101
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Testa S, Palareti G, Legnani C, Dellanoce C, Cini M, Paoletti O, Ciampa A, Antonucci E, Poli D, Morandini R, Tala M, Chiarugi P, Santoro RC, Iannone AM, De Candia E, Pignatelli P, Faioni EM, Chistolini A, Esteban MDP, Marietta M, Tripodi A, Tosetto A. Thrombotic events associated with low baseline direct oral anticoagulant levels in atrial fibrillation: the MAS study. Blood Adv 2024; 8:1846-1856. [PMID: 38394387 PMCID: PMC11007438 DOI: 10.1182/bloodadvances.2023012408] [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: 12/14/2023] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
ABSTRACT Although effective and safe, treatment with direct oral anticoagulants (DOAC) in atrial fibrillation (AF) is still associated with thrombotic complications. Whether the measurement of DOAC levels may improve treatment efficacy is an open issue. We carried out the observational, prospective, multicenter Measure and See (MAS) study. Blood was collected 15 to 30 days after starting DOAC treatment in patients with AF who were followed-up for 1 year. Plasma samples were centralized for DOAC level measurement. Patients' DOAC levels were converted into drug/dosage standardized values to allow a pooled analysis in a time-dependent, competitive-risk model. The measured values were transformed into standardized values (representing the distance of each value from the overall mean) by subtracting the DOAC-specific mean value from the original values and dividing by the standard deviation. Trough and peak DOAC levels were assessed in 1657 and 1303 patients, respectively. In total, 21 thrombotic complications were recorded during 1606 years of follow-up (incidence of 1.31% of patients per year). Of 21 thrombotic events, 17 occurred in patients whose standardized activity levels were below the mean of each DOAC (0); the incidence was the highest (4.82% of patients per year) in patients whose standardized values were in the lowest class (-1.00 or less). Early measurement of DOAC levels in patients with AF allowed us to identify most of the patients who, having low baseline DOAC levels, subsequently developed thrombotic complications. Further studies are warranted to assess whether thrombotic complications may be reduced by measuring baseline DOAC levels and modifying treatment when indicated. This trial was registered at www.ClinicalTrials.gov as #NCT03803579.
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Affiliation(s)
- Sophie Testa
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | | | | | - Claudia Dellanoce
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Michela Cini
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Oriana Paoletti
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Antonio Ciampa
- Centro Emostasi, UOC Laboratorio Analisi, Ospedale S.G. Moscati, Avellino, Italy
| | | | - Daniela Poli
- Malattie Aterotrombotiche, AOU Careggi, Florence, Italy
| | - Rossella Morandini
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Maurizio Tala
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Paolo Chiarugi
- UO di Analisi chimico cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rita Carlotta Santoro
- Centro Emostasi e Trombosi, UO Emofilia e Patologie della Coagulazione, Dipartimento di Ematologia, Oncologia e Medicina Trasfusionale, Azienda Ospedaliero Universitaria Dulbecco, Catanzaro, Italy
| | | | - Erica De Candia
- UOSD Malattie Emorragiche e Trombotiche, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pasquale Pignatelli
- UOC Medicina Interna e Prevenzione dell’Aterosclerosi, Dipartimento di Medicina Interna e Specialità Mediche, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Elena Maria Faioni
- Servizio Immunologia e Medicina Trasfusionale, Ospedale San Paolo, ASST Santi Paolo e Carlo, Milan, Italy
| | - Antonio Chistolini
- UO Medicina Traslazionale e di Precisione, Dipartimento Medicina Interna e Specialità Mediche, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Maria del Pilar Esteban
- UO Laboratorio Analisi, Dipartimento dei Servizi Diagnostici, Ospedale Oglio Po, ASST Cremona, Cremona, Italy
| | - Marco Marietta
- Struttura Complessa di Ematologia, Policlinico di Modena, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Armando Tripodi
- Centro Emofila e Trombosi Angelo Bianchi Bonomi, presso la Fondazione IRCCS Ca’ Granda Ospedale Maggiore, Milan, Italy
| | - Alberto Tosetto
- UOC Ematologia, Centro Malattie Emorragiche e Trombotiche, AULSS 8 Berica Ospedale S. Bortolo, Vicenza, Italy
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102
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Wang X, Sin CF, Teo KC, Leung WCY, Wong YK, Liu RKC, Fok JW, Ip BY, Kwan HH, Lee TC, Sheng B, Yip EKK, Yap DYH, Luo H, Lau KK. Impact of renal function variability on long-term prognosis in ischemic stroke patients with atrial fibrillation. Front Neurol 2024; 15:1294022. [PMID: 38711560 PMCID: PMC11071668 DOI: 10.3389/fneur.2024.1294022] [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: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Background Although renal dysfunction is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) following stroke, the impact of renal function variability is unclear. Aim This study aimed to assess the association between renal function variability and various adverse clinical outcomes in patients with transient ischemic attack (TIA)/ischemic stroke and atrial fibrillation (AF). Methods We conducted a population-based study and retrospectively identified patients hospitalized with a diagnosis of TIA/ischemic stroke and AF during 2016-2020 using the Clinical Data Analysis and Reporting System of Hong Kong. Serial serum creatinine tested upon the onset of TIA/ischemic stroke and during their subsequent follow-up was collected. Renal function variability was calculated using the coefficient of variation of the estimated glomerular filtration rate (eGFR). Clinical endpoints that occurred during the study period were captured and included ischemic stroke/systemic embolism, intracerebral hemorrhage (ICH), total bleeding, major adverse cardiovascular events (MACE), cardiovascular, non-cardiovascular, and all-cause mortality. Competing risk regression and Cox proportional hazard regression models were used to assess the associations of renal function variability with the outcomes of interest. Results A total of 3,809 patients (mean age 80 ± 10 years, 43% men) who satisfied the inclusion and exclusion criteria were followed up for a mean of 2.5 ± 1.5 years (9,523 patient-years). The mean eGFR was 66 ± 22 mL/min/1.73 m2 at baseline, and the median number of renal function tests per patient during the follow-up period was 20 (interquartile range 11-35). After accounting for potential confounders, a greater eGFR variability was associated with increased risks of recurrent ischemic stroke/systemic embolism [fully adjusted subdistribution hazard ratio 1.11, 95% confidence interval (CI) 1.03-1.20], ICH (1.17, 1.01-1.36), total bleeding (1.13, 1.06-1.21), MACE (1.22, 1.15-1.30), cardiovascular (1.49, 1.32-1.69), non-cardiovascular (1.43, 1.35-1.52), and all-cause mortality (fully adjusted hazard ratio 1.44, 1.39-1.50). Conclusion Visit-to-visit renal function variability is independently associated with adverse clinical outcomes in TIA/ischemic stroke patients with AF. Further large-scale studies are needed to validate our results.
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Affiliation(s)
- Xiao Wang
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun-fung Sin
- Department of Pathology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kay-Cheong Teo
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - William C. Y. Leung
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuen-Kwun Wong
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Roxanna K. C. Liu
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Joshua W. Fok
- Department of Medicine, Yan Chai Hospital, Hong Kong, Hong Kong SAR, China
| | - Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hon Hang Kwan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Tsz Ching Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bun Sheng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Edwin Kin-Keung Yip
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hao Luo
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Computer Science, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kui-Kai Lau
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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103
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Yamashita T, Igawa Y, Fukuzawa M, Hayashi T, Hennig S, Okumura K. Pharmacokinetics of Edoxaban 15 mg in Very Elderly Patients with Nonvalvular Atrial Fibrillation: A Subanalysis of the ELDERCARE-AF Study. Thromb Haemost 2024. [PMID: 38641335 DOI: 10.1055/s-0044-1785511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND We evaluated the pharmacokinetics (PK) of low-dose (15 mg) edoxaban in very elderly patients (≥80 years) with nonvalvular atrial fibrillation (NVAF) and high bleeding risk. METHODS This subanalysis of the phase 3, randomized, double-blind, placebo-controlled, multicenter ELDERCARE-AF study evaluated edoxaban plasma concentrations and compared them with the Japanese population of the ENGAGE AF-TIMI 48 and Japanese severe renal impairment (SRI) studies. RESULTS The PK analysis population included 451 patients, 53.8% of whom concomitantly used antiplatelet drugs, 41.0% had SRI, and 38.0% had low body weight. Edoxaban plasma concentrations at trough and 1 to 3 hours post-dose in ELDERCARE-AF were 17.3 ± 13.9 (n = 427) and 93.3 ± 57.8 ng/mL (n = 447), respectively. These values were slightly higher than the 15 mg group in ENGAGE AF-TIMI 48 (n = 79; 12.4 ± 12.1 and n = 115; 78.7 ± 45.0 ng/mL, respectively), lower than the ENGAGE AF-TIMI 48 high-dose reduced to 30 mg group (n = 83; 25.1 ± 36.6 and n = 111; 150 ± 91.6 ng/mL, respectively), but similar to the Japanese SRI study (n = 39; 18.4 ± 11.2 and n = 40; 96.8 ± 48.3 ng/mL, respectively). ELDERCARE-AF patients with SRI and low body weight (≤45 kg) had higher concentrations than those without, and those taking antiplatelet drugs had lower concentrations than those who were not. CONCLUSION PK data support edoxaban 15 mg once daily for very elderly NVAF patients with high bleeding risk, with caution for patients with SRI and/or low body weight.
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Affiliation(s)
- Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Masayuki Fukuzawa
- Japan Business Unit, Primary Medical Science Department, Cardiovascular Group, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takuya Hayashi
- Data Analysis Group, Data Intelligence Department, Global DX, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
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104
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Sharma R, Hasan SS, Gilkar IA, Hussain WF, Conway BR, Ghori MU. Pharmacist-led interventions in optimising the use of oral anticoagulants in patients with atrial fibrillation in general practice in England: a retrospective observational study. BJGP Open 2024:BJGPO.2023.0113. [PMID: 38097269 DOI: 10.3399/bjgpo.2023.0113] [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: 07/10/2023] [Revised: 11/10/2023] [Accepted: 11/24/2023] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management. AIM To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF. DESIGN & SETTING A retrospective observational study in general practices in Bradford. METHOD The data were collected retrospectively from 1 November 2018-31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores. RESULTS Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients. CONCLUSION Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines.
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Affiliation(s)
- Raman Sharma
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | | | | | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Muhammad Usman Ghori
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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105
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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106
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Wegner FK, Eckardt L. Thromboembolic risk and oral anticoagulation in subclinical atrial fibrillation. Trends Cardiovasc Med 2024:S1050-1738(24)00032-X. [PMID: 38608971 DOI: 10.1016/j.tcm.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
Availability of devices capable of continuous rhythm monitoring such as smartwatches, implantable loop recorders, or pacemakers/defibrillators is continuously increasing. Importantly, device detected "subclinical" atrial fibrillation seems to convey a significantly lower risk of thromboembolism than "clinical" atrial fibrillation verified by a conventional ECG recording. While current guidelines indicate a possible role of oral anticoagulation in selected high-risk patients with subclinical AF, recent trials show an ambiguous risk/benefit relationship of anticoagulation in this setting. The present review therefore summarizes current data on the role of oral anticoagulation in subclinical AF, aims at aiding in the decision process of anticoagulation, and illustrates current gaps in evidence regarding subclinical AF.
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Affiliation(s)
- Felix K Wegner
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
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107
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Vanderstuyft E, Hias J, Hellemans L, Van Aelst L, Tournoy J, Van der Linden LR. Appropriateness of antithrombotics in geriatric inpatients with atrial fibrillation: a retrospective, cross-sectional study. Eur J Hosp Pharm 2024:ejhpharm-2023-004033. [PMID: 38580430 DOI: 10.1136/ejhpharm-2023-004033] [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: 11/02/2023] [Accepted: 03/19/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Atrial fibrillation occurs in nearly half of geriatric inpatients and is a major cause of morbidity and mortality. Suboptimal anticoagulation use is an important concern in this population. This study aimed to evaluate the appropriateness of antithrombotic therapies in this patient cohort. METHODS A retrospective analysis was conducted on the geriatric wards of a teaching hospital in Belgium, on a background of clinical pharmacy services. The first 90 atrial fibrillation patients from 2020 to 2022 were included if they received an oral anticoagulant. We assessed utilisation and appropriateness of antithrombotics at discharge, examined reasons for guideline deviations, and explored factors associated with underdosing. Temporal associations for appropriateness and type of anticoagulant (vitamin K antagonist (VKA) vs direct oral anticoagulant (DOAC)) were assessed. RESULTS The mean age of patients was 86.5 (±5.3) years and the median CHA2DS2-VASc score was 5 (interquartile range (IQR) 4-6). At discharge, 256 (94.8%) patients used a DOAC; nine (3.3%) used a VKA; one (0.4%) a DOAC-antiplatelet combination, and in four patients (1.5%) all antithrombotics were discontinued. The majority (64.4%) of patients received reduced DOAC doses with apixaban prescribed in 40.7%. In 39 (14.4%) patients, antithrombotic use was considered inappropriate, mostly without a rationale (23/39). Year 2022 (odds ratio (OR) 0.104; 95% confidence interval (CI), 0.012-0.878) was the sole determinant for underdosing. No significant differences were found with respect to appropriateness (p=0.533) or anticoagulant class (p=0.479) over time. CONCLUSION Most geriatric inpatients received a justified reduced DOAC dose. A significant proportion was managed inappropriately with underdosing (= unjustified reduced dose) being most common. Frequently no rationale was provided for deviating from trial-tested doses.
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Affiliation(s)
- Esther Vanderstuyft
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Julie Hias
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Laura Hellemans
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Lorenz Roger Van der Linden
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
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109
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Barilaite E, Watson H, Hocaoglu MB. Understanding Patient-Reported Outcome Measures Used in Adult Survivors Experiencing Long-Term Effects After COVID-19 Infection: A Rapid Review. J Patient Cent Res Rev 2024; 11:36-50. [PMID: 38596351 PMCID: PMC11000699 DOI: 10.17294/2330-0698.2041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Purpose Patient-reported outcome measures (PROMs) are used in individuals experiencing long-term effects from COVID-19 infection, or Long COVID, to evaluate the quality of life and functional status of these individuals. However, little is known about which PROMs are being utilised and the psychometric properties of these PROMs. Our purpose was thus to explore which PROMs are used in Long COVID patients and to discuss the psychometric properties of the PROMs. Methods For this rapid review, a systematic literature search was performed in the PubMed, Embase, and CINAHL databases. The found studies were screened using the PRISMA flowchart. We then performed study quality appraisal and assessed the psychometric properties of the found PROMs. Results Per the systematic literature search and after removal of duplicates, 157 publications were identified for individual screening. After screening and eligibility assessment, 74 articles were selected for our review. In total, 74 PROMs were used and primarily comprised quality of life, fatigue, breathlessness, mental health, and smell/taste issues in COVID "long haulers." Five studies used newly developed, COVID-19-specific PROMs. We assessed the psychometric properties of the 10 most-used PROMs. The majority were found to be reliable and valid instruments. EQ-5D-5L was the most popular and highly rated PROM. Conclusions We assessed PROMs used in Long COVID patients and evaluated their psychometric properties. EQ-5D-5L was the most favourably rated PROM. PROMs addressing mental health issues are crucial in managing anxiety and depression in Long COVID patients. New COVID-specific PROMs assess functional status and smell/taste perception and show great utilisation potential in olfactory training at COVID smell clinics. However, many reviewed PROMs currently lack sufficient analysis of their psychometric properties. Therefore, future research needs to examine these measures.
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Affiliation(s)
- Egle Barilaite
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, United Kingdom
| | - Harry Watson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, United Kingdom
| | - Mevhibe B Hocaoglu
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, United Kingdom
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Almegren M. Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Saudi Patients With Atrial Fibrillation. Cureus 2024; 16:e58886. [PMID: 38800246 PMCID: PMC11116736 DOI: 10.7759/cureus.58886] [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: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) significantly heightens stroke risk, which can be mitigated through anticoagulation therapy. Although warfarin was traditionally employed for this purpose, the use of direct-acting oral anticoagulants (DOACs) is on the rise. METHODS This retrospective study, which spanned from June 2016 to January 2018, focused on adult patients diagnosed with AF. Their treatments, either via warfarin or DOACs (apixaban, rivaroxaban, and dabigatran), were evaluated. Data analysis was done using Statistical Product and Service Solutions (SPSS, version 21; IBM SPSS Statistics for Windows, Armonk, NY). This study aims to evaluate the safety and effectiveness of DOACs versus warfarin in preventing thromboembolic complications among Saudi patients with AF. RESULTS A total of 396 patients with AF, averaging 66 ± 14 years of age, were part of the study. Among them, there were slightly more female patients (205 or 51.8%). The majority of patients (223 or 56.3%) were treated with a DOAC, while the rest (173 or 43.7%) received warfarin. Furthermore, 93 patients (23.5%) were taking anti-platelet drugs. Statistically, the rate of ischemic stroke was significantly higher among patients treated with DOACs than with warfarin (p=0.005), but bleeding rates were similar in both groups. Specifically, the DOACs apixaban and rivaroxaban showed a significant association with the occurrence of stroke when compared to warfarin (p=0.012 and p=007, respectively). CONCLUSION Overall, both DOACs and warfarin presented similar results regarding hemorrhagic complications when treating AF patients. However, the DOACs apixaban and rivaroxaban displayed higher risks of ischemic stroke compared to warfarin.
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Affiliation(s)
- Mosaad Almegren
- Department of Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
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111
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Sato Y, Yoshihisa A, Nozaki Y, Ohara H, Sugawara Y, Abe S, Misaka T, Sato T, Oikawa M, Kobayashi A, Yamaki T, Nakazato K, Takeishi Y. Geriatric Nutritional Risk Index predicts bleeding event in patients with heart failure. ESC Heart Fail 2024; 11:702-708. [PMID: 38115750 DOI: 10.1002/ehf2.14631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/10/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS We aimed to elucidate the association between malnutrition and the occurrence of bleeding events in patients with heart failure. METHODS AND RESULTS We evaluated the nutritional status of patients with heart failure [n = 2044, median (inter-quartile range) age 69.0 (59.0-78.0) years, 1209 (59.1%) males] using the Geriatric Nutritional Risk Index (GNRI). The primary endpoint was a composite of bleeding events such as haemorrhagic stroke or gastrointestinal bleeding. According to the survival classification and regression tree analysis, the accurate cut-off point of GNRI for predicting the primary endpoint was 106.2. We divided the patients into two groups based on GNRI levels: high GNRI group (GNRI ≥ 106.2, n = 606, 29.6%) and low GNRI group (GNRI < 106.2, n = 1438, 70.4%). We compared the patients' characteristics and prognosis between the two groups. The low GNRI group was older [72.0 (63.0-79.0) vs. 63.0 (53.0-73.0) years, P < 0.001] and had a lower prevalence of male sex (56.9% vs. 64.5%, P = 0.001). There were no differences in the use of antiplatelet agents and anticoagulants between the two groups. Levels of B-type natriuretic peptide were higher [321.1 (123.3-667.4) vs. 111.6 (42.6-235.4) pg/mL, P < 0.001] and levels of haemoglobin were lower [12.4 (10.8-13.7) vs. 14.2 (12.9-15.4) g/dL, P < 0.001] in the low GNRI group. The Kaplan-Meier analysis demonstrated that bleeding event rates were higher in the low GNRI group (log-rank P < 0.001). The multivariable Cox proportional hazard analysis revealed that low GNRI (hazard ratio 1.952, 95% confidence interval 1.002-3.805, P = 0.049) was associated with bleeding events. CONCLUSIONS Heart failure patients with poor nutritional status, determined by GNRI under 106.2, experienced high bleeding event rates. Comprehensive management is required to avoid bleeding event in those populations.
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Affiliation(s)
- Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Clinical Laboratory Sciences, Fukushima Medical University, Fukushima, Japan
| | - Yuji Nozaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Himika Ohara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yukiko Sugawara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Satoshi Abe
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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Stazi F. Management of atrial arrhythmias identified by cardiac devices. Eur Heart J Suppl 2024; 26:i123-i126. [PMID: 38867861 PMCID: PMC11167958 DOI: 10.1093/eurheartjsupp/suae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Implantable cardiac devices have shown that atrial fibrillation (AF) is more frequent than previously assumed, with subclinical, asymptomatic, self-limiting manifestations called atrial high-rate events (AHREs) or subclinical AF. The clinical significance and correct therapeutic management of these episodes of subclinical AF is less well defined than in the case of clinically manifest AF. Two important randomized studies on the topic have recently been published, NOAH-AFNET 6 and ARTESIA, which, however, have not definitively clarified the topic. In patients with AHRE or subclinical AF, the average thrombo-embolic risk is lower than that in patients with clinically manifest AF and is ∼1%. For this reason, in these patients, the possibility that the benefit of anticoagulant therapy is overshadowed by the risk of bleeding is very high. Therefore, while waiting for new tools that allow a better stratification of low-risk patients, we must rely on individual clinical evaluation and overcome the qualitative dichotomy (AHRE yes vs. AHRE no), preferring instead an approach that is as quantitative as possible and takes into account the number of episodes, their duration, and the patient's CHADSVASC score, before deciding, in each individual case, whether or not to use anticoagulant therapy.
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Affiliation(s)
- Filippo Stazi
- UOS Week Cardiology, UOC Cardiology, San Giovanni Addolorata Hospital, Rome
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113
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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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Yamazoe S, Imai H, Ogawa Y, Kano N, Murase Y, Mamiya K, Ikeda T, Hiramatsu K, Torii J, Kawaguchi K. The effect of off-label use of reduced-dose direct oral anticoagulants therapy in the treatment of pulmonary embolism comparable to standard-dose therapy. Heart Vessels 2024; 39:365-372. [PMID: 38381170 PMCID: PMC10920432 DOI: 10.1007/s00380-023-02339-5] [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] [Received: 04/04/2023] [Accepted: 11/08/2023] [Indexed: 02/22/2024]
Abstract
Direct oral anticoagulants (DOACs) have been shown to be effective and safe in preventing pulmonary embolism recurrence. In this single-center retrospective observational study, we aimed to evaluate the efficacy and safety of reduced-dose DOACs in 86 consecutive patients with acute pulmonary embolism. Patients were divided into standard-dose and reduced-dose DOACs groups. Initial clot volume did not significantly differ between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 18.8 [Q1-Q3 7.3-30.8] mL vs. 10.0 [Q1-Q3 3.2-27.9] mL, p = 0.1). Follow-up computed tomography (CT) within 30 days showed a higher rate of clot volume reduction or disappearance in the standard-dose group compared to the reduced-dose group (standard-dose DOACs vs. reduced-dose DOACs, 81.6% vs. 53.9%, p = 0.02). However, at the final follow-up CT, there was no significant difference in clot volume change between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 91.5% vs. 82.0%, p = 0.19). Major bleeding occurred in two patients in the standard-dose group (4.3%) and three patients in the reduced-dose DOACs group (7.7%) (p = 0.5). In conclusion, while standard-dose DOACs demonstrated superior efficacy in early clot reduction, reduced doses of apixaban and edoxaban showed comparable efficacy and safety profiles in long-term treatment of acute pulmonary embolism in certain patients.
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Affiliation(s)
- Shinji Yamazoe
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Hajime Imai
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan.
| | - Yasuhiro Ogawa
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Naoaki Kano
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Yosuke Murase
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Keita Mamiya
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Tomoyo Ikeda
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Kei Hiramatsu
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Jun Torii
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Katsuhiro Kawaguchi
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
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Kuryłowicz A, Babicki M, Wąsowski M, Jankowski P, Kapusta J, Chudzik M. Triglicerydes/high-density lipoprotein ratio as a risk factor of post-Covid-19 sinus tachycardia: A retrospective study. J Med Virol 2024; 96:e29586. [PMID: 38587173 DOI: 10.1002/jmv.29586] [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: 01/05/2024] [Revised: 02/14/2024] [Accepted: 03/24/2024] [Indexed: 04/09/2024]
Abstract
Inappropriate sinus tachycardia (IST) is one of the manifestations of the post-COVID-19 syndrome (PCS), which pathogenesis remains largely unknown. This study aimed to identify potential risk factors for IST in individuals with PCS. The 1349 patients with PCS were included into the study. Clinical examination, 24H Holter ECG, 24H ambulatory blood pressure monitoring and biochemical tests were performed 12-16 weeks after the COVID-19 in all participants. IST was found in 69 (3.5%) individuals. In the clinical assessment IST patients were characterized by a higher age (p < 0.001) and lower prevalence of the diagnosed hypertension (p = 0.012), compared to remaining patients. Biochemical testing showed higher serum triglycerides (1.66 vs. 1.31 pmol/L, p = 0.007) and higher prevalence of a low high-density lipoprotein (HDL) cholesterol (24.6% vs. 15.2%, p = 0.035) in the IST group. Subsequently, the triglicerydes (TG)/HDL ratio, an indicator of insulin resistance, was significantly higher in the IST individuals (3.2 vs. 2.4, p = 0.005). 24H monitoring revealed a significantly higher minimum diastolic, maximum systolic and mean arterial blood pressure values in the IST group (p < 0.001 for all), suggesting a high prevalence of undiagnosed hypertension. A multivariate analysis confirmed the predictive value TG/HDL ratio >3 (OR 2.67, p < 0.001) as predictors of IST development. A receiver operating characteristic curve analysis of the relationship between the TG/HDL ratio and the IST risk showed that the predictive cut-off point for this parameter was 2.46 (area under the ROC curve = 0.600, p = 0.004). Based on these findings, one can conclude that insulin resistance seems to be a risk factor of IST, a common component of PCS.
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Affiliation(s)
- Alina Kuryłowicz
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
- Department of Human Epigenetics, Mossakowski Medical Science Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Mateusz Babicki
- Department of Family Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Michał Wąsowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Joanna Kapusta
- Department of Internal Diseases, Rehabilitation and Physical Medicine, Medical University of Lodz, Lodz, Poland
| | - Michał Chudzik
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Lodz, Poland
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Wienhold J, Rayatdoost F, Schöchl H, Grottke O. Antidote vs. unspecific hemostatic agents for the management of direct oral anticoagulant-related bleeding in trauma. Curr Opin Anaesthesiol 2024; 37:101-109. [PMID: 38390922 DOI: 10.1097/aco.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The advent of direct oral anticoagulants (DOACs) marks a significant milestone in anticoagulant treatment. However, DOACs can exacerbate bleeding, which is challenging for the treating clinician, especially when combined with traumatic injury. RECENT FINDINGS In major bleeding associated with DOACs, rapid reversal of the anticoagulant effects is crucial. Recent observational and nonrandomized interventional trials have demonstrated the effectiveness of the specific antidotes andexanet alfa and idarucizumab as well as the unspecific prothrombin complex concentrates (PCCs) to counteract the anticoagulant effects of DOACs. The European Society of Anaesthesiology and Intensive Care guideline for severe perioperative bleeding and the European trauma guideline propose divergent recommendations for the use of andexanet alfa and PCC to obtain hemostasis in Factor Xa inhibitor-related bleeding. The conflicting recommendations are due to limited evidence from clinical studies and the potential increased risk of thromboembolic complications after the administration of andexanet. Regarding dabigatran-associated major bleeding, both guidelines recommend the specific reversal agent idarucizumab as first-line therapy. SUMMARY Current guidelines recommend specific antidots and PCCs in DOAC-related major bleeding. Prospective randomized trials comparing specific vs. nonspecific hemostatic agents in the perioperative setting are needed to evaluate the effectiveness and safety of the hemostatic agents.
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Affiliation(s)
- Jan Wienhold
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Farahnaz Rayatdoost
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
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Cadore NA, Lord VO, Recamonde-Mendoza M, Kowalski TW, Vianna FSL. Meta-analysis of Transcriptomic Data from Lung Autopsy and Cellular Models of SARS-CoV-2 Infection. Biochem Genet 2024; 62:892-914. [PMID: 37486510 DOI: 10.1007/s10528-023-10453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
Severe COVID-19 is a systemic disorder involving excessive inflammatory response, metabolic dysfunction, multi-organ damage, and several clinical features. Here, we performed a transcriptome meta-analysis investigating genes and molecular mechanisms related to COVID-19 severity and outcomes. First, transcriptomic data of cellular models of SARS-CoV-2 infection were compiled to understand the first response to the infection. Then, transcriptomic data from lung autopsies of patients deceased due to COVID-19 were compiled to analyze altered genes of damaged lung tissue. These analyses were followed by functional enrichment analyses and gene-phenotype association. A biological network was constructed using the disturbed genes in the lung autopsy meta-analysis. Central genes were defined considering closeness and betweenness centrality degrees. A sub-network phenotype-gene interaction analysis was performed. The meta-analysis of cellular models found genes mainly associated with cytokine signaling and other pathogen response pathways. The meta-analysis of lung autopsy tissue found genes associated with coagulopathy, lung fibrosis, multi-organ damage, and long COVID-19. Only genes DNAH9 and FAM216B were found perturbed in both meta-analyses. BLNK, FABP4, GRIA1, ATF3, TREM2, TPPP, TPPP3, FOS, ALB, JUNB, LMNA, ADRB2, PPARG, TNNC1, and EGR1 were identified as central elements among perturbed genes in lung autopsy and were found associated with several clinical features of severe COVID-19. Central elements were suggested as interesting targets to investigate the relation with features of COVID-19 severity, such as coagulopathy, lung fibrosis, and organ damage.
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Affiliation(s)
- Nathan Araujo Cadore
- Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Laboratory of Immunobiology and Immunogenetics, Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Vinicius Oliveira Lord
- Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Centro Universitário CESUCA, Cachoeirinha, Brazil
| | - Mariana Recamonde-Mendoza
- Bioinformatics Core, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Institute of Informatics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Thayne Woycinck Kowalski
- Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Post-Graduation Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Centro Universitário CESUCA, Cachoeirinha, Brazil
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Fernanda Sales Luiz Vianna
- Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.
- Laboratory of Immunobiology and Immunogenetics, Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Post-Graduation Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
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Kumano O, Suzuki S, Yamazaki M, An Y, Yasaka M, Ieko M. Age-related variation in coagulation factors in non-valvular atrial fibrillation patients receiving direct oral anticoagulants. Int J Hematol 2024; 119:407-415. [PMID: 38334914 DOI: 10.1007/s12185-024-03712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
Age is a significant risk factor for ischemic stroke. However, the influence of aging on coagulation parameters in non-valvular atrial fibrillation (NVAF) patients treated with direct oral anticoagulants (DOACs) remains unclear. A total of 775 samples were collected from 224 NVAF patients receiving apixaban, edoxaban or rivaroxaban. The samples were categorized into three age groups: (i) ≤ 64 years, (ii) 65-74 years, and (iii) ≥ 75 years (apixaban: N = 48, 108, 119; edoxaban: N = 63, 68, 126; rivaroxaban: N = 115, 90, 38, respectively). Coagulation parameters including fibrinogen (Fbg), factor II, factor V, factor VII, factor X, and D-dimer, were compared between the three age groups for each drug. The slopes in the correlation between drug concentrations and modified diluted prothrombin time (mdPT) were also assessed. Fbg and factor V increased with age, while factor II and factor X decreased. Factor VII and D-dimer showed no significant differences across age categories. The slope in response to drug concentrations was similar between the age groups. In NVAF patients treated with apixaban, edoxaban and rivaroxaban, some coagulation parameters exhibited age-related variation. However, the response of mdPT to drug concentration was consistent across age categories.
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Affiliation(s)
- Osamu Kumano
- Sysmex Corporation, Kobe, Japan
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Masako Yamazaki
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
- Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan.
- Department of Nursing, Sapporo University of Health Sciences, 1-15, Nakanuma Nishi-4-2, Higashi-ku, Sapporo, Hokkaido, 007-0894, Japan.
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119
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Araki T, Hayashi K, Sonoda Y, Honda T, Imamura Y, Koide Y, Hamada H, Nakao K. Dabigatran-induced esophagitis with full circumferential blue pigmentation. DEN OPEN 2024; 4:e271. [PMID: 37469668 PMCID: PMC10352591 DOI: 10.1002/deo2.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
Dabigatran is a useful and widely used drug for stroke prevention in patients with atrial fibrillation. However, it has been reported to cause esophagitis. Herein, we report the case of a 77-year-old man with dabigatran-induced esophagitis with blue pigmentation, which is known to be a rare adverse effect. The patient presented to our hospital with a tightness of the chest and anorexia. Computed tomography revealed a thickening of the entire esophageal wall, with an upper esophageal predominance. Esophagogastroduodenoscopy was performed, which showed that the cervical and upper thoracic esophagus had blue pigmentation with edematous changes, partial narrowing, and longitudinal sloping. We replaced dabigatran with edoxaban, a similar anticoagulation medication. The patient was closely monitored for 1 month after switching to edoxaban. The follow-up esophagogastroduodenoscopy showed marked improvements, revealing resolution of the bluish discoloration and edematous changes, and the patient's complaints regarding the tightness of the chest and anorexia were also resolved. It is important to recognize that such side effects can occur with dabigatran, a drug that is frequently used in daily practice. Considering the fact that strong edematous changes can cause indigo carmine pigmentation associated with dabigatran stagnation, we recommend switching to another anticoagulant if esophagitis occurs during dabigatran administration.
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Affiliation(s)
- Tomonori Araki
- Department of Gastroenterology and HepatologyGraduate School of Biomedical Sciences, Nagasaki UniversityNagasakiJapan
- Medical Education Development CenterNagasaki University HospitalNagasakiJapan
- Nagasaki Memorial HospitalNagasakiJapan
| | - Kohei Hayashi
- Department of Gastroenterology and HepatologyGraduate School of Biomedical Sciences, Nagasaki UniversityNagasakiJapan
| | - Yuki Sonoda
- Department of Gastroenterology and HepatologyGraduate School of Biomedical Sciences, Nagasaki UniversityNagasakiJapan
| | - Takuya Honda
- Department of Gastroenterology and HepatologyGraduate School of Biomedical Sciences, Nagasaki UniversityNagasakiJapan
| | - Yoshifumi Imamura
- Medical Education Development CenterNagasaki University HospitalNagasakiJapan
- Nagasaki Memorial HospitalNagasakiJapan
| | - Yuji Koide
- Medical Education Development CenterNagasaki University HospitalNagasakiJapan
- Nagasaki Memorial HospitalNagasakiJapan
| | - Hisayuki Hamada
- Medical Education Development CenterNagasaki University HospitalNagasakiJapan
| | - Kazuhiko Nakao
- Department of Gastroenterology and HepatologyGraduate School of Biomedical Sciences, Nagasaki UniversityNagasakiJapan
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Polo-García J, Pallares-Carratalá V, Turegano-Yedro M, Romero-Vigara JC, Prieto-Díaz MA, Cinza-Sanjurjo S. [Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. Semergen 2024; 50:102136. [PMID: 38052147 DOI: 10.1016/j.semerg.2023.102136] [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: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 12/07/2023]
Abstract
Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.
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Affiliation(s)
- J Polo-García
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - V Pallares-Carratalá
- Medicina Familiar y Comunitaria, Departamento de Medicina, Universidad JaimeI, Castellón, España.
| | - M Turegano-Yedro
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - J C Romero-Vigara
- Medicina Familiar y Comunitaria, Centro de Salud Alfajarín, Alfajarín, Zaragoza, España
| | - M A Prieto-Díaz
- Medicina Familiar y Comunitaria, Centro de Salud Vallobín-La Florida, Oviedo, España
| | - S Cinza-Sanjurjo
- Medicina Familiar y Comunitaria, Centro de Salud Milladoiro, Área de Salud de Santiago de Compostela. Instituto de Investigación en Salud de Santiago de Compostela (IDIS). Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, La Coruña, España
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121
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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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122
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Tittl L, Marten S, Naue C, Beyer-Westendorf J. Patterns of atrial fibrillation anticoagulation with rivaroxaban - 7-year follow-up from the Dresden NOAC registry. Thromb Res 2024; 236:61-67. [PMID: 38394987 DOI: 10.1016/j.thromres.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Data on long-term effectiveness and safety of rivaroxaban for stroke prevention in atrial fibrillation (SPAF) are scarce and not available from randomized clinical trials. METHODS We used data from the prospective, non-interventional DRESDEN NOAC REGISTRY to evaluate rates of stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and ISTH major bleeding, in general and changes of event patterns over time. RESULTS Between 1st October 2011 and 31st December 2022, 1204 SPAF patients receiving rivaroxaban were followed for 6.7 ± 3.4 years with a mean rivaroxaban exposure of 4.9 ± 3.5 years. During follow up, intention-to treat rates of stroke/TIA/SE were 3.5/100 pt. years (95 % CI 2.5-4.7) in the first year and fell to 1.6/100 pt. years (95 % CI 1.2-2.0) in years 2-5 and 2.1/100 pt. years (95 % CI 1.6-2.7) after 5 years. Similarly, on-treatment event rates fell from 2.4/100 pt. years (95 % CI 1.5-3.5) to 1.1 (95 % CI 0.7-1.5) and 1.6 (95 % CI 1.0-2.3), respectively. Major bleeding rates on treatment were 3.5/100 pt. years in the first treatment year (95 % CI 2.5-4.8) and 2.7 (95 % CI 2.2-3.4) and 3.5 (95 % CI 2.7-4.6) in the periods 2-5 and > 5 years, respectively. Of note, rates of fatal bleeding were low throughout follow-up (0.2 vs. 0.2 vs. 0.1/100 pt. years). CONCLUSIONS Our results demonstrate the long-term effectiveness and safety of rivaroxaban therapy in unselected SPAF patients in daily care. Our data indicate that patterns of cardiovascular events remain constant over many years. In contrast, bleeding patterns change over time, possibly due to effects of co-morbidities in an ageing population.
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Affiliation(s)
- Luise Tittl
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Sandra Marten
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Christiane Naue
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany.
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123
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Renda G, Bucciarelli V, Barbieri G, Lanuti P, Berteotti M, Malatesta G, Cesari F, Salvatore T, Giusti B, Gori AM, Marcucci R, De Caterina R. Ex Vivo Antiplatelet Effects of Oral Anticoagulants. J Cardiovasc Dev Dis 2024; 11:111. [PMID: 38667729 PMCID: PMC11049965 DOI: 10.3390/jcdd11040111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on platelet function is still unclear. We conducted a comprehensive ex vivo study aimed at assessing the effect of the four currently marketed NOACs on platelet function. METHODS We incubated blood samples from healthy donors with concentrations of NOACs (50, 150 and 250 ng/mL), in the range of those achieved in the plasma of patients during therapy. We evaluated generation of thrombin; light transmittance platelet aggregation (LTA) in response to adenosine diphosphate (ADP), thrombin receptor-activating peptide (TRAP), human γ-thrombin (THR) and tissue factor (TF); generation of thromboxane (TX)B2; and expression of protease-activated receptor (PAR)-1 and P-selectin on the platelet surface. RESULTS All NOACs concentration-dependently reduced thrombin generation compared with control. THR-induced LTA was suppressed by the addition of dabigatran at any concentration, while TF-induced LTA was reduced by factor-Xa inhibitors. ADP- and TRAP-induced LTA was not modified by NOACs. TXB2 generation was reduced by all NOACs, particularly at the highest concentrations. We found a concentration-dependent increase in PAR-1 expression after incubation with dabigatran, mainly at the highest concentrations, but not with FXa inhibitors; P-selectin expression was not changed by any drugs. CONCLUSIONS Treatment with the NOACs is associated with measurable ex vivo changes in platelet function, arguing for antiplatelet effects beyond the well-known anticoagulant activities of these drugs. There are differences, however, among the NOACs, especially between dabigatran and the FXa inhibitors.
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Affiliation(s)
- Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Valentina Bucciarelli
- Cardiovascular Sciences Department, Azienda Ospedaliero-Universitaria delle Marche, 60121 Ancona, Italy;
| | - Giulia Barbieri
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Paola Lanuti
- Department of Medicine and Aging Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Gelsomina Malatesta
- Cardiology Unit, National Institute of Health and Science on Aging (INRCA), 64125 Ancona, Italy;
| | - Francesca Cesari
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Tanya Salvatore
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Raffaele De Caterina
- Cardiology Division 1-Pisa University Hospital, University of Pisa, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, 37011 Città Sant’Angelo, Italy
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [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: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Poli D, Antonucci E, Ageno W, Berteotti M, Falanga A, Pengo V, Chiarugi P, Cosmi B, Paparo C, Chistolini A, Insana A, Lione D, Malcangi G, Martini G, Masciocco L, Pedrini S, Bucherini E, Pastori D, Pignatelli P, Toma A, Testa S, Palareti G. Inappropriate Underdosing of Direct Oral Anticoagulants in Atrial Fibrillation Patients: Results from the START2-AF Registry. J Clin Med 2024; 13:2009. [PMID: 38610775 PMCID: PMC11012240 DOI: 10.3390/jcm13072009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/12/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in non-valvular atrial fibrillation (NVAF) patients. We aimed to describe the prevalence of inappropriate DOACs dose prescription in the START2-AF Registry, the outcomes according to the appropriateness of the dosage, and the factors associated with inappropriate dose prescription. Methods: Patients' demographics and clinical data were prospectively collected as electronic files in an anonymous form on the website of the START2-Registry; DOACs dosage was determined to be appropriate when prescribed according to the European Heart Rhythm Association Guidelines. Results: We included 5943 NVAF patients on DOACs; 2572 (46.3%) were female patients. The standard dose (SD) was prescribed to 56.9% of patients and the low dose (LD) was prescribed to 43.1% of patients; 38.9% of all NVAF patients received an inappropriate LD DOAC and 0.3% received inappropriate SD. Patients treated with LD DOAC had a significantly higher rate of all bleedings (RR 1.5; 95% CI 1.2-2.0), major bleedings (RR 1.8; 95% CI 1.3-1.7), and mortality (RR 2.8; 95% CI 1.9-4.1) with respect to patients treated with SD DOAC. No difference was found among patients treated with appropriate and inappropriate LD regarding bleeding, thrombotic, and mortality rates. Age, body weight <60 kg, and renal failure were significantly associated with inappropriate LD DOAC prescription. Conclusions: Inappropriate LD DOACs in NVAF patients is not associated with a reduction in bleeding risk, nor with an increased thrombotic risk. Instead, it is associated with higher mortality rate, suggesting that, in clinical practice, underdosing is preferred for patients at particularly high risk for adverse events.
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Affiliation(s)
- Daniela Poli
- Center of Atherothrombotic Disease, Azienda Ospedaliero-Universitaria Careggi, 50134 Firenze, Italy;
| | - Emilia Antonucci
- Fondazione Arianna Anticoagulazione, 40138 Bologna, Italy; (E.A.); (G.P.)
| | - Walter Ageno
- SSD Degenza Breve Internistica, Dipartimento di Medicina Interna, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, 21100 Varese, Italy;
| | - Martina Berteotti
- Center of Atherothrombotic Disease, Azienda Ospedaliero-Universitaria Careggi, 50134 Firenze, Italy;
| | - Anna Falanga
- School of Medicine, Università di Milano Bicocca, 20126 Milano, Italy;
- Immunoematologia e Medicina Trasfusionale ASST Papa Giovanni XXIIIo, 24127 Bergamo, Italy
| | - Vittorio Pengo
- Dipartimento di Scienze Cardio-Toraco-Vascolari, AOU Padova, 35121 Padova, Italy;
| | - Paolo Chiarugi
- UO di Analisi Chimico Cliniche, Azienda Ospedaliero Universitaria Pisana, 56100 Pisa, Italy;
| | - Benilde Cosmi
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria S. Orsola-Malpighi Bologna, 40138 Bologna, Italy;
| | - Carmelo Paparo
- Laboratorio Analisi, Ospedale Maggiore, 10023 Chieri, Italy;
| | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione, Sapienza Università di Roma, 00185 Roma, Italy;
| | - Antonio Insana
- SC Laboratorio Analisi Chimico-Cliniche e Microbiologia, A.O. Ordine Mauriziano, 10128 Torino, Italy;
| | - Domenico Lione
- UOC di Patologia Clinica, Ospedale A Perrino, 72100 Brindisi, Italy;
| | - Giuseppe Malcangi
- U.O. Medicina Trasfusionale, Azienda Ospedaliero-Universitaria Policlinico di Bari, 70124 Bari, Italy;
| | - Giuliana Martini
- Centro Emostasi, Spedali Civili Di Brescia, 25123 Brescia, Italy;
| | | | - Simona Pedrini
- Servizio di Laboratorio, Istituto Ospedaliero Fondazione Poliambulanza, 25124 Brescia, Italy;
| | - Eugenio Bucherini
- Medicina Interna, Ambulatorio Emostasi Trombosi, Faenza (Ra) AUSL Romagna, 48018 Faenza, Italy;
| | - Daniele Pastori
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (D.P.); (P.P.)
| | - Pasquale Pignatelli
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (D.P.); (P.P.)
| | - Andrea Toma
- UOC di Patologia Clinica, Ambulatorio Terapia Anticoagulante Orale, O.C. “L. Cazzavillan”, 36071 Arzignano, Italy;
| | - Sophie Testa
- Haemostasis and Thrombosis Centre, Laboratory Medicine Department, ASST Cremona, 26100 Cremona, Italy;
| | - Gualtiero Palareti
- Fondazione Arianna Anticoagulazione, 40138 Bologna, Italy; (E.A.); (G.P.)
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Frydenlund J, Valentin JB, Norredam M, Frost L, Riahi S, Kragholm KH, Bøggild H, Lip GYH, Johnsen SP. Oral anticoagulation therapy initiation in patients with atrial fibrillation in relation to world region of origin: a register-based nationwide study. Open Heart 2024; 11:e002544. [PMID: 38553012 PMCID: PMC10982797 DOI: 10.1136/openhrt-2023-002544] [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: 10/27/2023] [Accepted: 02/29/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia and results in a high risk of stroke. The number of immigrants is increasing globally, but little is known about potential differences in AF care across migrant populations. AIM To investigate if initiation of oral anticoagulation therapy (OAC) differs for patients with incident AF in relation to country of origin. METHODS A nationwide register-based study covering 1999-2017. AF was defined as a first-time diagnosis of AF and a high risk of stroke. Stroke risk was defined according to guidelines from the European Society of Cardiology (ESC). Poisson regression adjusted for sex, age, socioeconomic position and comorbidity was made to compute incidence rate ratios (IRR) for initiation of OAC. RESULTS The AF population included 254 586 individuals of Danish origin, 6673 of Western origin and 3757 of non-Western origin. Overall, OAC was initiated within -30/+90 days relative to the AF diagnosis in 50.3% of individuals of Danish origin initiated OAC, 49.6% of Western origin and 44.5% of non-Western origin. Immigrants from non-Western countries had significantly lower adjusted IRR of initiating OAC according to all ESC guidelines compared with patients of Danish origin. The adjusted IRRs ranged from 0.73 (95% CI: 0.66 to 0.80) following the launch of the 2010 ESC guideline to 0.89 (95% CI: 0.82 to 0.97) following the launch of the 2001 ESC guideline. CONCLUSION Patients with AF with a high risk of stroke of non-Western origin have persistently experienced a lower chance of initiating OAC compared with patients of Danish origin during the last decades.
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Affiliation(s)
| | | | - Marie Norredam
- Section of Health Services Research Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Hvidovre University Hospital Copenhagen, Copenhagen, Denmark
| | - Lars Frost
- University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Henrik Bøggild
- Public Health and Epidemiology Department of Health Science and Technology, Aalborg University, Gistrup, Denmark
| | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Gistrup, Denmark
- Liverpool Heart & Chest Hospital, Liverpool, UK
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127
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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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128
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McIntyre WF, Benz AP, Becher N, Healey JS, Granger CB, Rivard L, Camm AJ, Goette A, Zapf A, Alings M, Connolly SJ, Kirchhof P, Lopes RD. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024; 149:981-988. [PMID: 37952187 DOI: 10.1161/circulationaha.123.067512] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear. METHODS We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212). RESULTS From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I2 statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I2=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I2=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I2=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence). CONCLUSIONS The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
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Affiliation(s)
- William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Alexander P Benz
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Jeffrey S Healey
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | | | | | - A John Camm
- St George's University of London and Imperial College London, United Kingdom (A.J.C.)
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz Hospital Paderborn, Germany (A.G.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (A.Z.)
| | | | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
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Isailă OM, Stoian VE, Fulga I, Piraianu AI, Hostiuc S. The Relationship between Subclinical Hypothyroidism and Carotid Intima-Media Thickness as a Potential Marker of Cardiovascular Risk: A Systematic Review and a Meta-Analysis. J Cardiovasc Dev Dis 2024; 11:98. [PMID: 38667716 PMCID: PMC11049994 DOI: 10.3390/jcdd11040098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/21/2024] [Accepted: 03/23/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Thyroid dysfunction is known to have significant consequences on the cardiovascular system. The correlation between carotid intima-media thickness (CIMT) and subclinical hypothyroidism (SCH) has been frequently evaluated in clinical studies in recent years. This study aimed to evaluate the significance of this association through a meta-analysis. METHODS We conducted a systematic search of PubMed, MedLine, Scopus, and Web of Science databases using the keywords 'subclinical hypothyroidism and carotid intima-media thickness', from the beginning of each database until January 2023. We established the inclusion and exclusion criteria and considered studies that met the inclusion criteria. We used Jamovi for statistical analysis of the data. RESULTS We identified 39 observational studies that met the inclusion criteria, with 3430 subjects: 1545 SCH and 1885 EU. Compared to euthyroid subjects (EU), subjects with subclinical hypothyroidism (SCH) had significantly increased carotid intima-media thickness (CIMT) values; the estimated average mean difference was 0.08 (95% CI 0.05 to 0.10), p < 0.01, I2 = 93.82%. After the sensitivity analysis, a total of 19 from the 39 abovementioned studies were analyzed, with most studies showing a positive association between SCH and thickening of the carotid wall; the estimated average mean difference was 0.04 (95% CI 0.02 to 0.07), p = 0.03, I2 = 77.7. In addition, female sex, advanced age, and high cholesterol levels statistically significantly influenced this association. CONCLUSIONS Our meta-analysis indicates a significant positive association between SCH and increased CIMT, but with some limitations.
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Affiliation(s)
- Oana-Maria Isailă
- Department of Legal Medicine and Bioethics, Faculty of Dentistry, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Victor Eduard Stoian
- Department of Legal Medicine, Legal Medicine Service Dâmbovița, 130083 Târgoviște, Romania
| | - Iuliu Fulga
- Department of Legal Medicine, Dunărea de Jos University, 800201 Galați, Romania (A.-I.P.)
| | - Alin-Ionut Piraianu
- Department of Legal Medicine, Dunărea de Jos University, 800201 Galați, Romania (A.-I.P.)
| | - Sorin Hostiuc
- Department of Legal Medicine and Bioethics, Faculty of Dentistry, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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130
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Al-Arkee S, Mason J, Haque MS, Alshehri A, Jalal Z. Pharmacist management of atrial fibrillation in UK primary care: a cross-sectional study. J Pharm Policy Pract 2024; 17:2321592. [PMID: 38516391 PMCID: PMC10956929 DOI: 10.1080/20523211.2024.2321592] [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] [Indexed: 03/23/2024] Open
Abstract
Background Atrial Fibrillation (AF) increases the risk of stroke by a factor of five, leading a significant cost burdens on healthcare system. Pharmacists, especially those based in a primary care environment are well placed to support patients in this therapeutic area. Objectives To assess primary care pharmacists' actual knowledge on the management of AF symptoms and anticoagulation. Furthermore, to investigate the resources used by pharmacists. Methods A cross-sectional study using survey was conducted, targeting UK-based registered pharmacists employed within primary care settings. Quantitative data were analysed utilising descriptive univariate and bivariate statistics. Results 349 pharmacists completed the adapted 19-questions of the pharmacists' knowledge. Out of a maximum of 19 points, the mean score was 14.34 ± 2.2 (75 ± 11.6%). The questionnaire revealed several significant gaps in pharmacists' knowledge. Most of the surveyed pharmacists (62.8%) reported that they used sources of information to support their consultations. Half reported that they used the National Institute for Health and Care Excellence (NICE) guidance (52.4%) and the British National Formulary (BNF) (50.7%). Conclusions Primary care pharmacists are knowledgeable about AF and its management; however, some gaps exist which may require addressing. Although pharmacists use a variety of information resources, it is the traditional resources that remain the most frequently used.
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Affiliation(s)
- Shahd Al-Arkee
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Julie Mason
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - M. Sayeed Haque
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Abdullah Alshehri
- Department of Clinical Pharmacy, Taif University, Taif, Saudi Arabia
| | - Zahraa Jalal
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
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Patel SM, Braunwald E, Steffel J, Boriani G, Palazzolo MG, Antman EM, Bohula EA, Carnicelli AP, Connolly SJ, Eikelboom JW, Gencer B, Granger CB, Morrow DA, Patel MR, Wallentin L, Ruff CT, Giugliano RP. Efficacy and Safety of Non-Vitamin-K Antagonist Oral Anticoagulants Versus Warfarin Across the Spectrum of Body Mass Index and Body Weight: An Individual Patient Data Meta-Analysis of 4 Randomized Clinical Trials of Patients With Atrial Fibrillation. Circulation 2024; 149:932-943. [PMID: 38264923 DOI: 10.1161/circulationaha.123.066279] [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: 10/30/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND The efficacy and safety of non-vitamin-K antagonist oral anticoagulants (NOACs) across the spectrum of body mass index (BMI) and body weight (BW) remain uncertain. METHODS We analyzed data from COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation), which pooled patient-level data from the 4 pivotal randomized trials of NOAC versus warfarin in patients with atrial fibrillation. The primary efficacy and safety outcomes were stroke or systemic embolic events (stroke/SEE) and major bleeding, respectively; secondary outcomes were ischemic stroke/SEE, intracranial hemorrhage, death, and the net clinical outcome (stroke/SEE, major bleeding, or death). Each outcome was examined across BMI and BW. Because few patients had a BMI <18.5 kg/m2 (n=598), the primary analyses were restricted to those with a BMI ≥18.5 kg/m2. RESULTS Among 58 464 patients, the median BMI was 28.3 (interquartile range, 25.2-32.2) kg/m2, and the median BW was 81.0 (interquartile range, 70.0-94.3) kg. The event probability of stroke/SEE was lower at a higher BMI irrespective of treatment, whereas the probability of major bleeding was lower at a higher BMI with warfarin but relatively unchanged across BMI with NOACs. NOACs reduced stroke/SEE overall (adjusted hazard ratio [HRadj], 0.80 [95% CI, 0.73-0.88]; P<0.001), with a generally consistent effect across BMI (Ptrend across HRs, 0.48). NOACs also reduced major bleeding overall (HRadj, 0.88 [95% CI, 0.82-0.94]; P<0.001), but with attenuation of the benefit at a higher BMI (trend test across BMI [Ptrend], 0.003). The overall treatment effects of NOACs versus warfarin for secondary outcomes were consistent across BMI, with the exception of the net clinical outcome and death. While these outcomes were overall reduced with NOACs (net clinical outcome, HRadj, 0.91 [95% CI, 0.87-0.95]; P<0.001; death, HRadj, 0.91 [95% CI, 0.86-0.97]; P=0.003), these benefits were attenuated at higher BMI (Ptrend, 0.001 and 0.08, respectively). All findings were qualitatively similar when analyzed across BW. CONCLUSIONS The treatment effect of NOACs versus warfarin in atrial fibrillation is generally consistent for stroke/SEE across the spectrum of BMI and BW, whereas the reduction in major bleeding is attenuated in those with higher BMI or BW. Death and the net clinical outcome are overall reduced with NOACs over warfarin, although there remain uncertainties for these outcomes at a very high BMI and BW.
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Affiliation(s)
- Siddharth M Patel
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Jan Steffel
- Hirslanden Clinic, Zurich, Switzerland and University of Zurich, Switzerland (J.S.)
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy (G.B.)
| | - Michael G Palazzolo
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Elliott M Antman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Erin A Bohula
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Anthony P Carnicelli
- Cardiology Division, Department of Internal Medicine, Medical University of South Carolina, Charleston (A.P.C.)
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, Canada (S.J.C., J.W.E.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada (S.J.C., J.W.E.)
| | - Baris Gencer
- Division of Cardiology, Geneva University Hospitals, Switzerland (B.G.)
- University of Bern Institute of Primary Health Care (BIHAM), Switzerland (B.G.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (C.B.G., M.R.P.)
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (C.B.G., M.R.P.)
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Sweden (L.W.)
| | - Christian T Ruff
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Robert P Giugliano
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
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Militaru M, Lighezan DF, Tudoran C, Militaru AG. Connections between Cognitive Impairment and Atrial Fibrillation in Patients with Diabetes Mellitus Type 2. Biomedicines 2024; 12:672. [PMID: 38540284 PMCID: PMC10967964 DOI: 10.3390/biomedicines12030672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/10/2024] [Accepted: 03/14/2024] [Indexed: 07/08/2024] Open
Abstract
(1) Background: Cognitive decline (CD), considered a precursory state of dementia, is frequently encountered in patients with diabetes mellitus type 2 (DM-2) and might even have a higher prevalence in those with associated atrial fibrillation (AF). In this study, we aimed to research if the association of DM-2 and AF favors a precocious onset of CD. (2) Methods: This study was conducted on 160 patients, featuring 50 with DM-2, 54 with DM-2 and AF, and 56 subjects without DM-2 and AF, all evaluated clinically and with five neuropsychiatric scales. (3) Results: The Mini-Mental-State-Examination (MMSE), Montreal Cognitive Assessment (MoCA), Activities of Daily Living Score (ADL), Instrumental Activities of Daily Living Score (IADL), and Geriatric Depression Scale (GDS-15) were significantly altered in patients with DM-2 and AF in comparison to patients without these diseases. The logistic regression model indicated that, in patients with DM-2 and AF, an increase of one year in age is associated with a 7.3% augmentation of the risk of a precocious onset of CD (MMSE < 27). (4) Conclusions: CD is more frequent in patients with DM-2, especially when associated with AF, versus those without DM-2 and AF. Our findings suggest that an older age and associated dyslipidemia represent risk factors for CD in patients with DM-2.
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Affiliation(s)
- Marius Militaru
- Department VIII, Neuroscience, Discipline of Neurology II, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania;
- Municipal Emergency Hospital Timisoara, Gheorghe Dima Street Nr. 5, 300254 Timisoara, Romania; (D.F.L.); (A.G.M.)
- Center of Advanced Research in Cardiology and Hemostasology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Daniel Florin Lighezan
- Municipal Emergency Hospital Timisoara, Gheorghe Dima Street Nr. 5, 300254 Timisoara, Romania; (D.F.L.); (A.G.M.)
- Center of Advanced Research in Cardiology and Hemostasology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Department V, Internal Medicine I, Discipline of Medical Semiology I, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Cristina Tudoran
- Department VII, Internal Medicine II, Discipline of Cardiology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Center of Molecular Research in Nephrology and Vascular Disease, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- County Emergency Hospital “Pius Brinzeu”, L. Rebreanu, Nr. 156, 300723 Timisoara, Romania
| | - Anda Gabriela Militaru
- Municipal Emergency Hospital Timisoara, Gheorghe Dima Street Nr. 5, 300254 Timisoara, Romania; (D.F.L.); (A.G.M.)
- Center of Advanced Research in Cardiology and Hemostasology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Department V, Internal Medicine I, Discipline of Medical Semiology I, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
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Tsai CT, Chan YH, Liao JN, Chen TJ, Lip GYH, Chen SA, Chao TF. The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery stenosis-a nationwide cohort study. BMC Med 2024; 22:113. [PMID: 38475752 DOI: 10.1186/s12916-024-03338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND In post-stroke atrial fibrillation (AF) patients who have indications for both oral anticoagulant (OAC) and antiplatelet agent (AP), e.g., those with carotid artery stenosis, there is debate over the best antithrombotic strategy. We aimed to compare the risks of ischemic stroke, composite of ischemic stroke/major bleeding and composite of ischemic stroke/intracranial hemorrhage (ICH) between different antithrombotic strategies. METHODS This study included post-stroke AF patients with and without extracranial artery stenosis (ECAS) (n = 6390 and 28,093, respectively) identified from the Taiwan National Health Insurance Research Database. Risks of clinical outcomes and net clinical benefit (NCB) with different antithrombotic strategies were compared to AP alone. RESULTS The risk of recurrent ischemic stroke was higher for patients with ECAS than those without (12.72%/yr versus 10.60/yr; adjusted hazard ratio [aHR] 1.104, 95% confidence interval [CI] 1.052-1.158, p < 0.001). For patients with ECAS, when compared to AP only, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy was associated with lower risks for ischaemic stroke (aHR 0.551, 95% CI 0.454-0.669), the composite of ischaemic stroke/major bleeding (aHR 0.626, 95% CI 0.529-0.741) and the composite of ischaemic stroke/ICH (aHR 0.577, 95% CI 0.478-0.697), with non-significant difference for major bleeding and ICH. When compared to AP only, warfarin monotherapy was associated with higher risks of major bleeding (aHR 1.521, 95% CI 1.231-1.880), ICH (aHR 2.045, 95% CI 1.329-3.148), and the composite of ischaemic stroke and major bleeding. With combination of AP plus warfarin, there was an increase in ischaemic stroke, major bleeding, and the composite outcomes, when compared to AP only. NOAC monotherapy was the only approach associated with a positive NCB, while all other options (warfarin, combination of AP-OAC) were associated with negative NCB. CONCLUSIONS For post-stroke AF patients with ECAS, NOAC monotherapy was associated with lower risks of adverse outcomes and a positive NCB. Combination of AP with NOAC or warfarin did not offer any benefit, but more bleeding especially with AP-warfarin combination therapy.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Movahedi Nia Z, Prescod C, Westin M, Perkins P, Goitom M, Fevrier K, Bawa S, Kong J. Cross-sectional study to assess the impact of the COVID-19 pandemic on healthcare services and clinical admissions using statistical analysis and discovering hotspots in three regions of the Greater Toronto Area. BMJ Open 2024; 14:e082114. [PMID: 38485179 PMCID: PMC10941105 DOI: 10.1136/bmjopen-2023-082114] [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: 11/24/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES The COVID-19 pandemic disrupted healthcare services, leading to the cancellation of non-urgent tests, screenings and procedures, a shift towards remote consultations, stalled childhood immunisations and clinic closures which had detrimental effects across the healthcare system. This study investigates the impact of the COVID-19 pandemic on clinical admissions and healthcare quality in the Peel, York and Toronto regions within the Greater Toronto Area (GTA). DESIGN In a cross-sectional study, the negative impact of the pandemic on various healthcare sectors, including preventive and primary care (PPC), the emergency department (ED), alternative level of care (ALC) and imaging, procedures and surgeries is investigated. Study questions include assessing impairments caused by the COVID-19 pandemic and discovering hotspots and critical subregions that require special attention to recover. The measuring technique involves comparing the number of cases during the COVID-19 pandemic with before that, and determining the difference in percentage. Statistical analyses (Mann-Whitney U test, analysis of variance, Dunn's test) is used to evaluate sector-specific changes and inter-relationships. SETTING This work uses primary data which were collected by the Black Creek Community Health Centre. The study population was from three regions of GTA, namely, the city of Toronto, York and Peel. For all health sectors, the sample size was large enough to have a statistical power of 0.95 to capture 1% variation in the number of cases during the COVID-19 pandemic compared with before that. RESULTS All sectors experienced a significant decline in patient volume during the pandemic. ALC admissions surged in some areas, while IPS patients faced delays. Surgery waitlists increased by an average of 9.75%, and completed IPS procedures decreased in several subregions. CONCLUSIONS The COVID-19 pandemic had a universally negative impact on healthcare sectors across various subregions. Identification of the hardest-hit subregions in each sector can assist health officials in crafting recovery policies.
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Affiliation(s)
- Zahra Movahedi Nia
- Africa-Canada Artificial Intelligence and Data Innovation Consortium (ACADIC), Department of Mathematics and Statistics, York University, Toronto, Ontario, Canada
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
| | - Cheryl Prescod
- Black Creek Community Health Centre, Toronto, Ontario, Canada
| | - Michelle Westin
- Black Creek Community Health Centre, Toronto, Ontario, Canada
| | - Patricia Perkins
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
- Faculty of Environment and Urban Change, York University, Toronto, Ontario, Canada
| | - Mary Goitom
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
- School of Social Work, York University, Toronto, Ontario, Canada
| | - Kesha Fevrier
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
- Department of Geography and Planning, Queen's University, Kingston, New York, Canada
| | - Sylvia Bawa
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
- Department of Sociology, York University, Toronto, Ontario, Canada
| | - Jude Kong
- Africa-Canada Artificial Intelligence and Data Innovation Consortium (ACADIC), Department of Mathematics and Statistics, York University, Toronto, Ontario, Canada
- Resilience Research Atlantic Alliance on Sustainability, Supporting Recovery and Renewal (REASURE2) Network, Toronto, Ontario, Canada
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Griffin M, Lip GY. Clinical trial evaluation: the EDOSURE clinical trial program. Future Cardiol 2024; 20:171-177. [PMID: 39049770 DOI: 10.1080/14796678.2024.2354079] [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: 09/11/2023] [Accepted: 05/08/2024] [Indexed: 07/27/2024] Open
Abstract
EDOSURE is a trial program of the direct oral anticoagulant drug edoxaban, comprising ten randomized clinical trials of which eight are currently published. They evaluate the use of edoxaban in the treatment of nonvalvular atrial fibrillation and acute venous thromboembolism, including in special circumstances such as patients undergoing cardiac procedures, cancer-associated venous thromboembolism, and elderly patients whose bleeding risk precludes conventional anticoagulation strategies. As a result of the collective evidence generated by EDOSURE, edoxaban is now recommended as a treatment option by numerous international guidelines. This review summarizes the context, rationale, and key findings of the studies.
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Affiliation(s)
- Michael Griffin
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University & Liverpool Heart & Chest Hospital, L14 3PE, Liverpool, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University & Liverpool Heart & Chest Hospital, L14 3PE, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9260, Aalborg, Denmark
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Choi JI, Kiatchoosakun S, Jiampo P, Tse HF, Soo YOY, Wang CC, Lee CH, Pecen L, Unverdorben M, De Caterina R, Kirchhof P. Prescribing Patterns and Outcomes of Edoxaban in Atrial Fibrillation Patients From Asia - One-Year Data From the Global ETNA-AF Program. Circ Rep 2024; 6:86-93. [PMID: 38464984 PMCID: PMC10920013 DOI: 10.1253/circrep.cr-23-0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 03/12/2024] Open
Abstract
Background: This study reports prescribing patterns and the 1-year effectiveness and safety of edoxaban in an Asian cohort of Edoxaban Treatment in routiNe clinical prActice (ETNA)-Atrial Fibrillation (AF) patients. Methods and Results: The Global ETNA-AF program integrates prospective, observational, noninterventional regional studies, collecting data on characteristics and clinical outcomes of patients with AF receiving edoxaban for stroke prevention. Baseline characteristics, medical history, and 1-year clinical event rates were assessed in patients from South Korea, Taiwan, Hong Kong, and Thailand. Clinically relevant events assessed at 12 months included all-cause death, cardiovascular death, ischemic and hemorrhagic stroke, systemic embolic events (SEEs), bleeding, and net clinical outcome (NCO). Overall, 3,359 patients treated with edoxaban 60 or 30 mg once daily completed 1-year follow-up; 70.9% of patients received recommended dosing according to local labels. Baseline mean±standard deviation age was 71.7±9.6 years, CHA2DS2-VASc score was 3.1±1.5, and modified HAS-BLED score was 2.3±1.1. Mean age and sex were similar across countries/regions. The 1-year event rate for all-cause death was 1.8%; major bleeding, 1.3%; ischemic stroke, 1.1%; cardiovascular mortality, 0.7%; hemorrhagic stroke, 0.3%; SEEs, 0%; and NCO, 4.1%; with differences observed between countries/regions and dosing groups. Conclusions: Most Asian patients with AF were prescribed recommended edoxaban dosing in routine care settings. At 1-year follow-up, this analysis supports the effectiveness and safety of edoxaban in these patients.
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Affiliation(s)
- Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center Seoul Republic of Korea
| | - Songsak Kiatchoosakun
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University Khon Kaen Thailand
| | - Panyapat Jiampo
- Department of Medicine, Bhumibol Adulyadej Hospital Bangkok Thailand
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong Hong Kong
| | - Yannie Oi Yan Soo
- Division of Neurology, Department of Medicine and Therapeutics, The Faculty of Medicine, The Chinese University of Hong Kong Hong Kong
| | - Chun-Chieh Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Linkou and Chang Gung University Taoyuan Taiwan
| | - Chang Hoon Lee
- Veterans Health Service Medical Center Seoul Republic of Korea
| | - Ladislav Pecen
- Institute of Computer Science of Academy of Sciences of the Czech Republic Prague Czech Republic
| | | | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham Birmingham UK
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Sciences (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
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Loucera C, Carmona R, Bostelmann G, Muñoyerro-Muñiz D, Villegas R, Gonzalez-Manzanares R, Dopazo J, Anguita M. Evidence of the association between increased use of direct oral anticoagulants and a reduction in the rate of atrial fibrillation-related stroke and major bleeding at the population level (2012-2019). Med Clin (Barc) 2024; 162:220-227. [PMID: 37989706 DOI: 10.1016/j.medcli.2023.10.008] [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: 08/07/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The introduction of direct-acting oral anticoagulants (DOACs) has shown to decrease atrial fibrillation (AF)-related stroke and bleeding rates in clinical studies, but there is no certain evidence about their effects at the population level. Our aim was to assess changes in AF-related stroke and major bleeding rates between 2012 and 2019 in Andalusia (Spain), and the association between DOACs use and events rates at the population level. METHODS All patients with an AF diagnosis from 2012 to 2019 were identified using the Andalusian Health Population Base, that provides clinical information on all Andalusian people. Annual ischemic and hemorrhagic stroke, major bleeding rates, and used antithrombotic treatments were determined. Marginal hazard ratios (HR) were calculated for each treatment. RESULTS A total of 95,085 patients with an AF diagnosis were identified. Mean age was 76.1±10.2 years (49.7% women). An increase in the use of DOACs was observed throughout the study period in both males and females (p<0.001). The annual rate of ischemic stroke decreased by one third, while that of hemorrhagic stroke and major bleeding decreased 2-3-fold from 2012 to 2019. Marginal HR was lower than 0.50 for DOACs compared to VKA for all ischemic or hemorrhagic events. CONCLUSIONS In this contemporary population-based study using clinical and administrative databases in Andalusia, a significant reduction in the incidence of AF-related ischemic and hemorrhagic stroke and major bleeding was observed between 2012 and 2019. The increased use of DOACs seems to be associated with this reduction.
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Affiliation(s)
- Carlos Loucera
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain
| | - Rosario Carmona
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), FPS, Hospital Virgen del Rocio, Sevilla, Spain
| | - Gerrit Bostelmann
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain
| | - Dolores Muñoyerro-Muñiz
- Subdirección Técnica Asesora de Gestión de la Información, Servicio Andaluz de Salud, Sevilla, Spain
| | - Román Villegas
- Subdirección Técnica Asesora de Gestión de la Información, Servicio Andaluz de Salud, Sevilla, Spain
| | - Rafael Gonzalez-Manzanares
- Department of Cardiology, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Joaquin Dopazo
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), FPS, Hospital Virgen del Rocio, Sevilla, Spain; FPS/ELIXIR-ES, Fundación Progreso y Salud (FPS), CDCA, Hospital Virgen del Rocio, Sevilla, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain.
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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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Østergaard L, Olesen JB, Petersen JK, Nielsen LS, Kristensen SL, Schou M, Køber L, Fosbøl E. Arterial Thromboembolism in Patients With Atrial Fibrillation and CHA 2DS 2-VASc Score 1: A Nationwide Study. Circulation 2024; 149:764-773. [PMID: 38152890 DOI: 10.1161/circulationaha.123.066477] [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: 08/08/2023] [Accepted: 12/01/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Oral anticoagulation is suggested in patients with atrial fibrillation and a CHA2DS2-VASc score ≥1 (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, and sex score). To assess granular differences within CHA2DS2-VASc 1, the incidence of arterial thromboembolism according to CHA2DS2-VASc 1 subgroups was examined. METHODS The Danish National Patient Registry and the Danish Prescription Registry were linked on a nationwide level to identify patients with atrial fibrillation from 2000 to 2021 without oral anticoagulation and categorized according to CHA2DS2-VASc score: CHA2DS2-VASc 0 (male and female subjects); CHA2DS2-VASc 1 (hypertension, heart failure, diabetes, vascular disease, and age 65-74 years); or CHA2DS2-VASc 2 (age ≥75 years without other risk factors). Female sex was not considered a risk factor in any risk group. The outcome was arterial thromboembolism (ischemic stroke, embolism of extremity, or transient cerebral ischemia). Study groups were compared using Cox regression analysis. RESULTS We included 26 701 patients with a CHA2DS2-VASc 0 score; 22 915 with CHA2DS2-VASc 1 (1483 patients with heart failure, 9066 with hypertension, 843 with diabetes, 770 with vascular disease, and 10 753 who were 65 to 74 years of age); and 14 525 patients with CHA2DS2-VASc 2 (≥75 years of age without other risk factors). With a median of 1 year of observation time, the cumulative incidence of arterial thromboembolism was 0.6% (n=154 [95% CI, 0.6%-0.8%]), 1.4% (n=16 [95% CI, 0.8%-2.2%]), 1.9% (n=141 [95% CI, 1.6%-2.2%]), 1.7% (n=12 [95% CI, 0.9%-2.9%]), 2.0% (n=13 [95% CI, 1.1%-3.4%]), 2.3% (n=187 [95% CI, 2.0%-2.7%]), and 4.4% (n=533 [95% CI, 4.1%-4.8%]) for CHA2DS2-VASc 0, heart failure, hypertension, diabetes, vascular disease, age 65 to 74 years (CHA2DS2-VASc 1), and age ≥75 years (CHA2DS2-VASc 2), respectively. No statistically significant difference was identified among subgroups of CHA2DS2-VASc 1 (P=0.15 for difference). CONCLUSIONS For patients with atrial fibrillation, all subgroups of CHA2DS2-VASc 1 were associated with lower incidence of arterial thromboembolism compared with age ≥75 years without other risk factors (ie, CHA2DS2-VASc 2) and a higher incidence compared with CHA2DS2-VASc 0. No statistically significant difference was identified between the subgroups of CHA2DS2-VASc 1. These findings support current recommendations that patients within this intermediate risk group could be identified with a similar risk of arterial thromboembolism.
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Affiliation(s)
- Lauge Østergaard
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev-Gentofte Hospital (J.B.O., M.S.), University of Copenhagen, Denmark
| | - Jeppe Kofoed Petersen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Lukas Schak Nielsen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Søren Lund Kristensen
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital (J.B.O., M.S.), University of Copenhagen, Denmark
| | - Lars Køber
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
| | - Emil Fosbøl
- The Heart Center, Rigshospitalet (L.Ø., J.K.P., L.S.N., S.L.K., L.K., E.F.), University of Copenhagen, Denmark
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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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141
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Shafer DH, Robles EL, Linsley CM, Lamb AN. Osteochondroma of the superomedial scapula managed with a novel muscle sparing approach: case report and review of literature. J Surg Case Rep 2024; 2024:rjae154. [PMID: 38495051 PMCID: PMC10942809 DOI: 10.1093/jscr/rjae154] [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: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Osteochondromas are a common type of benign primary bone tumor rarely occurring in the scapula. When it is symptomatic, surgical removal is recommended. There are multiple approaches for surgical excision that can be used depending on the location and size of the tumor. We present a case of a 14-year-old female who was seen in the orthopedic clinic with right shoulder pain, mechanical symptoms and medial scapular winging due to a superomedial osteochondroma of the scapula. A novel superior approach to the superomedial ventral surface of the scapula was utilized to excise the tumor with good clinical results.
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Affiliation(s)
- Dylan H Shafer
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St, Ventura, CA 93003, United States
| | - Emilio L Robles
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St, Ventura, CA 93003, United States
| | - Catherine M Linsley
- Department of College of Osteopathic Medicine, Lake Erie College, 1858 W. Grandview Blvd, Erie, PA 16509, United States
| | - Ashley N Lamb
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St, Ventura, CA 93003, United States
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Elshafei MN, El-Bardissy A, Salem M, Abdelmoneim MS, Khalil A, Elhadad S, Danjuma M. Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2024; 24:255-271. [PMID: 38386247 PMCID: PMC10973089 DOI: 10.1007/s40256-024-00628-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION oral anticoagulant (DOAC) agents are becoming the anticoagulation strategy of choice for most clinical risks for which they are indicated. However, residual uncertainty remains regarding their use in preventing stroke in patients with low bodyweight [< 60 kg or body mass index (BMI) < 18 kg/m2]. We have carried out pooled systematic analyses of published studies to determine the efficacy and safety of these agents compared with warfarin in stroke prevention in patients with low bodyweight. METHODS We carried out a comprehensive search of electronic databases from inception to June 2023 for eligible studies reporting on the efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. These include PubMed, EMBASE, the Cochrane Database of Systematic Reviews, the Science Citation Index, and the Database of Abstracts of Reviews of Effectiveness. Using the random effects model, derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes in patient cohorts exposed to direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. RESULTS Nine studies (n = 159,514 patients) were included in our meta-analysis. DOAC analogs were associated with lower stroke recurrence compared with warfarin [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.49-0.9]; however, there was no significant difference in the composite outcome (OR 0.81, 95% CI 0.59-1.09) and mortality (OR 0.82, 95% CI 0.48-1.41). Additionally, DOAC analogs showed a significant reduction in major bleeding events by 30% compared with warfarin (OR 0.70, 95% CI 0.62-0.80). CONCLUSION In this pooled meta-analytical synthesis of studies comprising both real-world and randomized controlled data, the use of DOAC analogs in patients with atrial fibrillation and low bodyweight (< 60 kg or BMI < 18 kg/m2) was associated with a significant reduction in risks of stroke and major bleeding compared with patient cohorts stabilized on warfarin-based therapy. There was uncertainty regarding the composite outcome and mortality point estimate between these two anticoagulation strategies. This finding helps to resolve the uncertainty associated with the use of DOACs in this cohort. Additionally, it suggests the need for confirmatory non-inferiority randomized controlled trials evaluating DOACs versus warfarin in this cohort of patients.
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Affiliation(s)
- Mohamed Nabil Elshafei
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar.
- Department of Pharmacy, Hamad Medical Corporation (HMC), P.O.3050, Doha, Qatar.
| | - Ahmed El-Bardissy
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Salem
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Khalil
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammed Danjuma
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
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143
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de Lucena LA, Freitas MAA, Souza AKC, Silva CHA, Watanabe JMF, Guedes FL, Almeida JB, de Oliveira RA. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and stage 5 chronic kidney disease under dialysis: A systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2024; 57:381-389. [PMID: 38281231 DOI: 10.1007/s11239-023-02945-0] [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: 12/29/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) and normal or slightly impaired renal function, the use of direct oral anticoagulants (DOACs) is preferable to vitamin K antagonists (VKAs). However, in patients undergoing hemodialysis, the efficacy, and safety of DOACs compared with VKAs are still unknown. PURPOSE To review current evidence about the safety and efficacy of DOACs compared to VKAs, in patients with AF and chronic kidney disease under hemodialysis. METHODS We systematically searched PubMed, Scopus, and Cochrane databases for RCTs comparing DOACs with VKAs for anticoagulation in patients with AF on dialysis therapy. Outcomes of interest were: (1) stroke; (2) major bleeding; (3) cardiovascular mortality; and (4) all-cause mortality. Statistical analysis was performed using RevMan 5.1.7 and heterogeneity was assessed by I2 statistics. RESULTS Three randomized controlled trials were included, comprising a total of 383 patients. Of these, 218 received DOACs (130 received apixaban; 88 received rivaroxaban), and 165 were treated with VKAs (116 received warfarin; 49 received phenprocoumon). The incidence of stroke was significantly lower in patients treated with DOACs (4.7%) compared with those using VKAs (9.5%) (RR 0.42; 95% CI 0.18-0.97; p = 0.04; I2 = 0%). However, the difference was not statistically significant in the case of ischemic stroke specifically (RR 0.42; 95% CI 0.17-1.04; p = 0.06; I2 = 0%). As for the major bleeding outcome, the DOAC group (11%) had fewer events than the VKA group (13.9%) but without statistical significance (RR 0.75; 95% CI 0.45-1.28; p = 0.29; I2 = 0%). There was no significant difference between groups regarding cardiovascular mortality (RR 1.23; 95% CI 0.66-2.29; p = 0.52; I2 = 13%) and all-cause mortality (RR 0.98; 95% CI 0.77-1.24; p = 0.84; I2 = 16%). CONCLUSION This meta-analysis suggests that in patients with AF on dialysis, the use of DOACs was associated with a significant reduction in stroke, and a numerical trend of less incidence of major bleeding compared with VKAs, but in this case with no statistical significance. Results may be limited by a small sample size or insufficient statistical power.
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Affiliation(s)
- Larissa A de Lucena
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Marcos A A Freitas
- Department of Medicine, State University of Região Tocantina do Maranhão, Department of Medicine, Imperatriz, Brazil
| | - Ana K C Souza
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Caroliny H A Silva
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Felipe L Guedes
- Division of Nephrology, University Hospital Onofre Lopes, Natal, Brazil
| | - Jose B Almeida
- Department of Integrated Medicine, Federal University of Rio Grande do Norte, Nilo Peçanha Avenue, 620, 3rd underground - Petroópolis, Natal, 59012-300, Brazil
| | - Rodrigo A de Oliveira
- Department of Integrated Medicine, Federal University of Rio Grande do Norte, Nilo Peçanha Avenue, 620, 3rd underground - Petroópolis, Natal, 59012-300, Brazil.
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144
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Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Department of General Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Shinichi Goto
- Department of Medicine (Cardiology), Department of General Medicine, Tokai University School of Medicine, Isehara, Japan
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145
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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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146
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Cemin R, Cappato R. Lessons derived from post authorisation safety studies (ETNA-AF and XANTUS) on once daily direct oral anticoagulants for atrial fibrillation. Int J Cardiol 2024; 398:131618. [PMID: 38030040 DOI: 10.1016/j.ijcard.2023.131618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/19/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Phase III trials should be integrated by post authorisation safety studies (PASS) to confirm their conclusions in real life. In this setting, comorbidities are commonly more prevalent, decisions about drugs and regimens are left to the attending physicians and therapy monitoring is not usually as strict as in pivotal trials. AIMS AND METHODS To evaluate real life safety and effectiveness of edoxaban and rivaroxaban, ETNA-AF Europe (ETNA-AF-Eu) and XANTUS studies were reviewed and compared. A further comparison between data collected in these studies and in the pivotal studies ENGAGE AF-TIMI 48 and ROCKET-AF was also performed. RESULTS ETNA-AF-Eu and XANTUS showed lower bleeding, stroke, cardiovascular- and all-cause mortality rates as compared to those observed in Phase 3 trials, even when including subgroups with lower comorbidities. Patients in ETNA-AF-Eu were older, with a larger proportion of octogenarians (≥85 years in 10.5%) and patients with impaired renal function as compared to patients in XANTUS (CrCl <50 ml/min in 18.2% vs 12.2%) and in ENGAGE AF-TIMI 48 and ROCKET-AF, without paying any excess tribute in terms of safety. Therapy persistence was very high in the two real life studies (91.9% in ETNA-AF-Eu and 79.9% in XANTUS), thus showing that edoxaban and rivaroxaban are well tolerated in real life. CONCLUSION The ETNA-AF-Eu and XANTUS confirmed the safety and effectiveness of edoxaban and rivaroxaban in real life.
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Affiliation(s)
- Roberto Cemin
- Department of Cardiology, San Maurizio Regional Hospital of Bolzano, Bolzano, Italy.
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
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147
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Toribio-Fernandez R, Ceron C, Tristão-Pereira C, Fernandez-Nueda I, Perez-Castillo A, Fernandez-Ferro J, Moro MA, Ibañez B, Fuster V, Cortes-Canteli M. Oral anticoagulants: A plausible new treatment for Alzheimer's disease? Br J Pharmacol 2024; 181:760-776. [PMID: 36633908 DOI: 10.1111/bph.16032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/02/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Alzheimer's disease (AD) and cardiovascular disease (CVD) are strongly associated. Both are multifactorial disorders with long asymptomatic phases and similar risk factors. Indeed, CVD signatures such as cerebral microbleeds, micro-infarcts, atherosclerosis, cerebral amyloid angiopathy and a procoagulant state are highly associated with AD. However, AD and CVD co-development and the molecular mechanisms underlying such associations are not understood. Here, we review the evidence regarding the vascular component of AD and clinical studies using anticoagulants that specifically evaluated the development of AD and other dementias. Most studies reported a markedly decreased incidence of composite dementia in anticoagulated patients with atrial fibrillation, with the highest benefit for direct oral anticoagulants. However, sub-analyses by differential dementia diagnosis were scarce and inconclusive. We finally discuss whether anticoagulation could be a plausible preventive/therapeutic approach for AD and, if so, which would be the best drug and strategy to maximize clinical benefit and minimize potential risks. LINKED ARTICLES: This article is part of a themed issue From Alzheimer's Disease to Vascular Dementia: Different Roads Leading to Cognitive Decline. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.6/issuetoc.
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Affiliation(s)
- Raquel Toribio-Fernandez
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Carlos Ceron
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | | | - Irene Fernandez-Nueda
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Ana Perez-Castillo
- Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Instituto de Investigaciones Biomédicas "Alberto Sols" (CSIC-UAM), Madrid, Spain
| | - Jose Fernandez-Ferro
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Stroke Unit, Neurology Service, Hospital Universitario Rey Juan Carlos (HURJC), Madrid, Spain
| | - Maria Angeles Moro
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Borja Ibañez
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- CIBER de enfermedades cardiovasculares (CIBERCV), ISCIII, Madrid, Spain
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marta Cortes-Canteli
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Zhao S, Dai H, Chen J, Ni M, Peng W, Li X, Li F, Chen B, Cai H, Liu Y, Gu Z, Du S, Ma P. Prevalence, contemporary trends and associated factors of potentially inappropriate prescription of edoxaban in real-world clinical practice: A subanalysis of the SUNSHINE registry. Br J Clin Pharmacol 2024; 90:837-848. [PMID: 37949652 DOI: 10.1111/bcp.15961] [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: 08/08/2023] [Revised: 10/19/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
AIM As the direct oral anticoagulant most recently approved in China, data pertaining to clinical edoxaban use are still scarce. This study investigated the prevalence of and contemporary trends in edoxaban prescription among Chinese patients as well as factors associated with its inappropriate use in a multicentre registry of patients treated in real-world clinical practice. METHODS This real-world, prospective, multicentre and non-interventional study included 1005 inpatients treated with edoxaban. According to National Medical Products Administration and European Heart Rhythm Association guidelines, edoxaban therapy was determined to be appropriate or inappropriate in each case. RESULTS The median patient age was 70.0 years (interquartile range 61.0-78.0 years) and 46.3% were women. Overall, 456 (45.4%) patients received inappropriate edoxaban therapy, and common issues included an inappropriately low dosage (183, 18.2%) or wrong drug selection (109, 10.8%), high dosage (73, 7.3%), unreasonable off-label use (49, 4.9%), contraindicated medication combinations (27, 2.7%) and incorrect administration timing (16, 1.6%). Several factors, such as age ≥75 years (odds ratio [OR] = 1.921, 95% confidence interval [CI] 1.355-2.723, P < 0.001), weight >60 kg (OR = 2.657, 95%CI 1.970-3.583, P < 0.001), severe renal insufficiency (OR = 1.988, 95% CI 1.043-3.790, P = 0.037), current anaemia (OR = 1.556, 95% CI 1.151-2.102, P = 0.004) and history of bleeding (OR = 2.931, 95% CI 1.605-5.351, P < 0.001) were associated with an increased risk of inappropriate edoxaban therapy, whereas factors associated with cardiovascular specialties, such as admission to a cardiovascular department (OR = 0.637, 95% CI 0.464-0.873, P = 0.005), dronedarone use (OR = 0.065, 95% CI 0.026-0.165, P < 0.001) and amiodarone use (OR = 0.365, 95% CI 0.209-0.637, P < 0.001) decreased this risk. CONCLUSION In this real-world study, 45.4% of patients received an inappropriate treatment with edoxaban. Multiple clinical characteristics can help identify patients who should receive edoxaban. Further development and implantation of educational activities and management strategies are needed to ensure the correct use of edoxaban.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Jiaxin Chen
- Department of Pharmacy, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
| | - Ming Ni
- Department of Clinical Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Wenxing Peng
- Department of Pharmacy, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
- Department of Pharmacy, Central's Hospital of Xinxiang, Xinxiang, China
| | - Fen Li
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
- Department of Pharmacy, The First People's Hospital of Xinxiang, Xinxiang, China
| | - Boya Chen
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Yinping Liu
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Zhichun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Du
- Department of Cardiovascular Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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149
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Harbison J, McCormack J, Brych O, Collins R, O'Connell N, Randles M, Kennedy C, Kelly PJ, Cassidy T. Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013-2021. Int J Stroke 2024; 19:342-347. [PMID: 37771031 DOI: 10.1177/17474930231206680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis. METHODS AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice were assessed. RESULTS AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and 56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total IS due to AF decreased by 15.3% (31.3%-26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes over time (r = -0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14, p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = -0.83, p = 0.006) and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = -0.89, p = 0.001). CONCLUSION DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.
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Affiliation(s)
- Joseph Harbison
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Joan McCormack
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Olga Brych
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Ronan Collins
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Niamh O'Connell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Mary Randles
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Cormac Kennedy
- Department of Pharmacology & Therapeutics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Peter J Kelly
- Department of Neurology, University College Dublin, Dublin, Ireland
- Institute of Neurology, The Mater Hospital, Dublin, Ireland
| | - Tim Cassidy
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Acute Stroke Service, St. Vincent's University Hospital, Dublin, Ireland
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150
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Lee M, Lee BC, Yu KH, Oh MS, Kim BJ, Kim JY, Kang J, Lee KJ, Kim DY, Park JM, Kang K, Park TH, Lee KB, Hong KS, Park HK, Cho YJ, Kim DE, Lee SJ, Kim JG, Lee J, Cha JK, Kim DH, Kim JT, Choi KH, Choi JC, Sohn SI, Hong JH, Lee SH, Kim C, Shin DI, Yum KS, Lee J, Lee JS, Gorelick PB, Bae HJ. Secular Trends in Outcomes and Impact of Novel Oral Anticoagulants in Atrial Fibrillation-Related Acute Ischemic Stroke. Stroke 2024; 55:625-633. [PMID: 38328909 DOI: 10.1161/strokeaha.123.044487] [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: 07/12/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) are currently recommended for the secondary prevention of stroke in patients with acute ischemic stroke (AIS) accompanied by atrial fibrillation (AF). However, the impact of NOACs on clinical outcomes in real-world practice remains ambiguous. This study analyzes the trend of clinical events in patients with AF-related AIS and determines how much the introduction of NOACs has mediated this trend. METHODS We identified patients with AIS and AF between January 2011 and December 2019 using a multicenter stroke registry. Annual rates of NOAC prescriptions and clinical events within 1 year were evaluated. The primary outcome was a composite of recurrent stroke, myocardial infarction, and all-cause mortality. To assess the mediation effect of NOACs on the relationship between the calendar year and these outcomes, we used natural effect models and conducted exposure-mediator, exposure-outcome, and mediator-outcome analyses using multivariable regression models or accelerated failure time models, adjusting for potential confounders. RESULTS Among the 12 977 patients with AF-related AIS, 12 500 (average age: 74.4 years; 51.3% male) were analyzed after excluding cases of valvular AF. Between 2011 and 2019, there was a significant decrease in the 1-year incidence of the primary composite outcome from 28.3% to 21.7%, while the NOAC prescription rate increased from 0% to 75.6%. A 1-year increase in the calendar year was independently associated with delayed occurrence of the primary outcome (adjusted time ratio, 1.10 [95% CI, 1.07-1.14]) and increased NOAC prescription (adjusted odds ratio, 2.20 [95% CI, 2.14-2.27]). Increased NOAC prescription was associated with delayed occurrence of the primary outcome (adjusted time ratio, 3.82 [95% CI, 3.17 to 4.61]). Upon controlling for NOAC prescription (mediator), the calendar year no longer influenced the primary outcome (adjusted time ratio, 0.97 [95% CI, 0.94-1.00]). This suggests that NOAC prescription mediates the association between the calendar year and the primary outcome. CONCLUSIONS Our study highlights a temporal reduction in major clinical events or death in Korean patients with AF-related AIS, mediated by increased NOAC prescription, emphasizing NOAC use in this population.
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Affiliation(s)
- Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea (M.L., B.-C.L., K.-H.Y., M.-S.O.)
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea (K.-J.L.)
| | - Do Yeon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
| | - Jong-Moo Park
- Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea (J.-M.P.)
| | - Kyusik Kang
- Nowon Elji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea (K.K.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Republic of Korea (T.H.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital Seoul, Republic of Korea (K.B.L.)
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Republic of Korea (K.-S.H., H.-K.P., Y.-J.C.)
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, Republic of Korea (D.-E.K., S.J.L.)
| | - Soo Joo Lee
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, Republic of Korea (D.-E.K., S.J.L.)
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, Republic of Korea (J.G.K.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Republic of Korea (Jun Lee)
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea (J.-K.C., D.-H.K.)
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea (J.-K.C., D.-H.K.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K., K.-H.C.)
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (J.-T.K., K.-H.C.)
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Republic of Korea (J.C.C.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea (S.-I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea (S.-I.S., J.-H.H.)
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Republic of Korea (S.-H.L., C.K.)
| | - Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Republic of Korea (S.-H.L., C.K.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea (D.-I.S., K.S.Y.)
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea (D.-I.S., K.S.Y.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Juneyoung Lee)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.S.L.)
| | - Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.B.G.)
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Republic of Korea (B.J.K., J.Y.K., J.K., D.Y.K., H.-J.B.)
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