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Święczkowski M, Dąbrowski EJ, Muszyński P, Pogorzelski P, Jemielita P, Dudzik JM, Januszko T, Duzinkiewicz M, Południewski M, Kuźma Ł, Kożuch M, Kralisz P, Dobrzycki S. A Comprehensive Review of Percutaneous and Surgical Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 2024; 11:234. [PMID: 39195142 DOI: 10.3390/jcdd11080234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide, and is associated with a significant risk of thromboembolic events. Left atrial appendage occlusion (LAAO) has emerged as a promising alternative for patients with contraindications or intolerance to anticoagulant therapy. This review summarises the current evidence, indications, and technical advancements in surgical and percutaneous LAAO. Preprocedural planning relies on various imaging techniques, each with unique advantages and limitations. The existing randomised clinical trials and meta-analyses demonstrate favourable results for both percutaneous and surgical LAAO. Postprocedural management emphasises personalised anticoagulation strategies and comprehensive imaging surveillance to ensure device stability and detect complications. Future focus should be put on antithrombotic regimens, investigating predictors of device-related complications, and simplifying procedural aspects to enhance patient outcomes. In summary, LAAO is presented as a valuable therapeutic option for preventing AF-related thromboembolic events, with ongoing research aimed at refining techniques and improving patient care.
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Affiliation(s)
- Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Paweł Muszyński
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Piotr Pogorzelski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Piotr Jemielita
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Joanna Maria Dudzik
- Second Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Tomasz Januszko
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Małgorzata Duzinkiewicz
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Maciej Południewski
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Marcin Kożuch
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Paweł Kralisz
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, 24A Sklodowskiej-Curie St., 15-276 Bialystok, Poland
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Jannati M, Ardecani AA. Prevention of Pulmonary and Venous Thromboembolism Post Coronary Artery Bypass Graft Surgery - Literature Review. Braz J Cardiovasc Surg 2020; 35:368-374. [PMID: 32549108 PMCID: PMC7299585 DOI: 10.21470/1678-9741-2018-0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective The current review evaluates recent literature on the different aspects of prophylaxis in postoperative pulmonary and venous thromboembolism and their main risk factors. Methods The literature survey was carried out based on the PubMed data using the keywords “coronary artery bypass graft” and “venous thromboembolism” as components of the search field title. Results Studies reported several risk factors for postoperative thromboembolism including advanced age, postoperative immobilization, type of thromboprophylaxis, obesity, and location of the surgery. Conclusion According to the studies, tailored prophylaxis could be easily adapted to decrease the intensity and duration of postoperative thromboembolism in a patient with several disorders and comorbidities, especially in cardiovascular disease.
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Affiliation(s)
- Mansour Jannati
- Shiraz University of Medical Sciences Faghihi Hospital Department of Cardiovascular Surgery Shiraz Iran Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Abdi Ardecani
- Shiraz University of Medical Sciences Faghihi Hospital Department of Cardiovascular Surgery Shiraz Iran Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Vizcarra P, Guillemi S, Eyawo O, Hogg RS, Montaner JS, Bennett M. Stroke and Systemic Thromboembolism Prevention in People Living With Human Immunodeficiency Virus With Atrial Fibrillation: A Review of Its Implications for Clinical Practice. CJC Open 2019; 1:245-255. [PMID: 32159116 PMCID: PMC7063632 DOI: 10.1016/j.cjco.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/09/2019] [Indexed: 11/17/2022] Open
Abstract
In the last few decades, types of diseases affecting people living with human immunodeficiency virus (PLHIV) have shifted as the population ages, with cardiovascular disease becoming a leading cause of death in this population. Atrial fibrillation (AF) is an increasingly common arrhythmia both in the general population and in PLHIV, with an estimated prevalence of 2% to 3% among PLHIV. Prevention of stroke and systemic thromboembolism (SSE) with antithrombotic therapy is a cornerstone of AF treatment and substantially decreases AF-related morbidity and mortality. Although updated guidelines extensively discuss this issue, they do not address the peculiarities of PLHIV. The role of human immunodeficiency virus (HIV) infection as an independent factor for SSE in individuals with AF and whether the presence of HIV should alter the threshold for SSE thromboprophylaxis are unknown. Nevertheless, a growing body of evidence describes the increasing burden of comorbidities such as hypertension and stroke in PLHIV, which predispose them to AF and SSE. In the absence of HIV-specific AF guidelines, PLHIV with AF should be comprehensively assessed for their risk of SSE and bleeding using commonly available scores despite them having been primarily validated in the non-HIV population. Both vitamin K antagonists and direct oral anticoagulants can be used in PLHIV. Addressing HIV-related comorbidities and potential drug-drug interactions with antiretrovirals is crucial to prevent SSE and reduce adverse reactions of oral anticoagulants. This review summarizes the current guidelines for SSE prevention in patients with AF and describes key considerations for their implementation among PLHIV receiving antiretroviral therapy.
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Affiliation(s)
- Pilar Vizcarra
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Infectious Disease, Hospital “Gral. José de San Martín,” La Plata, Buenos Aires, Argentina
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Oghenowede Eyawo
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Robert S. Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Julio S. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Bennett
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Huiart L, Ferdynus C, Renoux C, Beaugrand A, Lafarge S, Bruneau L, Suissa S, Maillard O, Ranouil X. Trends in initiation of direct oral anticoagulant therapies for atrial fibrillation in a national population-based cross-sectional study in the French health insurance databases. BMJ Open 2018; 8:e018180. [PMID: 29602837 PMCID: PMC5884337 DOI: 10.1136/bmjopen-2017-018180] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Unlike several other national health agencies, French health authorities recommended that the newer direct oral anticoagulant (DOAC) agents only be prescribed as second choice for the treatment of newly diagnosed non-valvular atrial fibrillation (NVAF), with vitamin K antagonists (VKA) remaining the first choice. We investigated the patterns of use of DOACs versus VKA in the treatment of NVAF in France over the first 5 years of DOAC availability. We also identified the changes in patient characteristics of those who initiated DOAC treatment over this time period. METHODS Based on the French National Health Administrative Database, we constituted a population-based cohort of all patients who were newly treated for NVAF between January 2011 and December 2015. Trends in drug use were described as the percentage of patients initiating each drug at the time of treatment initiation. A multivariate analysis using logistic regression model was performed to identify independent sociodemographic and clinical predictors of initial anticoagulant choice. RESULTS The cohort comprised 814 446 patients who had received a new anticoagulant treatment for NVAF. The proportion of patients using DOACs as initial anticoagulant therapy reached 54% 3 months after the Health Ministry approved the reimbursement of dabigatran for NVAF, and 61% by the end of 2015, versus VKA use. In the multivariate analysis, we found that DOAC initiators were younger and healthier overall than VKA initiators, and this tendency was reinforced over the 2011-2014 period. DOACs were more frequently prescribed by cardiologists in 2012 and after (adjusted OR in 2012: 2.47; 95% CI 2.40 to 2.54). CONCLUSION Despite recommendations from health authorities, DOACs have been rapidly and massively adopted as initial therapy for NVAF in France. Observational studies should account for the fact that patients selected to initiate DOAC treatment are healthier overall, as failure to do so may bias the risk-benefit assessment of DOACs.
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Affiliation(s)
- Laetitia Huiart
- Unité de Soutien Méthodologique, CHU de la Réunion, Saint-Denis, France
- CHU de la Réunion, INSERM, CIC1410, Saint-Pierre, France
- Université de La Réunion, UFR Santé, Saint-Denis, France
- INSERM, Université d’Aix-Marseille, IRD, UMR912 "Sciences Économiques et Sociales de la Santé et Traitement de l’Information Médicale" (SESSTIM), Marseille, France
| | - Cyril Ferdynus
- Unité de Soutien Méthodologique, CHU de la Réunion, Saint-Denis, France
- CHU de la Réunion, INSERM, CIC1410, Saint-Pierre, France
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montréal, Canada
| | - Amélie Beaugrand
- Unité de Soutien Méthodologique, CHU de la Réunion, Saint-Denis, France
- Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, Paris, France
| | - Sophie Lafarge
- CHU de la Réunion, INSERM, CIC1410, Saint-Pierre, France
| | - Léa Bruneau
- Unité de Soutien Méthodologique, CHU de la Réunion, Saint-Denis, France
- INSERM, Université d’Aix-Marseille, IRD, UMR912 "Sciences Économiques et Sociales de la Santé et Traitement de l’Information Médicale" (SESSTIM), Marseille, France
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montréal, Canada
| | - Olivier Maillard
- CHU de la Réunion, INSERM, CIC1410, Saint-Pierre, France
- INSERM, Université d’Aix-Marseille, IRD, UMR912 "Sciences Économiques et Sociales de la Santé et Traitement de l’Information Médicale" (SESSTIM), Marseille, France
| | - Xavier Ranouil
- CHU de la Réunion, Service de cardiologie, Saint-Denis, France
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Larsen T, Rasmussen L, Lip GYH, Skjøth F. Efficacy and safety of edoxaban in comparison with dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation. Thromb Haemost 2017; 111:981-8. [DOI: 10.1160/th14-02-0118] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 02/18/2014] [Indexed: 01/16/2023]
Abstract
SummaryLarge Phase 3 clinical trials for stroke prevention in atrial fibrillation (AF) have compared non-vitamin K antagonist oral anticoagulants (NOACs) against warfarin, with the edoxaban trial only recently reported. In the absence of head to head trials directly comparing these NOACs against each other, we compared the efficacy and safety of edoxaban to other agents by an indirect comparison analysis. We performed an indirect comparison analysis of edoxaban (2 dose strategies) against apixaban (1 dose), dabigatran etexilate (2 doses) and rivaroxaban (1 dose), for their relative efficacy and safety against each other. For high-dose edoxaban vs apixaban, there were no significant differences in efficacy endpoints, mortality, myocardial infarction and major bleeding. Apixaban was associated with less major or clinically relevant non-major bleeding (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.70–0.90) and gastrointestinal bleeding (HR 0.72; 95% CI 0.53–0.99). For dabigatran 110 mg twice daily, there were no significant differences in the main efficacy or safety endpoints. Dabigatran 150 mg bid was associated with lower stroke/systemic embolism (SE) (HR 0.75; 95% CI 0.56–0.99), stroke (HR 0.73; 95% CI 0.55–0.96) and haemorrhagic stroke (HR 0.48; 95% CI 0.23–0.99). There were no significant differences between high-dose edoxaban vs rivaroxaban for efficacy endpoints or mortality, but rivaroxaban had more major and/or clinically relevant non-major bleeding. When compared to low-dose edoxaban, apixaban was associated with lower stroke/SE (HR 0.70; 95% CI 0.55–0.89), stroke (HR 0.70; 95% CI 0.55–0.92) and ischaemic stroke (HR 0.65; 95% CI 0.50–0.89), but more major bleeding (HR 1.47; 95% CI 1.20–1.80). For dabigatran 110 mg bid, there were no significant differences in the efficacy endpoints, but dabigatran 110 mg bid had higher major (and gastrointestinal) bleeding. Dabigatran 150 mg bid and rivaroxaban were associated with lower stroke/SE and ischaemic stroke, but higher bleeding rates. In the present analysis, we have provided for the first time, comparisons of efficacy and safety of edoxaban against other NOACs. Notwithstanding the significant limitations of an indirect comparison analysis, some differential effects are evident with the NOACs for stroke prevention, allowing us to allow the prescriber a ‘choice’ to be able to fit the drug to the patient clinical profile (and vice versa).Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Costs of major intracranial, gastrointestinal and other bleeding events in patients with atrial fibrillation - a nationwide cohort study. BMC Health Serv Res 2017; 17:398. [PMID: 28606079 PMCID: PMC5469002 DOI: 10.1186/s12913-017-2331-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 05/23/2017] [Indexed: 01/08/2023] Open
Abstract
Background Use of oral anticoagulation therapy in patients with atrial fibrillation (AF) involves a trade-off between a reduced risk of ischemic stroke and an increased risk of bleeding events. Different anticoagulation therapies have different safety profiles and data on the societal costs of both ischemic stroke and bleeding events are necessary for assessing the cost-effectiveness and budgetary impact of different treatment options. To our knowledge, no previous studies have estimated the societal costs of bleeding events in patients with AF. The objective of this study was to estimate the 3-years societal costs of first-incident intracranial, gastrointestinal and other major bleeding events in Danish patients with AF. Methods The study was an incidence-based cost-of-illness study carried out from a societal perspective and based on data from national Danish registries covering the period 2002-2012. Costs were estimated using a propensity score matching and multivariable regression analysis (first difference OLS) in a cohort design. Results Average 3-years societal costs attributable to intracranial, gastrointestinal and other major bleeding events were 27,627, 17,868, and 12,384 EUR per patient, respectively (2015 prices). Existing evidence shows that the corresponding costs of ischemic stroke were 24,084 EUR per patient (2012 prices). The average costs of bleeding events did not differ between patients with AF who were on oral anticoagulation therapy prior to the event and patients who were not. Conclusions The societal costs attributable to major bleeding events in patients with AF are significant. Intracranial haemorrhages are most costly to society with average costs of similar magnitude as the costs of ischemic stroke. The average costs of gastrointestinal and other major bleeding events are lower than the costs of intracranial haemorrhages, but still substantial. Knowledge about the relative size of the costs of bleeding events compared to ischemic stroke in patients with AF constitutes valuable evidence for decisions-makers in Denmark as well as in other countries. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2331-z) contains supplementary material, which is available to authorized users.
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7
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Rose MFLDS. Pharmacological profile of non-vitamin K antagonist oral anticoagulants. ACTA ACUST UNITED AC 2017. [DOI: 10.5897/ajpp2017.4744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Machado-Alba JE, García-Betancur S, Villegas-Cardona F, Medina-Morales DA. Patrones de prescripción de los nuevos anticoagulantes orales y sus costos económicos en Colombia. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Voukalis C, Lip GY, Shantsila E. Emerging Tools for Stroke Prevention in Atrial Fibrillation. EBioMedicine 2016; 4:26-39. [PMID: 26981569 PMCID: PMC4776061 DOI: 10.1016/j.ebiom.2016.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023] Open
Abstract
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.
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Key Words
- Atrial fibrillation
- CKD, chronic kidney disease
- CrCl, creatinine clearance
- DM, diabetes mellitus
- ESRF, end stage renal failure
- HF, heart failure
- HTN, hypertension
- ICH, intracranial haemorrhage
- INR, international normalised ratio
- LV, left ventricle
- NCB, net clinical benefit
- NICE, National institute for Health and Care Excellence
- NVAF, non-valvular atrial fibrillation
- Net clinical benefit
- Non-vitamin K oral anticoagulants
- Oral anticoagulation
- PCI, percutaneous coronary intervention
- RSM, risk stratification model
- Risk stratification
- SE, systemic embolism
- Stroke prevention
- TE, thromboembolic episode
- TIA, transient ischaemic attack
- TTR, time in therapeutic range
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
| | | | - Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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da Silva RMFL. Novel oral anticoagulants in non-valvular atrial fibrillation. Cardiovasc Hematol Agents Med Chem 2015; 12:3-8. [PMID: 25470147 PMCID: PMC4428103 DOI: 10.2174/187152571201141201091848] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/01/2014] [Accepted: 07/18/2014] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is the most frequent arrhythmia in clinical practice, reaching 2% of the people in the world and is associated with systemic embolism. Thus, the use of anticoagulants is indicated if CHA2DS2-VASc score ≥ 2 or in patients with previous transient ischemic attack or stroke. For decades, warfarin, a vitamin K antagonist, was the only choice for chronic oral anticoagulation. Recently, novel oral anticoagulants (NOACs) have been introduced, offering similar (or better) effectiveness, safety, and convenience to the vitamin K antagonists. Dabigatran was the first NOAC approved and is a direct thrombin inhibitor. Rivaroxaban and apixaban are factor Xa inhibitors. They display rapid onset of action, more predictable of pharmacological profile, less interactions with other drugs, lack of significant effects in the diet, and less risk of intracranial hemorrhage than warfarin. Despite that dose adjustment is necessary for patients with chronic kidney disease or according to body weight, these new drugs do not require regular monitoring. There are recommendations for the start and follow-up therapy with NOACs, planning for cardioversion, ablation and surgical interventions and the management of bleeding. This article is a review of the major studies of the NOACs. The clinical use of these drugs in patients with non-valvular atrial fibrillation is presented.
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Affiliation(s)
- Rose M F L da Silva
- Avenue Alfredo Balena, 190, room 246, Santa Efigênia, Code 30.130-100, Belo Horizonte/Minas Gerais, Brazil.
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Prisco D, Cenci C, Silvestri E, Ciucciarelli L, Di Minno G. Novel oral anticoagulants in atrial fibrillation. J Cardiovasc Med (Hagerstown) 2015; 16:512-9. [DOI: 10.2459/jcm.0000000000000262] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Lauffenburger JC, Farley JF, Gehi AK, Rhoney DH, Brookhart MA, Fang G. Factors driving anticoagulant selection in patients with atrial fibrillation in the United States. Am J Cardiol 2015; 115:1095-101. [PMID: 25724781 DOI: 10.1016/j.amjcard.2015.01.539] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/18/2015] [Accepted: 01/18/2015] [Indexed: 12/16/2022]
Abstract
With the introduction of novel oral anticoagulants (NOACs), the factors driving anticoagulant selection in atrial fibrillation (AF) in real-world practice are unclear. The goal was to examine whether and to what extent utilization has been driven by predictions of stroke risk (treatment benefit), bleeding risk (treatment harm), or prescription benefits' coverage. We extracted a cohort of patients with nonvalvular AF initiating anticoagulation from October 2010 to December 2012 from a large US database of commercial and Medicare supplement claims. Multivariable regression examined associations between ischemic stroke (CHA2DS2-VASc) and bleeding (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA]) risk scores and benefits' generosity (proportion of costs covered by patients relative to total) with warfarin and novel oral anticoagulant (NOAC) selection and also between dabigatran and rivaroxaban. C-statistics and partial chi-square statistics were used to assess the variation explained. Of 70,498 patients initiating anticoagulation, 29.9% and 7.9% used dabigatran and rivaroxaban, respectively. Compared with warfarin, patients were less likely to receive an NOAC with high ischemic stroke risk (CHA2DS2-VASc ≥2; adjusted relative risk [aRR] 0.75, 95% confidence interval [CI] 0.72 to 0.77) and high bleeding risk (ATRIA ≥5; aRR 0.66, 95% CI 0.64 to 0.69) but more likely with good benefits' generosity (≤20% of costs borne by patient; aRR 2.03, 95% CI 1.92 to 2.16). Prescription generosity explained almost twice the model variation as either risk score. Compared with dabigatran, patients were more likely to fill rivaroxaban with high bleeding risk (aRR 1.16, 95% CI 1.09 to 1.24). In conclusion, patients with greater bleeding and ischemic stroke risk were more likely to initiate warfarin, but generous benefits more strongly predicted NOAC usage and drove more selection.
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Abumuaileq RRY, Abu-Assi E, Raposeiras-Roubin S, Lopez-Lopez A, Redondo-Dieguez A, Alvarez-Iglesias D, Rodriguez-Manero M, Pena-Gil C, Gonzalez-Juanatey JR. Evaluation of SAMe-TT2R2 risk score for predicting the quality of anticoagulation control in a real-world cohort of patients with non-valvular atrial fibrillation on vitamin-K antagonists. Europace 2015; 17:711-7. [DOI: 10.1093/europace/euu353] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/03/2014] [Indexed: 01/08/2023] Open
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García Callejo FJ, Bécares Martínez C, Calvo González J, Martínez Beneyto P, Marco Sanz M, Marco Algarra J. Epistaxis and Dabigatran, a New Non-Vitamin K Antagonist Oral Anticoagulant. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014. [DOI: 10.1016/j.otoeng.2014.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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García Callejo FJ, Bécares Martínez C, Calvo González J, Martínez Beneyto P, Marco Sanz M, Marco Algarra J. Epistaxis y dabigatrán, nuevo anticoagulante oral no antagonista de la vitamina K. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014; 65:346-54. [DOI: 10.1016/j.otorri.2014.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/20/2014] [Accepted: 02/25/2014] [Indexed: 12/15/2022]
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Dzeshka MS, Lip GY. Warfarin versus dabigatran etexilate: an assessment of efficacy and safety in patients with atrial fibrillation. Expert Opin Drug Saf 2014; 14:45-62. [PMID: 25341529 DOI: 10.1517/14740338.2015.973847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Oral anticoagulation is the mainstay for stroke and thromboembolic event prevention in patients with atrial fibrillation (AF). Given limitations of warfarin therapy, non-vitamin K oral anticoagulants have been developed including direct thrombin inhibitors (i.e., dabigatran etexilate). Dabigatran etexilate has been tested thoroughly in terms of efficacy and safety in clinical trials and studies, involving 'real-world' cohorts. In this review, currently available evidence in patients with non-valvular AF is discussed. AREAS COVERED The pharmacology, efficacy and safety, and current aspects of use of dabigatran etexilate in patients with non-valvular AF are reviewed in a comparative manner to warfarin both for chronic anticoagulation and in different clinical settings. EXPERT OPINION Dabigatran etexilate appeared to have several pharmacokinetic and pharmacodynamic advantages over warfarin, as well as a favorable efficacy and safety profile being at least noninferior and often superior to warfarin in patients with non-valvular AF. The latter was shown in the clinical trials, meta-analyses and studies with 'real-world' data. Currently ongoing trials will expand the body of evidence on warfarin and will aid decision making in currently controversial areas. Important limitations of dabigatran etexilate include contraindications for its use in patients with prosthetic heart valves and end-stage chronic kidney disease.
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Affiliation(s)
- Mikhail S Dzeshka
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital , Birmingham B18 7QH , UK
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Lip GYH, Haguenoer K, Saint-Etienne C, Fauchier L. Relationship of the SAMe-TT 2 R 2 Score to Poor-Quality Anticoagulation, Stroke, Clinically Relevant Bleeding, and Mortality in Patients With Atrial Fibrillation. Chest 2014; 146:719-726. [PMID: 24722973 DOI: 10.1378/chest.13-2976] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, England.
| | - Ken Haguenoer
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Christophe Saint-Etienne
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Laurent Fauchier
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
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Lau YC, Lip GYH. New advances in the treatment of atrial fibrillation: focus on stroke prevention. Expert Opin Pharmacother 2014; 15:2193-204. [DOI: 10.1517/14656566.2014.948418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lip GY, Laroche C, Boriani G, Cimaglia P, Dan GA, Santini M, Kalarus Z, Rasmussen LH, Popescu MI, Tica O, Hellum CF, Mortensen B, Tavazzi L, Maggioni AP. Sex-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Observational Research Programme Pilot survey on Atrial Fibrillation. ACTA ACUST UNITED AC 2014; 17:24-31. [DOI: 10.1093/europace/euu155] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Anticoagulation therapy is one of the most important advances in modern medicine, saving thousands of lives from the complications of atrial fibrillation and mechanical heart valves and preventing recurrent venous thromboembolism. Warfarin and heparins have been the predominant anticoagulants used until the past decade. However, the arrival of newer target-specific anticoagulants has brought us easier and equally effective agents, although no specific antidotes are yet available. Being relatively newer drugs, physicians need to be familiar with the various practical issues that may be encountered with the prescription of these drugs, which are summarised in this review.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary
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