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Garay OU, Guiñazú G, Adamczuk YP, Duboscq C. Cost-Utility and Budget Impact Analysis of Implementing Anticoagulation Clinics and Point-of-Care Monitoring Devices in Anticoagulated Patients in Argentina. PHARMACOECONOMICS - OPEN 2022; 6:657-668. [PMID: 35835938 PMCID: PMC9440177 DOI: 10.1007/s41669-022-00352-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Worldwide, 1 % of the population receives anticoagulation therapy, with prevalence higher in older adults. Difficulties in the adequate management of these patients have led to the development of strategies focused on achieving therapeutic control and reducing adverse events with efficient use of resources. OBJECTIVE To estimate the cost utility and budget impact on the Argentinean health system of implementation of anticoagulation clinics (ACs) (with and without use of point-of-care [POC] CoaguChek® devices [Roche Diagnostics International Ltd]) compared with the traditional laboratory method (non-AC settings) for the management of anticoagulated patients. METHODS For the cost-utility analysis, a cohort-based state transition model was designed to compare costs and health outcomes of implementing ACs for outpatient management of anticoagulated patients. The budget impact analysis used an analytical model to estimate the differential costs of implementing an AC and the expected adverse events avoided, and the differential costs of an international normalized ratio (INR) determination using a POC device rather than a conventional laboratory. RESULTS We calculated the study outcomes for a cohort of 1000 patients. Considering a 5 % discount rate, the use of ACs generated 13.9 additional quality-adjusted life-years (0.014 per patient) and 12.5 additional life-years (0.013 per patient). Incremental cost-effectiveness ratios of AC implementation with and without the use of POC devices compared with the scenario without ACs were dominant in both cases. In the probabilistic sensitivity analysis, nearly all simulated results were cost effective (i.e., below the 1 or 3 gross domestic product per capita thresholds). Budget impact analysis results showed AC implementation generated savings from the first year of implementation, with savings of AR $265,325 by year 5. The addition of POC devices in the ACs also generated savings as early as the first year of implementation, with savings of AR $488,072 by year 5 (AR $488 per patient). CONCLUSIONS Anticoagulation clinics are estimated to be cost effective and generate notable savings in the treatment of patients on long-term oral anticoagulant therapy when compared with non-AC settings. These savings are considerably higher when POC devices are added as part of the patient management, due to lower laboratory technician costs per INR determination.
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Affiliation(s)
| | - Gonzalo Guiñazú
- Roche Diagnostics Argentina, Rawson 3150 B1610BAL-Ricardo Rojas, Tigre, Buenos Aires, Argentina.
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Barcellona D, Schirru P, Mameli A, Cornacchini S, Fenu L, Marongiu F. Over-anticoagulation by vitamin K antagonists and gender differences. Int J Cardiol 2022; 362:147-151. [DOI: 10.1016/j.ijcard.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/25/2022]
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Singh B, Pai P, Kumar H, George S, Mahapatra S, Garg V, Gupta GN, Makineni K, Ganeshwala G, Narkhede P, Naqvi SMH, Gaurav K, Hukkeri MYK. Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction. Cardiol Ther 2022; 11:49-79. [PMID: 35137335 PMCID: PMC8933593 DOI: 10.1007/s40119-022-00254-w] [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: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are a new class of anticoagulant drugs used in the prevention and treatment of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulation requires the integration of the correct type and dose of oral anticoagulants based on patient characteristic, and therefore therapy needs to be individualized for each patient. Growing scientific evidence from studies on NOACs has led to a better understanding of their benefits and safety. A large amount of available data creates a necessity for an adaptable practical document for the usage of NOACs in India. The current consensus, developed by experts from India, aims to give recommendations on various frequently raised clinical questions with regards to NOACs and its usage. This practical document provides a platform upon which future guidelines, policies, training, and education for the use of NOACs can be tailored.
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Affiliation(s)
- Balbir Singh
- Max Super Speciality Hospital, Saket, New Delhi, India
| | - Paresh Pai
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Harish Kumar
- Moorthy Hospital Pvt. Ltd., Trichy, Tamil Nadu, India
| | - Sheeba George
- Sree Mookambika Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | | | - Vineet Garg
- Blossoms Hospitals, Agra, Uttar Pradesh, India
| | - G N Gupta
- Gupta Heart and Medical Centre, Gorakhpur, Uttar Pradesh, India
| | - Kiran Makineni
- Kirans Vascular Surgery Centre, Vijayawada, Andhra Pradesh, India
| | | | | | - Syed M H Naqvi
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
| | - Kumar Gaurav
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India.
| | - Mohammed Y K Hukkeri
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
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4
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Ferroni E, Denas G, Gennaro N, Fedeli U, Pengo V. Gender Related Differences in Gastrointestinal Bleeding With Oral Anticoagulation in Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2022; 27:10742484211054609. [PMID: 34994209 DOI: 10.1177/10742484211054609] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: DOACs are characterized by a higher incidence of gastrointestinal bleeding and this may be different among males and females. Female patients were underrepresented in the DOAC pivotal trials. We aimed to assess real-world differences in gastrointestinal bleeding with oral anticoagulants (DOACs and VKAs) among males and females with atrial fibrillation. Methods: We performed a population-based retrospective analysis on linked administrative claims. Atrial fibrillation patients of 65 years and above were considered. Bleeding risk factors were assessed through HASBED and previous history of gastrointestinal disease. A time-to-event analysis compared gastrointestinal bleeding between males and females. Results: The overall cohort consisted of 15338 (55% female) DOAC and 44542 (50% female) VKA users. Most of the patients showed HASBED ≥2. Incidence rate of GI bleeding was higher in females as compared to males among DOAC users (0.90% vs 0.59%), and significant gender difference in GI bleeding was found, after adjustment, in the Cox regression analysis (HR 1.48, 95%CI 1.02-2.16). In the VKA group, no significant difference among genders was found in the time-to-event analysis. Conclusions: Our data suggest that female patients treated with DOACs have a higher risk of GI bleeding versus male patients; this difference is not observed in VKA patients.
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Affiliation(s)
- Eliana Ferroni
- 463969Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Nicola Gennaro
- 463969Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Ugo Fedeli
- 463969Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
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Palareti G, Legnani C, Antonucci E, Cosmi B, Falanga A, Poli D, Mastroiacovo D, Pengo V, Ageno W, Testa S. Do women with venous thromboembolism bleed more than men during anticoagulation? Data from the real-life, prospective START-Register. Ther Adv Drug Saf 2022; 12:20420986211062965. [PMID: 34987749 PMCID: PMC8689616 DOI: 10.1177/20420986211062965] [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: 05/09/2021] [Accepted: 11/06/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Venous thromboembolism (VTE) is a frequent and serious disease that requires immediate and long-term anticoagulant treatment, which is inevitably associated with a risk of bleeding complications. Some studies, though not all, reported a higher risk of bleeding in female patients treated with either old anticoagulants [vitamin k antagonists (VKAs)] or recent anticoagulants [direct oral anticoagulants (DOACs)]. Furthermore, analyses of clinical trials reported an abnormal vaginal bleeding in women of reproductive age treated with DOACs. This study aimed at comparing the risk of bleeding in an inception cohort of VTE women and men included in a prospective observational registry. Methods: Baseline characteristics and bleeding events occurring during anticoagulation in patients of both sexes, included in the START-Register after a first VTE, were analyzed. Results: In all, 1298 women were compared with 1290 men. Women were older and more often had renal diseases; their index events were often provoked (often by hormonal contraception and pregnancy), and more frequently presented as isolated pulmonary embolism (PE). The rate of bleeding was similar in women (2.9% patient-years) and men (2.1% patient-years), though it was higher when uterine bleeds were included (3.5% patient-years, p = 0.0141). More bleeds occurred in VKA- than DOAC-treated patients (6.4% versus 2.6%, respectively; p = 0.0013). At multivariate analysis, age ⩾ 75 years was associated with higher prevalence of bleeds. Conclusion: The occurrence of bleeding was not different between women and men during anticoagulation after VTE. Only after inclusion of vaginal/uterine bleeds, the rate of bleeding was higher in women. The incidence of bleeding was higher in women treated with VKAs. Plain Language Summary
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Affiliation(s)
- Gualtiero Palareti
- 'Arianna Anticoagulazione' Foundation, Via Paolo Fabbri, 1/3, 40138 Bologna, Italy
| | | | | | - Benilde Cosmi
- Unit of Angiology & Blood Coagulation, Department of Specialty, Diagnostics & Experimental Medicine, University Hospital, IRCCS, Bologna, Italy
| | - Anna Falanga
- Dipartimento di Medicina e Chirurgia, Università Milano Bicocca, Milan, Italy; UOC Immunoematologia e Medicina Trasfusionale ASST, Bergamo, Italy
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | | | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padua, Padua, Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
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Magon A, Arrigoni C, Graffigna G, Barello S, Moia M, Palareti G, Caruso R. The effect of health literacy on vaccine hesitancy among Italian anticoagulated population during COVID-19 pandemic: the moderating role of health engagement. Hum Vaccin Immunother 2021; 17:5007-5012. [PMID: 34643478 DOI: 10.1080/21645515.2021.1984123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Assessing vaccine hesitancy and its determinants is pivotal to optimize vaccine acceptance in anticoagulated patients, given that this population has been described to have a higher risk of severe COVID-19-related complications. This study assessed the moderator role of patients' health engagement on the relationship between health literacy and vaccine hesitancy. A web-based survey was performed in Italy during the first wave (June-August 2020) and the second wave (October 2020-March 2021) of the COVID-19 pandemic, enrolling 288 patients. The rates of vaccine hesitancy reported during the first pandemic wave were 38.4% and 30.8% during the second wave (when a vaccine was available) (p = .164). A moderation analysis was performed to assess the role of health engagement in influencing the relationship from health literacy to vaccine hesitancy. Patients' health engagement enhanced the effects of health literacy on decreasing vaccine hesitancy (p < .001), suggesting that co-construction strategies for communicative action are pivotal.
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Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Guendalina Graffigna
- Department of Psychology, EngageMinds Hub - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Serena Barello
- Department of Psychology, EngageMinds Hub - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | | | | | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milano, Italy
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Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population. J Clin Med 2021; 10:jcm10204670. [PMID: 34682796 PMCID: PMC8537827 DOI: 10.3390/jcm10204670] [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: 08/27/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the 'Geisinger Neuroscience Ischemic Stroke' (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62-1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.
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Valerio L, Fedeli U, Schievano E, Avossa F, Barco S. Decline in Overall Pulmonary Embolism-Related Mortality and Increasing Prevalence of Cancer-Associated Events in the Veneto Region (Italy), 2008-2019. Thromb Haemost 2021; 122:789-795. [PMID: 34255341 DOI: 10.1055/a-1548-4948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite evidence of ongoing epidemiological changes in deaths from venous thromboembolism in high-income countries, little recent information is available on the time trends in mortality related to pulmonary embolism (PE) as underlying or concomitant cause of death in Europe. METHODS We accessed the regional database of death certificates of Veneto Region (Northern Italy, population 4,900,000) from 2008 to 2019. We analyzed the trends in crude and age-adjusted annual rates of mortality related to PE (reported either as underlying cause or in any position in the death certificate) using Joinpoint regression; in the contribution of PE to mortality (proportionate mortality); and, using logistic regression, in the association between PE and cancer at death. RESULTS Between 2008 and 2019, the annual age-standardized mortality rate related to PE in Veneto decreased from 20.7 to 12.6 deaths per 100,000 population for PE in any position of the death certificate, and from 4.6 to 2.2 deaths per 100,000 population for PE as underlying cause of death. PE-related proportionate mortality remained up to twice as high in women. The age- and sex-adjusted odds ratio for cancer in deaths with versus without PE constantly increased from 1.01 (95% confidence interval [CI]: 0.88-1.16) in 2008 to 1.58 (95% CI: 1.35-1.83) in 2019. CONCLUSION The descending trends in PE-related mortality reported for Europe up to 2015 for both sexes continued thereafter in this high-income region of Northern Italy. However, sex differences in proportionate mortality persist. The increasing strength in the association between cancer and PE may indicate a change in risk factor distribution, calling for tailored management practices in this patient group.
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Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Ugo Fedeli
- Epidemiological Department, Azienda Zero, Veneto Region, Padua, Italy
| | - Elena Schievano
- Epidemiological Department, Azienda Zero, Veneto Region, Padua, Italy
| | - Francesco Avossa
- Epidemiological Department, Azienda Zero, Veneto Region, Padua, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Zurich, Switzerland
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Marongiu F, Ntoukas DM, Barberini L, Ruberto MF, Piras MS, Conti M, Di Martino ML, Mura M, Marongiu S, Vannini ML, Lillu M, Piras M, Fanni D, Fenu L, Porcu C, Barcellona D, Faa G, Congiu T. Clot characterization by multidisciplinary approach: biochemical and imaging parameters in a hypocoagulative setting. A pilot study. J Public Health Res 2021; 10. [PMID: 34036778 PMCID: PMC9136229 DOI: 10.4081/jphr.2021.2358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Clot characterization is, to the present days, a multimodal approach:
scanning the clot by electron microscopy (SEM) is helpful for the
visualization of fibrin structure along with laboratory parameters such as
the clot waveform analysis (CWA) and thrombin generation in different
settings of clot abnormalities. This study aimed to assess whether the
coagulative parameters were consistent with the clot images texture acquired
by SEM, and therefore to propose a more generalist and integrative approach
to clots classification. Design and methods In this pilot study, the examined population consists of eight healthy
subjects, seven patients affected by Acquired Hemophilia A (AHA) and seven
patients treated with Vitamin K Antagonists (VKAs), similar for age and
gender. We studied the velocity and acceleration (1st and
2nd derivative of the aPTT) of clot formation (CWA), the
thrombin generation, and the clots’ scanning by SEM. Images acquired with
SEM were then analyzed with the MATLAB software with the “Texture Analysis”
methods to perform classification. Among the various texture parameters, we
reported Contrast and Energy. Results Significant differences among healthy subjects, patients with AHA and those
treated with VKAs were detected for the coagulative parameters. We found no
differences between VKAs and AHA patients. Contrast and energy highlighted a
significant difference among the three groups in agreement with the
laboratory's parameters. We found no significant differences between VKAs
and AHA patients. Conclusions The use of SEM, CWA and thrombin generation parameters may be a starting
point for studies aimed to demonstrate the general characteristics of clot
formation in different clinical conditions with a multiparametric
approach.
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Affiliation(s)
- Francesco Marongiu
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Dimitrios Marco Ntoukas
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Luigi Barberini
- Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Filomena Ruberto
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Sebastiana Piras
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Conti
- Liver Unit, Department of Internal Medicine, University Hospital of Cagliari.
| | - Maria Luisa Di Martino
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Mario Mura
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Silvia Marongiu
- Internal Medicine Unit, SS Trinità Hospital, Azienda Tutela della Salute, Cagliari.
| | - Maria Luigia Vannini
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Mattia Lillu
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Monica Piras
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Daniela Fanni
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Lara Fenu
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | | | - Doris Barcellona
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Gavino Faa
- SHRO Temple University, Philadelphia, PA.
| | - Terenzio Congiu
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
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Van't Land RP, Banga JD, van den Besselaar AMHP. Therapeutic quality control in a regional thrombosis center: The effect of changing the target intensity of anticoagulation with vitamin K antagonists. Thromb Res 2021; 203:85-89. [PMID: 33989982 DOI: 10.1016/j.thromres.2021.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The target ranges (TR) for anticoagulation with vitamin K antagonists (VKA) in the Netherlands were changed in 2016 from INR 2.0-3.5 ('low intensity') and INR 2.5-4.0 ('high intensity') to INR 2.0-3.0 and INR 2.5-3.5, respectively. AIM To assess the effect of the TR change on therapeutic quality control (TQC) in a Dutch regional thrombosis center taking care of approximately 3600-5500 patients annually. METHODS TQC of chronically treated patients was assessed as the average time in therapeutic range (TTR). Evaluations were performed for non-self-management (NSM), as well as self-management patients. INR percentiles were assessed from all INR determinations in all patients, i.e. including those of induction episodes and patients treated for a short-term. RESULTS The number of NSM patients treated chronically decreased gradually, while their average age increased, with a marginal but significant gradual increase in bleeding complications. In the period 2011-2015, i.e. before the TR change, there was a gradual increase of the TTR in NSM patients from 77.5% to 88.9% (low intensity) and from 75.3% to 84.1% (high intensity). In the same period, the median INR of all patients in the low and high intensity ranges decreased from 2.9 to 2.7, and from 3.3 to 3.2, respectively. The TTR in self-management patients remained virtually constant. After TR changes from 2016 on, the TTR of all NSM patients in the low and high intensity groups decreased to 77% and 70%, respectively, and median INRs decreased to 2.6 and 3.0, respectively. CONCLUSIONS Introduction of internationally harmonized target ranges in 2016 resulted in further lowering of median INR values in both target ranges. As expected, TTR was reduced slightly. These findings, together with a slight increase in average age and concomitant bleeding complications, suggest that the patients on long-term VKA treatment will require intensified monitoring and treatment.
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Affiliation(s)
| | | | - Antonius M H P van den Besselaar
- Thrombosis Center "Neder-Veluwe", Ede, the Netherlands; Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands.
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11
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Avarello I, Bianchi S, Toschi V, Zighetti ML, Faioni EM. Time in therapeutic range is lower in women than in men and is not explained by differences in age or comorbidity. Thromb Res 2021; 203:18-21. [PMID: 33901765 DOI: 10.1016/j.thromres.2021.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/18/2021] [Accepted: 04/06/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Time in therapeutic range (TTR) measures the stability of the international normalized ratio in patients on vitamin K antagonists (VKA). Low values are associated with poor outcomes. Women were shown to have lower TTR than men, but the causes are poorly defined. It was suggested that women on VKA are older and more morbid than men, and this could affect the stability of anticoagulation. We aimed to identify variables that affect TTR differently in women and men. MATERIALS AND METHODS This is a retrospective study in patients referred to a University hospital anticoagulant clinic. Age, sex, comorbidities, number of daily medications, indication and type of anticoagulant, weekly dosage and distribution, were derived from electronic records. Differences by sex and regression analysis to identify significant modulators of TTR were computed. RESULTS 1182 women and 1281 men on VKA were studied. Women were older than men (81.5 yrs. ± 11.2 vs 78.4 yrs. ± 12.2), and had lower TTR (65% ± 20.3 vs 69% ± 19.8). Comorbidity was similar between sexes and negatively affected TTR in both. Mechanical valves as an indication to anticoagulation and acenocoumarol as an anticoagulant as opposed to warfarin had a strong negative influence on TTR, while age increased TTR. Being a man rather than a woman afforded more than three TTR points. Number of medications and average anticoagulant dose were equal between sexes. DISCUSSION Women have a lower TTR than men, on average below the safety threshold. They were indeed older, but age positively influenced TTR. Since women and men were equally comorbid, neither age nor disease explains differences in TTR. None of the other variables included in the study could explain the gender gap in TTR. Since women are at increased risk of cardioembolic stroke in atrial fibrillation, an effort at defining other causes for the observed differences, closer monitoring and switching to direct anticoagulants whenever possible is warranted.
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Affiliation(s)
- Ilaria Avarello
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Susanna Bianchi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Vincenzo Toschi
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Elena M Faioni
- SIMT, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy.
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12
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Patients' adherence to oral anticoagulants therapy: Comparison between vitamin K antagonists and direct oral anticoagulants. Int J Cardiol 2021; 333:162-166. [PMID: 33705844 DOI: 10.1016/j.ijcard.2021.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patient's adherence to oral anticoagulant therapy is essential to prevent and treat thrombotic events. METHODS To assess the patients' adherence Morisky Medication Adherence Scale 8-items was used. The target population included 785 consecutive outpatients, of whom 384 were on Vitamin K Antagonists and 401 on Direct Oral Anticoagulants. Moreover, we evaluate which variable among age, gender, having experienced a thrombotic episode, time in the therapeutic range for patients on Vitamin K Antagonists, being naive and once versus twice daily drug assumption for patients on Direct Oral Anticoagulants, could affect adherence to therapy. RESULTS Morisky Medication Adherence Scale 8-items score was 8 in both groups. The intentional non-adherence obtained the lowest score while the unintentional non-adherence is the most frequent problem in patients treated with either Vitamin K Antagonists or Direct Oral Anticoagulants. Age > 75 years, male gender, having experienced a thrombotic episode, being naive and assuming Direct Oral Anticoagulants twice a day were significantly associated with a higher risk to forget assuming the oral anticoagulant, to have more difficulty in remembering to take it or to bring it in case of travel or leaving home. A low percentage of time in therapeutic range was associated with a not regularly assumption of the anticoagulants. CONCLUSION Patients treated with Vitamin K Antagonists or Direct Oral Anticoagulants show a good adherence and persistence to their oral anticoagulant therapy. Several factors have been identified to affect patients' adherence and deserve a careful attention by the doctors at the Anticoagulation Clinic.
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Barcellona D, Marongiu F. Thrombosis centres and AVKs monitoring in COVID-19 pandemic. Intern Emerg Med 2020; 15:1365-1368. [PMID: 32686059 PMCID: PMC7369471 DOI: 10.1007/s11739-020-02439-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
Abstract
Vitamin K-Antagonists (VKAs) are the treatment of choice in patients with indications other than atrial fibrillation and venous thromboembolism. Moreover, some patients still assume VKAs refusing to change their therapy when direct oral anticoagulants (DOACs) are properly indicated. The COVID-19 pandemic has completely changed our lives, nullifying inter-personal relationships to avoid contagion, making difficult the VKAs monitoring. We describe the re-organization of our thrombosis centre (TC) as an example on how to face the emergency due to the COVID-19 pandemic. In the first phase, to avoid overcrowding at the TC, we planned to increase the interval time between INRs checks and to encourage blood sampling at home, especially for elderly patients. Moreover, precise scheduled blood sampling was also organized while telephone and email counselling were guaranteed by two doctors of the TC. In the second phase, to reduce the number of patients who daily attended our TC a switch from VKAs to DOACs was carried out, if no contraindications were identified. In the third phase, to protect patients, healthcare staff and hospital from COVID-19 widespread, telemedicine was strengthened. We tried to extend self-testing at home by means of portable coagulometers to as more patients as possible. To avoid patients staying or coming back to the TC an ad hoc web platform for sending the therapeutic dose adjustment and the next scheduled appointment was developed. The TC re-organization allowed us to monitor anticoagulated patients respecting personal isolation and security measures to avoid possible COVID-19 contagion.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
- SHRO, Temple University, Philadelphia, PA, USA.
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Margaglione M, Antonucci E, D’Andrea G, Migliaccio L, Ageno W, Bucherini E, Cosmi B, Falanga A, Martini G, Mastroiacovo D, Paparo C, Poli D, Testa S, Palareti G. Anticoagulation in Italian patients with venous thromboembolism and thrombophilic alterations: findings from START2 register study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:486-495. [PMID: 32955425 PMCID: PMC7605886 DOI: 10.2450/2020.0091-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Randomised control trials have assessed the efficacy and safety of direct oral anticoagulants in the prophylaxis and treatment of venous thromboembolism (VTE). Positive but limited results have been reported in patients with inherited thrombophilia. Using an Italian, multicentre, prospective registry of consecutive patients presenting with symptomatic, acute VTE, we aimed to assess which factors are involved in making the choice of the drug that best fits the patient's risk profile in a large real-world setting of VTE patients. MATERIALS AND METHODS We investigated 4,866 VTE patients who took oral anticoagulants in the period between 2012 and April 2018 to prevent a new thromboembolic episode. RESULTS The large majority of patients who underwent thrombophilic screening, regardless of the results obtained, were prescribed direct oral anticoagulants rather than conventional anticoagulant therapy (p<0.001). During anticoagulation, bleeding events occurred more frequently in patients on conventional anticoagulant therapy (4.2%) than in those receiving direct oral anticoagulants (1.8%) and an increase in bleeding events was observed in patients who tested positive at the thrombophilic screening. Overall, a higher number of recurrent VTE was observed in patients not screened for thrombophilia (n=36; 1.7%) than in those screened (n=20; 0.7%; adjusted odds ratio: 2.2; 95% confidence interval: 1.2-4.1). DISCUSSION The present data confirm previous findings from other post-marketing registries and suggest that the choice of oral anticoagulation is strongly driven by patients' characteristics and VTE manifestations. Factors leading to the prescription of thrombophilic screening may identify a patient with a lower risk of VTE recurrence during anticoagulation.
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Affiliation(s)
- Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Giovanna D’Andrea
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Benilde Cosmi
- Angiology Unit, “Sant’Orsola Malpighi” University Hospital, Bologna, Italy
| | - Anna Falanga
- Thrombosis and Haemostasis Centre, Department of Immunohaematology and Transfusion Medicine, Bergamo, Italy
| | | | | | | | - Daniela Poli
- Centre for Atherothrombotic Diseases, “Careggi” University Hospital, Florence, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Centre, Hospital of Cremona, Cremona, Italy
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15
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Magon A, Arrigoni C, Moia M, Mancini M, Dellafiore F, Manara DF, Caruso R. Determinants of health-related quality of life: a cross-sectional investigation in physician-managed anticoagulated patients using vitamin K antagonists. Health Qual Life Outcomes 2020; 18:73. [PMID: 32178684 PMCID: PMC7077005 DOI: 10.1186/s12955-020-01326-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Literature has paid little attention in describing the specific contribution of each modifiable and non-modifiable characteristics on health-related quality of life (HRQoL) in physician-managed anticoagulated patients using vitamin K antagonists (VKAs). To describe how patients' treatment-specific knowledge, health literacy, treatment beliefs, clinical, and socio-demographic characteristics influence HRQoL in Italian physician-managed anticoagulated patients using VKAs. METHODS Cross-sectional multicentre study with a consecutive sampling strategy, enrolling 164 long-term anticoagulated patients. Clinical and socio-demographic characteristics were collected from electronic medical records. Valid and reliable questionnaires were used to collect patients' treatment-specific knowledge, health literacy, beliefs about VKAs, physical and health perceptions. RESULTS Obtaining and understanding health information (i.e., communicative health literacy) positively predicts both adequate mental (ORadjusted = 10.9; 95%CI = 1.99-19.10) and physical (ORadjusted = 11.54; 95%CI = 1.99-34.45) health perceptions. Conversely, the ability to perform proper health decision making (i.e., critical health literacy) was associated with lower rates of adequate mental health perception (ORadjusted = 0.13; 95%CI = 0.03-0.63). Further, age negatively predicted physical health perception (ORadjusted = 0.87; 95%CI = 0.81-0.93). CONCLUSIONS Health literacy plays an interesting role in predicting HRQoL. The relationship between critical health literacy and mental health perception could be influenced by some psychological variables, such as distress and frustration, which could be present in patients with higher levels of critical health literacy, as they could be more inclined for self-monitoring. For this reason, future research are needed to identify the most suitable patients' profile for each OAC-management model, by longitudinally describing the predictive performance of each modifiable and non-modifiable determinant of HRQoL.
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Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 - 00133, Rome, Italy.
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Marco Moia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Michela Mancini
- Nursing Office, ASST Melegnano e della Martesana, Melzo, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Duilio F Manara
- School of Nursing, Vita-Salute San Raffaele University, Milan, Italy
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Marzona I, Proietti M, Vannini T, Tettamanti M, Nobili A, Medaglia M, Bortolotti A, Merlino L, Roncaglioni MC. Sex-related differences in prevalence, treatment and outcomes in patients with atrial fibrillation. Intern Emerg Med 2020; 15:231-240. [PMID: 31243639 DOI: 10.1007/s11739-019-02134-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022]
Abstract
To analyze sex-related differences about AF prevalence, use of OAC and outcomes focusing on the older age classes. We used administrative data of the Lombardy Region, describing period prevalence, use of OAC and outcomes from 2002 to 2014 for all patients diagnosed with AF. AF prevalence over the 2002-2014 period was higher in males than in females (2.7% vs. 2.1%, p < 0.001), increasing with age. From 2003 to 2014, not treated AF patients decreased mostly in males (from 40.3 to 33.7% with respect to 43.7-39.8% in females). Age-stratified adjusted logistic regression analysis found that females were more likely treated with OAC when < 65 years in 2003 (OR 1.51, 95% CI 1.35-1.69) and in 2014 (OR 1.32, 95% CI 1.13-1.53); contrariwise, were less likely treated with OAC when age ≥ 75 years, in 2003 (OR 0.92, 95% CI 0.86-0.98) and in 2014 (OR 0.77, 95% CI 0.72-0.81).Adjusted Cox regression analysis confirmed that female AF patients had a higher risk of stroke (HR 1.18, 95% CI 1.14-1.21) and a lower risk of major bleeding (HR 0.83, 95% CI 0.80-0.86), while, had a lower risk for all-cause death (HR 0.82, 95% CI 0.80-0.83). AF prevalence was higher in male than in female patients, while thromboembolic risk was higher in female. Older female patients were under-treated with OAC particularly in recent years. Over long-term follow-up, female had a higher risk of stroke and a lower risk of major bleeding and all-cause death.
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Affiliation(s)
- Irene Marzona
- Laboratory of Cardiovascular Prevention, Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Via Giuseppe La Masa 19, 20156, Milan, Italy.
| | - Marco Proietti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - Tommaso Vannini
- Laboratory of Cardiovascular Prevention, Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Via Giuseppe La Masa 19, 20156, Milan, Italy
| | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - Alessandro Nobili
- Department of Neuroscience, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | | | | | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Maria Carla Roncaglioni
- Laboratory of Cardiovascular Prevention, Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Via Giuseppe La Masa 19, 20156, Milan, Italy
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Valerio L, Trinchero A, Barco S. Telemedicine and decentralized models of care: from anticoagulant monitoring to an expanded concept of vascular medicine. Intern Emerg Med 2019; 14:1213-1215. [PMID: 31428920 DOI: 10.1007/s11739-019-02174-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Langebeckstraße 1, 551131, Mainz, Germany
| | - Alice Trinchero
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Langebeckstraße 1, 551131, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Langebeckstraße 1, 551131, Mainz, Germany.
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Sebastián OG, Fernández MI, Fernández RM, Bernal LP. Use of rivaroxaban in patients attending a hematology unit in clinical practice. Future Cardiol 2019; 15:347-353. [PMID: 31468995 DOI: 10.2217/fca-2018-0086] [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: 11/21/2022] Open
Abstract
Aim: To determine drug persistence and rates of events among patients treated with rivaroxaban in a hematology unit. Methods: Retrospective study of patients that started treatment with rivaroxaban, in the hematology unit of a tertiary hospital. Results: A total of 161 patients were included, of whom 83.9% had atrial fibrillation and 11.2% venous thromboembolism, and 76.4% of patients were taking rivaroxaban 20 mg, 22.4% 15 mg and 1.2% 10 mg. After a follow-up of 1.8 ± 1.1 years, only four patients (2.5%) discontinued treatment. Rates of thromboembolic events, major bleeding/clinically relevant nonmajor bleeding and intracranial hemorrhage were 1.1, 2.8, 0.3 events per 100 patient-years, respectively. Conclusion: In patients attended in a hematology unit, medication persistence was high, and the incidence of outcomes low.
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Affiliation(s)
- Olga Gavín Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Luis Palomera Bernal
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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19
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Tosetto A, Palareti G. The American College of Chest Physicians score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism-Response. J Thromb Haemost 2019; 17:1182-1183. [PMID: 31257733 DOI: 10.1111/jth.14519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Alberto Tosetto
- Hemostasis and Thrombosis Unit, Hematology Department, San Bortolo Hospital, Vicenza, Italy
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20
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Response to: "Direct oral anticoagulants, vitamin K antagonists and simple single tooth extraction". Clin Oral Investig 2019; 23:1497-1498. [PMID: 30706140 DOI: 10.1007/s00784-019-02837-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
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Ageno W, Donadini M. Breadth of complications of long-term oral anticoagulant care. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:432-438. [PMID: 30504343 PMCID: PMC6245998 DOI: 10.1182/asheducation-2018.1.432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The majority of patients with venous thromboembolism (VTE) have a considerable long-term risk of recurrence and may require extended duration of anticoagulant treatment after the initial 3 to 6 months. The decision to extend treatment is based not only on the individual risk of recurrence, but should also consider the potential complications associated with anticoagulation, taking into account that anticoagulant drugs are among the drugs most frequently associated with hospital admission due to adverse drug reactions. The most feared complication of oral anticoagulants is bleeding, which in some cases may be fatal or may affect critical organs. Case-fatality rates of bleeding have been reported to be ∼3 times higher than case-fatality rates of recurrent VTE. Even when nonserious, bleeding may require medical intervention and/or may impact on patient quality of life or working activity. Factors associated with bleeding during anticoagulant treatment include, among others, advanced age, cancer, renal or liver insufficiency, or concomitant antithrombotic drugs, but no bleeding risk score is sufficiently accurate for use in clinical practice. Not uncommonly, bleeding occurs as a complication of trauma or medically invasive procedures. Nonbleeding complications associated with oral anticoagulants are unusual, and their relevance is extremely uncertain, and include vascular calcification, anticoagulation-related nephropathy, and osteoporosis. Finally, because VTE not uncommonly affects young individuals and the mean age of the population is ∼60 years, the costs associated with extended anticoagulation should not be forgotten. The costs of the drugs need to be balanced against health outcome costs associated with both recurrent VTE and bleeding.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Marco Donadini
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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22
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Pengo V, Denas G. Optimizing quality care for the oral vitamin K antagonists (VKAs). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:332-338. [PMID: 30504329 PMCID: PMC6245991 DOI: 10.1182/asheducation-2018.1.332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Vitamin K antagonists (VKAs) have been the only oral anticoagulants for decades. The management of anticoagulant therapy with VKA is challenging because of the intricate pharmacological properties of these agents. The success of VKA therapy depends on the quality of treatment that is ensured through continuing comprehensive communication and education. The educational program should address important issues of the VKA therapy such as beginning of treatment, pharmacological, dietary, and drug-drug interactions, as well as treatment temporary suspension during surgical interventions or invasive maneuvers. In addition, the initial and continuing patient education is of imperative importance. A major role in the educational process may be addressed by patient associations. The quality of treatment is better reached if patients are followed in anticoagulation clinics. Moreover, a federation of anticoagulation clinics may improve patient care through regular meetings to update knowledge on VKA treatment. Learning objectives of this paper is to allow readers to correctly approach patients starting VKA treatment, recognize possible pitfalls of treatment, and provide adequate solutions.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
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Marongiu F, Barcellona D. Direct oral anticoagulants: what can we learn? Intern Emerg Med 2018; 13:989-992. [PMID: 29500618 DOI: 10.1007/s11739-018-1811-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/25/2018] [Indexed: 11/25/2022]
Abstract
Direct oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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Palareti G, Poli D. The prevention of venous thromboembolism recurrence in the elderly: a still open issue. Expert Rev Hematol 2018; 11:903-909. [PMID: 30257119 DOI: 10.1080/17474086.2018.1526667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is frequent in the elderly, with an unclear recurrence risk. After the initial and early maintenance anticoagulant treatment, the decision about its extension versus recurrences is difficult because of the high risk of bleeding in this population. Areas covered: This paper analyzes recent literature on VTE recurrence and risk of bleeding associated with extended anticoagulation in elderly patients with VTE, focusing on available data regarding efficacy and safety of old anticoagulant or recent direct oral anticoagulant (DOACs). Expert commentary: The following are clinically important and still unmet needs in elderly patients with VTE: the current real risks for recurrence or for bleeding are still uncertain; the available clinical predictive rules for recurrence are of less use; in general, the phase III trials on DOACs proved less satisfactory in the elderly than in the general population; low dose DOACs use for extended treatment seems promising and data on long periods of therapy are needed; low dose aspirin does not seem an appropriate therapeutic alternative to anticoagulants due to the high rate of bleeding in the elderly; antithrombotic drugs, with low risk of bleeding should be assessed as alternative therapeutic options for extended treatment in the elderly.
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Affiliation(s)
| | - Daniela Poli
- b Thrombosis Centre , Azienda Ospedaliero-Universitaria Careggi , Florence , Italy
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Magon A, Arrigoni C, Roveda T, Grimoldi P, Dellafiore F, Moia M, Obamiro KO, Caruso R. Anticoagulation Knowledge Tool (AKT): Further evidence of validity in the Italian population. PLoS One 2018; 13:e0201476. [PMID: 30106955 PMCID: PMC6091938 DOI: 10.1371/journal.pone.0201476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/16/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Oral Anticoagulation therapy (OAC) is highly effective in the management of thromboembolic disorders. An adequate level of knowledge is important for self-management and optimizing clinical outcomes. The Anticoagulation Knowledge Tool (AKT) was developed to assess OAC knowledge and caters for both patients prescribed direct oral anticoagulants or vitamin K antagonist (VKA). However, evidence regarding its psychometric proprieties, validity and reliability are unavailable in non-English speaking settings. For this reason, the aim of this study is to provide further evidence of validity for AKT and also developing an Italian AKT version (I-AKT) supported by evidence of validity and reliability. METHODS A multiphase study was conducted which included the following: cultural and linguistic validity; i.e. content validity; construct validity; reliability assessment. The Construct validity was performed using the contrasted group approach using three groups comprised of health care providers, patients and the general public. Furthermore, Exploratory Structural Equation Modelling (ESEM) was performed to confirm the mono-dimensional structure of the items in the AKT. RESULTS In construct validity phase 334 participants were enrolled. One-way ANOVA and post hoc analysis test demonstrated significant differences between the means knowledge scores of the three groups: 30.42±3.04 vs 23.45± 4.57 vs14.32±6.07 (Statistic F = 266.83; p < .001). ESEM analysis demonstrates the I-AKT mono-dimensionally structure with an explained variance of 56.42%. The scale also showed both good internal consistency reliability (Cronbach's α = 0.896) and test-retest reliability (r = 0.855). CONCLUSION This study developed and validated I-AKT with supporting evidence for validity and reliability. The study also confirms the mono-dimensional of the items in the AKT. This suggest that the instrument can be useful in non-English setting for knowledge assessment and in potentially developing patient education materials.
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Affiliation(s)
- Arianna Magon
- Health Professions Research and Development Unit, IRCCS Policlinic San Donato University Hospital, San Donato Milanese, Milan, Italy
- * E-mail:
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Tiziana Roveda
- Haemostasis and Thrombosis Center, Cardiological Department of ASST Sette Laghi, Galmarini Hospital, Tradate, Varese, Italy
| | - Paola Grimoldi
- Haemostasis and Thrombosis Center, Cardiological Department of ASST Sette Laghi, Galmarini Hospital, Tradate, Varese, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinic San Donato University Hospital, San Donato Milanese, Milan, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, University of Milan, IRCCS Ca’ Granda Maggiore Hospital Foundation, Milan, Italy
| | - Kehinde O. Obamiro
- Centre for Rural Health, College of Health and Medicine, University of Tasmania, Tasmania, Australia
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinic San Donato University Hospital, San Donato Milanese, Milan, Italy
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Gavín Sebastián O, Izuzquiza Fernández M, Martínez Fernández R, Palomera Bernal L. Anticoagulation with rivaroxaban in a hematology unit: clinical profile, events and discontinuation rates in real-life patients with nonvalvular atrial fibrillation. Future Cardiol 2018; 14:25-30. [PMID: 29848092 DOI: 10.2217/fca-2018-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess the clinical profile and thromboembolic and bleeding events in patients with nonvalvular atrial fibrillation (AF) who were attended in a hematology unit. METHODS Retrospective study of AF patients that started treatment with rivaroxaban between February 2012 and June 2016 in a hematology unit from a tertiary hospital in Spain. RESULTS Overall, 243 patients (mean age 78.4 ± 10.1 years; 47.5% women, CHA2DS2-VASc 3.7 ± 1.5) were included. After a mean follow-up of 16.5 ± 12.7 months, rivaroxaban was discontinued in only 2.4% of patients. During the follow-up, seven (2.0 events/100 patient-years) patients had a thromboembolic event and six patients (1.7 events/100 patient-years) a major bleeding. CONCLUSION Rivaroxaban was effective and safe among AF patients treated in a hematology unit, with very low discontinuation rates.
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Affiliation(s)
- Olga Gavín Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Luis Palomera Bernal
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Barcellona D, Mastino D, Marongiu F. Portable coagulometer for vitamin K-antagonist monitoring: the patients' point of view. Patient Prefer Adherence 2018; 12:1521-1526. [PMID: 30197503 PMCID: PMC6112808 DOI: 10.2147/ppa.s164680] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The aim of this study was to know the patients' point of view on the monitoring of vitamin K-antagonist (VKA) therapy by means of a point of care testing (POCT), ie, using a portable coagulometer by self-testing at home. At first, patients had prothrombin time (PT) international normalized ratio (INR) monitoring at a thrombosis center; afterward, they were shifted to self-testing at home. An interview was done to evaluate the patients' point of view on the two monitoring periods. PATIENTS AND METHODS A total of 92 oral anticoagulated patients were enrolled. The questionnaire contained nine questions that elicited a maximum of five closer answers that were arranged in increasing levels of satisfaction: very little, little, enough, much and completely. Percentage of time in therapeutic range (TTR) and adverse events were compared during the two periods of conventional monitoring and self-testing. RESULTS The period of conventional monitoring was shorter than that of self-testing (p<0.0001), and the median TTR was satisfactory but lower than that of self-testing (p<0.0001). A total of 85% of the patients were satisfied with self-testing at home. In all, 83% and 73% (p=0.06) of patients felt comfortable about side effects while measuring the PT INR at both home and the thrombosis center, respectively. During the self-testing period, quality of life was improved in 87% of the patients. The cost of test strips was medium-high for 89% of the patients, and 75% of them stated that it was worth improving their quality of life. A switch from VKA to a direct oral anticoagulant (DOAC) was proposed to 24% of the patients, but 68% of them declined because they felt more comfortable monitoring their oral anticoagulant therapy by POCT. CONCLUSION VKA monitoring using POCT at home may play a role in improving the patients' quality of life and may be considered as an alternative to the use of DOAC at least in certain settings of patients.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
| | - Diego Mastino
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
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Dentali F, Galliazzo S, Zuretti F, Gianni M. Vitamin K antagonists in the era of direct oral anticoagulants: is there still a room for their use? Intern Emerg Med 2017; 12:1087-1089. [PMID: 28779447 DOI: 10.1007/s11739-017-1725-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/29/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, U.O. Medicina Interna, Ospedale di Circolo, Viale Borri 57, 21100, Varese, Italy.
| | - Silvia Galliazzo
- Department of Medicine and Surgery, University of Insubria, U.O. Medicina Interna, Ospedale di Circolo, Viale Borri 57, 21100, Varese, Italy
| | - Francesca Zuretti
- Department of Medicine and Surgery, University of Insubria, U.O. Medicina Interna, Ospedale di Circolo, Viale Borri 57, 21100, Varese, Italy
| | - Monica Gianni
- Department of Cardiology, Tradate Hospital, Tradate, Italy
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