3451
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Abstract
The introduction of direct oral anticoagulants (OACs) for the treatment and prevention of thromboembolic disease represents a shift from the traditional vitamin K antagonist-based therapies, which have been the mainstay of treatment for almost 60 years. A challenge for hospital formularies will be to manage the use of direct OACs from hospital to outpatient settings. Three direct OACs—apixaban, dabigatran and rivaroxaban—are widely approved across different indications, with rivaroxaban approved across the widest breadth of indications. A fourth direct OAC, edoxaban, has also completed phase III trials. Implementation of these agents by physicians will require an understanding of the efficacy and safety profile of these drugs, as well as an awareness of renal function, comedication use, patient adherence and compliance. Optimal implementation of direct OACs in the hospital setting will provide improved patient outcomes when compared with traditional anticoagulants and will simplify the treatment and prevention of thromboembolic diseases.
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3452
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Evolution of stroke prevention in nonvalvular atrial fibrillation patients. J Am Coll Cardiol 2014; 64:13-5. [PMID: 24998122 DOI: 10.1016/j.jacc.2014.04.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/03/2014] [Indexed: 11/22/2022]
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3453
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Ruff CT, Giugliano RP, Braunwald E, Antman EM. New oral anticoagulants in patients with atrial fibrillation - Authors'reply. Lancet 2014; 384:25-6. [PMID: 24998809 DOI: 10.1016/s0140-6736(14)61106-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christian T Ruff
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
| | - Robert P Giugliano
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Eugene Braunwald
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Elliott M Antman
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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3454
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3455
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Survenue d’un accident ischémique cérébral chez un patient en fibrillation atriale sous anticoagulant oral : que faire de plus ? Presse Med 2014; 43:784-8. [DOI: 10.1016/j.lpm.2014.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/17/2014] [Indexed: 11/24/2022] Open
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3456
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Andrew NE, Hankey GJ, Cadilhac DA. Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.
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Affiliation(s)
- Nadine E Andrew
- Translational Public Health Unit, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, 1/43-51 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Crawley, WA 6009, Australia
| | - Dominique A Cadilhac
- Translational Public Health Unit, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, 1/43-51 Kanooka Grove, Clayton, VIC 3168, Australia
- Florey Institute of Neuroscience & Mental Health, 245 Burgundy St, Heidelberg, VIC 3084, Australia
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3457
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¿Qué aportan los nuevos anticoagulantes en la prevención del tromboembolismo venoso y arterial? HIPERTENSION Y RIESGO VASCULAR 2014. [DOI: 10.1016/j.hipert.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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3458
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Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm. Int J Cardiol 2014; 174:471-83. [DOI: 10.1016/j.ijcard.2014.04.179] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/06/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
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3459
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3460
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3461
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Manenti V, Aliot E. [Novel oral anticoagulants in patients with atrial fibrillation, how to avoid accidents?]. Presse Med 2014; 43:775-83. [PMID: 24957560 DOI: 10.1016/j.lpm.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 11/17/2022] Open
Abstract
Know the indications of these new drugs, and respect them. Do not confuse easiness of administration and absence of precautions. Renal function: a key parameter before and during treatment. Know when to use a low-dose drug regimen. Cardioversion: lack of safety evidence for some drugs. Drug interactions: beware of P-glycoprotein and cytochrome P450.
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Affiliation(s)
- Vladimir Manenti
- Institut Lorrain du cœur et des vaisseaux, département de cardiologie, 54511 Vandœuvre-lès-Nancy, France.
| | - Etienne Aliot
- Institut Lorrain du cœur et des vaisseaux, département de cardiologie, 54511 Vandœuvre-lès-Nancy, France
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3462
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Verdecchia P, Angeli F, Lip GYH, Reboldi G. Edoxaban in the evolving scenario of non vitamin K antagonist oral anticoagulants imputed placebo analysis and multiple treatment comparisons. PLoS One 2014; 9:e100478. [PMID: 24955573 PMCID: PMC4067355 DOI: 10.1371/journal.pone.0100478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/26/2014] [Indexed: 01/25/2023] Open
Abstract
Background Edoxaban recently proved non-inferior to warfarin for prevention of thromboembolism in patients with non-valvular atrial fibrillation (AF). We conducted an imputed-placebo analysis with estimates of the proportion of warfarin effect preserved by each non vitamin K antagonist oral anticoagulant (NOAC) and indirect comparisons between edoxaban and different NOACs. Methods and Findings We performed a literature search (up to January 2014), clinical trials registers, conference proceedings, and websites of regulatory agencies. We selected non-inferiority randomised controlled phase III trials of dabigatran, rivaroxaban, apixaban and edoxaban compared with adjusted-dose warfarin in non-valvular AF. Compared to imputed placebo, all NOACs reduced the risk of stroke (ORs between 0.24 and 0.42, all p<0.001) and all-cause mortality (ORs between 0.55 and 0.59, all p<0.05). Edoxaban 30 mg and 60 mg preserved 87% and 112%, respectively, of the protective effect of warfarin on stroke, and 133% and 121%, respectively, of the protective effect of warfarin on all-cause mortality. The risk of primary outcome (stroke/systemic embolism), all strokes and ischemic strokes was significantly higher with edoxaban 30 mg than dabigatran 150 mg and apixaban. There were no significant differences between edoxaban 60 mg and other NOACs for all efficacy outcomes except stroke, which was higher with edoxaban 60 mg than dabigatran 150 mg. The risk of major bleedings was lower with edoxaban 30 mg than any other NOAC, odds ratios (ORs) ranging between 0.45 and 0.67 (all p<0.001). Conclusions This study suggests that all NOACs preserve a substantial or even larger proportion of the protective warfarin effect on stroke and all-cause mortality. Edoxaban 30 mg is associated with a definitely lower risk of major bleedings than other NOACs. This is counterbalanced by a lower efficacy in the prevention of thromboembolism, although with a final benefit on all-cause mortality.
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Affiliation(s)
- Paolo Verdecchia
- Department of Medicine, Hospital of Assisi, Assisi, Italy
- * E-mail:
| | - Fabio Angeli
- Cardiology and Cardiovascular Pathophysiology, University Hospital of Perugia, Perugia, Italy
| | - Gregory Y. H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
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3463
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Nicholls SG, Brehaut JC, Arim RG, Carroll K, Perez R, Shojania KG, Grimshaw JM, Poses RM. Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians. Thromb J 2014; 12:13. [PMID: 25161388 PMCID: PMC4144316 DOI: 10.1186/1477-9560-12-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/13/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. METHODS Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. RESULTS Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ (2) (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ (2) (3) =10.7, p = 0.013). CONCLUSIONS Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin, even in the presence of falls risk.
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Affiliation(s)
- Stuart G Nicholls
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie C Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada ; Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Rubab G Arim
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Richard Perez
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kaveh G Shojania
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada ; Department of Medicine, University of Ottawa, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada
| | - Roy M Poses
- Foundation for Integrity and Responsibility in Medicine, Warren, Rhode Island, USA ; Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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3464
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Mearns ES, Hawthorne J, Song JS, Coleman CI. Measures of vitamin K antagonist control reported in atrial fibrillation and venous thromboembolism studies: a systematic review. BMJ Open 2014; 4:e005379. [PMID: 24951111 PMCID: PMC4067815 DOI: 10.1136/bmjopen-2014-005379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To aid trialists, systematic reviewers and others, we evaluated the degree of standardisation of control measure reporting that has occurred in atrial fibrillation (AF) and venous thromboembolism (VTE) studies since 2000; and attempted to determine whether the prior recommendation of reporting ≥2 measures per study has been employed. DESIGN Systematic review. SEARCH STRATEGY We searched bibliographic databases (2000 to June 2013) to identify AF and VTE studies evaluating dose-adjusted vitamin K antagonists (VKAs) and reporting ≥1 control measure. The types of measures reported, proportion of studies reporting ≥2 measures and mean (±SD) number of measures per study were determined for all studies and compared between subgroups. DATA EXTRACTION Through the use of a standardised data extraction tool, we independently extracted all data, with disagreements resolved by a separate investigator. RESULTS 148 studies were included, 57% of which reported ≥2 control measures (mean/study=2.13±1.36). The proportion of time spent in the target international normalised ratio range (TTR) was most commonly reported (79%), and was frequently accompanied by time above/below range (52%). AF studies more frequently reported ≥2 control measures compared with VTE studies (63% vs 37%; p=0.004), and reported a greater number of measures per study (mean=2.36 vs 1.53; p<0.001). Observational studies were more likely to provide ≥2 measures compared with randomised trials (76% vs 33%; p<0.001) and report a greater number of measures (mean=2.58 vs 1.63; p<0.001). More recent studies (2004-2013) reported ≥2 measures more often than older (2000-2003) studies (59% vs 35%; p=0.05) and reported more measures per study (mean=2.23 vs 1.48; p=0.02). CONCLUSIONS While TTR was often utilised, studies reported ≥2 measures of VKA control only about half of the time and lacked consistency in the types of measures reported. A trend towards studies reporting greater numbers of VKA control measures over time was observed over our review time horizon, particularly, with AF and observational studies.
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Affiliation(s)
- Elizabeth S Mearns
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- The University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, Connecticut, USA
| | - Jessica Hawthorne
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Ju-Sung Song
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- The University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, Connecticut, USA
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3465
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Mani H, Lindhoff-Last E. New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:789-98. [PMID: 24970997 PMCID: PMC4069048 DOI: 10.2147/dddt.s45644] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) continues to be a leading cause of cerebrovascular morbidity and mortality resulting from cardioembolic stroke. Oral anticoagulation therapy has been shown to decrease the incidence of cardioembolic stroke in patients with AF by more than 50%. Appropriate use of anticoagulation with vitamin K antagonists requires precise adherence and monitoring. A number of factors that potentially induce patients’ dissatisfaction reduce quality of patient life. New direct oral anticoagulants, such as the direct factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and the thrombin inhibitor dabigatran, were developed to overcome the limitations of the conventional anticoagulant drugs. However, models to optimize the benefit of therapy and to ensure that therapy can be safely continued are missing for the new oral anticoagulants. This review will briefly describe the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban with focus on their use for prevention of embolic events in AF. Moreover, it will discuss the safety, efficacy, cost data, and benefit for patients’ quality of life and adherence.
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Affiliation(s)
- Helen Mani
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
| | - Edelgard Lindhoff-Last
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
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3466
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Veltkamp R, Prabhakaran S. Critique of Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation trial. Stroke 2014; 45:2151-3. [PMID: 24916907 DOI: 10.1161/strokeaha.114.004971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Roland Veltkamp
- From the Department of Stroke Medicine, Imperial College London, London, United Kingdom (R.V.); Department of Neurology, University of Heidelberg, Heidelberg, Germany (R.V.); and Department of Neurology, Northwestern University, Chicago, IL (S.P.).
| | - Shyam Prabhakaran
- From the Department of Stroke Medicine, Imperial College London, London, United Kingdom (R.V.); Department of Neurology, University of Heidelberg, Heidelberg, Germany (R.V.); and Department of Neurology, Northwestern University, Chicago, IL (S.P.)
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3467
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Twice- or once-daily dosing of novel oral anticoagulants for stroke prevention: a fixed-effects meta-analysis with predefined heterogeneity quality criteria. PLoS One 2014; 9:e99276. [PMID: 24911432 PMCID: PMC4049736 DOI: 10.1371/journal.pone.0099276] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/13/2014] [Indexed: 11/19/2022] Open
Abstract
Background A number of novel oral anticoagulants (direct thrombin inhibitors or factor Xa inhibitors) are in clinical use for various indications. The dosing regimens differ between twice-daily and once-daily dosing for the prevention of stroke in patients with atrial fibrillation. With the availability of the results from four phase 3 studies (>70,000 patients), we explored whether twice-daily or once-daily dosing provides better risk-benefit balance among novel oral anticoagulants. Methods We conducted a strict, stepwise, fixed-effects meta-analysis with predefined heterogeneity quality criteria to generate the most appropriate common estimates for twice-daily (BID) or once-daily (QD) dosing regimens. An indirect comparison of these dosing regimens with fixed-effects meta-analysis common estimates (where available), or individual compound results, was done respectively. Results Comparing indirectly BID vs QD dosing regimens resulted in hazard ratios (HR [95% confidence interval]) for stroke and systemic embolism of 0.75 (0.58–0.96) for dabigatran 150 mg BID, and 0.91 (0.73–1.13) for apixaban BID vs the QD dosing regimen. For ischemic stroke, the HR of BID vs QD was 0.85 (0.69–1.05). For intracranial hemorrhage, BID vs rivaroxaban QD was 0.57 (0.37–0.88) and, vs edoxaban QD, 0.81 (0.54–1.22). Due to heterogeneity, common estimates for major bleeding QD or BID were not justified, therefore indirect comparison of regimens were not possible. All non-vitamin K antagonist oral anticoagulants reduced all-cause mortality vs warfarin with a HR of 0.90 (0.86–0.96) without differences between regimen. Conclusions Based on the available phase 3 study evidence, the twice-daily dosing regimen of non-vitamin K antagonist oral anticoagulants appears to offer a more balanced risk-benefit profile with respect to stroke prevention and intracranial hemorrhage.
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3468
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Douxfils J, Buckinx F, Mullier F, Minet V, Rabenda V, Reginster JY, Hainaut P, Bruyère O, Dogné JM. Dabigatran etexilate and risk of myocardial infarction, other cardiovascular events, major bleeding, and all-cause mortality: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2014; 3:e000515. [PMID: 24906369 PMCID: PMC4309041 DOI: 10.1161/jaha.113.000515] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Signals of an increased risk of myocardial infarction (MI) have been identified with dabigatran etexilate in randomized controlled trials (RCTs). Methods and Resules We conducted searches of the published literature and a clinical trials registry maintained by the drug manufacturer. Criteria for inclusion in our meta‐analysis included all RCTs and the availability of outcome data for MI, other cardiovascular events, major bleeding, and all‐cause mortality. Among the 501 unique references identified, 14 RCTs fulfilled the inclusion criteria. Stratification analyses by comparators and doses of dabigatran etexilate were conducted. Peto odds ratio (ORPETO) values using the fixed‐effect model (FEM) for MI, other cardiovascular events, major bleeding, and all‐cause mortality were 1.34 (95% CI 1.08 to 1.65, P=0.007), 0.93 (95%CI 0.83 to 1.06, P=0.270), 0.88 (95% CI 0.79 to 0.99, P=0.029), and 0.89 (95% CI 0.80 to 1.00, P=0.041). When compared with warfarin, ORPETO values using FEM were 1.41 (95% CI 1.11 to 1.80, P=0.005), 0.94 (95%CI 0.83 to 1.06, P=0.293), 0.85 (95% CI 0.76 to 0.96, P=0.007), and 0.90 (95% CI 0.81 to 1.01, P=0.061), respectively. In RCTs using the 150‐mg BID dosage, the ORPETO values using FEM were 1.45 (95% CI 1.11 to 1.91, P=0.007), 0.95 (95% CI 0.82 to 1.09, P=0.423), 0.92 (95% CI 0.81 to 1.05, P=0.228), and 0.88 (95% CI 0.78 to 1.00, P=0.045), respectively. The results of the 110‐mg BID dosage were mainly driven by the RE‐LY trial. Conclusions This meta‐analysis provides evidence that dabigatran etexilate is associated with a significantly increased risk of MI. This increased risk should be considered taking into account the overall benefit in terms of major bleeding and all‐cause mortality.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
| | - Fanny Buckinx
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - François Mullier
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.) Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), CHU Dinant-Godinne UCL Namur, Yvoir, Belgium (F.M.)
| | - Valentine Minet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
| | - Véronique Rabenda
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Philippe Hainaut
- Department of General Internal Medicine, Cliniques Universitaires Saint Luc, UCL, Bruxelles, Belgium (P.H.)
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium (F.B., R., J.Y.R., O.B.)
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium (J.D., F.M., V.M., J.M.D.)
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3469
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Polívka J, Rohan V, Ševčík P, Polívka J. Personalized approach to primary and secondary prevention of ischemic stroke. EPMA J 2014; 5:9. [PMID: 24949113 PMCID: PMC4063244 DOI: 10.1186/1878-5085-5-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/28/2014] [Indexed: 01/05/2023]
Abstract
Primary and secondary prevention of ischemic stroke represents a significant part of stroke management and health care. Although there are official guidelines concerning stroke management, new knowledge are introduced to them with a slight delay. This article provides an overview of current information on primary and secondary prevention of ischemic stroke. It summarizes information especially in the field of cardioembolic stroke, the use of new anticoagulants and the management of carotid stenosis based on the results of recent clinical studies. The optimal approach in stroke management is to follow these recommendations, to know new strategies and to apply an individual personalized approach in our clinical decisions.
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Affiliation(s)
- Jiří Polívka
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University in Prague, Alej Svodody 80, Pilsen 304 60, Czech Republic
- Department of Neurology, University Hospital Pilsen, Alej Svodody 80, Pilsen 304 60, Czech Republic
| | - Vladimír Rohan
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University in Prague, Alej Svodody 80, Pilsen 304 60, Czech Republic
- Department of Neurology, University Hospital Pilsen, Alej Svodody 80, Pilsen 304 60, Czech Republic
| | - Petr Ševčík
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University in Prague, Alej Svodody 80, Pilsen 304 60, Czech Republic
- Department of Neurology, University Hospital Pilsen, Alej Svodody 80, Pilsen 304 60, Czech Republic
| | - Jiří Polívka
- Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University in Prague, Karlovarska 48, Pilsen 301 66, Czech Republic
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Karlovarska 48, Pilsen 301 66, Czech Republic
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3470
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Cameron C, Coyle D, Richter T, Kelly S, Gauthier K, Steiner S, Carrier M, Coyle K, Bai A, Moulton K, Clifford T, Wells G. Systematic review and network meta-analysis comparing antithrombotic agents for the prevention of stroke and major bleeding in patients with atrial fibrillation. BMJ Open 2014; 4:e004301. [PMID: 24889848 PMCID: PMC4054633 DOI: 10.1136/bmjopen-2013-004301] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To examine the comparative efficacy and safety of antithrombotic treatments (apixaban, dabigatran, edoxaban, rivaroxaban and vitamin K antagonists (VKA) at a standard adjusted dose (target international normalised ratio 2.0-3.0), acetylsalicylic acid (ASA), ASA and clopidogrel) for non-valvular atrial fibrillation and among subpopulations. DESIGN Systematic review and network meta-analysis. DATA SOURCES A systematic literature search strategy was designed and carried out using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and the grey literature including the websites of regulatory agencies and health technology assessment organisations for trials published in English from 1988 to January 2014. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials were selected for inclusion if they were published in English, included at least one antithrombotic treatment and involved patients with non-valvular atrial fibrillation eligible to receive anticoagulant therapy. RESULTS For stroke or systemic embolism, dabigatran 150 mg and apixaban twice daily were associated with reductions relative to standard adjusted dose VKA, whereas low-dose ASA and the combination of clopidogrel plus low-dose ASA were associated with increases. Absolute risk reductions ranged from 6 fewer events per 1000 patients treated for dabigatran 150 mg twice daily to 15 more events for clopidogrel plus ASA. For major bleeding, edoxaban 30 mg daily, apixaban, edoxaban 60 mg daily and dabigatran 110 mg twice daily were associated with reductions compared to standard adjusted dose VKA. Absolute risk reductions with these agents ranged from 18 fewer per 1000 patients treated each year for edoxaban 30 mg daily to 24 more for medium dose ASA. CONCLUSIONS Compared with standard adjusted dose VKA, new oral anticoagulants were associated with modest reductions in the absolute risk of stroke and major bleeding. People on antiplatelet drugs experienced more strokes compared with anticoagulant drugs without any reduction in bleeding risk. To fully elucidate the comparative benefits and harms of antithrombotic agents across the various subpopulations, rigorously conducted comparative studies or network meta-regression analyses of patient-level data are required. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO registry-CRD42012002721.
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Affiliation(s)
- Chris Cameron
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Doug Coyle
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Trevor Richter
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | - Shannon Kelly
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Kasandra Gauthier
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | | | - Marc Carrier
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kathryn Coyle
- Applied Health Economics Research Unit, Ottawa, Canada
| | - Annie Bai
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | - Kristen Moulton
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | - Tammy Clifford
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Canada
| | - George Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, Ottawa, Canada
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3471
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Affiliation(s)
- Ben J. Connolly
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
| | - Lesly A. Pearce
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
| | - Robert G. Hart
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
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3472
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Brouwer JLP, Stoevelaar H, Sucker C. The clinical impact of different coagulometers on patient outcomes. Adv Ther 2014; 31:639-56. [PMID: 24895179 PMCID: PMC4082646 DOI: 10.1007/s12325-014-0124-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Indexed: 01/04/2023]
Abstract
Introduction Long-term anticoagulation therapy using vitamin K antagonists (VKA) is used in millions of patients worldwide to reduce the risk of thrombotic or thromboembolic events. Control and monitoring of VKA therapy is improved by the regular self-measurement of international normalized ratio (INR) using a home monitoring device. This retrospective analysis of a large cohort of patients in the Netherlands seeks to determine whether the choice of INR monitor could have a clinical impact on patient outcomes. Methods The National Thrombosis Service provides medical supervision, training and support to anticoagulant patients eligible for home-monitoring of INR in the Netherlands. Two INR monitors (CoaguChek XS and INRatio2) have been distributed at random to patients since June 2011, and patient self-testing data (INR measurements and other clinical parameters) have been recorded to measure and improve treatment outcomes. The data have been retrospectively analyzed to determine any effect of the choice of monitor. Univariate and multivariate statistical tests are used to assess any differences between groups in terms of efficacy and safety parameters. Results Data from 4,326 patients were collated, and 156,507 INR values were included in the analysis. Over half the patients (54.3%) were being treated for atrial fibrillation, and 77.6% were prescribed acenocoumarol. There were few differences between the patient populations using the two different monitors. Anticoagulant control overall was good, with high percentage of time (87.9%) in the appropriate INR range and low incidence of excessively high or low INR values (0.085/month). Minor clinical events related to safety were low (0.78 per patient-year) and showed few differences between monitors. Mortality rates were similar [hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.65–1.70]. Conclusion Self-testing data from a large cohort of patients in the Netherlands suggest that there is no clinically relevant effect of the choice of coagulation monitor (CoaguChek XS or INRatio2) on the time in therapeutic range (TTR), minor or fatal outcomes of long-term anticoagulation management. Electronic supplementary material The online version of this article (doi:10.1007/s12325-014-0124-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan Leendert Pouwel Brouwer
- De Nationale Trombose Dienst (The National Thrombosis Service), Zonneoordlaan 17, 6718 TK, Ede, The Netherlands,
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3473
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Ezekowitz MD, Spahr J, Ghosh P, Corelli K. Stroke prevention in atrial fibrillation: established oral anticoagulants versus novel anticoagulants—translating clinical trial data into practice. J Interv Card Electrophysiol 2014; 40:261-8. [DOI: 10.1007/s10840-014-9893-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/24/2014] [Indexed: 11/30/2022]
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3474
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Bang OY, Hong KS, Heo JH, Koo J, Kwon SU, Yu KH, Bae HJ, Lee BC, Yoon BW, Kim JS. New oral anticoagulants may be particularly useful for asian stroke patients. J Stroke 2014; 16:73-80. [PMID: 24949312 PMCID: PMC4060270 DOI: 10.5853/jos.2014.16.2.73] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 03/23/2014] [Accepted: 03/29/2014] [Indexed: 01/07/2023] Open
Abstract
Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jaseong Koo
- Department of Neurology, Catholic University of Korea, College of Medicine, St. Mary's Hospital, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Hee-Joon Bae
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea
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3475
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Mohanty BD, Looser PM, Gokanapudy LR, Handa R, Mohanty S, Choi SS, Goldman ME, Fuster V, Halperin JL. Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation. Vasc Med 2014; 19:190-204. [PMID: 24879715 DOI: 10.1177/1358863x14532869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing use of the new oral anticoagulants (NOACs) – dabigatran, rivaroxaban, and apixaban – has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.
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Affiliation(s)
- Bibhu D Mohanty
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Patrick M Looser
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | | | - Rishi Handa
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Sudipta Mohanty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sharon S Choi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Martin E Goldman
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Valentin Fuster
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Jonathan L Halperin
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
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3476
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Jalota A, Scarabelli TM, Saravolatz L, Bakhsh MU, Agrawal P, Jalota R, Chen-Scarabelli C, Fuster V, Halperin J. Novel Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 2014; 28:247-62. [DOI: 10.1007/s10557-014-6524-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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3477
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Zamani P, Verdino RJ. Management of Atrial Fibrillation. J Intensive Care Med 2014; 30:484-98. [PMID: 24828991 DOI: 10.1177/0885066614534603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/03/2014] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation remains the most prevalent cardiac arrhythmia, and its incidence is increasing as the population ages. Common conditions associated with an increased incidence include advanced age, hypertension, heart failure, and valvular heart disease. Patients with atrial fibrillation may complain of palpitations, fatigue, and decreased exercise tolerance or may be completely asymptomatic. Options for treating patients who experience atrial fibrillation include rate-controlling drugs such as digoxin, β-blockers, and calcium channel blockers or a rhythm-controlling strategy with agents such as sodium channel blockers and potassium channel blockers. Atrial fibrillation increases the risk of stroke due to atrial thrombus formation and embolization. Anticoagulation with the vitamin K antagonist, warfarin, remains the most widely prescribed treatment option to decrease stroke risk. Several other antithrombotic agents have recently become available and offer excellent alternatives to warfarin. Catheter ablation can be undertaken as a nonpharmacologic rhythm control option with varying degrees of success depending on duration of atrial fibrillation and follow-up time from the procedure. This review article further describes the management options for patients presenting with atrial fibrillation.
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Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ralph J Verdino
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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3478
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Bista D, Chalmers L, Bereznicki L, Peterson G. Potential use of NOACs in developing countries: pros and cons. Eur J Clin Pharmacol 2014; 70:817-28. [PMID: 24817486 DOI: 10.1007/s00228-014-1693-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/25/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems. METHODS A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles. RESULTS Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised. CONCLUSION The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.
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Affiliation(s)
- Durga Bista
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia,
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3479
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102-65. [PMID: 24814377 DOI: 10.1016/j.hrthm.2014.05.009] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 02/07/2023]
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3480
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Ikeda T. Which score should be used for risk stratification of ischemic stroke in patients with atrial fibrillation. Circ J 2014; 78:1331-2. [PMID: 24805355 DOI: 10.1253/circj.cj-14-0409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
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3481
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Hart RG, Eikelboom JW. Stroke prevention in atrial fibrillation: Commentary regarding the AAN's evidence-based guideline update. Neurol Clin Pract 2014; 4:96-98. [PMID: 24790796 DOI: 10.1212/cpj.0000000000000003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Atrial fibrillation is a common, potentially preventable cause of disabling stroke in the elderly, particularly in elderly women, resulting from embolism of stasis-precipitated thrombi formed in the left atrial appendage. In 1989, the first randomized clinical trial of anticoagulant therapy in atrial fibrillation showed that warfarin produced a large reduction in ischemic stroke.1 In the ensuing 25 years, more than 40 additional randomized trials have permitted stroke prophylaxis to be importantly refined. It has been a period of remarkable progress in stroke prevention. Here, we discuss selected aspects of the American Academy of Neurology (AAN)'s evidence-based guideline update.2.
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Affiliation(s)
- Robert G Hart
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - John W Eikelboom
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
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3482
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Song S, Kang D, Halim AB, Miller R. Population pharmacokinetic-pharmacodynamic modeling analysis of intrinsic FXa and bleeding from edoxaban treatment. J Clin Pharmacol 2014; 54:910-6. [DOI: 10.1002/jcph.306] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/03/2014] [Indexed: 11/10/2022]
Affiliation(s)
- SaeHeum Song
- Daiichi Sankyo Pharma Development; Edison NJ USA
| | - Dongwoo Kang
- Daiichi Sankyo Pharma Development; Edison NJ USA
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3483
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Reversal of New, Factor-specific Oral Anticoagulants by rFVIIa, Prothrombin Complex Concentrate and Activated Prothrombin Complex Concentrate: A Review of Animal and Human Studies. Thromb Res 2014; 133:705-13. [DOI: 10.1016/j.thromres.2014.01.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/23/2014] [Accepted: 01/26/2014] [Indexed: 01/13/2023]
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3484
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Neue orale direkte Antikoagulanzien. Internist (Berl) 2014; 55:537-8, 540-5. [DOI: 10.1007/s00108-013-3424-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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3485
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Plunkett O, Lip GYH. The Potential Role of Edoxaban in Stroke Prevention Guidelines. Arrhythm Electrophysiol Rev 2014; 3:40-3. [PMID: 26835064 DOI: 10.15420/aer.2011.3.1.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 03/11/2014] [Indexed: 11/04/2022] Open
Abstract
With the emergence of edoxaban, the oral factor Xa inhibitors now appear consolidated as the dominant class of novel oral anticoagulants (NOACs) for stroke prevention in non-valvular atrial fibrillation (AF). The oral factor Xa inhibitors do not require an adequate time in therapeutic range to be effective, presenting a potential advantage over the vitamin K antagonists (VKAs). Guidelines are changing to reflect the increased choice of anticoagulants and as clinicians move away from the VKAs towards the relative safety and efficacy of NOACs, they must consider which one offers the best therapy for their patient. The ENGAGE-AF study was the latest phase III trial to report on the safety and efficacy of a new factor Xa inhibitor relative to warfarin. Both edoxaban 60mg once daily, and edoxaban 30mg once daily were found to be non-inferior compared to warfarin for the prevention of ischaemic stroke and systemic embolism, being associated with significantly lower rates of major bleeding, intracranial haemorrhage and cardiovascular death. A two-tiered dosing option may present clinicians with a further element of choice for the individual patient.
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Affiliation(s)
| | - Gregory Y H Lip
- Professor of Cardiovascular Medicine, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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3486
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Affiliation(s)
- Masahiro Yasaka
- From the Department of Cerebrovascular Medicine and Neurology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan (M.Y.); and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.)
| | - Gregory Y H Lip
- From the Department of Cerebrovascular Medicine and Neurology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan (M.Y.); and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.).
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3487
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Wong KSL, Hu DY, Oomman A, Tan RS, Patel MR, Singer DE, Breithardt G, Mahaffey KW, Becker RC, Califf R, Fox KAA, Berkowitz SD, Hacke W, Hankey GJ. Rivaroxaban for stroke prevention in East Asian patients from the ROCKET AF trial. Stroke 2014; 45:1739-47. [PMID: 24763930 DOI: 10.1161/strokeaha.113.002968] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE In Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial, rivaroxaban was noninferior to dose-adjusted warfarin in preventing stroke or systemic embolism among patients with nonvalvular atrial fibrillation at moderate to high stroke risk. Because of differences in patient demographics, epidemiology, and stroke risk management in East Asia, outcomes and relative effects of rivaroxaban versus warfarin were assessed to determine consistency among East Asians versus other ROCKET AF participants. METHODS Baseline demographics and interaction of treatment effects of rivaroxaban and warfarin among patients within East Asia and outside were assessed. RESULTS A total of 932 (6.5%) ROCKET AF participants resided in East Asia. At baseline, East Asians had lower weight, creatinine clearance, and prior vitamin K antagonist use; higher prevalence of prior stroke; and less congestive heart failure and prior myocardial infarction than other participants. Despite higher absolute event rates for efficacy and safety outcomes in East Asians, the relative efficacy of rivaroxaban (20 mg once daily; 15 mg once daily for creatinine clearance of 30-49 mL/min) versus warfarin with respect to the primary efficacy end point (stroke/systemic embolism) was consistent among East Asians and non-East Asians (interaction P=0.666). Relative event rates for the major or nonmajor clinically relevant bleeding in patients treated with rivaroxaban and warfarin were consistent among East Asians and non-East Asians (interaction P=0.867). CONCLUSIONS Observed relative efficacy and safety of rivaroxaban versus warfarin were similar among patients within and outside East Asia. Rivaroxaban, 20 mg once daily, is an alternative to warfarin for stroke prevention in East Asians with nonvalvular atrial fibrillation.
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Affiliation(s)
- Ka Sing Lawrence Wong
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.).
| | - Dai Yi Hu
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Abraham Oomman
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Ru-San Tan
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Manesh R Patel
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Daniel E Singer
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Günter Breithardt
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Kenneth W Mahaffey
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Richard C Becker
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Robert Califf
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Keith A A Fox
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Scott D Berkowitz
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Werner Hacke
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
| | - Graeme J Hankey
- From the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (K.S.L.W.); Heart Center, Peking University People's Hospital, Beijing, China (D.Y.H.); Department of Cardiology, Apollo Hospital, Chennai, India (A.O.); National Heart Centre, Singapore, Singapore (R.-S.T.); Department of Medicine, Division of Cardiology, Duke Clinical Research Institute (M.R.P., K.W.M., R.C.B.) and Department of Medicine, Division of Cardiology, Duke Translational Medicine Institute (R.C.), Duke University Medical Center, Durham, NC; Department of Epidemiology, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.S.); Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany (G.B.); Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, Scotland (K.A.A.F.); Bayer HealthCare Pharmaceuticals, Montville, NJ (S.D.B.); Department of Neurology, Ruprecht-Karls-University, Heidelberg, Germany (W.H.); and Stroke Unit, Department of Neurology, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.)
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3488
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Li S, Liu B, Xu D, Xu Y. Bleeding risk and mortality of edoxaban: a pooled meta-analysis of randomized controlled trials. PLoS One 2014; 9:e95354. [PMID: 24736694 PMCID: PMC3988190 DOI: 10.1371/journal.pone.0095354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/25/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE(S) Edoxaban, a factor Xa inhibitor, is a new oral anticoagulant that has been developed as an alternative to vitamin K antagonists. However, its safety remains unexplored. METHODS Medline, Embase and Web of Science were searched to March 8, 2014 for prospective, randomized controlled trials (RCTs) that assessed the safety profile of edoxaban with warfarin. Safety outcomes examined included bleeding risk and mortality. RESULTS Five trials including 31,262 patients that met the inclusion criteria were pooled. Overall, edoxaban was associated with a significant decrease in major or clinically relevant nonmajor bleeding events [risk ratio (RR) 0.78, 95% confidence interval (CI) 0.74 to 0.82, p<0.001] and any bleeding events [RR 0.82, 95% CI 0.79 to 0.85, p<0.001]. Edoxaban also showed superiority to warfarin both in all-cause mortality [RR 0.92, 95% CI 0.85 to 0.99, p = 0.02] and cardiovascular mortality [RR 0.87, 95% CI 0.79 to 0.96, p = 0.004]. Subgroup analyses indicated that RRs of edoxaban 30, 60 or 120 mg/d were 0.67 (p<0.001), 0.87 (p<0.001) and 3.3 (p = 0.004) respectively in major or clinically relevant nonmajor bleeding; 0.71 (p<0.001), 0.89 (p<0.001) and 2.29 (p = 0.002) respectively in any bleeding; as well as 0.86 (p = 0.01), 0.87 (p = 0.01) and 0.28 (p = 0.41) respectively in cardiovascular death… Meanwhile, paramount to note that pooled results other than the largest trial showed edoxaban was still associated with a decrease in the rate of major or clinically relevant nonmajor bleeding event (p = 0.02) and any bleeding (p = 0.002), but neither in all-cause death (p = 0.66) nor cardiovascular death (p = 0.70). CONCLUSIONS Edoxaban, a novel orally available direct factor Xa inhibitor, seems to have a favorable safety profiles with respect to bleeding risk and non-inferior in mortality when compared to warfarin. Further prospective RCTs are urgently needed to confirm the results of this meta-analysis.
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Affiliation(s)
- Shuang Li
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Baoxin Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dachun Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- * E-mail: (DX); (YX)
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- * E-mail: (DX); (YX)
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3489
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Abstract
Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin's shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.
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Affiliation(s)
- Benjamin A Steinberg
- Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA
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3490
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Caldeira D, Costa J, Ferreira JJ, Pinto FJ. Net clinical benefit outcome should be standardized in trials evaluating antithrombotic drugs: the example of NOACs in atrial fibrillation. Int J Cardiol 2014; 174:405-6. [PMID: 24774363 DOI: 10.1016/j.ijcard.2014.04.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 04/02/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Caldeira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Portugal.
| | - João Costa
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Portugal; Evidence Based Medicine Centre, Faculty of Medicine, University of Lisbon, Portugal; Portuguese Collaborating Centre of the Cochrane Iberoamerican Network, Faculty of Medicine, University of Lisbon, Portugal
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Portugal
| | - Fausto J Pinto
- Cardiology Department, CCUL, CAML, Faculty of Medicine, Lisbon, Portugal
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3491
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Palareti G. Direct Oral Anticoagulants and Bleeding Risk (in Comparison to Vitamin K Antagonists and Heparins), and the Treatment of Bleeding. Semin Hematol 2014; 51:102-11. [DOI: 10.1053/j.seminhematol.2014.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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3492
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3493
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3494
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Whisenant B, Weiss P. Left Atrial Appendage Closure with Transcatheter-Delivered Devices. Interv Cardiol Clin 2014; 3:209-218. [PMID: 28582166 DOI: 10.1016/j.iccl.2014.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Left atrial appendage (LAA) closure with transcatheter-delivered devices is an evolving story of compelling randomized data and the potential to dramatically reduce the incidence of stroke and improve the quality of life among patients with atrial fibrillation. Oral anticoagulation is the standard of care for stroke prevention in atrial fibrillation but falls short of providing an adequate solution to this common threat when considered from efficacy and safety perspectives. The robust series of Watchman device trials has demonstrated the Watchman device to provide stroke prevention efficacy similar to that of warfarin and by extension provides proof of concept of LAA closure.
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Affiliation(s)
- Brian Whisenant
- Division of Cardiology, Intermountain Medical Center, 5121 South Cottonwood Street, Level 6, Salt Lake City, UT 84157, USA.
| | - Peter Weiss
- Division of Cardiology, Intermountain Medical Center, 5121 South Cottonwood Street, Level 6, Salt Lake City, UT 84157, USA
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3495
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Gonzalez-Quesada CJ, Giugliano RP. Comparison of the phase III clinical trial designs of novel oral anticoagulants versus warfarin for the treatment of nonvalvular atrial fibrillation: implications for clinical practice. Am J Cardiovasc Drugs 2014; 14:111-27. [PMID: 24504768 DOI: 10.1007/s40256-013-0062-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Although vitamin K antagonists (VKAs) have been the backbone of thromboprophylaxis in nonvalvular atrial fibrillation, their limitations have encouraged the development of a new generation of oral anticoagulants. This review compares the different designs and procedures used to conduct four phase III trials that tested dabigatran, rivaroxaban, apixaban, and edoxaban versus VKAs. Although pharmacologic characteristics and results of the main trials are briefly discussed, this review mainly focuses on study designs, enrollment criteria, populations studied, quality metrics, and transition strategies between oral anticoagulants. While each of the trials was of high quality, performed independently, and led by independent academic groups, substantial differences exist in terms of drug pharmacology and trial characteristics. Caution is advised when comparing results across trials as practicing clinicians strive to personalize anticoagulation treatments for their individual patients. We believe that the differences in the pharmacokinetic and pharmacodynamic profiles of the available novel oral anticoagulants (NOACs), coupled with substantial heterogeneity in the trial populations and designs and procedures used to conduct the trials, support an important role for each of the NOACs dependent upon the specific clinical scenario faced by the practicing clinician.
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Affiliation(s)
- Carlos J Gonzalez-Quesada
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St., Phyllis Jen Center for Primary Care (Suite A), Boston, MA, 02115, USA
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3496
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Abstract
Atrial fibrillation (AF) is associated with increases in the risk of mortality, congestive heart failure, and stroke. Medical treatment is aimed at preventing thrombo-embolic complications and reducing symptoms and consequences related to the arrhythmia. In the first section of this review, we discuss the principles of mainstream oral anticoagulant therapy and the possible advantages of the new oral anticoagulants. In the second section, we review the catheter ablation approaches to paroxysmal and persistent/long-standing AF, their results, and the current application of new catheters.
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3497
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Meyer dos Santos S, Harder S. Benefit–Risk Assessment of Dabigatran in the Treatment of Stroke Prevention in Non-Valvular Atrial Fibrillation. Drug Saf 2014; 37:295-307. [DOI: 10.1007/s40264-014-0151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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3498
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2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76. [PMID: 24685669 DOI: 10.1016/j.jacc.2014.03.022] [Citation(s) in RCA: 2854] [Impact Index Per Article: 285.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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3499
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Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383:955-62. [PMID: 24315724 DOI: 10.1016/s0140-6736(13)62343-0] [Citation(s) in RCA: 3385] [Impact Index Per Article: 338.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Four new oral anticoagulants compare favourably with warfarin for stroke prevention in patients with atrial fibrillation; however, the balance between efficacy and safety in subgroups needs better definition. We aimed to assess the relative benefit of new oral anticoagulants in key subgroups, and the effects on important secondary outcomes. METHODS We searched Medline from Jan 1, 2009, to Nov 19, 2013, limiting searches to phase 3, randomised trials of patients with atrial fibrillation who were randomised to receive new oral anticoagulants or warfarin, and trials in which both efficacy and safety outcomes were reported. We did a prespecified meta-analysis of all 71,683 participants included in the RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI 48 trials. The main outcomes were stroke and systemic embolic events, ischaemic stroke, haemorrhagic stroke, all-cause mortality, myocardial infarction, major bleeding, intracranial haemorrhage, and gastrointestinal bleeding. We calculated relative risks (RRs) and 95% CIs for each outcome. We did subgroup analyses to assess whether differences in patient and trial characteristics affected outcomes. We used a random-effects model to compare pooled outcomes and tested for heterogeneity. FINDINGS 42,411 participants received a new oral anticoagulant and 29,272 participants received warfarin. New oral anticoagulants significantly reduced stroke or systemic embolic events by 19% compared with warfarin (RR 0·81, 95% CI 0·73-0·91; p<0·0001), mainly driven by a reduction in haemorrhagic stroke (0·49, 0·38-0·64; p<0·0001). New oral anticoagulants also significantly reduced all-cause mortality (0·90, 0·85-0·95; p=0·0003) and intracranial haemorrhage (0·48, 0·39-0·59; p<0·0001), but increased gastrointestinal bleeding (1·25, 1·01-1·55; p=0·04). We noted no heterogeneity for stroke or systemic embolic events in important subgroups, but there was a greater relative reduction in major bleeding with new oral anticoagulants when the centre-based time in therapeutic range was less than 66% than when it was 66% or more (0·69, 0·59-0·81 vs 0·93, 0·76-1·13; p for interaction 0·022). Low-dose new oral anticoagulant regimens showed similar overall reductions in stroke or systemic embolic events to warfarin (1·03, 0·84-1·27; p=0·74), and a more favourable bleeding profile (0·65, 0·43-1·00; p=0·05), but significantly more ischaemic strokes (1·28, 1·02-1·60; p=0·045). INTERPRETATION This meta-analysis is the first to include data for all four new oral anticoagulants studied in the pivotal phase 3 clinical trials for stroke prevention or systemic embolic events in patients with atrial fibrillation. New oral anticoagulants had a favourable risk-benefit profile, with significant reductions in stroke, intracranial haemorrhage, and mortality, and with similar major bleeding as for warfarin, but increased gastrointestinal bleeding. The relative efficacy and safety of new oral anticoagulants was consistent across a wide range of patients. Our findings offer clinicians a more comprehensive picture of the new oral anticoagulants as a therapeutic option to reduce the risk of stroke in this patient population. FUNDING None.
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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
| | - Elaine B Hoffman
- 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
| | - Michael D Ezekowitz
- Jefferson Medical College, Philadelphia, PA, USA; Cardiovascular Research Foundation, New York, NY, USA
| | | | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | | | | | - Elliott M Antman
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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