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Mortality in Patients With Atrial Fibrillation Receiving Nonrecommended Doses of Direct Oral Anticoagulants. J Am Coll Cardiol 2020; 76:1425-1436. [DOI: 10.1016/j.jacc.2020.07.045] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 11/18/2022]
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Ortiz MR, Muñiz J, Esteve-Pastor MA, Marín F, Roldán I, Cequier A, Martínez-Sellés M, Saldivar HG, Bertomeu V, Anguita M. Direct Anticoagulants Versus Vitamin K Antagonists in Patients Aged 80 Years or Older With Atrial Fibrillation in a "Real-world" Nationwide Registry: Insights From the FANTASIIA Study. J Cardiovasc Pharmacol Ther 2020; 25:316-323. [PMID: 32228180 DOI: 10.1177/1074248420916316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe major events at follow up in octogenarian patients with atrial fibrillation (AF) according to anticoagulant treatment: direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). METHODS A total of 578 anticoagulated patients aged ≥80 years with AF were included in a prospective, observational, multicenter study. Basal features, embolic events (stroke and systemic embolism), severe bleedings, and all-cause mortality at follow up were investigated according to the anticoagulant treatment received. RESULTS Mean age was 84.0 ± 3.4 years, 56% were women. Direct oral anticoagulants were prescribed to 123 (21.3%) patients. Compared with 455 (78.7%) patients treated with VKAs, those treated with DOACs presented a lower frequency of permanent AF (52.9% vs 61.6%, P = .01), cancer history (4.9% vs 10.9%, P = .046), renal failure (21.1% vs 32.2%, P = .02), and left ventricular dysfunction (2.4% vs 8.0%, P = .03); and higher frequency of previous stroke (26.0% vs 16.6%, P = .02) and previous major bleeding (8.1% vs 3.6%, P = .03). There were no significant differences in Charlson, CHA2DS2VASc, nor HAS-BLED scores. At 3-year follow up, rates of embolic events, severe bleedings, and all-cause death (per 100 patients-year) were similar in both groups (DOACs vs VKAs): 0.34 vs 1.35 (P = .15), 3.45 vs 4.41 (P = .48), and 8.2 vs 11.0 (P = .18), respectively, without significant differences after multivariate analysis (hazard ratio [HR]: 0.25, 95% confidence interval [CI]: 0.03-1.93, P = .19; HR: 0.88, 95% CI: 0.44-1.76, P = .72 and HR: 0.84, 95% CI: 0.53-1.33, P = .46, respectively). CONCLUSION In this "real-world" registry, the differences in major events rates in octogenarians with AF were not statistically significant in those treated with DOACs versus VKAs.
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Affiliation(s)
- Martín Ruiz Ortiz
- Cardiology Department, University Hospital Reina Sofia, Córdoba, Spain
| | - Javier Muñiz
- Instituto Universitario de Ciencias de la Salud, A Coruña, Spain
| | | | - Francisco Marín
- Cardiology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Angel Cequier
- Cardiology Department, University Hospital of Bellvitge, IDIBELL, University of Barcelona, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, European University, Complutense University, Madrid, Spain
| | - Hugo González Saldivar
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, European University, Complutense University, Madrid, Spain
| | - Vicente Bertomeu
- Cardiology Department, University Hospital San Juan de Alicante, Alicante, Spain
| | - Manuel Anguita
- Cardiology Department, University Hospital Reina Sofia, Córdoba, Spain
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Yeo SH, Toh MPHS, Lee SH, Seet RCS, Wong LY, Yau WP. Temporal Trends and Patient Characteristics Associated With Drug Utilisation After
First-Ever Stroke: Insights From Chronic Disease Registry Data in Singapore. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.2019196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Data on drug utilisation among stroke patients of Asian ethnicities are
lacking. The objectives of the study were to examine the temporal trends and patient
characteristics associated with prescription of thrombolytic, antithrombotic and statin
medications among patients with first-ever stroke. Materials and Methods: First-ever
ischaemic and haemorrhagic stroke patients admitted to 2 Singapore tertiary hospitals
between 2010‒2014 were included. Data were extracted from the National Healthcare
Group Chronic Disease Management System. Association between drug utilisation and
admission year, as well as characteristics associated with drug use, were explored using multivariable logistic regression. Results: There was an increasing trend in the combined use of all 3 guideline medications in ischaemic stroke patients (P<0.001) ―specifically thrombolytic agents (P <0.001), oral antithrombotics (P = 0.002) and statins (P = 0.003) at discharge. Among antithrombotics, the use of clopidogrel (P <0.001) and aspirinclopidogrel (P <0.001) had increased, whereas prescription of dipyridamole (P <0.001) and aspirin-dipyridamole (P <0.001) had declined. For statins, the increase in atorvastatin prescription (P <0.001) was accompanied by decreasing use of simvastatin (P <0.001). Age, ethnicity and certain comorbidities (hyperlipidaemia, atrial fibrillation and chronic kidney disease) were associated with the combined use of all 3 guideline medications (P <0.05). In haemorrhagic stroke, prescription of statins at discharge were comparatively lower. Conclusion: This study reveals changes in prescription behaviour over time in a multiethnic Asian population with first-ever stroke. Patient characteristics including younger age, Malay ethnicity and certain comorbidities (i.e. hyperlipidaemia, atrial fibrillation) were associated with the combined use of all 3 guideline medications among ischaemic stroke patients.
Key words: Antithrombotics, Asian, Statins, Thrombolytic agents
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Affiliation(s)
| | - Matthias Paul HS Toh
- National Healthcare Group, Singapore.National University of Singapore, Singapore
| | - Sze Haur Lee
- National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore
| | - Raymond CS Seet
- National University of Singapore, Singapore. National University Health System, Singapore
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Fender AC, Dobrev D. One for all and all for one? The dilemma of optimal management of atrial fibrillation with cardiac co-morbidities. Int J Cardiol 2020; 299:175-176. [PMID: 31611083 DOI: 10.1016/j.ijcard.2019.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Anke C Fender
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Germany.
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Germany
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5
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Cho IY. Using non-vitamin K oral anticoagulants in specific patient populations: a study of Korean cases. Ther Clin Risk Manag 2019; 15:1183-1206. [PMID: 31632045 PMCID: PMC6790210 DOI: 10.2147/tcrm.s204377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/27/2019] [Indexed: 12/19/2022] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) are increasingly used as alternatives to conventional therapies and have considerable accumulated real-world clinical data in patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). However, it is not easy to make a complete changeover to NOACs in real-world clinical practice because NOACs still have challenges in specific patient populations (eg, Asian patients, NVAF patients presenting with acute coronary syndrome [ACS], dialysis patients with NVAF, patients with cancer-associated VTE, etc.). Clinical data on the optimal dose of NOACs in Asian patients with NVAF are not sufficient. The intensity of NOAC and antiplatelet treatment and the duration of antiplatelet treatment should be adjusted according to the bleeding and thrombotic risk profiles of the individual NVAF patient presenting with ACS. Increased bleeding risk and unclear efficacy of NOACs in dialysis patients with NVAF should be considered when making decisions on whether to give NOACs for these patients. If dialysis patients with NVAF require anticoagulant for stroke prevention, then apixaban could be considered while awaiting more clinical efficacy and safety data. Additional studies are needed to determine the utility of continuing treatment with reduced-dose NOACs for long-term therapy after VTE. We have enough experiences in using NOACs in cancer patients showing the benefit of antithrombotic treatment counterbalanced the bleeding risk; however, some challenges of cancer-associated VTE management exist due to differences in cancer types or chemotherapy regimens and comorbidities. Different dosing regimens among NOACs may impact on medication adherence; thus, individual patient preference should be considered in choosing a particular NOAC. A significant proportion of patients remain on warfarin because of the high price of NOACs and variability in reimbursement coverage. To compensate clinical-evidence and achieve optimal use of NOACs, we should pay attention to the outcomes of ongoing studies and evaluate more real-world data.
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Affiliation(s)
- Il Young Cho
- College of Pharmacy, Ewhawomans University, Seoul, Republic of Korea
- Pharmaceutical Safety Bureau, Ministry of Food and Drug Safety, Cheongju-si, Republic of Korea
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6
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Cheng CM, Lin CH, Chou P, Jong GP. Antithrombotic Treatment May Reduce Mortality Among New-Onset Atrial Fibrillation Patients with Gray-Zone Risk of Stroke. Int Heart J 2019; 60:303-309. [PMID: 30745533 DOI: 10.1536/ihj.18-174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In clinical practice, some atrial fibrillation (AF) patients were classified as having low and moderate stroke risk by the CHADS2 score (≤ 1) in 2001 but in 2012 they were not truly classified as low risk of stroke according to the CHA2DS2-VASc score (≥ 2) (defined gray zone). Therefore, a treatment gap exists in gray zone AF patients. This study aimed to evaluate whether gray zone AF patients could benefit from reduced all-cause mortality under antithrombotic treatment. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance from January 2000 to December 2011. The new-onset AF patients consisted of a gray zone cohort with a total of 1237 patients being enrolled. The primary outcome was all-cause mortality between 2001 and 2011. Patients in the gray zone receiving antithrombotic treatment had a significant reduction in all-cause mortality [hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.16-0.28] compared with the no treatment group [warfarin only: HR, 0.28 (95% CI, 0.15-0.52); warfarin + Aspirin: HR, 0.21 (95% CI, 0.15-0.30); and Aspirin only: HR, 0.22 (95% CI, 0.16-0.29) ]. All-cause mortality was notably increased when any of the following risk factors were present: age 65-74 years, age ≥ 75 years, chronic kidney disease, and vascular disease. We concluded that AF patients in the gray zone must receive either anticoagulant and/or antiplatelet treatment and there is a lower mortality in these groups during long-term follow-up. Further investigation is needed to observe whether the antithrombotic drugs have benefits for patients with AF with a CHA2DS2-VASc score < 2.
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Affiliation(s)
- Chien-Ming Cheng
- Division of Cardiology, Department of Medicine, Feng Yuan Hospital, Department of Health, Executive Yuan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital
| | - Pesus Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University
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Ugowe FE, Jackson LR, Thomas KL. Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: A systematic review. Heart Rhythm 2018; 15:1337-1345. [PMID: 29803022 DOI: 10.1016/j.hrthm.2018.05.019] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and is associated with increased morbidity, mortality, and health care expenditures. In this review, our aim was to assess the racial and ethnic differences in the epidemiology, management, and outcomes of patients with AF. A search of relevant studies from January 1, 2007, to December 30, 2017, was conducted in PubMed, EMBASE, and Web of Science and supplemented by manual searches of the bibliographies of retrieved articles. We identified 152 studies of which 64 were subsequently included. We found that underrepresented racial and ethnic groups have a higher prevalence of established risk factors associated with the development of AF but an overall lower incidence and prevalence of AF as compared with non-Hispanic whites. Moreover, racial and ethnic differences exist in detection, awareness, and AF-associated symptoms. Nonwhite populations also experience decreased use of rhythm control modalities and anticoagulation for stroke prevention. Lastly, among those with AF, underrepresented racial and ethnic groups had increased morbidity and mortality relative to white groups. Racial and ethnic differences exist in the prevalence, quality of life, management, and outcomes of individuals with AF; however, the mechanisms for these differences have yet to be fully elucidated. Racial and ethnic differences in AF warrant further analysis to understand the factors contributing to the differences in prevalence and management to ensure the delivery of high quality care that prevents stroke, reduces deaths, and decreases expenses associated with caring for underrepresented populations with AF.
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Affiliation(s)
| | - Larry R Jackson
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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8
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Wei Y, Xu J, Wu H, Zhou G, Chen S, Wang C, Shen Y, Yang S, Wang B, He Z, Sun J, Sun W, Ouyang P, Liu S. Survey of Antithrombotic Treatment in Rural Patients (>60 years) with Atrial Fibrillation in East China. Sci Rep 2018; 8:6830. [PMID: 29717155 PMCID: PMC5931550 DOI: 10.1038/s41598-018-24878-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/11/2018] [Indexed: 11/25/2022] Open
Abstract
The prevalence and antithrombotic treatment of atrial fibrillation (AF) in Chinese rural population is not well known. The aim of this study was to investigate the extent to which antithrombotic treatment was prescribed for rural AF patients >60 years. We identified 828 AF patients from 36734 rural residents >60 years in Shanghai China. Our data indicated the overall prevalence rate of AF was 2.3% in rural population >60 years in East China and 38.9% of AF patients underwent antithrombotic therapy, including warfarin (5.9%), aspirin (29.6%), clopidogrel (2.9%) and aspirin combined with clopidogrel (0.5%). Of enrolled subjects, 98.4% had CHA2DS2-VASc score ≥1, 72.0% had HAS-BLED score <3 and 59.2% had CHA2DS2-VASc score ≥2 with HAS-BLED score <3. Missing early detection (34.9%), delay in seeking treatment for asymptomatic AF (25.5%) and doctors’s incomplete inform of AF-related risk of stroke to patients (21.7%) were three dominant causes for failing anticoagulant usage. In conclusion, most AF patients were with a high risk of thrombosis and a low risk of bleeding in China, but a large majority of them failed to take anticoagulants mainly for missing an early screening of AF and lack of awareness on AF for both patients and primary care physicians.
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Affiliation(s)
- Yong Wei
- Department of Cardiology, Shanghai Songjiang Central Hospital, Shanghai, 201600, China.,Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China
| | - Juan Xu
- Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China
| | - Haiqing Wu
- Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China
| | - Genqing Zhou
- Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China
| | - Songwen Chen
- Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China
| | - Caihong Wang
- Xinbang Community Health Service Center, Songjiang District, Shanghai, 201605, China
| | - Yahong Shen
- Maogang Community Health Service Center, Songjiang District, Shanghai, 201605, China
| | - Shunhong Yang
- Chedun Community Health Service Center, Songjiang District, Shanghai, 201611, China
| | - Bin Wang
- Dongjing Community Health Service Center, Songjiang District, Shanghai, 201613, China
| | - Zheng He
- Xiaokunshan Community Health Service Center, Songjiang District, Shanghai, 201616, China
| | - Jianping Sun
- Shihudang Community Health Service Center, Songjiang District, Shanghai, 201604, China
| | - Weidong Sun
- Yexie Community Health Service Center, Songjiang District, Shanghai, 201609, China
| | - Ping Ouyang
- Department of Cardiology, Shanghai Songjiang Central Hospital, Shanghai, 201600, China.
| | - Shaowen Liu
- Department of Cardiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200800, China.
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9
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Long-Term Statin Administration Does Not Affect Warfarin Time in Therapeutic Range in Australia or Singapore. J Clin Med 2018; 7:jcm7050097. [PMID: 29723987 PMCID: PMC5977136 DOI: 10.3390/jcm7050097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Warfarin requires ongoing monitoring of the International Normalised Ratio (INR). This is because numerous factors influence the response, including drug interactions with commonly-prescribed medications, such as statins. The administration of statins with warfarin may change INR; however, there is limited information regarding the effects on warfarin control as measured by time in therapeutic range (TTR). Statins may also alter bleeds with warfarin, but there are conflicting reports demonstrating both increased and decreased bleeds, and limited data on diverse ethnic populations. Therefore, the aim of this study was to determine the effect of statin administration on warfarin control and bleeds in patients in Australia and Singapore. METHODS Retrospective data were collected for patients on warfarin between January and June 2014 in Australia and Singapore. Patient data were used to calculate TTR and bleed events. Concurrent statin therapy was assessed and comparisons of TTR and bleed incidence were made across patient subgroups. RESULTS Warfarin control in Australia and Singapore was not significantly affected by statins, as measured by TTR (83% and 58%, respectively), frequency of testing, and warfarin doses. In Australia, statin use did not significantly affect bleeds, whilst in Singapore the bleed incidence was significantly lower for patients on statins. CONCLUSIONS Chronic concurrent administration of statins with warfarin does not adversely affect warfarin TTR in Australia or Singapore. In Singapore, patients on statins, compared to no statins, had a lower bleed incidence and this requires further investigation, especially given the potential genetic influences of ethnicity on both statin and warfarin metabolism.
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10
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Seow SC, How AK, Chan SP, Teoh HL, Lim TW, Singh D, Yeo WT, Kojodjojo P. High Incidence of Occult Atrial Fibrillation in Asian Patients with Cryptogenic Stroke. J Stroke Cerebrovasc Dis 2018; 27:2182-2186. [PMID: 29678635 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/05/2018] [Accepted: 03/25/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Occult atrial fibrillation (AF) is not uncommon in patients with stroke. In western cohorts, insertable loop recorders (ILRs) have been shown to be the gold-standard and are cost-effective for AF detection. Anticoagulation for secondary stroke prevention is indicated if AF is detected. The incidence of occult AF among Asian patients with cryptogenic stroke is unclear. METHODS Patients with cryptogenic stroke referred between August 2014 and February 2017 had ILRs implanted. Episodes of AF >2 minutes duration were recorded using proprietary algorithms within the ILRs, whereupon clinicians and patients were alerted via remote monitoring. All AF episodes were adjudicated using recorded electrograms. Once AF was detected, patients were counseled for anticoagulation. RESULTS Seventy-one patients with cryptogenic stroke, (age 61.9 ± 13.5 years, 77.5% male, mean CHA2DS2VASc score of 4.2 ± 1.3) had ILRs implanted. Time from stroke to the ILR implant was a median of 66 days. Duration of ILR monitoring was 345 ± 229 days. The primary endpoint of AF detection at 6 months was 12.9%; and at 12 months it was 15.2%. Median time to detection of AF was 50 days. The AF episodes were all asymptomatic and lasted a mean of 77 minutes (± 118.9). Anticoagulation was initiated in all but 1 patient found to have AF. CONCLUSIONS The incidence of occult AF is high in Asian patients with cryptogenic stroke and comparable to western cohorts. The combination of ILR and remote monitoring is a highly automated, technologically driven, and clinically effective technique to screen for AF.
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Affiliation(s)
- Swee-Chong Seow
- Department of Cardiology, National University Hospital, Singapore.
| | - Ann-Kee How
- Department of Cardiology, Serdang Hospital, Malaysia
| | - Siew-Pang Chan
- Cardiovascular Research Institute, National University Hospital, Singapore
| | - Hock-Luen Teoh
- Department of Neurology, National University Hospital, Singapore
| | - Toon-Wei Lim
- Department of Cardiology, National University Hospital, Singapore
| | - Devinder Singh
- Department of Cardiology, National University Hospital, Singapore
| | - Wee-Tiong Yeo
- Department of Cardiology, National University Hospital, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Hospital, Singapore
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Abstract
BACKGROUND Patients with atrial fibrillation not being adequately treated with oral anticoagulant (OAC) therapy, with therapy underutilization or premature termination, have been commonly reported. However, studies on the utilization pattern of OAC therapy for patients with atrial flutter (AFL) are few. The aim of this study was to investigate the utilization of OAC therapy, and its influencing factors for patients with AFL in South Korea, as well as the types and percentages of anticoagulants used. METHODS We analyzed Aged Population Sample data compiled by the Health Insurance Review & Assessment Service from 2011 to 2015. We identified patients with AFL having the KCD-6 code I48.1. Patients at high risk of stroke with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (or transient ischemic attack), vascular disease, sex score of ≥2 and at low risk of bleeding with an anticoagulation and risk factors in atrial fibrillation score of ≤4 were included in the study. Oral anticoagulant therapy underutilization was estimated in these patients using anticoagulant underutilization (ACU) scales. Demographic and clinical factors associated with OAC therapy underutilization were investigated using a logistic regression model. RESULTS The mean ACU value was calculated as 67.4% between 2011 and 2015. Positive risk factors for ACU were identified as follows: female sex, aspirin utilization, and limited anticoagulant options. Negative risk factors included comorbidities, such as congestive heart failure and valvular heart disease, and a history of stroke or transient ischemic attack. CONCLUSIONS Our study demonstrates that two-third of patients with AFL in South Korea failed to obtain adequate stroke prevention treatment, even in the era of direct OAC availability. This tendency was more profound in women or those on aspirin therapy.
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Affiliation(s)
- Sanghun Lee
- 1 College of Pharmacy, Pusan National University, Geumjeong-gu, Busan, Republic of Korea
| | - Nam Kyung Je
- 1 College of Pharmacy, Pusan National University, Geumjeong-gu, Busan, Republic of Korea
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12
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Hwong WY, Abdul Aziz Z, Sidek NN, Bots ML, Selvarajah S, Kappelle LJ, Sivasampu S, Vaartjes I. Prescription of secondary preventive drugs after ischemic stroke: results from the Malaysian National Stroke Registry. BMC Neurol 2017; 17:203. [PMID: 29169331 PMCID: PMC5701494 DOI: 10.1186/s12883-017-0984-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/15/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evaluation of secondary stroke prevention in low and middle-income countries remains limited. This study assessed the prescription of secondary preventive drugs among ischemic stroke patients upon hospital discharge in Malaysia and identified factors related to the prescribing decisions. METHODS From Malaysian National Stroke Registry, we included patients with non-fatal ischemic stroke. Prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs were assessed. Multi-level logistic regressions were performed to determine the relation between potential factors and drug prescriptions. RESULTS Of 5292 patients, 48% received antihypertensive drugs, 88.9% antiplatelet and 88.7% lipid-lowering drugs upon discharge. Thirty-three percent of patients with an indication for anticoagulants (n = 391) received it. Compared to patients <=50 years, patients above 70 years were less likely to receive antiplatelet (OR: 0.72, 95% CI: 0.50-1.03), lipid-lowering drugs (OR: 0.66, 95% CI: 0.45-0.95) and anticoagulants (OR: 0.27, 95% CI: 0.09-0.83). Patients with moderate to severe disability upon discharge had less odds of receiving secondary preventive drugs; an odds ratio of 0.57 (95% CI: 0.45-0.71) for antiplatelet, 0.86 (95% CI: 0.75-0.98) for antihypertensive drugs and 0.78 (95% CI: 0.63-0.97) for lipid-lowering drugs in comparison to those with minor disability. Having prior specific comorbidities and drug prescriptions significantly increased the odds of receiving these drugs. No differences were found between sexes and ethnicities. CONCLUSIONS Prescription of antihypertensive drugs and anticoagulants among ischemic stroke patients in Malaysia were suboptimal. Efforts to initiate regular clinical audits to evaluate the uptake and effectiveness of secondary preventive strategies are timely in low and middle-income settings.
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Affiliation(s)
- Wen Yea Hwong
- National Clinical Research Centre, Ministry of Health Malaysia, Kuala Lumpur, Malaysia. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Zariah Abdul Aziz
- Department of Neurology, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Norsima Nazifah Sidek
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sharmini Selvarajah
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Sharmini Selvarajah Consulting, Selangor, Malaysia
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sheamini Sivasampu
- National Clinical Research Centre, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Kohsaka S, Murata T, Izumi N, Katada J, Wang F, Terayama Y. Bleeding risk of apixaban, dabigatran, and low-dose rivaroxaban compared with warfarin in Japanese patients with non-valvular atrial fibrillation: a propensity matched analysis of administrative claims data. Curr Med Res Opin 2017; 33:1955-1963. [PMID: 28857611 DOI: 10.1080/03007995.2017.1374935] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES There is scarce evidence comparing novel oral anticoagulants (NOACs) with warfarin in real-world settings in Japan. This study compared the risk of bleeding events among patients with non-valvular atrial fibrillation (NVAF) initiating treatment with NOACs versus warfarin. METHODS A retrospective cohort study was conducted using a de-identified electronic health record based database of health claims and Diagnosis Procedure Combination data from 275 consenting hospitals in Japan. NVAF patients newly initiated on oral anticoagulants were eligible. Based on the first prescription, patients were assigned to 5/2.5 mg BID apixaban, 150/110 mg BID dabigatran, 15/10 mg QD rivaroxaban (approved dose lower in Japan compared to Western countries [20/15 mg QD]) or warfarin groups. One-to-one propensity score matching (PSM) was used to balance patient characteristics between warfarin and each NOAC. Patients were followed up to 1 year post-first prescription. RESULTS Among 38,662 eligible patients, a total of 5977, 5090, and 6726 matched pairs were identified for warfarin versus apixaban, warfarin versus dabigatran, and warfarin versus rivaroxaban, respectively after PSM. Compared to warfarin, apixaban (hazard ratio [HR] 0.586; 95% CI 0.421-0.815), dabigatran (HR 0.617; 0.425-0.895) and rivaroxaban (HR 0.693; 0.514-0.933) were associated with a significantly lower risk of major bleeding. The risk of any bleeding was significantly lower for apixaban (HR 0.782; 0.682-0.896), but not for dabigatran (HR 0.988; 0.860-1.135) or rivaroxaban (HR 0.938; 0.832-1.057) when comparing to warfarin. CONCLUSIONS Among Japanese patients with NVAF, treatment with apixaban 5/2.5 mg BID was associated with a significantly lower risk of major bleeding and any bleeding when compared to warfarin. Treatment with dabigatran 150/110 mg BID or rivaroxaban 15/10 mg QD was associated with a significantly lower risk of major bleeding, but not any bleeding, than warfarin. The potential benefit of individual NOACs in real-world practice needs to be assessed further.
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Affiliation(s)
- Shun Kohsaka
- a Department of Cardiology , Keio University School of Medicine , Tokyo , Japan
| | | | | | | | - Feng Wang
- d Bristol-Myers Squibb Co. , NY , USA
| | - Yasuo Terayama
- e Department of Gerontology , School of Medicine, Iwate Medical University , Iwate , Japan
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Bernaitis N, Ching CK, Teo SC, Chen L, Badrick T, Davey AK, Crilly J, Anoopkumar-Dukie S. Factors influencing warfarin control in Australia and Singapore. Thromb Res 2017; 157:120-125. [PMID: 28738273 DOI: 10.1016/j.thromres.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Warfarin is widely used for patients with non-valvular atrial fibrillation (NVAF). Variations in warfarin control, as measured by time in therapeutic range (TTR), have been reported across different regions and ethnicities, particularly between Western and Asian countries. However, there is limited data on comparative factors influencing warfarin control in Caucasian and Asian patients. Therefore, the aim of this study was to determine warfarin control and potential factors influencing this in patients with NVAF in Australia and Singapore. METHODS Retrospective data was collected for patients receiving warfarin for January to June 2014 in Australia and Singapore. TTR was calculated for individuals with mean patient TTR used for analysis. Possible influential factors on TTR were analysed including age, gender, concurrent co-morbidities, and concurrent medication. RESULTS The mean TTR was significantly higher in Australia (82%) than Singapore (58%). At both sites, chronic kidney disease significantly lowered this TTR. Further factors influencing control were anaemia and age<60years in Australia, and vascular disease, CHA2DS2-VASc score of 6, and concurrent platelet inhibitor therapy in Singapore. DISCUSSION Warfarin control was significantly higher in Australia compared to Singapore, however chronic kidney disease reduced control at both sites. The different levels of control in these two countries, together with patient factors further reducing control may impact on anticoagulant choice in these countries with better outcomes from warfarin in Australia compared to Singapore.
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Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Tony Badrick
- RCPA Quality Assurance Programs, New South Wales, Australia
| | - Andrew K Davey
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Julia Crilly
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; Department of Emergency Medicine Gold Coast Health, Queensland, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia.
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Bernaitis N, Ching CK, Chen L, Hon JS, Teo SC, Badrick T, Davey AK, Anoopkumar-Dukie S. A High HASBLED Score Identifies Poor Warfarin Control in Patients Treated for Non-Valvular Atrial Fibrillation in Australia and Singapore. Basic Clin Pharmacol Toxicol 2017. [PMID: 28639436 DOI: 10.1111/bcpt.12836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Warfarin reduces stroke risk in atrial fibrillation (AF) patients. The quality of warfarin control, measured by time in therapeutic range (TTR), impacts outcome and adverse events. One tool evaluating risk of adverse events and potential warfarin control would simplify risk-benefit assessment of warfarin. Recently, HASBLED was demonstrated effective for this purpose, but this was in well-controlled patients with deep vein thrombosis. HASBLED as a predictor of warfarin control has not been validated in other populations including differing indications, warfarin control levels and ethnicities. The aim of this study was to determine whether HASBLED can predict warfarin control in patients with AF in Australia and Singapore. Retrospective data were collected for patients receiving warfarin between January and June 2014 in Australia and Singapore. Patient data were used to calculate HASBLED at the start and end of the study period. TTR was calculated for each patient, and mean TTR used for analysis to stratified HASBLED scores. Of the 4370 patients, there were 3199 in Australia and 1171 in Singapore with mean TTRs of 82% and 58%, respectively. At the start of the study, a HASBLED score ≥3 predicted significantly lower TTR in Singapore, whilst at the end of the study, this score identified patients with poor control in both Australia and Singapore. A HASBLED score ≥3 in patients treated with warfarin can differentiate significantly lower TTRs in Australian and Singapore patients with AF. HASBLED may assess bleed risk and warfarin control, identifying patients at high risk of poor warfarin outcome requiring additional INR monitoring or alternative anticoagulation.
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Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute and Quality Use of Medicines Network, Griffith University, QLD, Australia.,School of Pharmacy, Griffith University, QLD, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Jin Shing Hon
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Tony Badrick
- RCPA Quality Assurance Programs, St Leonards, NSW, Australia
| | - Andrew K Davey
- Menzies Health Institute and Quality Use of Medicines Network, Griffith University, QLD, Australia.,School of Pharmacy, Griffith University, QLD, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute and Quality Use of Medicines Network, Griffith University, QLD, Australia.,School of Pharmacy, Griffith University, QLD, Australia
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Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:365-379. [PMID: 27896543 PMCID: PMC5337242 DOI: 10.1007/s11239-016-1446-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.
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Affiliation(s)
- Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Abstract
In 10 % of patients, who suffer an acute coronary syndrome (ACS), a major cardiovascular event occurs despite optimal therapy. The occlusion of the vessel is driven by atherothrombosis, which arises from platelet activation and activation of the coagulation cascade. In the last decade the secondary prevention continuously improved by development of dual anti-platelet therapy with new P2Y12-inhibitors such as clopidogrel, prasugrel, and ticagrelor. Until recently, the coagulation cascade was not targeted in secondary prevention. The coagulation factor Xa plays a crucial role in thrombosis and is elevated in patients after acute coronary syndrome, therefore representing an attractive target for novel therapies in ACS. Former studies with vitamin K antagonists showed reduction of cardiovascular events but increased major bleedings. Two phase-3 trials investigated the role of novel oral anticoagulant agents on top of aspirin and clopidogrel in patients with ACS. The APPRAISE-2 study, which tested the oral factor Xa inhibitor apixaban was prematurely terminated because of an increase of major bleedings in the absence of an effect on cardiovascular events. In contrast, the ATLAS ACS2 TIMI-51 trial interrogating the oral factor Xa inhibitor rivaroxaban in a low dose regimen showed significant reduction of cardiovascular events as well as total mortality. Thus, add-on treatment with low dose rivaroxaban emerged as a new option for patients with ACS. This review illustrates recent advances in the development of antithrombotic therapy in acute coronary syndromes, provides guidance on which patients should receive which therapy for secondary prevention of events, and points out potentially fruitful new strategies for the future of antithrombotic treatment in ACS.
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Affiliation(s)
- Peter Stachon
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Ingo Ahrens
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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Bernaitis N, Ching CK, Chen L, Hon JS, Teo SC, Davey AK, Anoopkumar-Dukie S. The Sex, Age, Medical History, Treatment, Tobacco Use, Race Risk (SAMe TT 2R 2) Score Predicts Warfarin Control in a Singaporean Population. J Stroke Cerebrovasc Dis 2016; 26:64-69. [PMID: 27671097 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/14/2016] [Accepted: 08/18/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Warfarin reduces stroke risk in atrial fibrillation (AF) patients but requires ongoing monitoring. Time in therapeutic range (TTR) is used as a measure of warfarin control, with a TTR less than 60% associated with adverse patient outcomes. The Sex, Age, Medical history, Treatment, Tobacco use, Race (SAMe-TT2R2) score has been identified as a model able to predict warfarin control, but this has been tested in mainly Caucasian populations. Therefore, the aim of this study was to determine the ability of the SAMe-TT2R2 score to predict warfarin control in a Singaporean population consisting of Chinese, Malay, and Indian race. METHODS Retrospective data were collected from the National Heart Centre Singapore for AF patients receiving warfarin between January and June 2014. The TTR and the SAMe-TT2R2 score were calculated for each patient. RESULTS The 1137 non-valvular AF patients had a mean TTR of 58.0 ± 34.3% and a median SAMe-TT2R2 score of 3. The categorized SAMe-TT2R2 scores (2 versus >2) showed a significant reduction in mean TTR for the entire population (63.2% versus 55.8%, P = .0004) and also when categorized according to race for Chinese (62.7% versus 56.9%, P = .0075) and Malay (68.4% versus 50.6%, P = .0131) populations. CONCLUSION The SAMe-TT2R2 tool is effective in predicting warfarin control in a Singaporean population as patients with a score greater than 2 had poor control. The minimum score for non-Caucasian patients is 2; thus, in these patients, the presence of any additional risk factors identified in the SAMe-TT2R2 tool categorizes them as unlikely to achieve adequate warfarin control and possible candidates for alternative anticoagulants.
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Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Jin Shing Hon
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Andrew K Davey
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia.
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Assessing bleeding risk in 4824 Asian patients with atrial fibrillation: The Beijing PLA Hospital Atrial Fibrillation Project. Sci Rep 2016; 6:31755. [PMID: 27557876 PMCID: PMC4997334 DOI: 10.1038/srep31755] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/25/2016] [Indexed: 01/01/2023] Open
Abstract
The risks of major bleeding and intracranial hemorrhage (ICH) are higher in Asian patients with atrial fibrillation (AF) compared to non-Asians. We aimed to investigate risk factors for bleeding, and validate the predictive value of available bleeding risk scores (mOBRI, HEMORR2HAGES, Shireman, HAS-BLED, ATRIA and ORBIT) in a large cohort of Chinese inpatients with AF. Using hospital electronic medical databases, we identified 4824 AF patients (mean age 67 years; 34.9% female) from January 1, 1995 to May 30, 2015, with median (interquartile) in-hospital days of 10 (7-16) days. On multivariate analysis, prior bleeds, vascular disease, anemia, prior stroke, and liver dysfunction were independent risk factors of major bleeding (all p < 0.05). C-statistics (95%CI) of the HAS-BLED score were 0.72 (0.65-0.79) for major bleeding events and 0.83 (0.75-0.91) for ICH (all p < 0.001). Compared to other risk scores, the HAS-BLED score was significantly better in predicting major bleeding events (Delong test, all P < 0.05, apart from mOBRI, HEMORR2HAGES) and ICH (all p < 0.05), and additionally, resulted in a net reclassification improvement (NRI) of 17.1-65.5% in predicting major bleeding events and 29.5-67.3% in predicting ICH (all p < 0.05). We conclude that the HAS-BLED score had the best predictive and discriminatory ability for major bleeding and ICH in an Asian/Chinese AF population.
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Proietti M, Lane DA, Lip GY. Relation of Nonvalvular Atrial Fibrillation to Body Mass Index (from the SPORTIF Trials). Am J Cardiol 2016; 118:72-8. [PMID: 27184172 DOI: 10.1016/j.amjcard.2016.04.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 11/26/2022]
Abstract
Obesity is well-established as a major cardiovascular (CV) risk factor. Obesity confers a greater risk for developing atrial fibrillation (AF), but the relation between obesity and established nonvalvular AF for stroke and all-cause death is still unclear. To ascertain the prevalence of overweight and obesity in patients with nonvalvular AF, their influence on adverse events, and the relation with anticoagulation control, we performed this post hoc analysis of the pooled Stroke Prevention using an Oral Thrombin Inhibitor in patients with atrial Fibrillation (SPORTIF) III and V data sets. For this study, we analyzed all patients assigned to the warfarin arm with data on body mass index (BMI). Time in therapeutic range was used as an index of the quality of anticoagulation control. The 3,630 patients eligible for this analysis were categorized as follows: (1) BMI 18.5 to 24.9 ("normal weight") in 24.1%; (2) BMI 25.0 to 29.9 ("overweight") in 39.8%; and BMI ≥30 ("obese") in 36.1%. Both overweight (hazard ratio [HR] 0.70) and obese (HR 0.59) categories were inversely associated with the composite outcome of stroke/all-cause death. A similar inverse association was seen for the end point of stroke (HR 0.61 and 0.47, respectively). Good anticoagulation control also attenuated the association between BMI categories and outcomes. In patients with time in therapeutic range >70%, BMI category was not significantly associated with the composite outcome of stroke/death and stroke. Stroke and all-cause death progressively reduced in overweight and obese anticoagulated patients with AF. The inverse relation of BMI categories to the risk of stroke and all-cause death was mitigated by good anticoagulation control.
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21
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Kristensen SL, Martinez F, Jhund PS, Arango JL, Bĕlohlávek J, Boytsov S, Cabrera W, Gomez E, Hagège AA, Huang J, Kiatchoosakun S, Kim KS, Mendoza I, Senni M, Squire IB, Vinereanu D, Wong RCC, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR, Packer M, McMurray JJV. Geographic variations in the PARADIGM-HF heart failure trial. Eur Heart J 2016; 37:3167-3174. [PMID: 27354044 PMCID: PMC5106574 DOI: 10.1093/eurheartj/ehw226] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/07/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022] Open
Abstract
Aims The globalization of clinical trials has highlighted geographic variations in patient characteristics, event rates, and treatment effects. We investigated these further in PARADIGM-HF, the largest and most globally representative trial in heart failure (HF) to date. Methods and results We looked at five regions: North America (NA) 602 (8%), Western Europe (WE) 1680 (20%), Central/Eastern Europe/Russia (CEER) 2762 (33%), Latin America (LA) 1433 (17%), and Asia-Pacific (AP) 1487 (18%). Notable differences included: WE patients (mean age 68 years) and NA (65 years) were older than AP (58 years) and LA (63 years) and had more coronary disease; NA and CEER patients had the worst signs, symptoms, and functional status. North American patients were the most likely to have a defibrillating-device (54 vs. 2% AP) and least likely prescribed a mineralocorticoid receptor antagonist (36 vs. 65% LA). Other evidence-based therapies were used most frequently in NA and WE. Rates of the primary composite outcome of cardiovascular (CV) death or HF hospitalization (per 100 patient-years) varied among regions: NA 13.6 (95% CI 11.7–15.7) WE 9.6 (8.6–10.6), CEER 12.3 (11.4–13.2), LA 11.2 (10.0–12.5), and AP 12.5 (11.3–13.8). After adjustment for prognostic variables, relative to NA, the risk of CV death was higher in LA and AP and the risk of HF hospitalization lower in WE. The benefit of sacubitril/valsartan was consistent across regions. Conclusion There were many regional differences in PARADIGM-HF, including in age, symptoms, comorbidity, background therapy, and event-rates, although these did not modify the benefit of sacubitril/valsartan. Clinical trial registration URL http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
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Affiliation(s)
- Søren Lund Kristensen
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK .,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Felipe Martinez
- Emeritus Professor of Medicine, Universidad Nacional of Cordoba, Cordoba, Argentina
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Jan Bĕlohlávek
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Sergey Boytsov
- National Research Center for Preventive Medicine, Moscow, Russia
| | | | | | - Albert A Hagège
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Cardiologie ; Paris Descartes University, Sorbonne Paris Cité ; INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Jun Huang
- First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | | | - Kee-Sik Kim
- Daegu Catholic University Hospital, Daegu, Korea
| | - Iván Mendoza
- Venezuela Instituto Tropical Medicine Universidad Central Venezuela, Caracas, Venezuela
| | - Michele Senni
- Azienda Ospedaliera Papa Giovanni XXIII, Cardiologia 1 - Scompenso e Trapianti di Cuore, Bergamo, Italy
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila - University and Emergency Hospital, Bucharest, Romania
| | | | - Jianjian Gong
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor C Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | - Karl Swedberg
- University of Gothenburg, Gothenburg, Sweden .,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
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Lee CWS, Muo CH, Liang JA, Lin MC, Kao CH. Atrial Fibrillation is Associated With Morphine Treatment in Female Breast Cancer Patients: A Retrospective Population-Based Time-Dependent Cohort Study. Medicine (Baltimore) 2016; 95:e3102. [PMID: 26986153 PMCID: PMC4839934 DOI: 10.1097/md.0000000000003102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We investigated the relationship between morphine treatment and the risk of atrial fibrillation (AF) in female patients with breast cancer. We identified a malignancy cohort of 73,917 female breast cancer patients without an AF history before the date of breast cancer diagnosis between 2000 and 2010 by using the Longitudinal Health Insurance Database for Catastrophic Illness Patients in Taiwan. This malignancy cohort was divided into morphine and comparison cohorts comprising 18,671 and 55,246 patients, respectively, and the incidences of newly diagnosed AF were calculated. We used the Cox proportional hazard model with time-dependent exposure covariates to estimate the risk of AF. The effect of morphine was assessed through multivariable Cox proportional hazard regression controlling for age, the Charlson comorbidity index (CCI) score, and the use of bisphosphonates and paclitaxel. Compared with nonmorphine users, patients who received morphine exhibited a 4.37-fold (95% CI = 3.56-5.36) increase in the risk of developing AF. The risk of AF increased as the CCI score increased, but decreased in patients with tamoxifen treatment. This risk is especially significant in current morphine users of all ages and with low CCI score. AF risk increased as the duration of morphine use lengthened (P for trend <0.0001). The incidence of AF in female breast cancer patients in Taiwan is associated with morphine, but prevented by tamoxifen treatment.
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Affiliation(s)
- Cynthia Wei-Sheng Lee
- From the Center for Drug Abuse and Addiction (CW-SL), China Medical University Hospital, China Medical University; Management Office for Health Data (C-HM), China Medical University Hospital, China Medical University; Graduate Institute of Clinical Medicine Science (J-AL, C-HK), College of Medicine, China Medical University; Department of Radiation Oncology (J-AL), China Medical University Hospital, Taichung; Department of Nuclear Medicine (M-CL), I-Shou University, Kaohsiung; and Department of Nuclear Medicine and PET Center (C-HK), China Medical University Hospital, Taichung, Taiwan
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Tsujimoto M, Kuroyanagi G, Matsushima-Nishiwaki R, Kito Y, Enomoto Y, Iida H, Ogura S, Otsuka T, Tokuda H, Kozawa O, Iwama T. Factor Xa Inhibitor Suppresses the Release of Phosphorylated HSP27 from Collagen-Stimulated Human Platelets: Inhibition of HSP27 Phosphorylation via p44/p42 MAP Kinase. PLoS One 2016; 11:e0149077. [PMID: 26867010 PMCID: PMC4750972 DOI: 10.1371/journal.pone.0149077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/26/2016] [Indexed: 11/18/2022] Open
Abstract
Selective inhibitors of factor Xa (FXa) are widely recognized as useful therapeutic tools for stroke prevention in non-valvular atrial fibrillation or venous thrombosis. Thrombin, which is rapidly generated from pro-thrombin through the activation of factor X to FXa, acts as a potent activator of human platelets. Thus, the reduction of thrombin generation by FXa inhibitor eventually causes a suppressive effect on platelet aggregation. However, little is known whether FXa inhibitors directly affect the function of human platelets. We have previously reported that collagen induces the phosphorylation of heat shock protein 27 (HSP27), a low-molecular weight heat shock protein via Rac-dependent activation of p44/p42 mitogen-activated protein (MAP) kinase in human platelets, eventually resulting in the release of HSP27. In the present study, we investigated the direct effect of FXa inhibitor on the collagen-induced human platelet activation. Rivaroxaban as well as edoxaban significantly reduced the collagen-induced phosphorylation of both HSP27 and p44/p42 MAP kinase without affecting the platelet aggregation. Rivaroxaban significantly inhibited the release of phosphorylated HSP27 from collagen-stimulated platelets but not the secretion of platelet derived growth factor-AB. In patients administrated with rivaroxaban, the collagen-induced levels of phosphorylated HSP27 were markedly diminished after 2 days of administration, which failed to affect the platelet aggregation. These results strongly suggest that FXa inhibitor reduces the collagen-stimulated release of phosphorylated HSP27 from human platelets due to the inhibition of HSP27 phosphorylation via p44/p42 MAP kinase.
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Affiliation(s)
- Masanori Tsujimoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Pharmacology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Gen Kuroyanagi
- Department of Pharmacology, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Yuko Kito
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroki Iida
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takanobu Otsuka
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Haruhiko Tokuda
- Department of Pharmacology, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Clinical Laboratory, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Osamu Kozawa
- Department of Pharmacology, Gifu University Graduate School of Medicine, Gifu, Japan
- * E-mail:
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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