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Maigrot JLA, Weiss AJ, Zhou G, Jenkins HN, Koroukian SM, Dewan KC, Soltesz EG. Outcomes After Left Atrial Appendage Clip Placement During Cardiac Surgery: A Nationwide Analysis. Am J Cardiol 2024; 220:39-46. [PMID: 38583697 DOI: 10.1016/j.amjcard.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/05/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
This study evaluated the nationwide associations between concomitant left atrial appendage clip (LAAC) placement during cardiac surgery and postoperative outcomes. We identified 1,260,999 patients who underwent coronary artery bypass grafting, valve, and aortic surgeries in the 2016 to 2020 Nationwide Readmissions Database and stratified by concomitant LAAC versus no LAAC placement. Patients who underwent surgical ablation were excluded. Mortality and complications were compared during index admissions and for patients readmitted within 30 and 90 days of the index discharge date for unmatched and propensity score-matched groups. Overall, 6.7% (84,293) of patients underwent cardiac surgery and concomitant LAAC placement without surgical ablation. After propensity score matching, the index admission mortality and overall complications were not different in patients with LAAC versus patients without LAAC. LAAC placement was associated with increased any-cause 30-day readmissions (15% vs 13%, p <0.01). In patients with LAAC, within 30 days, there were no differences in mortality (3.9% vs 3.8%, p = 0.60) or overall complications (64% vs 63%, p = 0.20), whereas stroke was lower (5.3% vs 6.5%, p <0.01) and heart failure was higher (35% vs 30%, p <0.01). For patients readmitted within 90 days, similar findings were observed for any-cause readmissions, mortality, overall complications, stroke, and heart failure. In conclusion, concomitant LAAC placement during cardiac surgery was associated with lower early postdischarge incidence of stroke and a favorable overall risk-benefit profile. Given these short-term findings in a real-world population of all patients who underwent cardiac surgery, longer-term studies with more granular data are needed to evaluate the potential benefit of this practice.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Haley N Jenkins
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Krish C Dewan
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Uchida M, Jo T, Okada A, Matsui H, Yasunaga H. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation at low risk of stroke in japan: a retrospective cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:20-26. [PMID: 37858298 DOI: 10.1093/ehjcvp/pvad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
AIMS Contemporary guidelines differ in their recommendations regarding initiating non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) at low risk of stroke. This study aimed to examine the effectiveness and safety of NOACs for low-risk AF in a Japanese cohort. METHODS AND RESULTS In this retrospective cohort study based on the JMDC Claims Database extracted between April 2011 and November 2022, we identified 13 291 patients with AF at low risk of stroke. We performed inverse probability of treatment weighting Cox regression analyses to compare the embolization and bleeding risks between the nontreatment and NOAC groups. Net clinical benefit was defined as the annual incidence of ischaemic stroke events prevented by NOACs after subtracting intracranial haemorrhage (ICH) events attributable to NOACs, multiplied by a weighting factor. The incidences of stroke and ICH in the nontreatment group were 0.47 and 0.15 per 100 person-years, respectively. The NOAC group had higher incidences of ICH (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 0.75-4.00) and stroke (HR: 1.41, 95% CI: 0.84-2.36). The net clinical benefit of NOAC treatment was -0.35% per year (95% CI: -0.99-0.29%). CONCLUSION Non-vitamin K antagonist oral anticoagulants treatment may be associated with a slightly high risk of ICH, and it yielded a neutral clinical benefit in the present Japanese population, which provides reassurance concerning the role of ethnicity in NOAC treatment for patients with AF and suggests a need to assess comprehensive weighting of the respective risk factors.
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Affiliation(s)
- Masato Uchida
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson AL, Murray KT. Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation : A Retrospective Cohort Study. Ann Intern Med 2023; 176:769-778. [PMID: 37216662 DOI: 10.7326/m22-3238] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding. OBJECTIVE For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants' elimination. DESIGN Retrospective cohort study. SETTING U.S. Medicare beneficiaries aged 65 years or older. PATIENTS Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs. MEASUREMENTS Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting. RESULTS There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: P = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (P = 0.001). LIMITATION Possible residual confounding. CONCLUSION In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - C Michael Stein
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
| | - Walter Smalley
- Departments of Health Policy and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (W.S.)
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee (E.Z.)
| | - William D Dupont
- Departments of Health Policy and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (W.D.D.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - James R Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - Katherine T Murray
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
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Ono S, Ishimaru M, Yokota I, Konishi T, Okada A, Ono Y, Matsui H, Itai S, Yonenaga K, Tonosaki K, Watanabe R, Hoshi K, Yasunaga H. Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: Retrospective cohort study using large scale claims data in Japan. Thromb Res 2023; 222:24-30. [PMID: 36563522 DOI: 10.1016/j.thromres.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/22/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Comparative safety of direct oral anticoagulants vs. warfarin in patients undergoing tooth extraction remains unclear. We compared the incidence of post-extraction bleeding between patients taking warfarin and those taking direct oral anticoagulants (DOACs) using administrative claims data. MATERIALS AND METHODS We identified outpatients on anticoagulant therapy who underwent permanent tooth extraction between 2015 and 2020 and categorized them into the warfarin and DOAC groups based on medication prescribed within six months prior to tooth extraction. We used the overlap propensity score weighting method to balance the baseline characteristics between the groups and compared the incidence of post-extraction bleeding within seven days after tooth extraction. RESULTS Among 5253 eligible patients, those in the DOAC group (n = 3696) were older and less frequently prescribed antiplatelets than those in the warfarin group (n = 1557). The distribution of tooth extraction type and number of teeth extracted in a single procedure did not differ between the groups. The unadjusted incidences of post-extraction bleeding in the warfarin and DOAC groups were 35 (2.2 %) and 71 (1.9 %), respectively. Moreover, the overlap weighting analysis showed that the adjusted odds ratio of post-extraction bleeding in the DOAC group in comparison with that in the warfarin group was 0.84 (95 % confidence interval, 0.54-1.31). CONCLUSION The incidence of post-extraction bleeding in patients taking DOACs was comparable to that in patients taking warfarin. The findings suggest that dentists and physicians should exercise the same degree of caution when extracting teeth in patients on DOACs and those on warfarin in terms of post-extraction bleeding.
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Affiliation(s)
- Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Miho Ishimaru
- Department of Oral Health Promotion, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo 060-8638, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shunsuke Itai
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazumichi Yonenaga
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kanata Tonosaki
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Rinji Watanabe
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazuto Hoshi
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Konish T, Ono S, Okada A, Matsui H, Tanabe M, Seto Y, Yasunaga H. Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants. Endosc Int Open 2023; 11:E52-E59. [PMID: 36644535 PMCID: PMC9839429 DOI: 10.1055/a-1981-2946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background and study aims Despite the widespread use of direct oral anticoagulants (DOACs), the association between DOAC use and complications (e. g., bleeding) following gastrointestinal endoscopic biopsy remains unclear. This study aimed to evaluate complications after biopsy in patients treated with DOACs in Japan, where biopsies would be generally performed without DOAC withdrawal based on guideline recommendations. Patients and methods Using a Japanese nationwide database, we identified patients taking DOACs who underwent gastrointestinal endoscopic biopsy (n = 2,769, DOAC group) and those not taking DOACs (n = 129,357, control group) from April 2015 to November 2020. We conducted 1:4 propensity score (PS) matching and overlap PS-weighting analyses with adjustment for background characteristics to compare occurrence of post-procedure hemorrhage and stroke within 1 week after biopsy, and thrombin use on the day of biopsy without a diagnosis of hemorrhage. Results In total, 578 patients (0.44 %) developed post-procedure hemorrhage, and 13 patients (0.01 %) developed stroke. The DOAC group had more comorbidities than the control group. The PS matching analysis revealed no significant differences in post-procedure hemorrhage (odds ratio, 1.52 [95 % confidential interval, 0.96-2.41]) or stroke (1.00 [0.21-4.71]), whereas the DOAC group received thrombin more often than the control group (1.60 [1.30-1.95]). The results were equivalent in the overlap PS-weighting analysis. Conclusions The PS analyses showed no significant differences in complications following gastrointestinal endoscopic biopsy between DOAC users and non-users. These results suggest the safety of endoscopic biopsy without DOAC withdrawal although the need for careful hemostasis remains.
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Affiliation(s)
- Takaaki Konish
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Jaakkola S, Paana T, Airaksinen J, Sipilä J, Kytö V. Association of CHA2DS2-VASc Score with Long-Term Incidence of New-Onset Atrial Fibrillation and Ischemic Stroke after Myocardial Infarction. J Clin Med 2022; 11:jcm11237090. [PMID: 36498665 PMCID: PMC9739941 DOI: 10.3390/jcm11237090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
The CHA2DS2-VASc score is a reliable tool used to estimate the risk of ischemic stroke (IS) in patients with atrial fibrillation (AF). Few tools exist for the prediction of new-onset AF (NOAF) after myocardial infarction (MI) and its relation to IS. We studied the usefulness of CHA2DS2-VASc in predicting NOAF and IS in a long-term follow-up after MI. Consecutive MI patients without baseline AF (n = 70,922; mean age: 68.2 years), discharged from 20 hospitals in Finland during 2005−2018, were retrospectively studied using national registries. The outcomes of interest after discharge were NOAF- and IS-assessed with competing risk analyses at one and ten years. The median follow-up was 4.2 years. The median baseline CHA2DS2-VASc score was 3 (IQR 2−5). The likelihood of both NOAF and NOAF-related IS increased stepwise with this score at one and ten years (all p < 0.0001). The one-year-adjusted subdistribution hazard ratio (sHR) was 4.03 (CI 3.68−4.42) for NOAF in patients with CHA2DS2-VASc scores ≥6 points. The cumulative incidence of IS was 15.2% in patients with NOAF vs. 6.2% in patients without AF at 10 years after MI (adj. sHR 2.12; CI 1.98−2.28; p < 0.0001). Coronary artery bypass surgery was associated with a higher NOAF incidence compared to percutaneous coronary intervention (adj. sHR 1.87; CI 1.65−2.13; p < 0.0001 one year after MI). The CHA2DS2-VASc score is a simple tool used to estimate the long-term risk of NOAF and IS after MI in patients without baseline AF. Coronary bypass surgery is associated with an increased NOAF incidence after MI.
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Affiliation(s)
- Samuli Jaakkola
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
- Correspondence:
| | - Tuomas Paana
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
| | - Jussi Sipilä
- Department of Neurology, Siun Sote, North Karelia Central Hospital, 80210 Joensuu, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
- Turku Clinical Research Center, Turku University Hospital, 20521 Turku, Finland
- Center for Population Health Research, Turku University Hospital, University of Turku, 20521 Turku, Finland
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Xu Y, Chang AR, Inker LA, McAdams‐DeMarco M, Grams ME, Shin J. Concomitant Use of Diltiazem With Direct Oral Anticoagulants and Bleeding Risk in Atrial Fibrillation. J Am Heart Assoc 2022; 11:e025723. [PMID: 35861836 PMCID: PMC9707838 DOI: 10.1161/jaha.122.025723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
Background Diltiazem, a moderate cytochrome P450 3A4 isozyme/P-glycoprotein inhibitor, may potentiate the bleeding risk of direct oral anticoagulants (DOACs) through pharmacokinetic interactions. We evaluated the association between concomitant use of diltiazem with DOACs and bleeding among patients with atrial fibrillation, across varying degrees of kidney function. Methods and Results We identified 4544 patients with atrial fibrillation who were initiated on rivaroxaban (n=1583), apixaban (n=2373), or dabigatran (n=588), between 2010 and 2019 in Geisinger Health, with a mean age of 72 years and an estimated glomerular filtration rate of 70 mL/min per 1.73 m2. At the time of DOAC initiation, 15% patients were taking diltiazem and an additional 5% were initiated on diltiazem during follow-up. Among DOAC users, using diltiazem concurrently (versus DOAC alone) was associated with an increased risk of any bleeding-related hospitalization (unadjusted risk difference, 2.4; 95% CI, 0.6-4.2 events per 100 person-years; adjusted hazard ratio, 1.56, 95% CI, 1.15-2.12), as well as major bleeding (unadjusted risk difference, 1.4 [95% CI, 0.1-2.6 events per 100 person-years]; adjusted hazard ratio, 1.84 [95% CI, 1.18-2.85]). Increased risk of any/major bleeding with diltiazem was observed in both patients with and without CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2) (P for interaction=0.524 and 0.629, respectively). Among 13 179 warfarin users (the negative control), concomitant diltiazem use was not associated with bleeding. Conclusions Concomitant use of diltiazem with DOACs was associated with a higher bleeding risk in patients with atrial fibrillation, consistently in both subgroups of chronic kidney disease and non-chronic kidney disease. For DOAC users, concomitant diltiazem should be prescribed only when the benefit outweighs the risk, with close monitoring for signs of bleeding.
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Affiliation(s)
- Yunwen Xu
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Alex R. Chang
- Division of NephrologyGeisinger Health SystemDanvillePA
| | - Lesley A. Inker
- Division of Nephrology, Department of Internal MedicineTufts Medical CenterBostonMA
| | - Mara McAdams‐DeMarco
- Department of SurgeryNew York University Grossman School of Medicine and Langone HealthNew YorkNY
- Department of Population HealthNew York University Grossman School of Medicine and Langone HealthNew YorkNY
| | - Morgan E. Grams
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Department of Population HealthNew York University Grossman School of Medicine and Langone HealthNew YorkNY
- Department of MedicineNew York University Grossman School of Medicine and Langone HealthNew YorkNY
| | - Jung‐Im Shin
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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Kubota K, Ooba N. Effectiveness and Safety of Reduced and Standard Daily Doses of Direct Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: A Cohort Study Using National Database Representing the Japanese Population. Clin Epidemiol 2022; 14:623-639. [PMID: 35520279 PMCID: PMC9064485 DOI: 10.2147/clep.s358277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the effectiveness and safety of reduced or standard daily doses of direct oral anticoagulants (DOACs) with warfarin in Japanese patients with nonvalvular atrial fibrillation (NVAF). We used post-hoc analyses to identify patient groups that could benefit from reduced-dose DOACs. Patients and Methods Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan, we identified 944,776 patients with NVAF who had started an oral anticoagulant after at least one year of non-use between April 2011 and March 2016. We matched patients taking any, reduced, or standard doses of DOACs 1:1 with those taking warfarin. We measured treatment effectiveness based on admission due to stroke or systemic embolism (S/SE) and safety based on admission due to any bleeding (defined as major bleeding, MB). We compared both outcomes between DOACs and warfarin using the Cox proportional hazards model. We used post-hoc analysis to match patients receiving reduced-dose DOACs to those receiving standard-dose DOACs and compared treatment effectiveness and safety. Results More than half of patients receiving DOACs used a reduced dose. The occurrences of S/SE and MB in patients receiving any, reduced, or standard doses of DOACs were equal to or lower than those receiving warfarin. In the post-hoc analysis, the risk of S/SE and MB was similar between reduced and standard doses of DOACs except for those with a history of cerebral infarction and CHA2DS2-VASc score ≥3, where the risk of S/SE was lower for reduced doses of any and individual DOACs. Conclusion Findings from the current study are consistent with recent Asian and global studies but different from most studies conducted in North America and Europe, where patients receiving a reduced dose of DOACs had an increased risk of S/SE. Future studies should test the reproducibility of results from the current study.
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Affiliation(s)
- Kiyoshi Kubota
- NPO Drug Safety Research Unit Japan, Tokyo, Japan
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
- Correspondence: Kiyoshi Kubota, NPO Drug Safety Research Unit Japan, 6-2-9-2F Soto-Kanda, Chiyoda-ku, Tokyo, 101-0021, Japan, Tel +81-3-6284-4206, Fax +81-3-6284-4207, Email
| | - Nobuhiro Ooba
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
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Feldman K, Duncan RG, Nguyen A, Cook-Wiens G, Elad Y, Nuckols T, Pevnick JM. Will Apple devices' passive atrial fibrillation detection prevent strokes? Estimating the proportion of high-risk actionable patients with real-world user data. J Am Med Inform Assoc 2022; 29:1040-1049. [PMID: 35190832 PMCID: PMC9093037 DOI: 10.1093/jamia/ocac009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/17/2021] [Accepted: 01/27/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Utilizing integrated electronic health record (EHR) and consumer-grade wearable device data, we sought to provide real-world estimates for the proportion of wearers that would likely benefit from anticoagulation if an atrial fibrillation (AFib) diagnosis was made based on wearable device data. MATERIALS AND METHODS This study utilized EHR and Apple Watch data from an observational cohort of 1802 patients at Cedars-Sinai Medical Center who linked devices to the EHR between April 25, 2015 and November 16, 2018. Using these data, we estimated the number of high-risk patients who would be actionable for anticoagulation based on (1) medical history, (2) Apple Watch wear patterns, and (3) AFib risk, as determined by an existing validated model. RESULTS Based on the characteristics of this cohort, a mean of 0.25% (n = 4.58, 95% CI, 2.0-8.0) of patients would be candidates for new anticoagulation based on AFib identified by their Apple Watch. Using EHR data alone, we find that only approximately 36% of the 1802 patients (n = 665.93, 95% CI, 626.0-706.0) would have anticoagulation recommended even after a new AFib diagnosis. DISCUSSION AND CONCLUSION These data suggest that there is limited benefit to detect and treat AFib with anticoagulation among this cohort, but that accessing clinical and demographic data from the EHR could help target devices to the patients with the highest potential for benefit. Future research may analyze this relationship at other sites and among other wearable users, including among those who have not linked devices to their EHR.
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Affiliation(s)
- Keith Feldman
- Division of Health Services and Outcomes Research, Children’s Mercy Kansas City, Kansas City, Missouri, USA,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Ray G Duncan
- Enterprise Information Services, Cedars-Sinai Health System, Los Angeles, California, USA,Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - An Nguyen
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Galen Cook-Wiens
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yaron Elad
- Enterprise Information Services, Cedars-Sinai Health System, Los Angeles, California, USA,Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Teryl Nuckols
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joshua M Pevnick
- Corresponding Author: Joshua M. Pevnick, MD, MSHS, Department of Medicine, Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
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