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Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. Lancet Neurol 2024; 23:404-417. [PMID: 38508836 DOI: 10.1016/s1474-4422(24)00037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland.
| | - Virginia Cancelloni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lorenz Räber
- Department of Cardiology, Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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52
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Thomas VV, Lenin A, George TK, Thenmozhi M, Iyadurai R, Sudarsanam TD. Trends in oral anticoagulant use - A 10-year retrospective analysis from a general medicine department of a tertiary care hospital in south India. J Postgrad Med 2024; 70:77-83. [PMID: 37470633 PMCID: PMC11160985 DOI: 10.4103/jpgm.jpgm_10_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The prescribing practice of newer oral anticoagulants (NOACs) has not been adequately studied in the Indian scenario. AIMS We aimed to describe the prescribing practices of oral anticoagulants, the patient profile and medical comorbidities among patients admitted in a general medicine unit. METHODS In this retrospective study of the 2742 patients prescribed vitamin- K antagonists (VKAs), during the study period, 150 cases were randomly taken for analysis to match the 105 NOACs cases. Their demographic details, clinical characteristics and treatment details were analyzed. RESULTS More than 95% of anticoagulants prescribed were VKAs. The prescription of anticoagulants was more common in men (median age 63 years) for prescription of NOACs and 52 years for VKAs. Dabigatran (60.9%) and warfarin (81.3%) were the most prescribed drugs in their respective classes. The most common indication was for cardiovascular diseases with atrial fibrillation (32%). Diabetes and hypertension were the most common comorbidities in patients prescribed oral anticoagulants with a larger proportion of patients with heart failure being prescribed VKAs ( P < 0.01). Patients in the NOACs group had a higher HAS-BLED high-risk score (33.3% vs. 17.3%; P = 0.002). Logistic regression analysis revealed that patients with co-morbidities of congestive heart failure were more likely to be prescribed VKAs while diabetics were more likely to receive NOACs. CONCLUSIONS VKAs were the most prescribed anticoagulants; congestive heart failure, diabetes, and hypertension were the commonest comorbidities; and atrial fibrillation was the commonest indication. Patients with a high HAS-BLED score were prescribed NOACs more often.
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Affiliation(s)
- VV Thomas
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A Lenin
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - TK George
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - M Thenmozhi
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - R Iyadurai
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - TD Sudarsanam
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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53
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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54
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Ozdemir H, Sagris D, Abdul-Rahim AH, Lip GYH, Shantsila E. Management of ischaemic stroke survivors in primary care setting: the road to holistic care. Intern Emerg Med 2024; 19:609-618. [PMID: 37875703 PMCID: PMC11039521 DOI: 10.1007/s11739-023-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023]
Abstract
The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.
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Affiliation(s)
- Hizir Ozdemir
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Azmil Husin Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Yoke Hong Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Eduard Shantsila
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.
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Huma H, Rawat A, Kaur M, Jha O, Shaukat Gill F, Moqattash M, Wei CR, Allahwala D. Comparison of Effectiveness and Safety of Apixaban, Dabigatran, and Rivaroxaban in Patients With Valvular Atrial Fibrillation: A Network Meta-Analysis of Randomized-Control Trials and Observational Studies. Cureus 2024; 16:e57656. [PMID: 38707166 PMCID: PMC11070143 DOI: 10.7759/cureus.57656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
The objective of this network meta-analysis was to assess the efficacy and safety of apixaban, dabigatran, rivaroxaban, and edoxaban in patients diagnosed with atrial fibrillation and valvular heart disease. A comprehensive search was conducted across various electronic databases, including PubMed, Embase, and Web of Science, from inception to February 15, 2024. The search strategy utilized a combination of medical subject headings (MeSH) terms and relevant keywords related to valvular heart disease, atrial fibrillation, anticoagulant therapy, and study design, such as randomized controlled trials and observational studies. The outcomes evaluated in this analysis comprised the incidence of stroke or systemic embolism (SE), as well as the occurrences of major bleeding events. A total of 10 studies were incorporated into this meta-analysis, encompassing 40,662 participants. Of these, 12,385 received apixaban, 2,829 received dabigatran, 13,662 received rivaroxaban, 2,582 received edoxaban, and 9,202 received warfarin. The duration of follow-up in the included studies ranged from 3 to 54 months. Among the four direct oral anticoagulants (DOACs) studied, apixaban demonstrated a significant reduction in the risk of stroke or SE when compared to other DOACs and warfarin, highlighting its efficacy in patients with atrial fibrillation and valvular heart disease. Additionally, apixaban exhibited a lower risk of major bleeding events, further emphasizing its favorable safety profile compared to the other agents assessed. In conclusion, our findings suggest that apixaban may be more effective and safer than other DOACs and warfarin in this patient population. However, additional studies are warranted to compare the various DOACs in this cohort to identify the optimal treatment strategy for preventing adverse outcomes.
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Affiliation(s)
- Huria Huma
- Cardiology, Glenifield General Hospital, Leicester, GBR
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Mandeep Kaur
- Internal Medicine, Hospital Corporation of America (HCA) Florida Capital Hospital, Tallahassee, USA
| | - Omkar Jha
- Medicine, Health Foundation Nepal, Kathmandu, NPL
| | | | | | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
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Krahn KM, Koshman SL, Wang T, Chen J, Bungard TJ, Zhou JS, Omar MA, Cowley EC. Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2024; 117:859-865. [PMID: 38081497 DOI: 10.1016/j.athoracsur.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.
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Affiliation(s)
- Kaitlyn M Krahn
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Ting Wang
- Data and Research Services, Alberta Strategy for Patient Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - June Chen
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tammy J Bungard
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jian Song Zhou
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Emily C Cowley
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada.
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57
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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58
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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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59
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Woodland M, Thompson A, Lipford A, Goyal N, Schexnaildre JC, Mottamal M, Afosah DK, Al-Horani RA. New Triazole-Based Potent Inhibitors of Human Factor XIIa as Anticoagulants. ACS OMEGA 2024; 9:10694-10708. [PMID: 38463342 PMCID: PMC10918664 DOI: 10.1021/acsomega.3c09335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/10/2024] [Accepted: 02/06/2024] [Indexed: 03/12/2024]
Abstract
Factor XIIa (FXIIa) functions as a plasma serine protease within the contact activation pathway. Various animal models have indicated a substantial role for FXIIa in thromboembolic diseases. Interestingly, individuals and animals with FXII deficiency seem to maintain normal hemostasis. Consequently, inhibiting FXIIa could potentially offer a viable therapeutic approach for achieving effective and safer anticoagulation without the bleeding risks associated with the existing anticoagulants. Despite the potential, only a limited number of small molecule inhibitors targeting human FXIIa have been documented. Thus, we combined a small library of 32 triazole and triazole-like molecules to be evaluated for FXIIa inhibition by using a chromogenic substrate hydrolysis assay under physiological conditions. Initial screening at 200 μM involved 18 small molecules, revealing that 4 molecules inhibited FXIIa more than 20%. In addition to being the most potent inhibitor identified in the first round, inhibitor 8 also exhibited a substantial margin of selectivity against related serine proteases, including factors XIa, Xa, and IXa. However, the molecule also inhibited thrombin with a similar potency. It also prolonged the clotting time of human plasma, as was determined in the activated partial thromboplastin time and prothrombin time assays. Subsequent structure-activity relationship studies led to the identification of several inhibitors with submicromolar activity, among which inhibitor 22 appears to demonstrate significant selectivity not only over factors IXa, Xa, and XIa, but also over thrombin. In summary, this study introduces novel triazole-based small molecules, specifically compounds 8 and 22, identified as potent and selective inhibitors of human FXIIa. The aim is to advance these inhibitors for further development as anticoagulants to provide a more effective and safer approach to preventing and/or treating thromboembolic diseases.
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Affiliation(s)
- Ma’Lik
D. Woodland
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Anthony Thompson
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Amanda Lipford
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Navneet Goyal
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - John C. Schexnaildre
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Madhusoodanan Mottamal
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Daniel K. Afosah
- Department
of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia 23219, United States
| | - Rami A. Al-Horani
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
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Presume J, Ferreira J, Ribeiras R. Factor XI Inhibitors: A New Horizon in Anticoagulation Therapy. Cardiol Ther 2024; 13:1-16. [PMID: 38306010 PMCID: PMC10899133 DOI: 10.1007/s40119-024-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Anticoagulation therapy has undergone significant evolution, marked by the emergence of direct oral anticoagulants with distinct advantages. Despite these advancements, challenges persist in managing residual thrombotic and bleeding risks, particularly among vulnerable populations. The pursuit of alternative drugs has honed in on factor XI/XIa inhibitors. This comprehensive review delves into several key aspects regarding this new target: (i) the role of factor XI in the coagulation cascade; (ii) the genetic evidence and pathophysiologic rationale supporting factor XI inhibition as a therapeutic target; (iii) an exploration of the various types of factor XI/XIa inhibitors currently under investigation; (iv) potential applications of these medications, spanning thromboprophylaxis after orthopedic surgery, stroke prevention in atrial fibrillation, secondary prevention after acute coronary syndrome, non-cardioembolic stroke, thromboprophylaxis after foreign material implantation, end-stage renal disease, and patients with cancer; and (v) an overview of ongoing studies, recent findings, and the future trajectory of research into these drugs.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Ferreira
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
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Marongiu F, Barcellona D. Why Does Rivaroxaban Not Work in Severe Mitral Stenosis? Semin Thromb Hemost 2024; 50:303-306. [PMID: 37160162 DOI: 10.1055/s-0043-1768938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Francesco Marongiu
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Doris Barcellona
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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62
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Jin C, Cui C, Seplowe M, Lee KI, Vegunta R, Li B, Frishman WH, Iwai S. Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views. Cardiol Rev 2024; 32:131-139. [PMID: 36730534 DOI: 10.1097/crd.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.
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Affiliation(s)
- Chengyue Jin
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Can Cui
- Department of Immunobiology, School of Medicine, Yale University, New Haven, CT
| | - Matthew Seplowe
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Kyu-In Lee
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | | | - Bo Li
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Sei Iwai
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
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O'Neil MJ, Garr BN, Faircloth JM, Ciambarella JA, Lubert AM, Nelson NL, Cooper DS. Utility of a pharmacist-managed Anticoagulation Program in patients with congenital heart disease. Cardiol Young 2024; 34:628-633. [PMID: 37681464 DOI: 10.1017/s1047951123003268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Warfarin remains the preferred anticoagulant for many patients with CHD. The complexity of management led our centre to shift from a nurse-physician-managed model with many providers to a pharmacist-managed model with a centralized anticoagulation team. We aim to describe the patient cohort managed by our Anticoagulation Program and evaluate the impact of implementation of this consistent, pharmacist-managed model on time in therapeutic range, an evidence-based marker for clinical outcomes. METHODS A single-centre retrospective cohort study was conducted to evaluate the impact of the transition to a pharmacist-managed model to improve anticoagulation management at a tertiary pediatric heart centre. The percent time in therapeutic range for a cohort managed by both models was compared using a paired t-test. Patient characteristics and time in therapeutic range of the program were also described. RESULTS After implementing the pharmacist-managed model, the time in therapeutic range for a cohort of 58 patients increased from 65.7 to 80.2% (p < .001), and our Anticoagulation Program consistently maintained this improvement from 2013 to 2022. The cohort of patients managed by the Anticoagulation Program in 2022 included 119 patients with a median age of 24 years (range 19 months-69 years) with the most common indication for warfarin being mechanical valve replacement (n = 81, 68%). CONCLUSIONS Through a practice change incorporating a collaborative, centralized, pharmacist-managed model, this cohort of CHD patients on warfarin had a fifteen percent increase in time in therapeutic range, which was sustained for nine years.
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Affiliation(s)
- Meredith J O'Neil
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - BreAnn N Garr
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Julie A Ciambarella
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nicole L Nelson
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Chao TF, Potpara TS, Lip GY. Atrial fibrillation: stroke prevention. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100797. [PMID: 38362551 PMCID: PMC10867001 DOI: 10.1016/j.lanepe.2023.100797] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024]
Abstract
Stroke prevention is central to the management of patients with atrial fibrillation (AF) which has moved towards a more holistic or integrative care approach. The published evidence suggests that management of AF patients following such a holistic approach based on the Atrial fibrillation Better Care (ABC) pathway is associated with a lower risk of stroke and adverse events. Risk assessment, re-assessment and use of direct oral anticoagulants (DOACs) are important for stroke prevention in AF. The stroke and bleeding risks of AF patients are not static and should be re-assessed regularly. Bleeding risk assessment is to address and mitigate modifiable bleeding risk factors, and to identify high bleeding risk patients for early review and follow-up. Well-controlled comorbidities and healthy lifestyles also play an important role to achieve a better clinical outcome. Digital health solutions are increasingly relevant in the diagnosis and management of patients with AF, with the potential to improve stroke prevention. In this review, we provide an update on stroke prevention in AF, including importance of holistic management, risk assessment/re-assessment, and stroke prevention for special AF populations. Evidence-based and structured management of AF patients would reduce the risk of stroke and other adverse events.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tatjana S. Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Eikelboom R, Whitlock RP, Sibilio S, Nguyen F, Perez R, Weitz JI, Belley-Cote E. Direct Oral Anticoagulation Versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves: a Retrospective, Real-World Cohort Study. Cardiovasc Drugs Ther 2024; 38:109-117. [PMID: 36121587 DOI: 10.1007/s10557-022-07381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In this retrospective cohort study of consecutive patients with atrial fibrillation and surgical or transcatheter bioprosthetic valve, we compared the efficacy and safety of direct oral anticoagulants with warfarin. METHODS Using linked health administrative databases housed at the Institute for Clinical Evaluative Sciences, we identified consecutive patients in Ontario (Canada) 65 years of age or older with AF who underwent bioprosthetic valve replacement between 1 April 2012 and 31 March 2017. We created a time-varying Cox model to examine the relationship between the type of anticoagulant and time to thrombotic or bleeding events after adjustment for baseline risk of thrombosis using the CHA2DS2-VASc score and risk of bleeding using the HAS-BLED scores. We conducted prespecified subgroup analyses according to whether valve implantation was surgical or transcatheter. RESULTS We identified 2245 eligible patients. The mean age was 79 years, 41% were female, and 39% had transcatheter aortic valve replacement. Risk of death or thrombosis was not different between direct oral anticoagulants and warfarin after adjustment for CHA2DS2-VASc score (hazard ratio [HR] 1.02, 95% confidence interval [CI], 0.83-1.25). Risk of death or bleeding was not different between direct oral anticoagulants and warfarin after adjustment for HAS-BLED score (HR 0.89, 95% CI 0.75-1.07). Subgroup analyses of surgical or transcatheter valves were consistent with overall results. CONCLUSIONS In a real-world population of patients with atrial fibrillation and bioprosthetic valve replacement, we found no difference between direct oral anticoagulants and warfarin with regard to the risk of thrombosis or bleeding.
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Affiliation(s)
- Rachel Eikelboom
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Serena Sibilio
- Dipartimento Di Cardiochirurgia, Istituto Clinico Sant'Ambrogio, Milan, Lombardy, Italy
| | - Francis Nguyen
- Institute for Clinical Evaluative Sciences McMaster, McMaster University, Hamilton, ON, Canada
| | - Richard Perez
- Institute for Clinical Evaluative Sciences McMaster, McMaster University, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Wu JJ, Jiang J, Ye J, Turgeon RD, Wang EH. Direct Oral Anticoagulant Use Early After Cardiac Surgery: A Retrospective Cohort Study. CJC Open 2024; 6:65-71. [PMID: 38585681 PMCID: PMC10994972 DOI: 10.1016/j.cjco.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/19/2023] [Indexed: 04/09/2024] Open
Abstract
Background There is limited literature guiding the prescribing of direct oral anticoagulants (DOACs) early after cardiac surgery as this population has been excluded from landmark randomized controlled trials. This study aims to determine the rate of in-hospital DOAC use compared with warfarin early after cardiac surgery, evaluate factors associated with DOAC use, determine difference in postoperative length of stay, and characterize bleeding events. Methods A retrospective cohort study was conducted in adult patients with indications for anticoagulation and receiving either a DOAC or warfarin after cardiac surgery during their index hospitalization. Patients were excluded if they had any contraindications to DOAC use. The primary outcome was the proportion of patients discharged on a DOAC compared with warfarin. Results Of included 210 patients, 30% received DOACs and 70% received warfarin on discharge. The most common DOAC used was apixaban (74.6%), and median postoperative day of initiation was 5 days. Patients receiving DOACs were older (70.8 vs 68.0 years), had less valvular heart disease (38.1% vs 63.9%), were more likely to be on DOACs preoperatively (50.8% vs 31.3%), and were more likely to have undergone coronary artery bypass graft alone (54.0% vs 24.5%) compared with those on warfarin. Postoperative length of stay (7 vs 9 days; P = 0.59) and in-hospital bleeding (1.6% vs 2.0%; P = 1.00) did not differ between DOAC and warfarin groups. Conclusions At a quaternary referral centre for cardiac surgery, DOACs were used in approximately one-third of patients with an indication for anticoagulation early after cardiac surgery.
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Affiliation(s)
- Jung-Jin Wu
- Department of Pharmacy, Ridge Meadows Hospital, and Faculty of Pharmaceutical Sciences, Maple Ridge, British Columbia, Canada
| | - Jessie Jiang
- Department of Pharmacy, Vancouver General Hospital, and Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
| | - Jian Ye
- Division of Cardiac Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D. Turgeon
- Department of Pharmacy, St. Paul’s Hospital, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erica H.Z. Wang
- Department of Pharmacy, St. Paul’s Hospital, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Kramer A, Patti G, Nielsen-Kudsk JE, Berti S, Korsholm K. Left Atrial Appendage Occlusion and Post-procedural Antithrombotic Management. J Clin Med 2024; 13:803. [PMID: 38337496 PMCID: PMC10856063 DOI: 10.3390/jcm13030803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45-90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 13100 Vercelli, Italy;
- Department of Thoracic and Cardiovascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Sergio Berti
- Department of Interventional and Diagnostic Cardiology, Fondazione CNR-Regione Toscana G, Monasterio, Ospedale del Cuore, 54100 Massa, Italy;
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Erba N, Tosetto A, Abdallah SA, Langer M, Giovanella E, Lentini S, Masini F, Mocini A, Portella G, Salvati AC, Squizzato A, Testa S, Lip GYH, Poli D. Association of sex with major bleeding risks in sub-Saharian anticoagulated patients with mechanical heart valves: A cohort study from the Khartoum Emergency Salam Centre. Int J Cardiol 2024; 394:131398. [PMID: 37769970 DOI: 10.1016/j.ijcard.2023.131398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/05/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Rheumatic heart disease (RHD) with mechanical heart valve (MHV) replacement is common in Africa. However, MHV requires lifelong anticoagulation that could have a particular impact in women in reproductive age. METHODS We report data of a prospective observational cohort study conducted between August 2018 and September 2019 in MHV patients in the Salam Centre for Cardiac Surgery built in Khartoum by Emergency, an Italian Non-Governmental Organization, to evaluate bleeding risk, its associated determinants, and the impact of lifelong anticoagulation in fertile women. RESULTS We studied 3647 patients (median age 25.1 years; 53.9% female). During follow-up [median time 1.1 (0.1-1.2) years], we recorded 85 major bleedings (rate 2.16 × 100 pt-years), Major bleedings occurred more frequently among women (64/85 cases, 75.3%; rate 3.0 × 100 pt-years), compared to men (21/85 cases, 24.7%; rate 1.16 × 100 pt-years) (RR 2.6; 95% CI 1.6-4.5; p = 0.0001). Multivariate analysis was performed to identify variables associated with major bleeding, and female sex was the only risk factor significantly associated, whereas aspirin treatment and higher INR target showed a non-significant trend for higher bleeding risk. Thirty-two/85 (37.6%) of major bleedings were metrorrhagias. When we calculate the incidence of major bleedings after the exclusion of gynecological events, no sex differences in the bleeding risk were found (HR 1.3, 95% CI 0.8-2.3; p = 0.3). CONCLUSIONS Bleeding risk of young MHV patients on oral anticoagulant therapy is higher among women, mainly due to metrorrhagia. Women in the reproductive life are at high risk for gynecological bleeding when treated with anticoagulants.
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Affiliation(s)
- Nicoletta Erba
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | | | - Suha Abdelwahab Abdallah
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Martin Langer
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Elena Giovanella
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Salvatore Lentini
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Franco Masini
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Alessandro Mocini
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | - Gennarina Portella
- Medical Division, Emergency, ONG Onlus, Milan, Italy; Salam Centre for Cardiac Surgery, Khartoum, Sudan
| | | | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, ASST Cremona, Cremona, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Department of Clinical Medicine, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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74
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Safouris A, Psychogios K, Palaiodimou L, Orosz P, Magoufis G, Kargiotis O, Theodorou A, Karapanayiotides T, Spiliopoulos S, Nardai S, Sarraj A, Nguyen TN, Yaghi S, Walter S, Sacco S, Turc G, Tsivgoulis G. Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment. J Stroke 2024; 26:13-25. [PMID: 38326704 PMCID: PMC10850459 DOI: 10.5853/jos.2023.01578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | | | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Orosz
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - George Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thanh N. Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
- Université Paris Cité, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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75
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Kantar Y, Baykan N. The use of fluoroscopy for detecting hypertensive lung edema due to prosthetic valve dysfunction: a case report. World J Emerg Med 2024; 15:313-315. [PMID: 39050217 PMCID: PMC11265636 DOI: 10.5847/wjem.j.1920-8642.2024.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/05/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Yusuf Kantar
- Emergency Department, Akçaabat Haçkalibaba State Hospital, Trabzon 61060, Turkiye
| | - Necmi Baykan
- Emergency Department, Kayseri City Hospital, Kayseri 38080, Turkiye
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76
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Zhou Q, Liu X, Yang X, Huang XH, Wu YZ, Tao YY, Wei M. Effectiveness and safety of short-term anticoagulant regimens after left atrial appendage occlusion: A systematic review and meta-analysis. Thromb Res 2024; 233:88-98. [PMID: 38035647 DOI: 10.1016/j.thromres.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/12/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Left atrial appendage occlusion (LAAO) provides an alternative for poor candidates of long-term oral anticoagulant (OAC) therapy; however, anticoagulant therapy after surgical procedures has limited use due to associated uncertainties. We aimed to evaluate the effectiveness and safety of the short-term use of direct oral anticoagulant (DOAC) and warfarin after LAAO. METHOD Electronic databases such as PubMed, Embase, Medline, and Cochrane Library databases were searched up to November 11, 2022. Our study compared DOAC therapy and warfarin in patients after LAAO. A meta-analysis was conducted with the Review Manager software (version 5.4). RESULTS The meta-analysis included 13 cohort studies with a total of 32,607 patients. Our findings indicated that the incidence of stroke/TIA/SE, peri-device leaks>5 mm, device-related thrombosis, and all-cause mortality were not significantly different between the two groups after LAAO (P > 0.05). The DOAC group had a significantly lower incidence of major bleeding (OR = 0.83, 95 % CI: 0.74-0.94, P = 0.003), any bleeding (OR = 0.34, 95 % CI: 0.23-0.51, P < 0.001), stroke/TIA/SE and major bleeding (OR = 0.57, 95 % CI: 0.34-0.95, P = 0.03), and any major adverse event (OR = 0.89, 95 % CI:0.82-0.97, P = 0.010) than the warfarin group. The subgroup analysis revealed that the rate of stroke/TIA/SE was similar in the two groups in terms of the different regions, follow-up time, study type, anticoagulant strategy, and bleeding risk. The incidence of major bleeding in the DOAC group was significantly lower than that in the warfarin group in North America, as well as at follow-up period ≤6 months, retrospective cohort, HAS-BLED average score ≥ 3. In addition, the risk of major bleeding was higher with the combination of OAC and single antiplatelet therapy (SAPT) than with OAC alone. Finally, in the North American region, retrospective cohort, and HAS-BLED average score ≥ 3, the incidence of any serious adverse event in the DOAC group was still significantly lower than that in the warfarin group. CONCLUSION Compared to warfarin, DOAC reduced the risk of major bleeding and any serious adverse event in patients after LAAO. This advantage was particularly notable in North America and high-risk populations for bleeding. In addition, the incidence of device-related thrombosis, peri-device leaks, stroke/TIA/SE and all-cause mortality were similar in both groups. The risk of major bleeding was lower in patients taking OAC alone compared with those taking OAC plus SAPT, without increasing the risk of thrombosis.
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Affiliation(s)
- Qiang Zhou
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiang Liu
- Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China
| | - Xian Yang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiao-Hui Huang
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan-Zi Wu
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ying-Ying Tao
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Meng Wei
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Cheng A, Malkin C, Briffa NP. Antithrombotic therapy after heart valve intervention: review of mechanisms, evidence and current guidance. Heart 2023; 110:87-93. [PMID: 37438054 DOI: 10.1136/heartjnl-2022-321387] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/12/2023] [Indexed: 07/14/2023] Open
Abstract
As the population ages and treatment options for heart valve disease increase, the number of patients with intracardiac valve prostheses is growing rapidly. Although all devices have the potential to cause thrombus formation, the propensity depends on the type of prosthesis as well as risk of the individual patient. Mechanical valve prostheses carry the highest (and persistent) risk of thromboembolism, and these patients require anticoagulation with vitamin K antagonists (warfarin). Required international normalised ratio levels are dependent on the location of the valve (mitral>aortic), type of valve (ball and cage vs bilealfet vs On-X bilealfet) and rhythm. The risk of tissue (biological) prosthesis is highest soon after surgery and is dependent on individual patient risk including age, valve location (mitral>aortic), history of thromboembolic events and rhythm. In patients with no other indication for anticoagulation, there is uncertainty on the benefits of anticoagulation versus antiplatelet therapy in patients with tissue prostheses or repaired native valves. Patients with an a priori indication for anticoagulation with a direct oral anticoagulant can continue taking this class of drug. Patients with transcatheter aortic valve implantation devices and no additional evidence-based indication for dual antiplatelet therapy or anticoagulation can be maintained on aspirin monotherapy. Patients undergoing transcatheter instrumentation in the mitral valve position should be anticoagulated, although there is currently no published evidence for antithrombotic management in this group of patients. Patients with thrombosed devices (commonly mitral mechanical) should preferably be treated surgically. Patients at high risk of thromboembolism (with mechanical prostheses) should undergo bridging therapy when undergoing surgery.
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Affiliation(s)
- Ann Cheng
- Infection Immunity and cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Norman Paul Briffa
- Infection Immunity and cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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78
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Quang Ho TH, Ton MT, Nguyen VL, Pham HM, Hoang SV, Vo NT, Nguyen TQ, Pham LT, Mai TD, Nguyen TH. Selection of Non-vitamin K Antagonist Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Based on Patient Profile: Perspectives from Vietnamese Experts. Part 1. Eur Cardiol 2023; 18:e61. [PMID: 38174217 PMCID: PMC10762681 DOI: 10.15420/ecr.2023.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/18/2023] [Indexed: 01/05/2024] Open
Abstract
In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF.
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Affiliation(s)
| | | | | | - Hung Manh Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
- Hanoi Medical UniversityHanoi, Vietnam
| | - Sy Van Hoang
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh CityHo Chi Minh City, Vietnam
| | - Nhan Thanh Vo
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- Cardiovascular Center, Vinmec HospitalHo Chi Minh City, Vietnam
| | | | - Linh Tran Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
| | - Ton Duy Mai
- Hanoi Medical UniversityHanoi, Vietnam
- Stroke Center, Bach Mai HospitalHanoi, Vietnam
- VNU-University of Medicine and PharmacyHanoi, Vietnam
| | - Thang Huy Nguyen
- Cerebrovascular Disease Department, People’s 115 HospitalHo Chi Minh City, Vietnam
- Pham Ngoc Thach University of MedicineHo Chi Minh City, Vietnam
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79
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Mameli A, Sestu A, Marongiu F, Barcellona D. Living on Oral Anticoagulants: Duke Anticoagulation Satisfaction Scale Results. J Clin Med 2023; 12:7574. [PMID: 38137642 PMCID: PMC10743469 DOI: 10.3390/jcm12247574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used in patients with atrial fibrillation and venous thromboembolism. The lack of the need for laboratory monitoring and a better safety than vitamin K antagonists (VKAs) has probably changed the quality of life of patients on these oral anticoagulants. This was a real-life prospective observational cohort study. The aim was to evaluate if a long-term treatment with DOACs could offer a better quality of life than VKAs. Moreover, age, gender, education level, time in therapeutic range for VKAs, taking medication once or twice a day for DOACs, the total daily number of medications and thrombotic and bleeding complications were considered as variables probably associated with the quality of life of these patients. METHODS Between January and December 2021, the Duke Anticoagulation Satisfaction Scale (DASS) 25-items was administered as an interview to patients on either VKAs or DOACs therapy. During the follow-up period, all of the patients were closely monitored to evaluate possible bleeding and thrombotic events. RESULTS The analysis included 300 outpatients treated with VKAs and 254 treated with DOACs. In general, the quality of life was better in patients taking DOACs (DASS total score: DOACs = 44.7, 42.9-46.5 vs. VKAs = 51, 49.2-52.8, p < 0.0001) as the daily-life limitations, hassles and burdens and the psychological impact were less important than in patients on VKAs therapy. CONCLUSIONS VKAs negatively influence the daily-life of the patients in terms of both less satisfaction and time-consuming tasks. DOACs confer a better quality of life even if some concerns emerge from not knowing how their therapy is working.
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Affiliation(s)
- Antonella Mameli
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Cagliari, 09123 Cagliari, Italy; (A.M.); (A.S.)
| | - Alessandro Sestu
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Cagliari, 09123 Cagliari, Italy; (A.M.); (A.S.)
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, 09123 Cagliari, Italy;
| | - Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, 09123 Cagliari, Italy;
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80
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Paciaroni M, Caso V, Romoli M, Becattini C, Salerno A, Rapillo C, Simonnet F, Strambo D, Canavero I, Zedde M, Pascarella R, Sohn SI, Sacco S, Ornello R, Barlinn K, Schoene D, Rahmig J, Mosconi MG, Leone De Magistris I, Alberti A, Venti M, Silvestrelli G, Ciccone A, Padroni M, Laudisi M, Zini A, Gentile L, Kargiotis O, Tsivgoulis G, Tassi R, Guideri F, Acampa M, Masotti L, Grifoni E, Rocco A, Diomedi M, Karapanayiotides T, Engelter ST, Polymeris AA, Zietz A, Bandini F, Caliandro P, Reale G, Moci M, Zauli A, Cappellari M, Emiliani A, Gasparro A, Terruso V, Mannino M, Giorli E, Toni D, Andrighetti M, Falcou A, Palaiodimou L, Ntaios G, Sagris D, Karagkiozi E, Adamou A, Halvatsiotis P, Flomin Y, Scoditti U, Genovese A, Popovic N, Pantoni L, Mele F, Molitierno N, Lochner P, Pezzini A, Del Sette M, Sassos D, Giannopoulos S, Kosmidou M, Ntais E, Lotti EM, Mastrangelo V, Chiti A, Naldi A, Vanacker P, Ferrante M, Volodina V, Mancuso M, Giannini N, Baldini M, Vadikolias K, Kitmeridou S, Saggese CE, Tassinari T, Saia V, Michel P. Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study. Eur Stroke J 2023; 8:1030-1040. [PMID: 37452632 PMCID: PMC10683741 DOI: 10.1177/23969873231186863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group). PATIENTS AND METHODS For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days. RESULTS Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05-3.18; p = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84-3.47; p = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95-3.73; p = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95-2.85; p = 0.07). CONCLUSION Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.
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Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alexander Salerno
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Costanza Rapillo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Fanny Simonnet
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Isabella Canavero
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico “Carlo Besta,” Milano, Italy
| | - Marialuisa Zedde
- Neurology Unit, AUSL - IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy
| | - Marina Padroni
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Michele Laudisi
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Luana Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | | | | | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | | | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabio Bandini
- Department of Neurology, ASL 3 Genovese, Genova, Italy
| | - Pietro Caliandro
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Reale
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Moci
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aurelia Zauli
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Emiliani
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | | | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant’Andrea Hospital, La Spezia, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marco Andrighetti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Anne Falcou
- Stroke Unit – Emergency Department, Policlinico Umberto I, Rome, Italy
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anastasia Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Panagiotis Halvatsiotis
- Second Department of Internal Medicine-Propaedeutic and Diabetes Center, Medical School, University General Hospital “Attikon,” National and Kapodistrian University of Athens, Greece
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit MC ‘Universal Clinic “Oberig” Kyiv, Kyiv, Ukraine
| | - Umberto Scoditti
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Antonio Genovese
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Nemanja Popovic
- Clinic of Neurology, University Clinical Center of Vòsvodina, University of Novi Sad, Novi Sad, Serbia
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Francesco Mele
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Nicola Molitierno
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University, Medical Center, Homburg, Germany
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | | | - Davide Sassos
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Kosmidou
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Evangelos Ntais
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | | | | | | | - Andrea Naldi
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Peter Vanacker
- NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Groeninge Hospital, Kortrijk, Belgium
| | - Mario Ferrante
- Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital # 1, Novosibirsk (Russia) at the Novosibirsk State Medical University, Novosibirsk, Russia
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Nicola Giannini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Marco Baldini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Kostantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Tiziana Tassinari
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Valentina Saia
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Patrik Michel
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
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Abstract
For more than 60 years, anticoagulation drugs have served as a mainstay in preserving and improving the cardiovascular health of patients across the globe. Functioning to reduce a patient's ability to produce blood clots, prescription rates for anticoagulants have been steadily rising year-over-year both in the United States and abroad. Despite decades of clinical usage, modern-day anticoagulants have been shown to predispose an individual to pathological bleeding. Even in seemingly benign instances of bleeding, patients on anticoagulation therapy might require intensive and expensive medical procedures or monitoring. Understanding the clinical implications of pathological bleeding, research and development of future anticoagulants seeking to minimize these effects. One emerging category of anticoagulant drugs are Factor XI/XIa (FXI) inhibitors. Targeting the coagulation cascade, clinical trials of Factor XIa inhibitors have shown promising results in preventing blood clot formation without increasing the instances of spontaneous and/or pathological bleeding events. While still in phase II and III clinical trials, and potentially years away from being implemented as standard of care, these novel drugs might have the potential to improve the safety and quality of life of patients taking anticoagulants. In this review, we discuss a brief history of anticoagulation therapy, followed by an analysis of the potential risks, benefits, and implications of Factor XI/XIa inhibitors across elements of patient care.
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82
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Helin TA, Raatikainen P, Lehto M, Haukka J, Lassila R. Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case-control study. BMJ Open 2023; 13:e071342. [PMID: 37918932 PMCID: PMC10626859 DOI: 10.1136/bmjopen-2022-071342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 10/18/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES We studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin. DESIGN This was a retrospective nested case-control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up. SETTING National FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007-31 December 2011. PARTICIPANTS A total of 54 568 warfarin-anticoagulated patients. RESULTS The number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111-141 g/L vs 123-147 g/L, p<0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8-2.6 vs 2.1-2.7, p<0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4. CONCLUSIONS The deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.
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Affiliation(s)
- Tuukka Antero Helin
- Clinical Chemistry, HUS Diagnostic Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pekka Raatikainen
- Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mika Lehto
- Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Internal Medicine, Jorvi Hospital, Espoo, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Riitta Lassila
- Coagulation Disorders Unit and Clinical Chemistry, HUS Helsinki University Hospital, Helsinki, Finland
- Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Santagata D, Donadini MP, Ageno W. Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon? Blood Rev 2023; 62:101119. [PMID: 37580207 DOI: 10.1016/j.blre.2023.101119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.
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Affiliation(s)
- D Santagata
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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84
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Halperin JL, Rothman KJ. Initial Antithrombotic Therapy After Percutaneous Left Atrial Appendage Occlusion: Shifting Approaches to a Moving Target. J Am Coll Cardiol 2023; 82:1774-1776. [PMID: 37879781 DOI: 10.1016/j.jacc.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA.
| | - Kenneth J Rothman
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
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Hohmann C, Pfister R, Frerker C, Beckmann A, Walther T, Bleiziffer S, Ensminger S, Bekeredjian R, Seiffert M, Sinning JM, Möllmann H, Beyersdorf F, Baldus S, Böning A, Herrmann E, Balaban Ü, Kuhn E. Direct oral anticoagulants versus vitamin K antagonist after transcatheter aortic valve implantation. Heart 2023; 109:1706-1713. [PMID: 37407220 DOI: 10.1136/heartjnl-2023-322548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE After transcatheter aortic valve implantation (TAVI), the optimal regimen of anticoagulant therapy in patients with an additional indication for oral anticoagulation remains a matter of debate. This study investigates the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients after TAVI in a real-world population. METHODS The German Aortic Valve RegistrY (GARY) is a prospective, multicentre registry enrolling patients undergoing invasive treatment for aortic valve disease. From January 2011 to December 2019, 1 41 790 patients from 92 hospitals in Germany were enrolled. Anticoagulatory treatment regimens were assessed at hospital discharge for patients after TAVI procedures. All-cause mortality and the combined endpoint 'cardiac and cerebrovascular events' containing myocardial infarction, stroke, transient ischaemic attack, aortic prosthesis reintervention and all-cause mortality in the first year after TAVI were examined by treatment regimen. RESULTS Of 45 598 patients (mean age 80.7±5.7 years, 49.3% males) undergoing TAVI, 16 974 patients (37.2%) received an anticoagulant regimen that included VKA or DOAC. Hereof, the majority of patients were prescribed VKA (n=11 333, 66.8%) compared with DOAC (n=5641, 33.2%) with an increase of DOAC use from 9.4% in 2011 to 69.9% in 2019. During the 1-year follow-up, the absolute event rates per 100 person-years for all-cause mortality and the combined endpoint cardiac and cerebrovascular events were 1.9 and 1.3 for VKA-treated and 1.7 and 1.2 for DOAC-treated patients, respectively. After adjustment for baseline confounders, all-cause mortality (HR 0.95, 95% CI 0.88 to 1.01, p=0.114) and cardiac and cerebrovascular event-free survival (HR 0.93, 95% CI 0.86 to 1.01, p=0.071) did not differ significantly between VKA and DOAC groups. CONCLUSIONS This study supports evidence of the efficacy of DOAC use after TAVI in patients with an indication for oral anticoagulation.
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Affiliation(s)
- Christopher Hohmann
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Christian Frerker
- Department of Cardiology, Vascular Medicine and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andreas Beckmann
- Department of Cardiac Surgery, Heart Centre Duisburg, Evangelisches Krankenhaus Niederrhein, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Germany
| | - Thomas Walther
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Department of Cardiothoracic Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Sabine Bleiziffer
- Department of Cardiothoracic Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital SchleswigHolstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Moritz Seiffert
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jan-Malte Sinning
- Department of Cardiology, St. Vinzenz-Hospital Cologne, Cologne, Germany
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Andreas Böning
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Eva Herrmann
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Ümniye Balaban
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
- Department of Cardiothoracic Surgery, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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87
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Liang S, Guan M, Liu Z, Ruan X, Huang H, Zhong H. Sailing between scylla and charybdis-anticoagulation dilemma in a patient with calciphylaxis and mechanical cardiac valve replacement: a case report and literature review. Ren Fail 2023; 45:2264401. [PMID: 37799073 PMCID: PMC10561572 DOI: 10.1080/0886022x.2023.2264401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023] Open
Abstract
Calciphylaxis is a rare and life-threatening condition in patients with end-stage kidney disease (ESKD). In this case report, we reported a 72-year-old female who had undergone aortic and mitral mechanical valve replacement 22 years ago due to rheumatic aortic and mitral stenosis. Following the valve replacement, she initiated warfarin treatment. Five years ago, she received a diagnosis of uremia and has since been undergoing regular hemodialysis. Ten months prior to her current admission, she experienced excruciating pain and was diagnosed with calciphylaxis. Additionally, an electrocardiogram revealed atrial fibrillation, while echocardiography indicated that the aortic and mitral mechanical valves were appropriately positioned, with normal perivalvular surroundings and good valve leaflet activity. No noticeable thrombosis was observed in the left atrium or left atrial appendage. Color Doppler imaging showed moderate stenosis in the lower extremity arteries, with no venous thromboembolism present. Extensive eggshell-like calcification within the arterial media was detected. The patient was managed with regular hemodialysis, symptomatic treatments (including anticoagulation and analgesia), and sodium thiosulfate. Unfortunately, symptomatic management provided limited relief, and during the one-month follow-up period, the patient passed away due to septic shock. Currently, there is insufficient conclusive evidence regarding alternative influential anticoagulants or appropriate prosthetic valve selection. For individuals with ESKD receiving maintenance hemodialysis, early identification, diagnosis, and treatment of calciphylaxis are of paramount importance.
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Affiliation(s)
- Shichu Liang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Mingjing Guan
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaomiao Ruan
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - He Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Zhong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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Heuts S, Ceulemans A, Kuiper GJAJM, Schreiber JU, van Varik BJ, Olie RH, Ten Cate H, Maessen JG, Milojevic M, Maesen B. Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice. Eur J Cardiothorac Surg 2023; 64:ezad340. [PMID: 37812245 PMCID: PMC10585358 DOI: 10.1093/ejcts/ezad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. METHODS A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. RESULTS When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. CONCLUSIONS DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Angelique Ceulemans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Gerhardus J A J M Kuiper
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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Basu Roy P, Tejani VN, Dhillon SS, Damarlapally N, Winson T, Usman NUB, Panjiyar BK. Efficacy and Safety of Novel Oral Anticoagulants in Atrial Fibrillation: A Systematic Review. Cureus 2023; 15:e46385. [PMID: 37927673 PMCID: PMC10620341 DOI: 10.7759/cureus.46385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
In recent times, novel oral anticoagulants (NOACs)/direct oral anticoagulants (DOACs) have emerged as an alternative to the traditionally used Vitamin K oral antagonists (VKA) like warfarin for the treatment of atrial fibrillation (AF). This systematic review and meta-analysis aims to evaluate the efficacy and safety of NOACs in patients with AF and, thus, the related thromboembolic risks and sequelae. Of the 131 published articles we examined, 11 were included in an in-depth systematic review. The articles we reviewed were from the past ten years, from 2013 onward. The analysis derived the efficacy and safety of NOACs in patients with AF and also included different patients' baseline characteristics and subgroups. This systematic review reiterates previous research findings of superior efficacy and safety of the use of NOACs in the AF population and also illuminates certain head-to-head comparisons of individual NOACs with warfarin. It digressed into subgroups of patients with different baseline characteristics to provide evidence and support the existing guidelines for the use of NOACs in the treatment of AF. Overall, there is marked efficacy and safety of NOACs in patients with AF, be they elderly or Asian, with decreased renal function, or with other comorbidities. Adherence to NOACs was also satisfactory. Despite such a review, there needs to be more research on vast subgroups and also on reversal antidotes like andexanet alfa and idarucizumab, as well as more head-to-head analysis between NOACs over a long duration of study, which would provide more answers and pinpoint reasons as to the differences that exist between demographics and subgroups in the usage of NOACs.
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Affiliation(s)
- Prithvi Basu Roy
- Medicine, KPC (Kali Pradip Chaudhuri) Medical College and Hospital, Kolkata, West Bengal, India, Kolkata, IND
| | - Vitrag N Tejani
- Medicine, Parul Institute of Medical Sciences and Research, Vadodara, IND
| | - Sukhmeet S Dhillon
- Internal Medicine, Baba Farid University of Health Sciences, Faridkot, IND
| | - Nanush Damarlapally
- Health Sciences, Houston Community College - Coleman College for Health Sciences, Houston, USA
| | | | | | - Binay K Panjiyar
- Global Clinical Scholars Research Training, Harvard Medical School, Boston, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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90
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Marco-Rico A, Marco-Vera P. Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature. Semin Thromb Hemost 2023; 49:736-743. [PMID: 36996874 DOI: 10.1055/s-0043-1767728] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.
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Affiliation(s)
- Ana Marco-Rico
- Department of Thrombosis and Hemostasis, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
| | - Pascual Marco-Vera
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
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91
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Vedovati MC, Becattini C, Agnelli G. A new strategy for anticoagulation: The factor XI inhibitors. Eur J Intern Med 2023; 116:8-15. [PMID: 37544845 DOI: 10.1016/j.ejim.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Direct oral anticoagulants (DOACs) are currently the first-choice therapy for the prevention of cardioembolic events in patients with atrial fibrillation and for the treatment of venous thromboembolism (VTE) due to their more favorable efficacy to safety profile in comparison to vitamin K antagonists (VKA). DOACs did not show a clinical benefit when used for in stroke prevention in patients with mechanic or rheumatic valves or in those who underwent transcatheter aortic valve implantation (TAVI), in the treatment of VTE in patients with antiphospholipid antibody syndrome and in prevention of VTE in medically ill patients. There are some concerns for bleeding excess at the gastrointestinal site for some, but not all, DOACs. In recent years, in order to overcome the limitations of the available DOACs and to explore the advantages of anticoagulation in additional clinical settings, the development of factor XI and factor XII inhibitors as anticoagulant agents has been proposed. Emerging data show that factor XI has a minor role in the physiological process of hemostasis and an important role in the development of thrombosis. Bleeding has been viewed for several years as an unavoidable side effect of anticoagulant therapy. The aim of factor XI inhibitors is to challenge this dogma by favoring the uncoupling between hemostasis and thrombosis. This paper provides an update on the rationale for the use of factor XI inhibitors, their pharmacological properties and the preliminary clinical findings.
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Affiliation(s)
- Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy.
| | - Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy; Maugeri Scientific Clinical Institutes - IRCCS, Pavia, Italy
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92
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Carrel T, Vogt PR, Obrist D, Schaff H. Evolving technology: the TRIFLO tri-leaflet mechanical valve without oral anticoagulation: a potential major innovation in valve surgery. Front Cardiovasc Med 2023; 10:1220633. [PMID: 37840955 PMCID: PMC10570810 DOI: 10.3389/fcvm.2023.1220633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
The aortic valve is the most frequently diseased valve and aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. The diseased native aortic valve can be replaced by either a biological or mechanical valve prosthesis. The main concerns relate to durability, the need for oral anticoagulants and the incidence of complications related to this medication. Experimental, computational and biomolecular blood flow studies have demonstrated that the systolic forward flow but also the reverse flow phase at the end of the systole and leakage during the diastolic phase is mainly responsible for platelet activation and thrombosis. Better design of mechanical prosthetic heart valves must ensure smooth closing during flow deceleration and must eliminate high-shear hinge flow during diastole to prevent life-threatening thrombosis. A novel tri-leaflet valve should combine the favorable hemodynamics and the durability of existing mechanical heart valves and eliminate the less favorable characteristics, including the extremely rapid closing. In this paper, we discuss some issues of current mechanical heart valve prostheses and present a new valve design with the potential for significant innovation in the field. The TRIFLO Heart Valve, is a rigid, three-leaflet central flow heart valve prosthesis consisting of an alloyed titanium housing, and three rigid polymer (PEEK) cusps. This valve has a physiological operating mode. During the forward flow phase, the intraventricular pressure opens the leaflets so that blood can freely flow through with little obstruction, and with the deceleration of the blood flow, the leaflets close early and smoothly, minimizing blood flow regurgitation, blood cell damage, and activation of the coagulation cascade. Pre-clinical studies have shown pretty favorable results and a first-in-man study should start very soon.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Basel, Switzerland
| | | | - Dominique Obrist
- ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
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93
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Caus T, Chabry Y, Nader J, Fusellier JF, De Brux JL. Trends in SAVR with biological vs. mechanical valves in middle-aged patients: results from a French large multi-centric survey. Front Cardiovasc Med 2023; 10:1205770. [PMID: 37701140 PMCID: PMC10493300 DOI: 10.3389/fcvm.2023.1205770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/16/2023] [Indexed: 09/14/2023] Open
Abstract
Background/introduction Currently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure. Purpose To assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD. Methods Patients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age. Results We considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p < 0.001) while patients above 60 years-old received principally biological SAVR (p < 0.0001). Concerning patients between 50 and 60 years-old patients, MPVR was 1.04 (p = 0.03). Patients 50-60 years-old from the first and second study duration quartile (before August 2015) received preferentially mechanical SAVR (p < 0.001). We observed a shift towards more biological SAVR (p < 0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, simultaneous mitral valve replacement were more common in case of mechanical SAVR (p < 0.0001), while associated CABGs were more frequent in case of biological SAVR (p < 0.0001). Conclusion In a large contemporary French patient population, real world practice showed a recent shift towards a lower age-threshold for biological SAVR as compared to what would suggest contemporary guidelines.
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Affiliation(s)
- Thierry Caus
- Department of Cardiac Surgery University Hospital Amiens-Picardie, Amiens, France
- Laboratoire MP3CV-University Picarde Jules Vernes-UR7517, Amiens, France
| | - Yuthiline Chabry
- Laboratoire MP3CV-University Picarde Jules Vernes-UR7517, Amiens, France
- Department of Cardiac Surgery University Paris Diderot, Paris, France
| | - Joseph Nader
- Department of Thoracic and Cardiovascular Surgery, Clinique du Millénaire, Montpellier, France
| | | | - Jean Louis De Brux
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
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94
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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95
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Renda G. Direct oral anticoagulants in patients with bioprosthetic heart valves. Intern Emerg Med 2023; 18:1269-1272. [PMID: 37243834 DOI: 10.1007/s11739-023-03288-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/22/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Giulia Renda
- Institute of Cardiology, Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University Chieti-Pescara, Via L. Polacchi 11, 66100, Chieti, Italy.
- Cardiology Unit - SS. Annunziata Hospital, Via Dei Vestini 31, 66100, Chieti, Italy.
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96
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Mernissi T, Demagny J, Le Guyader M, Renou M, Choukroun G, Kamel S, Liabeuf S, Bodeau S. Quantitative determination of plasma free and total concentrations of antivitamin K drugs using a new sensitive and rapid LC-MS/MS method: Application in hemodialysis patients. Clin Chim Acta 2023; 548:117498. [PMID: 37482192 DOI: 10.1016/j.cca.2023.117498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND AND AIMS Vitamin K antagonists (VKAs) are the first-line anticoagulants used in end stage renal disease. This population experiences a significant variability in their International Normalized Ratio (INR) over time. There is a need for methods allowing the study of the pharmacokinetics of free and total concentrations of VKAs to explain INR variability. MATERIALS AND METHODS We developed and validated a high-performance liquid chromatography-tandem mass spectrometry method allowing the quantification of warfarin and fluindione free and total plasma concentrations. Chromatographic separation was achieved in a raptor biphenyl column and the spectrometry acquisition was set in multiple reaction monitoring mode after negative electrospray ionization. We then applied it in describing the plasma free and total concentrations of VKAs in samples from 50 hemodialysis patients. RESULTS The developed method is rapid, sensitive and specific. Our cohort results showed a correlation between free and total VKA concentrations. The free VKA concentrations tended to be higher in patients with higher INR. Although VKAs are highly albumin-bound drugs, albumin concentration did not totally explain the high inter-individual total VKA concentrations variability. CONCLUSION This opens the door to further studies to understand the factors involved in their variability.
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Affiliation(s)
- Touria Mernissi
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, F-80000 Amiens, France; Department of Clinical Pharmacology, Amiens University Medical Center, F-80000 Amiens, France
| | - Julien Demagny
- Department of Hematology, Amiens University Medical Center, F-80000 Amiens, France
| | - Mailys Le Guyader
- Department of Hematology, Amiens University Medical Center, F-80000 Amiens, France
| | - Marianne Renou
- Department of Nephrology, Dialysis and Transplantation, Amiens University Medical Center, F-80000 Amiens, France
| | - Gabriel Choukroun
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, F-80000 Amiens, France; Department of Nephrology, Dialysis and Transplantation, Amiens University Medical Center, F-80000 Amiens, France
| | - Saïd Kamel
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, F-80000 Amiens, France; Department of Biochemistry, Amiens University Medical Center, F-80000 Amiens, France
| | - Sophie Liabeuf
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, F-80000 Amiens, France; Department of Clinical Pharmacology, Amiens University Medical Center, F-80000 Amiens, France
| | - Sandra Bodeau
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, F-80000 Amiens, France; Department of Clinical Pharmacology, Amiens University Medical Center, F-80000 Amiens, France.
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97
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Langenaeken T, Vanoppen A, Janssens F, Tanghe L, Verbrugghe P, Rega F, Meuris B. DOACs in the Anticoagulation of Mechanical Valves: A Systematic Review and Future Perspectives. J Clin Med 2023; 12:4984. [PMID: 37568386 PMCID: PMC10419922 DOI: 10.3390/jcm12154984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Valvular heart disease is a common disease often necessitating valve replacement. Mechanical heart valves (MHVs) are often used in younger patients because of their longer durability. Their main disadvantage is the need for lifelong anticoagulation. Warfarin is considered a standard treatment, but it is far from perfect. Direct oral anticoagulants (DOACs) are a new and more patient-friendly alternative to warfarin when anticoagulation is required, but have not yet been approved for the indication of mechanical valves. EVIDENCE ACQUISITION A literature search of Pubmed, Embase, Web of Science (Core Collection), and Cochrane Library (from inception to May 2023) was performed using a search string that was well defined and not modified during the study. An extensive overview of the search terms used in each database can be found in the Appendix. Only prospective clinical trials were included in this review. A total of 10 publications were included in this review. RELEVANCE TO CLINICAL PRACTICE This systematic review summarizes the different types of DOACs and their possible use in the anticoagulation of mechanical valves. We aim to propose future directions in anticoagulation research for mechanical valves. CONCLUSIONS DOAC use in MHVs has been halted due to the failure of both dabigatran and apixaban in two major clinical trials. However, rivaroxaban was successful in two small clinical trials. Ample research is still needed to explore new valve designs as well as new anticoagulation targets.
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Affiliation(s)
- Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (B.M.)
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Abstract
Evidence for diagnosis and treatment of atrial fibrillation (AF) has expanded substantially since 2017, when In the Clinic last considered this subject. Direct oral anticoagulants have become the predominant therapy for thromboembolic disease, and antidotes for these drugs are now available. Device-based left atrial appendage occlusion is frequently used in patients who cannot tolerate systemic anticoagulation, and growing evidence suggests that early rhythm control improves outcomes. Catheter ablation is now frequently performed to prevent recurrent AF. Managing risk factors for AF, such as hypertension, diabetes, and obesity, remains paramount in prevention of this condition.
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99
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Chan N, Hirsh J. Unresolved issues in the use of direct acting oral anticoagulants. Expert Rev Cardiovasc Ther 2023; 21:913-921. [PMID: 37837206 DOI: 10.1080/14779072.2023.2271388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/12/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Currently approved direct oral anticoagulants (DOACs) target thrombin or coagulation factor Xa. Administered in fixed doses without routine laboratory monitoring, DOACs have simplified the approach to oral anticoagulation, when previously the choice was limited to vitamin K antagonists (VKAs). AREA COVERED We discuss a) unresolved issues related to optimal use of DOACs and b) new developments including the potential for FXIa inhibitors to be effective and safer anticoagulants. EXPERT OPINION By simplifying oral anticoagulation, DOACs have facilitated the uptake of anticoagulation. The DOACs are approved for stroke prevention in atrial fibrillation and for the prevention and treatment of venous thromboembolism, and their indications are expanding to include the prevention of atherothrombosis. DOACs have now replaced vitamin K antagonists (VKAs) for most indications, but not all. DOACs are inferior to VKAs for patients with mechanical heart valves, left ventricular assist device, rheumatic atrial fibrillation, and those with antiphospholipid syndrome, and their safety and efficacy are uncertain in some populations (e.g. advanced renal and liver disease). Impediments to use include concerns for bleeding and cost. The newly developed FXIa and FXIIa inhibitors have the potential to be safer than current anticoagulants, but phase 3 trials are needed to confirm their clinical efficacy and safety.
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Affiliation(s)
- Noel Chan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Raskob GE. Anticoagulant Therapy for Mechanical Heart Valves - Unmet Need Persists. NEJM EVIDENCE 2023; 2:EVIDe2300106. [PMID: 38320170 DOI: 10.1056/evide2300106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Direct oral anticoagulants such as apixaban or dabigatran have revolutionized anticoagulant treatment. These drugs, which specifically inhibit either factor Xa or thrombin, respectively, are at least as effective as vitamin K antagonists (e.g., warfarin) in patients with atrial fibrillation or venous thromboembolism and have important safety advantages that include reduced risks of intracranial hemorrhage, fatal bleeding, and all-cause mortality.1-3 They are also much easier to use because they are given in a fixed dose without routine laboratory monitoring of the anticoagulant effect and dose adjustment in the individual patient.
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Affiliation(s)
- Gary E Raskob
- University of Oklahoma Health Sciences Center, Oklahoma City
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