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Wu S, Huang N, Chen X, Jiang S, Zhang W, Hu W, Su J, Dai H, Gu P, Huang X, Du X, Li R, Zheng Q, Lin X, Zhang Y, Zou L, Liu Y, Zhang M, Liu X, Zhu Z, Sun J, Hong S, She W, Zhang J. Association between Body Mass Index and Clinical Outcomes in Patients with Non-valvular Atrial Fibrillation Receiving Direct Oral Anticoagulants: A New Piece of Evidence on the Obesity Paradox from China. Cardiovasc Drugs Ther 2023; 37:715-727. [PMID: 35394582 DOI: 10.1007/s10557-022-07332-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE We conducted a multicenter real-world study in China to assess the association between body mass index (BMI) and clinical outcomes in patients with atrial fibrillation (AF) taking direct oral anticoagulants (DOACs). METHOD This is a retrospective multicenter cohort study conducted in 15 centers in China. We collected demographic information through the hospital information system and obtained clinical events through follow-up visits to patients or relatives. Clinical outcomes include major, minor, total bleeding, thromboembolism, and all-cause death. RESULT A total of 6164 patients with non-valvular AF (NVAF) were included in this study. The incidence of major bleeding in patients with NVAF differed significantly by BMI category (P < 0.001), with 5.2% in the underweight group, 2.6% in the normal group, 1.4% in the overweight group, 1.1% in the obese I group, and 1.3% in the obese II group. There was no significant difference in minor, total bleeding, and thrombosis in the five groups (P = 0.493; P = 0.172; P = 0.663). All-cause death was significantly different among the five groups (P < 0.001), with 8.9% in the underweight group, 6.3% in the normal group, 4.8% in the overweight group, 2.2% in the obese I group, and 0.4% in the obese II group. High BMI was negatively associated with major bleeding (OR = 0.353, 95% CI 0.205-0.608), total bleeding (OR = 0.664, 95% CI 0.445-0.991), and all-cause death (OR = 0.370, 95% CI 0.260-0.527). CONCLUSION In patients with NVAF treated with DOACs, higher BMI was associated with lower major bleeding and better survival. BMI was a negative correlate of total bleeding, but not minor bleeding and thrombosis.
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Affiliation(s)
- Shuyi Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji(Wuhan) Hospital, Wuhan, 430000, China
| | - Xia Chen
- Department of Pharmacy, Fuling Hospital of Chongqing University, Chongqing, 408099, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Wang Zhang
- Department of Pharmacy, The First People's Hospital of Changde City, Changde City, 415000, Hunan, China
| | - Wei Hu
- Department of Pharmacy, Xinyang Central Hospital, Xinyang Hospital Affiliated to Zhengzhou University, Zhengzhou, 464000, Henan, China
| | - Jun Su
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Anhui, 233004, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fujian, 350009, China
| | - Ping Gu
- Department of Pharmacy, Suining Central Hospital, Suining, 629000, Sichuan, China
| | - Xiaohong Huang
- Department of Pharmacy, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, 363000, China
| | - Xiaoming Du
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ruijuan Li
- Department of Pharmacy, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Shanxi, 030032, China
| | - Qiaowei Zheng
- Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiangsheng Lin
- Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fujian, 350400, China
| | - Yanxia Zhang
- Department of Pharmacy, The First Affiliated Hospital of Jiamusi University, Heilongjiang, 154002, China
| | - Lang Zou
- Department of Pharmacy, Second Affiliated Hospital, Army Medical University, Chongqing, 400037, China
| | - Yuxin Liu
- Department of Pharmacy, Huaihe Hospital of Henan University, Henan, 475000, China
| | - Min Zhang
- Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Shandong, 266041, China
| | - Xiumei Liu
- Department of Pharmacy, People's Hospital of He'nan University of Chinese Medicine (People's Hospital of Zhengzhou), Zhengzhou, 450003, China
| | - Zhu Zhu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, 215004, China
| | - Jianjun Sun
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, 010050, China
| | - Shanshan Hong
- Department of Pharmacy, Quanzhou First Hospital, Fujian, 362000, China
| | - Weibin She
- Department of Medical Administration, Dongguan Kanghua Hospital, Guangdong, 523000, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China.
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Zhao C, Luo W, Liu X, Luo J, Song J, Yuan J, Liu S, Huang J, Kong W, Hu J, Yang J, Sun R, Yue C, Xie D, Li L, Sang H, Qiu Z, Li F, Wu D, Zi W, Yang Q. Effect of atrial fibrillation on outcomes after mechanical thrombectomy and long-term ischemic recurrence in patients with acute basilar artery occlusion. Front Neurol 2022; 13:909677. [PMID: 35968276 PMCID: PMC9372365 DOI: 10.3389/fneur.2022.909677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction According to the literature on anterior circulation, comorbid atrial fibrillation (AF) is not associated with a worse functional outcome, lower reperfusion rates, or higher rates of intracranial hemorrhage after mechanical thrombectomy (MT) compared to intravenous thrombolysis (IVT) or treatment with supportive care. However, data are limited for the effect of comorbid AF on procedural and clinical outcomes of acute basilar artery occlusion (ABAO) after MT. This study aimed to investigate the effect of atrial fibrillation on outcomes after MT and long-term ischemic recurrence in patients with ABAO. Methods We performed a registered study of the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR, which is registered in the Chinese Clinical Trial Registry, http://www.chictr.org.cn; ChiCTR1800014759) from January 2014 to May 2019, which included 647 patients who underwent MT for ABAO, 136 of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared. Results On multivariate analysis, AF predicted a shorter puncture-to-recanalization time, higher first-pass effect rate, and lower incidence of angioplasty and/or stenting (p < 0.01). AF had no effect on intracranial hemorrhage incidence [adjusted odds ratio (aOR), 1.093; 95% confidence interval (CI), 0.451–2.652], 90-day functional outcomes (adjusted common odds ratio, 0.915; 95% CI, 0.588–1.424), or mortality (aOR, 0.851; 95% CI, 0.491–1.475) after MT. The main findings were robust in the subgroup and 1-year follow-up analyses. Comorbid AF was the remaining predictor of ischemic recurrence (aOR, 4.076; 95% CI, 1.137–14.612). Conclusions The study revealed no significant difference in the safety and efficacy of MT for ABAO regardless of whether patients had comorbid AF. However, a higher proportion of patients with AF experienced ischemic recurrence within 1 year after MT.
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Affiliation(s)
- Chenhao Zhao
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xing Liu
- Department of Medicine, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Luo
- Department of Neurology, The 404th Hospital of Mianyang, Mianyang, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ruidi Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Deping Wu
- Huaian Medical District of Jingling Hospital, Medical School of Nanjing University, Huaian, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- *Correspondence: Wenjie Zi
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Qingwu Yang
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Xu YY, Gu HQ, Li ZX, Xiong YY, Zhou Q, Liu LP, Zhao XQ, Wang YL, Meng X, Wang YJ. In-hospital prognosis of first-ever noncardiogenic ischemic stroke in patients with and without indication for prestroke antiplatelet therapy: Chinese Stroke Center Alliance. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:626. [PMID: 33987324 PMCID: PMC8106102 DOI: 10.21037/atm-20-7902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background It is unknown about the influence of prestroke antiplatelet use on early outcomes in patients with and without the indication. We aimed to evaluate the in-hospital prognosis of first-ever noncardiogenic ischemic stroke patients with and without indications of antiplatelet use for primary prevention. Methods This was a retrospective, observational study based on a prospective hospital-based registry (Chinese Stroke Center Alliance). Using the data with 436,660 first-ever noncardiogenic acute ischemic strokes recorded from Aug 1, 2015, to July 31, 2019, from 1,453 hospitals in China, we examined the associations between the indication for prestroke antiplatelet use and in-hospital clinical outcomes. Results Among 436,660 first-ever noncardiogenic ischemic stroke patients, 42,409 patients (9.7%) had a documented previous vascular indication and 394,251 (90.3%) did not. Compared to those without, patients with the indication were associated with increased prevalence of in-hospital morbid conditions, including stroke severity (OR 2.71; 95% CI: 2.62–2.81; P<0.0001), length of stay >14 days (OR 1.16; 95% CI: 1.13–1.19; P<0.0001), mortality (OR 2.20; 95% CI: 1.96–2.46, P<0.0001), and recurrence of ischemic stroke and transient ischemic attack (TIA) (OR 1.5; 95% CI: 1.43–1.59, P<0.0001). Among patients without indication, prestroke antiplatelet use was associated with lower mortality (OR 0.73, 95% CI: 0.56–0.96; P=0.0221); while among patients with indication, those receiving prestroke antiplatelet had lower odds ratios in stroke severity (P<0.0001) and disability (P=0.0003) than those who not. Conclusions Patients with indications of prestroke antiplatelet use were more likely to have unfavorable outcomes than those without. Prestroke antiplatelet might be associated with lower mortality, less disability, and less stroke severity in certain population groups. Future studies to improve risk prediction rules are needed to guide effective primary prevention for ischemic stroke.
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Affiliation(s)
- Yu-Yuan Xu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yun-Yun Xiong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qi Zhou
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Efficacy and Safety of Direct Oral Anticoagulants vs Warfarin in Patients with Chronic Kidney Disease and Dialysis Patients: A Systematic Review and Meta-Analysis. Clin Drug Investig 2021; 41:341-351. [PMID: 33709339 DOI: 10.1007/s40261-021-01016-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE: Systematic reviews and meta-analyses of direct oral anticoagulants (DOACs) for patients with chronic kidney disease (CKD) or dialysis patients are lacking. We aimed to compare the efficacy and safety of DOACs and warfarin in patients with CKD requiring anticoagulation therapy. METHODS We performed a systematic review and meta-analysis of six randomized controlled trials and 19 observational studies, with the inclusion criteria being a comparative study between DOACs and warfarin in patients with CKD or dialysis patients from database inception until August 2020. The efficacy outcomes were stroke, systemic embolism (SE), or venous thromboembolism (VTE), and the safety outcome was major bleeding. RESULTS Compared with warfarin, DOACs significantly reduced the risk of stroke/SE/VTE by 22% (hazard ratio [HR] = 0.78, 95% confidence interval [CI] 0.64-0.95) and major bleeding by 17% (HR = 0.83, 95% CI 0.71-0.97). On comparing factor Xa inhibitors and dabigatran with warfarin separately, factor Xa inhibitors significantly reduced the risk of stroke/SE/VTE (HR = 0.78, 95% CI 0.62-0.98) and major bleeding (HR = 0.76, 95% CI 0.64-0.91) overall in patients. Comparing each DOACs with warfarin separately, apixaban was associated with a significantly better risk reduction of stroke/SE/VTE (25% risk reduction) and major bleeding (35% risk reduction) than warfarin. Compared with warfarin, DOACs significantly reduced the risk of stroke, SE, or VTE by 19% (HR = 0.81, 95% CI 0.68-0.97) in patients with CKD stage 3 and significantly lowered the risk of major bleeding by 31% (HR = 0.69, 95% CI 0.56-0.85) in patients with CKD stages 4-5. CONCLUSIONS In pooled, analyzed randomized controlled trials and observational studies, DOACs were associated with better efficacy in early CKD, as well as similar efficacy and safety outcomes to warfarin in patients with CKD stages 4-5 or dialysis patients. The results of patients with CKD stages 4-5 and dialysis patients were from observational studies. Well-designed randomized controlled trials focused on DOAC use in patients with CKD and dialysis patients are needed. PROSPERO register number: CRD42020150599, 6 February, 2020.
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Paquette M, Alotaibi AM, Nieuwlaat R, Santesso N, Mbuagbaw L. A meta-epidemiological study of subgroup analyses in cochrane systematic reviews of atrial fibrillation. Syst Rev 2019; 8:241. [PMID: 31653275 PMCID: PMC6814034 DOI: 10.1186/s13643-019-1152-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/10/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Information on subgroup assessments in systematic reviews (SR) of atrial fibrillation (AF) is limited. This review aims to describe subgroup analyses in AF SRs to inform the design of SRs and randomized trials as well as clinical practice. METHODS We conducted a cross sectional meta-epidemiological study of Cochrane AF reviews by searching AF (including variants) in the title, abstract, or keyword field without date or language restrictions (Issue 9; September 2018). Two reviewers independently extracted study characteristics to summarize frequency of subgroups pre-specified and conducted and report credibility of subgroup effects claimed. RESULTS Of 39 Cochrane reviews identified, 17 met inclusion criteria (including 168 reports of 127 randomized trials) and the majority (16; 94.1%) conducted meta-analysis of outcomes. Most (13; 76.5%) planned pre-specified subgroup analyses; 7 of which (41.2%) conducted subgroups. In these 7 reviews, 56 subgroups were planned, 17 (30.4%) conducted and 6 (10.7%) yielded subgroup effects. Variables such as co-morbid disease, stroke risk factors, prior stroke/transient ischemic attack, age, race, and sex represented 44% (24 subgroups) of all planned subgroups (8 conducted; 14.3%); however, information on covariate selection was lacking. Overall, more subgroups were planned than conducted (mean difference (95% CI) 2.3 (1.2-3.5, p < 0.001)). Of all subgroups conducted, anticoagulant characteristics comprised a third of all subgroup effects (n = 5, 35.7%). The credibility of subgroups identified (n = 14) was assessed and less than half (43%) represented one of a small number of pre-specified hypothesis and rarely were effects seen within studies (7%). Of 5 reviews that reported subgroup effects, only 3 discussed subgroup effects as part of the overall conclusions; none discussed credibility of subgroup effects. CONCLUSIONS This meta-epidemiological review of a subset of Cochrane AF reviews suggests that planning and reporting of subgroup analyses in AF reviews can be improved to better inform clinical management. Most pre-specified subgroup analyses were not performed, important variables (such as stroke, bleeding risk, and other comorbidities) were rarely examined and credibility of subgroup effects claimed was low. Future reviews should aim to identify important subgroups in their protocols and use recommended approaches to test subgroup effects in order to better support clinical decision-making.
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Affiliation(s)
- Miney Paquette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1 Canada
- Medical Department, Boehringer Ingelheim Ltd., Burlington, Ontario Canada
| | - Ahlam Mohammed Alotaibi
- Pediatric Endocrinology Department, King Abdullah bin Abdulaziz University hospital, Princess Noura University, Riyadh, Saudi Arabia
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1 Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1 Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1 Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario Canada
- Centre for the Development of Best Practices in Health, Yaoundé, Cameroon
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Al-Shahi Salman R, Dennis MS, Murray GD, Innes K, Drever J, Dinsmore L, Williams C, White PM, Whiteley WN, Sandercock PAG, Sudlow CLM, Newby DE, Sprigg N, Werring DJ. The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: study protocol for a randomised controlled trial. Trials 2018; 19:162. [PMID: 29506580 PMCID: PMC5838871 DOI: 10.1186/s13063-018-2542-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/12/2018] [Indexed: 01/08/2023] Open
Abstract
Background For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet drugs results in an increase in the risk of recurrent ICH or a beneficial net reduction of all serious vascular events compared to avoiding antiplatelet drugs. Methods/design The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, randomised, open, assessor-blind, parallel-group, randomised trial comparing starting versus avoiding antiplatelet drugs for adults surviving antithrombotic-associated ICH at 122 hospital sites in the United Kingdom. RESTART uses a central, web-based randomisation system using a minimisation algorithm, with 1:1 treatment allocation to which central research staff are masked. Central follow-up includes annual postal or telephone questionnaires to participants and their general (family) practitioners, with local provision of information about adverse events and outcome events. The primary outcome is recurrent symptomatic ICH. The secondary outcomes are: symptomatic haemorrhagic events; symptomatic vaso-occlusive events; symptomatic stroke of uncertain type; other fatal events; modified Rankin Scale score; adherence to antiplatelet drug(s). The magnetic resonance imaging (MRI) sub-study involves the conduct of brain MRI according to a standardised imaging protocol before randomisation to investigate heterogeneity of treatment effect according to the presence of brain microbleeds. Recruitment began on 22 May 2013. The target sample size is at least 720 participants in the main trial (at least 550 in the MRI sub-study). Discussion Final results of RESTART will be analysed and disseminated in 2019. Trial registration ISRCTN71907627 (www.isrctn.com/ISRCTN71907627). Prospectively registered on 25 April 2013. Electronic supplementary material The online version of this article (10.1186/s13063-018-2542-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Gordon D Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Karen Innes
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Lynn Dinsmore
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Carol Williams
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Philip M White
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle-upon-Tyne, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Peter A G Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Cathie L M Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Institute of Neurology, University College London, London, UK
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Hawkes MA, Rabinstein AA. Anticoagulation for atrial fibrillation after intracranial hemorrhage: A systematic review. Neurol Clin Pract 2018. [PMID: 29517050 DOI: 10.1212/cpj.0000000000000425] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We summarize the existing evidence on the potential benefit of oral anticoagulation (OAC) in intracerebral hemorrhage (ICH) survivors with nonvalvular atrial fibrillation (NVAF). Methods Systematic review of the literature to address the following issues: (1) prevalence of NVAF in ICH survivors, (2) current prescription of OAC, (3) factors associated with resumption of OAC, (4) risk of ischemic stroke (IS) and recurrent ICH, and (5) ideal timing for restarting OAC in ICH survivors with NVAF. Results After screening 547 articles, 26 were included in the review. Only 3 focused specifically on patients with ICH as primary event, NVAF as indication for OAC, and recurrent ICH and IS as primary endpoints. In addition, 19 letters to the editor/reviews/editorials/experts' surveys/experts' opinion were used for discussion purposes. Conclusions NVAF is highly prevalent among ICH survivors. The risks of IS, recurrent ICH, and mortality are heightened in this group. Most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted. However, those studies are observational and mostly retrospective, therefore selection bias may play a major role in the results observed in these cohorts. Only randomized controlled trials, either pragmatic or explanatory, can provide more conclusive answers for this important clinical question.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
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8
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Son MK, Lim NK, Park HY. Trend of Prevalence of Atrial Fibrillation and use of Oral Anticoagulation Therapy in Patients With Atrial Fibrillation in South Korea (2002-2013). J Epidemiol 2017; 28:81-87. [PMID: 29109364 PMCID: PMC5792231 DOI: 10.2188/jea.je20160149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This study examined the annual prevalence of atrial fibrillation (AF) and its associated comorbidities, as well as the prevalence of warfarin therapy in South Korean patients with AF. METHODS The National Health Insurance Service-National Sample Cohort database was searched for subjects aged ≥30 years diagnosed with AF from 2002-2013. The prevalence of AF was analyzed by sex and age, as was the current status of warfarin therapy in AF patients according to CHA2DS2-VASc score and comorbidities. RESULTS The age-standardized prevalence of AF in men and women was 0.15% and 0.14%, respectively, in 2002, increasing to 0.54% and 0.39%, respectively, in 2013. In 2013, the prevalence of AF in men and women aged 30-39 years was 0.08% and 0.03%, respectively, increasing to 2.35% and 1.71%, respectively, in those in aged ≥60 years. During 2002-2013, the prevalence of AF in men significantly increased among subjects aged ≥30 years and increased in women aged ≥60 years. The age-standardized prevalence of hypertension and diabetes mellitus among AF patients were markedly increased during 2002-2013. Of these AF patients, 86.1% had a CHA2DS2-VASc score of ≥2; however, only 39.1% of these were receiving warfarin. CONCLUSIONS The age-standardized prevalence of AF increased 2.89-fold over the 12-year study period. The total number of patients with AF in South Korea has been drastically increasing, due to not only aging society but also increasing age-specific prevalence of AF, especially in middle-aged and elderly individuals. The rate of warfarin therapy increased slightly over the study period but remains low.
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Affiliation(s)
- Mi Kyoung Son
- Division of Cardiovascular and Rare Diseases, Center for Biomedical Science, Korea National Institute of Health
| | - Nam-Kyoo Lim
- Division of Cardiovascular and Rare Diseases, Center for Biomedical Science, Korea National Institute of Health
| | - Hyun-Young Park
- Division of Cardiovascular and Rare Diseases, Center for Biomedical Science, Korea National Institute of Health
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9
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Meinshausen M, Rieckert A, Renom-Guiteras A, Kröger M, Sommerauer C, Kunnamo I, Martinez YV, Esmail A, Sönnichsen A. Effectiveness and patient safety of platelet aggregation inhibitors in the prevention of cardiovascular disease and ischemic stroke in older adults - a systematic review. BMC Geriatr 2017; 17:225. [PMID: 29047342 PMCID: PMC5647552 DOI: 10.1186/s12877-017-0572-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Platelet aggregation inhibitors (PAI) are among the most frequently prescribed drugs in older people, though evidence about risks and benefits of their use in older adults is scarce. The objectives of this systematic review are firstly to identify the risks and benefits of their use in the prevention and treatment of vascular events in older adults, and secondly to develop recommendations on discontinuing PAI in this population if risks outweigh benefits. METHODS Staged systematic review consisting of three searches. Searches 1 and 2 identified systematic reviews and meta-analyses. Search 3 included controlled intervention and observational studies from review-articles not included in searches 1 and 2. All articles were assessed by two independent reviewers regarding the type of study, age of participants, type of intervention, and clinically relevant outcomes. After data extraction and quality appraisal we developed recommendations to stop the prescribing of specific drugs in older adults following the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. RESULTS Overall, 2385 records were screened leading to an inclusion of 35 articles reporting on 22 systematic reviews and meta-analyses, 11 randomised controlled trials, and two observational studies. Mean ages ranged from 57.0 to 84.6 years. Ten studies included a subgroup analysis by age. Overall, based on the evaluated evidence, three recommendations were formulated. First, the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) in older people cannot be recommended due to an uncertainty in the risk-benefit ratio (weak recommendation; low quality of evidence). Secondly, the combination of ASA and clopidogrel in patients without specific indications should be avoided (strong recommendation; moderate quality of evidence). Lastly, to improve the effectiveness and reduce the risks of stroke prevention therapy in older people with atrial fibrillation (AF) and a CHA2DS2-VASc score of ≥ 2, the use of ASA for the primary prevention of stroke should be discontinued in preference for the use of oral anticoagulants (weak recommendation; low quality of evidence). CONCLUSIONS The use of ASA for the primary prevention of CVD and the combination therapy of ASA and clopidogrel for the secondary prevention of vascular events in older people may not be justified. The use of oral anticoagulants instead of ASA in older people with atrial fibrillation may be recommended. Further high quality studies with older adults are needed.
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Affiliation(s)
- Maren Meinshausen
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany.
| | - Anja Rieckert
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Anna Renom-Guiteras
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany.,Department of Geriatrics, In the University Hospital Parc de Salut Mar, Passeig Marítim, Barcelona, Spain
| | - Moritz Kröger
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Christina Sommerauer
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Kalevankatu, Helsinki, Finland
| | - Yolanda V Martinez
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Oxford Rd, Manchester, UK
| | - Aneez Esmail
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Manchester, UK
| | - Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße, Witten, Germany
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10
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Lee TM, Ivers NM, Bhatia S, Butt DA, Dorian P, Jaakkimainen L, Leblanc K, Legge D, Morra D, Valentinis A, Wing L, Young J, Tu K. Improving stroke prevention therapy for patients with atrial fibrillation in primary care: protocol for a pragmatic, cluster-randomized trial. Implement Sci 2016; 11:159. [PMID: 27912776 PMCID: PMC5135743 DOI: 10.1186/s13012-016-0523-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background The prevalence of atrial fibrillation (AF) is growing as the population ages, and at least 15% of ischemic strokes are attributed to AF. However, many high-risk AF patients are not offered guideline-recommended stroke prevention therapy due to a variety of system, provider, and patient-level barriers. Methods We will conduct a pragmatic, cluster-randomized controlled trial randomizing primary care clinics to test a “toolkit” of quality improvement interventions in primary care. In keeping with the recommendations of the chronic care model to simultaneously activate patients and facilitate proactive care by providers, the toolkit includes provider-focused strategies (education, audit and feedback, electronic decision support, and reminders) plus patient-directed strategies (educational letters and reminders). The trial will include two feedback cycles at baseline and approximately 6 months and a final data collection at approximately 12 months. The study will be powered to show a difference of 10% in the primary outcome of proportion of patients receiving guideline-recommended stroke prevention therapy. Analysis will follow the intention-to-treat principle and will be blind to treatment allocation. Unit of analysis will be the patient; models will use generalized estimating equations to account for clustering at the clinical level. Discussion Stroke prevention therapy using anticoagulation in patients with AF is known to reduce strokes by two thirds or more in clinical trials, but most studies indicate under-use of this treatment in real-world practice. If the toolkit successfully improves care for patients with AF, stakeholders will be engaged to facilitate broader application to maximize the potential to improve patient outcomes. The intervention toolkit tested in this project could also provide a model to improve quality of care for other chronic cardiovascular conditions managed in primary care. Trial registration ClinicalTrials.gov (NCT01927445). Registered August 14, 2014 at https://clinicaltrials.gov/. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0523-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Theresa M Lee
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Noah M Ivers
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, Women's College Hospital, 77 Grenville St, Toronto, ON, M5S 1B3, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Sacha Bhatia
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Debra A Butt
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Department of Family and Community Medicine, The Scarborough Hospital, 3030 Lawrence Avenue East, Suite 414, Scarborough, ON, M1P 2V5, Canada
| | - Paul Dorian
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division of Cardiology, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Liisa Jaakkimainen
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Sunnybrook Academic Family Health Team, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Kori Leblanc
- Centre for Innovation in Complex Care, University Health Network, 200 Elizabeth Street Rm 13 N 1382, Toronto, ON, M5G 2C4, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, M5S 3M2, Canada
| | - Dan Legge
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Dante Morra
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Centre for Innovation in Complex Care, University Health Network, 200 Elizabeth Street Rm 13 N 1382, Toronto, ON, M5G 2C4, Canada.,Institute for Better Health, Trillium Health Partners, 2200 Eglinton Avenue West, Mississauga, ON, L5M 2N1, Canada
| | - Alissia Valentinis
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Taddle Creek Family Health Team, 790 Bay St #522, Toronto, ON, M5G 1N8, Canada
| | - Laura Wing
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jacqueline Young
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Karen Tu
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Toronto Western Hospital Family Health Team, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
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11
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Karlsson WK, Jensen JS, Jakobsen JC. Antiplatelet therapy for preventing stroke in people with atrial fibrillation. Hippokratia 2016. [DOI: 10.1002/14651858.cd012428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- William K Karlsson
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Jakob S Jensen
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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12
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Shantsila E, Lip GYH. Antiplatelet versus anticoagulation treatment for patients with heart failure in sinus rhythm. Cochrane Database Syst Rev 2016; 9:CD003333. [PMID: 27629776 PMCID: PMC6457803 DOI: 10.1002/14651858.cd003333.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Morbidity in patients with chronic heart failure is high, and this predisposes them to thrombotic complications, including stroke and thromboembolism, which in turn contribute to high mortality. Oral anticoagulants (e.g. warfarin) and antiplatelet agents (e.g. aspirin) are the principle oral antithrombotic agents. Many heart failure patients with sinus rhythm take aspirin because coronary artery disease is the leading cause of heart failure. Oral anticoagulants have become a standard in the management of heart failure with atrial fibrillation. However, a question remains regarding the appropriateness of oral anticoagulants in heart failure with sinus rhythm. This update of a review previously published in 2012 aims to address this question. OBJECTIVES To assess the effects of oral anticoagulant therapy versus antiplatelet agents for all-cause mortality, non-fatal cardiovascular events and risk of major bleeding in adults with heart failure (either with reduced or preserved ejection fraction) who are in sinus rhythm. SEARCH METHODS We updated the searches in September 2015 on CENTRAL (The Cochrane Library), MEDLINE and Embase. We searched reference lists of papers and abstracts from cardiology meetings and contacted study authors for further information. We did not apply any language restrictions. Additionally, we searched two clinical trials registers: ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal apps.who.int/trialsearch/) (searched in July 2016). SELECTION CRITERIA We included randomised controlled trials comparing antiplatelet therapy versus oral anticoagulation in adults with chronic heart failure in sinus rhythm. Treatment had to last at least one month. We compared orally administered antiplatelet agents (aspirin, ticlopidine, clopidogrel, prasugrel, ticagrelor, dipyridamole) versus anticoagulant agents (coumarins, warfarin, non-vitamin K oral anticoagulants). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed the risks and benefits of antithrombotic versus antiplatelet therapy using relative measures of effects, such as risk ratios (RR), accompanied with 95% confidence intervals (CI). The data extracted included data relating to the study design, patient characteristics, study eligibility, quality, and outcomes. We used GRADE criteria to assess the quality of the evidence. MAIN RESULTS This update identified one additional study for inclusion, adding data for 2305 participants. This addition more than doubled the overall number of patients eligible for the review. In total, we included four randomised controlled trials (RCTs) with a total of 4187 eligible participants. All studies compared warfarin with aspirin. One RCT additionally compared warfarin with clopidogrel. All included RCTs studied patients with heart failure with reduced ejection fraction.Analysis of all outcomes for warfarin versus aspirin was based on 3663 patients from four RCTs. All-cause mortality was similar for warfarin and aspirin (RR 1.00, 95% CI 0.89 to 1.13; 4 studies; 3663 participants; moderate quality evidence). Oral anticoagulation was associated with a reduction in non-fatal cardiovascular events, which included non-fatal stroke, myocardial infarction, pulmonary embolism, peripheral arterial embolism (RR 0.79, 95% CI 0.63 to 1.00; 4 studies; 3663 participants; moderate quality evidence). The rate of major bleeding events was twice as high in the warfarin groups (RR 2.00, 95% CI 1.44 to 2.78; 4 studies; 3663 participants; moderate quality evidence). We generally considered the risk of bias of the included studies to be low.Analysis of warfarin versus clopidogrel was based on a single RCT (N = 1064). All-cause mortality was similar for warfarin and clopidogrel (RR 0.93, 95% CI 0.72 to 1.21; 1 study; 1064 participants; low quality evidence). There were similar rates of non-fatal cardiovascular events (RR 0.85, 95% CI 0.50 to 1.45; 1 study; 1064 participants; low quality evidence). The rate of major bleeding events was 2.5 times higher in the warfarin group (RR 2.47, 95% CI 1.24 to 4.91; 1 study; 1064 participants; low quality evidence). Risk of bias for this study can be summarised as low. AUTHORS' CONCLUSIONS There is evidence from RCTs to suggest that neither oral anticoagulation with warfarin or platelet inhibition with aspirin is better for mortality in systolic heart failure with sinus rhythm (high quality of the evidence for all-cause mortality and moderate quality of the evidence for non-fatal cardiovascular events and major bleeding events). Treatment with warfarin was associated with a 20% reduction in non-fatal cardiovascular events but a twofold higher risk of major bleeding complications (high quality of the evidence). We saw a similar pattern of results for the warfarin versus clopidogrel comparison (low quality of the evidence). At present, there are no data on the role of oral anticoagulation versus antiplatelet agents in heart failure with preserved ejection fraction with sinus rhythm. Also, there were no data from RCTs on the utility of non-vitamin K antagonist oral anticoagulants compared to antiplatelet agents in heart failure with sinus rhythm.
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Affiliation(s)
- Eduard Shantsila
- City Hospital, Sandwell and West Birmingham Hospitals NHS TrustUniversity of Birmingham, Institute of Cardiovascular SciencesBirminghamUKB18 7QH
| | - Gregory YH Lip
- University of LiverpoolInstitute of Ageing and Chronic DiseaseLiverpoolUK
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13
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van Nieuwenhuizen KM, van der Worp HB, Algra A, Kappelle LJ, Rinkel GJE, van Gelder IC, Schutgens REG, Klijn CJM. Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation (APACHE-AF): study protocol for a randomised controlled trial. Trials 2015; 16:393. [PMID: 26340977 PMCID: PMC4560912 DOI: 10.1186/s13063-015-0898-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 08/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is a marked lack of evidence on the optimal prevention of ischaemic stroke and other thromboembolic events in patients with non-valvular atrial fibrillation and a recent intracerebral haemorrhage during treatment with oral anticoagulation. These patients are currently treated with oral anticoagulants, antiplatelet drugs, or no antithrombotic treatment, depending on personal and institutional preferences. Compared with warfarin, the direct oral anticoagulant apixaban reduces the risk of stroke or systemic embolism, intracranial haemorrhage, and case fatality in patients with atrial fibrillation. Compared with aspirin, apixaban reduces the risk of stroke or systemic embolism in patients with atrial fibrillation, and has a similar risk of intracerebral haemorrhage. Novel oral anticoagulants have not been evaluated in patients with atrial fibrillation and a recent intracerebral haemorrhage. To inform a phase III trial, the phase II Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation (APACHE-AF) trial aims to obtain estimates of the rates of vascular death or non-fatal stroke in patients with atrial fibrillation and a recent anticoagulation-associated intracerebral haemorrhage treated with apixaban and in those in whom oral anticoagulation is avoided. METHODS/DESIGN APACHE-AF is a phase II, multicentre, open-label, parallel-group, randomised clinical trial with masked outcome assessment. One hundred adults with a history of atrial fibrillation and a recent intracerebral haemorrhage during treatment with anticoagulation in whom clinical equipoise exists on the optimal stroke prevention strategy will be enrolled in 14 hospitals in The Netherlands. These patients will be randomly assigned in a 1:1 ratio to either apixaban or to avoiding oral anticoagulation. Patients in the control group may be treated with antiplatelet drugs at the discretion of the treating physician. The primary outcome is the composite of vascular death or non-fatal stroke during follow-up. We aim to include 100 patients in 2.5 years. All patients will be followed-up for the duration of the study, but at least for 1 year. Recruitment commenced in September 2014 and is ongoing. This trial is funded by the Dutch Heart Foundation (2012 T077) and ZonMW (015008048). TRIAL REGISTRATION NTR4526 (16 April 2014).
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Affiliation(s)
- Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR. 7.140, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Isabelle C van Gelder
- Department of Cardiology, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, C01.425, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
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Iqbal A, Rodriguez F, Schirmer H. Antiplatelet Therapy During PCI for Patients with Stable Angina and Atrial Fibrillation. Curr Cardiol Rep 2015; 17:64. [PMID: 26104508 DOI: 10.1007/s11886-015-0615-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The pharmacological treatment options for anticoagulation in patients with atrial fibrillation (Afib) have increased with the introduction of novel oral anticoagulants, compared with earlier times, when vitamin K antagonist was the drug of choice. As they age, many Afib patients require percutaneous coronary intervention (PCI), necessitating antiplatelet medication in addition to anticoagulation therapy. Choosing the appropriate combination and duration of anticoagulation and antiplatelet therapies may be challenging in stable coronary artery disease (CAD) and even more complicated during and after coronary intervention with the introduction of additional antithrombotic drugs. In this article, we review the scientific basis for the recent guidelines for anticoagulation and antithrombotic therapy in patients with Afib and stable CAD before, during, and after elective PCI.
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Affiliation(s)
- Amjid Iqbal
- Division of Cardiothoracic and Respiratory Medicine, Department of Cardiology, University Hospital of North Norway, Tromso, Norway,
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15
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Steinhubl SR, Eikelboom JW, Hylek EM, Dauerman HL, Smyth SS, Becker RC. Antiplatelet therapy in prevention of cardio- and venous thromboembolic events. J Thromb Thrombolysis 2013; 37:362-71. [DOI: 10.1007/s11239-013-1023-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Ng KH, Hart RG, Eikelboom JW. Anticoagulation in Patients Aged ≥75 years with Atrial Fibrillation: Role of Novel Oral Anticoagulants. Cardiol Ther 2013; 2:135-49. [PMID: 25135392 PMCID: PMC4107426 DOI: 10.1007/s40119-013-0019-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) is an important cause of preventable, disabling stroke and is increasingly prevalent with advancing age. As life expectancies increase around the world, AF-related stroke is a growing global public health concern. Most AF patients are elderly (≥75 years old) and increasing age is a consistent independent risk factor for AF-associated stroke. Warfarin anticoagulation is highly effective for stroke prevention in AF patients, but is underutilized especially in the elderly. Although elderly patients are at increased risk of hemorrhage with oral anticoagulants, the benefit for ischemic stroke reduction exceeds the risk of hemorrhage for most elderly patients. Consequently, age alone should not be considered a contraindication for anticoagulation. Novel oral anticoagulants such as dabigatran, rivaroxaban and apixaban are at least as effective as warfarin in preventing strokes in patients with AF. Relative to warfarin, these novel agents reduce the risk of intracranial hemorrhage, the most devastating complication of anticoagulation therapy in elderly AF patients. The novel oral anticoagulants are especially appealing for stroke prevention in elderly patients with AF.
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Affiliation(s)
- Kuan H Ng
- Department of Medicine (Stroke Program), Population Health Research Institute, McMaster University and Hamilton Health Sciences, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada,
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17
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Guo Y, Lip GYH, Apostolakis S. The Challenge of Antiplatelet Therapy in Patients with Atrial Fibrillation and Heart Failure. J Cardiovasc Transl Res 2012. [DOI: 10.1007/s12265-012-9427-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Norgard NB, Dinicolantonio JJ, Topping TJ, Wee B. Novel anticoagulants in atrial fibrillation stroke prevention. Ther Adv Chronic Dis 2012; 3:123-36. [PMID: 23251773 PMCID: PMC3513906 DOI: 10.1177/2040622312438934] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
This review article evaluates novel oral anticoagulants in comparison with warfarin for thromboembolism prophylaxis in patients with atrial fibrillation (AF). AF is the most frequently diagnosed arrhythmia in the United States. The most serious side effect of AF is stroke. Warfarin has several decades of proven efficacy in AF-related stroke prevention but the drug's numerous drawbacks make its implementation difficult for practitioners and patients. The difficulties of warfarin have prompted the development of alternative anticoagulants for AF-related stroke prevention with better efficacy, safety, and convenience. The oral direct thrombin inhibitor, dabigatran, and the oral factor Xa inhibitors, rivaroxaban and apixaban, have been evaluated in a large phase III trial. Dabigatran, rivaroxaban and apixaban were shown to be noninferior compared with warfarin in the prevention of stroke. Dabigatran and apixaban were found to be statistically superior to warfarin. All three may also have a better safety profile than warfarin. In conclusion, novel anticoagulants have a different pharmacologic profile compared with warfarin that may eliminate many of the treatment inconveniences. Practitioners must also be aware of the disadvantages these new drugs possess when choosing a management strategy for their patients. Drug selection may become clearer as these new drugs are used more extensively.
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Sá SP, Rodrigues RP, Santos-Antunes J, Gonçalves FR, Nunes JPL. Antithrombotic therapy in nonvalvular atrial fibrillation: A narrative review. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2011. [DOI: 10.1016/j.repce.2011.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kavanagh LE, Jack GS, Lawrentschuk N. Prevention and management of TURP-related hemorrhage. Nat Rev Urol 2011; 8:504-14. [PMID: 21844906 DOI: 10.1038/nrurol.2011.106] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
Cardiac causes of ischemic stroke lead to severe neurological deficits from large intracranial artery occlusion compared to small vessel ischemic stroke. The most common cause of cardioembolic stroke is atrial fibrillation (AF), which has an increasing incidence with age. AF stroke trials demonstrate that anti-coagulation is superior to anti-platelet therapy in terms of ischemic stroke prevention. Recently, warfarin was compared with dabigatran, an oral, direct thrombin inhibitor, and was found to be at least equally effective in reducing ischemic stroke with less intracranial bleeding risk. Future research is investigating other direct thrombin inhibitors as potential alternatives to warfarin, which has a narrow therapeutic index, requires frequent blood monitoring, has multiple drug interactions, and a higher rate of intracranial bleeding. Other causes of cardioembolic stroke include myocardial infarction, left ventricular thrombus, reduced ejection fraction, valvular abnormalities, and endocarditis. Patent foramen ovale is a common finding on echocardiograms in patients with and without stroke (up to 20% of the population), and it is a controversial source of cryptogenic stroke. The best way to prevent cardioembolic stroke remains early detection and treatment of AF, and treating the underlying stroke mechanism. Cardiac magnetic resonance imaging is an emerging technology and reveals some sources of cardiac embolism missed by echocardiography, and might provide an additional diagnostic tool in investigating cardioembolic stroke.
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Atrial Fibrillation in the Elderly. CURRENT CARDIOVASCULAR RISK REPORTS 2010. [DOI: 10.1007/s12170-010-0120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sandercock PAG, Gibson LM, Liu M. Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack. Cochrane Database Syst Rev 2009; 2009:CD000248. [PMID: 19370555 PMCID: PMC7066483 DOI: 10.1002/14651858.cd000248.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND After a first ischaemic stroke, further vascular events due to thromboembolism are common and often fatal. Anticoagulants could potentially reduce the risk of such events, but any benefits could be offset by an increased risk of fatal or disabling haemorrhages. OBJECTIVES To assess the effect of prolonged anticoagulant therapy compared with placebo or open control following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register in May 2008. In June 2008 we searched three online trial registers, used Web of Science Cited Reference Search to identify new citations of previously included studies, contacted a pharmaceutical company, and also contacted authors for additional information on included trials. SELECTION CRITERIA Randomised and quasi-randomised trials comparing at least one month of anticoagulant therapy with control in people with previous, presumed non-cardioembolic, ischaemic stroke or transient ischaemic attack. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS Eleven trials involving 2487 participants were included. The quality of the nine trials which predated routine computerised tomography (CT) scanning and the use of the International Normalised Ratio to monitor anticoagulation was poor. There was no evidence of an effect of anticoagulant therapy on either the odds of death or dependency (two trials, odds ratio (OR) 0.83, 95% confidence interval (CI) 0.52 to 1.34) or of 'non-fatal stroke, myocardial infarction, or vascular death' (four trials, OR 0.96, 95% CI 0.68 to 1.37). Death from any cause (OR 0.95, 95% CI 0.73 to 1.24) and death from vascular causes (OR 0.86, 95% CI 0.66 to 1.13) were not significantly different between treatment and control. The inclusion of two recently completed trials did not alter these conclusions. There was no evidence of an effect of anticoagulant therapy on the risk of recurrent ischaemic stroke (OR 0.85, 95% CI 0.66 to 1.09). However, anticoagulants increased fatal intracranial haemorrhage (OR 2.54, 95% CI 1.19 to 5.45), and major extracranial haemorrhage (OR 3.43, 95% CI 1.94 to 6.08). This is equivalent to anticoagulant therapy causing about 11 additional fatal intracranial haemorrhages and 25 additional major extracranial haemorrhages per year for every 1000 patients given anticoagulant therapy. AUTHORS' CONCLUSIONS Compared with control, there was no evidence of benefit from long-term anticoagulant therapy in people with presumed non-cardioembolic ischaemic stroke or transient ischaemic attack, but there was a significant bleeding risk.
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Affiliation(s)
- Peter A G Sandercock
- Division of Clinical Neurosciences, University of Edinburgh, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU.
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25
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Affiliation(s)
- Gregory Y H Lip
- University Department of Medicine, City Hospital, Birmingham, UK.
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26
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Helft G, Gilard M, Le Feuvre C, Zaman AG. Drug Insight: antithrombotic therapy after percutaneous coronary intervention in patients with an indication for anticoagulation. ACTA ACUST UNITED AC 2006; 3:673-80. [PMID: 17122800 DOI: 10.1038/ncpcardio0712] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Accepted: 09/01/2006] [Indexed: 01/30/2023]
Abstract
Antiplatelet therapy with aspirin and clopidogrel is standard care following revascularization by percutaneous coronary intervention with stent insertion. This so-called dual therapy is recommended for up to 4 weeks after intervention for bare-metal stents and for 6-12 months after intervention for drug-eluting stents. Although it is estimated that 5% of patients undergoing percutaneous coronary intervention require long-term anticoagulation because of an underlying chronic medical condition, continuing treatment with triple therapy (warfarin, aspirin and clopidogrel) increases the risk of bleeding. In most patients triple antithrombotic therapy seems justified for a short period of time. In some patients, however, a more considered judgment based on absolute need for triple therapy, risk of bleeding and risk of stent thrombosis is required, but the optimum antithrombotic treatment for these patients who require long-term anticoagulation has not been defined. This Review summarizes the existing literature concerning antithrombotic therapy and makes recommendations for initiation and duration of triple therapy in the small proportion of patients already receiving anticoagulant therapy who require percutaneous coronary intervention.
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Affiliation(s)
- Gérard Helft
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Boulevard de l'Hôpital, 75013 Paris, France.
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Wadelius M, Pirmohamed M. Pharmacogenetics of warfarin: current status and future challenges. THE PHARMACOGENOMICS JOURNAL 2006; 7:99-111. [PMID: 16983400 DOI: 10.1038/sj.tpj.6500417] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Warfarin is an anticoagulant that is difficult to use because of the wide variation in dose required to achieve a therapeutic effect, and the risk of serious bleeding. Warfarin acts by interfering with the recycling of vitamin K in the liver, which leads to reduced activation of several clotting factors. Thirty genes that may be involved in the biotransformation and mode of action of warfarin are discussed in this review. The most important genes affecting the pharmacokinetic and pharmacodynamic parameters of warfarin are CYP2C9 (cytochrome P(450) 2C9) and VKORC1 (vitamin K epoxide reductase complex subunit 1). These two genes, together with environmental factors, partly explain the interindividual variation in warfarin dose requirements. Large ongoing studies of genes involved in the actions of warfarin, together with prospective assessment of environmental factors, will undoubtedly increase the capacity to accurately predict warfarin dose. Implementation of pre-prescription genotyping and individualized warfarin therapy represents an opportunity to minimize the risk of haemorrhage without compromising effectiveness.
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Affiliation(s)
- M Wadelius
- Department of Medical Sciences, Clinical Pharmacology, Uppsala University Hospital, Uppsala, Sweden.
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28
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Affiliation(s)
- L Kalra
- Cardiovascular Division, King's College London School of Medicine, London, UK.
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