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Cohen M, Spyropoulos AC, Goodman SG, Spinler SA, Bonaca MP, Redling TM, Visveswaran G, Sohal S. Rivaroxaban Versus Apixaban: A Comparison Without a Simple Solution. Mayo Clin Proc Innov Qual Outcomes 2024; 8:321-328. [PMID: 38974528 PMCID: PMC11223068 DOI: 10.1016/j.mayocpiqo.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Affiliation(s)
- Marc Cohen
- Department of Medicine, Newark Beth Israel Medical Center, Newark, NJ
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Alex C. Spyropoulos
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
- Institute of Health System Science, The Feinstein Institutes for Medical Research, New York, NY
| | - Shaun G. Goodman
- Division of Cardiology, Department of Medicine, St. Michael’s Hospital Professor and Heart & Stroke Foundation of Ontario (Polo), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto Consultant, Ontario, Canada
- Canadian Heart Research Centre, Canadian VIGOUR Centre Ontario, Canada
| | - Sarah A. Spinler
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY
| | - Marc P. Bonaca
- Division of Cardiology and Vascular Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Theresa M. Redling
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
- Division of Geriatric Health and Disease Management, Cooperman Barnabas Medical Center Maida Geriatric Institute, Livingston, NJ
| | - Gautam Visveswaran
- Division of Cardiology, Department of Medicine, Newark Beth Israel Medical Center, Newark, NJ
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Sumit Sohal
- Division of Cardiology, Department of Medicine, Yale New Haven Hospital, New Haven, CT
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Yuan Z, Levitan B, Deng H, Szarek M, Bauersachs RM, Berkowitz SD, Haskell L, Barnathan ES, Bonaca MP. Quantitative Benefit-Risk Evaluation of Rivaroxaban in Patients After Peripheral Arterial Revascularization: The VOYAGER PAD Trial. J Am Heart Assoc 2024; 13:e032782. [PMID: 38563380 PMCID: PMC11262494 DOI: 10.1161/jaha.123.032782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/02/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The VOYAGER PAD (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities) trial compared rivaroxaban (2.5 mg twice a day) plus aspirin with aspirin alone in patients with symptomatic peripheral artery disease requiring endovascular or surgical limb revascularization, with 50% receiving clopidogrel background therapy. The New Drug Indication application includes benefit-risk assessments using clinical judgment to balance benefits against risks. During its review, the US Food and Drug Administration requested additional quantitative benefit-risk analyses with formal weighting approaches. METHODS AND RESULTS Benefits and risks were assessed using rate differences between treatment groups (unweighted analysis). To account for clinical importance of the end points, a multi-criteria decision analysis was conducted using health state utility values as weights. Monte Carlo simulations incorporated statistical uncertainties of the event rates and utility weights. Intent-to-treat and on-treatment analyses were conducted. For unweighted intent-to-treat analyses, rivaroxaban plus aspirin would result in 120 (95% CI, -208 to -32) fewer events of the primary composite end point (per 10 000 patient-years) compared with aspirin alone. Rivaroxaban caused an excess of 40 (95% CI, 8-72) Thrombolysis in Myocardial Infarction major bleeding events, which was largely driven by nonfatal, nonintracranial hemorrhage Thrombolysis in Myocardial Infarction major bleeding events. For weighted analyses, rivaroxaban resulted in the utility equivalent of 13.7 (95% CI, -85.3 to 52.6) and 68.1 (95% CI, 7.9-135.7) fewer deaths per 10 000 patient-years (intent-to-treat and on-treatment, respectively), corresponding to probabilities of 64.4% and 98.7%, respectively, that benefits outweigh risks favoring rivaroxaban per Monte Carlo simulation. CONCLUSIONS These analyses show a favorable benefit-risk profile of rivaroxaban therapy in the VOYAGER PAD trial, with findings generally consistent between the unweighted and weighted approaches.
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Affiliation(s)
- Zhong Yuan
- Janssen Research & DevelopmentLLCHorshamPA
| | | | | | - Michael Szarek
- CPC Clinical Research, Department of MedicineUniversity of ColoradoAuroraCO
| | - Rupert M. Bauersachs
- Cardioangiologisches Centrum Bethanien ‐ CCBGefäß‐CentrumFrankfurt am MainGermany
| | - Scott D. Berkowitz
- CPC Clinical Research, Department of MedicineUniversity of ColoradoAuroraCO
| | | | | | - Marc P. Bonaca
- CPC Clinical Research, Department of MedicineUniversity of ColoradoAuroraCO
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Creixell M, Harxhi A. The importance of assessing the safe and effective use of oral anticoagulants in older adults. J Am Geriatr Soc 2023; 71:3954-3956. [PMID: 37738020 DOI: 10.1111/jgs.18587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/05/2023] [Indexed: 09/23/2023]
Abstract
See the Reply by Semla and Steinman in this issue.
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Affiliation(s)
- Mar Creixell
- Medical Affairs-Cardiovascular & Metabolism, Janssen Pharmaceuticals, Inc., Titusville, New Jersey, USA
| | - Ante Harxhi
- Medical Affairs-Cardiovascular & Metabolism, Janssen Pharmaceuticals, Inc., Titusville, New Jersey, USA
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Marín F, Fernández MS, Barón-Esquivias G, Barrios V, Lekuona I, Pérez-Cabeza AI, Masjuan J, del Vigo ER, Vázquez Rodríguez JM, Freixa-Pamias R, Schilling VR, Arribas F, Priu CR, Sánchez MA. Non-embolic outcomes in patients with cardiovascular disease and atrial fibrillation treated with rivaroxaban. J Comp Eff Res 2023; 12:e220049. [PMID: 36749006 PMCID: PMC10288946 DOI: 10.57264/cer-2022-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 11/25/2022] [Indexed: 02/08/2023] Open
Abstract
Aim: It is not well known how comorbidities may change the prognosis of atrial fibrillation (AF) patients. This study was aimed to analyze the impact of cardiovascular disease on this population. Materials & methods: EMIR was a multicenter, prospective study, including 1433 AF patients taking rivaroxaban for ≥6 months. Data were analyzed according to the presence of vascular disease. Results: Coronary artery disease was detected in 16.4%, peripheral artery disease/aortic plaque in 6.7%, vascular disease in 28.3%. Patients with coronary artery disease had higher rates (per 100 patient-years) of major adverse cardiovascular events (2.98 vs 0.71; p < 0.001) and cardiovascular death (1.79 vs 0.41; p = 0.004). Those with vascular disease had higher rates of thromboembolic events (1.47 vs 0.44; p = 0.007), major adverse cardiovascular events (2.03 vs 0.70; p = 0.004), and cardiovascular death (1.24 vs 0.39; p = 0.025). Patients with peripheral artery disease/aortic plaque had similar rates. Conclusion: AF patients with vascular disease have a higher risk of non-embolic outcomes.
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Affiliation(s)
- Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | | | - Gonzalo Barón-Esquivias
- Department of Cardiology, Hospital Universitario Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain
- Unidad Cardiovascular, Instituto de Biotecnología de Sevilla. Centro de Investigación en Red Cardiovascular, Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Alcalá University, Madrid, Spain
| | | | | | - Jaime Masjuan
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, IRYCIS, Departamento de Medicina, Universidad de Alcalá. Red INVICTUS, Madrid, Spain
| | | | | | | | - Vanessa Roldán Schilling
- Department of Haematology & Clinical Oncology, Hospital Universitario Morales Meseguer. University of Murcia, Murcia, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre, Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Instituto de Investigacion Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
| | | | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Reina Sofía Córdoba, IMIBIC, University of Cordoba, Córdoba, Spain
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5
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Raskob GE, Ageno W, Albers G, Elliott CG, Halperin J, Maynard G, Steg PG, Weitz JI, Albanese J, Yuan Z, Levitan B, Lu W, Suh EY, Spiro T, Lipardi C, Barnathan ES, Spyropoulos AC. Benefit-Risk Assessment of Rivaroxaban for Extended Thromboprophylaxis After Hospitalization for Medical Illness. J Am Heart Assoc 2022; 11:e026229. [PMID: 36205248 DOI: 10.1161/jaha.122.026229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Venous thromboembolism (VTE) often occurs after hospitalization in medically ill patients, but the population benefit-risk of extended thromboprophylaxis remains uncertain. Methods and Results The MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) study (NCT02111564) was a randomized double-blind trial that compared thromboprophylaxis with rivaroxaban 10 mg daily versus placebo for 45 days after hospital discharge in medically ill patients with a creatinine clearance ≥50 mL/min. The benefit-risk balance in this population was quantified by calculating the between-treatment rate differences in efficacy and safety end points per 10 000 patients treated. Clinical characteristics of the study population were consistent with a hospitalized medical population at risk for VTE. Treating 10 000 patients with rivaroxaban resulted in 32.5 fewer symptomatic VTE and VTE-related deaths but was associated with 8 additional major bleeding events. The treatment benefit was driven by the prevention of nonfatal symptomatic VTE (26 fewer events). There was no between-treatment difference in the composite of critical site or fatal bleeding. Conclusions Extending thromboprophylaxis with rivaroxaban for 45 days after hospitalization provides a positive benefit-risk balance in medically ill patients at risk for VTE who are not at high risk for bleeding. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT02111564.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | - Gregory Albers
- Stanford Stroke Center Stanford University Medical Center Stanford CA
| | - C Gregory Elliott
- Department of Medicine Intermountain Medical Center and the University of Utah Salt Lake City UT
| | | | | | - Philippe Gabriel Steg
- Universite Paris-Cite Assistance Publique-Hôpitauxde Paris, and INSERM U-1148 Paris France.,Imperial College, Royal Brompton Hospital London United Kingdom
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | | | - Zhong Yuan
- Janssen Research & Development, LLC Titusville NJ
| | | | - Wentao Lu
- Janssen Research & Development, LLC Raritan NJ
| | | | - Theodore Spiro
- Clinical Development Pharmaceuticals, Bayer U.S. LLC Whippany NJ
| | | | | | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell The Feinstein Institute for Medical Research, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lennox Hill Hospital New York NY
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6
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Chew DS, Zhou K, Pokorney SD, Matchar DB, Vemulapalli S, Allen LA, Jackson KP, Samad Z, Patel MR, Freeman JV, Piccini JP. Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis. Ann Intern Med 2022; 175:1230-1239. [PMID: 35969865 DOI: 10.7326/m21-4653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN Decision analysis with a Markov model. DATA SOURCES Evidence from the published literature informed model inputs. TARGET POPULATION Women and men with nonvalvular AF and without prior stroke. TIME HORIZON Lifetime. PERSPECTIVE Clinical. INTERVENTION LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada (D.S.C.)
| | - Ke Zhou
- Duke-National University of Singapore Medical School, Singapore (K.Z.)
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - David B Matchar
- Duke-National University of Singapore Medical School, Singapore, and Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (D.B.M.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado (L.A.A.)
| | - Kevin P Jackson
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina (K.P.J.)
| | - Zainab Samad
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, and Department of Medicine, Aga Khan University, Karachi, Pakistan (Z.S.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - James V Freeman
- Yale University School of Medicine, New Haven, Connecticut (J.V.F.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
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7
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Pazan F, Collins R, Gil VM, Hanon O, Hardt R, Hoffmeister M, Monteiro P, Quinn TJ, Ropers D, Sergi G, Verheugt FWA, Wehling M. A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019). Drugs Aging 2020; 37:539-548. [PMID: 32500503 PMCID: PMC8203545 DOI: 10.1007/s40266-020-00771-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Evidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019. METHODS A structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA. RESULTS A total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p < 0.05) and the proposed FORTA classes were confirmed in all cases during the first round (consensus coefficient > 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A. CONCLUSION OAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ronan Collins
- Stroke-Service/Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - Victor M Gil
- Cardiovascular Department, Hospital dos Lusíadas, Rua Abílio Mendes, 1500-458, Lisbon, Portugal
| | - Olivier Hanon
- Service de Gérontologie, Hôpital Broca-Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Equipe d'Accueil (EA) 4468, Paris, France
| | - Roland Hardt
- Department of Geriatrics, University Medical Center, University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Hoffmeister
- Cardiology, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Germany
| | - Pedro Monteiro
- Cardiology Department, Coimbra University Hospital, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G4 0SF, UK
| | - Dieter Ropers
- Department of Internal Medicine 1-Cardiology, St. Theresien-Krankenhaus Nuremberg, Mommsenstrasse 24, 90941, Nuremberg, Germany
| | - Giuseppe Sergi
- Clinica Geriatrica-Ospedale Giustinianeo (2nd piano), University of Padova, via Giustiniani 2, 35128, Padua, Italy
| | | | - Martin Wehling
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Riera-Mestre A, Camafort M, María Suriñach J, Muñoz Rodríguez FJ, Padilla F, Francisco-Pascual J, Mateo Arranz J, Martínez Rubio A, Villuendas Sabaté R, Freixa-Pamias R, Suárez Fernández C, Santamaría A. Anticoagulación del paciente anciano pluripatológico con fibrilación auricular no valvular: papel del rivaroxabán. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2020. [DOI: 10.1016/s1131-3587(20)30011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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Pinto CA, Tervonen T, Marsh K, Lambrelli D, Schultze A, Tershakovec A, Hyacinthe J, Prawitz T, Hammad TA. Personalized benefit-risk assessments combining clinical trial and real-world data provide further insights into which patients may benefit most from therapy: Demonstration for a new oral antiplatelet therapy. Pharmacoepidemiol Drug Saf 2019; 28:443-451. [PMID: 30848010 DOI: 10.1002/pds.4752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE Quantitative benefit-risk (B-R) assessments are used to characterize treatment by combining key benefits and risks into a single metric but have historically been done for the "average" patient. Our aim was to conduct an individualized assessment for the oral antiplatelet vorapaxar by combining trial and real-world data to further personalize the treatment profiles. METHODS Using linked UK health care databases, we developed risk prediction equations for key ischemic and bleeding events using Cox proportional hazards models. Trial hazard ratios, relative to placebo, were applied to baseline risk estimates to compute expected attributable risks, summed to derive a per-patient net clinical benefit (NCB). High risk subgroups were defined a priori, and Gaussian mixture models (GMM) were fit to characterize the NCB distribution and identify subgroups with similar NCBs. RESULTS NCB was consistently positive for all subgroups, likely due to the outcome correlation, and would remain positive with a 12-fold increase in bleeding risk. GMMs identified three distinct NCB subgroups. Compared with the middle/lower NCB subgroups, those with a higher NCB tended to be older, female, and have higher CV disease burden. CONCLUSIONS Personalized B-R assessments are feasible and clinically valuable and can be used to better predict who would benefit most from therapy.
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10
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Prandoni P, Lensing AWA, Prins MH, Gebel M, Pap AF, Homering M, Bauersachs R, Beyer-Westendorf J, Bounameaux H, Cohen AT, Davidson BL, van Bellen B, Verhamme P, Wells PS, Yuan Z, Levitan B, Weitz JI. Benefits and risks of extended treatment of venous thromboembolism with rivaroxaban or with aspirin. Thromb Res 2018; 168:121-129. [PMID: 30064683 DOI: 10.1016/j.thromres.2018.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/25/2018] [Accepted: 06/13/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Full- or lower-dose anticoagulant therapy or aspirin can be used for extended therapy in patients with venous thromboembolism (VTE), but information on their relative benefit-risk profiles is limited. METHODS Data from the EINSTEIN-CHOICE trial were used to compare the benefit-risk profiles of extended treatment with rivaroxaban (20 or 10 mg once daily) and aspirin (100 mg once daily) in VTE patients who had completed 6 to 12 months of anticoagulation therapy. One-year cumulative incidences of recurrent VTE and major bleeding were estimated and benefits and risks were calculated by determining the between group differences in a hypothetical population of 10,000 VTE patients treated for 1 year. FINDINGS A total of 1107 patients were treated with 20 mg of rivaroxaban, 1127 with 10 mg of rivaroxaban, and 1131 with aspirin. The cumulative incidences of recurrent VTE in the rivaroxaban 20-mg, rivaroxaban 10-mg and aspirin groups were 1.9%, 1.6%, and 5.0%, respectively, whereas the cumulative incidences of major bleeding were 0.7%, 0.4% and 0.5%, respectively. The incidences of the combined outcome of recurrent VTE and major bleeding were 2.8% and 3.4% lower in the rivaroxaban 20-mg and 10-mg groups than in the aspirin group. For 10,000 patients treated for 1 year, there would be 284 (95% confidence interval [CI] 106 to 462) and 339 (95% CI 165 to 512) fewer events with rivaroxaban 20 mg or 10 mg than with aspirin. INTERPRETATION Compared with aspirin, extended anticoagulation with once daily rivaroxaban reduces recurrent VTE with a favourable benefit-risk profile. FUNDING Bayer AG.
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Affiliation(s)
- Paolo Prandoni
- Department of Cardiothoracic & Vascular Sciences, Vascular Medicine Unit, University of Padua, Italy
| | | | - Martin H Prins
- Department of Epidemiology and Technology Assessment, University of Maastricht, Maastricht, The Netherlands
| | | | | | | | | | - Jan Beyer-Westendorf
- Department of Hematology, Medical Clinic I, University Hospital "Carl Gustav Carus" Dresden, Germany; Department of Haematology, Oncology Kings College London, UK
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas' Hospitals, King's College Hospital, London, UK
| | | | | | - Peter Verhamme
- Vascular Medicine and Hemostasis, University of Leuven, Belgium
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ontario, Canada
| | - Zhong Yuan
- Janssen Research & Development, Raritan, NJ, USA
| | | | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
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11
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Pérez Cabeza AI, González Correa JA, Chinchurreta Capote PA, Marqués RB, Mateas FR, Cervantes GR, Prado FM, Tejero SL, Alberca AV. Drug persistence and outcomes in a cohort of patients with nonvalvular atrial fibrillation treated with rivaroxaban after 2 years of follow-up in clinical practice. Future Cardiol 2018; 14:9-16. [DOI: 10.2217/fca-2018-0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate medication persistence and outcomes in patients with atrial fibrillation after 2 years of treatment with rivaroxaban in routine practice. Methods: Retrospective study of atrial fibrillation patients in whom rivaroxaban was prescribed during the first quarter of 2014 in the healthcare area of Costa del Sol (Málaga). Results: A total of 111 patients (mean age 74.9 ± 10.9 years; 52.3% men; CHA2DS2-VASc 3.6 ± 1.3; HAS-BLED 1.3 ± 0.6) were included. A total of 96.3 and 90.6% of patients remained on rivaroxaban therapy after 1 and 2 years of treatment, respectively. During this period, stroke, net clinical benefit outcome (thromboembolic events, myocardial infarction, cardiovascular death and major bleeding) and cardiovascular death occurred in 3.6, 5.4 and 1.8% of patients, respectively. Conclusion: In routine practice, medication persistence with rivaroxaban was high. Rates of major cardiac events were low.
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Affiliation(s)
| | | | | | | | | | | | - Fidel Mesa Prado
- Department of Cardiology, Hospital Costa del Sol, Marbella, Spain
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