey RF, Bueno H, Collet JP, Fauchier L, Halvorsen S, Lettino M, Morais J, Mueller C, Potpara TS, Rasmussen LH, Rubboli A, Tamargo J, Valgimigli M, Zamorano JL. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014; 35:3155-79. [DOI: 10.1093/eurheartj/ehu298] [Citation(s) in RCA: 432] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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865
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Yoon CH, Park YK, Kim SJ, Lee MJ, Ryoo S, Kim GM, Chung CS, Lee KH, Kim JS, Bang OY. Eligibility and preference of new oral anticoagulants in patients with atrial fibrillation: comparison between patients with versus without stroke. Stroke 2014; 45:2983-8. [PMID: 25147329 DOI: 10.1161/strokeaha.114.005599] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Recent randomized clinical trials (RCTs) have evaluated the benefit of new oral anticoagulants in reducing the risk of vascular events and bleeding complications in patients with atrial fibrillation (AF). However, abundant and strict enrollment criteria may limit the validity and applicability of results of RCTs to clinical practice. We estimated the eligibility for participation in RCTs of an unselected group of patients with AF. In addition, we compared features favoring new oral anticoagulant use between patients with versus without stroke. Randomized Evaluation of Long-Term Anticoagulation Therapy METHODS We applied enrollment criteria of 4 RCTs (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) to 695 patients with AF taking warfarin, prospectively and consecutively collected at a university medical center; 500 patients with and 195 patients without stroke. Time in therapeutic range and bleeding risk scheme (anticoagulation and risk factors in atrial fibrillation) were also measured. RESULTS The proportions of patients fulfilling the trial enrollment criteria varied, ranging from 39% to 72.8%, depending on the differences in indications/contraindications among studies and presence/absence of stroke. The main reasons for ineligibility for RCTs were hemorrhagic risk (anticoagulation and risk factors in atrial fibrillation [ATRIA] score) (10.8%-40.5%) and planned cardioversion (5.1%-7.7%) for nonstroke patients, and a low creatinine clearance (5.6%-9.2%) and higher risk of bleeding (15.2%-20.8%) for patients with stroke. When compared with nonstroke patients, patients with stroke showed a lower time in therapeutic range (54.4±42.8% versus 65.4±34.9%, especially with severe disability) and a high hemorrhagic risk (ATRIA score) (3.06±2.30 versus 2.18±2.16) (P<0.05 in both cases). CONCLUSIONS Patients enrolled in RCTs are partly representative of patients with AF in clinical practice. When time in therapeutic range and bleeding tendency with warfarin use were considered, the use of new oral anticoagulants was preferred in patients with stroke than in nonstroke patients, but they were more likely to be excluded in RCTs.
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Affiliation(s)
- Chang Hyo Yoon
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon Kyung Park
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk Jae Kim
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Mi-ji Lee
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sookyung Ryoo
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyeong-Moon Kim
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chin-Sang Chung
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwang Ho Lee
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - June Soo Kim
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Oh Young Bang
- From the Department of Neurology (C.H.Y., Y.K.P., S.J.K., M.-j.L., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Department of Cardiology (J.S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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866
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Affiliation(s)
- Catherine M Otto
- From the Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle (C.M.O.); and the Department of Cardiology, John Radcliffe Hospital, Oxford, United Kingdom (B.P.)
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867
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Franchi F, Hammad JS, Rollini F, Tello-Montoliu A, Patel R, Darlington A, Kraemer DF, Cho JR, DeGroat C, Bhatti M, Taha M, Angiolillo DJ. Role of thromboelastography and rapid thromboelastography to assess the pharmacodynamic effects of vitamin K antagonists. J Thromb Thrombolysis 2014; 40:118-25. [DOI: 10.1007/s11239-014-1130-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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868
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Lau YC, Lip GYH. New advances in the treatment of atrial fibrillation: focus on stroke prevention. Expert Opin Pharmacother 2014; 15:2193-204. [DOI: 10.1517/14656566.2014.948418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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869
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Molteni M, Polo Friz H, Primitz L, Marano G, Boracchi P, Cimminiello C. The definition of valvular and non-valvular atrial fibrillation: results of a physicians' survey. Europace 2014; 16:1720-5. [DOI: 10.1093/europace/euu178] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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870
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Tsolka P. Dental Procedures in Patients with Atrial Fibrillation and New Oral Anticoagulants. Arrhythm Electrophysiol Rev 2014; 3:85-9. [PMID: 26835072 DOI: 10.15420/aer.2014.3.2.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 07/29/2014] [Indexed: 12/11/2022] Open
Abstract
This review discusses the basic pharmacology of new oral anticoagulants that are used for prevention of thromboembolism in patients with atrial fibrillation. It presents available evidence, and provides recommendations for the management of patients requiring invasive procedures in dental practice.
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Affiliation(s)
- Pepie Tsolka
- Assistant Professor, Department of Dental Technology, Faculty of Health and Caring Professions, Technological Educational Institute of Athens, Athens, Greece
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871
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Abstract
Multiple, potentially practice-changing cardiology trials have been presented or published over the past year. In this paper, we summarize and place in clinical context, new data regarding management of acute coronary syndrome and ST-elevation myocardial infarction (copeptin assessment, otamixaban, cangrelor, prasugrel, sodium nitrite, inclacumab, ranolazine, preventive coronary intervention of non-culprit lesions, immediate thrombolytic therapy versus transfer for primary intervention), new coronary intervention data (thrombectomy, radial access, pressure wire fractional flow reserve, antiplatelet therapy duration and gene-guidance, permanent and biodegradable polymers, coronary bifurcation and strategies), and coronary artery bypass data (off pump vs. on pump). Latest trials in trans-aortic valve implantation, heart failure (eplerenone, aliskiren, spironolactone, sildenafil, dopamine, nesiritide, omecamtiv mecarbil, the algisyl left ventricular augmentation device, and echo-guided cardiac resynchronization), atrial fibrillation (edoxaban, dabigatran, and ablation), cardiac arrest (hypothermia, LUCAS™ mechanical chest compression), and cardiovascular prevention (vitamins, renal denervation for resistant hypertension, renal artery stenting, saxagliptin, alogliptin, and gastric banding) are also discussed.
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Affiliation(s)
- Andrew H McNeice
- Craigavon Cardiac Centre, Southern Trust, Northern Ireland, BT63 5QQ, UK
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872
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Plitt A, Giugliano RP. Target-specific oral anticoagulants: practice issues for the clinician. Hosp Pract (1995) 2014; 42:48-61. [PMID: 25255406 DOI: 10.3810/hp.2014.08.1117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Venous thromboembolism and atrial fibrillation are among the most common cardiovascular disorders in the United States. For over 50 years, the standard of care has been anticoagulation with vitamin K antagonists. However, the numerous limitations of vitamin K antagonists led to the development of target-specific oral anticoagulants. Dabigatran, rivaroxaban, apixaban, and edoxaban have been shown to be as effective as warfarin in the treatment and prevention of venous thromboembolism and prevention of stroke in nonvalvular atrial fibrillation. This article compares the basic pharmacologic properties of these anticoagulants, reviews the data supporting their use, and discusses practical clinical issues including measurement of the anticoagulation effect, reversal strategies, and management of patients prior to surgery.
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873
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Successful resolution of a left ventricular thrombus with apixaban treatment following acute myocardial infarction. Heart Vessels 2014; 31:118-23. [DOI: 10.1007/s00380-014-0562-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/18/2014] [Indexed: 12/22/2022]
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874
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Saraf K, Morris PD, Morris P, Garg P, Sheridan P, Storey R. Non-vitamin K antagonist oral anticoagulants (NOACs): clinical evidence and therapeutic considerations. Postgrad Med J 2014; 90:520-8. [PMID: 25085900 DOI: 10.1136/postgradmedj-2014-132605] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Warfarin, a vitamin K antagonist, is the most widely used oral anticoagulant in the world. It is cheap and effective, but its use is limited in many patients by unpredictable levels of anticoagulation, which increases the risk of thromboembolic or haemorrhagic complications. It also requires regular blood monitoring and dose adjustment. New classes of drugs, non-vitamin K antagonist oral anticoagulants (NOACs), are now supported as alternatives to warfarin. Three NOACs are licensed: dabigatran, a direct thrombin inhibitor, and rivaroxaban and apixaban, antagonists of factor Xa. NOACs do not require routine blood monitoring or dose adjustment. They have a rapid onset and offset of action and fewer food and drug interactions. Current indications include treatment and prophylaxis of venous thromboembolism and prevention of cardioembolic disease in non-valvular atrial fibrillation. Effective antidotes are lacking and some caution must be used in severe renal impairment, but favourable trial evidence has led to their widespread adoption. Research is ongoing, and an increase in their use and indications is expected in the coming years.
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Affiliation(s)
- Karan Saraf
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | | | - Paul Morris
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK Department of Cardiovascular Science, University of Sheffield, Medical School, Sheffield, UK
| | - Pankaj Garg
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Paul Sheridan
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK Department of Cardiovascular Science, University of Sheffield, Medical School, Sheffield, UK
| | - Robert Storey
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK Department of Cardiovascular Science, University of Sheffield, Medical School, Sheffield, UK
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875
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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876
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Anderson E, Dyke C, Levy JH. Anticoagulation strategies for the management of postoperative atrial fibrillation. Clin Lab Med 2014; 34:537-61. [PMID: 25168941 DOI: 10.1016/j.cll.2014.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing thoracic and cardiac procedures are at the highest risk for postoperative atrial fibrillation (POAF). POAF is associated with poor short-term and long-term outcomes, including high rates of early and late stroke, and late mortality. Patients with POAF that persists for longer than 48 hours should be anticoagulated on warfarin. Three new oral anticoagulants are available for the treatment of nonvalvular atrial fibrillation and have been found to be as efficacious or superior to warfarin in the prevention of stroke in high-risk patients, with similar to lower rates of major bleeding, and lower rates of intracranial hemorrhage.
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Affiliation(s)
- Eric Anderson
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, 501 North Columbia Road Stop 9037, ND 58103, USA
| | - Cornelius Dyke
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, 501 North Columbia Road Stop 9037, ND 58103, USA; Department of Cardiothoracic Surgery, Sanford Health Fargo, 801 Broadway North, Fargo, ND 58122, USA.
| | - Jerrold H Levy
- Duke University School of Medicine, Divisions of Cardiothoracic Anesthesiology and Critical Care, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA
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877
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Abstract
The introduction of direct oral anticoagulants (OACs) for the treatment and prevention of thromboembolic disease represents a shift from the traditional vitamin K antagonist-based therapies, which have been the mainstay of treatment for almost 60 years. A challenge for hospital formularies will be to manage the use of direct OACs from hospital to outpatient settings. Three direct OACs—apixaban, dabigatran and rivaroxaban—are widely approved across different indications, with rivaroxaban approved across the widest breadth of indications. A fourth direct OAC, edoxaban, has also completed phase III trials. Implementation of these agents by physicians will require an understanding of the efficacy and safety profile of these drugs, as well as an awareness of renal function, comedication use, patient adherence and compliance. Optimal implementation of direct OACs in the hospital setting will provide improved patient outcomes when compared with traditional anticoagulants and will simplify the treatment and prevention of thromboembolic diseases.
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878
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Skeppholm M, Hjemdahl P, Antovic JP, Muhrbeck J, Eintrei J, Rönquist-Nii Y, Pohanka A, Beck O, Malmström RE. On the monitoring of dabigatran treatment in "real life" patients with atrial fibrillation. Thromb Res 2014; 134:783-9. [PMID: 25172669 DOI: 10.1016/j.thromres.2014.06.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 06/06/2014] [Accepted: 06/30/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The oral direct thrombin inhibitor dabigatran is increasingly used to prevent thromboembolic stroke in patients with atrial fibrillation (AF). Routine laboratory monitoring is currently not recommended, but measurements of dabigatran and/or its effect are desirable in certain situations. We studied dabigatran exposure and compared different tests for monitoring of dabigatran in a real-life cohort of AF patients. MATERIAL AND METHODS Ninety AF patients (68 ± 9 years, 67% men, mean CHADS2 score 1.5) were treated with dabigatran 150 (n=73) or 110 mg BID (n=17). Trough plasma concentrations of total and free dabigatran by liquid chromatography-tandem mass-spectrometry (LC-MS/MS) were compared to indirect measurements by Hemoclot thrombin inhibitors (HTI) and Ecarin clotting assay (ECA), as well as PT-INR and aPTT. RESULTS Total plasma dabigatran varied 20-fold (12-237 ng/mL with 150 mg BID) and correlated well with free dabigatran (r(2)=0.93). There were strong correlations between LC-MS/MS and HTI or ECA (p<0.001) but these assays were less accurate with dabigatran below 50 ng/mL. The aPTT assay was not dependable and PT-INR not useful at all. There were weak correlations between creatinine clearance (Cockcroft-Gault) and LC-MS/MS, HTI and ECA (p<0.001 for all). A high body weight with normal kidney function was associated with low dabigatran levels. CONCLUSIONS HTI and ECA reflect the intensity of dabigatran anticoagulation, but LC-MS/MS is required to quantify low levels or infer absence of dabigatran. Most real life patients with a normal creatinine clearance had low dabigatran levels suggesting a low risk of bleeding but possibly limited protection against stroke.
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Affiliation(s)
- Mika Skeppholm
- Department of Medicine Solna, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden; Department of Cardiology, Danderyd Hospital & Department of clinical sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Jovan P Antovic
- Department of Coagulation Research, Institute for Molecular Medicine and Surgery, Karolinska Institutet, Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Josephine Muhrbeck
- Department of Cardiology, Danderyd Hospital & Department of clinical sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jaak Eintrei
- Department of Coagulation Research, Institute for Molecular Medicine and Surgery, Karolinska Institutet, Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Yuko Rönquist-Nii
- Department of Laboratory Medicine Huddinge, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Anton Pohanka
- Department of Laboratory Medicine Huddinge, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Beck
- Department of Laboratory Medicine Huddinge, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Rickard E Malmström
- Department of Medicine Solna, Clinical Pharmacology Unit, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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879
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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880
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Choi PM, Hill MD. Newer Anticoagulants Can Be Used Off-Label. Stroke 2014; 45:2154-5. [DOI: 10.1161/strokeaha.113.002694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Philip M.C. Choi
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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881
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882
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883
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Affiliation(s)
- Patricia A Howard
- Professor and Vice Chair, Department of Pharmacy Practice, University of Kansas Medical Center , Mailstop 4047, 3901 Rainbow Boulevard, Kansas City, KS 66160 ; phone: 913-588-5391 ; fax: 913-588-2355 ; e-mail:
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884
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Manenti V, Aliot E. [Novel oral anticoagulants in patients with atrial fibrillation, how to avoid accidents?]. Presse Med 2014; 43:775-83. [PMID: 24957560 DOI: 10.1016/j.lpm.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 11/17/2022] Open
Abstract
Know the indications of these new drugs, and respect them. Do not confuse easiness of administration and absence of precautions. Renal function: a key parameter before and during treatment. Know when to use a low-dose drug regimen. Cardioversion: lack of safety evidence for some drugs. Drug interactions: beware of P-glycoprotein and cytochrome P450.
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Affiliation(s)
- Vladimir Manenti
- Institut Lorrain du cœur et des vaisseaux, département de cardiologie, 54511 Vandœuvre-lès-Nancy, France.
| | - Etienne Aliot
- Institut Lorrain du cœur et des vaisseaux, département de cardiologie, 54511 Vandœuvre-lès-Nancy, France
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885
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Veltkamp R, Prabhakaran S. Critique of Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation trial. Stroke 2014; 45:2151-3. [PMID: 24916907 DOI: 10.1161/strokeaha.114.004971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Roland Veltkamp
- From the Department of Stroke Medicine, Imperial College London, London, United Kingdom (R.V.); Department of Neurology, University of Heidelberg, Heidelberg, Germany (R.V.); and Department of Neurology, Northwestern University, Chicago, IL (S.P.).
| | - Shyam Prabhakaran
- From the Department of Stroke Medicine, Imperial College London, London, United Kingdom (R.V.); Department of Neurology, University of Heidelberg, Heidelberg, Germany (R.V.); and Department of Neurology, Northwestern University, Chicago, IL (S.P.)
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886
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Labaf A, Grzymala-Lubanski B, Stagmo M, Lövdahl S, Wieloch M, Själander A, Svensson PJ. Thromboembolism, major bleeding and mortality in patients with mechanical heart valves- a population-based cohort study. Thromb Res 2014; 134:354-9. [PMID: 24985036 DOI: 10.1016/j.thromres.2014.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/07/2014] [Accepted: 06/05/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Low incidences of thromboembolism (TE) and bleeding in patients with mechanical heart valves (MHV) have previously been reported. This study assesses the incidence of and clinical risk factors predicting TE, major bleeding and mortality in a clinical setting. METHODS AND RESULTS All 546 patients undergoing anticoagulation treatment due to MHV replacement at hospitals in Malmö and Sundsvall in Sweden were monitored during 2008-2011 and the incidence of TE, major bleeding and mortality was prospectively followed. There were 398, 122 and 26 patients in the aortic group (AVR), mitral (MVR) group and the combined aortic/mitral valve group respectively. The incidence of TE was 1.8 and 2.2 per 100 patient-years in the AVR group MVR group respectively. The corresponding incidences of bleeding were 4.4 and 4.6, respectively. Independent predictor of thromboembolism was vascular disease (Odds ratio {OR}: 4.2; 95% CI: 1.0-17.4). Predictor of bleeding was previous bleeding (OR: 2.7; 95% CI: 1.4-5.3). Independent predictors of mortality was age (Hazard ratio {HR}: 1.03; 95% CI: 1.00-1.05), hypertension (HR: 2.4; 95% CI: 1.3-4.5), diabetes (HR: 2.4; 95% CI: 1.3-4.3) and alcohol overconsumption (HR: 5.2; 95% CI: 1.7-15.9). Standardized mortality/morbidity ratio for mortality and AMI was 0.99 (95% CI: 0.8-1.2) and 0.87 (95% CI: 0.5-1.2) respectively. CONCLUSION The incidence of TE and major bleeding in this unselected clinical population exceeds that of previously reported retrospective and randomized trials. Despite this, mortality is equal to that of the general population.
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Affiliation(s)
- Ashkan Labaf
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | - Bartosz Grzymala-Lubanski
- Department of Internal Medicine, General Hospital in Sundsvall, Sundsvall, Sweden; Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Martin Stagmo
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Susanna Lövdahl
- Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Mattias Wieloch
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Emergency Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anders Själander
- Department of Internal Medicine, General Hospital in Sundsvall, Sundsvall, Sweden; Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Peter J Svensson
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Coagulation disorders, Skåne University Hospital, Malmö, Sweden
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887
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Douxfils J, Buckinx F, Mullier F, Minet V, Rabenda V, Reginster JY, Hainaut P, Bruyère O, Dogné JM. Dabigatran etexilate and risk of myocardial infarction, other cardiovascular events, major bleeding, and all-cause mortality: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2014; 3:e000515. [PMID: 24906369 PMCID: PMC4309041 DOI: 10.1161/jaha.113.000515] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Signals of an increased risk of myocardial infarction (MI) have been identified with dabigatran etexilate in randomized controlled trials (RCTs). Methods and Resules We conducted searches of the published literature and a clinical trials registry maintained by the drug manufacturer. Criteria for inclusion in our meta‐analysis included all RCTs and the availability of outcome data for MI, other cardiovascular events, major bleeding, and all‐cause mortality. Among the 501 unique references identified, 14 RCTs fulfilled the inclusion criteria. Stratification analyses by comparators and doses of dabigatran etexilate were conducted. Peto odds ratio (ORPETO) values using the fixed‐effect model (FEM) for MI, other cardiovascular events, major bleeding, and all‐cause mortality were 1.34 (95% CI 1.08 to 1.65, P=0.007), 0.93 (95%CI 0.83 to 1.06, P=0.270), 0.88 (95% CI 0.79 to 0.99, P=0.029), and 0.89 (95% CI 0.80 to 1.00, P=0.041). When compared with warfarin, ORPETO values using FEM were 1.41 (95% CI 1.11 to 1.80, P=0.005), 0.94 (95%CI 0.83 to 1.06, P=0.293), 0.85 (95% CI 0.76 to 0.96, P=0.007), and 0.90 (95% CI 0.81 to 1.01, P=0.061), respectively. In RCTs using the 150‐mg BID dosage, the ORPETO values using FEM were 1.45 (95% CI 1.11 to 1.91, P=0.007), 0.95 (95% CI 0.82 to 1.09, P=0.423), 0.92 (95% CI 0.81 to 1.05, P=0.228), and 0.88 (95% CI 0.78 to 1.00, P=0.045), respectively. The results of the 110‐mg BID dosage were mainly driven by the RE‐LY trial. Conclusions This meta‐analysis provides evidence that dabigatran etexilate is associated with a significantly increased risk of MI. This increased risk should be considered taking into account the overall benefit in terms of major bleeding and all‐cause mortality.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
| | - Fanny Buckinx
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - François Mullier
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.) Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), CHU Dinant-Godinne UCL Namur, Yvoir, Belgium (F.M.)
| | - Valentine Minet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
| | - Véronique Rabenda
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Philippe Hainaut
- Department of General Internal Medicine, Cliniques Universitaires Saint Luc, UCL, Bruxelles, Belgium (P.H.)
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
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888
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Affiliation(s)
- Michael Nanna
- Yale University School of Medicine and Yale New Haven Hospital, Department of Medicine, New Haven, CT (M.N.)
| | - Kathleen Stergiopoulos
- Division of Cardiovascular Disease, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY (K.S.)
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889
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Patel KK, Mehdirad AA, Lim MJ, Ferreira SW, Mikolajczak PC, Stolker JM. Beyond warfarin: a patient-centered approach to selecting novel oral anticoagulants for stroke prevention in atrial fibrillation. J Hosp Med 2014; 9:400-6. [PMID: 24715600 DOI: 10.1002/jhm.2201] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 03/02/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Warfarin reduces stroke in patients with atrial fibrillation. However, its narrow therapeutic index and need for chronic monitoring are barriers to its optimal utilization in many patients. The recent introduction of 3 novel oral anticoagulants (NOACs), as alternatives to warfarin, may change the eligibility and management of patients with nonvalvular atrial fibrillation (NVAF) who require systemic anticoagulation. PURPOSE To summarize contemporary indications for anticoagulation in NVAF, and to help provide patient-centered clinical decision making for selecting warfarin or 1 of the NOACs (dabigatran, rivaroxaban, apixaban) based on randomized trials and mechanistic data for each drug. DATA SOURCES AND STUDY SELECTION The primary clinical outcome trials of warfarin and the NOACs, pharmacologic studies, and briefing documents from the US Food and Drug Administration were reviewed. DATA EXTRACTION AND DATA SYNTHESIS In randomized trials, NOACs were consistently noninferior to warfarin for reducing stroke or systemic embolism in patients with NVAF, with reductions in intracranial bleeding as well. However, NOACs have several important drug-drug interactions, exclusion criteria for specific patient subgroups (eg, severe renal disease), and each medication may have a different impact on other clinical outcomes such as myocardial infarction or gastrointestinal bleeding. Benefits of the new drugs are particularly pronounced when international normalized ratio levels on warfarin are labile. CONCLUSIONS Warfarin continues to play an important role in the prevention of stroke or systemic embolism in NVAF. Among selected patients, the use of NOACs provides equal or superior benefit, without the need for chronic anticoagulation monitoring or ongoing dose titration.
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Affiliation(s)
- Keval K Patel
- Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
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890
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'Real-world' antithrombotic treatment in atrial fibrillation: The EORP-AF pilot survey. Am J Med 2014; 127:519-29.e1. [PMID: 24486284 DOI: 10.1016/j.amjmed.2013.12.022] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current guidelines strongly recommend that oral anticoagulation should be offered to patients with atrial fibrillation and ≥1 stroke risk factors. The guidelines also recommend that oral anticoagulation still should be used in the presence of stroke risk factors irrespective of rate or rhythm control. METHODS In an analysis from the dataset of the EURObservational Research Programme on Atrial Fibrillation Pilot Survey (n = 3119), we examined antithrombotic therapy prescribing, with particular focus on the risk factors determining oral anticoagulation or antiplatelet therapy use. RESULTS When oral anticoagulation was used among admitted patients in whom no pharmacologic cardioversion, electrical cardioversion, or catheter ablation was performed or planned, vitamin K antagonist therapy was prescribed in the majority (72.2%), whereas novel oral anticoagulants were used in the minority (7.7%). There was no significant difference in bleeding risk factors among the patients treated with the different types of antithrombotic therapies, except for those with chronic kidney disease, in whom oral anticoagulation was less commonly used (P = .0318). Antiplatelet therapy was more commonly used in patients with a high Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly score (≥2) (P < .0001). More oral anticoagulation use was associated with female gender (P = .0245). Less novel oral anticoagulant use was associated with valvular heart disease (P < .0001), chronic heart failure (P = .0010), coronary artery disease (P < .0001), and peripheral artery disease (P = .0092). Coronary artery disease was the strongest reason for combination therapy with oral anticoagulation plus antiplatelet drug (odds ratio, 8.54; P < .0001). When the Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female] score was used, 95.6% of patients with a score ≥1 received antithrombotic therapy, with 80.5% of patients with a score ≥1 receiving oral anticoagulation. Of note, 83.7% of those with a score ≥2 received antithrombotic therapy. Of the latter, 70.9% of those with a score ≥2 received oral anticoagulation, vitamin K antagonists were used in 64.1%, and novel oral anticoagulants were used in 6.9%. CONCLUSIONS The EURObservational Research Programme on Atrial Fibrillation Pilot Survey provides contemporary data on oral anticoagulation prescribing by European cardiologists for atrial fibrillation. Although the uptake of oral anticoagulation (mostly vitamin K antagonist therapy) has improved since the Euro Heart Survey a decade ago, antiplatelet therapy is still commonly prescribed, with or without oral anticoagulation, whereas elderly patients are commonly undertreated with oral anticoagulation.
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891
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Gryn SE, Kim RB. Personalized medicine: importance of clinical interpretative skills for real-world patient care. Per Med 2014; 11:395-408. [PMID: 29783478 DOI: 10.2217/pme.14.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Sequencing of the human genome led to great hopes and expectations for a 'genomics revolution' where disease diagnosis as well as therapies would be based on an individual's genetic makeup. Although significant progress has been made, a number of challenging hurdles must be overcome prior to the broader adoption and implementation of pharmacogenomics and personalized medicine as a part of standard patient care. One aspect of pharmacogenomics-based personalized medicine that has not garnered as much attention, a key focus of this perspective, is the importance of interpreting pharmacogenomic test results in a patient-specific clinical context, and expert physicians and other allied health care providers with the requisite expertise in clinical pharmacology and genomics who are able to provide such services.
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Affiliation(s)
- Steven E Gryn
- Division of Clinical Pharmacology, Department of Medicine, Western University, London Health Sciences Centre-UH; 339 Windermere Road; London, ON. N6A 5A5; Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London Health Sciences Centre-UH; 339 Windermere Road; London, ON. N6A 5A5; Canada
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892
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Mohanty BD, Looser PM, Gokanapudy LR, Handa R, Mohanty S, Choi SS, Goldman ME, Fuster V, Halperin JL. Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation. Vasc Med 2014; 19:190-204. [PMID: 24879715 DOI: 10.1177/1358863x14532869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing use of the new oral anticoagulants (NOACs) – dabigatran, rivaroxaban, and apixaban – has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.
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Affiliation(s)
- Bibhu D Mohanty
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Patrick M Looser
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | | | - Rishi Handa
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Sudipta Mohanty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sharon S Choi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Martin E Goldman
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Valentin Fuster
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Jonathan L Halperin
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
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893
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[Outpatient anticoagulation]. MMW Fortschr Med 2014; 156:48-53; quiz 54-5. [PMID: 24908890 DOI: 10.1007/s15006-014-2868-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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894
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Pislaru SV, Hussain I, Pellikka PA, Maleszewski JJ, Hanna RD, Schaff HV, Connolly HM. Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series. Eur J Cardiothorac Surg 2014; 47:725-32. [PMID: 24829402 DOI: 10.1093/ejcts/ezu201] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Current guidelines favour surgery or thrombolysis as initial treatment. We set forth to characterize timing, diagnostic criteria and treatment strategies in BPVT. METHODS A free-text search tool was used to identify patients diagnosed with BPVT at Mayo Clinic between 1997 and 2013. We compared patients treated initially with vitamin K antagonists (VKA group; N = 15) versus surgery/thrombolysis (non-VKA group; N = 17). RESULTS Peak incidence of BPVT was 13-24 months after implantation in both groups. VKA and surgery/thrombolysis decreased prosthetic mean gradients to a similar extent (VKA group: 13 ± 5 to 6 ± 2 mmHg in mitral position, 9 ± 3 to 5 ± 1 mmHg in tricuspid position and 39 ± 3 to 24 ± 7 mmHg in aortic/pulmonary position; non-VKA group: 16 ± 12 to 5 ± 1 mmHg in mitral, 10 ± 5 to 4 ± 1 mmHg in tricuspid and 57 ± 9 to 18 ± 6 mmHg in aortic position; P = 0.59 for group effect). NYHA class improved in 11 of 15 patients in the VKA group and 10 of 17 patients in the non-VKA group (P = 0.39). There were no deaths, strokes or recognized embolic events; 1 patient in each group experienced gastrointestinal bleeding requiring transfusion. Index transthoracic echocardiogram formally identified BPVT in a minority of patients. CONCLUSIONS BPVT may occur late after surgical implantation. VKA therapy resulted in haemodynamic and clinical improvement with minimal risk, and should be considered the first-line therapy in haemodynamically stable patients. Echocardiographic criteria for improving BPVT diagnosis are proposed.
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Affiliation(s)
- Sorin V Pislaru
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Imad Hussain
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Richard D Hanna
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Hartzell V Schaff
- Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Heidi M Connolly
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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895
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Bista D, Chalmers L, Bereznicki L, Peterson G. Potential use of NOACs in developing countries: pros and cons. Eur J Clin Pharmacol 2014; 70:817-28. [PMID: 24817486 DOI: 10.1007/s00228-014-1693-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/25/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems. METHODS A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles. RESULTS Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised. CONCLUSION The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.
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Affiliation(s)
- Durga Bista
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia,
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896
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Affiliation(s)
- Carlos A Molina
- From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); and Stroke Division, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.).
| | - Magdy H Selim
- From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); and Stroke Division, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.).
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897
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102-65. [PMID: 24814377 DOI: 10.1016/j.hrthm.2014.05.009] [Citation(s) in RCA: 371] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 02/07/2023]
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898
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Hart RG, Eikelboom JW. Stroke prevention in atrial fibrillation: Commentary regarding the AAN's evidence-based guideline update. Neurol Clin Pract 2014; 4:96-98. [PMID: 24790796 DOI: 10.1212/cpj.0000000000000003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Atrial fibrillation is a common, potentially preventable cause of disabling stroke in the elderly, particularly in elderly women, resulting from embolism of stasis-precipitated thrombi formed in the left atrial appendage. In 1989, the first randomized clinical trial of anticoagulant therapy in atrial fibrillation showed that warfarin produced a large reduction in ischemic stroke.1 In the ensuing 25 years, more than 40 additional randomized trials have permitted stroke prophylaxis to be importantly refined. It has been a period of remarkable progress in stroke prevention. Here, we discuss selected aspects of the American Academy of Neurology (AAN)'s evidence-based guideline update.2.
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Affiliation(s)
- Robert G Hart
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - John W Eikelboom
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
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899
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STEIN P, BOSSHART M, BRAND B, SCHLICKER A, SPAHN DR, BETTEX D. Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence: Case report with literature review. Acta Anaesthesiol Scand 2014; 58:630-7. [PMID: 24601892 DOI: 10.1111/aas.12303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Novel oral anticoagulants are now encountered in patients needing emergency surgery. Knowledge and treatment options are limited. METHODS AND RESULT We present the case of a 76-year-old patient who suffered from an acute Stanford type A aortic dissection, needing emergency surgical aortic repair. He was anticoagulated with dabigatran due to past atrial fibrillation. Despite haemodiafiltration, surgical revision and massive transfusion of packed red blood cells, fresh frozen plasma, platelets, coagulation factors, and recombinant factor VIIa, the patient died from intractable bleeding with sustained therapeutic levels of dabigatran. CONCLUSION After reviewing the literature, we summarize the limited treatment options and show possible approaches for patients treated with dabigatran needing emergency surgery.
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Affiliation(s)
- P. STEIN
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - M. BOSSHART
- Division of Cardiovascular Anaesthesia and Intensive Care; University and University Hospital of Zurich; Zurich Switzerland
| | - B. BRAND
- Division of Haematology; University and University Hospital of Zurich; Zurich Switzerland
| | - A. SCHLICKER
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - D. R. SPAHN
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - D. BETTEX
- Division of Cardiovascular Anaesthesia and Intensive Care; University and University Hospital of Zurich; Zurich Switzerland
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900
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Mechanical heart valve prosthesis and warfarin – Treatment quality and prognosis. Thromb Res 2014; 133:795-8. [DOI: 10.1016/j.thromres.2014.02.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/26/2014] [Accepted: 02/27/2014] [Indexed: 11/18/2022]
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