3301
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Toeg H, Boodhwani M. Review of anticoagulation options for mechanical valve prosthesis. Interv Cardiol 2015. [DOI: 10.2217/ica.15.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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3302
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Zeitler EP, Eapen ZJ. Anticoagulation in Heart Failure: a Review. J Atr Fibrillation 2015; 8:1250. [PMID: 27957180 DOI: 10.4022/jafib.1250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/11/2015] [Accepted: 06/23/2015] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) with reduced left ventricular function inflicts a large and growing burden of morbidity and mortality in the US and across the globe. One source of this burden is stroke. While it appears that HF itself may impose some risk of stroke, it is in the presence of other risk factors, like atrial fibrillation, that the greatest risks are observed. Therapeutic anticoagulation is the mainstay of risk reduction strategies in this population. While warfarin was the only available therapy for anticoagulation for many decades, there are now four direct oral anticoagulants available. In three of these four, outcomes in the specific subgroup of patients with heart failure have been examined. In this review, we provide some pathophysiologic basis for the risk of stroke in heart failure. In addition, the available therapeutic options for stroke risk prevention in heart failure are described in detail including how these options are incorporated into relevant professional society guidelines.
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Affiliation(s)
- Emily P Zeitler
- Duke Clinical Research Institute and Duke University Medical Center, Durham NC
| | - Zubin J Eapen
- Duke Clinical Research Institute and Duke University Medical Center, Durham NC
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3303
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Jönsson S, Simonsson USH, Miller R, Karlsson MO. Population pharmacokinetics of edoxaban and its main metabolite in a dedicated renal impairment study. J Clin Pharmacol 2015; 55:1268-79. [PMID: 25966665 DOI: 10.1002/jcph.541] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 11/09/2022]
Abstract
A model characterizing the population pharmacokinetics (PK) of edoxaban and its major metabolite, M4, following a single oral dose of 15 mg administered to subjects with varying kidney function was developed. Thirty-two subjects contributed with edoxaban plasma, edoxaban urine, and M4 plasma concentrations. Edoxaban urine concentrations allowed estimation of renal clearance, and high contribution of renal to total clearance enabled estimation of absolute oral bioavailability. A 2-compartment model with delayed absorption and elimination parameterized as renal clearance linearly related to creatinine clearance (CLcr ) and nonrenal clearance forming M4 described edoxaban PK. The PK of M4 was described with a 1-compartment model. For a typical subject (70 kg; CLcr , 100 mL/min) bioavailability, clearance, and central and peripheral volume of distribution for edoxaban was estimated to 72.3%, 21.0 L/h, 95.4 L, and 54.3 L, respectively. For both edoxaban and M4, the model predicted systemic exposure to increase 57.0%, 35.0%, and 11.6% in a subject having CLcr of 30, 50, and 80 mL/min, respectively, compared with a subject having a CLcr of 100 mL/min. Concentration ratios (M4 over edoxaban) were predicted to vary with time after dose, but with minor influence of kidney function and body weight. Results were in agreement with previous analyses.
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Affiliation(s)
- Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | | | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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3304
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Charidimou A, Linn J, Vernooij MW, Opherk C, Akoudad S, Baron JC, Greenberg SM, Jäger HR, Werring DJ. Cortical superficial siderosis: detection and clinical significance in cerebral amyloid angiopathy and related conditions. Brain 2015; 138:2126-39. [PMID: 26115675 DOI: 10.1093/brain/awv162] [Citation(s) in RCA: 257] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/17/2015] [Indexed: 01/13/2023] Open
Abstract
Cortical superficial siderosis describes a distinct pattern of blood-breakdown product deposition limited to cortical sulci over the convexities of the cerebral hemispheres, sparing the brainstem, cerebellum and spinal cord. Although cortical superficial siderosis has many possible causes, it is emerging as a key feature of cerebral amyloid angiopathy, a common and important age-related cerebral small vessel disorder leading to intracerebral haemorrhage and dementia. In cerebral amyloid angiopathy cohorts, cortical superficial siderosis is associated with characteristic clinical symptoms, including transient focal neurological episodes; preliminary data also suggest an association with a high risk of future intracerebral haemorrhage, with potential implications for antithrombotic treatment decisions. Thus, cortical superficial siderosis is of relevance to neurologists working in neurovascular, memory and epilepsy clinics, and neurovascular emergency services, emphasizing the need for appropriate blood-sensitive magnetic resonance sequences to be routinely acquired in these clinical settings. In this review we focus on recent developments in neuroimaging and detection, aetiology, prevalence, pathophysiology and clinical significance of cortical superficial siderosis, with a particular emphasis on cerebral amyloid angiopathy. We also highlight important areas for future investigation and propose standards for evaluating cortical superficial siderosis in research studies.
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Affiliation(s)
- Andreas Charidimou
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Linn
- 3 Department of Neuroradiology, University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Meike W Vernooij
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Christian Opherk
- 5 Institute for Stroke and Dementia Research, Ludwig Maximilians University, Munich, and Department of Neurology, SLK-Kliniken, Heilbronn, Germany
| | - Saloua Akoudad
- 4 Department of Radiology and Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Jean-Claude Baron
- 6 UMR 894 INSERM-Université Paris 5, Sorbonne Paris Cité, Paris, France
| | - Steven M Greenberg
- 2 Stroke Research Centre, Massachusetts General Hospital, Boston, MA, USA
| | - Hans Rolf Jäger
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK 7 Lysholm Department of Neuroradiology, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Werring
- 1 Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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3305
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Lane DA, Aguinaga L, Blomström-Lundqvist C, Boriani G, Dan GA, Hills MT, Hylek EM, LaHaye SA, Lip GYH, Lobban T, Mandrola J, McCabe PJ, Pedersen SS, Pisters R, Stewart S, Wood K, Potpara TS, Gorenek B, Conti JB, Keegan R, Power S, Hendriks J, Ritter P, Calkins H, Violi F, Hurwitz J. Cardiac tachyarrhythmias and patient values and preferences for their management: the European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2015; 17:1747-69. [PMID: 26108807 DOI: 10.1093/europace/euv233] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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3306
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Morrill AM, Ge D, Willett KC. Dosing of Target-Specific Oral Anticoagulants in Special Populations. Ann Pharmacother 2015; 49:1031-45. [PMID: 26104052 DOI: 10.1177/1060028015591846] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To review current literature for target-specific oral anticoagulants (TSOACs) and provide critical analysis for dosing recommendations in special population groups. DATA SOURCES A literature search was conducted in Medline (1996 to April week 2 2015) and Embase (1980 to 2015 week 16) using key terms dabigatran, rivaroxaban, apixaban, edoxaban, kidney diseases, liver diseases, elderly, obesity, and special populations. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials in English assessing efficacy and safety of TSOACs in healthy adults and special populations were selected for analysis. DATA SYNTHESIS Phase 3 trials for TSOACs predominately excluded patients with severe renal impairment or active liver disease. There were no exclusion criteria based on age, body weight or body mass index. Additional conclusions were made in special populations, including those with renal or liver impairment and obese and elderly patients, based on secondary analyses, pharmacokinetic, and pharmacodynamic studies. CONCLUSIONS Pharmacokinetic and pharmacodynamic changes associated special populations may alter clinical decision with regard to drug selection and dosing. It is valuable to understand the rationale for labeled dosing recommendations in nonvalvular atrial fibrillation and venous thromboembolism treatment and prevention, particularly in patients that fall into special population groups. Furthermore, the use of TSOACs is likely to increase as clinicians gain experience with these agents and additional TSOACs and indications are approved.
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Affiliation(s)
| | - Dan Ge
- MCPHS University, Manchester, NH, USA
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3307
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Antman EM. Saving and Improving Lives in the Information Age: Presidential Address at the American Heart Association 2014 Scientific Sessions. Circulation 2015; 131:2238-42. [PMID: 26099959 DOI: 10.1161/cir.0000000000000224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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3308
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Abstract
Edoxaban is a once-daily oral anticoagulant that rapidly and selectively inhibits factor Xa in a concentration-dependent manner. This review describes the extensive clinical development program of edoxaban, including phase III studies in patients with non-valvular atrial fibrillation (NVAF) and symptomatic venous thromboembolism (VTE). The ENGAGE AF-TIMI 48 study (N = 21,105; mean CHADS2 score 2.8) compared edoxaban 60 mg once daily (high-dose regimen) and edoxaban 30 mg once daily (low-dose regimen) with dose-adjusted warfarin [international normalized ratio (INR) 2.0–3.0] and found that both regimens were non-inferior to warfarin in the prevention of stroke and systemic embolism in patients with NVAF. Both edoxaban regimens also provided significant reductions in the risk of hemorrhagic stroke, cardiovascular mortality, major bleeding and intracranial bleeding. The Hokusai-VTE study (N = 8,292) in patients with symptomatic VTE had a flexible treatment duration of 3–12 months and found that following initial heparin, edoxaban 60 mg once daily was non-inferior to dose-adjusted warfarin (INR 2.0–3.0) for the prevention of recurrent VTE, and also had a significantly lower risk of bleeding events. Both studies randomized patients at moderate-to-high risk of thromboembolic events and were further designed to simulate routine clinical practice as much as possible, with edoxaban dose reduction (halving dose) at randomisation or during the study if required, a frequently monitored and well-controlled warfarin group, a well-monitored transition period at study end and a flexible treatment duration in Hokusai-VTE. Given the phase III results obtained, once-daily edoxaban may soon be a key addition to the range of antithrombotic treatment options.
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Affiliation(s)
- Henri Bounameaux
- Department of Internal Medicine, University Hospital of Geneva, Geneva, Switzerland,
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3309
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Innovative designs of point-of-care comparative effectiveness trials. Contemp Clin Trials 2015; 45:61-8. [PMID: 26099528 DOI: 10.1016/j.cct.2015.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 12/28/2022]
Abstract
One of the provisions of the health care reform legislation in 2010 was for funding pragmatic clinical trials or large observational studies for comparing the effectiveness of different approved medical treatments, involving broadly representative patient populations. After reviewing pragmatic clinical trials and the issues and challenges that have made them just a small fraction of comparative effectiveness research (CER), we focus on a recent development that uses point-of-care (POC) clinical trials to address the issue of "knowledge-action gap" in pragmatic CER trials. We give illustrative examples of POC-CER trials and describe a trial that we are currently planning to compare the effectiveness of newly approved oral anticoagulants. We also develop novel stage-wise designs of information-rich POC-CER trials under competitive budget constraints, by using recent advances in adaptive designs and other statistical methodologies.
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3310
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Castillo JM, Afanador HF, Manjarrez E, Morales XA. Non-Traumatic Spontaneous Spinal Subdural Hematoma in a Patient with Non-Valvular Atrial Fibrillation During Treatment with Rivaroxaban. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:377-81. [PMID: 26090890 PMCID: PMC4479261 DOI: 10.12659/ajcr.893320] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 69 Final Diagnosis: Spontaneous spinal subdural hematoma Symptoms: Paraplegia Medication: Rivaroxaban Clinical Procedure: — Specialty: General Internal Medicine • Hospital Medicine • Cardiology • Hematology • Neurology
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Affiliation(s)
- Jessica M Castillo
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Hayley F Afanador
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Efren Manjarrez
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Ximena A Morales
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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3311
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Proietti M, Lip GYH. Antidotes to non-vitamin K oral anticoagulants: necessary or not? Expert Opin Pharmacother 2015; 16:1573-6. [DOI: 10.1517/14656566.2015.1057119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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3312
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Hägg L, Johansson C, Jansson JH, Johansson L. External validity of the ARISTOTLE trial in real-life atrial fibrillation patients. Cardiovasc Ther 2015; 32:214-8. [PMID: 24975869 DOI: 10.1111/1755-5922.12087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Our primary objective was to determine the proportion of patients with atrial fibrillation (AF) eligible for enrollment in a randomized controlled trial for a novel oral anticoagulant, the ARISTOTLE trial. A secondary objective was to describe the reasons for trial ineligibility. METHODS We performed a cross-sectional study of an unselected population including 2274 patients in Skellefteå, Sweden with at least one verified episode of AF on or before December 31, 2010. Patients were classified as suitable or unsuitable for anticoagulant treatment according to current guidelines. The enrollment criteria from the ARISTOTLE trial were extracted from the original publication and applied to the population. RESULTS Among all patients with AF, 1579 were classified as suitable for anticoagulant treatment. Of these, only 658 patients (42%) were eligible for participation in the ARISTOTLE trial. Among the 921 patients ineligible for participation, 498 did not meet the ECG criteria, 272 had psychosocial problems, and in addition, 78 patients were excluded due to both of these criteria. CONCLUSION Our study shows that a majority of the patients in an unselected population with AF suitable for anticoagulant treatment were ineligible for participation in the ARISTOTLE trial. The applicability of the ARISTOTLE trial is therefore unknown for a considerable proportion of patients with AF in real life.
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Affiliation(s)
- Lovisa Hägg
- Skellefteå Research Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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3313
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Rubboli A, Agewall S, Huber K, Lip GYH. New-onset atrial fibrillation after recent coronary stenting: Warfarin or non-vitamin K-antagonist oral anticoagulants to be added to aspirin and clopidogrel? A viewpoint. Int J Cardiol 2015; 196:133-8. [PMID: 26093527 DOI: 10.1016/j.ijcard.2015.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 06/12/2015] [Indexed: 01/10/2023]
Abstract
The antithrombotic management of patients on oral anticoagulation (OAC), with either warfarin or non-vitamin K-antagonist oral anticoagulants (NOACs), undergoing percutaneous coronary intervention with stent (PCI-S) has been recently addressed in a joint European consensus document. In accordance, triple therapy (TT) of OAC, aspirin and clopidogrel should generally be given as the initial therapy. More uncertainty exists over whether warfarin or a NOAC should be added in patients already on dual antiplatelet therapy of aspirin and clopidogrel (DAPT) after recent PCI-S. Upon review of available data, it appears that the risk of major bleeding of TT as compared to DAPT is similar with either warfarin or a NOAC. In particular, TT consistently appears associated to an approximately 2.5 fold increase in the risk of major bleeding. Because of the higher convenience, NOACs might be considered the preferred OAC to be added to DAPT. Given the reported different safety profiles of the various NOACs on the incidence of major, and gastrointestinal, bleeding, the NOACs, and the dose, showing the greatest safety in this regard should be selected. In accordance, dabigatran 110 mg and apixaban 2.5mg twice daily appear as the most valuable options in patients who are not and who are respectively, at increased risk of bleeding. As an alternative, apixaban 5mg twice daily might be considered in patients at risk of bleeding not increased, whereas rivaroxaban 15 mg once daily may be considered in the presence of increased risk of bleeding (essentially when related to moderate renal impairment).
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Affiliation(s)
- Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy.
| | - Stefan Agewall
- Institute of Clinical Sciences, Department of Cardiology, University of Oslo, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Gregory Y H Lip
- University of Birmingham, Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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3314
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Blann AD, Skjøth F, Rasmussen LH, Larsen TB, Lip GYH. Edoxaban versus placebo, aspirin, or aspirin plus clopidogrel for stroke prevention in atrial fibrillation. An indirect comparison analysis. Thromb Haemost 2015; 114:403-9. [PMID: 26062437 DOI: 10.1160/th15-05-0383] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/02/2015] [Indexed: 11/05/2022]
Abstract
As non-valvular atrial fibrillation (AF) brings a risk of stroke, oral anticoagulants (OAC) are recommended. In 'real world' clinical practice, many patients (who may be, or perceived to be, intolerant of OACs) are either untreated or are treated with anti-platelet agents. We hypothesised that edoxaban has a better net clinical benefit (NCB, balancing the reduction in stroke risk vs increased risk of haemorrhage) than no treatment or anti-platelet agents. We performed a network meta-analysis of published data from 24 studies of 203,394 AF patients to indirectly compare edoxaban with aspirin alone, aspirin plus clopidogrel, and placebo. Edoxaban 30 mg once daily significantly reduced the risk of all stroke, ischaemic stroke and mortality compared to placebo and aspirin. Compared to aspirin plus clopidogrel, there was a lower risk of intra-cranial haemorrhage (ICH). Edoxaban 60 mg once-daily had a reduced risk of any stroke and systemic embolism compared to placebo, aspirin, and aspirin plus clopidogrel. Mortality rates for both edoxaban doses were estimated to be lower compared to any anti-platelet, and significantly lower compared to placebo. With overall reduced risk of ischemic stroke and ICH, both edoxaban doses bring a NCB of mean (SD) 1.68 (0.15) saved events per 100 patients per year compared to anti-platelet drugs in a clinical trial population. The NCB was demonstrated to be lower, at 0.77 (0.12) events saved (p< 0.01) when modeled to data from a 'real world' cohort of AF patients. In conclusion, edoxaban is likely to provide even better protection from stroke and ICH than placebo, aspirin alone, or aspirin plus clopidogrel in both clinical trial populations and unselected community populations. Both edoxaban doses would also bring a positive NCB compared to anti-platelet drugs or placebo/non-treatment based on 'real world' data.
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Affiliation(s)
| | | | | | | | - G Y H Lip
- Prof. G. Y. H. Lip, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, UK, Tel.: +44 (0)121 507 5080, E-mail:
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3315
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Poli D, Antonucci E. Epidemiology, diagnosis, and management of atrial fibrillation in women. Int J Womens Health 2015; 7:605-14. [PMID: 26089706 PMCID: PMC4468997 DOI: 10.2147/ijwh.s45925] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and has become a serious public health problem. Moreover, epidemiological data demonstrate that incidence and prevalence of AF are increasing. Several differences in epidemiological patterns, clinical manifestations, and incidence of stroke have been reported between AF in women and in men, particularly in elderly women. Elderly women have higher blood pressure than men and a higher prevalence of heart failure with preserved ejection fraction, both independent risk factors for stroke. On the basis of the evidence on the higher stroke risk among AF in women, recently, female sex has been accepted as a risk factor for stroke and adopted to stratify patients, especially if they are not at high risk for stroke. This review focuses on available evidence on sex differences in AF patients, and examines factors contributing to different stroke risk, diagnosis, and prognosis of arrhythmia in women, with the aim to provide an analysis of the available evidence.
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Affiliation(s)
- Daniela Poli
- Thrombosis Centre, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Emilia Antonucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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3316
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Ment J. Direct oral anticoagulants: key considerations for use to prevent stroke in patients with nonvalvular atrial fibrillation. Vasc Health Risk Manag 2015; 11:317-32. [PMID: 26089678 PMCID: PMC4468938 DOI: 10.2147/vhrm.s79065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Strokes that occur as a complication of AF are usually more severe and associated with a higher disability or morbidity and mortality rate compared with non-AF-related strokes. The risk of stroke in AF is dependent on several risk factors; AF itself acts as an independent risk factor for stroke. The combination of effective anticoagulation therapy, risk stratification (based on stroke risk scores, such as CHADS2 and CHA2DS2-VASc), and recommendations provided by guidelines is essential for decreasing the risk of stroke in patients with AF. Although effective in preventing the occurrence of stroke, vitamin K antagonists (VKAs; eg, warfarin) are associated with several limitations. Therefore, direct oral anticoagulants, such as apixaban, dabigatran etexilate, edoxaban, and rivaroxaban, have emerged as an alternative to the VKAs for stroke prevention in patients with nonvalvular AF. Compared with the VKAs, these agents have more favorable pharmacological characteristics and, unlike the VKAs, they are given at fixed doses without the need for routine coagulation monitoring. It remains important that physicians use these direct oral anticoagulants responsibly to ensure optimal safety and effectiveness. This article provides an overview of the existing data on the direct oral anticoagulants, focusing on management protocols for aiding physicians to optimize anticoagulant therapy in patients with nonvalvular AF, particularly in special patient populations (eg, those with renal impairment) and other specific clinical situations.
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Affiliation(s)
- Jerome Ment
- Department of Cardiology, Birmingham Heartlands Hospital, Birmingham, UK
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3317
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Ruff CT, Giugliano RP, Braunwald E, Morrow DA, Murphy SA, Kuder JF, Deenadayalu N, Jarolim P, Betcher J, Shi M, Brown K, Patel I, Mercuri M, Antman EM. Association between edoxaban dose, concentration, anti-Factor Xa activity, and outcomes: an analysis of data from the randomised, double-blind ENGAGE AF-TIMI 48 trial. Lancet 2015; 385:2288-95. [PMID: 25769361 DOI: 10.1016/s0140-6736(14)61943-7] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND New oral anticoagulants for stroke prevention in atrial fibrillation were developed to be given in fixed doses without the need for the routine monitoring that has hindered usage and acceptance of vitamin K antagonists. A concern has emerged, however, that measurement of drug concentration or anticoagulant activity might be needed to prevent excess drug concentrations, which significantly increase bleeding risk. In the ENGAGE AF-TIMI 48 trial, higher-dose and lower-dose edoxaban were compared with warfarin in patients with atrial fibrillation. Each regimen incorporated a 50% dose reduction in patients with clinical features known to increase edoxaban drug exposure. We aim to assess whether adjustment of edoxaban dose in this trial prevented excess drug concentration and the risk of bleeding events. METHODS We analysed data from the randomised, double-blind ENGAGE AF-TIMI 48 trial. We correlated edoxaban dose, plasma concentration, and anti-Factor Xa (FXa) activity and compared efficacy and safety outcomes with warfarin stratified by dose reduction status. Patients with atrial fibrillation and at moderate to high risk of stroke were randomly assigned in a 1:1:1 ratio to receive warfarin, dose adjusted to an international normalised ratio of 2·0-3·0, higher-dose edoxaban (60 mg once daily), or lower-dose edoxaban (30 mg once daily). Randomisation was done with use of a central, 24 h, interactive, computerised response system. International normalised ratio was measured using an encrypted point-of-care device. To maintain masking, sham international normalised ratio values were generated for patients assigned to edoxaban. Edoxaban (or placebo-edoxaban in warfarin group) doses were halved at randomisation or during the trial if patients had creatinine clearance 30-50 mL/min, bodyweight 60 kg or less, or concomitant medication with potent P-glycoprotein interaction. Efficacy outcomes included the primary endpoint of all-cause stroke or systemic embolism, ischaemic stroke, and all-cause mortality. Safety outcomes included the primary safety endpoint of major bleeding, fatal bleeding, intracranial haemorrhage, and gastrointestinal bleeding. This trial is registered with ClinicalTrials.gov, number NCT00781391. FINDINGS Between Nov 19, 2008 and Nov 22, 2010, 21 105 patients were recruited. Patients who met clinical criteria for dose reduction at randomisation (n=5356) had higher rates of stroke, bleeding, and death compared with those who did not have a dose reduction (n=15 749). Edoxaban dose ranged from 15 mg to 60 mg, resulting in a two-fold to three fold gradient of mean trough drug exposure (16·0-48·5 ng/mL in 6780 patients with data available) and mean trough anti-FXa activity (0·35-0·85 IU/mL in 2865 patients). Dose reduction decreased mean exposure by 29% (from 48·5 ng/mL [SD 45·8] to 34·6 ng/mL [30·9]) and 35% (from 24·5 ng/mL [22·7] to 16·0 ng/mL [14·5]) and mean anti-FXa activity by 25% (from 0·85 IU/mL [0·76] to 0·64 IU/mL [0·54]) and 20% (from 0·44 IU/mL [0·37] to 0·35 IU/mL [0·28]) in the higher-dose and lower-dose regimens, respectively. Despite the lower anti-FXa activity, dose reduction preserved the efficacy of edoxaban compared with warfarin (stroke or systemic embolic event: higher dose pinteraction=0·85, lower dose pinteraction=0·99) and provided even greater safety (major bleeding: higher dose pinteraction 0·02, lower dose pinteraction=0·002). INTERPRETATION These findings validate the strategy that tailoring of the dose of edoxaban on the basis of clinical factors alone achieves the dual goal of preventing excess drug concentrations and helps to optimise an individual patient's risk of ischaemic and bleeding events and show that the therapeutic window for edoxaban is narrower for major bleeding than thromboembolism. FUNDING Daiichi-Sankyo Pharma Development.
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Affiliation(s)
- Christian T Ruff
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Robert P Giugliano
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Julia F Kuder
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Naveen Deenadayalu
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Petr Jarolim
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Edison, NJ, USA
| | - Karen Brown
- Daiichi-Sankyo Pharma Development, Edison, NJ, USA
| | | | | | - Elliott M Antman
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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3318
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Mega JL, Walker JR, Ruff CT, Vandell AG, Nordio F, Deenadayalu N, Murphy SA, Lee J, Mercuri MF, Giugliano RP, Antman EM, Braunwald E, Sabatine MS. Genetics and the clinical response to warfarin and edoxaban: findings from the randomised, double-blind ENGAGE AF-TIMI 48 trial. Lancet 2015; 385:2280-7. [PMID: 25769357 DOI: 10.1016/s0140-6736(14)61994-2] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Warfarin is the most widely used oral anticoagulant worldwide, but serious bleeding complications are common. We tested whether genetic variants can identify patients who are at increased risk of bleeding with warfarin and, consequently, those who would derive a greater safety benefit with a direct oral anticoagulant rather than warfarin. METHODS ENGAGE AF-TIMI 48 was a randomised, double-blind trial in which patients with atrial fibrillation were assigned to warfarin to achieve a target international normalised ratio of 2·0-3·0, or to higher-dose (60 mg) or lower-dose (30 mg) edoxaban once daily. A subgroup of patients was included in a prespecified genetic analysis and genotyped for variants in CYP2C9 and VKORC1. The results were used to create three genotype functional bins (normal, sensitive, and highly sensitive responders to warfarin). This trial is registered with ClinicalTrials.gov, number NCT00781391. FINDINGS 14,348 patients were included in the genetic analysis. Of 4833 taking warfarin, 2982 (61·7%) were classified as normal responders, 1711 (35·4%) as sensitive responders, and 140 (2·9%) as highly sensitive responders. Compared with normal responders, sensitive and highly sensitive responders spent greater proportions of time over-anticoagulated in the first 90 days of treatment (median 2·2%, IQR 0-20·2; 8·4%, 0-25·8; and 18·3%, 0-32·6; ptrend<0·0001) and had increased risks of bleeding with warfarin (sensitive responders hazard ratio 1·31, 95% CI 1·05-1·64, p=0·0179; highly sensitive responders 2·66, 1·69-4·19, p<0·0001). Genotype added independent information beyond clinical risk scoring. During the first 90 days, when compared with warfarin, treatment with edoxaban reduced bleeding more so in sensitive and highly sensitive responders than in normal responders (higher-dose edoxaban pinteraction=0·0066; lower-dose edoxaban pinteraction=0·0036). After 90 days, the reduction in bleeding risk with edoxaban versus warfarin was similarly beneficial across genotypes. INTERPRETATION CYP2C9 and VKORC1 genotypes identify patients who are more likely to experience early bleeding with warfarin and who derive a greater early safety benefit from edoxaban compared with warfarin. FUNDING Daiichi Sankyo.
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Affiliation(s)
- Jessica L Mega
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Francesco Nordio
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Naveen Deenadayalu
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James Lee
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | | | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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3319
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Affiliation(s)
- Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
| | - Jeffrey B Washam
- Duke Heart Center, Duke University Medical Center, Durham, NC 27705, USA
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3320
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Lauffenburger JC, Rhoney DH, Farley JF, Gehi AK, Fang G. Predictors of gastrointestinal bleeding among patients with atrial fibrillation after initiating dabigatran therapy. Pharmacotherapy 2015; 35:560-8. [PMID: 26044889 DOI: 10.1002/phar.1597] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES To identify demographic and clinical risk factors associated with gastrointestinal (GI) bleeding among a large cohort of patients with atrial fibrillation (AF) who initiated dabigatran therapy for stroke prevention, and to describe patterns of subsequent anticoagulant use after occurrence of the GI bleeding event. DESIGN Retrospective cohort study. DATA SOURCES Large, nationwide United States commercial insurance database. PATIENTS A total of 21,033 patients with nonvalvular AF who initiated dabigatran between October 19, 2010, and December 31, 2012. MEASUREMENTS AND MAIN RESULTS We used multivariate Cox regression analysis to estimate the effect of baseline demographic and clinical characteristics on the probability of a GI bleeding event. Patterns of anticoagulation use after GI bleeding were also examined descriptively. Of the 21,033 patients receiving dabigatran, 446 (2.1%) experienced a GI bleed during follow-up. GI bleeding rates differed across many baseline characteristics. Male sex was associated with a lower risk (adjusted hazard ratio [aHR] 0.78, 95% confidence interval [CI] 0.64-0.95) of GI bleeding. Compared with patients younger than 55 years, those aged 55-64, 65-74, and 75 years or older yielded aHRs of 1.54 (95% CI 0.89-2.68), 2.72 (95% CI 1.59-4.65), and 4.52 (95% CI 2.68-7.64), respectively. Renal impairment (aHR 1.67, 95% CI 1.24-2.25), heart failure (aHR 1.25, 95% CI 1.01-1.56), alcohol abuse (aHR 2.57, 95%CI 1.52-4.35), previous Helicobacter pylori infection (aHR 4.75, 95% CI 1.93-11.68), antiplatelet therapy (aHR 1.49, 95% CI 1.19-1.88), and digoxin use (aHR 1.49, 95% CI 1.19-1.88) were also associated with an increased GI bleeding risk. Of the 446 patients who experienced a GI bleed, 193 (43.3%) restarted an anticoagulant, with most (65.8%) filling prescriptions for dabigatran; the mean time was 50.4 days until restarting any subsequent anticoagulant. CONCLUSION The risk of GI bleeding in patients receiving dabigatran is highly associated with increased age and cardiovascular, renal, and other comorbidities, even after adjusting for other factors. Fewer than 50% of patients restarted an anticoagulant after experiencing a GI bleed. Clinicians should continue to monitor for these risk factors or consider whether alternative therapies may be appropriate.
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Affiliation(s)
- Julie C Lauffenburger
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joel F Farley
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anil K Gehi
- Department of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gang Fang
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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3321
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Ellis G, John Camm A, Datta SN. Novel anticoagulants and antiplatelet agents; a guide for the urologist. BJU Int 2015; 116:687-96. [DOI: 10.1111/bju.13131] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Gidon Ellis
- Department of Urology; Whittington Hospital; London UK
| | - Alan John Camm
- Department of Clinical Cardiology; St George's Healthcare NHS Trust; London UK
| | - Soumendra N. Datta
- Department of Urology; Colchester Hospital University Foundation Trust; Colchester UK
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3322
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Antwort auf den Kommentar von Jürgen Windeler, Stefan Lange zum Beitrag: Nutzenbewertung aus Sicht der Versorgungsforschung und der Epidemiologie. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz (2015): 298–307. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015; 58:634-5. [DOI: 10.1007/s00103-015-2156-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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3323
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Untereiner O, Seince PF, Chterev V, Leblanc I, Berroëta C, Bourel P, Philip I. Management of Direct Oral Anticoagulants in the Perioperative Setting. J Cardiothorac Vasc Anesth 2015; 29:741-8. [DOI: 10.1053/j.jvca.2014.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Indexed: 01/22/2023]
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3324
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Verheugt FWA. Triple therapy for percutaneous coronary intervention in atrial fibrillation: standard of care, or a nightmare soon to end? J Thromb Haemost 2015; 13 Suppl 1:S332-5. [PMID: 26149044 DOI: 10.1111/jth.12936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The need to combine anticoagulant and antiplatelet therapy ('triple therapy') in patients with atrial fibrillation and coronary artery disease increases the risk of bleeding. As percutaneous intervention is now the dominant therapy for coronary disease, clinicians question how to manage the risk of stroke in patients with atrial fibrillation and a coronary stent that require dual antiplatelet therapy. In this review, the risk of stroke and coronary thrombosis in this difficult group of patients will be summarized using current recommendations and guidelines. The scarce randomized data on triple therapy are reviewed, and there will be a focus on currently running trials on this topic.
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Affiliation(s)
- F W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
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3325
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Amin A, Bruno A, Trocio J, Lin J, Lingohr-Smith M. Comparison of differences in medical costs when new oral anticoagulants are used for the treatment of patients with non-valvular atrial fibrillation and venous thromboembolism vs warfarin or placebo in the US. J Med Econ 2015; 18:399-409. [PMID: 25586203 DOI: 10.3111/13696998.2015.1007210] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Medical costs that may be avoided when any of the four new oral anticoagulants (NOACs), dabigatran, rivaroxaban, apixaban, and edoxaban, are used instead of warfarin for the treatment of non-valvular atrial fibrillation (NVAF) were estimated and compared. Additionally, the overall differences in medical costs were estimated for NVAF and venous thromboembolism (VTE) patient populations combined. METHODS Medical cost differences associated with NOAC use vs warfarin or placebo among NVAF and VTE patients were estimated based on clinical event rates obtained from the published trial data. The clinical event rates were calculated as the percentage of patients with each of the clinical events during the trial periods. Univariate and multivariate sensitivity analyses were conducted for the medical-cost differences determined for NVAF patients. A hypothetical health plan population of 1 million members was used to estimate and compare the combined medical-cost differences of the NVAF and VTE populations and were projected in the years 2015-2018. RESULTS In a year, the medical-cost differences associated with NOAC use instead of warfarin were estimated at -$204, -$140, -$495, and -$340 per patient for dabigatran, rivaroxaban, apixaban, and edoxaban, respectively. In 2014, among the hypothetical population, the medical-cost differences were -$3.7, -$4.2, -$11.5, and -$6.6 million for NVAF and acute VTE patients treated with dabigatran, rivaroxaban, apixaban, and edoxaban, respectively. In 2014, for the combined NVAF, acute VTE, and extended VTE patient populations, medical-cost differences were -$10.0, -$10.9, -$21.0, and -$21.0 million for dabigatran, rivaroxaban, 2.5 mg apixaban, and 5 mg apixaban, respectively. Medical-cost differences associated with use of NOACs were projected to steadily increase from 2014 to 2018. CONCLUSIONS Medical costs are reduced when NOACs are used instead of warfarin/placebo for the treatment of NVAF or VTE, with apixaban being associated with the greatest reduction in medical costs.
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3326
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Yates SG, Sarode R. New strategies for effective treatment of vitamin K antagonist-associated bleeding. J Thromb Haemost 2015; 13 Suppl 1:S180-6. [PMID: 26149021 DOI: 10.1111/jth.12970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vitamin K antagonists have been used as oral anticoagulants in the treatment and prevention of thromboembolic events for over half a century. Although vitamin K antagonists are effective in the management of thromboembolic events, the need for routine monitoring and the associated risk of bleeding has resulted in the development and licensing of direct oral anticoagulants for specific clinical indications. Despite these developments, vitamin K antagonists remain the oral anticoagulants of choice in many clinical conditions. Severe bleeding associated with oral anticoagulation requires urgent reversal. Several options for the reversal of vitamin K antagonist exist, including vitamin K, prothrombin complex concentrates and plasma. In this manuscript, we review current evidence and provide physicians with treatment strategies for more effective management of vitamin K antagonist-associated bleeding.
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Affiliation(s)
- S G Yates
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - R Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
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3327
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Sarich TC, Seltzer JH, Berkowitz SD, Costin' J, Curnutte JT, Gibson CM, Hoffman M, Kaminskas E, Krucoff MW, Levy JH, Mintz PD, Reilly PA, Sager PT, Singer DE, Stockbridge N, Weitz JI, Kowey PR. Novel oral anticoagulants and reversal agents: Considerations for clinical development. Am Heart J 2015; 169:751-7. [PMID: 26027611 DOI: 10.1016/j.ahj.2015.03.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
This white paper provides a summary of presentations and discussions that were held at an Anticoagulant-Induced Bleeding and Reversal Agents Think Tank co-sponsored by the Cardiac Safety Research Consortium and the US Food and Drug Administration (FDA) at the FDA's White Oak Headquarters on April 22, 2014. Attention focused on a development pathway for reversal agents for the novel oral anticoagulants (NOACs). This is important because anticoagulation is still widely underused for stroke prevention in patients with atrial fibrillation. Undertreatment persists, although NOACs, in general, overcome some of the difficulties associated with anticoagulation provided by vitamin K antagonists. One reason for the lack of a wider uptake is the absence of NOAC reversal agents. As there are neither widely accepted academic and industry standards nor a definitive regulatory policy on the development of such reversal agents, this meeting provided a forum for leaders in the fields of cardiovascular clinical trials and cardiovascular safety to discuss the issues and develop recommendations. Attendees included representatives from pharmaceutical companies; regulatory agencies; end point adjudication specialist groups; contract research organizations; and active, academically based physicians. There was wide and solid consensus that NOACs overall offer improvements in convenience, efficacy, and safety compared with warfarin, even without reversal agents. Still, it was broadly accepted that it would be helpful to have reversal agents available for clinicians to use. Because it is not feasible to do definitive outcomes studies demonstrating a reversal agent's clinical benefits, it was felt that these agents could be approved for use in life-threatening bleeding situations if the molecules were well characterized preclinically, their pharmacodynamic and pharmacokinetic profiles were well understood, and showed no harmful adverse events in early human testing. There was also consensus that after such approval, efforts should be made to augment the available clinical information until such time as there is a body of evidence to demonstrate real-world clinical outcomes with the reversal agents. No recommendations were made for more generalized use of these agents in the setting of non-life-threatening situations. This article reflects the views of the authors and should not be construed to represent FDA's views or policies.
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3328
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Fiix-prothrombin time versus standard prothrombin time for monitoring of warfarin anticoagulation: a single centre, double-blind, randomised, non-inferiority trial. LANCET HAEMATOLOGY 2015; 2:e231-40. [DOI: 10.1016/s2352-3026(15)00073-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/13/2015] [Accepted: 04/14/2015] [Indexed: 01/21/2023]
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3329
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Tagaya M, Yoshikawa D, Sugishita Y, Yamauchi F, Ito T, Kamada T, Yoshinaga M, Mukaide D, Fujiwara W, Yokoi H, Hayashi M, Watanabe E, Ishii J, Ozaki Y, Izawa H. Prescription patterns of oral anticoagulants for patients with non-valvular atrial fibrillation: experience at a Japanese single institution. Heart Vessels 2015; 31:957-62. [PMID: 26022376 DOI: 10.1007/s00380-015-0694-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/22/2015] [Indexed: 01/15/2023]
Abstract
New oral anticoagulants (NOACs) are now clinically available. However, few studies have demonstrated which patients with non-valvular atrial fibrillation (NVAF) actually receive NOACs in a clinical setting. We analyzed 182 NVAF patients who received oral anticoagulants. Clinical backgrounds and the risk of stroke, systemic embolism, and bleeding associated with oral anticoagulants were investigated. Seventy-three (40 %) patients were treated with NOACs and 109 (60 %) patients were treated with warfarin. A significantly lower mean number of bleeding risk factors was observed among the patients treated with NOACs than among those treated with warfarin (P = 0.010). Of the bleeding risk factors, NOACs were significantly less frequently prescribed in patients with a bleeding history and elderly subjects (>65 years) than in those who received warfarin (P < 0.001 and P = 0.029). A multivariate logistic regression analysis revealed that CHF and bleeding history were independently and significantly associated with the administration of NOACs (P = 0.047 and P = 0.003). The rate of a history of intracranial hemorrhage was comparable between the patients treated with NOACs and those treated with warfarin (P = 1.000). Significantly lower rates of a history of gastrointestinal and other minor bleeding were observed in the patients who received NOACs versus those who received warfarin (P = 0.001 and P = 0.026). NOACs were less frequently prescribed in patients with a history of bleeding, especially those with a history of gastrointestinal bleeding in a clinical setting.
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Affiliation(s)
- Manaka Tagaya
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Daiji Yoshikawa
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan. .,Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yoshinori Sugishita
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Fumi Yamauchi
- Hospital Pharmacy, Fujita Health University Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Takehiro Ito
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Tomohito Kamada
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Masataka Yoshinaga
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Daisuke Mukaide
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Wakaya Fujiwara
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Hiroatsu Yokoi
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
| | - Mutsuharu Hayashi
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan.,Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Junichi Ishii
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University Banbuntane Hotokukai Hospital, 3-6-10, Otobashi, Nakagawa-ku, Nagoya, 454-0012, Japan
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3330
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Jung KH, Yu KH, Kim YD, Park JM, Hong KS, Rha JH, Kwon SU, Bae HJ, Heo JH, Lee BC, Yoon BW. Antithrombotic Management of Patients with Nonvalvular Atrial Fibrillation and Ischemic Stroke or Transient Ischemic Attack: Executive Summary of the Korean Clinical Practice Guidelines for Stroke. J Stroke 2015; 17:210-5. [PMID: 26060808 PMCID: PMC4460340 DOI: 10.5853/jos.2015.17.2.210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/06/2015] [Accepted: 03/13/2015] [Indexed: 12/18/2022] Open
Abstract
Cardioembolic stroke related to nonvalvular atrial fibrillation is associated with a high recurrence rate and high mortality and morbidity. In this population, therefore, optimal anticoagulant therapy is required to prevent the occurrence of second stroke. Oral anticoagulant, warfarin has been traditionally used, but it is greatly limited by its narrow efficacy window, complex pharmacokinetics, and multiple drug interactions, thus requiring frequent blood monitoring. Recently, oral anticoagulants targeted for a specific coagulation component have been newly developed and tested in large clinical trials. Dabigatran, direct thrombin inhibitor, and rivaroxaban, apixaban, and edoxaban, inhibitors of factor Xa harbor great merits of rapid action time, short half-life, stable plasma concentration, and little drug interaction. Recently, large randomized clinical trials and meta-analyses have been published to show the efficacy and safety of the new oral anticoagulants compared with warfarin. Based on the results from recent clinical trials, we revised recommendations to apply optimal anticoagulant therapy in patients with nonvalvular atrial fibrillation and ischemic stroke or transient ischemic attack.
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Affiliation(s)
- Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym Neurological Institute, Anyang, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Sun U Kwon
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym Neurological Institute, Anyang, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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3331
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Park YK, Lee MJ, Kim JH, Kim SJ, Kim JS, Lee SY, Bang OY. Lack of Association of Clinical Factors (SAMe-TT2R2) with CYP2C9/VKORC1 Genotype and Anticoagulation Control Quality. J Stroke 2015; 17:192-8. [PMID: 26060806 PMCID: PMC4460338 DOI: 10.5853/jos.2015.17.2.192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 02/27/2015] [Accepted: 02/27/2015] [Indexed: 12/28/2022] Open
Abstract
Background and Purpose Advantages of new oral anticoagulations may be greater in atrial fibrillation (AF) patients of poor anticoagulation control with warfarin. The SAMe-TT2R2 scoring system, based on clinical variables, was recently developed to aid in identifying these patients. In this study, we investigated the association of this clinical composite score with genetic factors related warfarin dosing and the quality of anticoagulation control. Methods Clinical and genetic data were collected from 380 consecutive Korean patients with AF (CHA2DS2-VASc score, 3.5±1.8) who were followed for an average of 4 years. We evaluated factors associated with time in therapeutic range (TTR, INR 2-3), including the CYP2C9 and VKORC1 genotypes and the SAMe-TT2R2 score (Sex female, Age <60 years, Medical history [>two co-morbidities], Treatment [interacting drugs, e.g., amiodarone], Tobacco use within 2 years [doubled], and Race non-white [doubled]). Results The average SAMe-TT2R2 score was 3.4±0.9, range 2-7; and 153 patients (40.2%) had SAMe-TT2R2 scores ≥4. Time in specific INR ranges varied depending on the VKORC1 genotype but not with the CYP2C9 genotype or the SAMe-TT2R2 score. TTR was higher in patients with the VKORC1 1173C>T than in VKORC1 TT (61.7±16% vs. 56.7±17.4%, P=0.031). Multivariate testing showed that VKORC1 genotype but not the SAMe-TT2R2 score was significantly associated with labile INRs. There was no correlation between the SAMe-TT2R2 scores and pharmacogenetic data. Conclusions A genetic factor, but none of the common clinical and demographic factors, as combined in the SAMe-TT2R2 score, was associated with the quality of anticoagulation control in Korean patients with AF.
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Affiliation(s)
- Yun Kyung Park
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ha Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk Jae Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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3332
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Bosch J, Eikelboom JW. Management of bleeding with oral anticoagulants in patients with atrial fibrillation. Hamostaseologie 2015; 35:351-7. [PMID: 26013362 DOI: 10.5482/hamo-14-12-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/04/2015] [Indexed: 11/05/2022] Open
Abstract
Fear of bleeding is a common barrier to the use of anticoagulants. Warfarin has been the only oral anticoagulant for more than 60 years and warfarin-related bleeding is reported to be the most common drug-related cause of emergency hospitalization in elderly Americans. Non-vitamin K oral antagonists were introduced five years ago and compared with warfarin are associated with lower risk of intracranial bleeding, and similar or lower case fatality after major bleeding. Despite their superior safety profile, serious bleeding can occur. Most bleeding can be managed with holding the drug, local measures to control the bleeding and transfusion support as required because the NOACs have a relatively short half life and their anticoagulant effect rapidly dissipates. In patients with ongoing bleeding despite supportive measures and in those with life-threatening bleeding, consideration may be given to the use of general hemostatic agents. Experimental and animal evidence suggests that 3 and 4 factor prothrombin complex concentrates can improve hemostasis in the presence of a NOAC and this is reinforced by anecdotal evidence in humans. Specific antidotes are currently in phase 3 trials and could become available in the near future.
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Affiliation(s)
| | - J W Eikelboom
- John W Eikelboom, Population Health Research Institute, McMaster University and Hamilton Health Sciences, 237 Barton St. E., Hamilton, ON, Canada L8L 2X2, Tel. 905-527-4322 ext 40323, Fax 905-297-3785, E-mail:
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3333
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Acharya T, Deedwania P. An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation. CORE EVIDENCE 2015; 10:63-73. [PMID: 26019695 PMCID: PMC4422295 DOI: 10.2147/ce.s61441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug-drug and drug-food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy.
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Affiliation(s)
- Tushar Acharya
- Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Prakash Deedwania
- Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
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3334
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Cresti A, García-Fernández MA, De Sensi F, Miracapillo G, Picchi A, Scalese M, Severi S. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study. Europace 2015; 18:450-6. [PMID: 26017468 DOI: 10.1093/europace/euv128] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/13/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Prevalence of left appendage thrombosis ranges from 6 to 18% in persistent atrial fibrillation (AF). Few and low sample size studies have assessed left and right atrial thrombosis in persistent atrial flutter (AFL) and a wide variety of frequencies, from 1 to 21%, has been reported. The aim of this study was to evaluate the prevalence of atrial appendage thrombosis in a large population of patients undergoing transoesophageal echocardiography (TEE)-guided cardioversion (CV) for recent AFL onset and compare it with AF. METHODS AND RESULTS From 1999 to September 2014, we collected data of 1081 patients to CV: 877 affected by AF (81.1%) and 204 by AFL (18.9%). The presence of auricular thrombosis was evaluated by TEE in AF or AFL persisting for more than 48 h. The presence of appendage thrombosis, Doppler emptying velocities, and severe spontaneous echo contrast (SEC) was studied. The overall prevalence of atrial thrombosis was 9.62% (104/1081). Frequency of atrial thrombosis in AFL patients was 6.4% (13/204) vs. 10.5% among AF (92/877), P = 0.074. Comparing the two appendages, frequency of left atrial appendage thrombosis was in AFL 5.9% (12/204) vs. 9.9% (87/877) in the AF group, P = 0.07. Right atrial appendage thrombosis was present in 0.5% (1/204) in the AFL group vs. 0.8% (7/877) in the AF group, P = 0.64. Moderate to severe SEC (3+/4+) was present in 28% of AFL patients (57/204) vs. 35% of AF patients (307/877), P = 0.05. CONCLUSION Auricular thrombosis is not an infrequent finding in AFL before CV. Our study suggests the use of TEE screening in AFL, as well as in AF, when patients arrive to clinical attention after more than 48 h from arrhythmia onset.
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Affiliation(s)
- Alberto Cresti
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Miguel Angel García-Fernández
- Department of Medicine, San Carlos University Hospital, Universidad Complutense, Facultad de Medicina, Madrid, Spain
| | - Francesco De Sensi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Gennaro Miracapillo
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Andrea Picchi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Marco Scalese
- Department of Epidemiology and Health Research, Institute of Clinical Physiology, National Council of Research, F. G. Monasterio, Pisa, Italy
| | - Silva Severi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
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3335
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Heidbuchel H, Berti D, Campos M, Desteghe L, Freixo AP, Nunes AR, Roldán V, Toschi V, Lassila R. Implementation of non-vitamin K antagonist oral anticoagulants in daily practice: the need for comprehensive education for professionals and patients. Thromb J 2015; 13:22. [PMID: 26124699 PMCID: PMC4484703 DOI: 10.1186/s12959-015-0046-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/10/2015] [Indexed: 02/06/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for the prevention and treatment of venous thromboembolism and for stroke prevention in patients with atrial fibrillation. NOACs do not require routine coagulation monitoring, creating a challenge to established systems for patient follow-up based on regular blood tests. Healthcare professionals (HCPs) are required to cope with a mixture of patients receiving either a vitamin K antagonist or a NOAC for the same indications, and both professionals and patients require education about the newer drugs. A European working group convened to consider the challenges facing HCPs and healthcare systems in different countries and the educational gaps that hinder optimal patient management. Group members emphasised the need for regular follow-up and noted national, regional and local variations in set-up and resources for follow-up. Practical incorporation of NOACs into healthcare systems must adapt to these differences, and practical follow-up that works in some systems may not be able to be implemented in others. The initial prescriber of a NOAC should preferably be a true anticoagulation specialist, who can provide initial patient education and coordinate the follow-up. The long-term follow-up care of patients can be managed through specialist coagulation nurses, in a dedicated anticoagulation clinic or by general practitioners trained in NOAC use. The initial prescriber should be involved in educating those who perform the follow-up. Specialist nurses require access to tools, potentially including specific software, to guide systematic patient assessment and workflow. Problem cases should be referred for specialist advice, whereas in cases for which minimal specialist attention is required, the general practitioner could take responsibility for patient follow-up. Hospital departments and anticoagulation clinics should proactively engage with all downstream HCPs (including pharmacists) to ensure their participation in patient management and reinforcement of patient education at every opportunity. Ideally, (transmural) protocols for emergency situations should be developed. Last but not least, patients should be well-informed about their condition, the treatment, possible risk scenarios, including the consequences of non-adherence to prescribed therapy, and the organisation of follow-up care.
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Affiliation(s)
- Hein Heidbuchel
- Hasselt University and Heart Center, Jessa Hospital, Stadsomvaart 11, Hasselt, 3500 Belgium
| | - Dana Berti
- Department of Cardiovascular Medicine, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Manuel Campos
- Department of Haematology, Thrombosis and Haemostasis, Unit- Centro Hospitalar do Porto, Porto, Portugal
| | - Lien Desteghe
- Hasselt University and Heart Center, Jessa Hospital, Stadsomvaart 11, Hasselt, 3500 Belgium
| | - Ana Parente Freixo
- Centre of Thrombosis and Haemostasis, Department of Transfusion Medicine, São João University Hospital, Porto, Portugal
| | - António Robalo Nunes
- Immunohaemotherapy Service, Centro Hospitalar Lisboa Norte and Hospital do SAMS-SBSI, Lisbon, Portugal
| | - Vanessa Roldán
- Haematology and Medical Oncology Unit, Hospital Universitario Morales Meseguer, University of Murcia, Murcia, Spain
| | - Vincenzo Toschi
- Department of Haematology and Blood Transfusion, Thrombosis Centre, San Carlo Borromeo Hospital, Milan, Italy
| | - Riitta Lassila
- Department of Haematology, Division of Coagulation Disorders, Cancer Centre, Helsinki University Central Hospital, Helsinki, Finland
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3336
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Masubuchi H, Maeno T, Uchida M, Kono S, Suzuki M, Takemura M, Yamaguchi A, Yamaguchi K, Kanbe M, Kitahara S, Hara K, Hara S, Aoki N, Suga T, Kurabayashi M. A case of Trousseau syndrome caused by pulmonary adenocarcinoma that was controlled for one year and 10 months with thrombosis treatment using an EGFR tyrosine kinase inhibitor and chemotherapy. Respir Med Case Rep 2015; 15:101-5. [PMID: 26236616 PMCID: PMC4501524 DOI: 10.1016/j.rmcr.2015.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/30/2015] [Accepted: 05/03/2015] [Indexed: 01/18/2023] Open
Abstract
A 47-year-old female with no history of previous illnesses developed cerebral infarction and was diagnosed with lung cancer, specifically EGFR mutation-positive adenocarcinoma, and Trousseau syndrome. The patient's response to anticoagulant therapy with non-fractionated heparin was very poor; however we were able to control the thrombosis with chemotherapy. She survived for one year and 10 months following treatment with gefitinib, CBDCA + PEM and erlotinib, without recurrence of thrombosis. Trousseau syndrome carries a poor prognosis and controlling thrombosis is difficult. In this case, the administration of anticancer therapy allowed use to control the patient's thrombosis. Therefore, this case highlights the importance of treating cancer in patients with Trousseau syndrome. In addition, the FDP and D-dimer levels changed in parallel with changes in the CEA level, which suggests that the activity of cancer is related to an internal thrombotic tendency. Hence, changes in the FDP and D-dimer values are associated with the efficacy of treatment with EGFR tyrosine kinase inhibitors and chemotherapy and may function as markers of recurrence.
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Affiliation(s)
- Hiroaki Masubuchi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Toshitaka Maeno
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Megumi Uchida
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Shunichi Kono
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Masafumi Suzuki
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Masao Takemura
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Aya Yamaguchi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Koichi Yamaguchi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Masahiko Kanbe
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Shinsuke Kitahara
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Kenichiro Hara
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Shiro Hara
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Nozomi Aoki
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Tatsuo Suga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Masahiko Kurabayashi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
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3337
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Antonucci E, Poli D, Tosetto A, Pengo V, Tripodi A, Magrini N, Marongiu F, Palareti G. The Italian START-Register on Anticoagulation with Focus on Atrial Fibrillation. PLoS One 2015; 10:e0124719. [PMID: 26001109 PMCID: PMC4441383 DOI: 10.1371/journal.pone.0124719] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 02/03/2015] [Indexed: 12/22/2022] Open
Abstract
START-Register – Survey on anTicoagulated pAtients RegisTer – is an independent, inception-cohort, observational, collaborative database aimed at recording prospectively the clinical history of adult patients starting anticoagulant treatment for any reason and using whatever drug. In this article we present the START-Register and give cross section baseline data focusing on non valvular atrial fibrillation (NVAF). Participants are asked to insert prospectively consecutive patients recorded as electronic file on the web-site of the registry. Required data are: demographic and clinical characteristics of patients, associated risk factors for stroke and bleeding, laboratory routine data, clinical indication for treatment, expected therapeutic range (in cases of treatment with vitamin K antagonists -VKAs). The follow-up is carried out to record: quality of treatment (for patients on VKAs), bleeding complications, thrombotic events, and the onset of any type of associated disease. To date 5252 patients have been enrolled; 97.6% were on VKAs because direct oral anticoagulants (DOAC) have been available in Italy only recently. The median age was 74 years [interquartile range (IQR) 64-80]; males 53.7%. This analysis is focused on the 3209 (61.1%) NVAF patients. Mean CHADS2 score was 2.1±1.1, CHADSVASc score was 3.1±1.3;median age was 76 years (IQR 70-81); 168 patients (5.3%) had severe renal failure [Creatinine clearance (CrCl) <30 ml/min]. Moderate renal failure (CrCl 30-59 ml/min) was found in 1265 patients (39.5%). The analysis of the START-Register data shows that two-third of patients who started chronic anticoagulant treatment had NVAF, one-third of them was > 80 years with high prevalence of renal failure.
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Affiliation(s)
- Emilia Antonucci
- Department of Experimental and Clinical Medicine, Thrombosis Centre, University of Florence, Florence, Italy
- * E-mail:
| | - Daniela Poli
- Department of Heart and Vessels, Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alberto Tosetto
- Department of Hematology, Vicenza S. Bortolo Hospital, Vicenza, Italy
| | - Vittorio Pengo
- Department of Clinical Cardiology, Thrombosis Centre, University of Padua, Padua, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Nicola Magrini
- Drug Evaluation Unit, WHO Collaborating Centre in Evidence-Based Research Synthesis and Guideline Development, Emilia Romagna Health and Social Care Agency, Bologna, Italy
| | - Francesco Marongiu
- Department of Medical Sciences, University Hospital of Cagliari, Cagliari, Italy
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3338
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Kalabalik J, Rattinger GB, Sullivan J, Slugocki M, Carbone A, Rivkin A. Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice. Drugs 2015; 75:979-98. [DOI: 10.1007/s40265-015-0405-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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3339
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Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M. Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis. Circulation 2015; 132:194-204. [PMID: 25995317 DOI: 10.1161/circulationaha.114.013267] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 04/27/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Evidence regarding the use of direct oral anticoagulants (DOACs) in the elderly, particularly bleeding risks, is unclear despite the presence of greater comorbidities, polypharmacy, and altered pharmacokinetics in this age group. METHODS AND RESULTS We performed a systematic review and meta-analysis of randomized trials of DOACs (dabigatran, apixaban, rivaroxaban, and edoxaban) for efficacy and bleeding outcomes in comparison with vitamin K antagonists (VKA) in elderly participants (aged ≥75 years) treated for acute venous thromboembolism or stroke prevention in atrial fibrillation. Nineteen studies were eligible for inclusion, but only 11 reported data specifically for elderly participants. The efficacy in managing thrombotic risks for each DOAC was similar or superior to VKA in elderly patients. A nonsignificantly higher risk of major bleeding than with VKA was observed with dabigatran 150 mg (odds ratio, 1.18; 95% confidence interval, 0.97-1.44) but not with the 110-mg dose. Significantly higher gastrointestinal bleeding risks with dabigatran 150 mg (1.78, 1.35-2.35) and dabigatran 110 mg (1.40, 1.04-1.90) and lower intracranial bleeding risks than VKA for dabigatran 150 mg (0.43, 0.26-0.72) and dabigatran 110 mg (0.36, 0.22-0.61) were also observed. A significantly lower major bleeding risk in comparison with VKA was observed for apixaban (0.63, 0.51-0.77), edoxaban 60 mg (0.81, 0.67-0.98), and 30 mg (0.46, 0.38-0.57), whereas rivaroxaban showed similar risks. CONCLUSIONS DOACs demonstrated at least equal efficacy to VKA in managing thrombotic risks in the elderly, but bleeding patterns were distinct. In particular, dabigatran was associated with a higher risk of gastrointestinal bleeding than VKA. Insufficient published data for apixaban, edoxaban, and rivaroxaban indicate that further work is needed to clarify the bleeding risks of these DOACs in the elderly. SYSTEMATIC REVIEW REGISTRATION http://www.crd.york.ac.uk/PROSPERO. Unique identifier: PROSPERO CRD42014007171/.
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Affiliation(s)
- Manuj Sharma
- From Department of Primary Care and Public Health Sciences, King's College London, United Kingdom (M.S., V.R.C., M.M.); Department of Clinical Pharmacy, Guy's and St Thomas Hospital NHS Foundation Trust, London, United Kingdom (M.S.); Department of Haematological Medicine, King's College Hospital, London, United Kingdom (J.P.P.); and Institute of Pharmaceutical Science, King's College London, United Kingdom (J.P.P., J.G.D.).
| | - Victoria R Cornelius
- From Department of Primary Care and Public Health Sciences, King's College London, United Kingdom (M.S., V.R.C., M.M.); Department of Clinical Pharmacy, Guy's and St Thomas Hospital NHS Foundation Trust, London, United Kingdom (M.S.); Department of Haematological Medicine, King's College Hospital, London, United Kingdom (J.P.P.); and Institute of Pharmaceutical Science, King's College London, United Kingdom (J.P.P., J.G.D.)
| | - Jignesh P Patel
- From Department of Primary Care and Public Health Sciences, King's College London, United Kingdom (M.S., V.R.C., M.M.); Department of Clinical Pharmacy, Guy's and St Thomas Hospital NHS Foundation Trust, London, United Kingdom (M.S.); Department of Haematological Medicine, King's College Hospital, London, United Kingdom (J.P.P.); and Institute of Pharmaceutical Science, King's College London, United Kingdom (J.P.P., J.G.D.)
| | - J Graham Davies
- From Department of Primary Care and Public Health Sciences, King's College London, United Kingdom (M.S., V.R.C., M.M.); Department of Clinical Pharmacy, Guy's and St Thomas Hospital NHS Foundation Trust, London, United Kingdom (M.S.); Department of Haematological Medicine, King's College Hospital, London, United Kingdom (J.P.P.); and Institute of Pharmaceutical Science, King's College London, United Kingdom (J.P.P., J.G.D.)
| | - Mariam Molokhia
- From Department of Primary Care and Public Health Sciences, King's College London, United Kingdom (M.S., V.R.C., M.M.); Department of Clinical Pharmacy, Guy's and St Thomas Hospital NHS Foundation Trust, London, United Kingdom (M.S.); Department of Haematological Medicine, King's College Hospital, London, United Kingdom (J.P.P.); and Institute of Pharmaceutical Science, King's College London, United Kingdom (J.P.P., J.G.D.).
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3340
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Shehab A, Elnour AA, Bhagavathula AS, Erkekoglu P, Hamad F, Al Nuaimi S, Al Shamsi A, Mukhtar I, Ali AbdElrazek AM, Al Suwaidi A, Mandil MA, Baraka M, Sadik A, Saraan K, Al Kalbani NMS, Mahmood AA, Barqawi Y, Al Hajjar M, Shehab OA, Al Amoodi A, Asim S, Abdulla R, Giraud CS, Ahmed EM, Shaaban ZA, Eltayeb AEYA. Novel oral anticoagulants and the 73rd anniversary of historical warfarin. J Saudi Heart Assoc 2015; 28:31-45. [PMID: 26778903 PMCID: PMC4685209 DOI: 10.1016/j.jsha.2015.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 01/22/2023] Open
Affiliation(s)
- Abdulla Shehab
- Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, United Arab Emirates
| | - Asim Ahmed Elnour
- Pharmacology Department, College of Medicine and Health Sciences, UAE University, United Arab Emirates; Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | | | - Pınar Erkekoglu
- Department of Toxicology, Faculty of Pharmacy, Hacettepe University, Sihhiye 06100, Ankara, Turkey
| | - Farah Hamad
- Ajman University of Sciences and Technology, AJman, United Arab Emirates
| | - Saif Al Nuaimi
- Internal Medicine-Tawam Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | - Ali Al Shamsi
- Internal Medicine-Tawam Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | - Iman Mukhtar
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | | | - Aeshal Al Suwaidi
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | | | - Mohamed Baraka
- Department of Pharmacy Practice, College of Clinical Pharmacy-University of Dammam Eastern Province, Damman, Saudi Arabia
| | - Adel Sadik
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | - Khalid Saraan
- Internal Medicine, Abu Dhabi Rehabilitation Center, Abu Dhabi, United Arab Emirates
| | - Naama M S Al Kalbani
- Internal Medicine-Tawam Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | - Alaa AbdulAziz Mahmood
- Pharmacology Department, College of Medicine and Health Sciences, UAE University, United Arab Emirates
| | - Yazan Barqawi
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | | | - Omer Abdulla Shehab
- Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, United Arab Emirates
| | - Abdulla Al Amoodi
- Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, United Arab Emirates
| | - Sahar Asim
- Ajman University of Sciences and Technology, AJman, United Arab Emirates
| | - Rauda Abdulla
- Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, United Arab Emirates
| | - Cristina Sanches Giraud
- Universidade Federal de São João del-Rei, Campus Centro-Oeste Dona Lindu, Av. Sebastião Gonçalves Coelho, 400 Chanadour, Divinópolis, Brazil
| | - El Mutasim Ahmed
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
| | - Zohdi Abu Shaaban
- Al Ain Hospital, Abu Dhabi Health Services, SEHA, United Arab Emirates
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3341
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Pollack CV. Coagulation assessment with the new generation of oral anticoagulants. Emerg Med J 2015; 33:423-30. [PMID: 25987596 PMCID: PMC4893109 DOI: 10.1136/emermed-2015-204891] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/13/2015] [Indexed: 01/01/2023]
Abstract
Long-term oral anticoagulant (OAC) therapy is used for the treatment and prevention of thrombosis and thromboembolism. As OAC use is so widespread, emergency physicians are likely to encounter patients on anticoagulant therapy in the emergency department (ED) on a regular basis, either for the same reasons as the population in general or as a result of the increased bleeding risk that OAC use entails. The vitamin K antagonist warfarin has been the standard OAC for several decades, but recently, the newer agents dabigatran etexilate, rivaroxaban and apixaban (collectively, novel OACs, non-vitamin K OACs, or simply ‘NOACs’) have become available for long-term use. Protocols for assessing and managing warfarin-treated patients in the ED are well established and include international normalised ratio (INR) testing, which helps guide patient management. However, the INR does not give an accurate evaluation of coagulation status with NOACs, and alternative tests are therefore needed for use in emergency settings. This paper discusses what information the INR provides for a patient taking warfarin and which coagulation tests can guide the physician when treating patients on one of the NOACs, as well as other differences in emergency anticoagulation management.
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3342
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Persistence of non-vitamin K antagonist oral anticoagulant use in Japanese patients with atrial fibrillation: A single-center observational study. J Arrhythm 2015; 31:339-44. [PMID: 26702312 PMCID: PMC4672038 DOI: 10.1016/j.joa.2015.04.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/08/2015] [Accepted: 04/14/2015] [Indexed: 11/23/2022] Open
Abstract
Background Non-vitamin K antagonist oral anticoagulants (NOACs) show a favorable balance between efficacy and safety compared with warfarin for patients with non-valvular atrial fibrillation (NVAF). In “real-world” practice, however, NOAC adherence and persistence among patients are not clear. The aim of this study is to evaluate NOAC and warfarin persistence in Japanese patients with NVAF who newly started these drugs. Methods We retrospectively studied 401 patients with NVAF who had newly started NOACs during the first 18 months after our hospital adopted their use (197 dabigatran, 107 rivaroxaban, 102 apixaban) and 200 patients with NVAF who had newly started warfarin during the same period. The endpoint was drug discontinuation for each drug. Results During the follow-up period (up to a maximum of 24 months), 113 (28%) patients who had newly started NOACs and 33 (17%) patients who had newly started warfarin discontinued the drug. The persistence rates of patients prescribed NOACs was lower than that of patients prescribed warfarin at 3, 6, and 12 months (85% versus 93%, 79% versus 88%, and 70% versus 82%, respectively). One-tenth of patients who had newly started NOACs discontinued the drug by their own decision. Drug adverse events, worsening renal dysfunction, and patient desire were the major causes of NOAC discontinuation. Conclusions The rate of persistence of prescribed NOACs was significantly lower than that of warfarin in Japanese patients with NVAF.
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3343
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Wright GEB. Warfarin pharmacogenetics in the era of new oral anticoagulants. Clin Genet 2015; 88:135-6. [PMID: 25970639 DOI: 10.1111/cge.12609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 11/30/2022]
Affiliation(s)
- G E B Wright
- Centre for Molecular Medicine and Therapeutics, Department of Medical Genetics, Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
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3344
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Steffel J, Giugliano RP, Braunwald E, Murphy SA, Atar D, Heidbuchel H, Camm AJ, Antman EM, Ruff CT. Edoxaban vs. warfarin in patients with atrial fibrillation on amiodarone: a subgroup analysis of the ENGAGE AF-TIMI 48 trial. Eur Heart J 2015; 36:2239-45. [PMID: 25971288 DOI: 10.1093/eurheartj/ehv201] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the ENGAGE AF-TIMI 48 trial, the higher-dose edoxaban (HDE) regimen had a similar incidence of ischaemic stroke compared with warfarin, whereas a higher incidence was observed with the lower-dose regimen (LDE). Amiodarone increases edoxaban plasma levels via P-glycoprotein inhibition. The current pre-specified exploratory analysis was performed to determine the effect of amiodarone on the relative efficacy and safety profile of edoxaban. METHODS AND RESULTS At randomization, 2492 patients (11.8%) were receiving amiodarone. The primary efficacy endpoint of stroke or systemic embolic event was significantly lower with LDE compared with warfarin in amiodarone treated patients vs. patients not on amiodarone (hazard ratio [HR] 0.60, 95% confidence intervals [CIs] 0.36-0.99 and HR 1.20, 95% CI 1.03-1.40, respectively; P interaction <0.01). In patients randomized to HDE, no such interaction for efficacy was observed (HR 0.73, 95% CI 0.46-1.17 vs. HR 0.89, 95% CI 0.75-1.05, P interaction = 0.446). Major bleeding was similar in patients on LDE (HR 0.35, 95% CI 0.21-0.59 vs. HR 0.53, 95% CI 0.46-0.61, P interaction = 0.131) and HDE (HR 0.94, 95% CI 0.65-1.38 vs. HR 0.79, 95% CI 0.69-0.90, P interaction = 0.392) when compared with warfarin, independent of amiodarone use. CONCLUSIONS Patients randomized to the LDE treated with amiodarone at the time of randomization demonstrated a significant reduction in ischaemic events vs. warfarin when compared with those not on amiodarone, while preserving a favourable bleeding profile. In contrast, amiodarone had no effect on the relative efficacy and safety of HDE.
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Affiliation(s)
- J Steffel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - R P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - E Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - S A Murphy
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - D Atar
- Department of Cardiology B, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - H Heidbuchel
- Hasselt University and Heart Center, Jessa Hospital, Hasselt, Belgium
| | - A J Camm
- Division of Clinical Sciences, St. George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - E M Antman
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - C T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
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3345
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Nielsen PB, Lane DA, Rasmussen LH, Lip GYH, Larsen TB. Renal function and non-vitamin K oral anticoagulants in comparison with warfarin on safety and efficacy outcomes in atrial fibrillation patients: a systemic review and meta-regression analysis. Clin Res Cardiol 2015; 104:418-29. [PMID: 25416564 DOI: 10.1007/s00392-014-0797-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 11/14/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the relative effect of warfarin versus non-vitamin K oral anticoagulants (NOACs) in thrombotic and bleeding outcomes in subgroups of atrial fibrillation (AF) patients with varying degrees of renal dysfunction. METHODS Systemic review and meta-regression analyses on NOACs versus warfarin, supplemented with indirect comparisons were conducted. The eligibility criteria for inclusion were randomised controlled trials comparing NOACs against warfarin for stroke prevention in AF patients. Outcomes of interest were stroke or systemic embolism (SE) and major bleeding. RESULTS Five studies comprising 72,845 AF patients randomised to either a NOAC or warfarin were included in the meta-regression analysis. A shift in strata from no renal impairment to renal impairment resulted in a non-significant impact on bleeding and stroke/SE, indicating similar safety and efficacy, despite renal function status. Apixaban was associated with less major bleeding compared to dabigatran and rivaroxaban but not edoxaban in patients with moderate renal impairment. For efficacy outcomes, only dabigatran 150 mg was statistically significantly favoured compared to edoxaban 30 mg. For efficacy outcomes in mild renal impairment, both dabigatran 150 mg and rivaroxaban 10 mg (J-ROCKET) were statistically significantly favoured against edoxaban 30 mg. CONCLUSION Non-vitamin K oral anticoagulants had similar efficacy and safety compared to warfarin across different levels of renal function. Indirect comparisons suggest that apixaban and edoxaban were associated with a better safety profile in patients with moderate renal impairment. However, caution is warranted when interpreting indirect comparisons of drugs investigated in different trials. Prescribers should fit the most appropriate NOAC to the AF patient characteristics (and vice versa) to individualise effective stroke prevention.
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Affiliation(s)
- Peter Brønnum Nielsen
- Department of Cardiology, Aalborg AF Study Group, Aalborg University Hospital, Aalborg, Denmark,
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3346
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Loffredo L, Perri L, Violi F. Impact of new oral anticoagulants on gastrointestinal bleeding in atrial fibrillation: A meta-analysis of interventional trials. Dig Liver Dis 2015; 47:429-31. [PMID: 25732432 DOI: 10.1016/j.dld.2015.01.159] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/27/2015] [Accepted: 01/30/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND New oral anticoagulants represent an alternative to standard therapy with vitamin K antagonists but data regarding gastrointestinal bleeding are still unclear. AIMS To investigate if new oral anticoagulants are associated with an enhanced risk of gastrointestinal bleeding vs warfarin in patients with atrial fibrillation. METHODS Meta-analysis of phase three randomized controlled trials to compare the incidence of gastrointestinal bleeding in atrial fibrillation patients treated with new oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) vs warfarin. RESULTS Four studies including 71,302 patients were selected. Compared with warfarin, new oral anticoagulants significantly increased gastrointestinal bleeding (RR: 1.23; 95% CI 1.03-1.46; p=0.01). Rivaroxaban (RR: 1.46; 95% CI 1.2-1.8; p<0.001) and high dosages of edoxaban (RR: 1.22; 95% CI 1.01-1.47; p=0.038) and dabigatran (RR: 1.50; 95% CI 1.20-1.88; p<0.001) significantly increased gastrointestinal bleeding while a null effect was detected with apixaban. CONCLUSIONS This meta-analysis suggests that rivaroxaban and high dosages of dabigatran and edoxaban should be avoided in patients at high risk of gastrointestinal bleeding.
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Affiliation(s)
- Lorenzo Loffredo
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.
| | - Ludovica Perri
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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3347
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Lip GYH, Merino J, Ezekowitz M, Ellenbogen K, Zamoryakhin D, Lanz H, Jin J, Al-Saadi N, Mercuri M, Goette A. A prospective evaluation of edoxaban compared to warfarin in subjects undergoing cardioversion of atrial fibrillation: The EdoxabaN vs. warfarin in subjectS UndeRgoing cardiovErsion of Atrial Fibrillation (ENSURE-AF) study. Am Heart J 2015; 169:597-604.e5. [PMID: 25965706 DOI: 10.1016/j.ahj.2015.02.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 02/07/2015] [Indexed: 11/29/2022]
Abstract
We designed a prospective, randomized, open-label, blinded end point evaluation parallel group Phase 3b clinical trial comparing edoxaban (a new oral factor Xa inhibitor) with enoxaparin/warfarin followed by warfarin alone in subjects undergoing planned electrical cardioversion of non-valvular atrial fibrillation. The primary efficacy end point is the composite end points of stroke, systemic embolic event, myocardial infarction, and cardiovascular (CV) mortality, from randomization until the end of follow-up (day 56 post cardioversion). The primary safety end point is the composite of major and clinically-relevant non-major bleeding, from the first administration of study drug to end of treatment (Day 28 post cardioversion) +3 days. The primary efficacy analysis will be conducted on the intention-to-treat population whereas the primary safety analysis, on the safety population. The study includes stratification on the following levels: (i) approach to cardioversion (transoesophagel echocardiography or non-transoesophagel echocardiography) as determined by the Investigator; (ii) subject's experience in taking anticoagulants at the time of randomization (anticoagulant-experienced or anticoagulant-naïve); and (iii) assigned edoxaban dose (full 60 mg QD or reduced 30 mg dose QD). A subject with one or more factors (CrCl ≥15 mL/min and ≤50 mL/min, low body weight [≤60 kg], and concomitant use of p-pg inhibitors (excluding amiodarone) will receive a reduced dose (30 mg) of edoxaban if the subject is randomized to the edoxaban group. ENSURE-AF will be the largest prospective randomised trial of anticoagulation for cardioversion, also involving a Non-VKA Oral Anticoagulant-edoxaban.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Aalborg University, Denmark.
| | - Jose Merino
- University Hospital La Paz - IdiPaz, Madrid, Spain
| | - Michael Ezekowitz
- Jefferson Medical College, Cardiovascular Research Foundation, New York, NY
| | | | | | - Hans Lanz
- Daiichi Sankyo Pharma Development, Edison, NJ
| | - James Jin
- Daiichi Sankyo Pharma Development, Edison, NJ
| | | | | | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital, Paderborn and Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
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3348
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Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm. J Am Med Dir Assoc 2015; 16:358-64. [DOI: 10.1016/j.jamda.2014.12.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/05/2014] [Indexed: 11/18/2022]
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3349
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del Molino F, Gonzalez I, Saperas E. [Management of new oral anticoagulants in gastrointestinal bleeding and endoscopy]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:501-10. [PMID: 25908223 DOI: 10.1016/j.gastrohep.2015.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/07/2015] [Accepted: 02/11/2015] [Indexed: 01/06/2023]
Abstract
New oral direct anticoagulants agents are alternatives to warfarin for long-term anticoagulation in a growing number of patients that require long-term anticoagulation for atrial fibrillation, deep venous thrombosis and pulmonary embolism. These new agents with predictable pharmacokinetic and pharmacodynamics profiles offer a favorable global safety profile, but increased gastrointestinal bleeding compared to the vitamin K antagonists. Many gastroenterologists are unfamiliar and may be wary of these newer drugs, since Clinical experience is limited and no specific antidote is available to reverse their anticoagulant effect. In this article the risk of these new agents and, how to manage these agents in both the presence of acute gastrointestinal bleeding and in patients undergoing endoscopic procedures is reviewed.
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Affiliation(s)
- Fátima del Molino
- Servicio de Médicina Interna, IDC Clínica del Vallés, Sabadell, Barcelona, España; Comité de Enfermedad Tromboembólica y Anticoagulación de IDC Hospitales de Cataluña
| | - Isabel Gonzalez
- Comité de Enfermedad Tromboembólica y Anticoagulación de IDC Hospitales de Cataluña; Servicio de Hematología y Hemoterapia BST, Hospital Mútua de Terrassa, Tarrasa, España
| | - Esteve Saperas
- Comité de Enfermedad Tromboembólica y Anticoagulación de IDC Hospitales de Cataluña; Servicio de Aparato Digestivo y Endoscopia, IDC Hospital General de Catalunya, Universidad Internacional de Catalunya, San Cugat del Vallés, Barcelona, España.
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3350
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Kilickiran Avci B, Vatan B, Ozden Tok O, Aidarova T, Sahinkus S, Uygun T, Gunduz H, Karakaya O, Yuksel H, Ongen Z. The Trends in Utilizing Nonvitamin K Antagonist Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation: A Real-Life Experience. Clin Appl Thromb Hemost 2015; 22:785-791. [PMID: 25878174 DOI: 10.1177/1076029615581365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dabigatran and rivaroxaban are novel nonvitamin K antagonist oral anticoagulants (NOACs) approved for thromboprophylaxis in atrial fibrillation (AF). In Turkey, like other countries, the efficacy of translation of the clinical trial results and current guideline recommendations into daily clinical practice is yet to be discovered. Using data from medical records of three tertiary care cardiology centers, we identified patients with nonvalvular AF on dabigatran or rivaroxaban treatment. Baseline characteristics and utilization trends were compared between dabigatran and rivaroxaban groups. Secondarily, clinical events including ischemic stroke and/or transient ischemic attack, systemic embolism, and bleeding were evaluated. Among 294 patients with AF included, dabigatran was utilized in 177 (60.2%) and rivaroxaban in 117 (39.8%). Overall, 76% of patients had received long-term warfarin therapy. The use of 110 mg twice a day (55.4%) was the prevailing strategy in dabigatran group, whereas in rivaroxaban group 20 mg every day (67.5%) was the preferred option. Of the patients, 37.3% had severe valvular disease in which mitral regurgitation was the predominant valve abnormality. Scores of CHADS2, CHA2DS2VASc, and HAS-BLED were similar in both the groups. Of the patients, 24% in dabigatran group and 13.7% in rivaroxaban group were prescribed the lower dose inappropriately. The two NOACs did not differ significantly in terms of clinical events. The results of this study indicate that in daily practice, the physicians' behavior in utilizing the NOACs is shaped by the clinical trials and the guideline recommendations. On the other hand, in dose selection, this adherence is not of high quality.
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Affiliation(s)
- Burcak Kilickiran Avci
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bulent Vatan
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ozge Ozden Tok
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Tamara Aidarova
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Salih Sahinkus
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Turgut Uygun
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Huseyin Gunduz
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Osman Karakaya
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Husniye Yuksel
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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