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Rizkallah J, Kuriachan V, Brent Mitchell L. The use of dronedarone for recurrent ventricular tachycardia: a case report and review of the literature. BMC Res Notes 2016; 9:370. [PMID: 27461025 PMCID: PMC4962476 DOI: 10.1186/s13104-016-2116-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/02/2016] [Indexed: 11/10/2022] Open
Abstract
Background Dronedarone is a benzofuran derivative resembling amiodarone that was intended to reduce the iodine-associated tissue deposition and organ toxicity seen with the latter. The utility of dronedarone for patients with ventricular arrhythmias has not been thoroughly evaluated. We present our experience with its use to treat refractory ventricular tachycardia storm and review the literature. Case presentation An 85 year-old gentleman with multiple medical comorbidities including ischemic and non-ischemic cardiomyopathy with severe biventricular systolic dysfunction presented with ventricular tachycardia storm. Therapeutic options were limited given his frail medical status, failures of sotalol, mexilitine, and catheter ablation therapies along with drug-toxicities from amiodarone. Dronedarone was thus considered as off-label use following informed consent. The patient unfortunately developed fatal multisystem organ failure including acute severe hepatotoxicity from dronedarone. Conclusion Novel therapies for drug-refractory ventricular arrhythmias are long overdue given the limitations of available pharmacologic and non-pharmacologic options. Off-label use of antiarrhythmic agents such as dronedarone is considered a treatment of last-resort in patients who otherwise have no therapeutic options. Given the paucity of reported cases regarding dronedarone for the treatment of ventricular tachyarrhythmias, no conclusive recommendations can be made at this time aside from words of caution. Despite the potential ventricular antiarrhythmic effects of dronedarone, careful patient evaluation is required to identify those at greatest risk of drug-related adverse events particularly in those patients with significant comorbidities such as advanced hepatic, renal, and cardiovascular disease.
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Affiliation(s)
- Jacques Rizkallah
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Vikas Kuriachan
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada. .,C829 Foothills Medical Centre, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada.
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102
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Zhu W, He W, Guo L, Wang X, Hong K. The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis. Clin Cardiol 2016; 38:555-61. [PMID: 26418409 DOI: 10.1002/clc.22435] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/20/2015] [Accepted: 04/24/2015] [Indexed: 02/02/2023] Open
Abstract
Our objective was to compare the diagnostic accuracy between the HAS-BLED score and any of HEMORR2 HAGES, ATRIA, CHADS2 , or CHA2 DS2 -VASc scores in anticoagulated patients with atrial fibrillation. We systematically searched the Cochrane Library, MEDLINE, PubMed, and Embase databases for relevant studies. Data were extracted and analyzed according to predefined clinical endpoints. Eleven studies were identified. Discrimination analysis demonstrates that HAS-BLED has no significant C-statistic differences for bleeding risk prediction compared with ATRIA or HEMORR2 HAGES, but it has significant differences compared with CHADS2 or CHA2 DS2 -VASc. The significant positive net reclassification improvement and integrated discrimination improvement values also show that HAS-BLED is superior to that of any of HEMORR2 HAGES, ATRIA, CHADS2 , or CHA2 DS2 -VASc scores. According to calibration analysis of HAS-BLED, it overpredicts the risk of bleeding in the low (risk ratio [RR]: 1.16, 95% confidence interval [CI]: 0.63-2.13, P = 0.64) risk stratification but underpredicts that in the moderate (RR: 0.66, 95% CI: 0.51-0.86, P = 0.002) and high (RR: 0.88, 95% CI: 0.70-1.10, P = 0.27) risk stratifications. The HAS-BLED score not only performs better than the HEMORR2 HAGES and ATRIA bleeding scores, but it also is superior to the CHADS2 and CHA2 DS2 -VASc stroke scores for bleeding prediction. The HAS-BLED score should be the optimal choice to assess major bleeding risk in clinical practice.
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Affiliation(s)
- Wengen Zhu
- Cardiology Department the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Wenfeng He
- Cardiology Department the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Linjuan Guo
- Cardiology Department the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Xixing Wang
- Cardiology Department the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Kui Hong
- Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
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Virani SA, Dent S, Brezden-Masley C, Clarke B, Davis MK, Jassal DS, Johnson C, Lemieux J, Paterson I, Sebag IA, Simmons C, Sulpher J, Thain K, Thavendiranathan P, Wentzell JR, Wurtele N, Côté MA, Fine NM, Haddad H, Hayley BD, Hopkins S, Joy AA, Rayson D, Stadnick E, Straatman L. Canadian Cardiovascular Society Guidelines for Evaluation and Management of Cardiovascular Complications of Cancer Therapy. Can J Cardiol 2016; 32:831-41. [DOI: 10.1016/j.cjca.2016.02.078] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 12/30/2022] Open
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Castilla E, Morillas P, Gómez M, Ahumada M, Monteagudo M, Fácila L, Pallares V. [Use of the CHADS2 score as a predictor of the risk of mortality in hypertensive patients. The FAPRES study]. Med Clin (Barc) 2016; 146:478-83. [PMID: 27143530 DOI: 10.1016/j.medcli.2016.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/26/2016] [Accepted: 03/03/2016] [Indexed: 11/15/2022]
Abstract
FOUNDATIONS AND AIM The aim of this study is to analyze the CHADS2 score as a marker of the risk of mortality in hypertensive patients, with and without the presence of atrial fibrillation. METHODS We included 1,003 hypertensive patients≥65 years. Risk factors, and CHADS2 score were recorded among other factors, as well as clinical follow-up of number and type of deaths. RESULTS Mean age was 72.8±5.8 years, and 47.5% were men. During follow-up there were 41 deaths, 20 were of cardiovascular origin. Patients with higher CHADS2 had a higher mortality: 1.5% CHADS2=1; 4.7% in CHADS2=2; 9.1% in CHADS2=3, and 7.8% in CHADS2≥4. CONCLUSIONS The CHADS2 score can be a clinical instrument of easy application to identify hypertensive patients with a high risk of mortality.
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Affiliation(s)
- Elena Castilla
- Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, España.
| | - Pedro Morillas
- Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Manuel Gómez
- Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Miguel Ahumada
- Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Marta Monteagudo
- Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Lorenzo Fácila
- Servicio de Cardiología, Hospital General de Valencia, Valencia, España
| | - Vicente Pallares
- Unidad de Vigilancia de la Salud, Unión de Mutuas, Departamento de Medicina, Universitat Jaume I, Castellón, España
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105
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Learning to Make Decisions: Are Medical Postgraduate Trainees Getting With the Atrial Fibrillation Guidelines? Can J Cardiol 2016; 32:714-6. [DOI: 10.1016/j.cjca.2015.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 11/22/2022] Open
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Abstract
Dronedarone is the newest antiarrhythmic drug approved for the maintenance of sinus rhythm in patients with nonpermanent atrial fibrillation (AF). It is a multi-channel blocker with diverse electrophysiologic properties. Dronedarone decreases the incidence of AF recurrence and the ventricular rate during recurrence. Dronedarone decreases rates of cardiovascular hospitalizations in patients with paroxysmal and persistent AF. Dronedarone increases mortality in patients with permanent AF and those with moderate-severe heart failure, and should thus be avoided in these populations. Dronedarone is less effective than amiodarone but also has less toxicity. Direct comparison with other antiarrhythmic drugs is not available.
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Affiliation(s)
- Rafik Tadros
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Stanley Nattel
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Jason G Andrade
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada; Heart Rhythm Services, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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107
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Kim YH, Roh SY. The Mechanism of and Preventive Therapy for Stroke in Patients with Atrial Fibrillation. J Stroke 2016; 18:129-37. [PMID: 27283277 PMCID: PMC4901955 DOI: 10.5853/jos.2016.00234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/20/2016] [Accepted: 05/20/2016] [Indexed: 01/05/2023] Open
Abstract
Atrial fibrillation is a major cardiac cause of stroke, and a pathogenesis involving thrombus formation in patients with atrial fibrillation is well established. A strategy for rhythm control that involves catheter ablation and anticoagulation therapy is evolving. A strategy for rhythm control that restores and maintains sinus rhythm should reduce the risk of ischemic stroke that is associated with atrial fibrillation; however, this is yet to be proven in large-scale randomized controlled trials. This paper reviews the emerging role of rhythm control therapy for atrial fibrillation to prevent stroke.
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Affiliation(s)
- Young-Hoon Kim
- Cardiology Division, Korea University Medical Center, Seoul, Korea
| | - Seung-Young Roh
- Cardiology Division, Korea University Medical Center, Seoul, Korea
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108
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Fauchier L, Chaize G, Gaudin AF, Vainchtock A, Rushton-Smith SK, Cotté FE. Predictive ability of HAS-BLED, HEMORR2HAGES, and ATRIA bleeding risk scores in patients with atrial fibrillation. A French nationwide cross-sectional study. Int J Cardiol 2016; 217:85-91. [PMID: 27179213 DOI: 10.1016/j.ijcard.2016.04.173] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/15/2016] [Accepted: 04/30/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The HAS-BLED, ATRIA, and HEMORR2HAGES risk scores were created to evaluate individual bleeding risk in atrial fibrillation (AF). We sought to estimate and compare the predictive ability of these scores for major hemorrhage in AF, including elderly (≥80years) and non-elderly (<80years) patients. METHODS This cross-sectional study is based on the French National Hospital Database (PMSI), which covers the entire French population. Data from all patients with an AF diagnosis in 2012 were extracted. Demographic and comorbidity data were used to calculate the three bleeding risk scores for each patient. Patients hospitalized with a principal diagnosis of major bleeding were identified. RESULTS Of the 533,044 AF patients identified, 53.2% were ≥80years; 7013 patients (1.3%) were hospitalized for a bleeding event (1785 for intracranial hemorrhage). Bleeding occurred more frequently in patients with higher HAS-BLED, HEMORR2HAGES, and ATRIA scores. In patients ≥80years, the c-statistics did not differ (p=0.27) between HAS-BLED (0.54; 95% confidence interval [CI]: 0.53-0.54), HEMORR2HAGES (0.53; 95% CI: 0.53-0.54), and ATRIA (0.53; 95% CI: 0.52-0.54). In patients <80years, HAS-BLED (0.59; 95% CI: 0.58-0.60) had a slightly higher c-statistic than HEMORR2HAGES (0.56; 95% CI: 0.55-0.57) and ATRIA (0.55, 95% CI: 0.55-0.56) (p<0.0001). CONCLUSIONS Given its simplicity and similar performance, HAS-BLED may be an attractive alternative to HEMORR2HAGES for estimation of bleeding risk in AF patients <80years. However, accurate determination of bleeding risk among the elderly is difficult with existing risk-prediction scores, indicating a clear need for improvement in their clinical utility.
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Affiliation(s)
- Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau, Tours 37044, France; Faculté de Médecine, Université François Rabelais, Tours 37032, France.
| | | | | | | | - Sophie K Rushton-Smith
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
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110
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Amara W, Antoniou S. Benefits of once-daily dosing with non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J Suppl 2016; 18:D1-D6. [DOI: 10.1093/eurheartj/suv062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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111
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Caldeira D, Ferreira JJ, Pinto FJ, Costa J. Safety of non-vitamin K antagonist oral anticoagulants - coronary risks. Expert Opin Drug Saf 2016; 15:731-40. [PMID: 26958897 DOI: 10.1517/14740338.2016.1164689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Since the approval and commercialization of non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban, and rivaroxaban) several studies and meta-analyses have raised safety concerns regarding myocardial infarction (MI) risk among NOAC-treated patients, particularly with dabigatran. Uncertainty remains regarding the coronary risk associated with dabigatran, and whether this putative risk also applies to the other NOACs. AREAS COVERED In this review, the coronary risks of NOACs based on findings from placebo-controlled trials are discussed, and randomized controlled trials and major cohort studies in AF patients are also appraised. We performed a random-effect meta-analysis, including both interventional trials and observational studies ("real-world" data). Further estimates were retrieved from the meta-analysis of coronary risk among NOAC-treated patients with concomitant AF and coronary disease. EXPERT OPINION Currently, the best available data from both clinical trials and observational studies do not support the claim that patients treated with NOACs, including dabigatran, are at increased coronary risk. However, a definitive conclusion cannot be made (especially regarding dabigatran) and further data are required to address the coronary risks, mostly of high-risk patients. As with any therapeutic intervention, the possible complications should be balanced against the potential benefits at an individual patient level.
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Affiliation(s)
- Daniel Caldeira
- a Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina , Universidade de Lisboa , Lisbon , Portugal.,b Clinical Pharmacology Unit , Instituto de Medicina Molecular , Lisbon , Portugal.,c Cardiology Department , Hospital Garcia de Orta , Almada , Portugal
| | - Joaquim J Ferreira
- a Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina , Universidade de Lisboa , Lisbon , Portugal.,b Clinical Pharmacology Unit , Instituto de Medicina Molecular , Lisbon , Portugal
| | - Fausto J Pinto
- d Cardiology Department , CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa , Lisbon , Portugal
| | - João Costa
- a Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina , Universidade de Lisboa , Lisbon , Portugal.,b Clinical Pharmacology Unit , Instituto de Medicina Molecular , Lisbon , Portugal.,e Center for Evidence-Based Medicine, Faculdade de Medicina , Universidade de Lisboa , Lisbon , Portugal.,f Portuguese Collaborating Center of the IberoAmerican Cochrane Network, Faculdade de Medicina , Universidade de Lisboa , Lisbon , Portugal
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112
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Bell AD, Gross P, Heffernan M, Deschaintre Y, Roux JF, Purdham DM, Shuaib A. Appropriate Use of Antithrombotic Medication in Canadian Patients With Nonvalvular Atrial Fibrillation. Am J Cardiol 2016; 117:1107-11. [PMID: 26879070 DOI: 10.1016/j.amjcard.2015.12.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/28/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
This national chart audit of 7,019 patients with nonvalvular atrial fibrillation (AF) from 735 primary care physician practices sought to examine the management of Canadian patients with AF through an evidence-based, guideline-recommended approach. The appropriate use of oral anticoagulants (OACs) in this patient population and the potential factors guiding OAC choice were examined. Suboptimal dosing was seen. In patients on warfarin, 30.9% had not achieved a time in therapeutic range (TTR) in excess of 65% and, despite current Canadian guideline recommendations, were continued on warfarin rather than one of the novel OACs. In patients who received no antithrombotic therapy, 65.5% met criteria for treatment with an OAC. In addition, 62.8% of patients who were treated with acetylsalicylic acid monotherapy met guideline criteria for the use of an OAC. In those patients treated with an OAC, 24.8% were not on the recommended dose based on the product monograph or, if on warfarin, had a TTR <65%. Of the patients on novel OACs (NOACs), 7.4% of patients were underdosed, whereas overdosing was seen in 4.3%. Factors that may have contributed to dosing outside recommendations included underestimation of stroke risk, overestimation of bleed risk, compliance concerns, and lack of provincial reimbursement. In conclusion, significant correctable gaps remain in optimal treatment for stroke prevention in AF.
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113
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Wong JA, Quinn FR, Gillis AM, Burland L, Chen G, Wyse DG, Wilton SB. Temporal Patterns and Predictors of Rate vs Rhythm Control in Patients Attending a Multidisciplinary Atrial Fibrillation Clinic. Can J Cardiol 2016; 32:1247.e7-1247.e13. [PMID: 26992570 DOI: 10.1016/j.cjca.2016.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/19/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Contemporary trends in the selection of and persistence with rate vs rhythm control for atrial fibrillation (AF) are not well studied, particularly in the context of multidisciplinary AF clinics. METHODS The initial arrhythmia management strategy in 1031 consecutive patients attending a multidisciplinary AF clinic from 2005-2012 was analyzed. RESULTS The 397 (38.5%) patients initially treated with rhythm control were younger (57.4 ± 14 years vs 65.6 ± 13 years; P < 0.0001) and more likely to be men (64.5% vs 56.9%; P = 0.019). They also had fewer comorbidities, lower CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores, and greater symptom burden. The proportion treated with rhythm control declined from 46.9% in 2005-2006 to 28.4% in 2012 (P for trend < 0.0001). Compared with those initially selecting rate control, patients treated with rhythm control required more frequent clinic encounters (7 [interquartile range {IQR}, 3-12] vs 3 [IQR, 2-7]; P < 0.001) and longer follow-up (266 days [IQR, 84-548 days] vs 99 days [IQR, 0-313 days]; P < 0.001). Younger age, absence of diabetes and sleep apnea, earlier treatment year, higher symptom burden, and rural residence were independently associated with rhythm control. Persistence with the initial treatment strategy was reduced in the rhythm-control group (P = 0.003). CONCLUSIONS Use of rhythm control as the initial arrhythmia management strategy for AF in a specialty AF clinic is declining. Rhythm control requires more intensive follow-up and was more likely to lead to a change in arrhythmia management strategy.
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Affiliation(s)
- Jorge A Wong
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - F Russell Quinn
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anne M Gillis
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laurie Burland
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - D George Wyse
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Wilton
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
This article summarizes recommendations for the clinical use of antiarrhythmic drugs for the treatment and prevention of atrial and ventricular arrhythmias based on current guideline and consensus documents. The choice of antiarrhythmic drug is based on the efficacy and safety profile and influenced by the presence or absence of structural heart disease. Because of its adverse side-effect profile, amiodarone is recommended for the management of atrial fibrillation only when other agents have failed or are contraindicated. For treatment of symptomatic ventricular arrhythmias in the setting of structural heart disease, amiodarone is generally the preferred agent.
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Affiliation(s)
- Anne M Gillis
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, 3280 Hospital Drive Northwest, Calgary, Alberta T2N 4Z6, Canada.
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115
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Fahmy P, Spencer R, Tsang M, Gooderham P, Saw J. Left Atrial Appendage Closure for Atrial Fibrillation Is Safe and Effective After Intracranial or Intraocular Hemorrhage. Can J Cardiol 2016; 32:349-54. [DOI: 10.1016/j.cjca.2015.07.723] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/09/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022] Open
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Essebag V, Healey JS, Ayala-Paredes F, Kalfon E, Coutu B, Nery P, Verma A, Sapp J, Philippon F, Sandhu RK, Coyle D, Eikelboom J, Wells G, Birnie DH. Strategy of continued vs interrupted novel oral anticoagulant at time of device surgery in patients with moderate to high risk of arterial thromboembolic events: The BRUISE CONTROL-2 trial. Am Heart J 2016; 173:102-7. [PMID: 26920602 DOI: 10.1016/j.ahj.2015.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/04/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients who require perioperative anticoagulation during cardiac implantable electronic device surgery are at increased risk for bleeding complications. The BRUISE CONTROL trial demonstrated that continuing warfarin was safer than heparin bridging, reducing the incidence of clinically significant pocket hematoma. Novel oral anticoagulants are being increasingly prescribed in place of warfarin. The best perioperative management of these new anticoagulants is unknown. METHODS/DESIGN A randomized controlled trial to investigate whether a strategy of continued vs interrupted novel oral anticoagulant (dabigatran, rivaroxaban, or apixaban) at the time of device surgery, in patients with moderate to high risk of arterial thromboembolic events, reduces the incidence of clinically significant hematoma (defined as a hematoma requiring reoperation and/or resulting in prolongation of hospitalization, and/or requiring interruption of anticoagulation). The secondary outcomes include components of the primary outcome, composite of all other major perioperative bleeding events, thromboembolic events, all-cause mortality, cost-effectiveness, patient quality of life, perioperative pain, and satisfaction. Planned analyses include descriptive statistics of all baseline variables. For the primary outcome, interrupted vs continued novel oral anticoagulant arms will be compared using the χ(2) test. If any clinically significant differences are identified, a logistic regression analysis will be conducted. Quality of life will be assessed using EuroQol-5D, and perioperative pain using a visual analog scale. DISCUSSION BRUISE CONTROL-2 is a randomized trial evaluating the best strategy to manage novel oral anticoagulants at the time of device surgery. We hypothesize that device surgery can be performed safely without interruption of these medications.
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Angaran P, Dorian P, Tan MK, Kerr CR, Green MS, Gladstone DJ, Mitchell LB, Fournier C, Cox JL, Talajic M, Lin PJ, Langer A, Goldin L, Goodman SG. The Risk Stratification and Stroke Prevention Therapy Care Gap in Canadian Atrial Fibrillation Patients. Can J Cardiol 2016; 32:336-43. [DOI: 10.1016/j.cjca.2015.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 12/11/2022] Open
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Tran K, Leblanc K, Valentinis A, Kavanagh D, Zahr N, Ivers NM. Evaluating the Usability and Perceived Impact of an Electronic Medical Record Toolkit for Atrial Fibrillation Management in Primary Care: A Mixed-Methods Study Incorporating Human Factors Design. JMIR Hum Factors 2016; 3:e7. [PMID: 27026394 PMCID: PMC4811663 DOI: 10.2196/humanfactors.4289] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 08/19/2015] [Accepted: 10/07/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common and preventable cause of stroke. Barriers to reducing stroke risk through appropriate prescribing have been identified at the system, provider, and patient levels. To ensure a multifaceted initiative to address these barriers is effective, it is essential to incorporate user-centered design to ensure all intervention components are optimized for users. OBJECTIVE To test the usability of an electronic medical record (EMR) toolkit for AF in primary care with the goal of further refining the intervention to meet the needs of primary care clinicians. METHODS An EMR-based toolkit for AF was created and optimized through usability testing and iterative redesign incorporating a human factors approach. A mixed-methods pilot study consisting of observations, semi-structured interviews, and surveys was conducted to examine usability and perceived impact on patient care and workflow. RESULTS A total of 14 clinicians (13 family physicians and 1 nurse practitioner) participated in the study. Nine iterations of the toolkit were created in response to feedback from clinicians and the research team; interface-related changes were made, additional AF-related resources were added, and functionality issues were fixed to make the toolkit more effective. After improvements were made, clinicians expressed that the toolkit improved accessibility to AF-related information and resources, served as a reminder for guideline-concordant AF management, and was easy to use. Most clinicians intended to continue using the toolkit for patient care. With respect to impact on care, clinicians believed the toolkit increased the thoroughness of their assessments for patients with AF and improved the quality of AF-related care received by their patients. CONCLUSIONS The positive feedback surrounding the EMR toolkit for AF and its perceived impact on patient care can be attributed to the adoption of a user-centered design that merged clinically important information about AF management with user needs. This study demonstrates the utility of a human factors approach to piloting and refining an intervention prior to wide-scale implementation.
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Affiliation(s)
- Kim Tran
- OpenLab, University Health Network, Toronto, ON, Canada.
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SAW JACQUELINE, FAHMY PETER, SPENCER RYAN, PRAKASH ROSHAN, MCLAUGHLIN PATRICK, NICOLAOU SAVVAS, TSANG MICHAEL. Comparing Measurements of CT Angiography, TEE, and Fluoroscopy of the Left Atrial Appendage for Percutaneous Closure. J Cardiovasc Electrophysiol 2016; 27:414-22. [DOI: 10.1111/jce.12909] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/16/2015] [Accepted: 12/22/2015] [Indexed: 11/27/2022]
Affiliation(s)
- JACQUELINE SAW
- Division of Cardiology; University of British Columbia; Vancouver British Columbia Canada
| | - PETER FAHMY
- Division of Cardiology; University of British Columbia; Vancouver British Columbia Canada
| | - RYAN SPENCER
- Division of Cardiology; University of British Columbia; Vancouver British Columbia Canada
| | - ROSHAN PRAKASH
- Division of Cardiology; University of British Columbia; Vancouver British Columbia Canada
| | - PATRICK MCLAUGHLIN
- Division of Radiology, Vancouver General Hospital; University of British Columbia; Vancouver British Columbia Canada
| | - SAVVAS NICOLAOU
- Division of Radiology, Vancouver General Hospital; University of British Columbia; Vancouver British Columbia Canada
| | - MICHAEL TSANG
- Division of Cardiology; University of British Columbia; Vancouver British Columbia Canada
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Chiang CE, Wang KL, Lin SJ. Asian strategy for stroke prevention in atrial fibrillation. Europace 2016; 17 Suppl 2:ii31-9. [DOI: 10.1093/europace/euv231] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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121
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Schaefer JK, McBane RD, Wysokinski WE. How to choose appropriate direct oral anticoagulant for patient with nonvalvular atrial fibrillation. Ann Hematol 2016; 95:437-49. [PMID: 26658769 PMCID: PMC4742513 DOI: 10.1007/s00277-015-2566-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 11/27/2015] [Indexed: 12/15/2022]
Abstract
The novel oral anticoagulants or direct oral anticoagulants (DOAC) are becoming more common in clinical practice for the prevention of stroke in non-valvular atrial fibrillation (NVAF). The availability of several agents with similar efficacy and safety for stroke prevention in NVAF patients offers more selection, but at the same time requires certain knowledge to make a good choice. This comparative analysis provides an appraisal of the respective clinical trials and highlights much of what remains unknown about four FDA-approved agents: dabigatran, apixaban, rivaroxaban, and edoxaban. It details how the DOACs compare to warfarin and to one another summarizes pharmacologic and pharmacodynamic properties, and drug interactions from the stand point of practical consequences of these findings. Common misconceptions and reservations are addressed. The practical application of this data is intended to help choosing the most appropriate agent for individual NVAF patient.
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Affiliation(s)
| | - Robert D McBane
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation for Education and Research, 200 1st Street SW, Rochester, MN, 55905, USA
- Division of Hematology Research, Mayo Clinic, Rochester, MN, USA
| | - Waldemar E Wysokinski
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation for Education and Research, 200 1st Street SW, Rochester, MN, 55905, USA.
- Division of Hematology Research, Mayo Clinic, Rochester, MN, USA.
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Lefebvre MCD, St-Onge M, Glazer-Cavanagh M, Bell L, Kha Nguyen JN, Viet-Quoc Nguyen P, Tannenbaum C. The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octogenarians With Atrial Fibrillation: The FRAIL-AF Study. Can J Cardiol 2016; 32:169-76. [DOI: 10.1016/j.cjca.2015.05.012] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 05/16/2015] [Accepted: 05/17/2015] [Indexed: 12/27/2022] Open
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123
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Ha AC, Singh N, Cox JL, Mancini GJ, Dorian P, Fournier C, Gladstone DJ, Lockwood E, Shuaib A, Kajil M, Tsigoulis M, Gupta MK. Oral Anticoagulation for Stroke Prevention in Canadian Practice: Stroke Prevention and Rhythm Interventions in Atrial Fibrillation (SPRINT-AF) Registry*. Can J Cardiol 2016. [DOI: 10.1016/j.cjca.2015.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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124
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Yang X, Li Z, Zhao X, Wang C, Liu L, Wang C, Pan Y, Li H, Wang D, Hart RG, Wang Y, Wang Y. Use of Warfarin at Discharge Among Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation in China. Stroke 2016; 47:464-70. [DOI: 10.1161/strokeaha.115.011833] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/13/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Guidelines recommend oral anticoagulation for ischemic stroke patients with atrial fibrillation, and previous studies have shown the underuse of anticoagulation for these patients in China. We sought to explore the underlying reasons and factors that currently affect the use of warfarin in China.
Methods—
From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with warfarin use at discharge.
Results—
Among the 952 acute ischemic stroke patients with nonvalvular atrial fibrillation, 19.4% were discharged on warfarin. The risk of bleeding (52.8%) and patient refusal (31.9%) were the main reasons for not prescribing anticoagulation. Larger/teaching hospitals were more likely to prescribe warfarin. Older patients, heavy drinkers, patients with higher National Institutes of Health Stroke Scale score on admission were less likely to be given warfarin, whereas patients with history of heart failure and an international normalized ratio between 2.0 and 3.0 during hospitalization were significantly associated with warfarin use at discharge.
Conclusions—
The rate of warfarin use remains low among patients with ischemic stroke and known nonvalvular atrial fibrillation in China. Hospital size and academic status together with patient age, heart failure, heavy alcohol drinking, international normalized ratio in hospital, and stroke severity on admission were each independently associated with the use of warfarin at discharge. There is much room for improvement for secondary stroke prevention in nonvalvular atrial fibrillation patients in China.
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Affiliation(s)
- Xiaomeng Yang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Zixiao Li
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Xingquan Zhao
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Chunjuan Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Liping Liu
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Chunxue Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yuesong Pan
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Hao Li
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - David Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Robert G. Hart
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yilong Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yongjun Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
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Cheng K, Harrogate S, Orchard E. The Use of Novel Oral Anticoagulants in Adult Congenital Heart Disease: A Single Center Experience. Am J Cardiol 2016; 117:312-3. [PMID: 26679425 DOI: 10.1016/j.amjcard.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
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126
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Tajer C, Ceresetto J, Bottaro FJ, Martí A, Casey M. Assessment of the Quality of Chronic Anticoagulation Control With Time in Therapeutic Range in Atrial Fibrillation Patients Treated With Vitamin K Antagonists by Hemostasis Specialists: The TERRA Registry: Tiempo en rango en la República Argentina. Clin Appl Thromb Hemost 2016; 23:445-453. [PMID: 26739542 DOI: 10.1177/1076029615623378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Oral anticoagulation therapy with vitamin K antagonists (VKA) such as warfarin and acenocoumarol is recommended in patients with atrial fibrillation (AF) and risk factors for embolism. The quality of anticoagulation control with VKA may be assessed by the time in therapeutic range (TTR). In our country, there are no data available about the quality of anticoagulation in patients with AF. The primary goal of our study was to assess the level of effective anticoagulation in a multicenter network of anticoagulation clinics in Argentina, which included patients with nonvalvular AF (NVAF) treated with VKA oral anticoagulants. METHODS The TERRA trial is a multicenter, cross-sectional study involving 14 anticoagulation clinics that were invited to participate and recruit 100 consecutive patients with NVAF treated with VKA for more than 1 year. The international normalized ratio (INR) values were retrospectively obtained from patient charts, and TTR was calculated using the Rosendaal method. RESULTS A total of 1190 patients were included in the analysis. Mean age was 74.9 ± 9.9 years, and 52.5% of the patients were male. Median TTR was 67.5% (interquartile interval 54-80). During 55% of the TTR, INR was >3. Interinstitution variability was substantial, with a range of 57.7% ± 17% to 87.7% ± 17%, P < .001. The 10th percentile of TTR was 41%, the 20th percentile was 50%, the 30th was 58%, and the 35th percentile was 60%. In 40% of patients, TTR was <70%. CONCLUSION In this multicenter study, mean TTR values in patients with AF under VKA were similar to those in international therapeutic clinical trials (55%-65%). Marked variations among institutions were observed and, although average results obtained were high, one third of the patients exhibited a TTR below 60%. This cutoff value is conservative according to current recommendations, and guidelines suggest that when management with VKA cannot be improved, patients should be switched to direct oral anticoagulants. The addition of TTR calculation to clinical practice may help improve the quality of oral anticoagulation in patients with AF, thus improving anticoagulation outcomes.
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Affiliation(s)
- Carlos Tajer
- 1 Cardiology Deparment, Hospital El Cruce, Florencio Varela, Argentina
| | - José Ceresetto
- 2 Hematology Deparment, Hospital Británico, Buenos Aires, Argentina
| | | | - Alejandra Martí
- 4 Hematology Department, Hospital El Cruce, Florencio Varela, Argentina
| | - Marcelo Casey
- 5 Hematology Department, FLENI, Buenos Aires, Argentina
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Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattel S, Verma A. The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines. Can J Cardiol 2016; 31:1207-18. [PMID: 26429352 DOI: 10.1016/j.cjca.2015.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 12/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Program has generated a comprehensive series of documents regarding the management of atrial fibrillation (AF) between 2010 and 2014. The guidelines provide evidence-based consensus management recommendations in a broad range of areas. These guidelines have proven useful in informing clinical practice, but often lack detail in specifications related to practical application, particularly for areas in which the evidence base is limited or conflicting. Based on feedback from the community, the CCS Atrial Fibrillation Guidelines Committee has identified a number of areas that require clarification to address commonly asked practical questions related to guidelines application. In the present article a number of such questions are presented and suggestions about how they can be answered are suggested. Among the issues considered are: (1) What duration of AF is clinically significant? (2) How are the risk factors in the CCS Algorithm for selecting anticoagulation therapy derived and defined? (3) How is valvular heart disease defined and how do different forms of valve disease affect the choice of anticoagulant therapy for AF patients? (4) How should we quantify renal dysfunction and how does it affect therapeutic choices? The response to these questions and the underlying logic are provided, along with an indication of future research needed where no specific approach can presently be recommended based on the literature.
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Affiliation(s)
- Laurent Macle
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada.
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Ng KH, Shestakovska O, Connolly SJ, Eikelboom JW, Avezum A, Diaz R, Lanas F, Yusuf S, Hart RG. Efficacy and safety of apixaban compared with aspirin in the elderly: a subgroup analysis from the AVERROES trial. Age Ageing 2016; 45:77-83. [PMID: 26590293 DOI: 10.1093/ageing/afv156] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 09/01/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND increasing age is associated with a higher prevalence of atrial fibrillation (AF), and higher risks of stroke and bleeding. We report the effects of apixaban versus acetylsalicylic acid (ASA) in older patients (≥75 years and ≥85 years) compared with younger patients with AF unsuitable for vitamin K antagonists. METHODS AVERROES (Apixaban Versus ASA to Prevent Stroke In AF Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment) trial (n = 5,599) included 1,898 patients ≥75 years and 366 patients ≥85 years. We compared the baseline characteristics and effects of apixaban compared with aspirin on clinical outcomes by age. RESULTS compared with aspirin, apixaban was more efficacious for preventing strokes and systemic embolism in patients ≥85 years (absolute rate [AR] 1%/year on apixaban versus 7.5%/year on aspirin; hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.02-0.48) compared with younger patients (AR 1.7%/year on apixaban versus 3.4%/year on aspirin; HR 0.50, 95% CI 0.35-0.69) (P-value for interaction = 0.05). Major haemorrhage was higher in patients ≥85 years compared with younger patients but similar with apixaban versus aspirin in both young and older individuals (4.9%/year versus 1.0%/year on aspirin and 4.7%/year versus 1.2%/year on apixaban) with no significant treatment-by-age interaction (P-value = 0.65). CONCLUSIONS older patients with AF are at particularly high risk of stroke if given aspirin and have substantially greater relative and absolute benefits from apixaban compared with younger patients with no greater risk of haemorrhage. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number: NCT00496769. URL: https://clinicaltrials.gov/ct2/show/NCT00496769.
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Affiliation(s)
- Kuan H Ng
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Olga Shestakovska
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Rafael Diaz
- Estudio Clinicos Latinoamerica, Rosario, Argentina
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
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129
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Hohnloser SH. [Treatment safety of non-vitamin K oral anticoagulants in patients with atrial fibrillation]. Herz 2015; 41:37-47. [PMID: 26669316 DOI: 10.1007/s00059-015-4383-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Non-vitamin K oral anticoagulants (NOAC) have now become established for stroke prevention in atrial fibrillation. The efficacy is at least as good if not better than that of vitamin K antagonists (VKA). The risk for major bleeding is less for NOAC than for VKA, with a particular superiority concerning the avoidance of intracerebral hemorrhage. The outcome after major bleeding is more favorable in patients receiving NOAC compared to those treated with VKA. Specific reversal agents for NOAC are currently being tested which neutralize the effects of NOAC within minutes and the clinical introduction of the first one for the thrombin inhibitor dabigatran is imminent. Such specific antidotes will further improve the safety profile of NAOC.
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Affiliation(s)
- S H Hohnloser
- Kardiologie, Abt. Klinische Elektrophysiologie, Johann Wolfgang Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland.
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130
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How to choose appropriate direct oral anticoagulant for patient with nonvalvular atrial fibrillation. Ann Hematol 2015. [PMID: 26658769 DOI: 10.1007/s00277‐015‐2566‐x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The novel oral anticoagulants or direct oral anticoagulants (DOAC) are becoming more common in clinical practice for the prevention of stroke in non-valvular atrial fibrillation (NVAF). The availability of several agents with similar efficacy and safety for stroke prevention in NVAF patients offers more selection, but at the same time requires certain knowledge to make a good choice. This comparative analysis provides an appraisal of the respective clinical trials and highlights much of what remains unknown about four FDA-approved agents: dabigatran, apixaban, rivaroxaban, and edoxaban. It details how the DOACs compare to warfarin and to one another summarizes pharmacologic and pharmacodynamic properties, and drug interactions from the stand point of practical consequences of these findings. Common misconceptions and reservations are addressed. The practical application of this data is intended to help choosing the most appropriate agent for individual NVAF patient.
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131
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Spencer RJ, DeJong P, Fahmy P, Lempereur M, Tsang MY, Gin KG, Lee PK, Nair P, Tsang TS, Jue J, Saw J. Changes in Left Atrial Appendage Dimensions Following Volume Loading During Percutaneous Left Atrial Appendage Closure. JACC Cardiovasc Interv 2015; 8:1935-1941. [DOI: 10.1016/j.jcin.2015.07.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/14/2015] [Accepted: 07/30/2015] [Indexed: 11/26/2022]
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132
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El Kadri M, Sharaf Dabbagh G, Oral H. Contemporary measures to reduce the risk of embolic events in patients with atrial fibrillation. Future Cardiol 2015; 11:635-43. [PMID: 26609866 DOI: 10.2217/fca.15.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation is a common arrhythmia with significant risk of embolic events. Patients with atrial fibrillation should undergo a careful assessment using validated risk score calculators to estimate the risk of embolic events and the risk of bleeding. Patients deemed to be at a high risk for arterial thromboembolism should be advised to take an oral anticoagulant with a vitamin K antagonist or a target-specific oral anticoagulant unless contraindicated. These agents significantly reduce the risk of embolic events, but at the expense of a higher risk of bleeding. Antiplatelet agents do not confer the same degree of protection and their use should limited. When antithrombotic treatment is contraindicated, novel approaches such as left atrial appendage occlusion should be considered.
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Affiliation(s)
- Moutaz El Kadri
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK.,Faculty of Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | | | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, 1500 E Medical Centre Drive, Ann Arbor, MI 48109, USA
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Shehab A, Elnour AA, Sadik A, Abu Mandil M, AlShamsi A, Al Suwaidi A, Bhagavathula A, Erkekoglu P, Hamad F, Al Nuaimi SK. Clinical utility of dabigatran in United Arab Emirates. A pharmacovigilance study. Saudi Med J 2015; 36:1290-8. [PMID: 26593161 PMCID: PMC4673365 DOI: 10.15537/smj.2015.11.12154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To provide early data regarding clinical utility of dabigatran in Al-Ain, United Arab Emirates (UAE). Methods: This was an ethics approved retrospective cross sectional study. We retrieved a total of 76 patients who were using dabigatran from September to December 2014 in the Cardiology Clinic at Al-Ain Hospital, Al-Ain, UAE. The primary analysis was designed to test the frequency of bleeding events (rate) with dabigatran 75, 110, and 150 mg. Results: The mean age ± standard deviation of cohort was 67.9 ± 1.5 years (range; 29-98 years), composed of males (52.6%) with mean age of 66.3 ± 1.7 years, and females (47.4%) with mean age of 69.6 ± 1.1 years. The highest age group was those between 61-80 years (60.5%). Most comprised the age strata of ≤75 years (73.7%). The main indication for dabigatran use was atrial fibrillation. The rate of bleeding with dabigatran was 18/76 (23.7%), and melena was the leading cause of bleeding 8/76 (10.7%). The hospitalization rate was 67.1%, dabigatran withdrawal rate was 0.01%, and mortality rate was 6.5%. The cohort had exhibited incidences of minor bleeding with one fatal major bleeding, high co-morbidities, admission, and readmission, which was not directly linked to dabigatran. We did not identify any relation of death due to dabigatran. Conclusion: Dabigatran is a suitable alternative to warfarin obviating the need for repetitive international normalized ratio monitoring, however, it may need plasma drug monitoring.
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Affiliation(s)
- Abdulla Shehab
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates. E-mail.
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Trends in Prescribing Oral Anticoagulants in Canada, 2008–2014. Clin Ther 2015; 37:2506-2514.e4. [DOI: 10.1016/j.clinthera.2015.09.008] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/10/2015] [Accepted: 09/13/2015] [Indexed: 11/19/2022]
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Long-term stroke rates after catheter ablation or antiarrhythmic drug therapy for atrial fibrillation: a meta-analysis of randomized trials. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:507-14. [PMID: 26512242 PMCID: PMC4605946 DOI: 10.11909/j.issn.1671-5411.2015.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and is associated with increased risk of death. Randomized studies suggest improved quality of life for patients with AF after successful catheter ablation compared to antiarrhythmic drug therapy. The value of ablation in long-term risk of ischemic stroke, however, has not been assessed. We conducted a meta-analysis to determine whether AF ablation reduces the long-term risk of stroke compared to antiarrhythmic drug therapy in randomized controlled trials. METHODS & RESULTS PubMed and the Cochrane Central Register were searched for randomized trials from January 1990 to December 2014 comparing AF catheter ablation to drug therapy. The results are reported as risk differences (RDs) and 95% CI. Thirteen trials were analyzed with 1097 patients treated by catheter ablation and 855 patients received antiarrhythmic drug therapy. Overall, seven patients (0.64%) in the catheter ablation group had ischemic stroke or transient ischemic attacks vs. two patients (0.23%) in the drug therapy group. No difference was shown in the rate of stroke or transient ischemic attack between ablation and drug therapy (RD: 0.003, 95% CI: -0.006 to 0.012, P = 0.470), and no evidence of heterogeneity was observed (I (2) = 0, P = 0.981). No potential publication bias was found. There was also no difference in mortality between the two groups (RD: -0.004, 95% CI: -0.014 to 0.006, P = 0.472). CONCLUSIONS This meta-analysis of randomized controlled trials showed similar rates of ischemic stroke or transient ischemic attack and death in AF patients undergoing catheter ablation compared to drug therapy. A larger prospective randomized trial to confirm this finding is warranted.
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Litmathe J, Dafotakis M, Sucker C, Schulz JB. Cardiovascular causes of emergency neurology presenting to an ICU. Perfusion 2015; 31:271-80. [PMID: 26494486 DOI: 10.1177/0267659115613429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stroke or transient ischemic attacks (TIA) represent an urgent clinical entity that is not limited only to elderly patients. The underlying causes of stroke and TIA are diverse, with those of cardiovascular origin being among the most prominent. This review seeks to elucidate some of the most important aspects of the disease in the context of emergency and critical care practice.
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Affiliation(s)
- Jens Litmathe
- Department of Neurology, RWTH University, Aachen, Germany
| | | | | | - Jörg B Schulz
- Department of Neurology, RWTH University, Aachen, Germany Jülich Aachen Research Alliance (JARA) - Translational Brain Medicine, Aachen, Germany
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Wu C, McMurtry MS, Sandhu RK, Youngson E, Ezekowitz JA, Kaul P, McAlister FA. Impact of Rural Residence on Warfarin Use and Clinical Events in Patients with Non-Valvular Atrial Fibrillation: A Canadian Population Based Study. PLoS One 2015; 10:e0140607. [PMID: 26466118 PMCID: PMC4605516 DOI: 10.1371/journal.pone.0140607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/27/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND PURPOSE We studied whether anticoagulant use and outcomes differed between rural versus urban Canadian non-valvular atrial fibrillation (NVAF) patients prior to the introduction of direct oral anticoagulant drugs. METHODS Retrospective cohort study of 25,284 adult Albertans with NVAF between April 1, 1999 and December 31, 2008. RESULTS Compared to urban patients, rural patients were older (p = 0.0009) and had more comorbidities but lower bleeding risk at baseline. In the first year after NVAF diagnosis, urban patients were less likely to be hospitalized (aOR 0.82, 95%CI 0.77-0.89) or have an emergency department visit for any reason (aOR 0.61, 95%CI 0.56-0.66) but warfarin dispensation rates (72.2% vs 71.8% at 365 days, p = 0.98) and clinical outcomes were similar: 7.8% died in both groups, 3.2% rural vs. 2.8% urban had a stroke or systemic embolism (SSE) (aOR 0.92, 95%CI 0.77-1.11), and 6.6% vs. 5.7% (aOR 0.93, 95%CI 0.81-1.06) had a bleed. Baseline SSE risk did not impact warfarin dispensation (73.0% in those with high vs. 72.8% in those with low CHADS2 score, p = 0.85) but patients at higher baseline bleeding risk were less likely to be using warfarin (69.2% high vs. 73.6% low HASBLED score, p<0.0001) in the first 365 days after diagnosis. In warfarin users, bleeding was more frequent (7.5% vs 6.2%, aHR 1.51 [95%CI 1.33-1.72]) but death or SSE was less frequent (7.0% vs 18.1%, aHR 0.60 [0.54-0.66]). CONCLUSION Warfarin use and clinical event rates did not differ between rural and urban NVAF patients in a universal access publically-funded healthcare system.
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Affiliation(s)
- Cynthia Wu
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Sean McMurtry
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Roopinder K. Sandhu
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A. Ezekowitz
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A. McAlister
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
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Brambatti M, Darius H, Oldgren J, Clemens A, Noack HH, Brueckmann M, Yusuf S, Wallentin L, Ezekowitz MD, Connolly SJ, Healey JS. Comparison of dabigatran versus warfarin in diabetic patients with atrial fibrillation: Results from the RE-LY trial. Int J Cardiol 2015; 196:127-31. [DOI: 10.1016/j.ijcard.2015.05.141] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/25/2015] [Accepted: 05/26/2015] [Indexed: 01/08/2023]
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Aronis KN, Thigpen JL, Tripodis Y, Dillon C, Forster K, Henault L, Quinn EK, Berger PB, Limdi NA, Hylek EM. Paroxysmal atrial fibrillation and the hazards of under-treatment. Int J Cardiol 2015; 202:214-20. [PMID: 26397414 DOI: 10.1016/j.ijcard.2015.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/23/2015] [Accepted: 09/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulants are highly efficacious for the prevention of stroke in atrial fibrillation, and are the preferred treatment by current guidelines. The purpose of our study was to assess the utilization of antithrombotic drugs in atrial fibrillation patients at the time of ischemic stroke and the factors associated with their use. METHODS We enrolled 759 consecutive patients admitted with ischemic stroke at Boston Medical Center, Geisinger Health System, and the University of Alabama. To be eligible, patients had to have electrocardiographically-confirmed atrial fibrillation at the time of admission or within 6 months of the index stroke. All stroke events and electrocardiograms were validated by study physicians. Patients with newly diagnosed atrial fibrillation were not eligible. RESULTS The mean age was 78 years, 43% were male, 19% black, and the mean CHADS2 score is 3.0. Atrial fibrillation was paroxysmal in 31%. At presentation, 181 (24%) patients were taking warfarin only, 96 (13%) both warfarin and aspirin, 294 (39%) aspirin alone, and 189 (25%) no antithrombotic therapy. The mean international normalized ratio was 1.6. Among patients with paroxysmal atrial fibrillation, one in five was taking warfarin. Although increasing stroke risk was associated with a greater likelihood of warfarin use, only 39% of highest risk CHADS2 3-6 were taking warfarin at the time of stroke. CONCLUSIONS Among high-risk individuals with atrial fibrillation, only 37% were taking warfarin at the time of stroke. Paroxysmal atrial fibrillation was associated with the highest risk of not receiving warfarin.
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Affiliation(s)
- Konstantinos N Aronis
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA.
| | - Jonathan L Thigpen
- Department of Pharmacy, Notre Dame of Maryland University, Baltimore, MD, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen Forster
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Lori Henault
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
| | - Emily Kate Quinn
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Peter B Berger
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Nita A Limdi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Elaine M Hylek
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
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Avgil-Tsadok M, Jackevicius CA, Essebag V, Eisenberg MJ, Rahme E, Behlouli H, Pilote L. Dabigatran use in elderly patients with atrial fibrillation. Thromb Haemost 2015; 115:152-60. [PMID: 26354766 DOI: 10.1160/th15-03-0247] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/10/2015] [Indexed: 01/12/2023]
Abstract
In elderly patients (≥ 75 years), evidence of dabigatran efficacy is lacking and increased vigilance is warranted. We aimed to assess dabigatran effectiveness and safety in elderly patients in real-world practice. We conducted a population-based study using administrative databases, in Quebec (1999-2013). Dabigatran users (110/150 mg) were compared with matched warfarin users with regard to stroke and bleeding events. Age was categorised into < 75 or ≥ 75 years. Propensity score adjusted models were used. The cohort consisted of 15,918 dabigatran users and 47,192 matched warfarin users, with 67.3% being elderly patients. The elderly predominantly used the lower dose (80.1%) while younger patients mainly used the higher dose (80.0%). In multivariable analyses adjusted for propensity score, the risk of stroke in elderly patients using dabigatran, was no different than the risk in warfarin users (HR 1.05, 95% CI: 0.93, 1.19) regardless of dabigatran dose. However, dabigatran was associated with lower rates of intracranial haemorrhage (HR 0.60, 95% CI: 0.47-0.76) and higher rates of gastrointestinal bleeding (HR 1.30 95% CI: 1.14-1.50) when compared to warfarin. Based on real-life experience, dabigatran can offer an alternative to warfarin in elderly patients, with fewer intracranial bleeding events. However, caution is warranted for gastrointestinal bleeding.
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Affiliation(s)
| | | | | | | | | | | | - Louise Pilote
- Louise Pilote, MD, MPH, PhD, McGill University Health Centre, 687 Pine Ave West, V Building, Montreal, Quebec, H3A 1A1 Canada, Tel.: +1 514 934 1934 ext. 44722, Fax: +1 514 934 8293, E-mail:
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Escolar G, Carne X, Arellano-Rodrigo E. Dosing of rivaroxaban by indication: getting the right dose for the patient. Expert Opin Drug Metab Toxicol 2015; 11:1665-77. [PMID: 26329812 DOI: 10.1517/17425255.2015.1085022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Vitamin K antagonists were the only oral anticoagulants available for several decades, but they require frequent coagulation monitoring and dose adjustment. The direct oral anticoagulants rivaroxaban , dabigatran, apixaban, and, most recently, edoxaban have been approved for the management of specific thromboembolic indications. AREAS COVERED This review will provide a brief overview of the cell-based coagulation model, the main determinants of arterial and venous thrombosis, and the pharmacological rationale and clinical evidence for the different dosing regimens of rivaroxaban. Published articles indexed on PubMed and Medline covering arterial and venous thrombi pathophysiology, pharmacokinetics, and pharmacodynamics of rivaroxaban, and Phase II and Phase III clinical studies with rivaroxaban as well as real-world evidence were analyzed. EXPERT OPINION Education on pharmacokinetic/pharmacodynamic characteristics, as well as how to manage adverse events, is needed to increase physician knowledge and confidence in using direct oral anticoagulants, as specifically discussed for rivaroxaban in this article. The continued uptake of direct oral anticoagulants in clinical practice depends on understanding of the clinical evidence and reassurance provided by emerging real-world data.
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Affiliation(s)
- Gines Escolar
- a 1 University of Barcelona, Centre de Diagnostic Biomedic (CDB), Department of Hemotherapy and Hemostasis , Barcelona, Spain +34 9 32 27 54 00, Ext 2571 ; +34 9 32 27 93 69 ;
| | - Xavier Carne
- b 2 University of Barcelona, Barcelona, Hospital Clinic, Clinical Pharmacology Service , Villarroel 170, Barcelona, Spain
| | - Eduardo Arellano-Rodrigo
- a 1 University of Barcelona, Centre de Diagnostic Biomedic (CDB), Department of Hemotherapy and Hemostasis , Barcelona, Spain +34 9 32 27 54 00, Ext 2571 ; +34 9 32 27 93 69 ;
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Engelberger RP, Noll G, Schmidt D, Alatri A, Frei B, Kaiser WE, Kucher N. Initiation of rivaroxaban in patients with nonvalvular atrial fibrillation at the primary care level: the Swiss Therapy in Atrial Fibrillation for the Regulation of Coagulation (STAR) Study. Eur J Intern Med 2015; 26:508-14. [PMID: 25935131 DOI: 10.1016/j.ejim.2015.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/09/2015] [Accepted: 04/13/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rivaroxaban has become an alternative to vitamin-K antagonists (VKA) for stroke prevention in non-valvular atrial fibrillation (AF) patients due to its favourable risk-benefit profile in the restrictive setting of a large randomized trial. However in the primary care setting, physician's motivation to begin with rivaroxaban, treatment satisfaction and the clinical event rate after the initiation of rivaroxaban are not known. METHODS Prospective data collection by 115 primary care physicians in Switzerland on consecutive nonvalvular AF patients with newly established rivaroxaban anticoagulation with 3-month follow-up. RESULTS We enrolled 537 patients (73±11years, 57% men) with mean CHADS2 and HAS-BLED-scores of 2.2±1.3 and 2.4±1.1, respectively: 301(56%) were switched from VKA to rivaroxaban (STR-group) and 236(44%) were VKA-naïve (VN-group). Absence of routine coagulation monitoring (68%) and fixed-dose once-daily treatment (58%) were the most frequent criteria for physicians to initiate rivaroxaban. In the STR-group, patient's satisfaction increased from 3.6±1.4 under VKA to 5.5±0.8 points (P<0.001), and overall physician satisfaction from 3.9±1.3 to 5.4±0.9 points (P<0.001) at 3months of rivaroxaban therapy (score from 1 to 6 with higher scores indicating greater satisfaction). In the VN-group, both patient's (5.4±0.9) and physician's satisfaction (5.5±0.7) at follow-up were comparable to the STR-group. During follow-up, 1(0.19%; 95%CI, 0.01-1.03%) ischemic stroke, 2(0.37%; 95%CI, 0.05-1.34%) major non-fatal bleeding and 11(2.05%; 95%CI, 1.03-3.64%) minor bleeding complications occurred. Rivaroxaban was stopped in 30(5.6%) patients, with side effects being the most frequent reason. CONCLUSION Initiation of rivaroxaban for patients with nonvalvular AF by primary care physicians was associated with a low clinical event rate and with high overall patient's and physician's satisfaction.
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Affiliation(s)
- Rolf P Engelberger
- Division of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; Clinic for Angiology, Swiss Cardiovascular Center, Inselspital, University Hospital and University of Bern, Switzerland.
| | - Georg Noll
- HerzKlinik, Klinik Hirslanden, Zürich, Switzerland
| | | | - Adriano Alatri
- Division of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Nils Kucher
- Clinic for Angiology, Swiss Cardiovascular Center, Inselspital, University Hospital and University of Bern, Switzerland; Clinic for Cardiology, Swiss Cardiovascular Center, Inselspital, University Hospital and University of Bern, Switzerland
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Atoui M, Gunda S, Lakkireddy D. Left atrial appendage closure is preferred to chronic warfarin therapy: the pro perspective. Card Electrophysiol Clin 2015; 7:403-13. [PMID: 26304519 DOI: 10.1016/j.ccep.2015.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is associated with increased rates of death, stroke, heart failure, hospitalization, degraded quality of life, reduced exercise capacity, and left ventricular dysfunction. An oral anticoagulant reduces the risk of stroke; however, it places the patient at risk for bleeding complications. Weighing the stroke and bleeding risks remains the key for optimal treatment. Cardiac interventions that can obviate long-term oral anticoagulation hold great promise for the future care of patients with AF and high stroke risk. The percutaneously deployable Watchman device is a paradigm shift in how clinicians can abate the need for continued oral anticoagulation.
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Affiliation(s)
- Moustapha Atoui
- Division of Electrophysiology, Kansas University Medical Center, University of Kansas Hospital, 3901 Rainbow Boulevard, Rm 1001B Eaton, MS 3006, Kansas City, KS 66160, USA
| | - Sampath Gunda
- Division of Electrophysiology, University of Kansas Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA
| | - Dhanunjaya Lakkireddy
- Division of Electrophysiology, University of Kansas Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA; Division of Cardiovascular Diseases, Center for Excellence in Atrial Fibrillation & EP Research, University of Kansas Medical Center and Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA.
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Li J, Wang L, Hu J, Xu G. Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis. Nutr Metab Cardiovasc Dis 2015; 25:706-713. [PMID: 26026205 DOI: 10.1016/j.numecd.2015.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/13/2015] [Accepted: 03/23/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM The efficacy and safety of warfarin therapy in hemodialysis (HD) patients with atrial fibrillation (AF) remains controversial. Thus, we performed, up to date, the first meta-analysis on the risks of stroke and bleeding in warfarin treatment in these populations. METHODS AND RESULTS The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library Database, PubMed, ISI, Ovid, and Chinese Biomedical Database from the establishment of the database to October 2014. The studies were included if (a) studies described the risk of stroke or bleeding with or without warfarin in dialysis patients with AF, (b) studies provided information about hazard ratio (HR) and 95% confidence interval (CI) of stroke or bleeding, and (c) the study design was a clinical cohort. The inverse variance method was used to obtain overall HRs and 95% CIs. Sensitivity analyses and publication bias were also performed. We identified six eligible studies with a total of 9816 patients. Combined HRs showed that warfarin cannot prevent strokes in HD patients with AF (HR = 1.23, 95% CI 0.80-1.87; P = 0.347), but its use was associated with a higher risk of bleeding (HR = 1.20, 95% CI 1.03-1.39; P = 0.019). CONCLUSION This meta-analysis suggested that warfarin should not be recommended for the routine treatment of HD patients with AF.
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Affiliation(s)
- Jingzhen Li
- Medical Center of the Graduate School, Nanchang University, Nanchang, PR China
| | - Lijuan Wang
- Medical Center of the Graduate School, Nanchang University, Nanchang, PR China
| | - Jinzhu Hu
- Department of Cardiology, Second Affiliated Hospital, Nanchang University, Nanchang, PR China
| | - Gaosi Xu
- Department of Nephrology, Second Affiliated Hospital, Nanchang University, No. 1, Minde Road, Nanchang 330006, PR China.
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Potpara TS, Lip GYH. Oral anticoagulant therapy in atrial fibrillation patients at high stroke and bleeding risk. Prog Cardiovasc Dis 2015; 58:177-94. [PMID: 26162958 DOI: 10.1016/j.pcad.2015.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. Most AF patients have a positive net clinical benefit from OAC, excluding those with AF and no conventional stroke risk factors. Balancing the risks of stroke and bleeding is necessary for optimal use of OAC in clinical practice, and modifiable bleeding risk factors must be addressed. Concerns remain over 'non-changeable' bleeding risk factors such as older age, significant renal or hepatic impairment, prior stroke(s) or prior bleeding event(s) and active malignancies. Such AF patients are often termed 'special' AF populations, due to their 'special' risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients. In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these 'special' AF populations.
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Affiliation(s)
- Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- School of Medicine, Belgrade University, Belgrade, Serbia; University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, United Kingdom.
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Micieli A, Wijeysundera HC, Qiu F, Atzema CL, Singh SM. A Decision Analysis of Percutaneous Left Atrial Appendage Occlusion Relative to Novel and Traditional Oral Anticoagulation for Stroke Prevention in Patients with New-Onset Atrial Fibrillation. Med Decis Making 2015; 36:366-74. [DOI: 10.1177/0272989x15593083] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 05/30/2015] [Indexed: 11/15/2022]
Abstract
Background. Percutaneous left atrial appendage occlusion (LAAO) is a nonpharmacologic approach for stroke prevention in nonvalvular atrial fibrillation (NVAF). No direct comparisons to novel oral anticoagulants (OACs) exists, limiting decision making on the optimal strategy for stroke prevention in NVAF patients. Addressing this gap in knowledge is timely given the recent debate by the US Food and Drug Administration regarding the effectiveness of LAAO. Objective. To assess the cost-effectiveness of LAAO and novel OACs relative to warfarin in patients with new-onset NVAF without contraindications to OAC. Design. A cost-utility analysis using a patient-level Markov micro-simulation decision analytic model was undertaken to determine the lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of LAAO and all novel OACs relative to warfarin. Effectiveness and utility data were obtained from the published literature and cost from the Ontario Drug Benefits Formulary and Case Costing Initiative. Results. Warfarin had the lowest discounted QALY (5.13 QALYs), followed by dabigatran (5.18 QALYs), rivaroxaban and LAAO (5.21 QALYs), and apixaban (5.25 QALYs). The average discounted lifetime costs were $15 776 for warfarin, $18 280 for rivaroxaban, $19 156 for apixaban, $20 794 for dabigatran, and $21 789 for LAAO. Apixaban dominated dabigatran and LAAO and demonstrated extended dominance over rivaroxaban. The ICER for apixaban relative to warfarin was $28 167/QALY. Apixaban was preferred in 40.2% of simulations at a willingness-to-pay threshold of $50 000/QALY. Limitations. Assumptions regarding clinical and methodological differences between published studies of each therapy were minimized. Conclusions. Apixaban is the most cost-effective therapy for stroke prevention in patients with new-onset NVAF without contraindications to OAC. Uncertainty around this conclusion exists, highlighting the need for further research.
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Affiliation(s)
- Andrew Micieli
- Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
- Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)
| | - Harindra C. Wijeysundera
- Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
- Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)
| | - Feng Qiu
- Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
- Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)
| | - Clare L. Atzema
- Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
- Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)
| | - Sheldon M. Singh
- Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
- Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)
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147
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Ferns SJ, Naccarelli GV. New oral anticoagulants: their role in stroke prevention in high-risk patients with atrial fibrillation. Med Clin North Am 2015; 99:759-80. [PMID: 26042881 DOI: 10.1016/j.mcna.2015.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Based on efficacy, safety, and ease of use, novel oral anticoagulants will likely replace VKAs for many if not most patients with atrial fibrillation. Novel anticoagulants have a lower rate of intracranial hemorrhage compared with vitamin K antagonists. The incidence of other life-threatening bleeds is similar if not lower. Dose adjustments need to be made based on renal function and advanced age. There is at present a need for an antidote for these new drugs.
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Affiliation(s)
- Sunita J Ferns
- Department of Pediatrics, University of North Carolina, College of Medicine, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Gerald V Naccarelli
- Penn State Hershey heart and Vascular Institute, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
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148
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Camm AJ, Pinto FJ, Hankey GJ, Andreotti F, Hobbs FDR. Non-vitamin K antagonist oral anticoagulants and atrial fibrillation guidelines in practice: barriers to and strategies for optimal implementation. Europace 2015; 17:1007-17. [PMID: 26116685 PMCID: PMC4482288 DOI: 10.1093/europace/euv068] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 02/27/2015] [Indexed: 01/27/2023] Open
Abstract
Stroke is a leading cause of morbidity and mortality worldwide. Atrial fibrillation (AF) is an independent risk factor for stroke, increasing the risk five-fold. Strokes in patients with AF are more likely than other embolic strokes to be fatal or cause severe disability and are associated with higher healthcare costs, but they are also preventable. Current guidelines recommend that all patients with AF who are at risk of stroke should receive anticoagulation. However, despite this guidance, registry data indicate that anticoagulation is still widely underused. With a focus on the 2012 update of the European Society of Cardiology (ESC) guidelines for the management of AF, the Action for Stroke Prevention alliance writing group have identified key reasons for the suboptimal implementation of the guidelines at a global, regional, and local level, with an emphasis on access restrictions to guideline-recommended therapies. Following identification of these barriers, the group has developed an expert consensus on strategies to augment the implementation of current guidelines, including practical, educational, and access-related measures. The potential impact of healthcare quality measures for stroke prevention on guideline implementation is also explored. By providing practical guidance on how to improve implementation of the ESC guidelines, or region-specific modifications of these guidelines, the aim is to reduce the potentially devastating impact that stroke can have on patients, their families and their carers.
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Affiliation(s)
- A John Camm
- Department of Clinical Cardiology, St George's University of London, London SW17 0RE, UK
| | | | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Nedlands, WA, Australia Department of Neurology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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149
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Abstract
Edoxaban is a once-daily oral anticoagulant that rapidly and selectively inhibits factor Xa in a concentration-dependent manner. This review describes the extensive clinical development program of edoxaban, including phase III studies in patients with non-valvular atrial fibrillation (NVAF) and symptomatic venous thromboembolism (VTE). The ENGAGE AF-TIMI 48 study (N = 21,105; mean CHADS2 score 2.8) compared edoxaban 60 mg once daily (high-dose regimen) and edoxaban 30 mg once daily (low-dose regimen) with dose-adjusted warfarin [international normalized ratio (INR) 2.0–3.0] and found that both regimens were non-inferior to warfarin in the prevention of stroke and systemic embolism in patients with NVAF. Both edoxaban regimens also provided significant reductions in the risk of hemorrhagic stroke, cardiovascular mortality, major bleeding and intracranial bleeding. The Hokusai-VTE study (N = 8,292) in patients with symptomatic VTE had a flexible treatment duration of 3–12 months and found that following initial heparin, edoxaban 60 mg once daily was non-inferior to dose-adjusted warfarin (INR 2.0–3.0) for the prevention of recurrent VTE, and also had a significantly lower risk of bleeding events. Both studies randomized patients at moderate-to-high risk of thromboembolic events and were further designed to simulate routine clinical practice as much as possible, with edoxaban dose reduction (halving dose) at randomisation or during the study if required, a frequently monitored and well-controlled warfarin group, a well-monitored transition period at study end and a flexible treatment duration in Hokusai-VTE. Given the phase III results obtained, once-daily edoxaban may soon be a key addition to the range of antithrombotic treatment options.
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Affiliation(s)
- Henri Bounameaux
- Department of Internal Medicine, University Hospital of Geneva, Geneva, Switzerland,
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150
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Morillas P, Pallarés V, Fácila L, Llisterri JL, Sebastián ME, Gómez M, Castilla E, Camarasa R, Sandin M, García-Honrubia A. La puntuación CHADS2 como predictor de riesgo de ictus en ausencia de fibrilación auricular en pacientes hipertensos de 65 o más años. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.06.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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