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Shang L, Wei J, Liu K, Ao Y, Huang S, Hou J, Wu Z, Yao J. Predictors of short-term survival in cardiac valvular surgery patients with intra-aortic balloon pump implantation. Gen Thorac Cardiovasc Surg 2024; 72:447-454. [PMID: 38038878 DOI: 10.1007/s11748-023-01989-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Intro-aortic balloon pump (IABP) is widely used in cardiac surgery patients nowadays. This study aimed to analyze the predictor of short-term survival in cardiac valvular surgery patients with intra-aortic balloon pump implantation. METHODS This was a retrospective study and a total of 102 cardiac valvular surgery patients who received intra-aortic balloon pump implantation were consecutively included. We retrospectively collected the baseline characteristics and short-term outcomes. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictors for short-term mortality. RESULTS Among all the patients, there were 71 (69.6%) patients successfully weaned from IABP and survived to discharge, the other 31 (30.4%) patients failed to wean from IABP and died within the first 30 days after surgery. When compared with non-survivors, survivors had a higher proportion of males (62% vs 32.3%, p = 0.006), a lower rate of Atrial fibrillation (38% vs 62%, p < 0.03). After IABP implantation, vasoactive drug use was significantly lower in survivors compared with non-survivors, and survivors showed significant improvements in cardiac function and urine volume. Univariate and multivariate logistic regression analysis indicated that atrial fibrillation and combined use of continuous renal replacement therapy (CRRT) were significant independent predictors for short-term mortality. CONCLUSION Timely implantation of IABP can improve patients' cardiac and renal function and reduce the dosage of vasoactive drugs. Atrial fibrillation and combined use of CRRT are independent predictors for short-term mortality in patients who underwent cardiac valvular surgery with IABP implantation.
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Affiliation(s)
- Liqun Shang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Jinhui Wei
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Kaizheng Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Yuanhan Ao
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China.
| | - Jianping Yao
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China.
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Wang X, Chen W, Guo J, Wen D, You C, Ma L. Anticoagulation therapy in non-valvular atrial fibrillation after intracerebral hemorrhage: A propensity score-matched study. J Clin Neurosci 2024; 124:144-149. [PMID: 38705027 DOI: 10.1016/j.jocn.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/09/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND The effect of antithrombotic therapy on patients with atrial fibrillation who sustained previous intracerebral hemorrhage (ICH) remains uncertain. Data regarding antithrombotic therapy use in these patients are limited. This study aims to compare the clinical and overall outcomes of antithrombotic therapy and usual care in patients with atrial fibrillation who sustained ICH. METHODS We assembled consecutive patients with atrial fibrillation sustaining an ICH from our institution. Multivariable regression analysis and propensity-matched analysis were applied to assess associations of different antithrombotic therapies and outcomes. The primary outcome was mortality within the longest follow-up. Kaplan-Meier curves and log-rank tests of the time-to-event data were used to assess differences in survival. RESULTS In total, 296 consecutive patients with atrial fibrillation who survived an ICH were included in this study. Our analysis demonstrated that antithrombotic therapy was associated with reduced mortality up to a 4-year duration of follow-up (OR, 0.49, 95 % CI 0.30-0.81). Similar results were obtained from the propensity-matched analysis (OR, 0.58, 95 % CI 0.34-0.98). Subgroup analysis showed that compared with usual care, direct oral anticoagulant (DOAC) with or without antiplatelet was associated with a lower risk of long-term mortality (OR, 0.34, 95 % CI 0.17-0.69). In addition, our analysis observed a significant interaction between cardiac insufficiency and treatment effect (P = 0.04). CONCLUSIONS In patients with atrial fibrillation who have a history of ICH, administration of antithrombotic therapy, especially DOAC, was associated with lower mortality. Future randomized trials are warranted to test the positive net clinical benefit of DOAC therapy.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wuqian Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiulin Guo
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China Brain Research Centre, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Sawczyńska K, Włodarczyk E, Pawlicka A, Kołodziejczyk B, Wrona P, Wężyk K, Homa T, Sarba P, Wróbel D, Zdrojewska K, Sobolewska M, Rolkiewicz D, Slowik A. Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes. Stroke Res Treat 2024; 2024:2285722. [PMID: 38371464 PMCID: PMC10874293 DOI: 10.1155/2024/2285722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. Materials and Methods In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). Results In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.
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Affiliation(s)
- Katarzyna Sawczyńska
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Ewa Włodarczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Bartosz Kołodziejczyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Wrona
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Kamil Wężyk
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Physiotherapy, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
| | | | - Dominik Wróbel
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Kaja Zdrojewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Maria Sobolewska
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Dawid Rolkiewicz
- Jagiellonian University Medical College, Faculty of Medicine, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, University Hospital in Kraków, Kraków, Poland
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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Atwater BD, Di Fusco M, Keshishian A, Delinger R, Ferri M, Jiang J, Seigel L, Yuce H, Guo JD. Geographic variation in clinical outcomes and anticoagulation among medicare beneficiaries with non-valvular atrial fibrillation. J Thromb Thrombolysis 2023; 56:626-634. [PMID: 37530954 PMCID: PMC10550860 DOI: 10.1007/s11239-023-02855-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 08/03/2023]
Abstract
Oral anticoagulants (OACs) have been used to prevent stroke/systemic embolism (SE) among patients with non-valvular atrial fibrillation (NVAF). To evaluate baseline clinical characteristics, incidence rates of stroke/SE and hospitalization for bleeding, and OAC use among elderly patients with NVAF in the US by geographic region. Patients with NVAF were selected from the US Centers for Medicare & Medicaid Services claims database (01JAN2013-31DEC2016). Twelve months of health plan enrollment was required before and after the NVAF diagnosis to evaluate baseline characteristics and outcomes, respectively. Each patient was assigned to a 3-digit zip code based on their primary residence, and geographic variation was visualized using ArcGIS Pro software. Over 2.8 million patients with NVAF were identified. Large geographic variation was observed in clinical characteristics, stroke/SE, hospitalization for bleeding, and OAC use among patients across the US. The zip codes with the highest mean CHA2DS2-VASc scores and frequency of prior bleeding also had the highest incidence of stroke/SE and hospitalization for bleeding. Across 3-digit zip codes, 35-63% of patients were untreated. Overall, the incidence of stroke/SE and hospitalization for bleeding were higher and OAC treatment was less frequent in zip codes located in the Southern US. Baseline clinical characteristics, incidence rates of stroke/SE and hospitalization for bleeding, and OAC usage vary considerably by 3-digit zip code in the US. The additional granularity provided in this study may help clinicians to identify small regions with high-risk of stroke/SE and hospitalization for bleeding and low use of OAC that may benefit from targeted care strategies.
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Affiliation(s)
- Brett D Atwater
- Inova Heart and Vascular Institute, Inova Heart and Vascular Institute, 4th floor Medical Directors Suite, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | | | | | | | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Lauren Seigel
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
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Guo R, Fan C, Sun Z, Zhang H, Sun Y, Song L, Jiang Z, Liu L. Clinical efficacy and safety of Cox-maze IV procedure for atrial fibrillation in patients with aortic valve calcification. Front Cardiovasc Med 2023; 10:1092068. [PMID: 37077739 PMCID: PMC10106572 DOI: 10.3389/fcvm.2023.1092068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
ObjectiveAtrial fibrillation is associated with a high incidence of heart valve disease. There are few prospective clinical research comparing aortic valve replacement with and without surgical ablation for safety and effectiveness. The purpose of this study was to compare the results of aortic valve replacement with and without the Cox-maze IV procedure in patients with calcific aortic valvular disease and atrial fibrillation.MethodsWe analyzed one hundred and eight patients with calcific aortic valve disease and atrial fibrillation who underwent aortic valve replacement. Patients were divided into concomitant Cox maze surgery (Cox-maze group) and no concomitant Cox-maze operation (no Cox-maze group). After surgery, freedom from atrial fibrillation recurrence and all-cause mortality were evaluated.ResultsFreedom from all-cause mortality after aortic valve replacement at 1 year was 100% in the Cox-maze group and 89%, respectively, in the no Cox-maze group. No Cox-maze group had a lower rate of freedom from atrial fibrillation recurrence and arrhythmia control than those in the Cox-maze group (P = 0.003 and P = 0.012, respectively). Pre-operatively higher systolic blood pressure (hazard ratio, 1.096; 95% CI, 1.004–1.196; P = 0.04) and post-operatively increased right atrium diameters (hazard ratio, 1.755; 95% CI, 1.182–2.604; P = 0.005) were associated with atrial fibrillation recurrence.ConclusionThe Cox-maze IV surgery combined with aortic valve replacement increased mid-term survival and decreased mid-term atrial fibrillation recurrence in patients with calcific aortic valve disease and atrial fibrillation. Pre-operatively higher systolic blood pressure and post-operatively increased right atrium diameters are associated with the prediction of recurrence of atrial fibrillation.
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Frost L, Halminen O, Lehto M, Airaksinen KEJ, Andersson T, Wändell P, Holzmann M, Cordsen P, Vinter N, Johnsen SP. Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland. TH OPEN 2023; 7:e133-e142. [PMID: 37288117 PMCID: PMC10243918 DOI: 10.1055/a-2080-6171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/19/2023] [Indexed: 06/09/2023] Open
Abstract
Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark ( N = 61,345), Sweden ( N = 124,120), and Finland ( N = 59,855) and a CHA 2 DS 2 -VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Mika Lehto
- Department of Internal Medicine, Hospital District of Helsinki and Uusimaa, Lohja Hospital, Lohja, Finland
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Martin Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Internal Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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Martinez KA, Eckman MH, Pappas MA, Rothberg MB. Prescribing of anticoagulation for atrial fibrillation in primary care. J Thromb Thrombolysis 2022; 54:616-624. [PMID: 35449383 PMCID: PMC10481404 DOI: 10.1007/s11239-022-02655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew A Pappas
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
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Woo BFY, Tam WWS, Rangpa T, Liau WF, Nathania J, Lim TW. A Nurse-Led Integrated Chronic Care E-Enhanced Atrial Fibrillation (NICE-AF) Clinic in the Community: A Preliminary Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084467. [PMID: 35457336 PMCID: PMC9026946 DOI: 10.3390/ijerph19084467] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
Abstract
The current physician-centric model of care is not sustainable for the rising tide of atrial fibrillation. The integrated model of care has been recommended for managing atrial fibrillation. This study aims to provide a preliminary evaluation of the effectiveness of a Nurse-led Integrated Chronic care E-enhanced Atrial Fibrillation (NICE-AF) clinic in the community. The NICE-AF clinic was led by an advanced practice nurse (APN) who collaborated with a family physician. The clinic embodied integrated care and shifted from hospital-based, physician-centric care. Regular patient education, supplemented by a specially curated webpage, fast-tracked appointments for hospital-based specialised investigations, and teleconsultation with a hospital-based cardiologist were the highlights of the clinic. Forty-three participants were included in the six-month preliminary evaluation. No significant differences were observed in cardiovascular hospitalisations (p-value = 0.102) and stroke incidence (p-value = 1.00) after attending the NICE-AF clinic. However, significant improvements were noted for AF-specific QoL (p = 0.001), AF knowledge (p < 0.001), medication adherence (p = 0.008), patient satisfaction (p = 0.020), and depression (p = 0004). The preliminary evaluation of the NICE-AF clinic demonstrated the clinical utility of this new model of integrated care in providing safe and effective community-based AF care. Although a full evaluation is pending, the preliminary results highlighted its promising potential to be expanded into a permanent, larger-scale service.
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Affiliation(s)
- Brigitte Fong Yeong Woo
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
- Correspondence: ; Tel.: +65-6601-6812
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Taiju Rangpa
- Bukit Batok—Medical, National University Polyclinics, National University Health System, Singapore 659164, Singapore;
| | - Wei Fong Liau
- Bukit Batok—Nursing, National University Polyclinics, National University Health System, Singapore 659164, Singapore;
| | - Jennifer Nathania
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore 119228, Singapore;
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Lin SY, Chang YC, Lin FJ, Tang SC, Dong YH, Wang CC. Post-Intracranial Hemorrhage Antithrombotic Therapy in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e022849. [PMID: 35243876 PMCID: PMC9075312 DOI: 10.1161/jaha.121.022849] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background To investigate the effectiveness and safety of withholding or restarting antithrombotic agents, and different antithrombotic therapies among patients with atrial fibrillation post‐intracranial hemorrhage. Methods and Results This is a nationwide retrospective cohort study involving patients with atrial fibrillation receiving antithrombotic therapies who subsequently developed intracranial hemorrhage between January 1, 2011 and December 31, 2017. The risk of ischemic stroke (IS), recurrent intracerebral hemorrhage (ICH), and all‐cause mortality were investigated between patients receiving no treatment versus patients reinitiating oral anticoagulants (OACs) or antiplatelet agents, and warfarin versus non‐vitamin K antagonist OACs. We applied inverse probability of treatment weighting to balance the baseline characteristics and Cox proportional hazards model to estimate the hazard ratios (HRs) of different outcomes of interest. Compared with no treatment, OACs reduced the risk of IS (HR, 0.61; 0.42–0.89), without increase in the risk of ICH (1.15, 0.66–2.02); antiplatelet agent users showed a similar risk of IS (1.13, 0.81–1.56) and increased risk of ICH (1.81, 1.07–3.04). Use of OACs or antiplatelet agents did not reduce the risk of all‐cause mortality (0.85, 0.72–1.01; and 0.88, 0.75–1.03, respectively). Compared with warfarin, non‐vitamin K antagonist OAC users showed a similar risk of IS (0.92, 0.50–1.70), non‐significantly reduced risk of ICH (0.53, 0.22–1.30), and significantly reduced all‐cause mortality (0.60, 0.43–0.84). Conclusions OACs are recommended in patients with atrial fibrillation and intracranial hemorrhage because they reduced the risk of IS with no increase in the risk of subsequent ICH. Non‐vitamin K antagonist OACs are recommended over warfarin owing to their survival benefits.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan.,School of Pharmacy College of MedicineNational Taiwan University Taipei Taiwan
| | - Yu-Chen Chang
- Graduate Institute of Clinical PharmacyCollege of MedicineNational Taiwan University Taipei Taiwan
| | - Fang-Ju Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan.,School of Pharmacy College of MedicineNational Taiwan University Taipei Taiwan.,Graduate Institute of Clinical PharmacyCollege of MedicineNational Taiwan University Taipei Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology National Taiwan University Hospital Taipei Taiwan
| | - Yaa-Hui Dong
- School of Pharmaceutical Science National Yang Ming Chiao Tung University Taipei Taiwan.,Institute of Public HealthSchool of MedicineNational Yang Ming Chiao Tung University Taipei Taiwan
| | - Chi-Chuan Wang
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan.,School of Pharmacy College of MedicineNational Taiwan University Taipei Taiwan.,Graduate Institute of Clinical PharmacyCollege of MedicineNational Taiwan University Taipei Taiwan
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Martha JW, Pranata R, Raffaelo WM, Wibowo A, Akbar MR. Direct Acting Oral Anticoagulant vs. Warfarin in the Prevention of Thromboembolism in Patients With Non-valvular Atrial Fibrillation With Valvular Heart Disease-A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:764356. [PMID: 35096994 PMCID: PMC8797143 DOI: 10.3389/fcvm.2021.764356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/04/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose: There is uncertainty as to which anticoagulant should be used in non-valvular atrial fibrillation (AF) with valvular heart disease. This systematic review and meta-analysis aimed to assess the efficacy and safety of direct-acting oral anticoagulants (DOACs) compared with warfarin in patients with non-valvular AF with valvular heart disease. Methods: We performed a comprehensive literature search using PubMed, Scopus, Embase, and Clinicaltrials.gov from the inception of databases up until August 2, 2021, and the search was updated and finalized on October 17, 2021. The intervention group was DOACs and the control group was warfarin. The primary outcome was systemic embolism and stroke (SSE), and the secondary outcome was major bleeding and intracranial hemorrhage. The pooled effect estimate was reported as the hazard ratio (HR) and odds ratio (OR). Results: There were 21,185 patients from seven studies included in this systematic review and meta-analysis. Stroke and systemic embolism were lower in patients receiving DOACs [HR 0.76 (95% CI 0.67, 0.87), p < 0.001; I2: 5%] compared with warfarin. The subgroup analysis on RCTs showed the significant reduction of SSE in the DOACs group [HR 0.73 (95% CI 0.60, 0.89), p = 0.002; I2: 16%]. There was no significant difference in terms of major bleeding [HR 0.89 (95% CI 0.75, 1.05), p = 0.18; I2: 69%]. Intracranial hemorrhage [HR 0.42 (95% CI 0.22, 0.80), p = 0.008; I2: 73%] were lower in the DOAC group. Conclusion: This meta-analysis indicates that DOACs were associated with a lower risk of SSE and intracranial hemorrhage compared with patients receiving warfarin. There was no significant difference between the two groups in terms of major bleeding.
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Affiliation(s)
- Januar Wibawa Martha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | | | - Arief Wibowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia
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11
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Hu B, Ge W, Wang Y, Zhang X, Li T, Cui H, Qian Y, Zhang Y, Li Z. Metabolomic and Proteomic Analyses of Persistent Valvular Atrial Fibrillation and Non-Valvular Atrial Fibrillation. Front Genet 2021; 12:789485. [PMID: 34917134 PMCID: PMC8669813 DOI: 10.3389/fgene.2021.789485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 02/05/2023] Open
Abstract
Atrial fibrillation (AF) is an abnormal heart rhythm related to an increased risk of heart failure, dementia, and stroke. The distinction between valvular and non-valvular AF remains a debate. In this study, proteomics and metabolomics were integrated to describe the dysregulated metabolites and proteins of AF patients relative to sinus rhythm (SR) patients. Totally 47 up-regulated and 41 down-regulated proteins in valvular AF, and 59 up-regulated and 149 down-regulated proteins in non-valvular AF were recognized in comparison to SR patients. Moreover, 58 up-regulated and 49 significantly down-regulated metabolites in valvular AF, and 47 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF patients were identified in comparison to SR patients. Based on analysis of differential levels of metabolites and proteins, 15 up-regulated and 22 down-regulated proteins, and 13 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF were identified relative to valvular AF. KEGG pathway enrichment analysis showed the altered proteins and metabolites were significantly related to multiple metabolic pathways, such as Glycolysis/Gluconeogenesis. Interestingly, the enrichment pathways related to non-valvular AF were obviously different from those in valvular AF. For example, valvular AF was significantly related to Glycolysis/Gluconeogenesis, but non-valvular AF was more related to Citrate cycle (TCA cycle). Correlation analysis between the differentially expressed proteins and metabolites was also performed. Several hub proteins with metabolites were identified in valvular AF and non-valvular AF. For example, Taurine, D-Threitol, L-Rhamnose, and DL-lactate played crucial roles in valvular AF, while Glycerol-3-phosphate dehydrogenase, Inorganic pyrophosphatase 2, Hydroxymethylglutaryl-CoAlyase, and Deoxyuridine 5-triphosphate nucleotidohydrolase were crucial in non-valvular AF. Then two hub networks were recognized as potential biomarkers, which can effectively distinguish valvular AF and non-valvular persistent AF from SR samples, with areas under curve of 0.75 and 0.707, respectively. Hence, these metabolites and proteins can be used as potential clinical molecular markers to discriminate two types of AF from SR samples. In summary, this study provides novel insights to understanding the mechanisms of AF progression and identifying novel biomarkers for prognosis of non-valvular AF and valvular AF by using metabolomics and proteomics analyses.
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Affiliation(s)
- Bo Hu
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wen Ge
- Department of Cardiothoracic Surgery, Shuguang Hospital, Affiliated to Shanghai University of TCM, Shanghai, China
| | - Yuliang Wang
- Department of Immunology, Nanjing Medical University, Nanjing, China
| | - Xiaobin Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tao Li
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Cui
- School of Life Science and Technology, Shanghai Tech University, Shanghai, China
| | - Yongjun Qian
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Yangyang Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi Li
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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12
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Mansi IA, Bhushan S, Albracht DE. Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation. Ann Intern Med 2021; 174:1489. [PMID: 34662169 DOI: 10.7326/l21-0563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ishak A Mansi
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sujata Bhushan
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas
| | - David E Albracht
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Gebreyohannes EA, Salter S, Chalmers L, Bereznicki L, Lee K. Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence. Am J Cardiovasc Drugs 2021; 21:419-433. [PMID: 33369718 DOI: 10.1007/s40256-020-00457-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.
| | - Sandra Salter
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Leanne Chalmers
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, WA, Australia
| | - Luke Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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14
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Dawwas GK, Dietrich E, Cuker A, Barnes GD, Leonard CE, Lewis JD. Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation : A Population-Based Cohort Study. Ann Intern Med 2021; 174:910-919. [PMID: 33780291 DOI: 10.7326/m20-6194] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used in place of warfarin, but evidence about their effectiveness and safety in patients with valvular atrial fibrillation (AF) remains limited. OBJECTIVE To assess the effectiveness and safety of DOACs compared with warfarin in patients with valvular AF. DESIGN New-user retrospective propensity score-matched cohort study. SETTING U.S.-based commercial health care database from 1 January 2010 to 30 June 2019. PARTICIPANTS Adults with valvular AF who were newly prescribed DOACs or warfarin. MEASUREMENTS The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding. RESULTS Among a total of 56 336 patients with valvular AF matched on propensity score, use of DOACs (vs. warfarin) was associated with lower risk for ischemic stroke or systemic embolism (hazard ratio [HR], 0.64 [95% CI, 0.59 to 0.70]) and major bleeding events (HR, 0.67 [CI, 0.63 to 0.72]). The results for the effectiveness and safety outcomes remained consistent for apixaban (HRs, 0.54 [CI, 0.47 to 0.61] and 0.52 [CI, 0.47 to 0.57], respectively) and rivaroxaban (HRs, 0.74 [CI, 0.64 to 0.86] and 0.87 [CI, 0.79 to 0.96], respectively); with dabigatran, results were consistent for the major bleeding outcome (HR, 0.81 [CI, 0.68 to 0.97]) but not for effectiveness (HR, 1.03 [CI, 0.81 to 1.31]). LIMITATION Relatively short follow-up; inability to ascertain disease severity. CONCLUSION In this comparative effectiveness study using practice-based claims data, patients with valvular AF who were new users of DOACs had lower risks for ischemic stroke or systemic embolism and major bleeding than new users of warfarin. These data may be used to guide risk-benefit discussions regarding anticoagulant choices for patients with valvular AF. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ghadeer K Dawwas
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
| | - Eric Dietrich
- College of Pharmacy, University of Florida, Gainesville, Florida (E.D.)
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.C.)
| | | | - Charles E Leonard
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
| | - James D Lewis
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
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15
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AlShoaibi N, Al Harbi M, Modaimegh H, Al Qubbany A, Al Saif S, Connolly DL, Kharabsheh S, Fathy M, Hegazy Y, Tarcha N, Al Fagih A. Use of NOACS in high-risk patients with atrial fibrillation in Saudi Arabia: Perspectives on improving patient care. Expert Rev Cardiovasc Ther 2021; 19:221-236. [PMID: 33475462 DOI: 10.1080/14779072.2021.1878878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite the widespread and increasing use of NOACs in Saudi Arabia, there is a lack of contemporary guidance specific to the region. In particular, guidance on NOAC use in high-risk patients who are more likely to experience bleeding with oral anticoagulant therapy is needed. There is an unmet need for a review of contemporary evidence coupled with expert insights on safe and effective NOAC use in high-risk patients with AF in Saudi Arabia. RESEARCH DESIGN AND METHODS This article provides a detailed review of contemporary literature on NOAC use in high-risk patients with AF. Additionally, key gaps in the literature are identified and expert insights are shared to guide effective management of patients and the significance of local data is evaluated with respect to challenges in optimizing the use of NOACs. CONCLUSIONS This article provides information that complements and expands on existing reviews and guidelines on NOAC use in patients with AF, with a focus on challenges specific to the Saudi Arabian context with the potential to make a positive contribution to the medical community in Saudi Arabia and in other nations.
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Affiliation(s)
| | - M Al Harbi
- King Fahad Specialist Hospital, Dammam KSA
| | | | - A Al Qubbany
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Research Center, Jeddah, KSA.,Ministry of National Guard, KSA
| | | | - D L Connolly
- Birmingham City Hospital & the Institute of Cardiovascular Sciences, University of Birmingham, UK
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16
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Bahuleyan CG, Namboodiri N, Jabir A, Lip GYH, Koshy A G, Shifas BM, Viswanathan S K, Zachariah G, Venugopal K, Punnose E, Natarajan KU, Mini GK, Joseph J, Nambiar C A, Jayagopal PB, Mohanan PP, George R, Unni G, Sajeev CG, Muhammed S, Syam N, Roby A, Daniel R, Krishnakumar VV, Pillai AM, Joseph S, Jinbert Lordson A. One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry. Indian Heart J 2020; 73:56-62. [PMID: 33714410 PMCID: PMC7961260 DOI: 10.1016/j.ihj.2020.11.152] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 11/04/2020] [Accepted: 11/29/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study. METHODS KERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF. RESULTS Mean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA2DS2-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%). CONCLUSIONS Despite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry.
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Affiliation(s)
- C G Bahuleyan
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India.
| | - Narayanan Namboodiri
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - A Jabir
- Lisie Heart Institute, Ernakulam, India
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom; Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - George Koshy A
- Medical College Hospital, Trivandrum, India 8Global Institute of Public Health, 6. Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Babu M Shifas
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Kartik Viswanathan S
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | - K Venugopal
- Pushpagiri Medical College, Thiruvalla, India
| | | | - K U Natarajan
- Amrita Institute of Medical Sciences, Ernakulam, India
| | - G K Mini
- Global Institute of Public Health, Trivandrum, Kerala, India
| | | | | | | | - P P Mohanan
- West Fort Hi-Tech Hospital, Ponkunam, Thrissur, India
| | - Raju George
- Government Medical College Hospital, Kottayam, India
| | | | - C G Sajeev
- Government Medical College Hospital, Calicut, India
| | | | - N Syam
- General Hospital, Kollam, India
| | - Anil Roby
- Dr Damodaran Memorial Hospital, Kollam, India
| | - Rachel Daniel
- N S Memorial Institute of Medical Sciences, Kollam, India
| | - V V Krishnakumar
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Anand M Pillai
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India
| | - Stigi Joseph
- Little Flower Hospital, M C Road, Angamali, India
| | - A Jinbert Lordson
- Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Trivandrum, India; Global Institute of Public Health, Trivandrum, Kerala, India
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17
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Melgaard L, Overvad TF, Jensen M, Lip GYH, Larsen TB, Nielsen PB. Thromboembolic Risk in Nonanticoagulated Patients With Atrial Fibrillation and Valvular Heart Disease. JACC Clin Electrophysiol 2020; 6:1672-1682. [PMID: 33334446 DOI: 10.1016/j.jacep.2020.07.005] [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: 04/14/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study sought to describe the risk of thromboembolism in nonanticoagulated atrial fibrillation patients with Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 2 valvular heart disease (VHD) <65 or 65 to 74 years of age and with 0 or 1 non-sex comorbidity of the CHA2DS2-VASc score. BACKGROUND A minor, but important, proportion of patients with atrial fibrillation and VHD beyond moderate-to-severe mitral stenosis and/or a mechanical prosthetic valve, so-called EHRA Type 2 VHD, have 0 or 1 coexisting non-sex comorbidities of the CHA2DS2-VASc score, and are therefore not strongly recommended oral anticoagulant therapy according to guidelines. Whether these patients are truly low risk of thromboembolism has not been investigated. METHODS This was a cohort study of 55,613 patients identified in nationwide Danish registries from 2000 to 2018, of which 1,907 patients had EHRA Type 2 VHD. Risk of thromboembolism after 1 and 5 years of follow-up were calculated. RESULTS At 1 year after atrial fibrillation diagnosis, patients with EHRA Type 2 VHD had a risk of thromboembolism between 1.2% and 1.5%, according to age group (<65 or 65 to 74 years of age), and number of non-sex comorbidities of the CHA2DS2-VASc score (0 or 1). Interestingly, in patients with EHRA Type 2 VHD <65 years of age with 0 or 1 comorbidity, the risk was 1.5% (95% confidence interval: 0.7% to 2.8%) and 1.5% (95% confidence interval: 0.6% to 3.4%) at 1 year after the atrial fibrillation diagnosis. CONCLUSIONS These observations suggest that in atrial fibrillation patients with EHRA Type 2 VHD, who are not currently recommended oral anticoagulant therapy according to guidelines, the risk of thromboembolism may exceed the level above which oral anticoagulation is considered beneficial.
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Affiliation(s)
- Line Melgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
| | - Thure Filskov Overvad
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Martin Jensen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Liverpool Centre for Cardiovascular Sciences, University Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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18
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Ng DLC, Malik NMBA, Chai CS, Goh GMKC, Tan SB, Bee PC, Gan GG, Said AB. Time in therapeutic range, quality of life and treatment satisfaction of patients on long-term warfarin for non-valvular atrial fibrillation: a cross-sectional study. Health Qual Life Outcomes 2020; 18:347. [PMID: 33081816 PMCID: PMC7576864 DOI: 10.1186/s12955-020-01600-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/13/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The use of warfarin in patients with non-valvular atrial fibrillation (NVAF) can be challenging. In this study, we evaluate the time in therapeutic range (TTR), health-related quality of life (HRQoL) and treatment satisfaction of patients on long-term warfarin for NVAF. The HRQoL and treatment satisfaction were compared based on the TTR. METHODS A cross-sectional study was conducted among patients on warfarin for NVAF who attended the anticoagulant clinic of a tertiary cardiology referral center in Sarawak from 1st June 2018 to 31st May 2019. Patients' TTR was calculated by using Rosendaal technique, while their HRQoL and treatment satisfaction were assessed by using Short Form 12 Health Survey version 2 (SF12v2) and Duke Anticoagulant Satisfaction Scale (DASS), respectively. RESULTS A total of 300 patients were included, with mean TTR score of 47.0 ± 17.3%. The physical component summary (PCS) and mental component summary (MCS) score of SF-12v2 were 47.0 ± 9.0 and 53.5 ± 9.6, respectively. The total score for DASS was 55.2 ± 21.3, while the score for limitations (L), hassles and burdens (H&B) and positive psychological impacts (PPI) were 18.0 ± 10.0, 15.6 ± 9.1 and 21.6 ± 5.9, respectively. Seventy-three (24.3%) patients had good TTR (≥ 60%), with mean of 70.2 ± 8.7%; while 227 (75.5%) patients with poor TTR had significantly lower mean of 39.5 ± 11.9% (p = 0.006). There was no significant difference in the score of PCS (p = 0.150), MCS (p = 0.919) and each domain of SF-12v2 (p = 0.184-0.684) between good and poor TTR, except for social functioning (p = 0.019). The total DASS score was also not significantly different between group (p = 0.779). Similar non-significant difference was also reported in all the DASS sub dimensions (p = 0.502-0.699). CONCLUSIONS Majority of the patients on long-term warfarin for NVAF in the current study have poor TTR. Their HRQoL and treatment satisfaction are independent of their TTR. Achieving a good TTR do not compromise the HRQoL and treatment satisfaction. Therefore, appropriate measures should be taken to optimise INR control, failing which direct oral anticoagulant therapy should be considered.
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Affiliation(s)
- Diana-Leh-Ching Ng
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Natasya Marliana Bt Abdul Malik
- Department of Nursing, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Chee-Shee Chai
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Greta-Miranda-Kim-Choo Goh
- Department of Nursing, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Seng-Beng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping-Chong Bee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Gin-Gin Gan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Asri B Said
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia.
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19
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Lévy S, Santini L, Cappato R, Steinbeck G, Capucci A, Saksena S. Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol 2020; 59:495-507. [PMID: 33048302 DOI: 10.1007/s10840-020-00859-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
Symptomatic atrial fibrillation (AF) or clinical AF is associated with impaired quality of life, higher risk of stroke, heart failure, and increased mortality. Current clinical classification of AF is based on the duration of AF episodes and the recurrence over time. Appropriate management strategy should follow guidelines of Scientific Societies. The last decades have been marked by the advances in mechanism comprehension, better management of symptomatic AF, particularly regarding stroke prevention with the use of direct oral anticoagulants and a wider use of AF catheter or surgical ablations. The advent of new tools for detection of asymptomatic AF including continuous monitoring with implanted electronic devices and the use of implantable cardiac monitors and recently wearable devices or garments have identified what is called "subclinical AF" encompassing atrial high-rate episodes (AHREs). New concepts such as "AF burden" have resulted in new management challenges. Oral anticoagulation has proven to reduce substantially stroke risk in patients with symptomatic clinical AF but carries the risk of bleeding. Management of detected asymptomatic atrial arrhythmias and their relation to clinical AF and stroke risk is currently under evaluation. Based on a review of recent literature, the validity of current clinical classification has been reassessed and appropriate updates are proposed. Current evidence supporting the inclusion of subclinical AF within current clinical classification is discussed as well as the need for controlled trials which may provide responses to current therapeutic challenges particularly regarding the subsets of asymptomatic AF patients that might benefit from oral anticoagulation.
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Affiliation(s)
- Samuel Lévy
- Marseille School of Medicine, Aix-Marseille University, Marseille, France.
| | - Luca Santini
- Cardiology Division, G. B. Grassi Hospital, Via G. Passeroni 28, Ostia Lido, RM, Italy
| | - Riccardo Cappato
- Arrhythmia and Elecrtrophysiology Center, IRCCS-MultiMedica Group, Via Milanese 300, 20099, Milan, Sesto San Giovanni, Italy
| | | | - Alessandro Capucci
- Department of Cardiology, Università Politecnica delle Marche, Ancona, Italy
| | - Sanjeev Saksena
- Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ, USA
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Liu Y, Wang J, Zeng WZ, Lyu QS. Nonlinear relationship between serum total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation. J Int Med Res 2020; 48:300060520962347. [PMID: 33100092 PMCID: PMC7645432 DOI: 10.1177/0300060520962347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objective This study aimed to examine the relationship between total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation. Methods This was a retrospective study. Atrial fibrillation was diagnosed by 24-hour Holter electrocardiography and serum total bilirubin levels were divided into quintiles. Ischemic stroke was diagnosed by symptoms, signs, and a medical image examination. The multivariate Cox proportional hazards model and survival analysis were used to estimate the association of total bilirubin with initial ischemic stroke. Results We studied 316 patients with non-valvular atrial fibrillation. During follow-up, there were 42 (13.29%) first ischemic strokes. After multivariate adjustment, for each 1 µmol/L increase in total bilirubin, the risk of first ischemic stroke increased by 4% (95% confidence interval [CI]: 1.01, 1.07). When using the first quintile as the reference, from the second to fifth quintiles, the risks of first ischemic stroke were 0.52 (95% CI: 0.17, 1.65), 0.23 (95% CI: 0.06, 0.87), 0.92 (95% CI: 0.32, 2.67), and 1.33 (95% CI: 1.09, 4.41), respectively. The optimal cut-off point of total bilirubin for the lowest risk of ischemic stroke was 17.0 µmol/L. Conclusions Total bilirubin levels are nonlinearly associated with initial ischemic stroke in patients with non-valvular atrial fibrillation.
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Affiliation(s)
- Ying Liu
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China
| | - Jie Wang
- Department of Cardiology, The Central Hospital of Yongzhou, Yongzhou, Hunan, China.,Jishou University, Jishou, Hunan, China
| | - Wen-Zhen Zeng
- Department of Cardiology, The Central Hospital of Yongzhou, Yongzhou, Hunan, China
| | - Qing-Shan Lyu
- Department of Cardiology, The Central Hospital of Yongzhou, Yongzhou, Hunan, China
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Melgaard L, Jensen M, Overvad TF, Larsen TB, Lip GYH, Nielsen PB. Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study. Int J Clin Pract 2020; 74:e13589. [PMID: 32574395 DOI: 10.1111/ijcp.13589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS The risks of thromboembolism and bleeding in patients with atrial fibrillation (AF) and valvular heart disease (VHD) are sparsely described. We described the risk of events in non-anticoagulated and anticoagulated patients with AF and VHD according to the evaluated heart valves, rheumatic or artificial valve classification (EHRA classification), EHRA Type 1 and Type 2 VHD, and within subgroups of EHRA Type 1 and Type 2 VHD. METHODS AND RESULTS Cohort study of AF patients with coexisting VHD, identified in nationwide Danish registries from 2000 to 2018. Risk of thromboembolism and bleeding after 1 year of follow-up were calculated in each group. We identified 28 770 incident AF patients with VHD. Not surprisingly, we observed the highest risks of thromboembolism in the non-anticoagulated AF patients with EHRA Type 1 and Type 2 VHD (4.9% vs 2.6% and 3.2% vs 1.9%) and the highest risks of bleeding in the anticoagulated AF patients with EHRA Type 1 and Type 2 VHD (6.6% vs 4.3% and 6.1% vs 4.9%). However, within the subgroups of AF patients with EHRA Type 1 and Type 2 VHD, we observed a large proportion of non-anticoagulated patients (32.9%-49.2%), despite a CHA2 DS2 -VASc score of 2≤ in the majority of these patients (81.9%-95.6%). CONCLUSIONS When using data reflecting contemporary clinical practice, we observed markedly different risks of thromboembolism and bleeding in EHRA Type 1 and Type 2 VHD. Additionally, we observed a potential underuse of oral anticoagulation within the subgroups of AF patients with EHRA Type 1 and Type 2 VHD, underlining need for further attention on this patient group.
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Affiliation(s)
- Line Melgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Martin Jensen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Thure F Overvad
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Torben B Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Liverpool Centre for Cardiovascular Sciences, University Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Peter B Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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Atrial Fibrillation and Aortic Stenosis: Complex Interactions Between 2 Diseases. JACC Cardiovasc Interv 2020; 13:2134-2136. [PMID: 32972575 DOI: 10.1016/j.jcin.2020.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/22/2022]
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Wang YP, Kehar R, Iansavitchene A, Lazo-Langner A. Bleeding Risk in Nonvalvular Atrial Fibrillation Patients Receiving Direct Oral Anticoagulants and Warfarin: A Systematic Review and Meta-Analysis of Observational Studies. TH OPEN 2020; 4:e145-e152. [PMID: 32676543 PMCID: PMC7358046 DOI: 10.1055/s-0040-1714918] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/26/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction In randomized trials in atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) have a lower risk of bleeding compared with warfarin. However, data from randomized trials may not extrapolate to general population. We aimed to determine the risk of bleeding in patients on DOACs in observational studies. Materials and Methods Observational studies from 1990 to January 2019 were included. A pooled effect hazard ratio (HR) was calculated with a random effects model using the generic inverse variance method. Subgroup analyses according to previous anticoagulants exposure, study type, funding source, and DOAC type (direct thrombin inhibitors vs. factor Xa inhibitors) were conducted. Results A total of 35 studies comprising 2,356,201 patients were included. The average pooled HR for observational data was 0.78 (95% confidence interval [CI] 0.71, 0.85). There were no statistically significant differences in pooled HR by previous exposure to anticoagulants, DOAC type (direct thrombin vs. factor Xa inhibitors), study type, and funding source. Among patients receiving factor Xa inhibitors, patients on apixaban had a lower risk of bleeding compared with warfarin (HR 0.60, 95% CI 0.50, 0.71, p < 0.001) in contrast to those on rivaroxaban (HR 0.98, 95% CI 0.91, 1.06, p = 0.60). Conclusion In observational studies, AF patients on DOACs experience less bleeding events compared with warfarin; however, apixaban and dabigatran, but not rivaroxaban, have a lower risk of bleeding than warfarin.
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Affiliation(s)
- Yimin Pearl Wang
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Rohan Kehar
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alla Iansavitchene
- Library Services, London Health Sciences Centre, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Arenas Miquélez A, Requena Calleja MA, Gullón A, Pose Reino A, Formiga F, Camafort M, Cepeda Rodrigo JM, Mostaza JM, Fernández CS, Díez-Manglano J. Nutritional Risk and Mortality at One Year for Elderly Patients Hospitalized with Nonvalvular Atrial Fibrillation. NONAVASC Registry. J Nutr Health Aging 2020. [DOI: 10.1007/s12603-020-1507-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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25
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Anticoagulant acrobatics: Surviving the global heparin shortage in the emergency department. Am J Emerg Med 2020; 38:1291-1293. [DOI: 10.1016/j.ajem.2019.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 11/20/2022] Open
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Mayer M. Shared decision making for thromboembolic prophylaxis in non-valvular atrial fibrillation: promise and problems with the American College of Cardiology's AnticoagEvaluator (based on SPARCtool). BMJ Evid Based Med 2020; 25:90-96. [PMID: 31040124 DOI: 10.1136/bmjebm-2018-111098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND METHODS People with atrial fibrillation face an increased risk of thromboembolic events, and deciding on an antithromboembolic strategy in non-valvular atrial fibrillation is a prime opportunity for shared decision making. Therefore, tools facilitating this process are highly desirable. The American College of Cardiology strives for such with its 'AnticoagEvaluator', which is based on Peter Loewen's 'SPARCtool'. However, it appears these tools were released without standard peer review. Therefore, an analysis of these tools was undertaken to evaluate their soundness, namely proper use of baseline risk and effect estimates from the available evidence. RESULTS Despite Loewen's laudable idea and the American College of Cardiology developing AnticoagEvaluator based on Loewen's work, both tools have a flaw: they use relative effect estimates based on composite outcomes (thromboembolic and haemorrhagic) that do not match the baseline risk to which they are applied (thromboembolic). This can lead to importantly inaccurate impressions of therapeutic efficacy. This analysis explores this issue and offers potential solutions. CONCLUSIONS The American College of Cardiology releasing and promoting a tool that gives misleading impressions of therapeutic efficacy is of considerable importance, though SPARCtool should also be corrected as a matter of importance. Means to correct the tools are identified herein, and if corrected, these tools stand to better fulfil their intended purpose as important and useful additions for clinical and shared decision making. This article's analysis of the tools has a directly practical purpose, but it also serves as an instructive example of key elements of evidence-based medicine and shared decision making.
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Affiliation(s)
- Martin Mayer
- Innovations and Evidence-Based Medicine Development, EBSCO Health|EBSCO Information Services, Ipswich, Massachusetts, USA
- East Carolina Heart Institute, General Medicine Service, Vidant Medical Center, Greenville, North Carolina, USA
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Chen N, Alam AB, Lutsey PL, MacLehose RF, Claxton JS, Chen LY, Chamberlain AM, Alonso A. Polypharmacy, Adverse Outcomes, and Treatment Effectiveness in Patients ≥75 With Atrial Fibrillation. J Am Heart Assoc 2020; 9:e015089. [PMID: 32448024 PMCID: PMC7429010 DOI: 10.1161/jaha.119.015089] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Polypharmacy is highly prevalent in elderly people with chronic conditions, including atrial fibrillation (AF). The impact of polypharmacy on adverse outcomes and on treatment effectiveness in elderly patients with AF remains unaddressed. Methods and Results We studied 338 810 AF patients ≥75 years of age enrolled in the MarketScan Medicare Supplemental database in 2007–2015. Polypharmacy was defined as ≥5 active prescriptions at AF diagnosis (defined by the presence of International Classification of Diseases, Ninth Revision, Clinical Modification [ICD‐9‐CM] codes) based on outpatient pharmacy claims. AF treatments (oral anticoagulation, rhythm and rate control) and cardiovascular end points (ischemic stroke, bleeding, heart failure) were defined based on inpatient, outpatient, and pharmacy claims. Multivariable Cox models were used to estimate associations of polypharmacy with cardiovascular end points and the interaction between polypharmacy and AF treatments in relation to cardiovascular end points. Prevalence of polypharmacy was 52%. Patients with polypharmacy had increased risk of major bleeding (hazard ratio [HR], 1.16; 95% CI, 1.12–1.20) and heart failure (HR, 1.33; 95% CI, 1.29–1.36) but not ischemic stroke (HR, 0.96; 95% CI, 0.92–1.00), compared with those not receiving polypharmacy. Polypharmacy status did not consistently modify the effectiveness of oral anticoagulants. Rhythm control (versus rate control) was more effective in preventing heart failure hospitalization in patients not receiving polypharmacy (HR, 0.87; 95% CI, 0.76–0.99) than among those with polypharmacy (HR, 0.98; 95% CI, 0.91–1.07; P=0.02 for interaction). Conclusion Polypharmacy is common among patients ≥75 with AF, is associated with adverse outcomes, and may modify the effectiveness of AF treatments. Optimizing management of polypharmacy in AF patients ≥75 may lead to improved outcomes.
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Affiliation(s)
- Nemin Chen
- Department of Epidemiology School of Public Health University of Pittsburgh PA
| | - Aniqa B Alam
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Richard F MacLehose
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - J'Neka S Claxton
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Lin Y Chen
- Cardiovascular Division Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Alanna M Chamberlain
- Division of Epidemiology Department of Health Sciences Research Mayo Clinic Rochester MN
| | - Alvaro Alonso
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
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Sasko B, Ritter O, Bramlage P, Riediger F. Late left atrial appendage closure device displacement and massive thrombus formation: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32352063 PMCID: PMC7180543 DOI: 10.1093/ehjcr/ytaa014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/14/2019] [Accepted: 01/16/2020] [Indexed: 11/13/2022]
Abstract
Background Left atrial appendage (LAA) closure with the WATCHMAN device is an alternative to anticoagulation therapy for the prevention of stroke in selected patients with atrial fibrillation (AF). Infrequently, left atrial (LA) device-related thrombus formation occurs and it is poorly understood. Thrombus formation due to incomplete covering of the LAA is even rarer and may occur within the first few months after device implantation. Case summary Here, we present a case of a 68-year-old male patient with permanent AF, drug- and hepatitis induced liver cirrhosis (CILD Score B), and prior aortic valve replacement. The patient had a history of percutaneous LAA closure using a WATCHMAN device. He developed massive peri-device leak and thrombus arising from the space between the device and appendage cleft 2 years after implantation. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation. The patient was discharged in good clinical condition and has been scheduled for a yearly follow-up. Discussion This case emphasizes the importance of choosing appropriately sized LAA occluder devices and planning for regular post-interventional follow-ups to minimize the risk of per-device leaks and thrombi.
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Affiliation(s)
- Benjamin Sasko
- Department of Internal Medicine I - Cardiology, Brandenburg Medical Faculty, Hochstr. 29, 14770 Brandenburg/Havel, Germany
| | - Oliver Ritter
- Department of Internal Medicine I - Cardiology, Brandenburg Medical Faculty, Hochstr. 29, 14770 Brandenburg/Havel, Germany
| | - Peter Bramlage
- Department of Internal Medicine I - Cardiology, Brandenburg Medical Faculty, Hochstr. 29, 14770 Brandenburg/Havel, Germany.,Institute for Pharmacology and Preventive Medicine, Bahnhofstraße 20, 49661 Cloppenburg, Germany
| | - Fabian Riediger
- Department of Internal Medicine I - Cardiology, Brandenburg Medical Faculty, Hochstr. 29, 14770 Brandenburg/Havel, Germany
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Chang JC. Stroke Classification: Critical Role of Unusually Large von Willebrand Factor Multimers and Tissue Factor on Clinical Phenotypes Based on Novel "Two-Path Unifying Theory" of Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620913634. [PMID: 32584600 PMCID: PMC7427029 DOI: 10.1177/1076029620913634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Stroke is a hemostatic disease associated with thrombosis/hemorrhage caused by intracranial vascular injury with spectrum of clinical phenotypes and variable prognostic outcomes. The genesis of different phenotypes of stroke is poorly understood due to our incomplete understanding of hemostasis and thrombosis. These shortcomings have handicapped properly recognizing each specific stroke syndrome and contributed to controversy in selecting therapeutic agents. Treatment recommendation for stroke syndromes has been exclusively derived from the result of laborious and expensive clinical trials. According to newly proposed "two-path unifying theory" of in vivo hemostasis, intracranial vascular injury would yield several unique stroke syndromes triggered by 3 distinctly different thrombogenetic mechanisms depending upon level of intracranial intravascular injury and character of formed blood clots. Five major phenotypes of stroke occur via thrombogenetic paths: (1) transient ischemic attack due to focal endothelial damage limited to endothelial cells (ECs), (2) acute ischemic stroke due to localized ECs and subendothelial tissue (SET) damage extending up to the outer vascular wall, (3) thrombo-hemorrhagic stroke due to localized vascular damage involving ECs and SET and extending beyond SET to extravascular tissue, (4) acute hemorrhagic stroke due to major localized intracranial hemorrhage/hematoma into the brain tissue or space between the coverings of the brain associated with vascular anomaly or obtuse trauma, and (5) encephalopathic stroke due to disseminated endotheliopathy leading to microthrombosis within the brain. New classification of stroke phenotypes would assist in selecting rational therapeutic regimen for each stroke syndrome and designing clinical trials to improve clinical outcome.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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Mitchell A, Welsh TJ, Watson MC, Snowball J, McGrogan A. Use of oral anticoagulants in older people with atrial fibrillation in UK general practice: protocol for a cohort study using the Clinical Practice Research Datalink (CPRD) database. BMJ Open 2019; 9:e032646. [PMID: 31843842 PMCID: PMC6924720 DOI: 10.1136/bmjopen-2019-032646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Warfarin has frequently been underused in older people for stroke prevention in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) entered the UK market from 2008 and have been recommended as an alternative to warfarin. This study aimed to describe any changes in the prescribing of oral anticoagulants (OACs) to people aged ≥75 years in UK general practice before and after the introduction of DOACs, to examine differences in patient characteristics which may influence prescribers' decisions regarding anticoagulation, to evaluate the time people stay on OACs and switching between OACs. METHODS AND ANALYSIS A retrospective cohort study design will be used. Patients with a diagnosis of AF will be identified from the Clinical Practice Research Datalink (CPRD). The study period will run from 1 January 2003 to 27 December 2017. Patients enter the cohort at the latest date of the start of the study period, first AF diagnosis, 75th birthday or a year from when they started to contribute research standard data. Follow-up continues until they leave the practice, death, the date the practice stops contributing research standard data or the end of the study period (27 December 2017). Exposure to OACs will be defined as ≥1 prescription issued for an OAC of interest during the study period. Patients issued an OAC in the year preceding study entry will be defined as 'prevalent users'. Patients starting on an OAC during the study period will be defined as 'incident users'. Incidence and prevalence of OAC prescribing, patient demographics and characteristics will be described during three time periods: 2003-2007, 2008-2012 and 2013-2017. Persistence (defined as the time from initiation to discontinuation of medication) with and switching between different OACs will be described. ETHICS AND DISSEMINATION The protocol for this study was approved by the CPRD Independent Scientific Advisory Committee. The results will be disseminated in a peer-reviewed journal and at conferences. TRIAL REGISTRATION NUMBER EUPAS29923.
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Affiliation(s)
- Anneka Mitchell
- Pharmacy and Pharmacology, University of Bath, Bath, Somerset, UK
- Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Tomas J Welsh
- Research Institute for the Care of Older People, Bath, Somerset, UK
- Institute of Clinical Neurosciences, University of Bristol, Bristol, Bristol, UK
- Older Persons Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, Somerset, UK
| | - Margaret C Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Glasgow, UK
| | - Julia Snowball
- Pharmacy and Pharmacology, University of Bath, Bath, Somerset, UK
| | - Anita McGrogan
- Pharmacy and Pharmacology, University of Bath, Bath, Somerset, UK
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Chowdhury R, Franchino-Elder J, Wang L, Yuce H, Wang C, Hartaigh BO. Healthcare resource utilization and expenditures among newly-diagnosed elderly non-valvular atrial fibrillation patients initiating oral anticoagulants. J Med Econ 2019; 22:1338-1350. [PMID: 31549883 DOI: 10.1080/13696998.2019.1672698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: Non-valvular atrial fibrillation (NVAF) prevalence increases with age. Hence, evaluating the economic burden among older-aged patients is vital. This study aimed to compare healthcare resource utilization (HRU) and costs among newly-diagnosed older-aged NVAF patients treated with warfarin, rivaroxaban, or apixaban vs. dabigatran.Materials and Methods: Newly-diagnosed older-aged (aged ≥65 years) NVAF patients initiating dabigatran, warfarin, rivaroxaban, or apixaban (first prescription date = index date) from 01JAN2010-31DEC2015 and with continuous enrollment for ≥12 months pre-index date were included from 100% Medicare database. Patient data were assessed until drug discontinuation/switch/dose change/death/disenrollment/study end (up to 12 months). Dabigatran initiators were 1:1 propensity score-matched (PSM) with warfarin, rivaroxaban, or apixaban initiators. Generalized linear models were used to compare all-cause HRU and costs per-patient-per-month (PPPM) between the matched cohorts.Results: After PSM with dabigatran, 70,531 warfarin, 51,673 rivaroxaban, and 25,209 apixaban patients were identified. Dabigatran patients had significantly fewer generalized-linear-model-adjusted PPPM hospitalizations (0.114 vs. 0.123; 0.111 vs. 0.121), and outpatient visits (2.864 vs. 4.201; 2.839 vs. 2.949) than warfarin and rivaroxaban patients, respectively, but had significantly more PPPM hospitalizations (0.103 vs. 0.090) and outpatient visits (2.780 vs. 2.673) than apixaban patients (all p < .0001). Dabigatran patients incurred significantly lower adjusted total PPPM costs ($3,309 vs. $3,362; $3,285 vs. $3,474) than warfarin and rivaroxaban patients, respectively (all p < .01) but higher total PPPM costs ($3,192 vs. $2,986) than apixaban patients (all p < .0001).Limitations: This study is subject to the inherent limitations of any claims dataset, including potential bias from coding errors and identification of medical conditions using diagnosis codes as opposed to clinical evidence. Medications filled over-the-counter or provided as samples by the physician are never captured in claims data.Conclusions: Newly-diagnosed older-aged NVAF patients initiating dabigatran incurred significantly lower adjusted all-cause HRU and costs than warfarin and rivaroxaban patients but higher adjusted HRU and costs than apixaban patients.
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Affiliation(s)
- Ritam Chowdhury
- Center for Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA, USA
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | - Li Wang
- STATinMED Research, Plano, TX, USA
- New York City College of Technology (CUNY), New York, NY, USA
| | - Huseyin Yuce
- New York City College of Technology (CUNY), New York, NY, USA
| | - Cheng Wang
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
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32
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Kalich BA. Complex management of atrial fibrillation. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Direct oral anticoagulants (DOACs) have been developed as a viable and in some cases superior alternative to warfarin. These agents have overcome some of the limitations of warfarin, which has a narrow therapeutic window and many food and drug interactions. DOACs have been demonstrated to have a more predictable and reliable pharmacology and, unlike warfarin, do not require frequent monitoring of anticoagulant effect. For these reasons, the use of DOACs is increasing. Despite the many positive attributes of these agents, limitations and contraindications do exist. An understanding of the pharmacology, indications, and contraindications is therefore crucial for effective patient management. We review the available agents to aid in effective drug utilization.
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Requena Calleja M, Arenas Miquélez A, Díez-Manglano J, Gullón A, Pose A, Formiga F, Mostaza J, Cepeda J, Suárez C. Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Batta A, Kalra BS, Khirasaria R. Critical Issues and Recent Advances in Anticoagulant Therapy: A Review. Neurol India 2019; 67:1200-1212. [PMID: 31744944 DOI: 10.4103/0028-3886.271256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
As the population is aging, clinicians are coming across more patients with atrial fibrillation and venous thromboembolism requiring anticoagulation to prevent stroke and systemic embolisms. Due to a high prevalence and unfavorable consequences, managing thromboembolic diseases have become areas of clinical concern. Traditional anticoagulants like heparin, low molecular weight heparin and warfarin have been used for the prevention and treatment of venous and arterial thromboses. But, issues of bleeding, parenteral route of administration, or the need for frequent monitoring due to variability in response respectively limit their use. The article gives an overview of coagulation along with existing therapy available for anticoagulation and to present an update on utility and recent advances of new oral anticoagulants (NOACs) beginning from their nomenclature, advantages, disadvantages, precautions and contraindications compared with those of vitamin K antagonists (VKAs) based on a large number of recent studies and clinical trials.
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Affiliation(s)
- Angelika Batta
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Bhupinder S Kalra
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Raj Khirasaria
- Department of Pharmacology, Baroda Medical College and SSG Hospital, Vadodara, Gujarat, India
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Duman H, Dilek N, Demirelli S, Inci S, Duman H, Çetin M, Durakoğlugil ME. The relationship between total atrial conduction time and left atrial global strain in patients with psoriasis vulgaris. Arch Med Sci 2019; 15:865-871. [PMID: 31360181 PMCID: PMC6657257 DOI: 10.5114/aoms.2019.82678] [Citation(s) in RCA: 4] [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: 12/27/2016] [Accepted: 03/30/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Psoriasis vulgaris is a chronic, multisystem disease that results in the development of atrial fibrillation (AF) over time. In this study, our goal was to assess predictors of AF in patients with psoriasis, including total atrial conduction time (TACT) and left atrial global longitudinal strain (LAGLS). MATERIAL AND METHODS A total of 80 individuals, including 40 psoriasis patients and 40 healthy controls, were enrolled in the study. A physical examination was performed, biochemical parameters were studied, and Holter electrocardiography was carried out. Conventional echocardiography, atrial tissue Doppler, and speckle tracking echocardiography were recorded. RESULTS No significant difference was observed between psoriasis patients and healthy controls with regard to age, and the average duration of psoriasis was 5.7 years. High-sensitivity C reactive protein levels were higher in the patient group compared to the control group (respectively, group 1: 1 ±0.8; group 2: 0.6 ±0.3, p < 0.05). Atrial arrhythmia was not detected in the Holter ECG monitoring. A significant moderate negative correlation between TACT and LAGLS (r = -0.57, p < 0.05) was observed, and there was a significant moderate positive correlation between the duration of disease and TACT (r = 0.52, p < 0.05). CONCLUSIONS In the current study, we determined that LAGLS decreased, TACT was prolonged, and P-wave dispersion increased in patients with psoriasis. The current results may improve predictions of AF risk in psoriasis patients in clinical practice.
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Affiliation(s)
- Hakan Duman
- Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Nursel Dilek
- Department of Dermatology, Rize University Medical Faculty, Rize, Turkey
| | - Selami Demirelli
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Sinan Inci
- Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey
| | - Handan Duman
- Department of Family Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Mustafa Çetin
- Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
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Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. Rev Clin Esp 2019; 219:424-432. [PMID: 31109685 DOI: 10.1016/j.rce.2019.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/20/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine the prevalence of sarcopenia, frailty and cognitive impairment in elderly patients with nonvalvular atrial fibrillation (NVAF) and the factors' influence on survival. METHODS Prospective, multicentre cohort study of patients older than 75 years with NVAF hospitalised in internal medicine departments in Spain. For each patient, we recorded the creatinine, haemoglobin and platelet levels, the scores on the CHA2DS2-VASc and HAS-BLED scales and Charlson index, as well as the use of oral anticoagulants. We measured sarcopenia with the SARC-F scale, frailty with the FRAIL scale and cognitive impairment with the Short Portable Mental State Questionnaire. We also conducted a 1-year follow-up. RESULTS The study included 596 patients with NVAF, with a mean age of 84.9 (SD: 5.2) years. Of these, 295 (49.5%) presented sarcopenia, 305 (51.2%) presented frailty, and 251 (42.1%) presented cognitive impairment. At the end of 1year, 226 (37.9%) patients had died. Mortality was greater for the patients with sarcopenia, frailty and cognitive impairment. In the multivariate analysis, sarcopenia (HR: 1.775; 95%CI: 1.270-2.481), age, comorbidity and a history of peripheral embolism were associated with increased mortality, and the use of oral anticoagulants at discharge (HR: 0.415; 95%CI: 0.307-0.560) was associated with lower mortality. CONCLUSIONS Sarcopenia, frailty and cognitive impairment are very common in elderly patients with NVAF and are frequently associated. Sarcopenia was associated with increased mortality.
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Brieger D, Amerena J, Attia J, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani H, Hendriks J, Hespe C, Hung J, Kalman JM, Sanders P, Worthington J, Yan TD, Zwar N. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2019; 27:1209-1266. [PMID: 30077228 DOI: 10.1016/j.hlc.2018.06.1043] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - John Amerena
- Geelong Cardiology Research Unit, University Hospital Geelong, Geelong, Australia
| | - John Attia
- University of Newcastle, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney & Department of Pharmacy, Royal North Shore Hospital, Australia
| | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Cia Connell
- The National Heart Foundation of Australia, Melbourne, Australia
| | - Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Caleb Ferguson
- Western Sydney University, Western Sydney Local Health District, Blacktown Clinical and Research School, Blacktown Hospital, Sydney, Australia
| | | | - Haris Haqqani
- University of Queensland, Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
| | - Jeroen Hendriks
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Director of Heart Rhythm Services, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John Worthington
- RPA Comprehensive Stroke Service, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nicholas Zwar
- Graduate Medicine, University of Wollongong, Wollongong, Australia
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Drivers of hospitalisation trends for non-valvular atrial fibrillation in Western Australia, 2000–2013. Int J Cardiol 2019; 276:273-277. [DOI: 10.1016/j.ijcard.2018.09.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 11/21/2022]
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Christesen AMS, Vinter N, Mortensen LS, Fenger-Grøn M, Johnsen SP, Frost L. Inequality in oral anticoagulation use and clinical outcomes in atrial fibrillation: a Danish nationwide perspective. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 4:189-199. [PMID: 30102321 DOI: 10.1093/ehjqcco/qcy011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/19/2018] [Indexed: 12/11/2022]
Abstract
Aim To explore the potential of small-area variation analysis as a tool for identifying unwarranted variation in oral anticoagulation (OAC) use and clinical outcomes in patients with atrial fibrillation (AF) and thereby identify locations with opportunity for improvement in AF care. Methods and results Based on Danish health care registries, we conducted a nationwide historical cohort study including first-time AF patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75, diabetes, thromboembolism, vascular disease, age 65-74, and sex category) score ≥ 2 between 2007 and 2014 (n = 94 482). For each administrative region and municipality, we assessed OAC initiation and persistence as well as the risk of ischaemic stroke, haemorrhagic stroke, and other major bleeding, respectively. In addition, potential temporal changes were examined for all outcomes. Initiation of OAC varied among regions from 49.5% to 62.4%. In patients initiating OAC, the proportion of patients still receiving OAC after 1 year varied from 73.9% to 79.3%. Oral anticoagulation use increased in all regions during the study period, particularly after 2010, but regional variation in OAC initiation persisted. Generally, the regions and municipalities with the highest initiation of OAC also had the highest OAC persistence. The risk of ischaemic stroke and other major bleeding was lower in these regions and municipalities. We found no significant difference between regions in risk of haemorrhagic stroke. Conclusion Substantial geographical variation in OAC use and clinical outcomes occurs in Denmark demonstrating the potential of small-area variation analysis as a tool for identifying unwarranted variation in AF care and clinical outcomes. Our findings demonstrate the need for additional initiatives to ensure uniform high-quality care for AF patients.
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Affiliation(s)
- Amanda Marie Somer Christesen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
| | | | - Morten Fenger-Grøn
- Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, Denmark
| | - Søren Paaske Johnsen
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N, Denmark.,Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Mølleparkvej 10, Aalborg, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
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Lombard FW, Liang Y. Risk Factors for Mitral Valve Surgery: Atrial Fibrillation and Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2019; 23:57-69. [PMID: 30608218 DOI: 10.1177/1089253218821694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Yafen Liang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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Elevated blood plasma levels of tissue factor-bearing extracellular vesicles in patients with atrial fibrillation. Thromb Res 2019; 173:141-150. [DOI: 10.1016/j.thromres.2018.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/05/2018] [Accepted: 11/27/2018] [Indexed: 02/06/2023]
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Characterization of circRNA‑associated ceRNA networks in patients with nonvalvular persistent atrial fibrillation. Mol Med Rep 2018; 19:638-650. [PMID: 30483740 DOI: 10.3892/mmr.2018.9695] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/13/2018] [Indexed: 11/05/2022] Open
Abstract
Circular RNAs (circRNAs) are non-coding RNAs forming closed-loop structures, and their aberrant expression may lead to disease. However, the potential network of circRNA‑associated competing endogenous RNA (ceRNA) involved in nonvalvular persistent atrial fibrillation (NPAF) has not been previously reported. In the present study, four left atrial appendages (LAA) of patients with NPAF and four normal LAAs were examined via RNA sequencing, and their potential functions were investigated via bioinformatics analysis. The circRNA‑enriched genes were analyzed using Gene Ontology (GO) categories, while the enrichment of circRNAs was detected via the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. A total of 296 significantly dysregulated circRNA transcripts were obtained, with 238 upregulated and 58 downregulated. A number of circRNAs were further confirmed using reverse transcription‑quantitative polymerase chain reaction analysis. Furthermore, the more comprehensive circRNA‑associated ceRNA networks were examined in patients with NPAF. GO categories and KEGG annotation analysis of circRNAs revealed that the circRNA‑associated ceRNA networks were likely to influence AF though alterations in calcium and cardiac muscle contraction. The circRNA‑associated ceRNA networks revealed that dysregulated circRNAs in NPAF may be involved in regulating hsa‑microRNA (miR)‑208b and hsa‑miR‑21. To the best of our knowledge, this study presents the circRNA‑associated ceRNA networks in NPAF for the first time, which may have potential implications for the pathogenesis of AF. This study reveals a potential perspective from which to investigate circRNAs in circRNA‑associated ceRNA networks (hsa_circRNA002085, hsa_circRNA001321) in NPAF, and provides a potential biomarker for AF.
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Clinical Outcomes of Valvular versus Nonvalvular Atrial Fibrillation in Acute Anterior Circulation Occlusive Stroke Undergoing Endovascular Treatment. J Stroke Cerebrovasc Dis 2018; 28:31-37. [PMID: 30291030 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/21/2018] [Accepted: 09/02/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Thrombectomy is the first choice for cardioembolism due to atrial fibrillation (AF), however, whether valvular AF and nonvalvular AF had different safety and functional outcomes has not been reported yet. We aimed to investigate the differences between patients with valvular AF and patients with nonvalvular AF on safety and functional outcomes in acute large artery occlusion undergoing thrombectomy. METHODS Valvular AF refers to patients with mitral stenosis or artificial heart valves and valve repair. Rate of symptomatic intracerebral hemorrhage [sICH], modified Rankin Scale Score (mRS), and death at 90 days were compared between valvular AF and nonvalvular AF groups. Univariate and multivariable logistic regression was performed to identify the predictors for unfavorable functional outcome (mRS 3-6). RESULTS 18.8% (51/271) of AF were valvular AF. The valvular AF group had significantly higher proportion of mRS 0-2 (49% [25/51] versus 33.3% [73/219], P = .04) and less death (21.6% [11/51] versus 38.4% [84/219], P = .02) comparing with nonvalvular AF group. The rates of sICH between both groups were nonsignificantly different (21.5% [47/219] for nonvalvular AF versus 13.7% [7/51] for valvular AF, P = .46). Valvular AF was not an independent predictor for unfavorable functional outcome (odds ratio .67, 95% confidence interval: .24-1.84) with age, collateral flow, chronic heart failure, NIHSS at admission, recanalization status, glucose at admission, occlusion site, ASPECTS, and ICH as covariates. CONCLUSIONS Valvular AF and nonvalvular AF have similar safety and functional outcomes in patients with acute anterior circulation large artery occlusion undergoing thrombectomy.
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Cohen A, Hill N, Luo X, Masseria C, Abariga S, Ashaye A. A systematic review of network meta-analyses among patients with nonvalvular atrial fibrillation: A comparison of efficacy and safety following treatment with direct oral anticoagulants. Int J Cardiol 2018; 269:174-181. [DOI: 10.1016/j.ijcard.2018.06.114] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/12/2018] [Accepted: 06/29/2018] [Indexed: 12/20/2022]
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Panaich SS, Munger T, Friedman P, Rihal CS, Holmes DR. Case-Based Discussion Regarding Challenges in Patient Selection and Procedural Planning in Left Atrial Appendage Occlusion. Mayo Clin Proc 2018; 93:630-638. [PMID: 29728202 DOI: 10.1016/j.mayocp.2018.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 11/15/2022]
Abstract
Atrial fibrillation (AF) accounts for most embolic strokes, especially in elderly individuals. Although anticoagulation is known to reduce the risk of embolic stroke, a significant proportion of patients have relative or absolute contraindications to anticoagulation. The left atrial appendage has been implicated as the major source of emboli in more than 90% of ischemic strokes in nonvalvular AF. Left atrial appendage occlusion offers an alternative for stroke prevention in patients with an elevated stroke risk (CHADS2 score ≥2 or CHA2DS2-VASc score ≥3) who have a rationale for avoiding long-term oral anticoagulation after a shared decision-making process. However, there remain significant challenges in left atrial appendage occlusion therapy related to patient selection, the procedure itself, and postprocedural patient management decisions. In this review article, we discuss some of these challenges in a case discussion-based approach.
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Affiliation(s)
| | - Thomas Munger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Paul Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Effectiveness and Safety of Different Rivaroxaban Dosage Regimens in Patients with Non-Valvular Atrial Fibrillation: A Nationwide, Population-Based Cohort Study. Sci Rep 2018; 8:3451. [PMID: 29472623 PMCID: PMC5823875 DOI: 10.1038/s41598-018-21884-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
The objective of this study is to evaluate the effectiveness of different rivaroxaban dosage regimens in preventing ischemic stroke and systemic thromboembolism among Asians. A retrospective cohort study was conducted on data from nationwide insurance claims in Taiwan. Patients with non-valvular atrial fibrillation under warfarin or rivaroxaban therapy were included. Propensity score matching was used to balance the covariates, and Cox-proportional hazard models were applied to compare the effectiveness and safety of each treatment group. Rivaroxaban was associated with a significantly lower risk of venous thromboembolism (hazard ratio [HR]: 0.51; 95% confidence interval [CI]: 0.29–0.92, P = 0.02) and intracranial hemorrhage (HR: 0.48; 95% CI: 0.32–0.72, P < 0.001) than warfarin. Rivaroxaban 20 mg and 15 mg were associated with a significantly lower risk of ischemic stroke (20 mg, HR: 0.48; CI: 0.29–0.80, P = 0.005; 15 mg, HR: 0.69; CI: 0.53–0.90, P = 0.005), but rivaroxaban 10 mg was not. In the subgroup analysis of patients older than 65 years, the results were generally the same, except that rivaroxaban had a significantly lower risk of ischemic stroke than warfarin.
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Vinereanu D, Wang A, Mulder H, Lopes RD, Jansky P, Lewis BS, Gersh BJ, Avezum A, Hanna M, Held C, Wallentin L, Granger CB, Alexander JH. Outcomes in anticoagulated patients with atrial fibrillation and with mitral or aortic valve disease. Heart 2018; 104:1292-1299. [DOI: 10.1136/heartjnl-2017-312272] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/12/2017] [Accepted: 12/20/2017] [Indexed: 11/03/2022] Open
Abstract
ObjectiveTo assess stroke/systemic embolism, major bleeding and other outcomes, and treatment effect of apixaban versus warfarin, in patients with atrial fibrillation (AF) and different types of valvular heart disease (VHD), using data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial.MethodsThere were 14 793 patients with known VHD status, categorised as having moderate or severe mitral regurgitation (MR) (n=3382), aortic regurgitation (AR) (n=842) or aortic stenosis (AS) (n=324); patients with moderate or severe mitral stenosis were excluded from the trial. Baseline characteristics, efficacy and safety outcomes were compared between each type and no significant VHD. Treatment effect was assessed using an adjusted model.ResultsPatients with MR or AR had similar rates of stroke/systemic embolism and bleeding compared with patients without MR or AR, respectively. Patients with AS had significantly higher event rates (presented as rate per 100 patient-years of follow-up) of stroke/systemic embolism (3.47 vs 1.36; adjusted HR (adjHR) 2.21, 95% CI 1.35 to 3.63), death (8.30 vs 3.53; adjHR 1.92, 95% CI 1.41 to 2.61), major bleeding (5.31 vs 2.53; adjHR 1.80, 95% CI 1.19 to 2.75) and intracranial bleeding (1.29 vs 0.51; adjHR 2.54, 95% CI 1.08 to 5.96) than patients without AS. The superiority of apixaban over warfarin on stroke/systemic embolism was similar in patients with versus without MR (HR 0.69, 95% CI 0.46 to 1.04 vs HR 0.79, 95% CI 0.63 to 1.00; interaction P value 0.52), with versus without AR (HR 0.57, 95% CI 0.27 to 1.20 vs HR 0.78, 95% CI 0.63 to 0.96; interaction P value 0.52), and with versus without AS (HR 0.44, 95% CI 0.17 to 1.13 vs HR 0.79, 95% CI 0.64 to 0.97; interaction P value 0.19). For each of the primary and secondary efficacy and safety outcomes, there was no evidence of a different effect of apixaban over warfarin in patients with any VHD subcategory.ConclusionsIn anticoagulated patients with AF, AS is associated with a higher risk of stroke/systemic embolism, bleeding and death. The efficacy and safety benefits of apixaban compared with warfarin were consistent, regardless of presence of MR, AR or AS.Clinical trial registrationARISTOTLE clinical trial number NCT00412984.
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Daniela Dünner E, Ramón Soto J. TRATAMIENTO ANTICOAGULANTE ORAL CON ÉNFASIS EN SUS INDICACIONES EN CARDIOLOGÍA. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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