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Adji AS, de Liyis BG. Comparison between non-vitamin K oral antagonist versus warfarin in atrial fibrillation with and without valvular heart disease: a systematic review and meta-analysis. Egypt Heart J 2024; 76:102. [PMID: 39120758 PMCID: PMC11315858 DOI: 10.1186/s43044-024-00535-w] [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: 04/20/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) poses a significant stroke risk in heart disease patients. This systematic review aims to evaluate the efficacy and safety of non-vitamin K oral antagonists (NOACs) versus vitamin K antagonists (VKAs) in AF patients with and without any valvular heart disease (VHD/N-VHD). METHODS A systematic search was conducted on PubMed, Scopus, and Google Scholar up to March 3, 2022. Efficacy and safety parameters were analyzed. RESULTS A total of 85,423 subjects from 10 studies were included in this meta-analysis. NOACs and VKAs showed similar effects on ischemic stroke in AF patients with VHD/N-VHD (RR 0.97; 95% CI 0.72-1.30; p = 0.83) and also on systemic embolic events (RR 1.02; 95% CI 0.83-1.25; p = 0.86). Similar effects were seen in VHD and N-VHD subgroups. Both treatments had similar effects on myocardial infarction in AF patients with VHD/N-VHD (RR 0.79; 95% CI 0.49-1.26; p = 0.32), VHD (RR 0.78; 95% CI 0.59-1.02; p = 0.07), and N-VHD subgroups (RR 0.82; 95% CI 0.30-2.21; p = 0.69). NOACs reduced the risk of intracranial bleeding in AF VHD/N-VHD (RR 0.64; 95% CI 0.54-0.77; p < 0.0001), VHD (RR 0.59; 95% CI 0.42-0.82; p = 0.002), and N-VHD subgroups (RR 0.70; 95% CI 0.57-0.85; p = 0.0003). Additionally, NOACs reduced the risk of gastrointestinal bleeding in AF VHD/N-VHD (RR 0.80; 95% CI 0.66-0.96; p = 0.02), specifically in the VHD subgroup (RR 0.69; 95% CI 0.54-0.89; p = 0.004). Moreover, NOACs were associated with a decreased risk for minor and non-fatal bleeding in AF patients with VHD/N-VHD (RR 0.86; 95% CI 0.75-0.99; p = 0.04). CONCLUSION NOACs are effective and safe for ischemic stroke, systemic embolic events, myocardial infarction, intracranial bleeding, and gastrointestinal bleeding in AF patients with VHD/N-VHD.
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Affiliation(s)
- Arga Setyo Adji
- Faculty of Medicine, Hang Tuah University, Surabaya, East Java, Indonesia.
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Kang F, Su L, Fan S, Lv L, Luo B. Efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients (≥80 years of age) with atrial fibrillation: systematic review and meta-analysis. Intern Med J 2023; 53:1524-1532. [PMID: 37178051 DOI: 10.1111/imj.16101] [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: 10/25/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023]
Abstract
Findings of prior studies about the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in patients (≥80 years of age) with atrial fibrillation (AF) are controversial. So we performed a meta-analysis to evaluate the efficacy and safety of NOACs versus vitamin K antagonists (VKAs) in patients (≥80 years of age) with AF. A systematic review of PubMed, Cochrane, Embase, Web of Science and Chinese BioMedical databases was conducted until 1 October 2022. Studies reporting the effects and safety of NOACs versus warfarin in patients (≥80 years of age) with AF were included. Two authors independently performed study selection and data extraction. Discrepancies were resolved by consensus or through an independent third reviewer. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews guidelines. We identified 15 studies providing data of 70 446 participants (≥80 years of age) suffering from AF. According to the meta-analysis (odds ratio (OR) (95% confidence interval, CI)), NOACs conferred better efficacy profile than VKAs in stroke and systemic embolism (0.8 (0.73-0.88)) and all-cause mortality (0.61 (0.57-0.65)). Otherwise, NOACs conferred a better safety profile than VKAs in major bleeding (0.76 (0.70-0.83)) and intracranial haemorrhage (ICH; 0.57 (0.47-0.68)). In conclusion, for patients (≥80 years of age) with AF, the risks of stroke and systemic embolism, all-cause mortality, were lower in NOACs compared to warfarin. The risks of major bleeding and ICH were also lower in NOACs compared to warfarin. NOACs showed better efficacy and safety than warfarin.
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Affiliation(s)
- Fengguang Kang
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Lijun Su
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Shuke Fan
- Department of Cardiology, Junan Hospital Affiliated to Shunde Hospital of Guangzhou University of Chinese Medicine, Guangdong, Foshan, China
| | - Lifen Lv
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Biru Luo
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
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Taoutel R, Ezekowitz MD, Chaudhry UA, Weber C, Hassan D, Gracely EJ, Kamareddine MH, Horn BI, Harper GR. Retrospective Comparison of Patients ≥ 80 Years With Atrial Fibrillation Prescribed Either an FDA-Approved Reduced or Full Dose Direct-Acting Oral Anticoagulant. IJC HEART & VASCULATURE 2022; 43:101130. [PMID: 36246771 PMCID: PMC9556913 DOI: 10.1016/j.ijcha.2022.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 11/21/2022]
Abstract
Direct-acting oral anticoagulants (DOACs) represent the standard for preventing stroke and systemic embolization (SSE) in patients with atrial fibrillation (AF). There is limited information for patients ≥ 80 years. We report a retrospective analysis of AF patients ≥ 80 years prescribed either a US Food and Drug Administration (FDA)-approved reduced (n = 514) or full dose (n = 199) DOAC (Dabigatran, Rivaroxaban, or Apixaban) between January 1st, 2011 (first DOAC commercially available) and May 31st, 2017. The following multivariable differences in baseline characteristics were identified: patients prescribed a reduced dose DOAC were older (p < 0.001), had worse renal function (p = 0.001), were more often prescribed aspirin (p = 0.004) or aspirin and clopidogrel (p < 0.001), and more often had new-onset AF (p = 0.001). SSE and central nervous system (CNS) bleed rates were low and not different (1.02 vs 0 %/yr and 1.45 vs 0.44 %/yr) for the reduced and full dose groups, respectively. For non-CNS bleeds, rates were 10.89 vs 4.15 %/yr (p < 0.001, univariable) for the reduced and full doses, respectively. The mortality rate was 6.24 vs 1.75 %/yr (p = 0.001, univariable) for the reduced and full doses. Unlike the non-CNS bleed rate, mortality rate differences remained significant when adjusted for baseline characteristics. Thus, DOACs in patients ≥ 80 with AF effectively reduce SSE with a low risk of CNS bleeding, independent of DOAC dose. The higher non-CNS bleed rate and not the mortality rate is explained by the higher risk baseline characteristics in the reduced DOAC dose group. Further investigation of the etiology of non-CNS bleeds and mortality is warranted.
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Key Words
- A2.5, Apixaban 2.5 mg twice daily
- A5, Apixaban 5 mg twice daily
- AF, atrial fibrillation
- Atrial fibrillation
- BMMSA, Bryn Mawr Medical Specialists Association
- CKD, chronic kidney disease
- CNS, central nervous system
- CrCl, creatinine clearance
- D110, Dabigatran 110 mg twice daily
- D150, Dabigatran 150 mg twice daily
- D75, Dabigatran 75 mg twice daily
- DOAC
- DOACs, direct-acting oral anticoagulants
- Direct-acting oral anticoagulants
- ESRD, end-stage renal disease
- Elderly
- FDA, Food and Drug Administration
- R15, Rivaroxaban 15 mg daily
- R20, Rivaroxaban 20 mg daily
- SSE, stroke and systemic embolization
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Affiliation(s)
- Roy Taoutel
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Michael D. Ezekowitz
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
- Bryn Mawr Hospital Main Line Health, Bryn Mawr, PA, USA
- Sidney Kimmel Medical College at Jefferson University, Philadelphia, PA, USA
| | - Usman A. Chaudhry
- Bryn Mawr Hospital Main Line Health, Bryn Mawr, PA, USA
- Sidney Kimmel Medical College at Jefferson University, Philadelphia, PA, USA
| | - Carly Weber
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Dana Hassan
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Ed J. Gracely
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
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Zhang Y, Yang R, Wang L, Li Y, Han J, Yang Y, Zheng H, Lu M, Shen Y, Yang H. Purification and characterization of a novel thermostable anticoagulant protein from medicinal leech Whitmania pigra Whitman. JOURNAL OF ETHNOPHARMACOLOGY 2022; 288:114990. [PMID: 35032585 DOI: 10.1016/j.jep.2022.114990] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/27/2021] [Accepted: 01/09/2022] [Indexed: 06/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The prevalence of cardiovascular disease (CVD) is increasing worldwide. Despite significant improvements in novel targeted treatment agents, natural products purified from medicinal animals with minimal side effects have attracted much attention. Several native proteins explored from suck-blood leeches, such as non-thermostable hirudin and its variants, revealed potent anticoagulant activity. Traditional Chinese medicine clinics have proved that non-suck-blood leech Whitmania pigra Whitman (W. pigra) also played notable roles in CVD treatments even after decoction. However, only a few natural proteins and peptides have been identified from the fresh material of this medicinal species. AIM OF THE STUDY We aimed to purify and characterize thermostable anticoagulant proteins from W. pigra for further development of a therapeutic agent for thrombosis. MATERIALS AND METHODS W. pigra crude extract was prepared by decoction in water. Anticoagulant proteins were purified by DEAE cellulose DE-52, Sephadex G-75, and reversed-phase liquid chromatography sequentially and analyzed by SDS-PAGE and LC-MS/MS for structural information. In addition, we conducted in vitro anticoagulant experiments, including plasma recalcification time (PRT) assay, fibrinolytic assay, activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen (Fib) assay, and cell viability assays. Furthermore, a carrageenan-induced chronic thromboembolism model was employed in ICR mice, and four coagulation factors (APTT, PT, TT, and Fib) activities were determined after intragastric administration. RESULTS The anticoagulant protein WP-77 has a relative molecular weight of ca. 20.8 kDa. It was effective over a broad temperature range from 20 °C to 100 °C and a pH 2-8 condition. The anticoagulant activity of WP-77 was retained after incubation with pepsin but was greatly inhibited by trypsin (P < 0.01). It significantly prolonged APTT and TT (P < 0.05) but had little effect on PT and Fib in vitro. Furthermore, WP-77 of a low concentration resulted in the recovery of injured EA.hy926 by thrombin. The protein also significantly prolonged APTT and TT (P < 0.01) and inhibited thrombus formation in carrageenan-induced thrombosis mice, demonstrating its antithrombotic effect in vivo. CONCLUSION Our results suggest that WP-77 from W. pigra plays a distinct role in treating thrombotic diseases, and it is an essential substance of anticoagulant activity of non-suck-blood medicinal leeches. This thermostable anticoagulant protein could be a promising candidate for the development of clinical antithrombosis medicines.
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Affiliation(s)
- Yajie Zhang
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Rong Yang
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Liwei Wang
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Ye Li
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Jing Han
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Yaya Yang
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Hanxue Zheng
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Mengyao Lu
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Yuping Shen
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
| | - Huan Yang
- Department of Chinese Materia Medica and Pharmacy, School of Pharmacy, Jiangsu University, Zhenjiang, Jiangsu, 212013, PR China.
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