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Deitelzweig S, Farmer C, Luo X, Li X, Vo L, Mardekian J, Fahrbach K, Ashaye A. Comparison of major bleeding risk in patients with non-valvular atrial fibrillation receiving direct oral anticoagulants in the real-world setting: a network meta-analysis. Curr Med Res Opin 2018; 34:487-498. [PMID: 29188721 DOI: 10.1080/03007995.2017.1411793] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To conduct a systematic literature review (SLR) and network meta-analysis (NMA) of real-world studies comparing major bleeding risk among patients with non-valvular atrial fibrillation (NVAF) on direct oral anticoagulants (DOACs) or warfarin. METHODS Systematic searches were conducted in MEDLINE and Embase for full-text articles published between January 1, 2003 and March 18, 2017. Eligible studies compared at least two of the following in a real-world setting: warfarin, apixaban, dabigatran, rivaroxaban, or edoxaban. A Bayesian NMA was conducted to estimate hazard ratios (HRs) for major bleeding using a random-effects model. RESULTS Eleven studies were included in the NMA. Nine studies included DOACs vs Warfarin comparisons, and four studies included DOACs vs DOACs comparisons (two studies included both comparisons). Median follow-up duration ranged from 2.6-31.2 months. No evidence was identified for edoxaban. Apixaban was associated with a significantly lower risk of major bleeding compared to other oral anticoagulants (warfarin HR = 0.58; 95% credible interval [CrI] = 0.48-0.69; dabigatran = 0.73; 0.61-0.87; rivaroxaban = 0.55; 0.46-0.66). Dabigatran was associated with a significantly lower risk than warfarin (0.79; 0.71-0.88) and rivaroxaban (0.76; 0.67-0.85), and rivaroxaban was not statistically different from warfarin (1.05; 0.91-1.19). Sensitivity analyses with standard dose and sponsorship showed consistent results. CONCLUSION DOACs were associated with lower or similar risk of major bleeding compared with warfarin in NVAF patients. Apixaban was associated with a significantly lower risk of major bleeding than other DOACs. Dabigatran was associated with a significantly lower risk of major bleeding compared to rivaroxaban and warfarin.
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Affiliation(s)
- S Deitelzweig
- a Ochsner Clinic Foundation , Department of Hospital Medicine , New Orleans , LA , USA
| | | | - X Luo
- c Pfizer, Inc. , New York , NY , USA
| | - X Li
- d Bristol-Myers Squibb , Lawrenceville , NJ , USA
| | - L Vo
- d Bristol-Myers Squibb , Lawrenceville , NJ , USA
| | | | | | - A Ashaye
- e Evidera, Inc. , Waltham , MA , USA
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Xu K, Chan NC, Eikelboom JW. The value of novel oral anticoagulants in rural Australia. Med J Aust 2018; 208:15-16. [PMID: 29320666 DOI: 10.5694/mja17.00592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/20/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Ke Xu
- Population Health Research Institute, Hamilton, ON, Canada
| | - Noel C Chan
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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103
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Xu XM, Vestesson E, Paley L, Desikan A, Wonderling D, Hoffman A, Wolfe CDA, Rudd AG, Bray BD. The economic burden of stroke care in England, Wales and Northern Ireland: Using a national stroke register to estimate and report patient-level health economic outcomes in stroke. Eur Stroke J 2017; 3:82-91. [PMID: 29900412 PMCID: PMC5992739 DOI: 10.1177/2396987317746516] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/09/2017] [Indexed: 02/02/2023] Open
Abstract
Introduction Stroke registries are used in many settings to measure stroke treatment and
outcomes, but rarely include data on health economic outcomes. We aimed to
extend the Sentinel Stroke National Audit Programme registry of England,
Wales and Northern Ireland to derive and report patient-level estimates of
the cost of stroke care. Methods An individual patient simulation model was built to estimate health and
social care costs at one and five years after stroke, and the cost-benefits
of thrombolysis and early supported discharge. Costs were stratified
according to age, sex, stroke type (ischaemic or primary intracerebral
haemorrhage) and stroke severity. The results were illustrated using data on
all patients with stroke included in Sentinel Stroke National Audit
Programme from April 2015 to March 2016 (n = 84,184). Results The total cost of health and social care for patients with acute stroke each
year in England, Wales and Northern Ireland was £3.60 billion in the first
five years after admission (mean per patient cost: £46,039). There was
fivefold variation in the magnitude of costs between patients, ranging from
£19,101 to £107,336. Costs increased with older age, increasing stroke
severity and intracerebral hemorrhage stroke. Increasing the proportion of
eligible patients receiving thrombolysis or early supported discharge was
estimated to save health and social care costs by five years after
stroke. Discussion The cost of stroke care is large and varies widely between patients.
Increasing the proportion of eligible patients receiving thrombolysis or
early supported discharge could contribute to reducing the financial burden
of stroke. Conclusion Extending stroke registers to report individualised data on costs may enhance
their potential to support quality improvement and research.
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Affiliation(s)
- Xiang-Ming Xu
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Emma Vestesson
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Anita Desikan
- 2Division of Health and Social Care Research, King's College London, London, UK
| | - David Wonderling
- 3National Guidelines Centre, Royal College of Physicians, London, UK
| | - Alex Hoffman
- Sentinel Stroke National Audit Programme, Royal College of Physicians, London, UK
| | - Charles DA Wolfe
- 2Division of Health and Social Care Research, King's College London, London, UK
| | - Anthony G Rudd
- 2Division of Health and Social Care Research, King's College London, London, UK
| | - Benjamin D Bray
- Farr Institute of Health Informatics Research, University College London, London, UK
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104
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López-López JA, Sterne JAC, Thom HHZ, Higgins JPT, Hingorani AD, Okoli GN, Davies PA, Bodalia PN, Bryden PA, Welton NJ, Hollingworth W, Caldwell DM, Savović J, Dias S, Salisbury C, Eaton D, Stephens-Boal A, Sofat R. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ 2017; 359:j5058. [PMID: 29183961 PMCID: PMC5704695 DOI: 10.1136/bmj.j5058] [Citation(s) in RCA: 328] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective To compare the efficacy, safety, and cost effectiveness of direct acting oral anticoagulants (DOACs) for patients with atrial fibrillation.Design Systematic review, network meta-analysis, and cost effectiveness analysis. Data sources Medline, PreMedline, Embase, and The Cochrane Library.Eligibility criteria for selecting studies Published randomised trials evaluating the use of a DOAC, vitamin K antagonist, or antiplatelet drug for prevention of stroke in patients with atrial fibrillation.Results 23 randomised trials involving 94 656 patients were analysed: 13 compared a DOAC with warfarin dosed to achieve a target INR of 2.0-3.0. Apixaban 5 mg twice daily (odds ratio 0.79, 95% confidence interval 0.66 to 0.94), dabigatran 150 mg twice daily (0.65, 0.52 to 0.81), edoxaban 60 mg once daily (0.86, 0.74 to 1.01), and rivaroxaban 20 mg once daily (0.88, 0.74 to 1.03) reduced the risk of stroke or systemic embolism compared with warfarin. The risk of stroke or systemic embolism was higher with edoxaban 60 mg once daily (1.33, 1.02 to 1.75) and rivaroxaban 20 mg once daily (1.35, 1.03 to 1.78) than with dabigatran 150 mg twice daily. The risk of all-cause mortality was lower with all DOACs than with warfarin. Apixaban 5 mg twice daily (0.71, 0.61 to 0.81), dabigatran 110 mg twice daily (0.80, 0.69 to 0.93), edoxaban 30 mg once daily (0.46, 0.40 to 0.54), and edoxaban 60 mg once daily (0.78, 0.69 to 0.90) reduced the risk of major bleeding compared with warfarin. The risk of major bleeding was higher with dabigatran 150 mg twice daily than apixaban 5 mg twice daily (1.33, 1.09 to 1.62), rivaroxaban 20 mg twice daily than apixaban 5 mg twice daily (1.45, 1.19 to 1.78), and rivaroxaban 20 mg twice daily than edoxaban 60 mg once daily (1.31, 1.07 to 1.59). The risk of intracranial bleeding was substantially lower for most DOACs compared with warfarin, whereas the risk of gastrointestinal bleeding was higher with some DOACs than warfarin. Apixaban 5 mg twice daily was ranked the highest for most outcomes, and was cost effective compared with warfarin.Conclusions The network meta-analysis informs the choice of DOACs for prevention of stroke in patients with atrial fibrillation. Several DOACs are of net benefit compared with warfarin. A trial directly comparing DOACs would overcome the need for indirect comparisons to be made through network meta-analysis.Systematic review registration PROSPERO CRD 42013005324.
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Affiliation(s)
- José A López-López
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Jonathan A C Sterne
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Howard H Z Thom
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Julian P T Higgins
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Aroon D Hingorani
- Faculty of Population Health Sciences, University College London, London, UK
| | - George N Okoli
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Philippa A Davies
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Pritesh N Bodalia
- University College London Hospitals NHS Foundation Trust, London, UK
- Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Peter A Bryden
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Deborah M Caldwell
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Jelena Savović
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sofia Dias
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Chris Salisbury
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | | | | | - Reecha Sofat
- Faculty of Population Health Sciences, University College London, London, UK
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105
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Dideriksen D, Damkier P, Nybo M. Rivaroxaban non-responders: do plasma measurements have a place? Clin Chem Lab Med 2017; 56:e16-e18. [PMID: 28688225 DOI: 10.1515/cclm-2017-0473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 01/16/2023]
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106
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Ioannou A, Tsappa I, Metaxa S, Missouris CG. Non-valvular atrial fibrillation: impact of apixaban on patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2017; 8:121-131. [PMID: 29138609 PMCID: PMC5680948 DOI: 10.2147/prom.s117549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.
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Affiliation(s)
- Adam Ioannou
- Cardiology Department, Royal Free NHS Foundation Trust, London, UK
| | - Irene Tsappa
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Sofia Metaxa
- Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
| | - Constantinos G Missouris
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus.,Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
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107
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Jun M, Lix LM, Durand M, Dahl M, Paterson JM, Dormuth CR, Ernst P, Yao S, Renoux C, Tamim H, Wu C, Mahmud SM, Hemmelgarn BR. Comparative safety of direct oral anticoagulants and warfarin in venous thromboembolism: multicentre, population based, observational study. BMJ 2017; 359:j4323. [PMID: 29042362 PMCID: PMC5641962 DOI: 10.1136/bmj.j4323] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective To determine the safety of direct oral anticoagulant (DOAC) use compared with warfarin use for the treatment of venous thromboembolism.Design Retrospective matched cohort study conducted between 1 January 2009 and 31 March 2016.Setting Community based, using healthcare data from six jurisdictions in Canada and the United States.Participants 59 525 adults (12 489 DOAC users; 47 036 warfarin users) with a new diagnosis of venous thromboembolism and a prescription for a DOAC or warfarin within 30 days of diagnosis.Main outcome measures Outcomes included hospital admission or emergency department visit for major bleeding and all cause mortality within 90 days after starting treatment. Propensity score matching and shared frailty models were used to estimate adjusted hazard ratios of the outcomes comparing DOACs with warfarin. Analyses were conducted independently at each site, with meta-analytical methods used to estimate pooled hazard ratios across sites.Results Of the 59 525 participants, 1967 (3.3%) had a major bleed and 1029 (1.7%) died over a mean follow-up of 85.2 days. The risk of major bleeding was similar for DOAC compared with warfarin use (pooled hazard ratio 0.92, 95% confidence interval 0.82 to 1.03), with the overall direction of the association favouring DOAC use. No difference was found in the risk of death (pooled hazard ratio 0.99, 0.84 to 1.16) for DOACs compared with warfarin use. There was no evidence of heterogeneity across centres, between patients with and without chronic kidney disease, across age groups, or between male and female patients.Conclusions In this analysis of adults with incident venous thromboembolism, treatment with DOACs, compared with warfarin, was not associated with an increased risk of major bleeding or all cause mortality in the first 90 days of treatment.Trial registration Clinical trials NCT02833987.
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Affiliation(s)
- Min Jun
- Departments of Medicine and Community Health Sciences, University of Calgary, AB, Canada
- The George Institute for Global Health, Sydney, NSW, Australia
- Faculty of Medicine, UNSW Sydney, NSW, Australia
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, MB, Canada
| | - Madeleine Durand
- Department of Internal Medicine, University of Montreal Health Centre, Montreal, QC, Canada
| | - Matt Dahl
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - J Michael Paterson
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Toronto
| | - Colin R Dormuth
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Pierre Ernst
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Shenzhen Yao
- College of Pharmacy and Nutrition, Department of Pharmacy, University of Saskatchewan, SK, Canada
| | - Christel Renoux
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montréal, QC, Canada
| | - Hala Tamim
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Salaheddin M Mahmud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, AB, Canada
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Barsam SJ, Patel JP, Roberts LN, Kavarthapu V, Patel RK, Green B, Arya R. The impact of body weight on rivaroxaban pharmacokinetics. Res Pract Thromb Haemost 2017; 1:180-187. [PMID: 30046688 PMCID: PMC6058267 DOI: 10.1002/rth2.12039] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 08/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is concern amongst clinicians that the fixed dosing strategy of rivaroxaban for the treatment of venous thromboembolism (VTE) might not be optimal in those patients under or overweight. OBJECTIVE To develop a pharmacokinetic model for rivaroxaban, based on real-world patients, specifically focusing on the impact of patients' body weight on rivaroxaban pharmacokinetics. PATIENTS/METHODS One hundred and one patients prescribed rivaroxaban prophylactic or treatment doses for the prevention or treatment of VTE were recruited at a London teaching hospital. Subjects had up to 3 rivaroxaban concentrations measured during a single dosing period (trough, 1 and 3 hours post dose). Population pharmacokinetic analyses was conducted to develop a rivaroxaban model, which was subsequently evaluated. RESULTS A one-compartment model with between-subject variability on rivaroxaban clearance and volume of distribution, with a combined (additive and proportional) error model, best fitted the data. Following a full covariate analysis, creatinine clearance on rivaroxaban clearance was found to be the significant covariate impacting on the pharmacokinetic profile of rivaroxaban in the dataset. CONCLUSIONS Our results suggest that the most important covariate impacting on rivaroxaban pharmacokinetics is creatinine clearance and the weight alone has little effect. These findings are in line with previous studies for rivaroxaban. Larger datasets, from real-world patients who are followed longitudinally, should be conducted to provide front-line clinicians with further reassurance when prescribing rivaroxaban for the acute management of VTE.
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Affiliation(s)
- Sarah J. Barsam
- Department of Haematological MedicineKing's Thrombosis CentreKing's College Hospital Foundation NHS TrustLondonUK
| | - Jignesh P. Patel
- Department of Haematological MedicineKing's Thrombosis CentreKing's College Hospital Foundation NHS TrustLondonUK
- Institute of Pharmaceutical ScienceKing's College LondonLondonUK
| | - Lara N. Roberts
- Department of Haematological MedicineKing's Thrombosis CentreKing's College Hospital Foundation NHS TrustLondonUK
| | - Venu Kavarthapu
- Department of Orthopaedic SurgeryKing's College Hospital Foundation NHS TrustLondonUK
| | - Raj K. Patel
- Department of Haematological MedicineKing's Thrombosis CentreKing's College Hospital Foundation NHS TrustLondonUK
| | | | - Roopen Arya
- Department of Haematological MedicineKing's Thrombosis CentreKing's College Hospital Foundation NHS TrustLondonUK
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Abstract
INTRODUCTION Atrial Fibrillation (AF) has a worldwide increasing incidence and prevalence, putting patients at risk for atrial thrombus formation and consecutive thromboembolic events. Morbidity and mortality have become a significant global public health care burden. Thus, there is increasing need for safe and effective medical prophylaxis of thromboembolic events. Edoxaban is the fourth approved non-vitamin K oral anticoagulant (NOAC) that has been introduced into the market for the prophylaxis of stroke or systemic embolism in non valvulär AF patients after dabigatran, rivaroxaban, and apixaban. The pivotal phase III clinical trial evaluating safety and efficacy of edoxaban included more than 21,000 patients. Areas covered: The aim of this expert opinion drug safety review is to introduce edoxaban as a compound, to discuss its development, and its pharmacologic properties. Furthermore, efficacy and safety data of edoxaban - with emphasis on a comparison to oral anticoagulation with warfarin and the other currently available NOACs - are discussed. Ongoing studies that further evaluate edoxaban in special patient populations and disease entities are summarized. Expert opinion: Concerning safety and efficacy, medical compliance, adherence and concomitant diseases like renal impairment are of utmost importance in daily clinical practice, why in the expert opinion part of this review emphasis is put on that issue.
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Affiliation(s)
- Matthias Hammwöhner
- a Department of Cardiology and Intensive Care, Medicine , St.Vincenz-Krankenhaus Paderborn , Paderborn , Germany
| | - Andreas Goette
- a Department of Cardiology and Intensive Care, Medicine , St.Vincenz-Krankenhaus Paderborn , Paderborn , Germany
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110
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Severity of Hypertension Correlates with Risk of Thromboembolic Stroke. J Cardiovasc Transl Res 2017; 10:368-373. [PMID: 28567670 DOI: 10.1007/s12265-017-9754-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/16/2017] [Indexed: 10/19/2022]
Abstract
Hypertension plays a significant role in the development of atrial fibrillation (AF) and its complications. The coexistence of the two diseases increases the risk of thromboembolism events. Although CHADS2 and CHA2DS2-VASc scores have been used in the evaluation of the thromboembolism events in AF patients, the different levels of the blood pressure are not appropriately recognized. In this study, the 970 AF patients were divided into three groups according to the severity of hypertension. The CHADS2 and CHA2DS2-VASc scores in the patients of grade 3 hypertension were significantly higher than those of the patients with grade 1 and 2 hypertension, respectively (P < 0.05). Both the CHADS2 and CHA2DS2-VASc scores were positively related to the severity of hypertension (P < 0.001). Our data demonstrated that three grades for hypertensive subjects with AF significantly improved antithrombotic risk stratification in addition to current clinical risk stratification models, such as CHADS2 and CHA2DS2-VASc scores.
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111
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Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
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