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Dinh PP, Quang Ho TH, Pham HM, Nguyen HH, Ton MT, Tran GS, Vu NQ, Pham HN, Cao SL, Hoang SV. Evaluating Renal Benefits of Rivaroxaban Versus Vitamin K Antagonists in Atrial Fibrillation: A Systematic Review and Meta-analysis of Real-world Evidence. Eur Cardiol 2024; 19:e05. [PMID: 38983579 PMCID: PMC11231818 DOI: 10.15420/ecr.2024.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/26/2024] [Indexed: 07/11/2024] Open
Abstract
Background AF is a global health concern, with systemic complications including renal dysfunction. This systematic review and meta-analysis compares the effects of rivaroxaban, a Factor Xa inhibitor, and vitamin K antagonists (VKAs) on renal outcomes in AF patients. Methods The study protocol is registered in PROSPERO (ID: CRD42023462756). We systematically searched the PubMed, Embase and Cochrane Library databases from 1 January 2017 to 30 June 2023 for real-world studies comparing the effects of rivaroxaban and VKAs on renal outcomes in AF patients, including acute kidney injury, a .30% decrease in estimated glomerular filtration rate, doubling of serum creatinine and worsening renal function. Subgroup analyses targeted diabetes, pre-existing kidney disease, the elderly (age .65 years) and Asian populations. The risk of bias was assessed used the Robins-I tool. HRs and 95% CIs were synthesised through a random-effects model. Two sensitivity analyses were performed, using a fixed-effects model and excluding conference abstracts. Results We identified 1,666 records. After screening, 14 studies comparing rivaroxaban and VKAs were included. Rivaroxaban exhibited superiority over VKAs in preventing: acute kidney injury (HR 0.68; 95% CI [0.61.0.77]; p<0.00001); a .30% decrease in estimated glomerular filtration rate (HR 0.71; 95% CI [0.60.0.84]; p<0.0001); doubling of serum creatinine (HR 0.50; 95% CI [0.36.0.70]; p<0.0001); and worsening renal function (HR 0.56; 95% CI [0.45.0.69]; p<0.00001). Subgroup and sensitivity analyses consistently confirmed rivaroxaban's favourable effects on renal outcomes in diabetes, pre-existing kidney disease, the elderly and Asian populations. Conclusion Our findings support the preference of rivaroxaban over VKAs for renal outcomes in AF. The findings endorse rivaroxaban as the preferred anticoagulant to mitigate renal complications, offering clinicians valuable insights for tailored strategies.
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Affiliation(s)
- Phong Phan Dinh
- Vietnam National Heart Institute, Bach Mai Hospital Hanoi, Vietnam
- Hanoi Medical University Hanoi, Vietnam
| | | | - Hung Manh Pham
- Vietnam National Heart Institute, Bach Mai Hospital Hanoi, Vietnam
- Hanoi Medical University Hanoi, Vietnam
| | | | | | - Giang Song Tran
- Vietnam National Heart Institute, Bach Mai Hospital Hanoi, Vietnam
| | | | | | - Son Luong Cao
- Department of Cardiology, University Medical Center Ho Chi Minh City Ho Chi Minh City, Vietnam
| | - Sy Van Hoang
- Cardiovascular Department, Cho Ray Hospital Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City Ho Chi Minh City, Vietnam
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Junejo RT, Gupta D, Snowdon RL, Lip GYH, Fisher JP. Relationship of Warfarin and Apixaban with Vascular Function in Patients with Atrial Fibrillation. J Vasc Res 2024; 61:59-67. [PMID: 38447552 PMCID: PMC10997243 DOI: 10.1159/000535618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/30/2023] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is associated with endothelial damage/dysfunction. Herein, we tested the hypothesis that brachial artery flow-mediated dilation (FMD) is superior in AF patients taking apixaban compared to warfarin. METHODS AF patients on apixaban (n = 46; 67 [7] years; mean [standard deviation]; 15 women) and warfarin (n = 27; 73 [9] years (p < 0.01); 11 women) were recruited. Duplex Doppler ultrasound imaging was undertaken during baseline (2 min), cuff inflation (5 min), and following cuff deflation (3 min). FMD was defined as peak increase in brachial artery diameter following cuff deflation and analysed as percentage change in diameter, as a ratio of FMD, shear rate area under the curve (SRAUC; FMD-to-SRAUC), and using SRAUC as a covariate (FMDSR). RESULTS Baseline artery diameter (4.96 [1.14] vs. 4.89 [0.88] mm), peak diameter (5.12 [1.17] vs. 5.14 [0.93] mm), and FMDSR (3.89 [3.62] vs. 4.80 [3.60] %) were not different between warfarin and apixaban (p > 0.05; analysis of covariance with age, CHA2DS2-VASc, years since AF diagnosis, number of diabetics, alcohol drinkers, and units of alcohol consumed per week as covariates). Stepwise multiple regression identified independent association of fibrillation, hypertension, and increased age with FMD. CONCLUSION AF patients on warfarin and apixaban exhibit similar endothelium-dependent vasodilation. Increased blood pressure negatively impacts vasodilator capacity in AF patients.
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Affiliation(s)
- Rehan T Junejo
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK,
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK,
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Richard L Snowdon
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - James P Fisher
- Department of Physiology, Faculty of Medical and Health Sciences, Manaaki Manawa - The Centre for Heart Research, University of Auckland, Auckland, New Zealand
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Escobar-Cervantes C, Díez-Villanueva P, Bonanad Lozano C, Reino AP, Almendro-Delia M, Facila L, Valle A, Suárez C. Vascular protection with rivaroxaban in the comprehensive management of atrial fibrillation. Expert Rev Cardiovasc Ther 2023; 21:791-802. [PMID: 37933665 DOI: 10.1080/14779072.2023.2276893] [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: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION In addition to an increased risk of thromboembolic complications, patients with atrial fibrillation (AF) are at risk for vascular events. Consequently, complete vascular protection is warranted in these patients. AREAS COVERED A narrative search was conducted on PubMed (MEDLINE), using the MeSH terms [Rivaroxaban] + [Atrial fibrillation] + [Cardiovascular] + [Vascular] + [Treatment]. Original data from clinical trials, prospective and retrospective studies, useful reviews and experimental studies, were selected. EXPERT OPINION The ROCKET-AF trial showed that rivaroxaban is effective in reducing the risk of stroke, with a lower risk of fatal and intracranial bleeding compared to warfarin. Remarkably, experimental data have provided a number of pathogenic mechanisms through which rivaroxaban could provide beneficial vascular properties beyond its antithrombotic activity. Moreover, in the AF population, additional to its ability to reduce the risk of thromboembolic complications, rivaroxaban is associated with a lower risk of myocardial infarction, major adverse cardiac and limb events, and vascular mortality in patients with diabetes, also attenuating renal impairment during follow-up. These findings suggest that rivaroxaban may provide a comprehensive vascular protection in patients with AF.
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Affiliation(s)
| | | | - Clara Bonanad Lozano
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (INCLIVA), Spain
| | - Antonio Pose Reino
- Hypertension and Vascular Risk Unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia Valencia, Spain
| | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Carmen Suárez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [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: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
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Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Zidrou C, Kapetanou A, Rizou S. The effect of drugs on implant osseointegration- A narrative review. Injury 2023; 54:110888. [PMID: 37390787 DOI: 10.1016/j.injury.2023.110888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 05/24/2023] [Accepted: 06/11/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE This narrative review aims to investigate the effects of drugs on implant osseointegration, analyzing their potential positive or negative impact on the direct structural and functional connection between bone and load-carrying implants. BACKGROUND The review seeks to provide a comprehensive understanding of osseointegration, which refers to the successful integration of an implant with living bone, resulting in no progressive relative movement between them. Exploring the effects of drugs on implant osseointegration is crucial for optimizing outcomes and enhancing patient care in orthopedic implant procedures. METHODS Relevant studies on the effects of drugs on implant osseointegration were identified through a literature search. Electronic databases, including PubMed, Embase, and Google Scholar, were utilized, employing appropriate keywords and MeSH terms related to osseointegration, implants, and drug interventions. The search was limited to English studies. DISCUSSION This overview presents a detailed analysis of the effects of drugs on implant osseointegration. It explores drugs such as bisphosphonates, teriparatide, statins, angiotensin-converting enzyme inhibitors, beta-blockers, nitrites, and thiazide diuretics as promoters of osseointegration. Conversely, loop diuretics, non-steroidal anti-inflammatory drugs, corticosteroids, cyclosporine A, cisplatin, methotrexate, antibiotics, proton pump inhibitors (PPIs), antiepileptics, selective serotonin reuptake inhibitors (SSRIs), and anticoagulants are discussed as inhibitors of the process. The role of vitamin D3 remains uncertain. The complex relationship between drugs and the biology of implant osseointegration is emphasized, underscoring the need for further in vitro and in vivo studies to validate their effects CONCLUSION: This narrative review contributes to the literature by providing an overview of the effects of drugs on implant osseointegration. It highlights the complexity of the subject and emphasizes the necessity for more extensive and sophisticated studies in the future. Based on the synthesis of the reviewed literature, certain drugs, such as bisphosphonates and teriparatide, show potential for promoting implant osseointegration, while others, including loop diuretics and certain antibiotics, may impede the process. However, additional research is required to solidify these conclusions and effectively inform clinical practice.
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Affiliation(s)
- Christiana Zidrou
- 2nd Orthopaedic Department, G. Papageorgiou General Hospital, Thessaloniki, Greece.
| | | | - Stavroula Rizou
- National and Kapodistrian University of Athens, Athens, Greece
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Chaushu L, Perez N, Botticelli D, Xavier SP, Kolerman R, Masri D. The Effect of Anticoagulants on Early Implant Failure: A Retrospective Cohort Study. J Funct Biomater 2023; 14:jfb14040186. [PMID: 37103275 PMCID: PMC10144258 DOI: 10.3390/jfb14040186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/17/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Abstract
Background: Anticoagulants (AC) are among the most often prescribed drugs in the world. Data regarding ACs’ effect on the osseointegration of dental implants is lacking. Purpose: The aim of the present retrospective cohort study was to evaluate the effect of anticoagulants (AC) on early implant failure (EIF). The null hypothesis was that the use of AC increases the incidence of EIF. Materials and Methods: The research included 687 patients who underwent 2971 dental implant placements in the department of oral and maxillofacial surgery in Rabin medical center, Beilinson hospital, by specialists in oral and maxillofacial surgery. The study group comprised 173 (25.2%) patients and 708 (23.8%) implants using AC. The rest of the cohort served as a control. A structured form was used to collect data at patient and implant level. EIF was defined as implant failure within a period of up to 12 months from loading. EIF was the primary outcome parameter. A logistic regression model was used to predict EIF. Results: Implants placed in individuals ≥ 80 (odds ratio (OR) = 0.34, p = 0.05), and ASA 2/3 vs. ASA 1 individuals (OR = 0.30, p = 0.02/OR = 0.33, p = 0.03, respectively) had decreased odds of EIF, and implants in those using anticoagulants (OR = 2.64, p = 0.01) had increased odds of EIF. At the patient level, the odds of EIF in ASA 3 (OR = 0.53, p = 0.02) and IHD (OR = 0.40, p = 0.02) individuals decreased. In AF/VF (OR = 2.95, p = 0.01) individuals, EIF odds increased. Conclusions: Within the limitations of the present study, the use of AC is significantly associated with an increased likelihood of EIF: the OR was 2.64. Future research is required to validate and examine the prospective impact of AC on the osseointegration phenomena.
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Yang N, Zhao Y, Bai Z, Chen H, Ning H, Zou M, Cheng G. The association of non-vitamin K antagonist oral anticoagulants vs. warfarin and the risk of fractures for patients with atrial fibrillation: a systematic review and meta-analysis. Acta Cardiol 2022; 78:298-310. [PMID: 36063197 DOI: 10.1080/00015385.2022.2030555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The fracture risks of non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin in patients with atrial fibrillation (AF) remain controversial. METHODS PubMed, Cochrane Library, EMBASE, Clinical Trials.gov databases for RCTs, and cohort studies were systematically searched from inception to 10 June 2021. RESULTS Twelve-two studies met the inclusion criteria and 477,821 patients were included. Warfarin increased the risk of fracture in AF patients compared with NOACs in overall any fracture (RR = 0.79; 95% CI = 0.70-10.88; p = 0.00), osteoporotic fracture (RR = 0.746; 95% CI = 0.630-0.883; p = 0.001). No significant difference was observed in the hip or pelvic fracture, vertebral fracture, extremity fracture, wrist fracture, femoral neck fracture, and ankle fracture. In subgroup analyses based on several aspects, NOACs were associated with a significant reduction in any fracture (standard dosage NOACs, cohort studies, elderly patients, rivaroxaban in RCTs, dabigatran, rivaroxaban, and apixaban in cohort studies), in the hip/pelvic fracture (follow-up time ≤1 year, cohort studies), and osteoporotic fracture (cohort studies). CONCLUSION NOACs were associated with a significantly lower risk of any fracture and osteoporotic fracture compared to warfarin. This benefit was also observed in specific NOACs types of dabigatran, rivaroxaban, and apixaban. However, whether NOACs had a less fracture risk than warfarin on the other risk of fractures was still uncertain.
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Affiliation(s)
- Nana Yang
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Ying Zhao
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Zhaohui Bai
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Haokun Chen
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Haoyu Ning
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Meijuan Zou
- Pharmaceutical College, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Gang Cheng
- Pharmaceutical College, Shenyang Pharmaceutical University, Shenyang, Liaoning, China.,NMPA Key Laboratory for Research and Evaluation of Drug Regulatory Technology, Shenyang, Liaoning, China
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Xie X, Liu Y, Li J, Gu F, Zhang K, Sui Z, Zhang J, Yu T. Fracture risks in patients with atrial fibrillation treated with different oral anticoagulants: a meta-analysis and systematic review. Age Ageing 2022; 51:6514231. [PMID: 35077554 PMCID: PMC8789302 DOI: 10.1093/ageing/afab264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/13/2021] [Indexed: 01/10/2023] Open
Abstract
Aims evidence on the difference in fracture risks for patients with atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs) versus warfarin remains controversial. We aim to compare the fracture risks between the DOAC and warfarin prescriptions among the AF patients. Methods and Results we systematically searched PubMed, EMBASE, the Cochrane Library and Web of Science up to 19 April 2021 for relevant studies. And the observational studies regarding the relationship between the DAOC versus warfarin prescriptions and fracture risks among the patients with AF were included in this meta-analysis. Two investigators independently screened the articles and extracted the relevant data. A random- or fixed-effect model was applied to calculate the pooled hazard ratio/relative ratios with 95% confidence intervals of fracture risks associated with the DOAC and warfarin prescriptions. Six studies comprising 351,208 patients and 9,424 fractures were included in this meta-analysis. Overall, the AF patients treated with DOACs tend to present a lower risk of any fracture compared with those treated with warfarin (relative ratio: 0.82, 95% confidence interval (CI): 0.74–0.91). Sub-analyses for each individual DOAC indicate that apixaban and rivaroxan are associated with lower risk of any fracture compared with warfarin (HR: 0.75, 95% CI: 0.60–0.92, and HR: 0.79, 95% CI: 0.71–0.88, respectively). Conclusion this meta-analysis suggests that DOAC users have a lower risk of fractures than the warfarin users. The results of this study may provide optimal anticoagulation opportunities for AF patients with high fracture risk factors.
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Affiliation(s)
| | | | | | | | | | | | | | - Tiecheng Yu
- Address correspondence to: Tiecheng Yu, Department of Orthopedics, The First Hospital of Jilin University, Changchun, China. Tel: +(0086) 135-9605-8780; E-mail:
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Cases A, Gomez P, Broseta JJ, Perez Bernat E, Arjona Barrionuevo JDD, Portolés JM, Gorriz JL. Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review. Front Med (Lausanne) 2021; 8:654620. [PMID: 34604247 PMCID: PMC8484537 DOI: 10.3389/fmed.2021.654620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.
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Affiliation(s)
- Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Gomez
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | | | | | | | | | - Jose Luis Gorriz
- Departament de Medicina, Universitat de Valencia, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación del Hospital Clinico Universitario, Valencia (INCLIVA), Valencia, Spain
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Nalevaiko JZ, Marques JVO, Oliveira MF, Raetsch AWP, Marques GL, Petterle RR, Moreira CA, Borba VZC. Bone density and quality in patients treated with direct-acting oral anticoagulants versus warfarin. Bone 2021; 150:116000. [PMID: 33971316 DOI: 10.1016/j.bone.2021.116000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/23/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Direct-acting oral anticoagulants (DOACs) are therapeutic alternatives to warfarin that act independently of vitamin K, thus not affecting bone matrix formation. The aim of this study was to compare bone mineral density (BMD) and microarchitecture in patients treated with DOACs versus warfarin. METHODS Cross-sectional, observational study in patients using oral anticoagulants for >1 year and a paired control group (CG). Based on the type of anticoagulant used, the patients were grouped into a DOAC (DOACG) or warfarin (WG) group. All patients filled out a questionnaire and underwent BMD evaluation and trabecular bone score (TBS) measurement. RESULTS In all, 150 patients were included (50 patients in each group). The mean age was 60.49 ± 7.48 years, and most participants were men (64%). The most frequent comorbidities were hypertension, dyslipidemia, and hyperglycemia (comparison between groups p > 0.05). Low bone mass was diagnosed in 42%, 50%, and 66% of the patients in the CG, DOACG, and WG, respectively (p = 0.012). On logistic regression analysis, BMD was associated with body mass index (BMI; odds ratio [OR] 0.846, 95% confidence interval [CI] 0.763-0.926, p = 0.001), creatinine level (OR 0.024, 95%CI 0.001-0.434, p = 0.017), and TBS value (OR 17.777, 95%CI 4.526-96.903, p = 0.000). The mean TBS decreased progressively from the CG to the DOACG and WG (1.328 ± 0.112, 1.264 ± 0.138, and 1.203 ± 0.112, respectively, p < 0.001). On multivariate linear regression, negative predictors of TBS included warfarin use (-0.06, 95%CI -0.11 to -0.02, p = 0.006), BMI (-0.01, 95%CI -0.01 to -0.00, p < 0.001), and hyperglycemia (-0.07, 95%CI -0.11 to -0.03, p = 0.003), while positive predictors were an active IPAQ classification (0.06, 95%CI 0.01-0.11, p = 0.029) and family history of hip fracture (0.07, 95%CI 0.01-0.14, p = 0.029). CONCLUSION Patients using anticoagulants have lower BMD and TBS values compared with controls. This negative effect on bone was more pronounced with warfarin, but was also seen with DOACs.
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Affiliation(s)
- Jeferson Zanovelli Nalevaiko
- Cardiology Division, Hospital de Clínicas, Universidade Federal do Paraná (HC/UFPR), Rua General Carneiro, 181 Curitiba, PR, Brazil
| | - Júlia Vieira Oberger Marques
- Endocrine Division, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Avenida Agostinho Leão Júnior, 285, Alto da Glória, Curitiba, PR, Brazil
| | | | | | - Gustavo Lenci Marques
- Cardiology Division, Hospital de Clínicas, Universidade Federal do Paraná (HC/UFPR), Rua General Carneiro, 181 Curitiba, PR, Brazil
| | | | - Carolina Aguiar Moreira
- Endocrine Division, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Avenida Agostinho Leão Júnior, 285, Alto da Glória, Curitiba, PR, Brazil
| | - Victória Zeghbi Cochenski Borba
- Endocrine Division, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Avenida Agostinho Leão Júnior, 285, Alto da Glória, Curitiba, PR, Brazil.
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Butler AJ, Eismont FJ. Effects of Anticoagulant Medication on Bone-Healing. JBJS Rev 2021; 9:e20.00194. [PMID: 33999912 DOI: 10.2106/jbjs.rvw.20.00194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» A substantial proportion of patients undergoing orthopaedic care are prescribed some form of anticoagulant medication, whether for perioperative venous thromboembolism prophylaxis or chronic anticoagulation in the setting of a cardiac or other condition. » An abundance of preclinical data suggests that many commonly used anticoagulant medications may have a harmful effect on bone-healing. » The orthopaedic surgeon should be informed and mindful of the added variable that anticoagulation may play in the outcomes of fracture treatment and bone-healing. » Heparin and warfarin appear to have a greater detrimental impact than low-molecular-weight heparin. Factor Xa inhibitors may confer the least risk, with some studies even suggesting the potential for enhancement of bone-healing.
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Affiliation(s)
- Alexander J Butler
- Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, Florida
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Fusaro M, Cianciolo G, Evenepoel P, Schurgers L, Plebani M. Vitamin K in CKD Bone Disorders. Calcif Tissue Int 2021; 108:476-485. [PMID: 33409597 DOI: 10.1007/s00223-020-00792-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/05/2020] [Indexed: 01/07/2023]
Abstract
Vitamin K is principally known because it is involved in blood coagulation. Furthermore, epidemiological studies showed that its deficit was associated with increased fragility fractures, vascular calcification and mortality. There are two main types of vitamin K vitamers: Phylloquinone (or PK) and Menaquinones (MKn). Vitamin K acts both as coenzyme of y-glutamyl carboxylase (GGCX) transforming undercarboxylated in carboxylated vitamin K-dependent proteins (e.g., Osteocalcin and Matrix Gla Protein) and as a ligand of the nuclear steroid and xenobiotic receptor (SXR) (in murine species Pregnane X Receptor: PXR), expressed in osteoblasts. It has been highlighted that the uremic state is a condition of greater vitamin K deficiency than the general population with resulting higher prevalence of bone fractures, vascular calcifications and mortality. The purpose of this literature review is to evaluate the protective role of Vitamin K in bone health in CKD patients.
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Affiliation(s)
- M Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa Via G. Moruzzi 1, 56124, Pisa, PI, Italy.
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, PD, Italy.
| | - G Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - P Evenepoel
- Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven, Leuven, Belgium
| | - L Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, 6200MD, Maastricht, The Netherlands
| | - M Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
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Jørgensen HS, David K, Salam S, Evenepoel P. Traditional and Non-traditional Risk Factors for Osteoporosis in CKD. Calcif Tissue Int 2021; 108:496-511. [PMID: 33586002 DOI: 10.1007/s00223-020-00786-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a state of bone fragility with reduced skeletal resistance to trauma, and consequently increased risk of fracture. A wide range of conditions, including traditional risk factors, lifestyle choices, diseases and their treatments may contribute to bone fragility. It is therefore not surprising that the multi-morbid patient with chronic kidney disease (CKD) is at a particularly high risk. CKD is associated with reduced bone quantity, as well as impaired bone quality. Bone fragility in CKD is a composite of primary osteoporosis, accumulation of traditional and uremia-related risk factors, assaults brought on by systemic disease, and detrimental effects of drugs. Some risk factors are modifiable and represent potential targets for intervention. This review provides an overview of the heterogeneity of bone fragility in CKD.
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Affiliation(s)
- Hanne Skou Jørgensen
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karel David
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
- Academic Unit of Bone Metabolism and 3 Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, UK
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review. Cells 2021; 10:cells10040773. [PMID: 33807457 PMCID: PMC8066517 DOI: 10.3390/cells10040773] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Warfarin has been utilized for decades as an effective anticoagulant in patients with a history of strong risk factors for venous thromboembolism (VTE). Established adverse effects include bleeding, skin necrosis, teratogenicity during pregnancy, cholesterol embolization, and nephropathy. One of the lesser-known long-term side effects of warfarin is an increase in systemic arterial calcification. This is significant due to the association between vascular calcification and cardiovascular morbidity and mortality. Direct oral anticoagulants (DOACs) have gained prominence in recent years, as they require less frequent monitoring and have a superior side effect profile to warfarin, specifically in relation to major bleeding. The cost and lack of data for DOACs in some disease processes have precluded universal use. Within the last four years, retrospective cohort studies, observational studies, and randomized trials have shown, through different imaging modalities, that multiple DOACs are associated with slower progression of vascular calcification than warfarin. This review highlights the pathophysiology and mechanisms behind vascular calcification due to warfarin and compares the effect of warfarin and DOACs on systemic vasculature.
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Jurin I, Lucijanić M, Radonić V, Letilović T, Lucijanić J, Mesarov S, Zagorec N, Hadžibegović I. The Risk of Falling and Consequences of Falling in Patients with Atrial Fibrillation Receiving Different Types of Anticoagulant. Drugs Aging 2021; 38:417-425. [PMID: 33650035 DOI: 10.1007/s40266-021-00843-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Our objective was to investigate the predictors of falls requiring a visit to the emergency department in patients with nonvalvular atrial fibrillation (AF) receiving different types of anticoagulants and to investigate the clinical consequences of falling in the same population. METHODS A total of 1217 patients with nonvalvular AF from two institutions were retrospectively evaluated. Each patient underwent a physical examination, and clinical histories and medication profiles were taken from each patient at baseline. RESULTS The median age of our cohort was 71 years; 52.3% were males, and 86.1% of patients were receiving anticoagulation at study baseline. The 5-year freedom-from-falling rate was 81.6%. The use and type of anticoagulation was not significantly associated with the risk of falling (P = 0.222), whereas higher Morse Fall Scale (MFS), CHA2DS2-VASC (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category), and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly) scores were significantly associated with a higher hazard of the first fall in univariate analyses. In the multivariate Cox regression model, MFS, older age, osteoporosis, higher levels of high-density lipoprotein cholesterol, higher diastolic blood pressure, and use of amiodarone, diuretics, or short- and medium-acting benzodiazepines were mutually independent predictors of the first fall. Of 163 patients, 93 (57%) had a bone fracture during the fall. Type of anticoagulation significantly affected survival after the first fall (P < 0.001): patients inadequately anticoagulated with warfarin had worse survival rates, and patients receiving apixaban and dabigatran had the best survival rates after the first fall. CONCLUSION Older patients who had comorbidities and were taking amiodarone, diuretics, or short- or medium-acting benzodiazepines had the highest risk of falls. The type and quality of anticoagulation did not seem to affect the risk of falling but did significantly affect survival after the first fall.
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Affiliation(s)
- Ivana Jurin
- Cardiology Department, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Lucijanić
- Hematology Department, University Hospital Dubrava, Av. Gojka Suska 6, 10000, Zagreb, Croatia. .,School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Vedran Radonić
- Division of Cardiology, Department of Medicine, University Hospital Merkur, Zagreb, Croatia
| | - Tomislav Letilović
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Division of Cardiology, Department of Medicine, University Hospital Merkur, Zagreb, Croatia
| | | | - Stjepan Mesarov
- Urology Department, University Hospital Dubrava, Zagreb, Croatia
| | - Nikola Zagorec
- Nephrology and Dialysis Department, University Hospital Dubrava, Zagreb, Croatia
| | - Irzal Hadžibegović
- Cardiology Department, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Dental Medicine and Health Care, Josip Juraj Strossmayer University, Osijek, Croatia
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The Safety and Efficacy of Rivaroxaban Compared with Warfarin in Patients with Atrial Fibrillation and Diabetes: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2021; 21:51-61. [PMID: 32514866 DOI: 10.1007/s40256-020-00407-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIMS This meta-analysis was conducted to compare the efficacy and safety of rivaroxaban with warfarin in patients with atrial fibrillation (AF) and diabetes mellitus. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched from the establishment of databases up to 15 October 2019. Studies on efficacy and safety outcomes of rivaroxaban and warfarin were included. Efficacy and safety outcomes, including stroke, ischemic stroke, stroke or systemic embolism, myocardial infarction, major adverse cardiac events, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding were collected for meta-analysis. RESULTS Compared with warfarin, rivaroxaban could significantly reduce stroke (risk ratio [RR] 0.77; 95% confidence interval [CI] 0.63-0.95; P = 0.01), ischemic stroke (RR 0.74; 95% CI 0.63-0.87; P = 0.0004), stroke or systemic embolism (RR 0.73; 95% CI 0.60-0.89; P = 0.002), myocardial infarction (RR 0.68; 95% CI 0.56-0.82; P < 0.0001), and major adverse cardiac events (RR 0.71; 95% CI 0.53-0.94; P = 0.02) in patients with AF and diabetes. Moreover, rivaroxaban was associated with a lower risk of major bleeding (RR 0.79; 95% CI 0.65-0.96; P = 0.02), intracranial hemorrhage (RR 0.52; 95% CI 0.39-0.69; P < 0.00001), and major gastrointestinal bleeding (RR 0.74; 95% CI 0.56-0.98; P = 0.04). Similar results were obtained in stratified meta-analysis of cohort studies. CONCLUSION Our study suggests a favorable risk-benefit profile of rivaroxaban, with superior efficacy and safety over warfarin in patients with AF and diabetes.
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Mastenbroek TG, Karel MFA, Nagy M, Chayoua W, Korsten EIJ, Coenen DM, Debets J, Konings J, Brouns AE, Leenders PJA, van Essen H, van Oerle R, Heitmeier S, Spronk HM, Kuijpers MJE, Cosemans JMEM. Vascular protective effect of aspirin and rivaroxaban upon endothelial denudation of the mouse carotid artery. Sci Rep 2020; 10:19360. [PMID: 33168914 PMCID: PMC7653917 DOI: 10.1038/s41598-020-76377-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/27/2020] [Indexed: 11/08/2022] Open
Abstract
While in recent trials the dual pathway inhibition with aspirin plus rivaroxaban has shown to be efficacious in patients with atherosclerotic cardiovascular disease, little is known about the effects of this combination treatment on thrombus formation and vascular remodelling upon vascular damage. The aim of this study was to examine the effects of aspirin and/or rivaroxaban on injury-induced murine arterial thrombus formation in vivo and in vitro, vessel-wall remodelling, and platelet-leukocyte aggregates. Temporary ligation of the carotid artery of C57BL/6 mice, fed a western type diet, led to endothelial denudation and sub-occlusive thrombus formation. At the site of ligation, the vessel wall stiffened and the intima-media thickened. Aspirin treatment antagonized vascular stiffening and rivaroxaban treatment led to a positive trend towards reduced stiffening. Local intima-media thickening was antagonized by both aspirin or rivaroxaban treatment. Platelet-leukocyte aggregates and the number of platelets per leukocyte were reduced in aspirin and/or rivaroxaban treatment groups. Furthermore, rivaroxaban restricted thrombus growth and height in vitro. In sum, this study shows vascular protective effects of aspirin and rivaroxaban, upon vascular injury of the mouse artery.
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Affiliation(s)
- T G Mastenbroek
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Complex Tissue Regeneration, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht, The Netherlands
| | - M F A Karel
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - W Chayoua
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Synapse Research Institute, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - E I J Korsten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - D M Coenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Debets
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Konings
- Synapse Research Institute, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A E Brouns
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - P J A Leenders
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H van Essen
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S Heitmeier
- Cardiovascular Research Institute, Bayer AG, Wuppertal, Germany
| | - H M Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M J E Kuijpers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J M E M Cosemans
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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ABCA1 Polymorphism Is Associated With the Warfarin-Induced Aortic Stiffness After Coronary Artery Bypass Surgery in the Chinese Population. J Cardiovasc Pharmacol 2020; 76:360-366. [PMID: 32902944 DOI: 10.1097/fjc.0000000000000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Warfarin is the most widely prescribed oral anticoagulant and is recommended for patients recovering from coronary artery bypass graft (CABG) with atrial fibrillation. Increasing evidence suggested that warfarin increased arterial stiffness in those patients. We aimed to examine the effect of warfarin therapy on aortic stiffness in patients who underwent CABG with or without postoperative warfarin treatment and explored the potential relationships of warfarin therapy with ABCA1 polymorphisms. This was a retrospect observational study of 24 patients who were continuously treated with warfarin were selected as the warfarin group and matched them by age (±3 years) and gender to 48 patients with nonuse of warfarin as the control group. The aortic stiffness, cholesterol efflux capacity, and plasma level of PIVKA-II were measured. Two ABCA1 polymorphisms were genotyped. Compared with baseline, treatment with warfarin for 1 year significantly increased the plasma level of PIVKA-II and aortic stiffness in pulse pressure and pulse wave velocity in patients after CABG. The increase of pulse wave velocity and plasma PIVKA-II level in the TT genotype was significantly greater than the CC genotype when comparing the -565C/T genotypes. The capacity of cholesterol efflux was significantly lower in the TT genotype at baseline and 1-year follow-up than the CC genotype. Postoperative treatment of warfarin for 1 year significantly increased aortic stiffness in patients who underwent CABG. ABCA1 -565C/T polymorphisms affected the cholesterol efflux capacity and were associated with the vitamin K status and the increased aortic stiffness after warfarin treatment in those patients.
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The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock. ACTA ACUST UNITED AC 2020; 6:152-158. [PMID: 32864460 PMCID: PMC7430353 DOI: 10.2478/jccm-2020-0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 04/23/2020] [Indexed: 11/20/2022]
Abstract
Introduction Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool. Material and methods The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality. Results The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student's t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml. Conclusions VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.
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Lau WCY, Cheung CL, Man KKC, Chan EW, Sing CW, Lip GYH, Siu CW, Lam JKY, Lee ACH, Wong ICK. Association Between Treatment With Apixaban, Dabigatran, Rivaroxaban, or Warfarin and Risk for Osteoporotic Fractures Among Patients With Atrial Fibrillation: A Population-Based Cohort Study. Ann Intern Med 2020; 173:1-9. [PMID: 32423351 DOI: 10.7326/m19-3671] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is unclear whether anticoagulant type is associated with the risk for osteoporotic fracture, a deleterious complication of anticoagulants among patients with atrial fibrillation (AF). OBJECTIVE To compare the risk for osteoporotic fracture between anticoagulants. DESIGN Population-based cohort study. SETTING Territory-wide electronic health record database of the Hong Kong Hospital Authority. PARTICIPANTS Patients newly diagnosed with AF between 2010 and 2017 who received a new prescription for warfarin or a direct oral anticoagulant (DOAC) (apixaban, dabigatran, or rivaroxaban). Follow-up ended on 31 December 2018. MEASUREMENTS Osteoporotic hip and vertebral fractures in anticoagulant users were compared using propensity score-weighted cumulative incidence differences (CIDs). RESULTS There were 23 515 patients identified (3241 apixaban users, 6867 dabigatran users, 3866 rivaroxaban users, and 9541 warfarin users). Overall mean age was 74.4 years (SD, 10.8), ranging from 73.1 years (warfarin) to 77.9 years (apixaban). Over a median follow-up of 423 days, 401 fractures were identified (crude event number [weighted rate per 100 patient-years]: apixaban, 53 [0.82]; dabigatran, 95 [0.76]; rivaroxaban, 57 [0.67]; and warfarin, 196 [1.11]). After 24-month follow-up, DOAC use was associated with a lower risk for fracture than warfarin use (apixaban CID, -0.88% [95% CI, -1.66% to -0.21%]; dabigatran CID, -0.81% [CI, -1.34% to -0.23%]; and rivaroxaban CID, -1.13% [CI, -1.67% to -0.53%]). No differences were seen in all head-to-head comparisons between DOACs at 24 months (apixaban vs. dabigatran CID, -0.06% [CI, -0.69% to 0.49%]; rivaroxaban vs. dabigatran CID, -0.32% [CI, -0.84% to 0.18%]; and rivaroxaban vs. apixaban CID, -0.25% [CI, -0.86% to 0.40%]). LIMITATION Residual confounding is possible. CONCLUSION Among patients with AF, DOAC use may result in a lower risk for osteoporotic fracture compared with warfarin use. Fracture risk does not seem to be altered by the choice of DOAC. These findings may help inform the benefit-risk assessment when choosing between anticoagulants. PRIMARY FUNDING SOURCE The University of Hong Kong and University College London Strategic Partnership Fund.
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Affiliation(s)
- Wallis C Y Lau
- UCL School of Pharmacy, London, United Kingdom, and Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (W.C.L., K.K.M.)
| | - Ching-Lung Cheung
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Kenneth K C Man
- UCL School of Pharmacy, London, United Kingdom, and Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (W.C.L., K.K.M.)
| | - Esther W Chan
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Chor Wing Sing
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Chung-Wah Siu
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (C.S.)
| | - Joanne K Y Lam
- Osteoporosis Centre, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (J.K.L., A.C.L.)
| | - Alan C H Lee
- Osteoporosis Centre, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (J.K.L., A.C.L.)
| | - Ian C K Wong
- UCL School of Pharmacy, London, United Kingdom, Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, and The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, China (I.C.W.)
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Ostroumova OD, Goloborodova IV. Clinical and Pathophysiological Aspects of the Effect of Anticoagulants on Bone Tissue. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-06-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- O. D. Ostroumova
- Russian Medical Academy of Continuous Professional Education; I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Correale M, Leopizzi A, Mallardi A, Ranieri A, Suriano MP, D'Alessandro D, Tricarico L, Mazzeo P, Tucci S, Pastore G, Maulucci G, Di Biase M, Brunetti ND. Switch to direct anticoagulants and improved endothelial function in patients with chronic heart failure and atrial fibrillation. Thromb Res 2020; 195:16-20. [PMID: 32634728 DOI: 10.1016/j.thromres.2020.06.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/07/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic heart failure (CHF) is characterized by higher rates of atrial fibrillation (AF) and endothelial dysfunction (ED). First line anticoagulant therapy in AF is represented by direct oral anticoagulants (DOACs); several patients, however, are still treated with vitamin-K inhibitors. The use of DOACs is associated in previous studies with an improved vascular function. We therefore sought to evaluate possible changes in endothelial function assessed by flow-mediated dilation (FMD) in patients with CHF and AF shifting from warfarin to DOACs. METHODS Forty-three consecutive outpatients were enrolled in the study. FMD was assessed at baseline and after 4 months. Patients were compared according to AC therapy. RESULTS After the first measurement of FMD, 18 patients "switched" to DOACs because of poor compliance to warfarin therapy or time in therapeutic range, 19 patients continued to use DOACs, 6 warfarin. "Switched" patients to DOACs therapy showed an improved FMD (19.0 ± 6.6% vs 3.8 ± 1.3%, p < 0.0001); C-reactive protein (CRP) levels decreased in "switched" patients from 1.4 ± 0.5 to 1.0 ± 0.7 mg/dl (p < 0.05). FMD and CRP changes were not significant in patients who did not changed anticoagulant therapy. In switched patients, changes in CRP levels were proportional to FMD changes (r = -0.50, p < 0.05). Shifting from warfarin to DOACs was significantly correlated to improved FMD levels even at multivariable analysis (p < 0.05). CONCLUSIONS Switch from warfarin to DOACs in patents with CHF and AF was associated in an observational non randomized study with an improved endothelial function. Changes in FMD values were related to changes in CRP levels.
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Affiliation(s)
- Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Alessandra Leopizzi
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Adriana Mallardi
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Alessandro Ranieri
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Miriam Pia Suriano
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Damiano D'Alessandro
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Pietro Mazzeo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Salvatore Tucci
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giuseppe Pastore
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.
| | - Guglielmo Maulucci
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Matteo Di Biase
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Switching from Warfarin to rivaroxaban induces sufficiency of vitamin K and reduction of arterial stiffness in patients with atrial fibrillation. Heart Vessels 2020; 35:1727-1733. [DOI: 10.1007/s00380-020-01651-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/17/2020] [Indexed: 12/22/2022]
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Osteoporotic Fractures in Patients With Atrial Fibrillation Treated With Conventional Versus Direct Anticoagulants. J Am Coll Cardiol 2020; 74:2150-2158. [PMID: 31648707 DOI: 10.1016/j.jacc.2019.08.1025] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Elderly patients in long-term treatment with vitamin K antagonists (VKAs) are at high risk of osteoporotic fractures compared with the background population. It has been speculated that the choice of oral anticoagulant (OAC) may affect the risk of osteoporotic fractures. OBJECTIVES The risk of osteoporotic fractures was evaluated among patients with atrial fibrillation treated with VKA or direct oral anticoagulants (DOACs). METHODS Patients were identified using the Danish national registries. Patients were included only if they had no prior use of osteoporosis medication and they had undergone 180 days of OAC treatment. Outcomes were hip fracture, major osteoporotic fracture, any fracture, initiation of osteoporosis medication, and a combined endpoint. RESULTS Overall, 37,350 patients were included. The standardized absolute 2-year risk of any fracture was low among DOAC-treated patients (3.1%; 95% CI: 2.9% to 3.3%) and among VKA-treated patients (3.8%; 95% CI: 3.4% to 4.2%). DOAC was associated with a significantly lower relative risk of any fracture (hazard ratio [HR]: 0.85; 95% CI: 0.74 to 0.97), major osteoporotic fractures (HR: 0.85; 95% CI: 0.72 to 0.99), and initiating osteoporotic medication (HR: 0.82; 95% CI: 0.71 to 0.95). A combined endpoint showed that patients treated with DOAC had a significantly lower relative risk of experiencing any fracture or initiating osteoporosis medication (HR: 0.84; 95% CI: 0.76 to 0.93). CONCLUSIONS In a nationwide population, the absolute risk of osteoporotic fractures was low among patients with atrial fibrillation on OAC, but DOAC was associated with a significantly lower risk of osteoporotic fractures compared with VKA.
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Akhtar T, Hajra A, Bhyan P, Ghosh RK, Bandyopadhyay D, Aronow WS. Association between direct-acting oral anticoagulants vs. warfarin with the risk of osteoporosis in patients with non-valvular atrial fibrillation. IJC HEART & VASCULATURE 2020; 27:100484. [PMID: 32309531 PMCID: PMC7154295 DOI: 10.1016/j.ijcha.2020.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 11/17/2022]
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Al-Suhaimi EA, Al-Jafary MA. Endocrine roles of vitamin K-dependent- osteocalcin in the relation between bone metabolism and metabolic disorders. Rev Endocr Metab Disord 2020; 21:117-125. [PMID: 31761961 DOI: 10.1007/s11154-019-09517-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Obesity and diabetes are important metabolic diseases and a major public health problem among the world, they have serious health and economic complications. Overweight and obesity are increased risk for deficiency of vitamin particularly shortage of fat soluble-vitamins. Studies reported that vitamin K supplementation reduces oxidative stress and metabolic risk biomarkers for diabetes, as well as reduces progression of insulin resistance. Vitamin K-dependent-protein osteocalcin (bone derived hormone) plays crucial roles in energy metabolism. There is a clear association between circulating vitamin k and dependent-osteocalcin concentrations with obesity and risk of Type 2 diabetes. Osteocalcin through molecular mechanisms improves insulin resistance, lipid and glucose profile, and mediate vitamin K positive effects. Insulin also signals osteocalcin to regulate bone mineralization. Normal carboxylation of vitamin K-dependent proteins/ hormones is a key step in preventing apoptosis and calcification of vascular endothelial cells. A missing relationship between bone, glucose and fat metabolism could clarify and manage many metabolic mechanisms. This review focuses on the physiological relationship between vitamin K-dependent-osteocalcin, metabolic and cardiovascular diseases through some molecular proteins and hormones including adipokines. A better understanding of the mechanism of action of osteocalcin modulated by vitamin K could help in implementing therapeutic drugs to cure metabolic diseases.
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Affiliation(s)
- Ebtesam Abdullah Al-Suhaimi
- Department of Biology, College of Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
- Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Meneerah Abdulrahman Al-Jafary
- Department of Biology, College of Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Millenaar D, Bachmann P, Böhm M, Custodis F, Schirmer SH. Effects of edoxaban and warfarin on vascular remodeling: Atherosclerotic plaque progression and collateral artery growth. Vascul Pharmacol 2020; 127:106661. [PMID: 32081687 DOI: 10.1016/j.vph.2020.106661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/09/2020] [Accepted: 02/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulation prevents thromboembolism in atrial fibrillation. Factor Xa inhibitors, like edoxaban, are known to reduce inflammation and proliferation of smooth muscle cells, while vitamin K antagonism can cause vascular calcific damage. The influence of edoxaban compared to warfarin on vascular remodeling, atherosclerosis and arteriogenesis is unknown. EXPERIMENTAL APPROACH Apolipoprotein E knockout (ApoE -/-) mice were fed cholesterol-rich diet alone (control, co), with warfarin+vitamin K1 (warf) or with edoxaban (Edo) for 8 weeks. After 6 weeks, femoral artery ligation was performed. KEY RESULTS There was no difference in hind-limb perfusion restoration between the three groups after 14 days (Co 0.36 ± 0.05 vs. Warf 0.39 ± 0.09 (p = .39), Co vs. Edo 0.51 ± 0.06 (p = .089), Warf vs. Edo (p = .83)) after ligation. Immuno-histologically, there was no difference in smooth muscle cell count in both hindlimbs between the three groups or in the amount of perivascular macrophages in collateral-bearing hindlimb tissue. Edoxaban showed the lowest amount of plaque tissue in the aortic sinus tissue (Co 74 ± 11% vs. Edo 62 ± 12% (p = .024), Co vs. Warf 69 ± 14% (p = .30), Edo vs. Warf (p = .14)) as well as the least amount of fibrosis (Co 3.1 ± 0.9% vs. Edo 1.7 ± 0.6% (p = .027), Co vs. Warf 4.1 ± 0.7% (p = .081), Edo vs. Warf (p < .001)). No difference in mRNA content of inflammatory cytokines in muscle tissue or spleen was detected between the three groups. CONCLUSION AND IMPLICATIONS These data suggest that treatment with edoxaban unlike warfarin prevents vascular maladaptive remodeling, which may be clinically important.
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Affiliation(s)
- Dominic Millenaar
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Saar, Germany.
| | - Philipp Bachmann
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Saar, Germany
| | - Florian Custodis
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Saar, Germany
| | - Stephan H Schirmer
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Saar, Germany
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Lutsey PL, Norby FL, Ensrud KE, MacLehose RF, Diem SJ, Chen LY, Alonso A. Association of Anticoagulant Therapy With Risk of Fracture Among Patients With Atrial Fibrillation. JAMA Intern Med 2020; 180:245-253. [PMID: 31764956 PMCID: PMC6902159 DOI: 10.1001/jamainternmed.2019.5679] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Warfarin is prescribed to patients with atrial fibrillation (AF) for the prevention of cardioembolic complications. Whether warfarin adversely affects bone health is controversial. The availability of alternate direct oral anticoagulant (DOAC) options now make it possible to evaluate the comparative safety of warfarin in association with fracture risk. OBJECTIVE To test the hypothesis that, among patients with nonvalvular AF, use of DOACs vs warfarin is associated with lower risk of incident fracture. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness cohort study used the MarketScan administrative claims databases to identify patients with nonvalvular AF and who were prescribed oral anticoagulants from January 1, 2010, through September 30, 2015. To reduce confounding, patients were matched on age, sex, CHA2DS2-VASc (congestive heart failure, hypertension, age [>65 years = 1 point; >75 years = 2 points], diabetes, and previous stroke/transient ischemic attack [2 points], vascular disease) score, and high-dimensional propensity scores. The final analysis included 167 275 patients with AF. Data were analyzed from February 27, 2019 to September 18, 2019. EXPOSURES Warfarin and DOACs (dabigatran etexilate, rivaroxaban, and apixaban). MAIN OUTCOMES AND MEASURES Incident hip fracture, fracture requiring hospitalization, and all clinical fractures (identified using inpatient or outpatient claims) defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS In the study population of 167 275 patients with AF (38.0% women and 62.0% men; mean [SD] age, 68.9 [12.5] years), a total of 817 hip fractures, 2013 hospitalized fractures, and 7294 total fractures occurred during a mean (SD) follow-up of 16.9 (13.7) months. In multivariable-adjusted, propensity score-matched Cox proportional hazards regression models, relative to new users of warfarin, new users of DOACs tended to be at lower risk of fractures requiring hospitalization (hazard ratio [HR], 0.87; 95% CI, 0.79-0.96) and all clinical fractures (HR, 0.93; 95% CI, 0.88-0.98), whereas the association with hip fractures (HR, 0.91; 95% CI, 0.78-1.07) was not statistically significant. When comparing individual DOACs with warfarin, the strongest findings were for apixaban (HR for hip fracture, 0.67 [95% CI, 0.45-0.98]; HR for fractures requiring hospitalization, 0.60 [95% CI, 0.47-0.78]; and HR for all clinical fractures, 0.86 [95% CI, 0.75-0.98]). In subgroup analyses, DOACs appeared more beneficial among patients with AF who also had a diagnosis of osteoporosis than among those without a diagnosis of osteoporosis. CONCLUSIONS AND RELEVANCE In this real-world population of 167 275 patients with AF, use of DOACs-particularly apixaban-compared with warfarin use was associated with lower fracture risk. These associations were more pronounced among patients with a diagnosis of osteoporosis. Given the potential adverse effects of warfarin on bone health, these findings suggest that caution should be used when prescribing warfarin to patients with AF at high risk of fracture.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Faye L Norby
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Kristine E Ensrud
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis.,Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Susan J Diem
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Lin Y Chen
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Alvaro Alonso
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
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Yokoyama S, Ieda S, Nagano M, Nakagawa C, Iwase M, Hosomi K, Takada M. Association between oral anticoagulants and osteoporosis: Real-world data mining using a multi-methodological approach. Int J Med Sci 2020; 17:471-479. [PMID: 32174777 PMCID: PMC7053309 DOI: 10.7150/ijms.39523] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/08/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction: Warfarin and direct oral anticoagulants (DOACs) have been widely used in antithrombotic therapy. Although warfarin use has been suspected to be associated with osteoporosis risk, several studies have shown otherwise. Conversely, a few reports have found an association between DOACs and osteoporosis. This study therefore clarifies the association between oral anticoagulants and osteoporosis by analyzing real-world data using different methodologies, algorithms, and databases. Methods: Real-world data from the US Food and Drug Administration Adverse Event Reporting System (FAERS; 2004-2016) and Japanese administrative claims database (2005-2017; JMDC Inc., Tokyo) were used. Reporting odds ratio (ROR) and information component (IC) were calculated through disproportionality analysis (DPA) using reports recorded in the FAERS. Sequence symmetry analysis (SSA) was employed to calculate the adjusted sequence ratio (SR) using the JMDC Claims Database. For the adjusted SR and ROR, a significant signal was detected when the lower limit of the two-sided 95% confidence interval (CI) was more than 1. For the IC, a significant signal was detected when the lower limit of the 95% CI was more than 0. Results: DPA for warfarin found significant signals for osteoporosis in ROR (1.43, 95% CI: 1.32-1.54) and IC (0.50, 95% CI: 0.39-0.61). SSA showed a significant association between warfarin use and osteoporosis or bisphosphonate use. Moreover, a significant association was observed in males and females, albeit only for warfarin. Conclusion: Multi-methodological data mining revealed that warfarin use, not DOACs, is significantly associated with osteoporosis regardless of sex difference.
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Affiliation(s)
- Satoshi Yokoyama
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
| | - Shoko Ieda
- Department of Pharmacy, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Mirai Nagano
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
| | - Chihiro Nakagawa
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
| | - Makoto Iwase
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-osaka, Osaka 577-8502, Japan
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30
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Abstract
Drugs may cause bone loss by lowering sex steroid levels (e.g., aromatase inhibitors in breast cancer, GnRH agonists in prostate cancer, or depot medroxyprogestone acetate - DMPA), interfere with vitamin D levels (liver inducing anti-epileptic drugs), or directly by toxic effects on bone cells (chemotherapy, phenytoin, or thiazolidinedions, which diverts mesenchymal stem cells from forming osteoblasts to forming adipocytes). However, besides effects on the mineralized matrix, interactions with collagen and other parts of the unmineralized matrix may decrease bone biomechanical competence in a manner that may not correlate with bone mineral density (BMD) measured by dual energy absorptiometry (DXA).Some drugs and drug classes may decrease BMD like the thiazolidinediones and consequently increase fracture risk. Other drugs such as glucocorticoids may decrease BMD, and thus increase fracture risk. However, glucocorticoids may also interfere with the unmineralized matrix leading to an increase in fracture risk, not mirrored in BMD changes. Some drugs such as selective serotonin reuptake inhibitors (SSRI), paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) may not per se be associated with bone loss, but fracture risk may be increased, possibly stemming from an increased risk of falls stemming from effects on postural balance mediated by effects on the central nervous system or cardiovascular system.This paper performs a systematic review of drugs inducing bone loss or associated with fracture risk. The chapter is organized by the Anatomical Therapeutic Chemical (ATC) classification.
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Affiliation(s)
- Peter Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
- Steno Diabetes Center North Jutland, Aalborg, Denmark.
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31
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Relationship of Anticoagulant Therapies on Coronary Plaque Progression. JACC Cardiovasc Imaging 2020; 13:169-170. [DOI: 10.1016/j.jcmg.2019.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/10/2019] [Accepted: 07/28/2019] [Indexed: 11/18/2022]
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32
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Signorelli SS, Scuto S, Marino E, Giusti M, Xourafa A, Gaudio A. Anticoagulants and Osteoporosis. Int J Mol Sci 2019; 20:ijms20215275. [PMID: 31652944 PMCID: PMC6862478 DOI: 10.3390/ijms20215275] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 12/20/2022] Open
Abstract
Anticoagulant agents are widely used in the treatment of thromboembolic events and in stroke prevention. Data about their effects on bone tissue are in some cases limited or inconsistent (oral anti-vitamin K agents), and in others are sufficiently strong (heparins) to suggest caution in their use in subjects at risk of osteoporosis. This review analyses the effects of this group of drugs on bone metabolism, on bone mineral density, and on fragility fractures. A literature search strategy was developed by an experienced team of specialists by consulting the MEDLINE platform, including published papers and reviews updated to March 2019. Literature supports a detrimental effect of heparin on bone, with an increase in fracture rate. Low molecular weight heparins (LMWHs) seem to be safer than heparin. Although anti-vitamin K agents (VKAs) have a significant impact on bone metabolism, and in particular, on osteocalcin, data on bone mineral density (BMD) and fractures are contrasting. To date, the new direct oral anticoagulants (DOACs) are found to safe for bone health.
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Affiliation(s)
| | - Salvatore Scuto
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Elisa Marino
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Michele Giusti
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Anastasia Xourafa
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy.
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Dadwal G, Schulte-Huxel T, Kolb G. Effect of antithrombotic drugs on bone health. Z Gerontol Geriatr 2019; 53:457-462. [PMID: 31414167 DOI: 10.1007/s00391-019-01590-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
With the increasing consumption of antithrombotic drugs among old people, expected as well as unexpected side effects on bone health are considerable, e.g. osteoporosis, fragility fractures, etc. This review focuses on antithrombotic drugs and their effects on bone health. The following groups were reviewed: parenteral long-term use of unfractionated heparin (UFH) is associated with osteopenia. The oral intake of vitamin K antagonists (VKA) makes them more convenient than UFH but chronic use also results in osteopenia. Limited reports of bone loss have been associated with low molecular weight heparins (LMWH) and indirect factor Xa inhibitors but in contrast to VKA and UFH they are less associated with osteopenia. There have been limited studies evaluating the effect of new oral anticoagulants (NOACs) on bones. Overall, they are considered safer than other drugs. There have been no reports about acetylsalicylic acid (ASA) and clopidogrel causing osteopenia but their metabolism by the kidneys and liver can cause reduced 25-hydroxy-vitamin D levels and can theoretically contribute to osteoporosis. Some reports suggested that high dosage clopidogrel can also negatively affect bones. After a detailed literature review long-term use of antithrombotic drugs can negatively affect the bones. Their role in bone health needs to be studied in detail and the clinical use in geriatric patients should be prudent.
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Affiliation(s)
- G Dadwal
- Department of Traumatology, Bonifatius Hospital Lingen, Wilhelmstraße 13, 49808, Lingen (Ems), Germany.
| | - T Schulte-Huxel
- Department of Traumatology, Bonifatius Hospital Lingen, Wilhelmstraße 13, 49808, Lingen (Ems), Germany
| | - G Kolb
- Department of Geriatrics and Physical Rehabilitation, Clinic of Internal Medicine, Bonifatius Hospital Lingen, Wilhelmstraße 13, 49808, Lingen (Ems), Germany
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Sanmartín M, Bellmunt S, Cosín-Sales J, García-Moll X, Riera-Mestre A, Almendro-Delia M, Hernández JL, Lozano F, Mazón P, Suarez Fernández C. Role of rivaroxaban in the prevention of atherosclerotic events. Expert Rev Clin Pharmacol 2019; 12:771-780. [DOI: 10.1080/17512433.2019.1637732] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Sergi Bellmunt
- Vascular Surgery Department, Hospital General Vall d´Hebron, Barcelona, Spain
| | - Juan Cosín-Sales
- Cardiology Department, Hospital Arnau de Vilanova, Valencia, Spain
| | | | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | | | - José Luis Hernández
- Internal Medicine Department, Hospital Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Francisco Lozano
- Department of Surgery, Hospital Clinico de Salamanca, Salamanca, Spain
| | - Pilar Mazón
- Cardiology Department, Hospital Clinico Universitario de Santiago de Compostela, CIBERCV, Santiago de Compostela, Spain
| | - Carmen Suarez Fernández
- Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Effects of Oral Anticoagulant Therapy on Gene Expression in Crosstalk between Osteogenic Progenitor Cells and Endothelial Cells. J Clin Med 2019; 8:jcm8030329. [PMID: 30857168 PMCID: PMC6462930 DOI: 10.3390/jcm8030329] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/31/2022] Open
Abstract
Direct oral anti-coagulants (DOACs) are employed in clinical practice for the prevention and treatment of recurrent venous thromboembolism and for the prevention of stroke in non-valvular atrial fibrillation. DOACs directly and reversibly inhibit activated factor X or thrombin and can interfere with other pathophysiological processes such as inflammation, lipid metabolism, and bone turnover. We aimed to evaluate the possible effects of DOACs on osteogenesis and angiogenesis. We treated 34 patients affected by cardiovascular disorders with DOACs; biochemical and molecular analyses were performed before and after three months of treatment. Circulating progenitors (CPs; CD34−, CD45−, CD14−, CD73+, CD105+), which share typical bone marrow stem cell (MSCs) features, were harvested from peripheral blood of the study subjects to monitor the expression of osteogenesis-related genes RUNX2 and SPARC. Human umbilical vein endothelial cells (HUVECs) were used to probe angiogenesis-related VEGF, CD31, and CD105 gene expression. We performed co-culture experiments using a commercial human mesenchymal stem cells line (hMSCs) obtained from bone marrow and HUVECs. Clinical parameters related to bone metabolism, coagulation, renal and liver function, and the lipid profile were evaluated. Values of the C-terminal telopeptide type I collagen (CTX) increased after the treatment. We found a significant increase in osteogenesis marker gene expression in CPs after three months of anticoagulant therapy. An increase in the RUNX2 expression determinant alone was detected instead in hMSCs co-cultured with HUVECs in the presence of treated patients’ sera. The VEGF, CD31, and CD105 marker genes appeared to be significantly upregulated in HUVECs co-cultured with hMSCs in the presence of treated patients’ sera. Under these conditions, new vessel formation increased as well. Our results highlight an unexpected influence of DOAC therapy on osteogenic commitment and vascular endothelial function promotion.
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Reesink KD, Spronck B. Constitutive interpretation of arterial stiffness in clinical studies: a methodological review. Am J Physiol Heart Circ Physiol 2019; 316:H693-H709. [DOI: 10.1152/ajpheart.00388.2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Clinical assessment of arterial stiffness relies on noninvasive measurements of regional pulse wave velocity or local distensibility. However, arterial stiffness measures do not discriminate underlying changes in arterial wall constituent properties (e.g., in collagen, elastin, or smooth muscle), which is highly relevant for development and monitoring of treatment. In arterial stiffness in recent clinical-epidemiological studies, we systematically review clinical-epidemiological studies (2012–) that interpreted arterial stiffness changes in terms of changes in arterial wall constituent properties (63 studies included of 514 studies found). Most studies that did so were association studies (52 of 63 studies) providing limited causal evidence. Intervention studies (11 of 63 studies) addressed changes in arterial stiffness through the modulation of extracellular matrix integrity (5 of 11 studies) or smooth muscle tone (6 of 11 studies). A handful of studies (3 of 63 studies) used mathematical modeling to discriminate between extracellular matrix components. Overall, there exists a notable gap in the mechanistic interpretation of stiffness findings. In constitutive model-based interpretation, we first introduce constitutive-based modeling and use it to illustrate the relationship between constituent properties and stiffness measurements (“forward” approach). We then review all literature on modeling approaches for the constitutive interpretation of clinical arterial stiffness data (“inverse” approach), which are aimed at estimation of constitutive properties from arterial stiffness measurements to benefit treatment development and monitoring. Importantly, any modeling approach requires a tradeoff between model complexity and measurable data. Therefore, the feasibility of changing in vivo the biaxial mechanics and/or vascular smooth muscle tone should be explored. The effectiveness of modeling approaches should be confirmed using uncertainty quantification and sensitivity analysis. Taken together, constitutive modeling can significantly improve clinical interpretation of arterial stiffness findings.
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Affiliation(s)
- Koen D. Reesink
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Bart Spronck
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, Connecticut
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Brichacek AL, Brown CM. Alkaline phosphatase: a potential biomarker for stroke and implications for treatment. Metab Brain Dis 2019; 34:3-19. [PMID: 30284677 PMCID: PMC6351214 DOI: 10.1007/s11011-018-0322-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/24/2018] [Indexed: 12/14/2022]
Abstract
Stroke is the fifth leading cause of death in the U.S., with more than 100,000 deaths annually. There are a multitude of risks associated with stroke, including aging, cardiovascular disease, hypertension, Alzheimer's disease (AD), and immune suppression. One of the many challenges, which has so far proven to be unsuccessful, is the identification of a cost-effective diagnostic or prognostic biomarker for stroke. Alkaline phosphatase (AP), an enzyme first discovered in the 1920s, has been evaluated as a potential biomarker in many disorders, including many of the co-morbidities associated with stroke. This review will examine the basic biology of AP, and its most common isoenzyme, tissue nonspecific alkaline phosphatase (TNAP), with a specific focus on the central nervous system. It examines the preclinical and clinical evidence which supports a potential role for AP in stroke and suggests potential mechanism(s) of action for AP isoenzymes in stroke. Lastly, the review speculates on the clinical utility of AP isoenzymes as potential blood biomarkers for stroke or as AP-targeted treatments for stroke patients.
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Affiliation(s)
- Allison L Brichacek
- Department of Microbiology, Immunology, and Cell Biology, Center for Basic and Translational Stroke Research, WVU Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Box 9177, Morgantown, WV, 26506, USA
- Department of Neuroscience, Emergency Medicine, and Microbiology, Immunology and Cell Biology, Center for Basic and Translational Stroke Research, WVU Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Box 9303, Morgantown, WV, 26506, USA
| | - Candice M Brown
- Department of Microbiology, Immunology, and Cell Biology, Center for Basic and Translational Stroke Research, WVU Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Box 9177, Morgantown, WV, 26506, USA.
- Department of Neuroscience, Emergency Medicine, and Microbiology, Immunology and Cell Biology, Center for Basic and Translational Stroke Research, WVU Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Box 9303, Morgantown, WV, 26506, USA.
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Lee J, Nakanishi R, Li D, Shaikh K, Shekar C, Osawa K, Nezarat N, Jayawardena E, Blanco M, Chen M, Sieckert M, Nelson E, Billingsley D, Hamal S, Budoff MJ. Randomized trial of rivaroxaban versus warfarin in the evaluation of progression of coronary atherosclerosis. Am Heart J 2018; 206:127-130. [PMID: 30227941 DOI: 10.1016/j.ahj.2018.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 08/14/2018] [Indexed: 12/12/2022]
Abstract
Warfarin, a vitamin K antagonist, is associated with systemic vascular calcification. We evaluated whether rivaroxaban (a direct oral factor Xa inhibitor with no interaction with vitamin K) will slow the progression in coronary plaque volumes compared with warfarin in patients with nonvalvular atrial fibrillation using coronary computed tomography angiography.
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Guerriero F, Orlando V, Monetti VM, Colaccio FM, Sessa M, Scavone C, Capuano A, Menditto E. Predictors of new oral anticoagulant drug initiation as opposed to warfarin in elderly adults: a retrospective observational study in Southern Italy. Ther Clin Risk Manag 2018; 14:1907-1914. [PMID: 30349269 PMCID: PMC6183659 DOI: 10.2147/tcrm.s171346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM The aim of this study was to assess the predictive role of age, gender, and number and type of co-treatments for new oral anticoagulant (NOAC) vs warfarin prescription in elderly patients naïve for the aforementioned drugs. MATERIALS AND METHODS Data collected in the period from January 1, 2014, to December 31, 2014, in Caserta Local Health Unit administrative databases (Campania Region, Italy) were screened to identify new users of oral anticoagulants (OACs) who were 75 years or older and whose OAC prescriptions amounted to >90 days of treatment. Age, gender, and number and type of concomitant medications at the time of first OAC dispensation were retrieved. Multivariable logistic regression analysis was used to assess the role of the aforementioned predictors for NOAC initiation as opposed to warfarin. RESULTS Overall, 2,132 incident users of OAC were identified, of whom 967 met all inclusion criteria. In all, 490 subjects (50.7%) received an NOAC and 477 (49.3%) received warfarin. Age >75 years was positively associated with lower odds of NOAC initiation (OR: 0.969, 95% CI: 0.941-0.998, P=0.038). Similarly, multiple concomitant medication was negatively associated with NOAC initiation compared to warfarin (OR [five to nine drugs] group: 0.607, 95% CI: 0.432-0.852, P=0.004; OR [ten+ drugs] group: 0.372, 95% CI: 0.244-0.567, P<0.001). Prior exposure to platelet aggregation inhibitor drugs was associated with the initiation of NOACs (OR: 3.474, 95% CI: 2.610-4.625). CONCLUSION Age and multiple co-medication were negatively associated with NOAC initiation.
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Affiliation(s)
- Francesca Guerriero
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
| | - Valentina Orlando
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
| | | | | | - Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, DK, Denmark
| | - Cristina Scavone
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
| | - Enrica Menditto
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
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Barrios V, Almendro-Delia M, Facila L, Garcia-Moll X, Mazón P, Camafort M, Cepeda JM, Mediavilla Garcia JD, Pose Reino A, Suarez Fernandez C. Rivaroxaban: searching the integral vascular protection. Expert Rev Clin Pharmacol 2018; 11:719-728. [PMID: 29965791 DOI: 10.1080/17512433.2018.1495559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Residual cardiovascular risk remains high in patients with atherosclerotic cardiovascular disease despite current antithrombotic therapy. On the other hand, patients with atrial fibrillation have an increased risk of myocardial infarction and cardiovascular death. As a result, a new antithrombotic approach appears necessary to reduce this risk. Areas covered: In this article, the role of rivaroxaban on vascular protection in patients with cardiovascular disease and/or atrial fibrillation was reviewed, with a particular focus, but not limited, on clinical trials. Expert commentary: Previous data have shown that factor Xa plays a key role in the etiopathogenesis of atherothrombosis. Experimental data suggest that rivaroxaban exhibits antiinflammatory and antioxidative stress properties, and may improve endothelial dysfunction. The COMPASS trial showed that among patients with stable atherosclerotic vascular disease, the addition of rivaroxaban 2.5 mg twice daily (vascular dose) to aspirin provided a higher cardiovascular protection than aspirin alone. In ROCKET-AF trial, compared with warfarin, rivaroxaban 20 mg once daily (15 mg if moderate renal dysfunction) (anticoagulant dose) was, at least, as effective as warfarin for the prevention of stroke or systemic embolism among patients with nonvalvular atrial fibrillation, with a trend toward a reduction in the risk of cardiovascular outcomes. All these data suggest that rivaroxaban might have a vascular protective effect beyond its stroke/systemic embolism preventive activity.
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Affiliation(s)
- Vivencio Barrios
- a Cardiology Department , Hospital Ramón y Cajal , Madrid , Spain
| | | | - Lorenzo Facila
- c Cardiology Department , Consorcio Hospital General Universitario de Valencia , Valencia , Spain
| | | | - Pilar Mazón
- e Cardiology Department , Hospital Clinico Universitario de Santiago de Compostela. CIBERCV , Spain
| | - Miguel Camafort
- f Internal Medicine Department , Atrial fibrillation Unit UFA Hospital Clinic, Universitat de Barcelona , Barcelona , Spain
| | - José María Cepeda
- g Internal Medicine Department , Hospital Vega Baja , Alicante , Spain
| | | | - Antonio Pose Reino
- i Internal Medicine Department , Complexo Hospitalario Universitario de Santiago , Santiago , Spain
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Abstract
OBJECTIVE Vitamin K antagonists (VKA) are associated with increased vascular calcification which may lead to an elevated cardiovascular risk. If the direct anticoagulants (DOACs) have similar negative vascular effects is unknown. We evaluated the influence of different anticoagulation strategies on coronary artery disease (CAD) using coronary computed tomography angiography (CTA). METHODS Overall 702 consecutive patients with non-valvular atrial fibrillation (AF) who underwent CTA for AF ablation planning were enrolled and stratified according to their anticoagulation into VKA, DOAC (all agents) and a control group without oral anticoagulation. Patients were propensity score matched 1:1:1, significant structural heart disease and comorbidities were excluded. CT images were evaluated for plaque burden (calcium score, segment involvement score (SIS) and non-calcified SIS, stenosis grading) and plaque morphology (high risk plaque features: low attenuation, positive remodeling, napkin-ring sign, spotty calcification). RESULTS Final analysis included 303 patients (101 patients each group) and showed increased overall plaque burden in patients using VKA compared to DOAC users and the control group (mean affected segments 2.58 vs 1.58 vs 2.100, p = 0.008), and a higher prevalence of high-risk plaque (HRP) features (42.6% vs 13.9% vs 26.7%, p < 0.0001). Patients treated with DOACs did not differ in conventional CT findings from the control group and showed an even lower prevalence of selected HRP features compared to the control group: low-attenuation plaques (4.0% vs. 14.4%, p = 0.014) and napkin-ring sign (0 vs. 5.0%, p = 0.029). CONCLUSION Vitamin K antagonists are associated with a higher plaque burden and increased high-risk plaque features, whereas DOACs may yield a benefit in cardiovascular atherosclerosis.
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Gradolí J, Vidal V, Brady AJ, Facila L. Anticoagulation in Patients with Ischaemic Heart Disease and Peripheral Arterial Disease: Clinical Implications of COMPASS Study. Eur Cardiol 2018; 13:115-118. [PMID: 30697356 DOI: 10.15420/ecr.2018.12.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Patients with established cardiovascular disease may suffer further cardiovascular events, despite receiving optimal medical treatment. Although platelet inhibition plays a central role in the prevention of new events, the use of anticoagulant therapies to reduce events in atheromatous disease has, until recently, been overlooked. The recent Rivaroxaban for the Prevention of Major Cardiovascular Events in Coronary or Peripheral Artery Disease (COMPASS) study showed an important reduction in cardiovascular events without increasing the risk of fatal and intracranial bleeding when using rivaroxaban, a novel oral anticoagulant, combined with aspirin. This article reviews the available evidence regarding the use of anticoagulant therapies for prevention of cardiovascular events, the results of the COMPASS study and how these results may affect patient management in everyday clinical practice.
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Affiliation(s)
- Josep Gradolí
- Department of Cardiology, Hospital General Universitario, University of Valencia Valencia, Spain
| | - Verónica Vidal
- Department of Cardiology, Hospital General Universitario, University of Valencia Valencia, Spain
| | - Adrian Jb Brady
- Department of Cardiology, Glasgow Royal Infirmary Glasgow, UK
| | - Lorenzo Facila
- Department of Cardiology, Hospital General Universitario, University of Valencia Valencia, Spain
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Cerit L. Atrial fibrillation, hip fracture, and oral anticoagulant therapy. Int J Cardiol 2017; 249:259. [PMID: 29121729 DOI: 10.1016/j.ijcard.2017.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Levent Cerit
- Department of Cardiology, Near East University, Nicosia, Cyprus.
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Millar SA, Patel H, Anderson SI, England TJ, O’Sullivan SE. Osteocalcin, Vascular Calcification, and Atherosclerosis: A Systematic Review and Meta-analysis. Front Endocrinol (Lausanne) 2017; 8:183. [PMID: 28824544 PMCID: PMC5534451 DOI: 10.3389/fendo.2017.00183] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/12/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Osteocalcin (OC) is an intriguing hormone, concomitantly being the most abundant non-collagenous peptide found in the mineralized matrix of bone, and expanding the endocrine function of the skeleton with far-reaching extra-osseous effects. A new line of enquiry between OC and vascular calcification has emerged in response to observations that the mechanism of vascular calcification resembles that of bone mineralisation. To date, studies have reported mixed results. This systematic review and meta-analysis aimed to identify any association between OC and vascular calcification and atherosclerosis. METHODS AND RESULTS Databases were searched for original, peer reviewed human studies. A total of 1,453 articles were retrieved, of which 46 met the eligibility criteria. Overall 26 positive, 17 negative, and 29 neutral relationships were reported for assessments between OC (either concentration in blood, presence of OC-positive cells, or histological staining for OC) and extent of calcification or atherosclerosis. Studies that measured OC-positive cells or histological staining for OC reported positive relationships (11 studies). A higher percentage of Asian studies found a negative relationship (36%) in contrast to European studies (6%). Studies examining carboxylated and undercarboxylated forms of OC in the blood failed to report consistent results. The meta-analysis found no significant difference between OC concentration in the blood between patients with "atherosclerosis" and control (p = 0.13, n = 1,197). CONCLUSION No definitive association was determined between OC and vascular calcification or atherosclerosis; however, the presence of OC-positive cells and histological staining had a consistent positive correlation with calcification or atherosclerosis. The review highlighted several themes, which may influence OC within differing populations leading to inconclusive results. Large, longitudinal studies are required to further current understanding of the clinical relevance of OC in vascular calcification and atherosclerosis.
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Affiliation(s)
- Sophie A. Millar
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
- *Correspondence: Sophie A. Millar,
| | - Hinal Patel
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
| | - Susan I. Anderson
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
| | - Timothy J. England
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
| | - Saoirse E. O’Sullivan
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
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