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Ren J, Wang N, Zhang X, Song F, Zheng X, Han X. A systematic review and meta-analysis of the morbidity of efficacy endpoints and bleeding events in elderly and young patients treated with the same dose rivaroxaban. Ann Hematol 2024:10.1007/s00277-024-05767-z. [PMID: 38710878 DOI: 10.1007/s00277-024-05767-z] [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: 02/19/2024] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
Rivaroxaban is a new direct oral anticoagulant, and the same dose is recommended for older and young patients. However, recent real-world studies show that older patients may need dose adjustment to prevent major bleeding. At present, the evidence for dose adjustment in older patients is extremely limited with only a few reports on older atrial fibrillation patients. The aim of this study was to review the morbidity data of adverse events and bleeding events across all indications for older and young patients treated with the same dose of rivaroxaban to provide some support for dosage adjustment in older patients. The PubMed, EMBASE, ClinicalTrials, Cochrane and Web of Science databases were searched for randomized controlled trials (RCTs) published between January 1, 2005, and October 10, 2023. The primary outcomes were the morbidity of bleeding events and efficacy-related adverse events. Summary estimates were calculated using a random effects model. Eighteen RCTs were included in the qualitative analysis. The overall morbidity of primary efficacy endpoints was higher in older patients compared to the young patients (3.37% vs. 2.60%, χ2 = 5.24, p = 0.022). Similarly, a higher morbidity of bleeding was observed in older patients compared to the young patients (4.42% vs. 6.03%, χ2 = 13.22, p < 0.001). Among all indications, deep vein thrombosis, pulmonary embolism and atrial fibrillation were associated with the highest incidence of bleeding in older patients, suggesting that these patients may be most need dose adjustment. Patients older than 75 years may require extra attention to prevent bleeding. The same dose of rivaroxaban resulted in higher bleeding morbidity and morbidity of efficacy-related adverse events in older patients compared to the young patients. An individualized dose adjustment may be preferred for older patients rather than a fixed dose that fits all.
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Affiliation(s)
- Jianwei Ren
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Na Wang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xuan Zhang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Fuyu Song
- Center for Food and Drug Inspection, National Medical Products Administration, Beijing, 100053, China
- NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Peking University Sixth Hospital, Peking University Institute of Mental Health, Peking University, Beijing, 100191, China
| | - Xin Zheng
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Xiaohong Han
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Choi J, No JE, Lee JY, Choi SA, Chung WY, Ah YM, Yu YM. Efficacy and Safety of Clinically Driven Low-Dose Treatment with Direct Oral Anticoagulants in Asians with Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2022; 36:333-345. [PMID: 33725229 DOI: 10.1007/s10557-021-07171-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Although clinically driven low-dose (CDLD) treatment with direct oral anticoagulants (DOACs) is frequently administered to Asian patients with atrial fibrillation, clinical evidence confirming its efficacy remains insufficient. We evaluated the clinical efficacy and safety of CDLD treatment with DOACs compared to on-label dose treatment in Asian patients with atrial fibrillation and assessed the differences in the baseline characteristics between patients receiving these treatments. METHODS We searched the MEDLINE, CENTRAL, EMBASE, Web of Science, and Scopus databases for articles from inception through July 2020. RESULTS Thirteen studies were included in this meta-analysis. The baseline characteristics of the CDLD group were significantly different from those of the standard dose (STD) and standard low-dose (SLD) groups. The incidences of thromboembolic events (risk ratio [RR] 0.46, 95% confidence interval [CI] 0.29-0.73, p < 0.001) and major bleeding (RR 0.55, 95% CI 0.35-0.87, p = 0.01) in the CDLD group were lower than those in the SLD group; however, they were comparable with those in the STD group. The incidence of a composite endpoint in the CDLD group was not significantly different from that in the STD group but was significantly lower than that in the SLD group (RR 0.50, 95% CI 0.38-0.65, p < 0.001). CONCLUSION The clinical outcomes of CDLD treatment showed no difference compared to those of the STD treatment despite the vulnerable baseline characteristics of the CDLD group for thromboembolic and major bleeding events.
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Affiliation(s)
- Jillie Choi
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Jae Eun No
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Soo An Choi
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Korea University, Sejong, Republic of Korea
| | - Woo-Young Chung
- Department of Internal Medicine, Seoul National University Boramae Medical Center and College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongsangbuk-do, 38541, Republic of Korea.
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, 85 Songdogwahak-ro, Yeonsu-gu, Incheon, 21983, Republic of Korea.
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea.
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Real-World Comparisons of Low-Dose NOACs versus Standard-Dose NOACs or Warfarin on Efficacy and Safety in Patients with AF: A Meta-Analysis. Cardiol Res Pract 2022; 2022:4713826. [PMID: 35449605 PMCID: PMC9017587 DOI: 10.1155/2022/4713826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective We aimed to further investigate the efficacy and safety of low-dose NOACs by performing a meta-analysis of cohort studies. Background Meta-analyses of randomized controlled trials (RCTs) have demonstrated that low-dose non-vitamin K antagonist oral anticoagulants (NOACs) showed inferior efficacy compared with standard-dose NOACs, although they are still frequently prescribed for patients with atrial fibrillation (AF) in the clinical practice. Methods Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically searched from the inception to September 9, 2021, for cohort studies that compared the efficacy and/or safety of low-dose NOACs in patients with AF. The primary outcomes were ischemic stroke and major bleeding, and the secondary outcomes were mortality, intracranial hemorrhage (ICH), and gastrointestinal hemorrhage (GH). Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with the random-effect model. Results Twenty-five publications involving 487856 patients with AF were included. Compared with standard-dose NOACs, low-dose NOACs had comparable risks of ischemic stroke (HR = 1.03, 95% CI 0.96 to 1.11), major bleeding (HR = 1.12, 95% CI 0.97 to 1.28), ICH (HR = 1.09, 95% CI 0.88 to 1.36), and GH (HR = 1.11, 95% CI 0.92 to 1.33), except for a higher risk of mortality (HR = 1.41, 95% CI 1.21 to 1.65). Compared with warfarin, low-dose NOACs were associated with lower risks of ischemic stroke (HR = 0.72, 95% CI .67 to 0.78), mortality (HR = 0.67, 95% CI 0.59 to 0.77), major bleeding (HR = 0.64, 95% CI 0.53 to 0.79), ICH (HR = 0.57, 95% CI 0.42 to 0.77), and GH (HR = 0.78, 95% CI 0.64 to 0.95). Conclusions Low-dose NOACs were comparable to standard-dose NOACs considering risks of ischemic stroke, major bleeding, ICH, and GH, and they were superior to warfarin. Low-dose NOACs might be prescribed effectively and safely for patients with AF. Considering limitations, further well-designed prospective studies are foreseen.
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Zhang XL, Zhang XW, Wang TY, Wang HW, Chen Z, Xu B, Xu W. Off-Label Under- and Overdosing of Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Meta-Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e007971. [PMID: 34932377 DOI: 10.1161/circoutcomes.121.007971] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prescriptions of off-label under- and overdosing of direct oral anticoagulants (DOACs) are common for patients with atrial fibrillation, but their efficacy and safety remain unknown. METHODS Databases were searched for randomized controlled trial or adjusted observational study that compared an off-label versus on-label dosing of DOACs through June 15, 2021. The primary efficacy outcome was ischemic stroke/system embolism (IS/SE), and primary safety outcome was major bleeding. Net clinical outcome was generally defined as the composite of IS/SE, major bleeding, and all-cause death. Hazard ratios (HRs) with 95% CIs were pooled with random-effects models with Hartung-Knapp-Sidik-Jonkman method for adjustment. RESULTS Sixteen studies with 130 609 patients were included. Compared with on-labeling dosing, off-label underdosing of DOACs was associated with a higher risk of IS/SE (HR, 1.22 [95% CI, 1.05-1.42], P=0.01). The incidence of major bleeding was similar (HR, 0.95 [95% CI, 0.82-1.11], P=0.48). Off-label underdosing was associated with a higher risk of net clinical outcome (HR, 1.19 [95% CI, 1.04-1.40], P=0.04) and all-cause death (HR, 1.24 [95% CI, 1.04-1.48], P=0.02). Stratified analysis of off-label underdosing of DOACs for IS/SE showed subgroup differences among different DOAC types and study regions. Limited data showed that off-label overdosing was associated with a higher risk of IS/SE (HR, 1.26 [95% CI, 1.11-1.43], P=0.003) and major bleeding (HR, 1.30 [95% CI, 1.04-1.62], P=0.025). CONCLUSIONS Compared with on-label dosing, off-label underdosing of DOACs increased the risk of thromboembolic events but did not decrease the risk of bleeding. Limited data for off-label overdosing showed higher risks of thromboembolic and bleeding. Further studies are warranted to confirm the results of off-label overdosing DOACs and subgroup results of underdosing DOACs.
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Affiliation(s)
- Xin-Lin Zhang
- Department of Cardiology (X.-L.Z., Z.C., B.X., W.X.), Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiao-Wen Zhang
- Department of Endocrinology (X.-W.Z.), Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ting-Yu Wang
- Central for translational medicine, Nanjing University School of Medicine, China (T.-Y.W., H.-W.W.)
| | - Hong-Wei Wang
- Central for translational medicine, Nanjing University School of Medicine, China (T.-Y.W., H.-W.W.)
| | - Zheng Chen
- Department of Cardiology (X.-L.Z., Z.C., B.X., W.X.), Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Biao Xu
- Department of Cardiology (X.-L.Z., Z.C., B.X., W.X.), Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wei Xu
- Department of Cardiology (X.-L.Z., Z.C., B.X., W.X.), Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
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Kotalczyk A, Guo Y, Wang Y, Lip GY. Are low doses of non-vitamin K antagonists effective in Chinese patients with atrial fibrillation? A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. Int J Stroke 2021; 17:17474930211053140. [PMID: 34657532 DOI: 10.1177/17474930211053140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Suboptimal low dosages of non-vitamin K antagonist oral anticoagulants (NOACs) are often inappropriately used due to a fear of bleeding, particularly among elderly patients. Such practice is common in Asia, and we aimed to evaluate the use of low-dose NOACs and their impact on clinical outcomes among Chinese patients with atrial fibrillation. METHODS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry was a prospective, multicenter study conducted in China from October 2014 to December 2018. For this report, we included NOAC-treated patients with available data on NOAC dosage and one-year follow-up. Logistic regression analysis assessed the association (adjusted for age, sex, prior ischemic stroke, prior major bleeding, heart failure, coronary artery disease, hypertension, diabetes mellitus, chronic kidney disease, liver disease, current anemia) between the low doses and study outcomes among NOAC-treated patients, as well as comparisons with non-anticoagulated patients. RESULTS The eligible cohort included 1310 NOAC-treated patients (mean age of 72.1 ± 10.9; 38.9% female), of whom 341 (26.0%) received a low "off-label" dose. The use of low-dose NOACs was independently associated with higher odds of the composite outcome (OR: 2.51; 95% CI: 1.11-5.71) and thromboembolism (OR: 4.73; 95% CI: 1.11-20.01). Compared with non-anticoagulated patients, lower rates of the composite outcome (7.3% vs. 11.3%; p = 0.025) and all-cause death (5.3% vs. 9.7%; p = 0.007) were seen in the low-dose group (ORs 0.50; 95% CI: 0.32-0.78, and 0.42; 95% CI: 0.26-0.70, respectively). CONCLUSIONS Low doses of NOACs should not be recommended as a part of standard therapy among Chinese patients with atrial fibrillation as their use was associated with a higher odds ratio of the composite outcome and thromboembolic events compared with standard dose NOAC regimens. Compared to non-treatment, the use of low-dose NOAC may result in a survival benefit (but not thromboembolic reduction) among high-risk patients.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Yutao Guo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yutang Wang
- Department of Cardiology, Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Xue Z, Zhou Y, Wu C, Lin J, Liu X, Zhu W. Non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: evidences from the real-world data. Heart Fail Rev 2021; 25:957-964. [PMID: 31655947 DOI: 10.1007/s10741-019-09878-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The role of non-vitamin K antagonist oral anticoagulants (NOACs) in stroke prevention remains unclear in Asian patients with atrial fibrillation (AF). Therefore, we performed a meta-analysis to compare the efficacy and safety outcomes of NOACs in Asian patients with AF from the real-world settings. The PubMed and Embase databases were systematically searched to identify eligible observational studies until June 2019. The odds ratios (OR) and 95% confidence intervals (CIs) were calculated and then pooled by a random-effects model. A total of 18 observational studies were included. Compared with warfarin, dabigatran (OR, 0.56, 95% CI 0.43-0.73), rivaroxaban (OR, 0.54, 95% CI 0.44-0.67), apixaban (OR, 0.41, 95% CI 0.35-0.48), and edoxaban (OR, 0.19, 95% CI 0.14- 0.25) reduced the risk of major bleeding, while dabigatran (OR, 0.78, 95% CI 0.71-0.85), rivaroxaban (OR, 0.74, 95% CI 0.68-0.82), and edoxaban (OR, 0.29, 95% CI 0.22-0.39) were associated with reduced risks of stroke or systemic embolism. In addition, dabigatran versus apixaban was associated with increased risks of ischemic stroke and gastrointestinal bleeding, while rivaroxaban versus apixaban was associated with elevated risks of stroke or systemic embolism, ischemic stroke, intracranial hemorrhage, and gastrointestinal bleeding. In Asian patients with AF, NOACs are non-inferior to warfarin for stroke prevention, and apixaban may be a better choice compared with dabigatran or rivaroxaban.
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Affiliation(s)
- Zhengbiao Xue
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, Jiangxi, China
| | - Yue Zhou
- Department of Children's Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Chaoyu Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, Jiangxi, China
| | - Jie Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, Jiangxi, China
| | - Xin Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, Jiangxi, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.
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Chao TF, Hong KS, Lee BC, De Caterina R, Kirchhof P, Reimitz PE, Chen C, Unverdorben M, Wang CC. Factors associated with the dosing of edoxaban for stroke prevention in patients with atrial fibrillation from South Korea and Taiwan: 1-year data from the Global ETNA-AF Program. J Chin Med Assoc 2021; 84:485-490. [PMID: 33742992 DOI: 10.1097/jcma.0000000000000516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have replaced vitamin K antagonists as the standard of care for stroke prevention in patients with atrial fibrillation (AF). However, DOAC prescriptions at dosages that do not adhere to labeling are common in daily practice. This analysis from the observational Global Edoxaban Treatment in routiNe clinical prActice (ETNA)-AF program focuses on edoxaban-treated patients from South Korea and Taiwan to identify patient baseline characteristics that may be associated with non-recommended dosing. METHODS We report baseline data from ETNA-AF, including patient demographics, clinical characteristics, and bleeding/stroke history of patients receiving recommended or non-recommended edoxaban dosing. RESULTS A total of 2677 patients were enrolled. Among 1543 patients who did not meet dose-reduction criteria, 1033 (66.9%) were prescribed the recommended 60-mg dose, and 510 (33.1%) were prescribed the non-recommended 30-mg dose. Among 1134 patients meeting ≥1 of the dose-reduction criteria, 863 (76.1%) were prescribed the recommended 30-mg dose; 271 (23.9%) were prescribed the nonrecommended 60-mg dose. Compared with the recommended 60-mg group, the nonrecommended 30-mg group had a higher proportion of patients aged ≥75 years, higher stroke and bleeding risks, and a history of major bleeding. The non-recommended 60-mg group had a lower proportion of patients aged ≥75 years, a higher history of stroke, and lower history of bleeding compared with the recommended 30-mg group. CONCLUSION The baseline data from ETNA-AF indicate that physicians take patient clinical characteristics (e.g., bleeding risks) into consideration when deviating from the dosing recommendation per label.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Raffaele De Caterina
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Pisa University Hospital and University of Pisa, Pisa, Italy
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Paul-Egbert Reimitz
- Biostatistics and Data Operations, Daiichi Sankyo Europe, GmbH, Munich, Germany
| | - Cathy Chen
- Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | | | - Chun-Chieh Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung University and Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
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Park J, Jung JH, Choi EK, Lee SW, Kwon S, Lee SR, Kang J, Han KD, Park KW, Oh S, Lip GYH. Longitudinal Patterns in Antithrombotic Therapy in Patients with Atrial Fibrillation after Percutaneous Coronary Intervention in the Non-Vitamin K Oral Anticoagulant Era: A Nationwide Population-Based Study. J Clin Med 2021; 10:jcm10071505. [PMID: 33916604 PMCID: PMC8038511 DOI: 10.3390/jcm10071505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
We investigated whether longitudinal patterns in antithrombotic therapy have changed after the introduction of non-vitamin K oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI). Using a claims database of the Korean AF population who underwent PCI between 2012 and 2016 (n = 18,691), we analyzed prescription records of oral anticoagulants (OACs) and antiplatelets at 3-month intervals over 2 years after PCI. The study population was stratified (pre-NOAC, transition, and NOAC era) using time-periods of NOAC introduction in Korea and an expansion of reimbursement for NOAC in AF as indicators. The overall rates of OAC were low at baseline (24.9%, 26.9%, and 35.2% in pre-NOAC, transition, and NOAC era, respectively), contrary to high rates of dual antiplatelet therapy (DAPT) (73.3%, 71.4%, and 63.6%). However, OAC prescription rates were increased at 1-year (18.5%, 22.5%, and 31.6%), and 2-year follow-up (17.8%, 24.2%, and 31.8%) from pre-NOAC to NOAC era. In NOAC era, 63.5% of baseline OAC prescriptions comprised NOAC, of which 96.4% included triple therapy with DAPT. Over 2 years, we observed increasing rates of double therapy with a single antiplatelet (18.3% and 20.0% at 1- and 2-year follow-up) and OAC monotherapy (2.7% and 8.9% at 1- and 2-year follow-up).
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-H.J.); (K.-D.H.)
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
- Correspondence: ; Tel.: +82-2-2072-0688; Fax: +82-2-762-9662
| | - Seung-Woo Lee
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea;
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Kyung-Do Han
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-H.J.); (K.-D.H.)
| | - Kyung-Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Gregory Y. H. Lip
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Chest & Heart Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
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Liu X, Huang M, Ye C, Xiao X, Yan C. Effect of non-recommended doses versus recommended doses of direct oral anticoagulants in atrial fibrillation patients: A meta-analysis. Clin Cardiol 2021; 44:472-480. [PMID: 33682184 PMCID: PMC8027572 DOI: 10.1002/clc.23586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022] Open
Abstract
Background Several observational studies have shown that the inappropriate dosing use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) that does not conform to recommendations is becoming a widespread phenomenon. Therefore, we performed a meta‐analysis and systematic review to assess the effect of non‐recommended doses versus recommended doses of DOACs on the effectiveness and safety outcomes among AF patients. Methods The PubMed and Ovid databases were systematically searched to identify the relevant studies until December 2020. The effect estimates were hazard ratios (HRs) and 95% confidence intervals (CIs), which were pooled using a fixed‐effects model (I2 ≤ 50%) or a random‐effects model (I2 > 50%). Results A total of 11 studies were included in this meta‐analysis. Compared with recommended dosing of DOACs, non‐recommended low dosing of DOACs was associated with increased risks of stroke or systemic embolism (SSE, HR = 1.29, 95% CI 1.12–1.49) and all‐cause death (HR = 1.37, 95% CI 1.15–1.62), but not the ischemic stroke, myocardial infarction, gastrointestinal bleeding, intracranial bleeding, and major bleeding. Compared with recommended dosing of DOACs, non‐recommended high dosing of DOACs was associated with increased risks of SSE (HR = 1.44, 95% CI 1.01–2.04), major bleeding (HR = 1.99, 95% CI 1.48–2.68), and all‐cause death(HR = 1.38, 95% CI 1.02–1.87). Conclusion Compared with recommended dosing of DOACs, non‐recommended low dosing of DOACs was associated with increased risks of SSE and all‐cause death. Further study should confirm the findings of non‐recommended high dosing versus recommended dosing of DOACs.
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Affiliation(s)
- Xuyang Liu
- Department of Cardiology, Jinggangshan University, Ji'an, Jiangxi, China
| | - Manxiang Huang
- Department of Cardiology, Jinggangshan University, Ji'an, Jiangxi, China
| | - Caisheng Ye
- Department of Cardiology, Jinggangshan University, Ji'an, Jiangxi, China
| | - Xiujuan Xiao
- Department of Cardiology, Jinggangshan University, Ji'an, Jiangxi, China
| | - Chengguang Yan
- Department of Cardiology, Jinggangshan University, Ji'an, Jiangxi, China
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10
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Abe I, Takahashi N. Wait a minute to prescribe off-label reduced dose of apixaban. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:424-425. [PMID: 33580682 DOI: 10.1093/ehjcvp/pvab006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ichitaro Abe
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Japan
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11
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Liu X, Huang M, Ye C, Zeng J, Zeng C, Ma J. The role of non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A PRISMA-compliant article. Medicine (Baltimore) 2020; 99:e21025. [PMID: 32629725 PMCID: PMC7337535 DOI: 10.1097/md.0000000000021025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Given the huge burden of atrial fibrillation (AF) and AF-related stroke in Asia, stroke prevention represents an urgent issue in this region. We herein performed a network meta-analysis to examine the role of non-vitamin K antagonist oral anticoagulants (NOACs) in Asian patients with AF. METHODS A systematic search of the publications was conducted in PubMed and Embase databases for eligible studies until July 2019. The odds ratios (ORs) and 95% confidence intervals (CIs) were regarded as the effect estimates. The surface under the cumulative ranking area (SUCRA) for the ranking probabilities was calculated. RESULTS A total of 17 studies were included. For comparisons of NOACs vs warfarin, dabigatran (OR = 0.77, 95% CI 0.68-0.86), rivaroxaban (OR = 0.72, 95% CI 0.65-0.81), apixaban (OR = 0.56, 95% CI 0.49-0.65), but not edoxaban reduced the risk of stroke or systemic embolism, wheres dabigatran (OR = 0.56, 95% CI 0.41-0.76), rivaroxaban (OR = 0.66, 95% CI 0.50-0.86), apixaban (OR = 0.49, 95% CI 0.36-0.66), and edoxaban (OR = 0.34, 95% CI 0.24-0.49) decreased the risk of major bleeding. In reducing the risk of stroke or systemic embolism, apixaban and rivaroxaban ranked the best and second best (SUCRA 0.2% and 31.4%, respectively), followed by dabigatran (50.2%), edoxaban (75.2%), and warfarin (93.0%). In reducing the risk of major bleeding, edoxaban, and apixaban ranked the best and second best (1.5% and 30.8%, respectively), followed by dabigatran (48.4%), rivaroxaban (69.2%), and warfarin (100%). CONCLUSION NOACs were at least as effective as warfarin, but more safer in Asians with AF. Apixaban was superior to other NOACs for reducing stroke or systemic embolism, while edoxaban showed a better safety profile than other NOACs.
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Affiliation(s)
| | | | | | | | - Changai Zeng
- Department of stomatology, Jinggangshan University, Ji’an, Jiangxi, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH
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12
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Santoso A, Raharjo SB. Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians. Int J Angiol 2020; 29:88-97. [PMID: 32499669 DOI: 10.1055/s-0040-1708477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)-vascular disease, age 65 to 74 years, sex category (female; CHA 2 DS 2 -VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, "triple therapy" comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for "triple therapy" would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.
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Affiliation(s)
- Anwar Santoso
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
| | - Sunu B Raharjo
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
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13
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Nagy Á, Kim JH, Jeong ME, Heo MH, Putzu A, Belletti A, Biondi-Zoccai G, Landoni G. Non-vitamin K oral anticoagulants for coronary or peripheral artery disease: a systematic review and meta-analysis of mortality and major bleeding. Minerva Cardioangiol 2019; 67:477-486. [PMID: 31625706 DOI: 10.23736/s0026-4725.19.05043-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Ádám Nagy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Jun H Kim
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Myeong E Jeong
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Min H Heo
- Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy -
- Vita-Salute San Raffaele University, Milan, Italy
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14
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Okumura K, Yamashita T, Suzuki S, Akao M. A multicenter prospective cohort study to investigate the effectiveness and safety of apixaban in Japanese elderly atrial fibrillation patients (J-ELD AF Registry). Clin Cardiol 2019; 43:251-259. [PMID: 31737921 PMCID: PMC7068106 DOI: 10.1002/clc.23294] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/26/2019] [Accepted: 11/04/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A global, randomized clinical trial indicated the efficacy and safety of apixaban in stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, data in the elderly NVAF patients ≥75 years, especially those on reduced dose, are limited. HYPOTHESIS To confirm the current dose reduction criteria of apixaban in elderly NVAF patients. METHOD With a large-scale, multicenter prospective observational study, one-year outcomes after administration of on-label doses of apixaban were analyzed in Japanese NVAF patients aged ≥75 years. Endpoints were stroke or systemic embolism, bleeding requiring hospitalization, total death, and cardiovascular death. RESULTS A total of 3031 patients (average age, 81.7 years; female, 48.2%) taking standard (5 mg bid) or reduced dose (2.5 mg bid) of apixaban were enrolled from 110 facilities. Standard and reduced apixaban doses were administered in 1284 (42.4%) and 1747 (57.6%) patients, respectively. Event rates (/100 person-years) in standard and reduced dose groups were 1.67 and 1.56, respectively, for stroke or systemic embolism, 1.42 and 2.25 for bleeding requiring hospitalization, 1.41 and 4.46 for total death, and 0.41 and 1.36 for cardiovascular death. Reduced apixaban dose was not significantly associated with stroke or systemic embolism and bleeding requiring hospitalization, but was independently associated with total and cardiovascular death. CONCLUSIONS Incidences of stroke or systemic embolism and bleeding requiring hospitalization were similar between standard and reduced apixaban doses in the elderly NVAF patients. The incidences of total and cardiovascular death were significantly higher in the reduced dose group due to the coexisting higher risks in this group.
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Affiliation(s)
- Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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15
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Xue Z, Zhang H. Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation: Meta-Analysis of Randomized Trials and Real-World Studies. Stroke 2019; 50:2819-2828. [PMID: 31422735 PMCID: PMC6756252 DOI: 10.1161/strokeaha.119.026054] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose- Several randomized trials and real-world studies have reported the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in Asian patients with atrial fibrillation; and therefore, this meta-analysis was aimed to compare the effects of NOACs with warfarin for atrial fibrillation stroke prevention in Asians. Methods- The PubMed and Embase databases were searched from January 2009 to February 2019 for studies on comparisons of NOACs versus warfarin in Asians. Risk ratios (RRs) with 95% CIs were pooled using a random-effects model. Results- Five NOAC trials and 21 observational cohorts were included. For the NOAC trials, compared with warfarin, NOACs was associated with reduced risks of stroke or systemic embolism (RR, 0.73; 95% CI, 0.59-0.90), all-cause death (RR, 0.83; 95% CI, 0.73-0.95), major bleeding (RR, 0.59; 95% CI, 0.48-0.72), and intracranial bleeding (RR, 0.36; 95% CI, 0.26-0.49). For the real-world data, compared with warfarin, NOACs was associated with decreased rates of stroke or systemic embolism (RR, 0.75; 95% CI, 0.68-0.82), ischemic stroke (RR, 0.70; 95% CI, 0.59-0.83), myocardial infarction (RR, 0.74; 95% CI, 0.58-0.93), all-cause death (RR, 0.67; 95% CI, 0.59-0.77), major bleeding (RR, 0.63; 95% CI, 0.55-0.73), intracranial bleeding (RR, 0.50; 95% CI, 0.43-0.59), and gastrointestinal bleeding (RR, 0.65; 95% CI, 0.51-0.84). The results did not change in the subgroup analyses based on the type and dose of NOACs. Conclusions- Based on published NOAC trials and real-world studies, the use of NOACs is noninferior to warfarin in Asians with atrial fibrillation irrespective of the NOAC type and dose.
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Affiliation(s)
- Zhengbiao Xue
- From the Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi Province, China (Z.X.)
| | - Hao Zhang
- From the Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi Province, China (Z.X.)
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16
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Zhang J, Tang J, Cui X, Wang B, Bu M, Bai Y, Wang K, Guo J, Shen D, Zhang J. Indirect comparison of novel Oral anticoagulants among Asians with non-Valvular atrial fibrillation in the real world setting: a network meta-analysis. BMC Cardiovasc Disord 2019; 19:182. [PMID: 31366374 PMCID: PMC6670242 DOI: 10.1186/s12872-019-1165-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
Background The development of novel oral anticoagulants (NOACs) has changed the landscape of non-valvular atrial fibrillation (NVAF) management. In this study, the effectiveness and the safety of several NOACs were evaluated in a real-world setting among Asian patients with NVAF. Methods The literature search was conducted crossing different databases including Embase, MEDLINE, and the Cochrane Library from inception through March 1, 2019, for studies which included real-world perspectives comparing the individual NOACs with each other or with warfarin among Asians with NVAF. The primary outcomes were defined as stroke or systemic embolism (SSE) and major bleeding; ischemic stroke, all-cause death as well as intracranial bleeding were classified as the secondary outcomes. Results From sixteen real-world studies, a total of 312,827 Asian patients were included in this analysis. In comparison with warfarin, the utilization of apixaban, dabigatran, and rivaroxaban significantly lowered the risk of major bleeding (apixaban: HR 0.47, 95%CI 0.35–0.63; dabigatran: HR 0.59, 95%CI 0.47–0.73; rivaroxaban: HR 0.66, 95%CI 0.52–0.83) and lessened the all-cause death rate (apixaban: HR 0.29, 95%CI 0.16–0.52; dabigatran: HR 0.40, 95%CI 0.27–0.60; rivaroxaban: HR 0.42, 95%CI 0.28–0.65). Apixaban (HR 0.59; 95%CI 0.40–0.85) reduced the possibility of ischemic stroke when compared against dabigatran. Rivaroxaban showed a higher chance of causing an ischemic stroke (HR 1.61; 95%CI 1.08–2.41) and major bleeding (HR 1.39; 95%CI 1.02–1.90) than Apixaban. Conclusions Apixaban, dabigatran and rivaroxaban were more effective than warfarin on reducing the risks of stroke and haemorrhage; meanwhile, apixaban was likely to lower the risk of major bleeding comparing to rivaroxaban. Trial registration PROSPERO registry number: CRD42018086914. Electronic supplementary material The online version of this article (10.1186/s12872-019-1165-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianchao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Junnan Tang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China.
| | - Xiaolin Cui
- Department of Orthopaedic Surgery, University of Otago, Christchurch, 8011, New Zealand
| | - Bo Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Mengsen Bu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Yan Bai
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Kai Wang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Jiacheng Guo
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Deliang Shen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China
| | - Jinying Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, NO.1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, 450052, Henan, China.
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17
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Woo HG, Chung I, Gwak DS, Kim BK, Kim BJ, Bae HJ, Han MK. Recurrent ischemic stroke in atrial fibrillation with non-vitamin K antagonist oral anticoagulation. J Clin Neurosci 2019; 64:127-133. [PMID: 30929960 DOI: 10.1016/j.jocn.2019.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/25/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for ≥48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke.
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Affiliation(s)
- Ho Geol Woo
- Department of Neurology, Ewha Womans University, College of Medicine, Seoul, Republic of Korea
| | - Inyoung Chung
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Dong Seok Gwak
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Baik Kyun Kim
- Department of Critical Care Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
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18
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Wang KL, Lopes RD, Patel MR, Büller HR, Tan DSY, Chiang CE, Giugliano RP. Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials. Eur Heart J 2018; 40:1492-1500. [DOI: 10.1093/eurheartj/ehy802] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/14/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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19
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Li YG, Lee SR, Choi EK, Lip GY. Stroke Prevention in Atrial Fibrillation: Focus on Asian Patients. Korean Circ J 2018; 48:665-684. [PMID: 30073805 PMCID: PMC6072666 DOI: 10.4070/kcj.2018.0190] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia conferring a fivefold increased risk of stroke. Stroke prevention is the cornerstone of management of patients with AF. Asians have a generally higher incidence of AF-related risks of stroke and bleeding (particularly intracranial bleeding), compared with non-Asians. Despite the well-documented efficacy and relative safety of oral anticoagulation for stroke prevention among Asians, the suboptimal use of oral anticoagulation remains common. The current narrative review aims to provide a summary of the available evidence on stroke prevention among patients with AF focused on the Asia region, regarding stroke and bleeding risk evaluation, the performance of oral anticoagulation, and current use of thromboprophylaxis.
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Affiliation(s)
- Yan Guang Li
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Chinese PLA Medical School, Beijing, China
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital Seoul, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Gregory Yh Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Chinese PLA Medical School, Beijing, China.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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20
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Wang KL, Chiu CC, Giugliano RP, Tan DSY, Lin CY, Lai EY, Goto S, Chiang CE. Drug Class, Renal Elimination, and Outcomes of Direct Oral Anticoagulants in Asian Patients: A Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 27:857-864. [PMID: 29239808 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/12/2017] [Accepted: 10/21/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have a better risk benefit profile in Asian patients with atrial fibrillation (AF). Whether treatment effects could be modified by drug class and dependency on renal elimination of studied agents has not yet been explored. METHODS We searched PubMed, CENTRAL, and CINAHL databases through November 2016 for phase III randomized controlled trials comparing DOACs with warfarin in patients with AF. Efficacy and safety outcomes were pooled according to drug class and dependency on renal elimination of DOACs and were compared with the Mantel-Haenszel fixed-effects model. Effect differences were assessed with Bucher's indirect comparisons using common estimates, once heterogeneity was low, and with the Bayesian method. RESULTS Among 6496 Asian patients from 6 trials, both direct thrombin inhibitors and factor Xa inhibitors, compared with warfarin, were associated with lower risks of stroke or systemic embolism and major bleeding (risk ratio [95% confidence interval], 0.51 [0.33-0.78], 0.74 ([0.58-0.96], 0.60 [0.41-0.86], and 0.59 [0.47-0.76], respectively). There was no between-group difference in direct thrombin inhibitors and factor Xa inhibitors or in DOACs with renal elimination less than 50% and 50% or greater (all I2 < 25% and interaction P > .05). Indirect comparisons within strata of drug class and dependency on renal elimination showed no preferential effect of any given regimen over another. There was no difference in effects on ischemic and hemorrhagic stroke, intracranial hemorrhage, myocardial infarction, and all-cause mortality between DOACs stratified by pharmacologic characteristics. CONCLUSIONS DOACs, as a therapeutic class, outperform warfarin in efficacy and safety in Asian patients with AF.
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Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Chun-Chih Chiu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chun-Yi Lin
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - En-Yu Lai
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
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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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Chiang CE, Okumura K, Zhang S, Chao TF, Siu CW, Wei Lim T, Saxena A, Takahashi Y, Siong Teo W. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm 2017; 33:345-367. [PMID: 28765771 PMCID: PMC5529598 DOI: 10.1016/j.joa.2017.05.004] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/29/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2-fold increase in mortality and a 5-fold increase in stroke. The Asian population is rapidly aging, and in 2050, the estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF-associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF-associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non-vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub-committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub-committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People׳s Republic of China
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore
| | - Anil Saxena
- Cardiac Pacing & Electrophysiology Center, Fortis Escorts Heart Institute, New Delhi, India
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Extracranial arterial and venous thromboembolism in patients with atrial fibrillation: A meta-analysis of randomized controlled trials. Heart Rhythm 2017; 14:599-605. [DOI: 10.1016/j.hrthm.2016.12.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Indexed: 11/19/2022]
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