151
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Yu HT, Yang PS, Kim TH, Jang E, Kim D, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GY, Joung B. Impact of Renal Function on Outcomes With Edoxaban in Real-World Patients With Atrial Fibrillation. Stroke 2018; 49:2421-2429. [DOI: 10.1161/strokeaha.118.021387] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Edoxaban is a direct oral factor Xa inhibitor with proven efficacy and safety among patients with atrial fibrillation. Concerns have been raised about an excess of stroke among patients with creatinine clearance (CrCl) >95 mg/mL treated with edoxaban. We assessed the real-world effectiveness and safety of edoxaban in atrial fibrillation patients in relation to CrCl.
Methods—
In the Korean National Health Insurance Service data during the period from January to December 2016, we identified 9537 edoxaban-treated patients. Effectiveness and safety outcomes were compared between high-dose edoxaban regimen (HDER, 60 mg daily, n=2840) and a propensity score–matched warfarin group (n=2840) and between low-dose edoxaban regimen (LDER, 30 mg daily, n=3016) and matched warfarin group (n=3016).
Results—
The median follow-up period was 5.0 months (interquartile range, 2–7 months). The mean age was 68 years, and 63% were men in HDER group, and the mean age was 73 years, and 52% were men in LDER group. Compared with warfarin, both HDER and LDER significantly decreased the risk for ischemic stroke or systemic embolism (S/SE; HDER: adjusted hazard ratio [aHR], 0.44; 95% CI, 0.31–0.64; LDER: aHR, 0.57; 95% CI, 0.42–0.78), major bleeding (HDER: aHR, 0.40; 95% CI, 0.26–0.61; LDER: aHR, 0.61; 95% CI, 0.43–0.85), and mortality (HDER: aHR, 0.34; 95% CI, 0.22–0.53; LDER: aHR, 0.55; 95% CI, 0.41–0.73). In patients with CrCl >95 mL/min, the incidence of S/SE was higher with LDER than warfarin and comparable between HDER and warfarin group. There was lower effectiveness for the prevention of S/SE with LDER compared with warfarin at higher CrCl levels (
P
for interaction=0.023).
Conclusions—
In real-world practice, both doses of edoxaban were associated with reduced risks for S/SE, major bleeding, and mortality compared with warfarin. LDER had lower effectiveness for the prevention of S/SE compared with warfarin at higher levels of CrCl (>95 mL/min).
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Affiliation(s)
- Hee Tae Yu
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea (P.-S.Y.)
| | - Tae-Hoon Kim
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Eunsun Jang
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Daehoon Kim
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Jae-Sun Uhm
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Jong-Youn Kim
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Hui-Nam Pak
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Moon-Hyoung Lee
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
| | - Gregory Y.H. Lip
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.)
| | - Boyoung Joung
- From the Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (H.T.Y., T.-H.K., E.J., D.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., G.Y.H.L., B.J.)
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152
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Mahmood M, Lip GY. Anticoagulantes orales no dependientes de la vitamina K para pacientes con fibrilación auricular e insuficiencia renal grave. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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153
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Weir MR, Kreutz R. Influence of Renal Function on the Pharmacokinetics, Pharmacodynamics, Efficacy, and Safety of Non-Vitamin K Antagonist Oral Anticoagulants. Mayo Clin Proc 2018; 93:1503-1519. [PMID: 30286834 DOI: 10.1016/j.mayocp.2018.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 12/17/2022]
Abstract
With the growing integration of non-vitamin K antagonist oral anticoagulants (NOACs) into clinical practice, questions have arisen regarding their use in special populations, including groups that may have been underrepresented in clinical trials. Patients with renal impairment, particularly in the lower echelons of renal function, are one such group. In an effort to elucidate the current evidence regarding the use of NOACs in patients with renal impairment, a systematic assessment of the literature was performed. The MEDLINE database was interrogated for studies and analyses evaluating the influence of renal function on the pharmacokinetics, pharmacodynamics, efficacy, and safety of NOACs published from January 1, 2000, through August 2, 2017. The 82 relevant publications retrieved highlight the diversity in the NOAC class regarding the impact of renal function on drug clearance, drug exposures, and clinical trial outcomes. In several large clinical trials, subgroup analyses revealed no significant differences when patients were stratified by creatinine clearance as a measure of renal function. Efficacy findings, in particular, were largely aligned with the overall population in the included studies. However, relative risks of bleeding were shown to vary, sometimes driven by changes in bleeding event rates in the comparator arm (eg, warfarin, enoxaparin). With few exceptions, minimal influence of mild renal impairment was observed on the relative efficacy and safety of NOACs. Taken together, the evidence suggests that the presence of renal impairment merits careful consideration of anticoagulant choice but should not deter physicians from appropriate use of NOACs.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
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154
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Bracey A, Shatila W, Wilson J. Bleeding in patients receiving non-vitamin K oral anticoagulants: clinical trial evidence. Ther Adv Cardiovasc Dis 2018; 12:361-380. [PMID: 30270775 DOI: 10.1177/1753944718801554] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In optimizing anticoagulation therapy, it is essential to balance treatment efficacy with the major adverse effect of anticoagulant treatment, bleeding risk. This narrative review examines the efficacy and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban compared with standard anticoagulation or placebo. NOAC therapies provide equivalent to superior protection versus standard therapy, with similar or superior safety, and potential benefits in convenience. We will review the phase III evidence for each of the available NOACs in different antithrombotic indications, including atrial fibrillation (in the absence of significant mitral stenosis or mechanical heart valves); prophylaxis of venous thromboembolism (VTE) in patients undergoing orthopedic surgery; and acute and long-term treatment of VTE. Further, we will illustrate scenarios in which the evidence is stronger for a particular agent in the context of the overall positive safety and efficacy profile of NOACs in general. Limitations of the factor Xa inhibitors include the lack of a specific antidote in case of a bleeding emergency (an approved agent is available for reversing the effect of the direct thrombin inhibitor). We discuss the options for mitigating bleeding and describe the ongoing developments towards specific reversal agents. In conclusion, the available data for efficacy and safety, together with reliable pharmacokinetics obviating the need for regular monitoring, indicate that NOACs may offer substantial benefits for patients with nonvalvular atrial fibrillation or VTE.
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Affiliation(s)
- Arthur Bracey
- Baylor St. Luke's Medical Center, 6720 Berner Avenue, Rm P-125, Houston, TX 77030-3411, USA
| | - Wassim Shatila
- Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, Houston, TX, USA
| | - James Wilson
- Texas Heart Institute, Houston, TX, USA.,Baylor St. Luke's Medical Center, Houston, TX, USA
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155
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Carrero JJ, Trevisan M, Sood MM, Bárány P, Xu H, Evans M, Friberg L, Szummer K. Incident Atrial Fibrillation and the Risk of Stroke in Adults with Chronic Kidney Disease: The Stockholm CREAtinine Measurements (SCREAM) Project. Clin J Am Soc Nephrol 2018; 13:1314-1320. [PMID: 30030271 PMCID: PMC6140568 DOI: 10.2215/cjn.04060318] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD have a high risk of atrial fibrillation. Both CKD and atrial fibrillation are associated with higher risk of stroke and death. However, the effect of incident atrial fibrillation on stroke risk among patients with CKD is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study included adults with CKD (eGFR<60 ml/min per 1.73 m2) without previously documented atrial fibrillation who had been in contact with health care in Stockholm, Sweden during 2006-2011. Incident atrial fibrillation was identified by administrative diagnostic codes in outpatient or inpatient care and treated as a time-updated exposure in the analysis of stroke and death risk. Stroke events and deaths were ascertained from regional and national registers with complete coverage. Covariates included demographics, comorbidities, therapeutic procedures, and medications. Multivariable Cox regression analysis and competing risk analysis (accounting for death) were used to estimate the association between incident atrial fibrillation and stroke. RESULTS Among 116,184 adults with CKD, 13,412 (12%) developed clinically recognized atrial fibrillation during a mean follow-up of 3.9 years (interquartile range, 2.3-5.7 years). Incidence of atrial fibrillation increased across lower eGFR strata: from 29.4 to 46.3 atrial fibrillations per 1000 person-years in subjects with eGFR=45-60 and <30 ml/min per 1.73 m2, respectively; 1388 (53.8 per 1000 person-years) cases of stroke and 5592 (205.1 per 1000 person-years) deaths occurred after incident atrial fibrillation compared with 6850 (16.6 per 1000 person-years) cases of stroke and 28,613 (67.5 per 1000 person-years) deaths during periods without atrial fibrillation. After adjustment, incident atrial fibrillation was associated with higher risk of stroke (hazard ratio, 2.00; 95% confidence interval, 1.88 to 2.14) and death (hazard ratio, 1.76; 95% confidence interval, 1.71 to 1.82). This was attributed to both ischemic stroke (hazard ratio, 2.11; 95% confidence interval, 1.96 to 2.28) and intracranial bleeds (hazard ratio, 1.64; 95% confidence interval, 1.42 to 1.90). Stroke risk was similar across all eGFR strata. In competing risk analyses accounting for death, the association between incident atrial fibrillation and stroke was attenuated but remained higher (subhazard ratio, 1.49; 95% confidence interval, 1.39 to 1.60). CONCLUSIONS Patients with CKD who develop atrial fibrillation are at higher risk of stroke and death.
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Affiliation(s)
| | - Marco Trevisan
- Departments of Medical Epidemiology and Biostatistics and
| | - Manish M. Sood
- Division of Nephrology, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Peter Bárány
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Departments of Medical Epidemiology and Biostatistics and
| | - Marie Evans
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Danderyds Hospital, Stockholm, Sweden; and
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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156
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Crass RL, Pai MP. Estimating Renal Function in Drug Development: Time to Take the Fork in the Road. J Clin Pharmacol 2018; 59:159-167. [PMID: 30184267 DOI: 10.1002/jcph.1314] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/15/2018] [Indexed: 01/29/2023]
Abstract
Renal function is the most commonly applied patient-specific quantitative variable used to determine drug doses. Measurement of renal function is not practical in most clinical settings; therefore, clinicians often rely on estimates when making dosing decisions. Similarly, renal function estimates are used to assign subjects in phase 1 pharmacokinetic studies, which inform dosing in late-phase clinical trials and ultimately the product label. The Cockcroft-Gault estimate of creatinine clearance has been the standard renal function metric; however, this paradigm is shifting toward the Modification of Diet in Renal Diseases (MDRD) estimate of the glomerular filtration rate (GFR). The proportion of approved new drug labels with dosing recommendations based on the MDRD equation was 16.7% in 2015, 70.0% in 2016, and 46.7% in 2017. Disharmonious recommendations from the United States Food and Drug Administration and the European Medicines Agency will continue to increase this heterogeneity in the assessment of renal function in drug development and negatively impact industry, health systems, and clinicians. In this review, we discuss the current regulatory guidance for the conduct of renal impairment pharmacokinetic studies and review the implications of this guidance across the medication use system with 3 recently approved antibiotics: ceftazidime/avibactam, delafloxacin, and meropenem/vaborbactam. Finally, we suggest measuring GFR in phase 1 studies and employing the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to integrate data across clinical trials. This will help to harmonize CKD staging, population pharmacokinetic analyses, and dosing by estimated renal function.
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Affiliation(s)
- Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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157
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Parker K, Thachil J. The use of direct oral anticoagulants in chronic kidney disease. Br J Haematol 2018; 183:170-184. [PMID: 30183070 DOI: 10.1111/bjh.15564] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Increasing use of direct oral anticoagulants (DOACs) has made management of non-valvular atrial fibrillation and venous thromboembolism easier in most patients. But the presence of co-existing renal impairment could render the use of DOACs problematic because all of these drugs have varying degrees of renal excretion. In this paper we address misconceptions about the safety and efficacy of DOACs in moderate-severe renal impairment by presenting a summary of the literature from phase III trials and real-world studies. It also addresses the important consideration of correct estimate of renal function for DOAC dosing. It is hoped that the review will serve as a valuable resource for clinicians involved in anticoagulation decision-making in patients with renal impairment to guide the choice of most suitable agent. Accurate dosing is of particular relevance as registry data suggests it is done inconsistently and may be resulting in avoidable thromboembolic and bleeding events.
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Affiliation(s)
- Kathrine Parker
- Department of Pharmacy, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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158
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Roetker NS, Lutsey PL, Zakai NA, Alonso A, Adam TJ, MacLehose RF. All-Cause Mortality Risk with Direct Oral Anticoagulants and Warfarin in the Primary Treatment of Venous Thromboembolism. Thromb Haemost 2018; 118:1637-1645. [PMID: 30103250 DOI: 10.1055/s-0038-1668521] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Oral anticoagulants used for the primary treatment of venous thromboembolism (VTE) include warfarin and the more recently introduced direct oral anticoagulants (DOACs), including rivaroxaban, apixaban, dabigatran and edoxaban. Information on the comparative safety of these medications in routine clinical practice is lacking. We identified patients with diagnoses for VTE and prescriptions for oral anticoagulants using claims data from a large U.S. insurance database from 2012 to 2017. Marginal structural logistic models were used to examine associations between type of oral anticoagulant and risk of all-cause mortality. Of 62,431 enrolees in this analysis, 51% were female and the mean age was 61.9 years. Initial oral anticoagulant prescriptions were for warfarin (n = 35,704), rivaroxaban (n = 21,064) and apixaban (n = 5,663). A total of 1,791 deaths occurred within 6 months of the initial oral anticoagulant prescription. Risk of all-cause mortality was not associated with having a prescription for warfarin versus any DOAC or between any head-to-head DOAC comparisons. Also, associations generally did not vary when stratified by VTE type, sex, age, co-morbidities (including renal disease) or anti-platelet medication use. In this observational study, the associations with all-cause mortality comparing DOACs versus warfarin agree with results from previous clinical trials and observational studies, while the associations for head-to-head DOAC comparisons provide new information on the comparative safety of DOACs. Our findings suggest that other criteria such as patient preference, cost, recurrent VTE risk or bleeding risk should be used when determining the choice of anticoagulant for the primary treatment of VTE.
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Affiliation(s)
- Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States.,OptumLabs Visiting Fellow, Cambridge, Massachusetts, United States.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
| | - Neil A Zakai
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, United States.,Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States
| | - Terrence J Adam
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, United States.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States
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159
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Andrade JG, Hawkins NM, Fordyce CB, Deyell MW, Er L, Djurdjev O, Macle L, Virani SA, Levin A. Variability in Non–Vitamin K Antagonist Oral Anticoagulants Dose Adjustment in Atrial Fibrillation Patients With Renal Dysfunction: The Influence of Renal Function Estimation Formulae. Can J Cardiol 2018; 34:1010-1018. [DOI: 10.1016/j.cjca.2018.04.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/19/2018] [Accepted: 04/19/2018] [Indexed: 12/13/2022] Open
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160
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Lee SR, Choi EK, Han KD, Jung JH, Oh S, Lip GY. Edoxaban in Asian Patients With Atrial Fibrillation. J Am Coll Cardiol 2018; 72:838-853. [DOI: 10.1016/j.jacc.2018.05.066] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 01/17/2023]
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161
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Pappas MA, Vijan S, Rothberg MB, Singer DE. Reducing age bias in decision analyses of anticoagulation for patients with nonvalvular atrial fibrillation - A microsimulation study. PLoS One 2018; 13:e0199593. [PMID: 29995900 PMCID: PMC6040745 DOI: 10.1371/journal.pone.0199593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/11/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Anticoagulation decreases a patient's risk of ischemic stroke and increases the risk of hemorrhage. Decision analyses regarding anticoagulation therefore require that different outcomes be weighted in comparison to one another. Most decision analyses to date have weighted intracranial hemorrhage (ICH) as 1.5 times worse than ischemic stroke, but because death and disability have lifelong impact, the expected impact should vary by life expectancy. Therefore, a fixed weighting ratio leads to age-related bias decision analyses of anticoagulation. We aimed to quantify the relative impact of ICH and ischemic stroke and derive a ratio that allows decision analysis without microsimulation. METHODS We created a microsimulation model to predict QALYs lost due to ICH and ischemic stroke. We then applied a meta-model to predict the ratio of QALYs lost from ICH relative to ischemic stroke. RESULTS Previously-used weighting ratios (1.5) are close to our derived mean weighting ratio (1.60). However, the weighting ratio of QALYs lost from ICH relative to ischemic stroke is sensitive to age and discount rate. Patients at younger ages have higher mean weighting ratios, as do patients with higher discount rates. CONCLUSIONS The ratio of QALYs lost to ICH relative to ischemic stroke varies with age and discount rate. We present a set of such ratios here for use in decision analyses that do not incorporate full microsimulation models. Use of weighting ratios that vary with age, rather than the current fixed ratios, has the potential to reduce age-based bias in decision-making regarding events with lifelong implications. In this case, use of dynamic ratios may change anticoagulation recommendations for patients with nonvalvular atrial fibrillation at relatively low stroke risk.
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Affiliation(s)
- Matthew A. Pappas
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Sandeep Vijan
- Division of General Internal Medicine, Department of Internal Medicine, The University of Michigan Health System, Ann Arbor, Michigan, United States of America
| | - Michael B. Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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162
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Nonvitamin K Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Renal Dysfunction. ACTA ACUST UNITED AC 2018; 71:847-855. [PMID: 29958809 DOI: 10.1016/j.rec.2018.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
Both atrial fibrillation (AF) and chronic kidney disease (CKD) are highly prevalent, especially with increasing age and associated comorbidities, such as hypertension, diabetes, heart failure, and vascular disease. The relationship between both AF and CKD seems to be bidirectional: CKD predisposes to AF while onset of AF seems to lead to progression of CKD. Stroke prevention is the cornerstone of AF management, and AF patients with CKD are at higher risk of stroke, mortality, cardiac events, and bleeding. Stroke prevention requires use of oral anticoagulants, which are either vitamin K antagonists (eg, warfarin), or the nonvitamin K antagonist oral anticoagulants (NOACs). While NOACs have been shown to be effective in mild-to-moderate renal dysfunction, there are a paucity of data regarding NOACs in severe and end-stage renal dysfunction. This review first discusses the evidence for NOACs in CKD. Second, we summarize the current knowledge regarding the efficacy and safety of NOACs to prevent AF-related stroke and systemic embolism in severe and end-stage renal disease.
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163
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State of play and future direction with NOACs: An expert consensus. Vascul Pharmacol 2018; 106:9-21. [DOI: 10.1016/j.vph.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/20/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
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164
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Burlacu A, Genovesi S, Ortiz A, Kanbay M, Rossignol P, Banach M, Malyszko J, Goldsmith D, Covic A. The quest for equilibrium: exploring the thin red line between bleeding and ischaemic risks in the management of acute coronary syndromes in chronic kidney disease patients. Nephrol Dial Transplant 2018; 32:1967-1976. [PMID: 28371905 DOI: 10.1093/ndt/gfx041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/16/2017] [Indexed: 11/13/2022] Open
Abstract
Coronary artery disease and acute coronary syndrome (ACS) are both common in patients with chronic kidney disease (CKD). CKD patients have higher risks of bleeding and thrombosis. However, they remain under-represented in major randomized clinical trials (RCTs), and there is no medical evidence-based foundation on which to issue specific recommendations about the management of ACS in CKD. CKD patients with ACS frequently are diagnosed later, receive fewer acute interventions and are at increased risk of over-dosage of medications and under-prescription/under-performance of interventional treatments than CKD patients without ACS. The lack of RCTs should not discourage reliance on clinical common sense, while clearer decisional algorithms with better outcomes are a priority for urgent development. Future guidelines should further refine the assessment of CKD with ACS while placing much greater emphasis on the correct dosing of medications based on contemporaneous renal function. Until a strategy is designed with specific measures translated into the actual decrease of bleeding risk, providers will be forced to balance the equilibrium on a thin red line that is not clearly established.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan Bicocca and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques, Plurithématique 14-33, Inserm U1116, CHRU Nancy, France.,Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Jolanta Malyszko
- 2nd Department of Nephrology, Medical University, Bialystok, Poland
| | - David Goldsmith
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK
| | - Adrian Covic
- 'Grigore T. Popa' University of Medicine, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. Parhon' University Hospital, Iasi, Romania
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165
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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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166
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Mohebbi N. [The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease]. PRAXIS 2018; 107:683-687. [PMID: 29921184 DOI: 10.1024/1661-8157/a003005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.
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Affiliation(s)
- Nilufar Mohebbi
- 1 Klinik für Nephrologie, Universitätsspital Zürich und Praxis und Dialysezentrum Zürich-City
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167
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Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular. Med Clin (Barc) 2018; 150 Suppl 1:8-24. [DOI: 10.1016/s0025-7753(18)30666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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168
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Li YG, Pastori D, Lip GYH. Fitting the right non-vitamin K antagonist oral anticoagulant to the right patient with non-valvular atrial fibrillation: an evidence-based choice. Ann Med 2018; 50:288-302. [PMID: 29608110 DOI: 10.1080/07853890.2018.1460489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia and is associated with an increased risk of ischemic stroke (IS) and systemic embolism (SE). Stroke prevention is a key element for the overall management of AF patients. The non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, apixaban and edoxaban, are at least as effective as warfarin in reducing IS/SE with a lower rate of major bleeding. Various analyses from the large Phase III randomized trials demonstrated different efficacy and safety of NOACs in specific subgroups of patients. The randomized trials are supplemented by effectiveness and safety data from real-world observational cohorts following the availability of these drugs for use in everyday clinical practice. Given the clinical heterogeneity of AF patients, the available data from trials and real-world studies allow us to fit the right NOAC to the particular patient's characteristics, with the aim of optimizing outcomes for the individual patient. This review article aims to provide a summary of the evidence on the performance of NOACs in AF patients with specific clinical characteristics. Evidence-based suggestions are presented to provide a simple and viable strategy for clinicians for the choice of a particular NOAC. KEY MESSAGE Given the different performance of the new-oral anticoagulants in patients with the different clinical situation, evidence-based choice of fitting the right new-oral anticoagulants to the patients is provided in this review article.
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Affiliation(s)
- Yan-Guang Li
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Department of Cardiology , Chinese PLA General Hospital, Chinese PLA Medical School , Beijing , China
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome, Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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169
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Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72:717-727. [PMID: 29728318 DOI: 10.1053/j.ajkd.2018.02.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN.
| | - Rachel Stoecker
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, MN
| | - Allyson Hart
- Division of Nephrology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
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170
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Aisenberg J, Chatterjee-Murphy P, Friedman Flack K, Weitz JI, Ruff CT, Nordio F, Mercuri MF, Choi Y, Antman EM, Braunwald E, Giugliano RP. Gastrointestinal Bleeding With Edoxaban Versus Warfarin. Circ Cardiovasc Qual Outcomes 2018; 11:e003998. [DOI: 10.1161/circoutcomes.117.003998] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
Affiliation(s)
- James Aisenberg
- Department of Medicine, Icahn School of Medicine, Mount Sinai Medical Center, New York, NY (J.A., P.C.-M.)
| | - Prapti Chatterjee-Murphy
- Department of Medicine, Icahn School of Medicine, Mount Sinai Medical Center, New York, NY (J.A., P.C.-M.)
| | | | - Jeffrey I. Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada (J.I.W.)
| | - Christian T. Ruff
- TIMI Study Group, Division of Cardiovascular Medicine and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (C.T.R., F.N., E.M.A., E.B., R.P.G.)
| | - Francesco Nordio
- TIMI Study Group, Division of Cardiovascular Medicine and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (C.T.R., F.N., E.M.A., E.B., R.P.G.)
| | | | - Youngsook Choi
- Daiichi Sankyo Pharma Development, Basking Ridge, NJ (M.F.M., Y.C.)
| | - Elliott M. Antman
- TIMI Study Group, Division of Cardiovascular Medicine and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (C.T.R., F.N., E.M.A., E.B., R.P.G.)
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (C.T.R., F.N., E.M.A., E.B., R.P.G.)
| | - Robert P. Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (C.T.R., F.N., E.M.A., E.B., R.P.G.)
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171
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Hijazi Z, Hohnloser SH, Oldgren J, Andersson U, Connolly SJ, Eikelboom JW, Ezekowitz MD, Reilly PA, Yusuf S, Wallentin L. Efficacy and safety of dabigatran compared with warfarin in patients with atrial fibrillation in relation to renal function over time-A RE-LY trial analysis. Am Heart J 2018; 198:169-177. [PMID: 29653640 DOI: 10.1016/j.ahj.2017.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/25/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Ulrika Andersson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | | | | | - Paul A Reilly
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Canada
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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172
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Olivera P, Gabilondo M, Constans M, Tàssies D, Plensa E, Pons V, Las Heras G, Jiménez C, Campoy D, Bustins A, Oliver A, Marzo C, Canals T, Varela A, Sorigue M, Sánchez E, Ene G, Perea G, Vicente L, López M, Cerdá M, Johansson E, Aguinaco MR, Santos N, Mateo J, Reverter JC, Moya Á, Santamaría A. Tromboc@t Working Group recommendations for management in patients receiving direct oral anticoagulants. Med Clin (Barc) 2018; 151:210.e1-210.e13. [PMID: 29602444 DOI: 10.1016/j.medcli.2018.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/07/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES In recent years, direct oral anticoagulants (DOACs) have become an alternative to vitamin K antagonists (VKA) for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) as well as for prevention and treatment of deep venous thrombosis. Pivotal trials have demonstrated non-inferiority and potential superiority compared to warfarin, which increases the options of anticoagulant treatment. In our setting, the Anticoagulant Treatment Units (ATUs) and Primary Care Centres (PCCs) play an important role in the education, follow-up, adherence control and management in special situations of anticoagulated patients. These considerations have motivated us to elaborate the present consensus document that aims to establish clear recommendations that incorporate the findings of scientific research into clinical practice to improve the quality of care in the field of anticoagulation. MATERIAL AND METHODS A group of experts from the Catalan Thrombosis Group (TROMBOC@T) reviewed all published literature from 2009 to 2016, in order to provide recommendations based on clinical evidence. RESULTS As a result of the project, a set of practical recommendations have been established that will facilitate treatment, education, follow-up and management in special situations of anticoagulated patients with ACODs. CONCLUSIONS Progressive increase in the use of DOACs calls for measures to establish and homogenise clinical management guidelines for patients anticoagulated with DOACs in ATUs and PCCs.
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Affiliation(s)
- Pável Olivera
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Miren Gabilondo
- Departamento de Hematología, Hospital Universitario Araba Txagorritxu, Vitoria, España
| | - Mireia Constans
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Dolors Tàssies
- Unidad de Hemostasia y Trombosis, Departamento de Hemoterapia y Hemostasia (ICMHO), Hospital Clínic, Barcelona, España
| | - Esther Plensa
- Departamento de Hematología, Consorci Sanitari del Maresme, Mataró, España
| | - Verónica Pons
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Germán Las Heras
- Departamento de Hematología, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, España
| | - Carmen Jiménez
- Departamento de Hematología, Hospital del Mar , Barcelona, España
| | - Desirée Campoy
- Departamento de Hematología, Hospital Universitari Sagrat Cor, Barcelona, España
| | - Anna Bustins
- Departamento de Hematología, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Artur Oliver
- Departamento de Hematología, Fundació Puigvert, Barcelona, España
| | - Cristina Marzo
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Tania Canals
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Anna Varela
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Marc Sorigue
- Unidad de Trombosis y Hemostasia, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Eva Sánchez
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Gabriela Ene
- Departamento de Hematología, Hospital Sant Joan de Déu de Martorell , España
| | - Granada Perea
- Departemento de Hematología, Corporació Sanitaria Parc Taulí, Sabadell, España
| | - Laura Vicente
- Departamento de Hematología, Consorci Sanitari de Terrasa - Hospital de Terrasa, , España
| | - Meritxell López
- Departamento de Hematología, Hospital Universitario Mútua Terrassa, España
| | - María Cerdá
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Erik Johansson
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - M Reyes Aguinaco
- Departamento de Hematología, Hospital Universitari Joan XXIII , Tarragona, España
| | - Nazly Santos
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - José Mateo
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - Ángel Moya
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Amparo Santamaría
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España.
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173
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Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction. Nat Rev Nephrol 2018; 14:337-351. [PMID: 29578207 DOI: 10.1038/nrneph.2018.19] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are increasingly prevalent in the general population and share common risk factors such as older age, hypertension and diabetes mellitus. The presence of CKD increases the risk of incident AF, and, likewise, AF increases the risk of CKD development and/or progression. Both conditions are associated with substantial thromboembolic risk, but patients with advanced CKD also exhibit a paradoxical increase in bleeding risk. In the landmark randomized clinical trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for thromboprophylaxis in patients with AF, the efficacy and safety of NOACs in patients with mild-to-moderate CKD were similar to those in patients without CKD. Dose adjustment of NOACs as per the prescribing label is required in this population. Owing to limited trial data, evidence-based recommendations for the management of patients with AF and severe CKD or end-stage renal disease on dialysis are lacking. Observational cohort studies have reported conflicting results, and the management of these particularly vulnerable patients remains challenging and requires careful assessment of stroke and bleeding risk and, where appropriate, use of warfarin with good-quality anticoagulation control.
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174
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Novel oral anticoagulants in chronic kidney disease: ready for prime time? Curr Opin Nephrol Hypertens 2018; 27:201-208. [PMID: 29570468 DOI: 10.1097/mnh.0000000000000410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease (CKD) are at increased risk of atrial fibrillation, stroke, and bleeding posing unique clinical challenges. Novel oral anticoagulants (NOACs) including dabigatran, rivaroxaban, and apixaban have become recognized as alternative therapy to Vitamin K Antagonists (VKA) regarding the prevention of venous thromboembolism (VTE) and reduce the risk of stroke in atrial fibrillation. However, the understanding of NOACs in CKD is still underdeveloped. This review summarizes recent literature on the efficacy and safety of NOACs in patients with CKD. RECENT FINDINGS Studies focusing on patients with moderate kidney disease were drawn from post hoc analyses from three major NOAC trials, meta-analyses, and postmarketing surveillance studies. Cumulatively, these studies continue to demonstrate NOACs as equivalent if not superior therapies to VKAs in regards to both efficacy and safety. These studies are limited by small sample sizes as well as a lack of direct comparison between NOACs. SUMMARY The role of NOACs in managing VTE and atrial fibrillation is increasing. Current research suggests that NOACs are at least as efficacious and well tolerated as VKAs. More research is required to elucidate which NOAC is preferable in the clinical setting.
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175
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Georg Haeusler K, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H, Lip GYH, Weitz J, Fauchier L, Lane D, Boriani G, Goette A, Keegan R, MacFadyen R, Chiang CE, Joung B, Shimizu W. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. Europace 2018; 20:1231-1242. [DOI: 10.1093/europace/euy054] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité - Universitätsmedizin Berlin
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin, Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George’s University, London, UK; Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Antwerp University and University Hospital, Antwerp, Belgium
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Feldberg J, Patel P, Farrell A, Sivarajahkumar S, Cameron K, Ma J, Battistella M. A systematic review of direct oral anticoagulant use in chronic kidney disease and dialysis patients with atrial fibrillation. Nephrol Dial Transplant 2018; 34:265-277. [DOI: 10.1093/ndt/gfy031] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jordanne Feldberg
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Param Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | | | - Karen Cameron
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Jennifer Ma
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
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Hsu JC, Freeman JV. Underuse of Vitamin K Antagonist and Direct Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation: A Contemporary Review. Clin Pharmacol Ther 2018; 104:301-310. [DOI: 10.1002/cpt.1024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/20/2017] [Accepted: 01/07/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Jonathan C. Hsu
- University of California San Diego Medical Center; La Jolla California USA
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Chen ST, Patel MR. Comparison of Anticoagulant Therapy for Atrial Fibrillation - Novel Oral Anticoagulants Versus Vitamin K Antagonists. Prog Cardiovasc Dis 2018; 60:514-523. [PMID: 29339167 DOI: 10.1016/j.pcad.2018.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/15/2022]
Abstract
In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulation is important for prevention of stroke and systemic embolism (SE). While Vitamin K antagonists (VKAs) have historically been the standard of care, these medications are limited by numerous food and drug interactions with onerous requirements for frequent monitoring and dose adjustments. Over the past decade, several novel oral anticoagulants (NOACs) have been developed to directly inhibit factor IIa/thrombin (dabigatran) or activated factor X (apixaban, rivaroxaban, edoxaban). These medications have been shown to be at least as effective as warfarin for stroke prevention in NVAF with more favorable safety profiles. However, their advantages are underscored by a lack of specific antidotes and assays quantifying their anticoagulant effects. This paper addresses the use of NOACs compared to VKAs in patients with NVAF, with a special focus on high-risk populations, including the elderly, those with renal disease, diabetes mellitus, coronary artery disease, and previous stroke. The current literature surrounding special clinical scenarios including the treatment of bleeding, perioperative management, and the use of NOACs in cardioversion and catheter ablation will be also discussed.
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Affiliation(s)
- Sean T Chen
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States.
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Sabbag A, Yao X, Siontis KC, Noseworthy PA. Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges. Korean Circ J 2018; 48:873-889. [PMID: 30238705 PMCID: PMC6158453 DOI: 10.4070/kcj.2018.0261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022] Open
Abstract
The burden of atrial fibrillation (AF) is projected to increase substantially over the next decade in parallel with the aging of the population. The increasing age, level of comorbidity, and polypharmacy will complicate the treatment of older adults with AF. For instance, advanced age and chronic kidney disease have been shown to increase the risk of both thromboembolism and bleeding in patients with AF. Frailty, recurrent falls and polypharmacy, while very common among elderly patients with AF, are often overlooked in the clinical decision making despite their significant interaction with oral anticoagulant (OAC) and profound impact on the patient's clinical outcomes. Such factors should be recognized, evaluated and considered in a comprehensive decision-making process. The introduction of non-vitamin K oral anticoagulants has radically changed the management of AF allowing for a more individualized selection of OAC. An understanding of the available data regarding the performance of each of the available OAC in a variety of at risk patient populations is paramount for the safe and effective management of this patient population. The aim of this review is to appraise the current evidence, point out the gaps in knowledge, and provide recommendations regarding stroke prevention in older adults with AF and comorbid conditions.
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Affiliation(s)
- Avi Sabbag
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease. Am J Cardiol 2018; 121:131-140. [PMID: 29132650 DOI: 10.1016/j.amjcard.2017.09.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/08/2017] [Accepted: 09/11/2017] [Indexed: 12/11/2022]
Abstract
Over the past decade, there have been tremendous advancements in anticoagulation therapies for stroke prevention in patients with atrial fibrillation (AF). Although the non-vitamin K antagonist oral anticoagulants (NOACs) demonstrated favorable clinical outcomes compared with warfarin overall, the decision to anticoagulate and the choice of appropriate agent in patients with AF and concomitant chronic kidney disease (CKD) or end-stage renal disease (ESRD) are a particularly complex issue. CKD and ESRD increase both the risk of stroke and bleeding, and since all of the NOACs undergo various levels of renal clearance, renal dysfunction inevitably affects the pharmacokinetics of the drug in each patient. Furthermore, the randomized controlled clinical trials of each NOAC versus warfarin often did not include patients with advanced CKD or ESRD. In this focused review, we describe the available evidence supporting the use of NOACs for prevention of stroke in patients with AF with concomitant advanced CKD or ESRD. Although questions of safety and appropriate use of these new agents in CKD and ESRD remain, NOACs offer a significant step forward in the anticoagulation management of at-risk patients with AF.
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Abstract
Direct oral anticoagulants (DOACs) are increasingly prescribed substances in patients with indication for effective anticoagulation. Patients with chronic kidney disease (CKD) have a high burden of cardiovascular risk and are more likely to develop atrial fibrillation (AF) than patients without CKD. Patients with mild to moderate CKD benefit from DOACs, especially when having intolerance to vitamin K-antagonists (VKA). DOACs may in some cases be considered in patients with rare renal disease and hypercoagulabilic state. DOACs are to a large extent eliminated by renal excretion. Since prospective randomised data in CKD patients are sparse, the decision for anticoagulative therapy is challenging especially in patients with severe renal impairment. The direct factor Xa-inhibitors are approved for use even in patients with an estimated glomerular filtration rate (eGFR) between 15 and 30 ml/min. Careful monitoring of renal function on a regular basis is essential before initiation and after start of DOAC, especially for patients at risk for acute renal failure (elderly, diabetics, patients with preexisting kidney disease). None of the DOACs is approved in CKD patients with end-stage-renal-disease (ESRD) with or without dialysis. DOACs are not recommended for kidney transplant patients under immunosuppression with calcineurin inhibitors. In these patients conventional therapy with VKA is the only option, which has to be monitored closely since it has potential adverse effects.
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Stamellou E, Floege J. Novel oral anticoagulants in patients with chronic kidney disease and atrial fibrillation. Nephrol Dial Transplant 2017; 33:1683-1689. [DOI: 10.1093/ndt/gfx322] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/14/2017] [Indexed: 02/03/2023] Open
Affiliation(s)
- Eleni Stamellou
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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Pottegård A, Grove EL, Hellfritzsch M. Use of direct oral anticoagulants in the first year after market entry of edoxaban: A Danish nationwide drug utilization study. Pharmacoepidemiol Drug Saf 2017; 27:174-181. [DOI: 10.1002/pds.4350] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/02/2017] [Accepted: 10/10/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Erik L. Grove
- Department of Cardiology; Aarhus University Hospital; Aarhus Denmark
- Department of of Clinical Medicine, Faculty of Health; Aarhus University; Aarhus Denmark
| | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
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Kimachi M, Furukawa TA, Kimachi K, Goto Y, Fukuma S, Fukuhara S. Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database Syst Rev 2017; 11:CD011373. [PMID: 29105079 PMCID: PMC6485997 DOI: 10.1002/14651858.cd011373.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an independent risk factor for atrial fibrillation (AF), which is more prevalent among CKD patients than the general population. AF causes stroke or systemic embolism, leading to increased mortality. The conventional antithrombotic prophylaxis agent warfarin is often prescribed for the prevention of stroke, but risk of bleeding necessitates regular therapeutic monitoring. Recently developed direct oral anticoagulants (DOAC) are expected to be useful as alternatives to warfarin. OBJECTIVES To assess the efficacy and safety of DOAC including apixaban, dabigatran, edoxaban, and rivaroxaban versus warfarin among AF patients with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register (up to 1 August 2017) through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) which directly compared the efficacy and safety of direct oral anticoagulants (direct thrombin inhibitors or factor Xa inhibitors) with dose-adjusted warfarin for preventing stroke and systemic embolic events in non-valvular AF patients with CKD, defined as creatinine clearance (CrCl) or eGFR between 15 and 60 mL/min (CKD stage G3 and G4). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed quality, and extracted data. We calculated the risk ratio (RR) and 95% confidence intervals (95% CI) for the association between anticoagulant therapy and all strokes and systemic embolic events as the primary efficacy outcome and major bleeding events as the primary safety outcome. Confidence in the evidence was assessing using GRADE. MAIN RESULTS Our review included 12,545 AF participants with CKD from five studies. All participants were randomised to either DOAC (apixaban, dabigatran, edoxaban, and rivaroxaban) or dose-adjusted warfarin. Four studies used a central, interactive, automated response system for allocation concealment while the other did not specify concealment methods. Four studies were blinded while the other was partially open-label. However, given that all studies involved blinded evaluation of outcome events, we considered the risk of bias to be low. We were unable to create funnel plots due to the small number of studies, thwarting assessment of publication bias. Study duration ranged from 1.8 to 2.8 years. The large majority of participants included in this study were CKD stage G3 (12,155), and a small number were stage G4 (390). Of 12,545 participants from five studies, a total of 321 cases (2.56%) of the primary efficacy outcome occurred per year. Further, of 12,521 participants from five studies, a total of 617 cases (4.93%) of the primary safety outcome occurred per year. DOAC appeared to probably reduce the incidence of stroke and systemic embolism events (5 studies, 12,545 participants: RR 0.81, 95% CI 0.65 to 1.00; moderate certainty evidence) and to slightly reduce the incidence of major bleeding events (5 studies, 12,521 participants: RR 0.79, 95% CI 0.59 to 1.04; low certainty evidence) in comparison with warfarin. AUTHORS' CONCLUSIONS Our findings indicate that DOAC are as likely as warfarin to prevent all strokes and systemic embolic events without increasing risk of major bleeding events among AF patients with kidney impairment. These findings should encourage physicians to prescribe DOAC in AF patients with CKD without fear of bleeding. The major limitation is that the results of this study chiefly reflect CKD stage G3. Application of the results to CKD stage G4 patients requires additional investigation. Furthermore, we could not assess CKD stage G5 patients. Future reviews should assess participants at more advanced CKD stages. Additionally, we could not conduct detailed analyses of subgroups and sensitivity analyses due to lack of data.
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Affiliation(s)
- Miho Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Kimihiko Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Yoshihito Goto
- Kyoto University School of Public HealthDepartment of Health InformaticsYoshida Konoecho, Sakyo‐kuKyotoJapan606‐8501
| | - Shingo Fukuma
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Shunichi Fukuhara
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
- Fukushima Medical UniversityCenter for Innovative Research for Communities and Clinical ExcellenceFukushimaJapan
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Lip GYH, Al-Saady N, Ezekowitz MD, Banach M, Goette A. The relationship of renal function to outcome: A post hoc analysis from the EdoxabaN versus warfarin in subjectS UndeRgoing cardiovErsion of Atrial Fibrillation (ENSURE-AF) study. Am Heart J 2017; 193:16-22. [PMID: 29129251 DOI: 10.1016/j.ahj.2017.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/16/2017] [Indexed: 01/05/2023]
Abstract
The ENSURE-AF study (NCT 02072434) of anticoagulation for electrical cardioversion in nonvalvular atrial fibrillation (NVAF) showed comparable low rates of bleeding and thromboembolism between the edoxaban and the enoxaparin-warfarin treatment arms. This post hoc analysis investigated the relationship between renal function and clinical outcomes. METHODS ENSURE-AF was a multicenter, PROBE evaluation trial of edoxaban 60 mg, or dose reduced to 30 mg/d for weight≤60 kg, creatinine clearance (CrCl; Cockcroft-Gault) ≤50 mL/min, or concomitant P-glycoprotein inhibitors compared with therapeutically monitored enoxaparin-warfarin in 2,199 NVAF patients undergoing electrical cardioversion. Efficacy and safety outcomes and time in therapeutic range in the warfarin arm were analyzed in relation to CrCl in prespecified ranges ≥15 and ≤30, >30 and ≤50, >50 and <80, and ≥80 mL/min, and an exploratory ≥95-mL/min analysis. RESULTS A total of 1,095 subjects were randomized to edoxaban and 1,104 to enoxaparin-warfarin. Mean age was 64.3±10 and 64.2±11 years. Mean time in therapeutic range was progressively lower with reducing CrCl strata, being 66.8% in those with CrCl >30 to ≤50 compared with 71.8% in those with CrCl ≥80. The odds ratios for the primary efficacy and safety end points were comparable for the different predefined renal function strata; given the small numbers, the 95% CI included 1.0. In the subset of those with CrCl ≥95, the odds ratios showed consistency with the other CrCl strata. When CrCl was assessed as a continuous variable, there was a nonsignificant trend toward higher major or clinically relevant nonmajor bleeding with reducing CrCl levels, with no significant differences between the 2 treatment arms. When we assessed CrCl at baseline compared with end of treatment, there were no significant differences in CrCl change between the edoxaban and enoxaparin-warfarin arms. The proportions with worsening of renal function (defined as a decrease of >20% from baseline) were similar in the 2 treatment arms. CONCLUSION Given the small number of events in ENSURE-AF, no effect of renal (dys)function was demonstrated in comparing edoxaban to enoxaparin-warfarin for cardioversion; efficacy and safety of edoxaban remained consistent even in patients with normal or supranormal renal function.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Naab Al-Saady
- Cardiovascular/Metabolic, Covance Inc, Osprey House, Maidenhead Park Office, Westacott Way, Littlewick Green, Maidenhead, United Kingdom
| | - Michael D Ezekowitz
- Department of Cardiovascular Medicine, Sidney Kimmel Jefferson Medical College at Thomas Jefferson University and Lankenau Medical Center, 1999 Sproul Rd, Suite 26, Broomall, PA, United States
| | | | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Am Busdorf 2, Paderborn, Nordrhein-Westfalen, Germany, and Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
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Zou R, Tao J, Shi W, Yang M, Li H, Lin X, Yang S, Hua P. Meta-analysis of safety and efficacy for direct oral anticoagulation treatment of non-valvular atrial fibrillation in relation to renal function. Thromb Res 2017; 160:41-50. [PMID: 29096154 DOI: 10.1016/j.thromres.2017.10.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 09/20/2017] [Accepted: 10/19/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We performed a meta-analysis of the safety and efficacy of anticoagulation treatment for atrial fibrillation (AF) in relation to renal function. We also examined the change in estimated glomerular filtration rate (eGFR) from baseline and compared the outcomes for patients with stable and worsening renal function. MATERIALS AND METHODS We selected studies that used randomized controlled trials in which outcomes for direct oral anticoagulants (DOACs) (dabigatran, rivaroxaban, apixaban, or edoxaban) were compared with those for warfarin in AF patients with normal, mild or moderate renal function, except the severe one (creatinine clearance<30). RESULTS We assessed five clinical trials, involving 72,608 patients. Pooled analysis indicated that the risk of stroke was lower for DOACs than for warfarin among patients with mild renal impairment (Risk ratio, 0.79; 95% confidence interval, 0.68-0.91) and moderate renal impairment (0.80, 0.69-0.92). No major differences were found in patients with normal renal function. Additionally, DOACs were associated with fewer major bleeds among patients with normal (0.77, 0.70-0.84), mild (0.86, 0.77-0.95), and moderate renal impairment (0.73, 0.65-0.82). Among those treated with DOACs, a lower dosage was associated with lower risk of major bleeding (0.75, 0.68-0.83) and higher risk of stroke or systemic embolism (1.28, 1.12-1.47). Further, DOACs tended to be associated with a lower estimated glomerular filtration rate (eGFR) than warfarin even after 30months. Finally, we found significant differences in the risk of stroke (2.09, 1.64-2.68) and major bleeding (2.01, 1.66-2.42) between patients with stable and worsening renal function. CONCLUSIONS DOACs have a greater clinical benefit than warfarin with respect to renal function. They are associated with a comparatively lower risk of stroke and major bleeding, as well lower eGFR. This suggests these agents are a better choice in patients with renal disease.
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Affiliation(s)
- Rongjun Zou
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Jun Tao
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Wanting Shi
- Department of gastroenterology, Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Minglei Yang
- Department of Genetics, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Hongmu Li
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Xifeng Lin
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Songran Yang
- The Biobank of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China; Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China.
| | - Ping Hua
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.
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Ueberham L, Dagres N, Potpara TS, Bollmann A, Hindricks G. Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation. Adv Ther 2017; 34:2274-2294. [PMID: 28956288 PMCID: PMC5656712 DOI: 10.1007/s12325-017-0616-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.
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Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany.
| | - Nikolaos Dagres
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Bollmann
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
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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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189
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Renal Function Considerations for Stroke Prevention in Atrial Fibrillation. Am J Med 2017; 130:1015-1023. [PMID: 28502818 DOI: 10.1016/j.amjmed.2017.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/14/2017] [Accepted: 04/18/2017] [Indexed: 01/13/2023]
Abstract
Renal impairment increases risk of stroke and systemic embolic events and bleeding in patients with atrial fibrillation. Direct oral anticoagulants (DOACs) have varied dependence on renal elimination, magnifying the importance of appropriate patient selection, dosing, and periodic kidney function monitoring. In randomized controlled trials of nonvalvular atrial fibrillation, DOACs were at least as effective and associated with less bleeding compared with warfarin. Each direct oral anticoagulant was associated with reduced risk of stroke and systemic embolic events and major bleeding compared with warfarin in nonvalvular atrial fibrillation patients with mild or moderate renal impairment. Renal function decrease appears less impacted by DOACs, which are associated with a better risk-benefit profile than warfarin in patients with decreasing renal function over time. Limited data address the risk-benefit profile of DOACs in patients with severe impairment or on dialysis.
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190
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Norby FL, Alonso A. Comparative effectiveness of rivaroxaban in the treatment of nonvalvular atrial fibrillation. J Comp Eff Res 2017; 6:549-560. [PMID: 28737102 DOI: 10.2217/cer-2017-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, a common arrhythmia. In this review, we summarize the effectiveness of rivaroxaban versus warfarin and the DOACs dabigatran, apixaban and edoxaban. The primary focus is on primary evidence from clinical trials, indirect comparison studies and real-world studies. While there are gaps in the literature, the evidence thus far indicates that rivaroxaban is superior to warfarin and similar to dabigatran, apixaban and edoxaban for the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation, although rivaroxaban may be associated with an elevated bleeding risk compared with other DOACs.
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Affiliation(s)
- Faye L Norby
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
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Chiang CE, Okumura K, Zhang S, Chao TF, Siu CW, Wei Lim T, Saxena A, Takahashi Y, Siong Teo W. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm 2017; 33:345-367. [PMID: 28765771 PMCID: PMC5529598 DOI: 10.1016/j.joa.2017.05.004] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/29/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2-fold increase in mortality and a 5-fold increase in stroke. The Asian population is rapidly aging, and in 2050, the estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF-associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF-associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non-vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub-committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub-committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People׳s Republic of China
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore
| | - Anil Saxena
- Cardiac Pacing & Electrophysiology Center, Fortis Escorts Heart Institute, New Delhi, India
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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192
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Abstract
The nonvitamin K antagonist oral anticoagulants (NOACs), also referred to as
direct oral anticoagulants (DOACs), dabigatran, apixaban, edoxaban, and
rivaroxaban, have emerged as effective alternatives to vitamin K antagonists
(VKAs) across several indications, including the prevention of stroke and
systemic embolism (SSE) in patients with atrial fibrillation (AF) and the
treatment of venous thromboembolism (VTE). Their use in patients with renal
impairment is of particular importance, given the prevalence of renal
dysfunction in the indicated populations and the impact of renal function on the
metabolism of the NOACs. This publication reviews the
pharmacokinetic/pharmacodynamic properties of the NOACs and clinical trial
results for patients with renal impairment within the AF and VTE indications.
Pharmacokinetic/pharmacodynamic data show the NOACs are dependent on renal
clearance to varying extents. Relative to VKAs, the efficacy and safety of the
NOACs is preserved in patients with moderate renal impairment. The dosing
recommendations for patients with renal impairment differ depending on the NOAC,
whereby some of the NOACs require dose reductions based solely on renal
function, while others require consideration of additional criteria. However,
despite these specific dosing recommendations, emerging real-world evidence
suggests patients are not being dosed appropriately, indicating a possible
knowledge gap. Adherence to recommended dosing algorithms has implications on
the optimal efficacy and safety of the NOACs. To this end, renal function should
be assessed in patients on a NOAC, as worsening of renal function may warrant
change in the dose of a NOAC or change in oral anticoagulant.
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193
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Abstract
Four non-vitamin K oral anticoagulants (NOACs) are now licensed and available in the UK, offering unprecedented choices in anticoagulant therapy for clinicians and patients. NOACs have many clear benefits over warfarin, the most striking being the reduction in intracranial haemorrhage. However, a number of uncertainties remain: their efficacy in certain situations, utility of drug assays, significance of drug interactions and management of bleeding. In the absence of any direct comparative trials, it is not clear that any of the NOACs is significantly better than the others in any of the licensed indications. The differential activities, pharmacokinetics, metabolism, excretion and side effects of the agents should be considered when selecting the most appropriate anticoagulant. In this article, we discuss how, with careful selection for the relevant indication, NOACs can simplify therapy while improving outcomes. We aim to provide clinicians with the information needed to select the most suitable anticoagulant drug for an individual patient in a given situation.
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Affiliation(s)
- Carolyn M Millar
- Imperial College, London, UK and consultant haematologist, Imperial College Healthcare NHS Trust, London, UK
| | - Mike A Laffan
- Imperial College, London, UK and honorary consultant in haematology, Imperial College Healthcare NHS Trust, London, UK
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194
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Larkin JW, Chan KE. Warfarin, Atrial Fibrillation, and CKD: Effective and Safe, but Soon Extinct? Am J Kidney Dis 2017; 69:720-722. [DOI: 10.1053/j.ajkd.2017.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/11/2022]
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195
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Bo M, Grisoglio E, Brunetti E, Falcone Y, Marchionni N. Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence. Eur J Intern Med 2017; 41:18-27. [PMID: 28343849 DOI: 10.1016/j.ejim.2017.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrica Grisoglio
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Yolanda Falcone
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, University of Florence, Florence, Italy
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196
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Ronco F, Mazzone P, Hosseinian L, Genovesi S. Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease. Cardiorenal Med 2017; 7:207-217. [PMID: 28736561 DOI: 10.1159/000470856] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/07/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in this population the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. SUMMARY In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared to VKA. Limited data from post hoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate, eGFR, between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR <30 mL/min, since there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacological alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared to patients with normal renal function. KEY MESSAGES Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.
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Affiliation(s)
- Federico Ronco
- Interventional Cardiology, Cardiovascular Department, ULSS-12 Veneziana, Venice and Mestre, Italy
| | - Patrizio Mazzone
- Arrhythmology and Cardiac Pacing Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Leila Hosseinian
- Department of Anesthesiology, Mount Sinai Hospital, New York, NY, USA
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Nephrology Unit, S. Gerardo Hospital, Monza, Italy
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197
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Andò G, Capranzano P. Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with chronic kidney disease: A systematic review and network meta-analysis. Int J Cardiol 2017; 231:162-169. [DOI: 10.1016/j.ijcard.2016.11.303] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/13/2016] [Accepted: 11/25/2016] [Indexed: 01/29/2023]
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198
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Edoxaban in Atrial Fibrillation and Venous Thromboembolism-Ten Key Questions and Answers: A Practical Guide. Adv Ther 2017; 34:620-637. [PMID: 28194578 PMCID: PMC5350200 DOI: 10.1007/s12325-017-0488-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Indexed: 12/13/2022]
Abstract
Edoxaban is the fourth non-vitamin K antagonist oral anticoagulant now available for clinical use in the prevention of stroke/systemic embolism in atrial fibrillation (AF) and in the treatment of venous thromboembolism (VTE), after the completion of large-scale randomized comparative clinical trials with the vitamin K antagonist warfarin. Edoxaban has some peculiar pharmacological properties and outcome data. Here a group of experts in AF and VTE answers a set of questions on its practical use, trying to define the profile of patients that would be most appropriate for its use.
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199
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Plitt A, Bansilal S. The Nonvitamin K Antagonist Oral Anticoagulants and Atrial Fibrillation: Challenges and Considerations. J Atr Fibrillation 2017; 9:1547. [PMID: 29250278 PMCID: PMC5673394 DOI: 10.4022/jafib.1547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 01/18/2023]
Abstract
The nonvitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are used for the reduction of the risk of stroke or systemic embolism (SEE) in patients with nonvalvular atrial fibrillation (NVAF). The purpose of this review is to highlight the safety and efficacy results of the pivotal NOAC clinical trials for use in NVAF, discuss some of the unique management challenges in the use of NOACs in special populations, summarize data on emerging and novel indications, and address potential future directions. METHODS A literature search was conducted and to identify relevant clinical trials and studies regarding the use of NOACs for the prevention of stroke or SEE in patients with atrial fibrillation. RESULTS Relative to warfarin, NOACs are as effective or superior in the prevention of stroke or SEE, and are associated with similar or lower rates of major bleeding and significantly decreased rates of intracranial bleeding, but may be associated with a slightly increased risk of gastrointestinal bleeding in patients with AF. The NOACs are not indicated for use and have not been widely tested in AF patients with other cardiovascular conditions. Additional ongoing and planned clinical trials will provide additional information regarding the use of NOACs in these patients. In situations requiring rapid reversal of anticoagulation, the availability of specific antidotes will improve safety and facilitate NOAC use. CONCLUSIONS Use of NOACs in clinical practice requires consideration of patient characteristics as well as potentially required procedures.
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Affiliation(s)
- Anna Plitt
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sameer Bansilal
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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200
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Hayase J, Boyle NG. Defibrillation Testing During ICD Implantation - Should we or Should we Not? J Atr Fibrillation 2017; 9:1508. [PMID: 29250267 PMCID: PMC5673383 DOI: 10.4022/jafib.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 11/30/2016] [Accepted: 01/23/2017] [Indexed: 11/10/2022]
Abstract
The implantable cardioverter defibrillator (ICD) is an established therapy for improving mortality for primary and secondary prevention of sudden cardiac death. Whether to perform defibrillation threshold testing (DFT) either intraoperatively or post-operatively remains a controversial issue. The DFT is defined as the minimum energy required at which two shocks can successfully terminate ventricular fibrillation and dates from the era of surgically implanted devices with epicardial patches. Typically, a safety margin of at least 10J is employed for device programming, though some trial data suggest that a margin of 5J could be just as effective. Various methods have been utilized to perform DFT testing, and no particular method has been shown to be superior to another [Figure 1]. Previously, guideline recommendations addressed the indications for ICD implantation but did not comment on DFT testing. Recent consensus statements now provide some guidance as to when it is appropriate to perform or not perform DFT testing in light of new trial data. This review will address some of the risk factors for having a higher DFT, impact of DFT testing on patient outcomes, and some of the risks and contraindications of DFT testing.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, UCLA Health System,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Noel G Boyle
- UCLA Cardiac Arrhythmia Center, UCLA Health System,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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