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La Fazia VM, Pierucci N, Mohanty S, Gianni C, Della Rocca DG, Compagnucci P, MacDonald B, Mayedo A, Torlapati PG, Bassiouny M, Gallinghouse GJ, Burkhardt JD, Horton R, Al-Ahmad A, Di Biase L, Natale A. Catheter ablation approach and outcome in HIV+ patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:2527-2534. [PMID: 37746923 DOI: 10.1111/jce.16076] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients. METHODS This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge. RESULTS Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found. CONCLUSION Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence.
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Affiliation(s)
- Vincenzo Mirco La Fazia
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
- Department of Cardiology, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Pierucci
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
- Department of Clinical, Internal, Anesthesiology, and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Sanghamitra Mohanty
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Carola Gianni
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Domenico Giovanni Della Rocca
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
- Department of Electrophysiology, Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Compagnucci
- Cardiology & Arrhythmology Clinic, University Hospital "Ospedali Riuniti,", Marche Polytechnic University, Ancona, Italy
| | - Bryan MacDonald
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Angel Mayedo
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Prem Geeta Torlapati
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Mohamed Bassiouny
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Gerald Joseph Gallinghouse
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - John D Burkhardt
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Rodney Horton
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Amin Al-Ahmad
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Luigi Di Biase
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
- Department of Electrophysiology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea Natale
- Department of Electrophysiology, St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
- Department of Electrophysiology, Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
- Department of Electrophysiology, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Piazza G, Hurwitz S, Campia U, Bikdeli B, Lou J, Khairani CD, Bejjani A, Snyder JE, Pfeferman M, Barns B, Rizzo S, Glezer A, Goldhaber SZ. Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2). Thromb Res 2023; 227:1-7. [PMID: 37182298 DOI: 10.1016/j.thromres.2023.05.006] [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: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier- NCT02958943.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale New Haven Hospital (YNHH), Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Junyang Lou
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briana Barns
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alexandra Glezer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Refaai MA, Jacobson AK, Rosenfeld JC, Orr RR. Performance of the microINR Point-of-Care System Used by Self-Testing Patients: A Multicenter Clinical Trial. TH OPEN 2022; 5:e577-e584. [PMID: 34984317 PMCID: PMC8718263 DOI: 10.1055/s-0041-1740962] [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: 06/21/2021] [Accepted: 11/04/2021] [Indexed: 10/31/2022] Open
Abstract
Introduction Anticoagulation monitoring is a major practical and clinical challenge. We assessed the performance of the microINR system in patient self-testing (PST). Methods This study was performed at four US medical centers. After the training visit of warfarin anticoagulated patients ( n = 117) on microINR system, PST was performed at home and in two visits to the medical centers. At the medical centers, both PST and healthcare professionals (HCPs) performed duplicate tests with the microINR System. A venous blood sample for the laboratory testing was also extracted. Accuracy and precision were assessed. Results The comparison between microINR PST results and microINR HCP results revealed an equivalence with a slope of 1.00 (95% confidence interval [CI]: 1.00-1.00), and an intercept of 0.00 (95% CI: 0.00-0.00). When compared with the laboratory analyzer, microINR PST results also showed good correlation with a slope of 0.94 (95% CI: 0.86-1.04) and an intercept of 0.14 (95% CI: -0.09-0.34). Predicted bias values at international normalized ratio (INR) 2.0, 3.5, and 4.5 were 0% against HCP and ≤2.5% against the laboratory. Analytical agreement with both HCP and laboratory was 100% according to ISO17593 and 99.1 and 100% according to CLSI POCT14 with HCP and laboratory, respectively. Clinical agreement with HCP regarding 2.0-4.0 as INR therapeutic range was 98% (within range). The precision (coefficient of variation) of microINR system used by PST was comparable to HCP. Conclusion The microINR results when used by self-testing patients show satisfactory concordance to both HCP results and laboratory analyzer. The microINR system is adequate for self-testing use.
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Affiliation(s)
- Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, United States
| | - Alan K Jacobson
- Department of Internal Medicine, VA Loma Linda Healthcare System, Loma Linda, California, United States
| | - Jack C Rosenfeld
- Green and Seidner Family Practice Associates, Lansdale, Pennsylvania, United States
| | - Robert R Orr
- Phoenix Medical Research, Peoria, Arizona, United States
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Piazza G, Hurwitz S, Galvin CE, Harrigan L, Baklla S, Hohlfelder B, Carroll B, Landman AB, Emani S, Goldhaber SZ. Alert-based computerized decision support for high-risk hospitalized patients with atrial fibrillation not prescribed anticoagulation: a randomized, controlled trial (AF-ALERT). Eur Heart J 2021; 41:1086-1096. [PMID: 31228189 DOI: 10.1093/eurheartj/ehz385] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/25/2019] [Accepted: 05/20/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Despite widely available risk stratification tools, safe and effective anticoagulant options, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is underprescribed. We created and evaluated an alert-based computerized decision support (CDS) strategy to increase anticoagulation prescription in hospitalized AF patients at high risk for stroke. METHODS AND RESULTS We enrolled 458 patients (CHA2DS2-VASc score ≥1) with AF who were not prescribed anticoagulant therapy and were hospitalized at Brigham and Women's Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) vs. control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. The CDS tool assigned 248 patients to the alert group and 210 to the control group. Patients in the alert group were more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%, P < 0.0001), at discharge (23.8% vs. 12.9%, P = 0.003), and at 90 days (27.7% vs. 17.1%, P = 0.007). The alert reduced the odds of a composite outcome of death, myocardial infarction (MI), cerebrovascular event, and systemic embolic event at 90 days [11.3% vs. 21.9%, P = 0.002; odds ratio (OR) 0.45; 95% confidence interval (CI) 0.27-0.76]. The alert reduced the odds of MI at 90 days by 87% (1.2% vs. 8.6%, P = 0.0002; OR 0.13; 95% CI 0.04-0.45) and cerebrovascular events or systemic embolism at 90 days by 88% (0% vs. 2.4%, P = 0.02; OR 0.12; 95% CI 0.0-0.91). CONCLUSION An alert-based CDS strategy increased anticoagulation in high-risk hospitalized AF patients and reduced major adverse cardiovascular events, including MI and stroke. CLINICALTRIALS.GOV IDENTIFIER NCT02339493.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Shelley Hurwitz
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Claire E Galvin
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Lindsay Harrigan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Sofia Baklla
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Benjamin Hohlfelder
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Brett Carroll
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA
| | - Adam B Landman
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Srinivas Emani
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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Piazza G, Hurwitz S, Carroll B, Goldhaber SZ. Patients with perceived high-bleeding risk and computerized decision support for stroke prevention in atrial fibrillation: an AF-ALERT substudy : Piazza: outcomes of high-bleeding risk AF patients. J Thromb Thrombolysis 2020; 52:281-290. [PMID: 33000390 DOI: 10.1007/s11239-020-02296-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2020] [Indexed: 01/27/2023]
Abstract
A perceived increased risk of bleeding is one of the most frequent reasons for withholding anticoagulation for stroke prevention in atrial fibrillation (AF). We previously conducted a randomized controlled trial of alert-based computerized decision support to increase prescription of anticoagulation in hospitalized patients with AF. To determine the clinical characteristics and outcomes of those patients whose inpatient health care providers received a computer alert, we analyzed all 248 patients in the alert group. Patients for whom providers elected to omit anticoagulation and provided a rationale of a perceived high risk of bleeding were compared with those who were not designated as high-risk. Perceived high risk of bleeding was the most common reason (77%) for omitting anticoagulation. Median HAS-BLED scores were similar in these patients compared with those who were not deemed to have an increased bleeding risk (3 vs. 3, p = 0.44). Despite being categorized as too high-risk for bleeding to receive antithrombotic therapy at the time of the alert, nearly 12% of these patients were ultimately prescribed anticoagulation by 90 days. The frequency of major and clinically-relevant non-major bleeding was similar between the groups. The frequency of death, myocardial infarction, stroke, or systemic embolic event was similar in both groups (10.2% vs. 12.4%, p = 0.59). In conclusion, a perceived high risk of bleeding was the most common reason for omission of anticoagulation in patients with AF after a computerized alert. Perceived high risk of bleeding was not reflected in a higher HAS-BLED score.Clinical trial registration: ClinicalTrials.gov Identifier: NCT02339493 https://clinicaltrials.gov/ct2/show/NCT02339493 In a randomized controlled trial of computerized decision support to increase prescription of antithrombotic therapy in hospitalized patients with atrial fibrillation (AF), a perceived high risk of bleeding was the most common reason (77%) for omitting antithrombotic therapy after an on-screen alert. Median HAS-BLED scores were similar in these patients compared with those who were not deemed to have an increased bleeding risk (3 vs. 3, p = 0.44). Despite being categorized as too high-risk for bleeding to receive antithrombotic therapy for stroke prevention at the time of the alert, nearly 12% of these patients were ultimately prescribed anticoagulation over the ensuing 90 days.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brett Carroll
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Boriani G, Ruff CT, Kuder JF, Shi M, Lanz HJ, Antman EM, Braunwald E, Giugliano RP. Edoxaban versus Warfarin in Patients with Atrial Fibrillation at the Extremes of Body Weight: An Analysis from the ENGAGE AF-TIMI 48 Trial. Thromb Haemost 2020; 121:140-149. [PMID: 32920808 DOI: 10.1055/s-0040-1716540] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The effects of anticoagulants at extremes of body weight (BW) are not well described. The aim of this study was to analyze the pharmacokinetics/pharmacodynamics and clinical outcomes in patients randomized to warfarin, higher dose edoxaban (HDER), and lower dose edoxaban (LDER) regimens at extremes of BW in ENGAGE AF-TIMI 48. METHODS AND RESULTS We analyzed three BW groups: low BW (LBW: <5th percentile, ≤55 kg, N = 1,082), middle BW (MBW: 45th-55th percentile, 79.8-84 kg, N = 2,153), and high BW (HBW: >95th percentile, ≥120 kg, N = 1,093). In the warfarin arm, LBW patients had higher rates of stroke/systemic embolism (SSE: 6.5 vs. 4.7 in MBW vs. 1.6% in HBW, P trend < 0.001), major bleeding (MB: 9.3 vs. 7.7 vs. 6.5%, P trend = 0.08), and worse net clinical outcome of systemic embolic event, MB, or death (31.5 vs. 19.1 vs. 16.0%, P trend < 0.0001). The time-in-therapeutic range with warfarin was lowest in LBW patients (63.0 vs. 69.3 vs. 70.1% patients, P trend < 0.001). The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across BW groups. The risk of SSE was similar between HDER and warfarin for each of the three weight groups (P int = 0.52, P int-trend = 0.86). MB was reduced by LDER versus warfarin (P int = 0.061, P int-trend = 0.023), especially in LBW patients. Net clinical outcomes were improved by HDER versus warfarin (P int = 0.087, P int-trend = 0.027), especially in LBW patients. CONCLUSION Patients with LBW in ENGAGE AF-TIMI 48 had in general a more fragile clinical status and poorer international normalized ratio control. The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across extremes of BW, resulting in similar efficacy compared with warfarin, while major or clinically relevant non-MB and net outcomes were most favorable with edoxaban as compared to warfarin in LBW patients.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Julia F Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Minggao Shi
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, United States
| | | | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG, Wilkins LR, Sarode R, Weinberg I. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. J Vasc Interv Radiol 2019; 30:1168-1184.e1. [DOI: 10.1016/j.jvir.2019.04.017] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
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8
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Shah NM, Chong SE, Yusoff SM, Mazlan MZ, Johan KB, Azman N, Lim JA, Mohamad SM, Noordin SS, Ghaffar ZA, Hassan MH, Zabidi MA, Rahim NAA. Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience. BMC HEMATOLOGY 2018; 18:34. [PMID: 30498571 PMCID: PMC6251212 DOI: 10.1186/s12878-018-0126-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/17/2018] [Indexed: 11/12/2022]
Abstract
Background Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding. Methods Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed. Results rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa. Conclusions rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.
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Affiliation(s)
- Nurfatin Mohd Shah
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Soon Eu Chong
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Syahirah Mohamed Yusoff
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Mohd Zulfakar Mazlan
- 2School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Khairul Bariah Johan
- 3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,5Department of Pharmacy, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Nizuwan Azman
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Jo Anne Lim
- 4Department of Internal Medicine, Hospital Sultan Abdul Halim, 08000 Sungai Petani, KDH Malaysia
| | - Siti Mardhiana Mohamad
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Siti Salmah Noordin
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Zainab Abdul Ghaffar
- 6Integrative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Mohd Hasyizan Hassan
- 2School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Muhammad Azrul Zabidi
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Nur Arzuar Abdul Rahim
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Phenome-wide association studies across large population cohorts support drug target validation. Nat Commun 2018; 9:4285. [PMID: 30327483 PMCID: PMC6191429 DOI: 10.1038/s41467-018-06540-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 09/05/2018] [Indexed: 12/12/2022] Open
Abstract
Phenome-wide association studies (PheWAS) have been proposed as a possible aid in drug development through elucidating mechanisms of action, identifying alternative indications, or predicting adverse drug events (ADEs). Here, we select 25 single nucleotide polymorphisms (SNPs) linked through genome-wide association studies (GWAS) to 19 candidate drug targets for common disease indications. We interrogate these SNPs by PheWAS in four large cohorts with extensive health information (23andMe, UK Biobank, FINRISK, CHOP) for association with 1683 binary endpoints in up to 697,815 individuals and conduct meta-analyses for 145 mapped disease endpoints. Our analyses replicate 75% of known GWAS associations (P < 0.05) and identify nine study-wide significant novel associations (of 71 with FDR < 0.1). We describe associations that may predict ADEs, e.g., acne, high cholesterol, gout, and gallstones with rs738409 (p.I148M) in PNPLA3 and asthma with rs1990760 (p.T946A) in IFIH1. Our results demonstrate PheWAS as a powerful addition to the toolkit for drug discovery. Testing the association between genetic variants and a range of phenotypes can assist drug development. Here, in a phenome-wide association study in up to 697,815 individuals, Diogo et al. identify genotype–phenotype associations predicting efficacy, alternative indications or adverse drug effects.
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11
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Hersi AS, Alhebaishi YS, Hamoui O, Hassan T, Khalifa Hamad A, Magdy M, Sabbour H, Shaheen S. Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa. J Saudi Heart Assoc 2018; 30:122-139. [PMID: 29910583 PMCID: PMC6000886 DOI: 10.1016/j.jsha.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/17/2017] [Accepted: 05/26/2017] [Indexed: 01/18/2023] Open
Abstract
Clinical guidelines for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) are available from several international cardiology associations. Patients with NVAF in the Middle East and North Africa (MENA) region present unique challenges and opportunities related to differences in geography, practice patterns, and patient demographics that are as yet unaddressed in practice guidelines. This review aims to offer a practical perspective on the management of NVAF in patients in MENA and draws on evidence-based guidelines as well as real-world evidence and expert opinion. The literature was searched for relevant original research articles, systematic reviews, meta-analyses, and guideline recommendations addressing the prevention of stroke in patients with NVAF with a focus on issues relevant to the MENA region. Guideline recommendations, best practices, and expert opinion were discussed and agreed on by a working group consisting of cardiologists from across the MENA region. The incidence of stroke secondary to atrial fibrillation in patients across the MENA region is higher than rates reported globally, and this might be attributed to a higher incidence of vascular risk factors and underuse of anticoagulants in patients in the MENA. The available evidence supports the established role of non-vitamin K antagonist oral anticoagulants (NOACs) in the prevention of stroke in patients with NVAF. There is a consistent body of clinical trial and real-world evidence supporting their efficacy for stroke prevention in NVAF, with more favorable bleeding risk profiles relative to vitamin K antagonists, such that guidelines now recommend the use of NOACs in preference over vitamin K antagonists. There are important opportunities to improve the management of NVAF outcomes for patients with NVAF by applying evidence-based guidelines for stroke prevention. Growing experience with NOACs in the MENA region will help guide patient selection and elucidate optimal dosing strategies to maximize the clinical benefits of the NOACs.
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Affiliation(s)
- Ahmad S. Hersi
- King Fahad Cardiac Center, Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Taher Hassan
- Cardiology Clinics, Al Badriyah Tower, Jeddah, Saudi Arabia
| | - Adel Khalifa Hamad
- Mohammed bin Khalifa Al Khalifa Cardiac Centre, Bahrain Defense Force Hospital, Riffa, Bahrain
| | - Mohamed Magdy
- Critical Care Cardiology and Electrophysiology Departments, Cairo University, Cairo, Egypt
- Electrophysiology Department, Alqassimi Cardiac Center, Sharjah, United Arab Emirates
| | - Hani Sabbour
- Cardiology & Electrophysiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Cardiology Department, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - Sameh Shaheen
- Cardiology Department, Ain-shams University, Cairo, Egypt
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12
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Oertel LB, Fogerty AE. Use of direct oral anticoagulants for stroke prevention in elderly patients with nonvalvular atrial fibrillation. J Am Assoc Nurse Pract 2017; 29:551-561. [PMID: 28805310 DOI: 10.1002/2327-6924.12494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Lynn B Oertel
- Anticoagulant Management Service, Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts
| | - Annemarie E Fogerty
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts
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13
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Wang KL, Chiu CC, Su-Yin Tan D, Lin CY, Lai EY, Goto S, Giugliano RP, Chiang CE. Once- or twice-daily non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A meta-analysis of randomized controlled trials. J Formos Med Assoc 2017. [DOI: 10.1016/j.jfma.2017.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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14
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Kirby A, Murphy A, Bradley C. New Oral Anaticoagulant Prescribing Decisions amongst General Practitioners: Handle with Care. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2017; 5:55-64. [PMID: 37664690 PMCID: PMC10471385 DOI: 10.36469/9798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background: Prescribing oral anticoagulants for atrial fibrillation patients is becoming more challenging as more alternatives enter the market. While warfarin has dominated the market it is a challenging medicine to use owing to its narrow therapeutic range, increased bleeding risk and requirement for continuous monitoring. The introduction of new oral anticoagulants (NOACs) offers a wider choice but they are more costly and their use also brings additional pharmacological considerations. Objective: This paper investigates if the identified risk factors (renal impairment, hepatic impairment, other co-morbidities & drug interactions) influence GPs' NOAC prescribing decisions, using a multivariate probit model, while controlling for other GP characteristics. Methods: Employing primary data, collected using a dedicated survey of Irish GPs in November 2015, a multivariate probit is employed. This measures the joint decision making process of prescribing a NOAC based on four risk factors - renal impairment, hepatic impairment, other comorbidities and drug interactions. Results: Younger GPs are more likely to consider 'other co-morbidities' and 'renal impairment' as important when making NOAC prescribing decisions. Male GPs are more likely to consider 'other co-morbidities' and 'drug interactions' as important when prescribing NOACs compared to female GPs. Prescribers who have initiated NOACs are more likely to consider 'renal impairment' as important compared with non-initiators. Conclusions: Our study highlights the importance for general practitioners prescribing NOACs and caring for patients on oral anticoagulants, of adequate education, of appropriate patient selection and of appropriate monitoring of such patients. While warfarin prescribing remains predominant, NOAC prescribing is increasing. Incorporating the risk factors into prescribing decisions signals responsible prescribing for atrial fibrillation patients. Existing prescribing guidelines/toolkits need to be used in an effective manner.
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Affiliation(s)
- Ann Kirby
- Cork University Business School University College Cork, Cork, Ireland
| | - Aileen Murphy
- Cork University Business School University College Cork, Cork, Ireland
| | - Colin Bradley
- Department of General Practice, School of Medicine University College Cork, Cork, Ireland
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15
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Fernandez-Prado R, Castillo-Rodriguez E, Velez-Arribas FJ, Gracia-Iguacel C, Ortiz A. Creatinine Clearance Is Not Equal to Glomerular Filtration Rate and Cockcroft-Gault Equation Is Not Equal to CKD-EPI Collaboration Equation. Am J Med 2016; 129:1259-1263. [PMID: 27612441 DOI: 10.1016/j.amjmed.2016.08.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/30/2022]
Abstract
Direct oral anticoagulants (DOACs) may require dose reduction or avoidance when glomerular filtration rate is low. However, glomerular filtration rate is not usually measured in routine clinical practice. Rather, equations that incorporate different variables use serum creatinine to estimate either creatinine clearance in mL/min or glomerular filtration rate in mL/min/1.73 m2. The Cockcroft-Gault equation estimates creatinine clearance and incorporates weight into the equation. By contrast, the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations estimate glomerular filtration rate and incorporate ethnicity but not weight. As a result, an individual patient may have very different renal function estimates, depending on the equation used. We now highlight these differences and discuss the impact on routine clinical care for anticoagulation to prevent embolization in atrial fibrillation. Pivotal DOAC clinical trials used creatinine clearance as a criterion for patient enrollment, and dose adjustment and Federal Drug Administration recommendations are based on creatinine clearance. However, clinical biochemistry laboratories provide CKD-EPI glomerular filtration rate estimations, resulting in discrepancies between clinical trial and routine use of the drugs.
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Affiliation(s)
- Raul Fernandez-Prado
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain
| | | | | | - Carolina Gracia-Iguacel
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain; Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain; Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.
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16
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Barnes GD, Kurtz B. Direct oral anticoagulants: unique properties and practical approaches to management. Heart 2016; 102:1620-6. [PMID: 27402803 DOI: 10.1136/heartjnl-2015-309075] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/18/2016] [Indexed: 11/03/2022] Open
Abstract
Since 2009, four direct oral anticoagulants (DOACs) have been introduced for treatment of venous thromboembolism and stroke prevention in non-valvular atrial fibrillation. While they are currently first-line therapy for a majority of patients, there are a number of clinical situations where warfarin is preferable. In both randomised trials and real-world populations, use of DOACs significantly reduces the risk of intracranial haemorrhage as compared with warfarin. While drug-specific reversal agents are currently only available for dabigatran, andexanet alpha is pending approval for reversal of factor Xa inhibitors, reducing concerns about major bleeding for many patients and providers. DOACs can be held for 2-4 days prior to a procedure, depending on a patient's renal function, but should not be restarted too rapidly post-procedurally given their fast time to peak activity (∼2 hours). The anticoagulation clinic should play an important role in managing patients on all oral anticoagulation, both warfarin and DOACs.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Kurtz
- Frankel Cardiovascular Center Outpatient Anticoagulation Service, University of Michigan, Ann Arbor, Michigan, USA
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