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Ioannou M, Leonidou E, Chaziri I, Mouzarou A. Direct Oral Anticoagulants: Navigating Through Clinical Challenges. Cardiovasc Drugs Ther 2024; 38:637-650. [PMID: 37552381 DOI: 10.1007/s10557-023-07499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
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Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
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2
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Talerico R, Pola R, Klok FA, Huisman MV. Direct-Acting Oral Anticoagulants in patients at extremes of body weight: a review of pharmacological considerations and clinical implications. TH OPEN 2024; 8:e31-e41. [PMID: 38197017 PMCID: PMC10774013 DOI: 10.1055/s-0043-1776989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/16/2023] [Indexed: 01/11/2024] Open
Abstract
Patients at extremes of body weight are underrepresented in randomized controlled trials of direct-acting oral anticoagulants (DOACs). Therefore, their optimal anticoagulant treatment remains a topic of debate. The aim of this narrative review is to summarize the evidence on the pharmacokinetic and pharmacodynamic profile of DOACs for treating patients at extremes of body weight in venous thromboembolism (VTE) and in the prevention of cardioembolic stroke in nonvalvular atrial fibrillation (NVAF). A literature search was conducted in the main bibliographic databases, and the most relevant reviews and original articles on the topic were selected. Although data in these patient groups are limited, apixaban and rivaroxaban show a favorable pharmacokinetic and pharmacodynamic profile in obese VTE treatment and NVAF patients and, in the case of apixaban, also in underweight patients. In particular, these drugs demonstrated comparable efficacy and safety to standard therapy. Very few data were available for dabigatran and edoxaban; the latter drug was safer at a lower dose, mainly in underweight patients. Our findings are in line with the last International Society of Haemostasis and Thrombosis position paper and European Heart Rhythm Association 2021 practical guide, suggesting the use of apixaban and rivaroxaban in morbidly obese patients (>120 kg or body mass index ≥40 kg/m 2 ) and the reduced dosage of edoxaban in low-weight patients. Future studies should focus on large populations of patients at extremes of body weights to acquire more clinical and pharmacokinetic evidence on all available DOACs, especially those currently less investigated.
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Affiliation(s)
- Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- IRCCS San Raffaele, Rome, Italy
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frederikus Albertus Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Menno Volkert Huisman
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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3
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Wu S, Huang N, Chen X, Jiang S, Zhang W, Hu W, Su J, Dai H, Gu P, Huang X, Du X, Li R, Zheng Q, Lin X, Zhang Y, Zou L, Liu Y, Zhang M, Liu X, Zhu Z, Sun J, Hong S, She W, Zhang J. Association between Body Mass Index and Clinical Outcomes in Patients with Non-valvular Atrial Fibrillation Receiving Direct Oral Anticoagulants: A New Piece of Evidence on the Obesity Paradox from China. Cardiovasc Drugs Ther 2023; 37:715-727. [PMID: 35394582 DOI: 10.1007/s10557-022-07332-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE We conducted a multicenter real-world study in China to assess the association between body mass index (BMI) and clinical outcomes in patients with atrial fibrillation (AF) taking direct oral anticoagulants (DOACs). METHOD This is a retrospective multicenter cohort study conducted in 15 centers in China. We collected demographic information through the hospital information system and obtained clinical events through follow-up visits to patients or relatives. Clinical outcomes include major, minor, total bleeding, thromboembolism, and all-cause death. RESULT A total of 6164 patients with non-valvular AF (NVAF) were included in this study. The incidence of major bleeding in patients with NVAF differed significantly by BMI category (P < 0.001), with 5.2% in the underweight group, 2.6% in the normal group, 1.4% in the overweight group, 1.1% in the obese I group, and 1.3% in the obese II group. There was no significant difference in minor, total bleeding, and thrombosis in the five groups (P = 0.493; P = 0.172; P = 0.663). All-cause death was significantly different among the five groups (P < 0.001), with 8.9% in the underweight group, 6.3% in the normal group, 4.8% in the overweight group, 2.2% in the obese I group, and 0.4% in the obese II group. High BMI was negatively associated with major bleeding (OR = 0.353, 95% CI 0.205-0.608), total bleeding (OR = 0.664, 95% CI 0.445-0.991), and all-cause death (OR = 0.370, 95% CI 0.260-0.527). CONCLUSION In patients with NVAF treated with DOACs, higher BMI was associated with lower major bleeding and better survival. BMI was a negative correlate of total bleeding, but not minor bleeding and thrombosis.
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Affiliation(s)
- Shuyi Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji(Wuhan) Hospital, Wuhan, 430000, China
| | - Xia Chen
- Department of Pharmacy, Fuling Hospital of Chongqing University, Chongqing, 408099, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Wang Zhang
- Department of Pharmacy, The First People's Hospital of Changde City, Changde City, 415000, Hunan, China
| | - Wei Hu
- Department of Pharmacy, Xinyang Central Hospital, Xinyang Hospital Affiliated to Zhengzhou University, Zhengzhou, 464000, Henan, China
| | - Jun Su
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Anhui, 233004, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fujian, 350009, China
| | - Ping Gu
- Department of Pharmacy, Suining Central Hospital, Suining, 629000, Sichuan, China
| | - Xiaohong Huang
- Department of Pharmacy, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, 363000, China
| | - Xiaoming Du
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ruijuan Li
- Department of Pharmacy, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Shanxi, 030032, China
| | - Qiaowei Zheng
- Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiangsheng Lin
- Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fujian, 350400, China
| | - Yanxia Zhang
- Department of Pharmacy, The First Affiliated Hospital of Jiamusi University, Heilongjiang, 154002, China
| | - Lang Zou
- Department of Pharmacy, Second Affiliated Hospital, Army Medical University, Chongqing, 400037, China
| | - Yuxin Liu
- Department of Pharmacy, Huaihe Hospital of Henan University, Henan, 475000, China
| | - Min Zhang
- Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Shandong, 266041, China
| | - Xiumei Liu
- Department of Pharmacy, People's Hospital of He'nan University of Chinese Medicine (People's Hospital of Zhengzhou), Zhengzhou, 450003, China
| | - Zhu Zhu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, 215004, China
| | - Jianjun Sun
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, 010050, China
| | - Shanshan Hong
- Department of Pharmacy, Quanzhou First Hospital, Fujian, 362000, China
| | - Weibin She
- Department of Medical Administration, Dongguan Kanghua Hospital, Guangdong, 523000, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, Fujian, China.
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Hjelmdal C, Draegert C, Vester-Andersen M, Kowark A, Coburn M, Rasmussen LS, Lundstrøm LH, Steinmetz J. Intra-operative blood transfusion in elderly patients on antithrombotic therapy. Acta Anaesthesiol Scand 2023; 67:412-421. [PMID: 36636858 DOI: 10.1111/aas.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/10/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Many elderly patients are receiving antithrombotics, which may increase intra-operative blood loss. We aimed to assess whether chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in patients at least 80 years of age undergoing elective procedures. METHODS We performed a secondary analysis of the prospective, observational European multicentre study entitled POSE (peri-interventional outcome study in the elderly) including 9497 surgical patients aged 80 years and older in 177 centres from October 2017 to December 2018. In this secondary analysis we included POSE patients who underwent elective procedures and with available data on chronic antithrombotic therapy. The primary outcome was intra-operative transfusion of packed red blood cells and results were analysed using multiple logistic regression model. We adjusted for the following predetermined explanatory variables: Age, sex, body mass index, American Society of Anaesthesiologists Physical Status Classification System, baseline haemoglobin concentration, disseminated cancer, and type and severity of surgery. RESULTS A total of 7174 patients were included of whom 4073 (56.8%) were on antithrombotic therapy. Among patients on antithrombotic therapy 191 (4.7%) received intra-operative blood transfusion compared with 98 (3.2%) of patients not on chronic antithrombotic therapy (crude odds ratio: 1.51, 95% CI 1.18-1.94). Following multiple logistic regression analysis, the adjusted odds ratio was 0.98; 0.73-1.32. We found that chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in elderly patients undergoing elective procedures in an unadjusted analysis, but not in a multivariate adjusted model.
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Affiliation(s)
- Caroline Hjelmdal
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina Draegert
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Anesthesiology, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ana Kowark
- Department of Anaesthesia, University Hospital RWTH, Aachen, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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Lim S, Choo EH, Choi IJ, Hwang Y, Lee KY, Lee SN, Hwang BH, Kim CJ, Park MW, Lee JM, Park CS, Kim HY, Yoo KD, Jeon DS, Chung WS, Kim MC, Jeong MH, Yim HW, Ahn Y, Chang K. Impact of the risk of malnutrition on bleeding, mortality, and ischemic events in patients with acute myocardial infarction. Nutr Metab Cardiovasc Dis 2023; 33:65-74. [PMID: 36411222 DOI: 10.1016/j.numecd.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND & AIMS Data regarding the relationship between malnutrition and clinical outcomes of acute myocardial infarction (AMI) is limited. The study aims to evaluate the clinical impact of malnutrition in AMI patients after percutaneous coronary intervention (PCI). METHODS AND RESULTS The COREA-AMI registries identified 10,161 AMI patients who underwent PCI from January 2004 to August 2014. Patients with geriatric nutritional risk index (GNRI) scores of <82, 82 to <92, 92 to <98, and ≥98 were categorized as having severe, moderate, mild malnutrition risk, and absence of risk, respectively. Associations of GNRI with Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding, all-cause death, and major cardiovascular events (MACEs; a composite of cardiovascular death, myocardial infarction, or ischemic stroke) were evaluated. Over 50% of AMI patients were malnourished, with 25.0%, 22.7%, and 4.9% having mild, moderate, and severe malnutrition risks, respectively. Over a median 4.9-year follow-up, patients with malnutrition risk had higher risks of BARC 3 or 5 bleeding (adjusted hazard ratios [aHRs], 1.27, 1.55, and 2.02 for mild, moderate, and severe, respectively; p < 0.001), all-cause death (aHRs, 1.26, 1.46, and 1.85 for mild, moderate, and severe, respectively; p < 0.001), and MACEs (aHRs, 1.14, 1.32, and 1.67 for mild, moderate, and severe, respectively; p < 0.001) than patients without risk. CONCLUSION Elevated malnutrition risk was common among AMI patients undergoing PCI and was strongly associated with a higher risk of major bleeding, all-cause death, and major ischemic events.
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Affiliation(s)
- Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Ho Choo
- Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngdeok Hwang
- Paul H. Chook Department of Information Systems and Statistics, Baruch College, City University of New York, New York, NY, United States
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Su Nam Lee
- Division of Cardiology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Min Lee
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Doo Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wook Sung Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Hyeon Woo Yim
- Department of Preventive Medicine, Clinical Research Coordinating Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Kiyuk Chang
- Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Boriani G, Vitolo M, Malavasi VL, Proietti M, Fantecchi E, Diemberger I, Fauchier L, Marin F, Nabauer M, Potpara TS, Dan GA, Kalarus Z, Tavazzi L, Maggioni AP, Lane DA, Lip GYH. Impact of anthropometric factors on outcomes in atrial fibrillation patients: analysis on 10 220 patients from the European Society of Cardiology (ESC)-European Heart Rhythm Association (EHRA) EurObservational Research Programme on Atrial Fibrillation (EORP-AF) general long-term registry. Eur J Prev Cardiol 2022; 29:1967-1981. [PMID: 35671129 DOI: 10.1093/eurjpc/zwac115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/07/2022] [Accepted: 05/31/2022] [Indexed: 09/07/2023]
Abstract
AIM To investigate the association of anthropometric parameters [height, weight, body mass index (BMI), body surface area (BSA), and lean body mass (LBM)] with outcomes in atrial fibrillation (AF). METHODS AND RESULTS Ten-thousand two-hundred twenty patients were enrolled [40.3% females, median age 70 (62-77) years, followed for 728 (interquartile range 653-745) days]. Sex-specific tertiles were considered for the five anthropometric variables. At the end of follow-up, survival free from all-cause death was worse in the lowest tertiles for all the anthropometric variables analyzed. On multivariable Cox regression analysis, an independent association with all-cause death was found for the lowest vs. middle tertile when body weight (hazard ratio [HR] 1.66, 95%CI 1.23-2.23), BMI (HR 1.65, 95%CI 1.23-2.21), and BSA (HR 1.49, 95%CI 1.11-2.01) were analysed in female sex, as well as for body weight in male patients (HR 1.61, 95%CI 1.25-2.07). Conversely, the risk of MACE was lower for the highest tertile (vs. middle tertile) of BSA and LBM in males and for the highest tertile of weight and BSA in female patients. A higher occurrence of haemorrhagic events was found for female patients in the lowest tertile of height [odds ratio (OR) 1.90, 95%CI 1.23-2.94] and LBM (OR 2.13, 95%CI 1.40-3.26). CONCLUSIONS In AF patients height, weight, BMI, BSA, and LBM were associated with clinical outcomes, with all-cause death being higher for patients presenting lower values of these variables, i.e. in the lowest tertiles of distribution. The anthropometric variables independently associated with other outcomes were also different between male and female subjects.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Vincenzo L Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- 'Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Zbigniew Kalarus
- Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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7
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Li X, Zuo C, Ji Q, Xue Y, Wang Z, Lv Q. Body Mass Index Influence on the Clinical Outcomes for Nonvalvular Atrial Fibrillation Patients Admitted to a Hospital Treated with Direct Oral Anticoagulants: A Retrospective Cohort Study. Drug Des Devel Ther 2021; 15:1931-1943. [PMID: 33986592 PMCID: PMC8110253 DOI: 10.2147/dddt.s303219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Considering that the current fixed dose of direct oral anticoagulants (DOACs) might have insufficient anticoagulation effect for overweight patients, the aim of this study was to compare the effectiveness and safety of anticoagulation between dabigatran and rivaroxaban in different body mass index (BMI) population. METHODS We conducted a retrospective cohort study of 2402 DOAC anticoagulated patients with atrial fibrillation who underwent catheter ablation (1290 dabigatran, 53.7% and 1112 rivaroxaban, 46.3%) between January 2017 and December 2018. Patients were distributed based on the BMI into nonobese (1362, BMI <25 kg/m2), preobese (521, BMI 25.0-29.9 kg/m2), class I obese (344, BMI 30.0-34.9 kg/m2) and class II+ obese (175, BMI ≥35.0 kg/m2). We collected information regarding clinical features, laboratory data, bleeding complications and systemic embolic events from the electrical medical records system during 12 months. RESULTS The incidence of systemic embolism and stroke complications was higher in the class II+ obese group (P=0.001 and P=0.003). The incidence of bleeding complications and the levels of anticoagulation parameters under the bleeding threshold were similar among the four groups (P>0.05). Cumulative Kaplan-Meier analysis illustrated that rivaroxaban-treated patients who belonged to higher BMI subgroups were more likely to experience shorter time to thrombosis (TTT) (12-month TTT rates of 0.5% for nonobese vs 1.7% for class I obese patients, HR=3.716, P=0.005; 12-month TTT rates of 0.5%, for nonobese vs 4.0% for class II+ obese patients, HR=6.843, P=0.001). However, no statistical significant difference in terms of the time to bleeding complications and the time to cumulative events among the four groups was observed. By multivariate analysis, a higher BMI value (BMI ≥25 kg/m2) (P=0.019; OR=2.094, 95%CI: 1.129-3.883) was an independent predictor for thrombosis in patients treated with dabigatran or rivaroxaban. Positive linear relationship was observed between BMI levels and occurrence rate of thrombosis and bleeding in under anticoagulation patients with NVAF (R2=0.451 and R2=0.383, respectively). CONCLUSION The fixed dose of 15 mg rivaroxaban might carry a risk of under exposure, which would lead to an increase of thromboembolic complications in patients with high BMI. Therefore, rivaroxaban dose increase was suggested for obese patients. Use of DOACs appears to have considerable safety in obese patients.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Chengchun Zuo
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Qiuyi Ji
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Ying Xue
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
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8
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Grymonprez M, Capiau A, De Backer TL, Steurbaut S, Boussery K, Lahousse L. The impact of underweight and obesity on outcomes in anticoagulated patients with atrial fibrillation: A systematic review and meta-analysis on the obesity paradox. Clin Cardiol 2021; 44:599-608. [PMID: 33769583 PMCID: PMC8119828 DOI: 10.1002/clc.23593] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022] Open
Abstract
Although obesity is associated with the development and progression of atrial fibrillation (AF), an obesity paradox may be present, illustrated by seemingly protective effects of obesity on AF-related outcomes. Body mass index (BMI) has an impact on outcomes in AF patients using oral anticoagulants. After searching Medline and Embase, meta-analysis of results of four randomized and five observational studies demonstrated significantly lower risks of stroke or systemic embolism (RR 0.80, 95%CI [0.73-0.87]; RR 0.63, 95%CI [0.57-0.70]; and RR 0.42, 95%CI [0.31-0.57], respectively) and all-cause mortality (RR 0.73, 95%CI [0.64-0.83]; RR 0.61, 95%CI [0.52-0.71]; and RR 0.56, 95%CI [0.47-0.66], respectively) in overweight, obese and morbidly obese anticoagulated AF patients (BMI 25 to <30, ≥30 and ≥40 kg/m2 , respectively) compared to normal BMI anticoagulated AF patients (BMI 18.5 to <25 kg/m2 ). In contrast, thromboembolic (RR 1.92, 95%CI [1.28-2.90]) and mortality (RR 3.57, 95%CI [2.50-5.11]) risks were significantly increased in underweight anticoagulated AF patients (BMI <18.5 kg/m2 ). In overweight and obese anticoagulated AF patients, the risks of major bleeding (RR 0.86, 95%CI [0.76-0.99]; and RR 0.88, 95%CI [0.79-0.98], respectively) and intracranial bleeding (RR 0.75, 95%CI [0.58-0.97]; and RR 0.57, 95%CI [0.40-0.80], respectively) were also significantly lower compared to normal BMI patients, while similar risks were observed in underweight and morbidly obese patients. This meta-analysis demonstrated lower thromboembolic and mortality risks with increasing BMI. However, as this paradox was driven by results from randomized studies, while observational studies rendered more conflicting results, these seemingly protective effects should still be interpreted with caution.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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9
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 423] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - 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
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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10
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Zhou B, Zhao S, Tang M, Chen K, Hua W, Su Y, Yang J, Liang Z, Xu W, Zhang S. Non-linear Association Between Body Mass Index and Ventricular Tachycardia/Ventricular Fibrillation in Patients With an Implantable Cardioverter-Defibrillator or Cardiac Resynchronization Therapy Defibrillator: A Multicenter Cohort Study. Front Cardiovasc Med 2020; 7:610629. [PMID: 33330674 PMCID: PMC7734049 DOI: 10.3389/fcvm.2020.610629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Results from studies on the effects of obesity on sudden cardiac death (SCD) or ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with an implantable cardioverter-defibrillator/cardiac resynchronization therapy defibrillator (ICD/CRT-D) are inconsistent. Our study aimed to explore the impact of BMI on VT/VF in patients with an ICD/CRT-D. Methods: We retrospectively analyzed the data from the Study of Home Monitoring System Safety and Efficacy in Cardiac Implantable Electronic Device–implanted Patients in China. Nine hundred and seventy ICD/CRT-D patients were enrolled. The outcome was the first occurrence of VT/VF requiring appropriate ICD/CRT-D therapy. A general linear model and general additive model were used to assess the relationship between BMI and VT/VF. Results: After a median follow-up of 5.17 years, 352 (36.3%) patients experienced VT/VF requiring appropriate ICD/CRT-D therapy. BMI, whether as a continuous variable or a categorical variable classified by various BMI classification criteria, had no significant effect on VT/VF according to a multivariable Cox proportional hazards model with adjustment for potential confounders. However, a non-linear association between BMI and VT/VF was identified using a cubic spline function model and smooth curve fitting. The inflection point for the curve was found at a BMI level of 23 kg/m2. The hazard ratios (95% confidence intervals) for VT/VF were 1.12 (1.01–1.24) and 0.96 (0.90–1.02) to the left and right of the inflection point, respectively. Conclusions: BMI is related to VT/VF in a non-linear manner in patients with an ICD/CRT-D. Our research suggests a complicated role of BMI in VT/VF with different impacts at different ranges.
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Affiliation(s)
- Bin Zhou
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Zhao
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Tang
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keping Chen
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangang Su
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, Beijing, China
| | - Zhaoguang Liang
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Shu Zhang
- Arrhythmia Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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Abstract
Abstract
Direct oral anticoagulants (
DOAC
s) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist.
DOAC
s are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010,
DOAC
s have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of
DOAC
s, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of
DOAC
s and act as a practical reference for clinicians to optimize
DOAC
use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology Section Knight Cardiovascular Institute Oregon Health & Science University Portland OR
| | - Bruce A. Warden
- Center for Preventive Cardiology Knight Cardiovascular Institute Oregon Health & Science University Portland OR
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12
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Abstract
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology SectionKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Bruce A. Warden
- Center for Preventive CardiologyKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
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13
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Liu X, Guo L, Xiao K, Zhu W, Liu M, Wan R, Hong K. The obesity paradox for outcomes in atrial fibrillation: Evidence from an exposure-effect analysis of prospective studies. Obes Rev 2020; 21:e12970. [PMID: 31849187 DOI: 10.1111/obr.12970] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
The impact of obesity on the prognosis of atrial fibrillation (AF) remains controversial. We conducted an exposure-effect meta-analysis of prospective studies to clarify the relationship between body mass index (BMI) and outcomes in patients with AF. The Cochrane Library, PubMed, and Embase databases were searched through May 1, 2019. Summary relative risks (RRs) were calculated using random-effects models. Nonlinear associations were explored using restricted cubic spline models. Twenty publications involving 161,922 individuals were included. Categorical variable analysis showed that underweight was associated with an increased risk of all-cause mortality (RR: 2.6), cardiovascular death (RR: 2.91), major bleeding (RR: 1.57), stroke or systemic embolism (RR: 1.62), and a composite endpoint (RR: 2.23). In exposure-effect analysis, the risk per 5 BMI increase was reduced for adverse outcomes (RR=0.86, 95% CI: 0.80-0.92 for all-cause death; RR=0.82, 95% CI: 0.71-0.95 for cardiovascular death; RR=0.89, 95% CI: 0.84-0.95 for stroke or systemic embolism; and RR=0.78, 95% CI: 0.67-0.92 for a composite endpoint). There was a significant "U"-shaped exposure-effect relationship with all-cause death, and the nadir of the curve was observed at a BMI of approximately 28. Our results showed that underweight is associated with a worse prognosis, but that overweight and obesity are associated with improved adverse outcomes in patients with AF.
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Affiliation(s)
- Xiao Liu
- Cardiology Department, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Linjuan Guo
- Cardiology Department, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Kaiwen Xiao
- Jiangxi Medical College, Nanchang University, Jiangxi, China
| | - Wengen Zhu
- Cardiology Department, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Menglu Liu
- Cardiology Department, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Rong Wan
- Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
| | - Kui Hong
- Cardiology Department, The Second Affiliated Hospital of Nanchang University, Jiangxi, China.,Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
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14
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Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients with Atrial Fibrillation Across BMI Categories: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2020; 20:51-60. [PMID: 31342343 DOI: 10.1007/s40256-019-00362-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Concerns have arisen recently over the relationship between body mass index (BMI) and outcomes in atrial fibrillation (AF) patients with direct oral anticoagulants (DOACs). This meta-analysis aimed to explore if there is an "obesity paradox" in anticoagulated AF patients, and compare the treatment effects between DOACs and warfarin in AF patients across BMI categories. METHODS We systematically searched the PubMed and Embase databases until February 26, 2019 for relevant studies. Risk ratios (RRs) with 95% confidence intervals (CIs) were extracted and pooled by a random-effects model. RESULTS A total of nine studies were included. Compared with normal weight, underweight was associated with an increased risk of stroke or systemic embolism (SSE) (RR 1.98, 95% CI 1.19-3.28), whereas either overweight or obesity was related with reduced rates of SSE (overweight: RR 0.81, 95% CI 0.71-0.91; obesity: RR 0.69, 95% CI 0.61-0.78) and all-cause death (overweight: RR 0.73, 95% CI 0.64-0.83; obesity: RR 0.72, 95% CI 0.66-0.79). Compared with patients receiving warfarin, patients receiving DOACs who were underweight, normal weight or overweight all had decreased risks of SSE (underweight: RR 0.61, 95% CI 0.46-0.80; normal weight: RR 0.72, 95% CI 0.58-0.91; overweight: RR 0.87, 95% CI 0.76-0.99) and major bleeding (underweight: RR 0.67, 95% CI 0.55-0.81; normal weight: RR 0.72, 95% CI 0.58-0.90; overweight: RR 0.83, 95% CI 0.71-0.96), while obese DOAC users were at no higher risks for SSE and major bleeding. CONCLUSIONS There may be an obesity paradox in anticoagulated patients with AF. DOACs have better efficacy and safety profiles than warfarin in underweight, normal weight and overweight patients, and are not inferior to warfarin in obese patients.
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15
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1268] [Impact Index Per Article: 253.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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16
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Shao SC, Chan YY, Kao Yang YH, Lin SJ, Hung MJ, Chien RN, Lai CC, Lai ECC. The Chang Gung Research Database-A multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan. Pharmacoepidemiol Drug Saf 2019; 28:593-600. [PMID: 30648314 DOI: 10.1002/pds.4713] [Citation(s) in RCA: 181] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/11/2018] [Accepted: 11/08/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE The Chang Gung Research Database (CGRD), the largest multi-institutional electronic medical records (EMR) collection in Taiwan, provides good access for researchers to efficiently use the standardized patient-level data. This study evaluates the capacity and representativeness of the CGRD to promote secondary use of EMR data for clinical research with more accurate estimates. METHODS The National Health Insurance Research Database (NHIRD) which covers over 99.9% of the Taiwanese population served as the comparator in this study. We compare the data components of the CGRD with the NHIRD, including records for health care facilities, patients, diagnoses, drugs, and procedures. Using the chi-square test, we compared the distributions of age categories and sex of patients, and the rates of their health conditions between NHIRD and CGRD based on the year 2015. RESULTS The CGRD contains more clinical information such as pathological and laboratory results than the NHIRD. The CGRD includes 6.1% of outpatients and 10.2% of hospitalized patients from the NHIRD. We found the CGRD includes more elderly outpatients (23.5% vs 12.5%) and pediatric inpatients (19.7% vs 14.4%) compared with the NHIRD. We found patients' sex distributions were similar between CGRD and NHIRD, but coverage rates of severe conditions, such as cancer, were higher than other health conditions in CGRD. CONCLUSIONS The CGRD could serve as the basis for accurate estimates in medical studies. However, researchers should pay special attention to selection biases since patients' characteristics from CGRD differ from those of the national database.
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Affiliation(s)
- Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuk-Ying Chan
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Ming-Jui Hung
- Section of Cardiology, Department of Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Chun Lai
- Department of Ophthalmology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
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17
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Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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