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Clinical outcomes in patients with atrial fibrillation treated with DOACs in a specialized anticoagulation center: Critical appraisal of real-world data. PLoS One 2023; 18:e0279297. [PMID: 36827286 PMCID: PMC9955586 DOI: 10.1371/journal.pone.0279297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/04/2022] [Indexed: 02/25/2023] Open
Abstract
AIMS Direct oral anticoagulants (DOAC) are progressively replacing vitamin K antagonists in the prevention of thromboembolism in patients with atrial fibrillation. However, their real-world clinical outcomes appear to be contradictory, with some studies reporting fewer and others reporting higher complications than the pivotal randomized controlled trials. We present the results of a clinical model for the management of DOACs in real clinical practice and provide a review of the literature. METHODS The MACACOD project is an ongoing, observational, prospective, single-center study with unselected patients that focuses on rigorous DOAC selection, an educational visit, laboratory measurements, and strict follow-up. RESULTS A total of 1,259 patients were included. The composite incidence of major complications was 4.93% py in the whole cohort vs 4.49% py in the edoxaban cohort. The rate of all-cause mortality was 6.11% py for all DOACs vs 5.12% py for edoxaban. There weren't differences across sex or between Edoxaban reduced or standard doses. However, there were differences across ages, with a higher incidence of major bleeding complications in patients >85 years (5.13% py vs 1.69% py in <75 years). CONCLUSIONS We observed an incidence of serious complications of 4.93% py, in which severe bleeding predominated (3.65% py). Considering our results, more specialized attention seems necessary to reduce the incidence of severe complications and also a more critical view of the literature. Considering our results, and our indirect comparison with many real-world studies, more specialized attention seems necessary to reduce the incidence of severe complications in AF patients receiving DOACs.
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Villines TC, Cziraky MJ, Amin AN. Awareness, Knowledge, and Utility of RCT Data vs RWE: Results From a Survey of US Cardiologists: Real-world Evidence in Clinical Decision Making. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820953410. [PMID: 32952404 PMCID: PMC7476349 DOI: 10.1177/1179546820953410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/04/2020] [Indexed: 02/01/2023]
Abstract
Real-world evidence (RWE) provides a potential rich source of additional information to the body of data available from randomized clinical trials (RCTs), but there is a need to understand the strengths and limitations of RWE before it can be applied to clinical practice. To gain insight into current thinking in clinical decision making and utility of different data sources, a representative sampling of US cardiologists selected from the current, active Fellows of the American College of Cardiology (ACC) were surveyed to evaluate their perceptions of findings from RCTs and RWE studies and their application in clinical practice. The survey was conducted online via the ACC web portal between 12 July and 11 August 2017. Of the 548 active ACC Fellows invited as panel members, 173 completed the survey (32% response), most of whom were board certified in general cardiology (n = 119, 69%) or interventional cardiology (n = 40, 23%). The survey results indicated a wide range of familiarity with and utilization of RWE amongst cardiologists. Most cardiologists were familiar with RWE and considered RWE in clinical practice at least some of the time. However, a significant minority of survey respondents had rarely or never applied RWE learnings in their clinical practice, and many did not feel confident in the results of RWE other than registry data. These survey findings suggest that additional education on how to assess and interpret RWE could help physicians to integrate data and learnings from RCTs and RWE to best guide clinical decision making.
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Affiliation(s)
- Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | | | - Alpesh N Amin
- Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA
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3
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Ballestri S, Capitelli M, Fontana MC, Arioli D, Romagnoli E, Graziosi C, Lonardo A, Marietta M, Dentali F, Cioni G. Direct Oral Anticoagulants in Patients with Liver Disease in the Era of Non-Alcoholic Fatty Liver Disease Global Epidemic: A Narrative Review. Adv Ther 2020; 37:1910-1932. [PMID: 32285340 PMCID: PMC7467481 DOI: 10.1007/s12325-020-01307-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent and relevant healthcare issues. Direct oral anticoagulants (DOACs) are now the first-choice for anticoagulant treatment of these conditions displaying a better efficacy/safety profile than vitamin-K antagonists, mainly due to significantly reduced risk of major bleeding, especially of intracranial haemorrhage. Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in developed countries showing a continuously growing prevalence. Nonalcoholic steatohepatitis (NASH), its evolutive form, will be the leading cause for liver transplantation by 2020. NAFLD is independently associated with an increased risk of abnormalities of cardiac structure and function, including cardiac rhythm disorders (mainly AF). Moreover, data suggest an increased risk of unprovoked VTE associated with NAFLD/NASH. Therefore, a growing number of patients with chronic liver disease (CLD) will be candidate for anticoagulant therapy in the near future. Cirrhosis of any etiology is characterized by an unstable thrombosis/bleeding haemostatic balance, making anticoagulant therapy particularly challenging in this condition. Given that patients with significant active liver disease and cirrhosis were excluded from all pivotal randomized controlled trials on DOACs, this comprehensive review aims at critically discussing real-world evidence, including the latest population studies, regarding the use of DOACs in patients with CLD/cirrhosis.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy.
| | - Mariano Capitelli
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | | | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Catia Graziosi
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | - Amedeo Lonardo
- Metabolic Syndrome Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giorgio Cioni
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
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4
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Chi NF, Wen CP, Liu CH, Li JY, Jeng JS, Chen CH, Lien LM, Lin CH, Sun Y, Chang WL, Hu CJ, Hsu CY. Comparison Between Aspirin and Clopidogrel in Secondary Stroke Prevention Based on Real-World Data. J Am Heart Assoc 2019; 7:e009856. [PMID: 30371321 PMCID: PMC6404870 DOI: 10.1161/jaha.118.009856] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Clopidogrel was thought to be superior to aspirin for secondary prevention of vascular diseases in clinical trials. In this study we assessed the safety and efficacy of clopidogrel versus aspirin in real‐world practice by using the Taiwan Stroke Registry. Methods and Results Patients with ischemic stroke (2006–2016) on aspirin or clopidogrel for secondary stroke prevention were identified in the Taiwan Stroke Registry. Stroke recurrence and mortality rates in patients receiving aspirin (N=34 679) were compared with those receiving clopidogrel (N=7611) during a 12‐month follow‐up period. Propensity score matching and conditional Cox proportional hazards regression model were applied to control confounding factors with 6443 patients in each group. After propensity score matching, stroke recurrence rates were comparable between groups, with 223 patients in the aspirin (3.46%) and 244 in the clopidogrel group (3.79%) (hazard ratio=1.13, 95% confidence interval=0.89–1.43, P=0.311). However, the mortality rate was significantly higher in the clopidogrel group (362 patients, 5.62%) than in the aspirin group (302 patients, 4.69%) (hazard ratio=1.30, 95% confidence interval=1.07–1.58, P=0.008). Results were consistent before and after propensity score matching. Conclusions Clopidogrel was as effective as aspirin for prevention of recurrent stroke in real‐world practice. However, the mortality rate was significantly higher in the clopidogrel than in the aspirin group.
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Affiliation(s)
- Nai-Fang Chi
- 1 Department of Neurology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan.,2 Department of Neurology Shuang Ho Hospital Taipei Medical University New Taipei City Taiwan.,3 Faculty of Medicine National Yang-Ming University School of Medicine Taipei Taiwan
| | - Chi-Pang Wen
- 4 Institute of Population Health Sciences National Health Research Institutes Zhunan Taiwan
| | - Chung-Hsiang Liu
- 5 Department of Neurology China Medical University Hospital Taichung Taiwan
| | - Jie-Yuan Li
- 6 Department of Neurology E-Da Hospital Kaohsiung Taiwan.,7 School of Medicine I-Shou University Kaohsiung Taiwan
| | - Jiann-Shing Jeng
- 8 Department of Neurology National Taiwan University Hospital Taipei Taiwan
| | - Chih-Hung Chen
- 9 Department of Neurology College of Medicine National Cheng Kung University Tainan Taiwan.,10 Stroke Center National Cheng Kung University Hospital Tainan Taiwan
| | - Li-Ming Lien
- 1 Department of Neurology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan.,11 Department of Neurology Shin Kong Wu Ho-Su Memorial Hospital Taipei Taiwan
| | - Ching-Huang Lin
- 12 Department of Neurology Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - Yu Sun
- 13 Department of Neurology En Chu Kong Hospital New Taipei City Taiwan
| | - Wei-Lun Chang
- 14 Department of Neurology Show-Chwan Memorial Hospital Changhua Taiwan
| | - Chaur-Jong Hu
- 1 Department of Neurology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan.,2 Department of Neurology Shuang Ho Hospital Taipei Medical University New Taipei City Taiwan.,15 The PhD Program for Neural Regenerative Medicine College of Medical Science and Technology Taipei Medical University Taipei Taiwan.,16 Taipei Neuroscience Institute Taipei Medical University Taipei Taiwan
| | - Chung Y Hsu
- 5 Department of Neurology China Medical University Hospital Taichung Taiwan.,17 Graduate Institute of Clinical Medical Science China Medical University Taichung Taiwan
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Sun Z, Liu Y, Zhang Y, Guo X, Xu Y. Differences in safety and efficacy of oral anticoagulants in patients with non-valvular atrial fibrillation: A Bayesian analysis. Int J Clin Pract 2019; 73:e13308. [PMID: 30589161 DOI: 10.1111/ijcp.13308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/19/2018] [Accepted: 12/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Novel oral anticoagulants are the cornerstone of therapy for non-valvular atrial fibrillation patients to lower the risk of ischaemic stroke. Given the lack of head-to-head comparisons among oral anticoagulants, a Bayesian analysis was used to evaluate their safety and efficacy based on studies from real-world practice. METHODS The PubMed, Embase, Cochrane and Web of Science databases were searched for relevant studies. Bayesian analyses were conducted to estimate hazard ratios (HR) and 95% credible intervals (CrI) for the safety and efficacy of oral anticoagulants. RESULTS In the 22 studies included in our analysis, novel oral anticoagulants exhibited a clear advantage over warfarin in preventing ischaemic stroke, haemorrhagic stroke and, especially, intracranial haemorrhage. Incidence of major bleeding was lowest for apixaban, followed by dabigatran, warfarin and rivaroxaban. Gastrointestinal bleeding risk was lowest for apixaban, followed by warfarin, and was slightly lower for dabigatran than for rivaroxaban with no statistical difference (HR 1.05, 95% CrI 0.99-1.11). Ischaemic stroke risk was lowest for rivaroxaban, followed by apixaban, dabigatran and warfarin (HR 1.13, 95% CrI 1.07-1.20). CONCLUSION In real-world practice, apixaban may represent the optimal treatment in terms of safety and efficacy for patients with non-valvular atrial fibrillation. For patients with high risk of ischaemic events but low bleeding risk, rivaroxaban may be preferable.
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Affiliation(s)
- Zhe Sun
- Department of Cardiology, First Center of Chinese, PLA General Hospital, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Yuqi Liu
- Department of Cardiology, First Center of Chinese, PLA General Hospital, Beijing, China
- Department of Cardiology & National Clinical Research Center of Geriatrics Disease, Chinese PLA General Hospital, Beijing, China
- Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, Chinese PLA General Hospital, Beijing, China
- National Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Ye Zhang
- Department of Cardiology, First Center of Chinese, PLA General Hospital, Beijing, China
| | - Xinhong Guo
- Department of Cardiology, First Center of Chinese, PLA General Hospital, Beijing, China
| | - Yong Xu
- Department of Cardiology, First Center of Chinese, PLA General Hospital, Beijing, China
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Costantino G, Podda GM, Falsetti L, Iannone P, Lages A, Marra AM, Masala M, Reiakvam OM, Savva F, Schovanek J, van Bree S, da Silva Chora IJ, Privitera G, Ragozzino S, von Rotz M, Woittiez L, Davidson C, Montano N. Guidelines on the management of atrial fibrillation in the emergency department: a critical appraisal. Intern Emerg Med 2017; 12:693-703. [PMID: 27905006 DOI: 10.1007/s11739-016-1580-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/19/2016] [Indexed: 01/24/2023]
Abstract
Several guidelines often exist on the same topic, sometimes offering divergent recommendations. For the clinician, it can be difficult to understand the reasons for this divergence and how to select the right recommendations. The aim of this study is to compare different guidelines on the management of atrial fibrillation (AF), and provide practical and affordable advice on its management in the acute setting. A PubMed search was performed in May 2014 to identify the three most recent and cited published guidelines on AF. During the 1-week school of the European School of Internal Medicine, the attending residents were divided in five working groups. The three selected guidelines were compared with five specific questions. The guidelines identified were: the European Society of Cardiology guidelines on AF, the Canadian guidelines on emergency department management of AF, and the American Heart Association guidelines on AF. Twenty-one relevant sub-questions were identified. For five of these, there was no agreement between guidelines; for three, there was partial agreement; for three data were not available (issue not covered by one of the guidelines), while for ten, there was complete agreement. Evidence on the management of AF in the acute setting is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control and no agreement on several other topics.
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Affiliation(s)
- Giorgio Costantino
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Dipartimento di Medicina Interna, Allergologia Immunologia Clinica, Università degli Studi di Milano, Via F. Sforza 34, Milan, Italy.
| | - Gian Marco Podda
- Unità di Medicina 3, Dipartimento di medicina Interna, ASST Santi Paolo e Carlo, Milan, Italy
| | - Lorenzo Falsetti
- Medicina Interna Generale e Semintensiva, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Primiano Iannone
- Dipartimento di Emergenza, Ospedale del Tigullio, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | - Ana Lages
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | | | - Maristella Masala
- Azienda Ospedaliera Universitaria AOU Sassari Medicina Interna, Sassari, Italy
| | | | - Florentia Savva
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | - Jan Schovanek
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | - Sjoerd van Bree
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | | | - Graziella Privitera
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | - Silvio Ragozzino
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | - Matthias von Rotz
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | - Lycke Woittiez
- The 22nd European Summer School of Internal Medicine, Muravera, Cagliari, Italy
| | | | - Nicola Montano
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Dipartimento di Medicina Interna, Allergologia Immunologia Clinica, Università degli Studi di Milano, Via F. Sforza 34, Milan, Italy
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Norby FL, Alonso A. Comparative effectiveness of rivaroxaban in the treatment of nonvalvular atrial fibrillation. J Comp Eff Res 2017; 6:549-560. [PMID: 28737102 DOI: 10.2217/cer-2017-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, a common arrhythmia. In this review, we summarize the effectiveness of rivaroxaban versus warfarin and the DOACs dabigatran, apixaban and edoxaban. The primary focus is on primary evidence from clinical trials, indirect comparison studies and real-world studies. While there are gaps in the literature, the evidence thus far indicates that rivaroxaban is superior to warfarin and similar to dabigatran, apixaban and edoxaban for the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation, although rivaroxaban may be associated with an elevated bleeding risk compared with other DOACs.
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Affiliation(s)
- Faye L Norby
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
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Raschi E, Bianchin M, Ageno W, De Ponti R, De Ponti F. Risk-Benefit Profile of Direct-Acting Oral Anticoagulants in Established Therapeutic Indications: An Overview of Systematic Reviews and Observational Studies. Drug Saf 2016; 39:1175-1187. [PMID: 27696300 PMCID: PMC5107188 DOI: 10.1007/s40264-016-0464-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since 2008, the direct-acting oral anticoagulants (DOACs) have expanded the therapeutic options of cardiovascular diseases with recognized clinical and epidemiological impact, such as non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE), and also in the preventive setting of orthopedic surgical patients. The large body of evidence, not only from pivotal clinical trials but also from 'real-world' postmarketing observational findings (e.g. analytical epidemiological studies and registry data) gathered to date allow for a first attempt at verifying a posteriori whether or not the pharmacological advantages of the DOACs actually translate into therapeutic innovation, with relevant implications for clinicians, regulators and patients. This review aims to synthesize the risk-benefit profile of DOACs in the aforementioned consolidated indications through an 'evidence summary' approach gathering the existent evidence-based data, particularly systematic reviews with meta-analyses of randomized controlled trials, as well as observational studies, comparing DOACs with vitamin K antagonists. Clinical evidence will be discussed and compared with major international guidelines to identify whether an update is needed. Controversial clinically relevant safety issues will be also examined in order to highlight current challenges and unsettled questions (e.g. actual bleeding risk in susceptible populations). It is anticipated that the large number of publications on NVAF or VTE (44 systematic reviews with meta-analyses and 12 observational studies retained in our analysis) suggests the potential existence of overlapping studies and calls for common criteria to qualitatively and quantitatively assess discordances, thus guiding future research.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Roberto De Ponti
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy.
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9
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Dentali F, Mumoli N, Gianni M, Cei M. "To treat or not to treat very elderly naïve patients with atrial fibrillation with vitamin K antagonists". Intern Emerg Med 2015; 10:765-7. [PMID: 26328803 DOI: 10.1007/s11739-015-1313-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Francesco Dentali
- Department of Clinical Medicine, U.O. Medicina Interna, Ospedale di Circolo, Insubria University, Viale Borri 57, 21100, Varese, Italy.
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile Livorno, Leghorn, Italy
| | - Monica Gianni
- Cardiology Unit, Hospital of Tradate, Tradate, Italy
| | - Marco Cei
- Department of Internal Medicine, Ospedale Civile Livorno, Leghorn, Italy
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