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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Viazis N, Christodoulou D, Papastergiou V, Mousourakis K, Kozompoli D, Stasinos G, Dimopoulou K, Apostolopoulos P, Fousekis F, Liatsos C, Kyriakos N, Argyropoulos T, Tribonias G. Diagnostic Yield and Outcomes of Small Bowel Capsule Endoscopy in Patients with Small Bowel Bleeding Receiving Antithrombotics. Diagnostics (Basel) 2024; 14:1361. [PMID: 39001251 PMCID: PMC11240733 DOI: 10.3390/diagnostics14131361] [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: 04/08/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
We aimed to determine the diagnostic yield and outcome of patients receiving antithrombotic drug therapy subjected to small bowel capsule endoscopy (SBCE) for the investigation of small bowel bleeding (SBB). A multicenter retrospective analysis of collected data from all patients undergoing SBCE for the investigation of SBB from March 2003 to June 2023 was performed. The diagnostic yield of SBCE was defined as the detection of positive findings that could explain the cause of the patient's bleeding. Rebleeding was defined as evidence of bleeding within 1 year after the index episode. During the study period, 8401 patients underwent SBCE for SBB investigation. Bleeding lesions were detected in 1103/2535 (43.5%) antithrombotic users, compared to 1113/5866 (18.9%) in nonusers (p < 0.00001). Following capsule endoscopy, a therapeutic intervention was possible in 390/2216 (17.5%) patients with a bleeding lesion. Rebleeding occurred in 927 (36.5%) of antithrombotic users (36.5%), compared to 795 (13.5%) of nonusers (13.5%, p < 0.00001). Both the diagnostic yield of SBCE and the rebleeding rates were higher in patients with SBB receiving antithrombotics. Therapeutic intervention was possible in a real-world setting only for a minority of patients with positive findings.
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Affiliation(s)
- Nikos Viazis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitris Christodoulou
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Vasilis Papastergiou
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Konstantinos Mousourakis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitra Kozompoli
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Giannis Stasinos
- Gastroenterology Department, NIMTS, 19010 Kalivia, Greece; (G.S.); (P.A.)
| | - Konstantina Dimopoulou
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | | | - Fotios Fousekis
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Christos Liatsos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Nikolaos Kyriakos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Theodoros Argyropoulos
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | - George Tribonias
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
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Lee SR, Ahn HJ, Choi EK, Park SH, Han KD, Oh S, Lip GYH. Reduction of Upper Gastrointestinal Bleeding Risk With Proton Pump Inhibitor Therapy in Asian Patients With Atrial Fibrillation Receiving Direct Oral Anticoagulant: A Nationwide Population-based Cohort Study. Clin Gastroenterol Hepatol 2024; 22:981-993.e11. [PMID: 38184099 DOI: 10.1016/j.cgh.2023.12.022] [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: 11/27/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND & AIMS In patients with atrial fibrillation (AF) receiving direct oral anticoagulant (DOAC), upper gastrointestinal bleeding (UGIB) is a serious complication. There are limited data on the benefit of preventive proton pump inhibitor (PPI) use to reduce the risk of UGIB in DOAC users. METHODS We included patients with AF receiving DOAC from 2015 to 2020 based on the Korean Health Insurance Review and Assessment database. The propensity score (PS) weighting method was used to compare patients with PPI use and those without PPI use. The primary outcome was hospitalization for UGIB. Weighted hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were evaluated using the Cox proportional hazards regression model. RESULTS A total of 165,624 patients were included (mean age: 72.2 ± 10.8 years; mean CHA2DS2-VASc score: 4.3 ± 1.8; mean HAS-BLED score: 3.3 ± 1.2). Among them, 99,868 and 65,756 were in the non-PPI group and PPI group, respectively. During a median follow-up of 1.5 years, the PPI group was associated with lower risks of hospitalization for UGIB and UGIB requiring red blood cell transfusion than non-PPI group (weighted HR, 0.825; 95% CI, 0.761-0.894 and 0.798; 95% CI, 0.717-0.887, respectively, both P < .001). The benefits of PPI on the risk of hospitalization for UGIB were greater in those with older age (≥75 years), higher HAS-BLED score (≥3), prior GIB history, and concomitant use of antiplatelet agent (all P-for-interaction < .1). Low-dose PPI was consistently associated with a lower risk of significant UGIB by 43.6-49.3% (P < .001). CONCLUSIONS In this large Asian cohort of patients with AF on DOAC, PPI co-therapy is beneficial for reducing the risk of hospitalization for UGIB, particularly in high-risk patients.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Sang-Hyun Park
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Do Han
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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Gennaro N, Ferroni E, Zorzi M, Denas G, Pengo V. ISCHEMIC STROKE AND MAJOR BLEEDING WHILE ON DIRECT ORAL ANTICOAGULANTS IN NAÏVE PATIENTS WITH ATRIAL FIBRILLATION: IMPACT OF RESUMPTION OR DISCONTINUATION OF ANTICOAGULANT TREATMENT. A population-based study. Int J Cardiol 2024; 394:131369. [PMID: 37722453 DOI: 10.1016/j.ijcard.2023.131369] [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: 04/12/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
AIMS We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, in patients experiencing an anticoagulation-related event (stroke or major bleeding), occurred during anticoagulation therapy for AF. METHODS AND RESULTS We performed a retrospective population-based analysis on linked claims data of patients resident in the Veneto Region, treated with DOACs for AF and discharged (2013-2020) from the hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after a 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, ischemic stroke (IS)intracranial haemorrhage (ICH), and other major bleeding events (MB) were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Overall, 1029 patients (mean age 77 years) were included in the final cohort: 23% experienced an IS, 18% an ICH, and 59% MB. Of these, 77% resumed anticoagulation. The cumulative incidence of events was significantly lower in patients resuming therapy. In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the risk of a cumulative event (HR 0.45, 95%CI 0.35-0.57, p < 0.01). Stratifying for the index event, among patients with IS (92% resumed therapy), we observed a risk reduction of 81%; in patients with ICH (64% resumed therapy), we observed a risk reduction of 64% and for patients with MB (76% resuming therapy), we observed a risk reduction of 49%. CONCLUSIONS In patients with AF who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.
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Affiliation(s)
- N Gennaro
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - E Ferroni
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - M Zorzi
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - G Denas
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy
| | - V Pengo
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy; Arianna Foundation on Anticoagulation. Bologna, Italy.
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Al-Hussainy N, Kragholm KH, Lundbye-Christensen S, Torp-Pedersen C, Pareek M, Therkelsen SK, Lip GYH, Riahi S. Gastrointestinal bleeding with direct oral anticoagulants in patients with atrial fibrillation and anaemia. Thromb Res 2023; 232:62-69. [PMID: 37939578 DOI: 10.1016/j.thromres.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION A high risk of gastrointestinal bleeding has been reported with the use of some direct oral anticoagulants (DOACs). This risk may be of particular concern in individuals with associated anaemia. The aim of this study is to investigate potential differences in the risks of gastrointestinal bleeding and stroke among the four available DOACs in patients with atrial fibrillation (AF) and moderate or severe anaemia. MATERIALS AND METHODS All Danish patients diagnosed with incident AF who had a baseline haemoglobin measurement and subsequently initiated DOAC therapy between 2012 and 2021 were identified through administrative registries. Only patients with moderate or severe anaemia (N = 7269) were included and evaluated regarding the risk of hospitalization for gastrointestinal bleeding and stroke. Standardized absolute 1-year risks of stroke and gastrointestinal bleeding were calculated from multivariable Cox regression analyses. DOACs were compared pairwise RESULTS: Compared with apixaban, both dabigatran and rivaroxaban were associated with a significantly increased risk of gastrointestinal bleeding with standardized 1-year risk ratios of 1.73 (95 % confidence interval [CI], 1.10-2.35) and 1.56 (95 % CI, 1.18-1.93), respectively, while no significant difference was seen in the comparison of apixaban with edoxaban 1.32 (95 % CI, 0.41-2.32). No significant differences in gastrointestinal bleeding were observed with pairwise comparisons of dabigatran, rivaroxaban and edoxaban. Finally, no significant difference in stroke risk among the four DOACs was observed. CONCLUSION In AF patients with moderate or severe anaemia, apixaban was associated with a significantly lower risk of gastrointestinal bleeding than dabigatran and rivaroxaban. No significant difference in stroke risk was observed across all four available DOACs.
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Affiliation(s)
- Nour Al-Hussainy
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Lundbye-Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | | | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Sam Riahi
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Pata F, Bracchitta LM, Nardo B, Gallo G, D’Ambrosio G, Bracchitta S. Sclerobanding in the treatment of second and third degree hemorrhoidal disease in high risk patients on antiplatelet/anticoagulant therapy without suspension: a pilot study. Front Surg 2023; 10:1290706. [PMID: 38026482 PMCID: PMC10657801 DOI: 10.3389/fsurg.2023.1290706] [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: 09/07/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Around 20% of population in western countries is under anticoagulant treatment. However, there is paucity of evidence about the treatment of HD in patients under anticoagulant/antiplatelet therapy, although both suspension and continuation in the perioperative period may increase the risk of severe complications. The aim of this pilot study was to confirm the feasibility and safety of sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy), an office-based procedure, for the treatment of second-and third-degree HD in patients under anticoagulant/antiplatelet therapy without suspension. Materials and methods Patients affected by second-third-degree haemorrhoids unresponsive to conservative treatment and under anticoagulant/antiplatelet were enrolled between November 2019 and October 2021. Postoperative complications, readmission, mortality and reintervention during the follow-up were evaluated. Results Fifty-one patients were recruited, 23 female (45.1%) and 28 male (54.9%), with an average age of 65 years ± 11.4 SD (range 42-90). Twenty-seven patients (52.9%) had II-degree haemorrhoidal disease, and 24 (47.1%) had grade III-degree. The most frequently taken medications were dual antiplatelet therapy (51%) and new oral anticoagulants (NOACs) (21.6%). The mean follow-up was 23 months. No intraoperative complications were recorded. The rate of complications in the first postoperative month was 13.7%, represented by mild complications: 6 cases of moderate to severe pain and 1 case (2%) of thrombosis of a residual haemorrhoidal nodule, all regressing after conservative therapy. No severe complications were reported. Postoperative complications were not statistically significantly associated with the number of nodules treated (1, 2, or 3), the disease grade (2nd vs. 3rd) or the specific anticoagulant/antiplatelet regimen. During follow-up, 2 patients (4%) required a new procedure for recurrent bleeding: one an infrared photocoagulation as outpatient, and another a haemorrhoidectomy after 3 months. No cases of intraoperative or postoperative mortality occurred. Conclusions Sclerobanding is a safe and effective technique in treating intermediate-grade haemorrhoidal disease in patients at high risk on anticoagulant/antiplatelet therapy. Sclerobanding is repeatable, usually does not require anaesthesia, and is cost-effective. Observational multicentre studies with a larger number of patients and controlled clinical trials will be needed to confirm these results.
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Affiliation(s)
- Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
- PhD Program in Arterial Hypertension and Vascular Biology, Sapienza University, Rome, Italy
| | | | - Bruno Nardo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Giancarlo D’Ambrosio
- Department of General Surgery, Surgical Specialties and Organ Transplantation, Sapienza University of Rome, Rome, Italy
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Helin TA, Raatikainen P, Lehto M, Haukka J, Lassila R. Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case-control study. BMJ Open 2023; 13:e071342. [PMID: 37918932 PMCID: PMC10626859 DOI: 10.1136/bmjopen-2022-071342] [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: 12/27/2022] [Accepted: 10/18/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES We studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin. DESIGN This was a retrospective nested case-control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up. SETTING National FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007-31 December 2011. PARTICIPANTS A total of 54 568 warfarin-anticoagulated patients. RESULTS The number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111-141 g/L vs 123-147 g/L, p<0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8-2.6 vs 2.1-2.7, p<0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4. CONCLUSIONS The deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.
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Affiliation(s)
- Tuukka Antero Helin
- Clinical Chemistry, HUS Diagnostic Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pekka Raatikainen
- Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mika Lehto
- Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Internal Medicine, Jorvi Hospital, Espoo, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Riitta Lassila
- Coagulation Disorders Unit and Clinical Chemistry, HUS Helsinki University Hospital, Helsinki, Finland
- Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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9
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Lassila R, Weisel JW. Role of red blood cells in clinically relevant bleeding tendencies and complications. J Thromb Haemost 2023; 21:3024-3032. [PMID: 37210074 PMCID: PMC10949759 DOI: 10.1016/j.jtha.2023.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
The multiple roles of red blood cells (RBCs) are often neglected as contributors in hemostasis and thrombosis. Proactive opportunities to increase RBC numbers, either acutely or subacutely in the case of iron deficiency, are critical as RBCs are the cellular elements that initiate hemostasis together with platelets and stabilize fibrin and clot structure. RBCs also possess several functional properties to assist hemostasis: releasing platelet agonists, promoting shear force-induced von Willebrand factor unfolding, procoagulant capacity, and binding to fibrin. Additionally, blood clot contraction is important to compress RBCs to form a tightly packed array of polyhedrocytes, making an impermeable seal for hemostasis. All these functions are important for patients having intrinsically poor capacity to cease bleeds (ie, hemostatic disorders) but, conversely, can also play a role in thrombosis if these RBC-mediated reactions overshoot. One acquired example of bleeding with anemia is in patients treated with anticoagulants and/or antithrombotic medication because upon initiation of these drugs, baseline anemia doubles the risk of bleeding complications and mortality. Also, anemia is a risk factor for reoccurring gastrointestinal and urogenital bleeds, pregnancy, and delivery complications. This review summarizes the clinically relevant properties and profiles of RBCs at various steps of platelet adhesion, aggregation, thrombin generation, and fibrin formation, including both structural and functional elements. Regarding patient blood management guidelines, they support minimizing transfusions, but this approach does not deal with severe inherited and acquired bleeding disorders where a poor hemostatic propensity is exacerbated by limited RBC availability, for which future guidance will be needed.
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Affiliation(s)
- Riitta Lassila
- Research Program Unit in Systems Oncology, Oncosys, Medical Faculty, University of Helsinki, Helsinki, Finland; Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital, Helsinki, Finland.
| | - John W Weisel
- Department of Cell and Developmental Biology, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Mardi P, Abbasi B, Shafiee A, Afsharmoghaddam T. Pharmacogenetic Approach for the Prevention of Rivaroxaban's ADRs: A Systematic Review and Meta-Analysis. Genet Res (Camb) 2023; 2023:6105320. [PMID: 37942082 PMCID: PMC10630013 DOI: 10.1155/2023/6105320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/23/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023] Open
Abstract
Introduction Pharmacogenetics is a potential approach that can be applied to decline the burden of rivaroxaban's ADRs. The current systematic review and meta-analysis aim to identify genetic variants correlated with rivaroxaban exposure and evaluate their importance. Methods We systematically searched PubMed, Web of Science, and Scopus databases for all observational and interventional studies. The fixed effect method was used to pool the data when the Q-test's p value was higher than 0.1. We used random models when the p value was less than 0.1. Results Data from ten studies (4721 participants) were analyzed in the current review. Qualitative synthesis from included studies found that two variants of ABCB1 (rs1045642 and rs2032582) and one variant of APOB (rs13306198) are potential contributors to rivaroxaban concentrations. Both wild homozygotes (AA) and heterozygotes (AC) of rs1045642 have significantly lower rivaroxaban concentrations compared to mutated homozygotes (CC) (SMD = 0.516, 95% CI: 0.115 to 0.917; SMD = 0.772, 95% CI: 0.088 to 1.455, respectively). Nevertheless, pooling unadjusted odds ratios did not yield a statistically significant correlation between rivaroxaban ADRs and genetic mutations. Conclusion This study revealed that being an AC or CC for rs1045642 is attributed to a considerably higher rivaroxaban level in participants using rivaroxaban. That is to say, rs1045642 is a remarkable predictor of rivaroxaban metabolism. We concluded that identifying rs1045642 before drug administration might decrease ADRs although further studies adjusted for potential confounders are strongly suggested.
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Affiliation(s)
- Parham Mardi
- Department of Medical Genetics, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - Bahareh Abbasi
- Department of Medical Genetics, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - Arman Shafiee
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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11
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Nam KW, Kwon HM, Lee YS, Won SH, Moon HS. Effectiveness and safety of secondary prevention of non-vitamin K oral anticoagulants use by drug type in Asian patients. Int J Stroke 2023; 18:927-936. [PMID: 37154599 DOI: 10.1177/17474930231176715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Although widely used in clinical fields, real-world data on the role of warfarin and non-vitamin K oral anticoagulants (NOACs) for the secondary prevention of thromboembolic complications in ischemic stroke patients with nonvalvular atrial fibrillation (NVAF) are scarce. AIMS This retrospective cohort study compared the effectiveness and safety of secondary prevention of NOAC and warfarin in ischemic stroke patients with NVAF. METHODS From the Korean National Health Insurance Service Database, we included 16,762 oral anticoagulants-naive acute ischemic stroke patients with NVAF between July 2016 and June 2019. The main outcomes included ischemic stroke, systemic embolism, major bleeding, and all-cause of death. RESULTS In total, 1717 warfarin and 15,025 NOAC users were included in the analysis. After 1:8 propensity score matching, during the observation period, all types of NOACs had a significantly lower risk of ischemic stroke and systemic embolism than warfarin (edoxaban: adjusted hazard ratio [aHR], 0.80; 95% confidence interval [CI], 0.68-0.93, rivaroxaban: aHR, 0.82; 95% CI, 0.70-0.96, apixaban: aHR, 0.79; 95% CI, 0.69-0.91, and dabigatran: aHR, 0.82; 95% CI, 0.69-0.97). Edoxaban (aHR, 0.77; 95% CI, 0.62-0.96), apixaban (aHR, 0.73; 95% CI, 0.60-0.90), and dabigatran (aHR, 0.66; 95% CI, 0.51-0.86) had lower risks of major bleeding and all-cause of death. CONCLUSIONS All NOACs were more effective than warfarin in the secondary prevention of thromboembolic complications in ischemic stroke patients with NVAF. Except for rivaroxaban, most NOACs demonstrated a lower risk of major bleeding and all-cause of death than warfarin.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Ho Won
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Korea
- RexSoft Inc., Seoul, Korea
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12
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson AL, Murray KT. Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation : A Retrospective Cohort Study. Ann Intern Med 2023; 176:769-778. [PMID: 37216662 DOI: 10.7326/m22-3238] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding. OBJECTIVE For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants' elimination. DESIGN Retrospective cohort study. SETTING U.S. Medicare beneficiaries aged 65 years or older. PATIENTS Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs. MEASUREMENTS Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting. RESULTS There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: P = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (P = 0.001). LIMITATION Possible residual confounding. CONCLUSION In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - C Michael Stein
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
| | - Walter Smalley
- Departments of Health Policy and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (W.S.)
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee (E.Z.)
| | - William D Dupont
- Departments of Health Policy and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (W.D.D.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - James R Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee (W.A.R., J.R.D.)
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee (C.P.C., A.M.H., A.L.D.)
| | - Katherine T Murray
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee (C.M.S., K.T.M.)
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13
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Martin AC, Benamouzig R, Gouin-Thibault I, Schmidt J. Management of Gastrointestinal Bleeding and Resumption of Oral Anticoagulant Therapy in Patients with Atrial Fibrillation: A Multidisciplinary Discussion. Am J Cardiovasc Drugs 2023:10.1007/s40256-023-00582-9. [PMID: 37145342 DOI: 10.1007/s40256-023-00582-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/06/2023]
Abstract
Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.
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Affiliation(s)
- Anne-Céline Martin
- Advanced Heart Failure Unit, AP-HP, Cardiology Department, European Hospital Georges Pompidou, Paris, France.
- INSERM UMRS_1140, Innovative Therapies in Haemostasis, Université Paris Cité, 75006, Paris, France.
| | - Robert Benamouzig
- Service de Gastroentérologie, Hôpital Avicenne, AP-HP, Université Paris-Nord-La Sorbonne, Bobigny, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, IRSET-INSERM UMRS 1085, Rennes University Hospital, Rennes, France
| | - Jeannot Schmidt
- LaPSCo, Physiological and Psychosocial Stress, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
- Emergency Department, CHU Clermont-Ferrand, University Hospital Gabriel Montpied, Clermont-Ferrand, France
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14
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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15
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Pastori D, Menichelli D, Di Rocco A, Farcomeni A, Sciacqua A, Pignatelli P, Fauchier L, Lip GYH. Bleeding and thrombotic events in atrial fibrillation patients with cancer: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:655-665. [PMID: 36480081 DOI: 10.1007/s11739-022-03156-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) and cancer are frequently coexisting in elderly patients. Pooled metanalytic data on the impact of cancer on clinical outcomes in AF patients are lacking. We performed a systematic review and meta-regression analysis of clinical studies retrieved from Medline (PubMed) and Cochrane (CENTRAL) databases according to PRISMA guidelines. Bleeding endpoints included any, major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH). Cardiovascular (CV) endpoints included myocardial infarction (MI), ischemic stroke/systemic embolism (IS/SE), CV and all-cause death. PROSPERO registration number: CRD42022315678. We included 15 studies with 2,868,010 AF patients, of whom 479,571 (16.7%) had cancer. The pooled hazard ratio (HR) for cancer was 1.43 (95% confidence interval [95%CI] 1.42-1.44) for any bleeding, 1.27 (95% CI 1.26-1.29) for major bleeding, 1.17 (95% CI 1.14-1.19) for GI bleeding, and 1.07 (95% CI 1.04-1.11) for ICH. The risk of major bleeding increased with the proportion of breast cancer. Cancer increased the risk of all-cause death (HR 2.00, 95% CI 1.99-2.02) whereas no association with MI and CV death was found. Patients with AF and cancer were less likely to suffer from IS/SE (HR 0.91, 95% CI 0.89-0.94). Cancer complicates the clinical history of AF patients, mainly increasing the risk of bleeding. Further analyses according to the type and stage of cancer are necessary to better stratify bleeding risk in these patients.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy.
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
| | - Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome "Tor Vergata", Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau Et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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16
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The Role of Anti-Factor Xa Activity in the Management of Ecchymosis in Patients Receiving Rivaroxaban after Total Knee Arthroplasty. J Clin Med 2023; 12:jcm12031161. [PMID: 36769808 PMCID: PMC9917433 DOI: 10.3390/jcm12031161] [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: 12/23/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
This study aims to evaluate the efficacy of anti-factor Xa activity (aFXa) in predicting ecchymosis after total knee arthroplasty (TKA). One hundred and two unilateral primary TKA patients were recruited consecutively in this prospective observational study. Participants received rivaroxaban (10 mg p.o. qd) from postoperative day 1 (POD1) to POD35 and were divided into a non-ecchymosis group (group A) and an ecchymosis group (group B). AFXa was assessed as the primary outcome on POD1 and POD3. Prothrombin time (PT), activated partial thromboplastin time (APTT) and thromboelastography (TEG) were recorded both preoperatively and postoperatively (on POD1 and POD3). Other outcomes, including venous thromboembolism (VTE), blood loss and wound complications were also collected and compared. As a result, 27.5% of the participants (n = 28) were allocated into group B. Demographic data were comparable between the two groups. The aFXa levels in group B were significantly higher than those in group A on POD1 and POD3, and the aFXa level was assessed as an independent risk factor for ecchymosis. The cut-off value of aFXa was determined to be 121.38 ng/mL at maximal Youden index, associated with area under the receiver operating characteristics curve of 0.67. Group B experienced significantly more blood loss and wound complications than group A. No statistical difference was detected regarding PT, APTT and TEG parameters. AFXa is a promising parameter to predict ecchymosis after TKA. Patients with aFXa > 121.38 ng/mL should be considered as high-risk population for postoperative ecchymosis and may require intense monitoring or dosage modification of anticoagulants.
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17
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Al-Hussainy N, Kragholm KH, Lundbye-Christensen S, Torp-Pedersen C, Pareek M, Therkelsen SK, Lip GYH, Riahi S. Safety and efficacy of direct oral anticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:840-851. [PMID: 34931662 DOI: 10.1093/ehjqcco/qcab095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
AIMS The aim of this study was to evaluate the risk of stroke and bleeding among patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) despite anaemia at treatment initiation time. METHODS AND RESULTS All Danish patients (N = 41 321) diagnosed with incident AF, having a baseline haemoglobin (Hb), and subsequently initiated DOAC therapy between 2012 and 2019 were identified through administrative registry databases. Patients with anaemia were subdivided according to the World Health Organization classification of anaemia and evaluated regarding risk of stroke and composite bleeding endpoint [hospitalization due to urogenital, gastrointestinal (GI), or intracranial bleeding or epistaxis]. Standardized absolute 1-year risks of stroke and composite bleeding endpoint were calculated using multivariable Cox regression analyses. The standardized absolute 1-year risk difference for composite bleeding increased by 0.96% [95% confidence interval (CI) 0.38-1.54] for patients with moderate/severe anaemia compared with patients with no anaemia. This risk was mainly driven by an increase in standardized absolute 1-year risk for serious GI bleeding, which increased by 0.41% (95% CI 0.19-0.63). No significant difference in standardized absolute 1-year bleeding risk was observed among patients with mild anaemia compared with patients with no anaemia 0.36% (95% CI -0.10 to 0.82). No significant difference in standardized absolute 1-year risk of stroke was observed among patients with mild anaemia, -0.16% (95% CI -0.13 to 0.15), and moderate/severe anaemia, -0.47% (95% CI -0.16 to 0.19), compared with patients with no anaemia. CONCLUSION For AF patients receiving DOACs, moderate/severe anaemia is a risk factor for serious GI bleeding, while stroke risk is the same regardless of whether anaemia was present at baseline or not.
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Affiliation(s)
- Nour Al-Hussainy
- Department of Medicine, Slagelse Hospital, Ingemannsvej 30, 4200 Slagelse, Denmark
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Lundbye-Christensen
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,AF Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | | | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,AF Study Group, Aalborg University Hospital, Aalborg, Denmark
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18
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Gastrointestinal Bleeding on Oral Anticoagulation: What is Currently Known. Drug Saf 2022; 45:1449-1456. [PMID: 36227528 DOI: 10.1007/s40264-022-01243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/03/2022]
Abstract
Gastrointestinal bleeding (GIB) is the most common type of bleeding occurring in patients on oral anticoagulation. A meta-analysis of the landmark randomized controlled trials (RCTs) for patients with atrial fibrillation demonstrated that direct oral anticoagulants (DOACs) were associated with higher GIB rates compared to warfarin. However, significant heterogeneity existed between studies. While rivaroxaban, high-dose dabigatran, and high-dose edoxaban were associated with higher GIB rates than warfarin, GIB rates were similar between warfarin users and both apixaban and low-dose dabigatran users. Additionally, previous observational studies have yielded conflicting reports on whether GIB rates differ between warfarin and DOACs. Meta-analyses of observational studies demonstrated that warfarin is associated with lower rates of GIB compared to rivaroxaban, similar or lower rates compared to dabigatran, and higher rates compared to apixaban. Importantly, no RCT has compared individual DOACs directly and due to the different selection criteria of the initial RCTs, indirect comparisons between DOACs using these studies are unreliable. The best available information of comparisons between individual DOACs is therefore limited to observational studies. There is mounting evidence that suggests that rivaroxaban is associated with a higher risk of GIB compared to other DOACs. Finally, GIB induced by oral anticoagulation may have some positive aspects. Interestingly, there are studies that indicate oral anticoagulation facilitates colorectal cancer detection. Furthermore, results from RCTs and observational studies suggest that warfarin may even decrease the incidence of cancer.
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC. ASIA 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - 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 Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Raithel M, Haibach M, Kremenevski I, Arnold E, Ringwald J. Moderne Antikoagulation mit FXa-Inhibitoren in der Onkologie: Ist die gastrointestinale Blutungsrate (mit)-entscheidend? ZEITSCHRIFT FÜR GASTROENTEROLOGIE 2022; 61:411-419. [PMID: 35878607 DOI: 10.1055/a-1886-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
ZusammenfassungDas erhöhte Thrombose- und Blutungsrisiko bei aktiver Tumorerkrankung wird als sog. „thrombo-hämorrhagisches Syndrom“ bezeichnet, welches hohe Anforderungen an die Antikoagulation stellt. Aktuell liegen 4 randomisierte, prospektive Studien zum Einsatz von neuen, nicht Vitamin K-abhängigen oralen Antikoagulantien (NOAK) zur Behandlung von in der Onkologie aufgetretenen venösen Thromboembolien (VTE) vor. Dabei wurden die FXa-Inhibitoren Rivaroxaban, Edoxaban und zweimal Apixaban jeweils in einzelnen Studien gegenüber dem Standardtherapeutikum Dalteparin eingesetzt. Da es keinen direkten Head-to-Head-Vergleich der genannten FXa-Inhibitoren innerhalb einer Studie gibt, wurde zu jedem NOAK die jeweils größte Studie – stets verglichen gegenüber Dalteparin – ausgewertet. Die Studien wurden bzgl. ihrer Wirksamkeit, Sicherheit, fataler Blutungsraten, dem Risiko für gastrointestinale Blutungen (GIB) und sonstiger Unterschiede anhand deskriptiver Statistik analysiert. Unter Dalteparin ergab sich eine mittlere VTE-Rezidivrate von ca. 9% bei einem 6-monatigen Behandlungszeitraum. Alle 3 FXa-Inhibitoren waren gegenüber Dalteparin bezüglich der Wirksamkeit nicht unterlegen. Die VTE-Rezidivrate war bei mit Edoxaban und Apixaban behandelten Patienten um – 2,3% und bei Rivaroxaban um – 5,0% niedriger.Bei der Sicherheit fanden sich – jeweils gegenüber Dalteparin – für Rivaroxaban und Edoxaban eine erhöhte Rate an schweren Blutungen (jeweils +2,4%); insbesondere war hierbei die Zahl GIB deutlich erhöht. Dagegen war für Apixaban die Zahl schwerer Blutungen, wie auch für verschiedene Blutungstypen inkl. GIB, nicht erhöht. In der Apixabanstudie war insgesamt die Rate von schweren GIB, die ca. 50% aller schweren Blutungen ausmachten, und die der klinisch-relevanten nicht schweren Blutungen, am niedrigsten. Die FXa-Inhibitoren sind der Standardtherapie mit Dalteparin in der VTE-Rezidivrate bei onkologischen Patienten nicht unterlegen. Die GIB-Rate scheint ein wichtiger prädiktiver Faktor für die Sicherheit dieser Substanzgruppe zu sein, sodass Tumorlokalisation, gastrointestinale Risikofaktoren und andere individuelle Kriterien in Zukunft stärker bei der Therapieentscheidung für oder gegen einen FXa-Inhibitor berücksichtigt werden sollten.
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Affiliation(s)
| | - Martina Haibach
- Internistische Schwerpunktpraxis (IISP) Onkologie, Erlangen, Germany
| | | | - Erich Arnold
- Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
| | - Jürgen Ringwald
- Institut Lütjensee, DRK-Blutspendedienst Nord-Ost gGmbh, Lütjensee, Germany
- Praxis für Transfusionsmedizin, Lütjensee, Germany
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Al-Maawali MS, Al-Naamani HH, Mokadem LN, Al-Maawali G, Salman B, Al-Zakwani I. Comparative Effectiveness and Safety of Rivaroxaban and Warfarin for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation in an Omani Tertiary Care Hospital. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2202281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:
The aim of the study was to compare the effectiveness and safety of rivaroxaban and warfarin as well as to determine the appropriateness of dosing and prescribing of rivaroxaban in Omani patients with non-valvular atrial fibrillation (NVAF).
Methods:
This retrospective cohort study was conducted using the Royal Hospital data registry. The study included all adults newly diagnosed with NVAF and treated with rivaroxaban or warfarin. The outcomes measured include ischaemic stroke, gastrointestinal bleeding (GIB), non-gastrointestinal bleeding (NGIB), as well as appropriateness of dosing and prescribing of rivaroxaban.
Results:
The analysis included 96 rivaroxaban users and 183 warfarin users; 51% of the cohort included males. There were no significant differences observed in the risk of ischaemic stroke between the two groups (hazard ratio (HR), 1.1; 95% confidence interval (CI): 0.4-3.4; p=0.8). However, those on rivaroxaban exhibited a significantly higher rate of GIB compared to those on warfarin (HR, 5.9; 95% CI: 2.9-11.7; p=0.001). There were no differences observed with regards to NGIB between the two groups (HR, 0.9; 95% CI: 0.4-1.9; p=0.8). Dosing and prescribing of rivaroxaban were found to be appropriate in 89% of the patients, with only 6% being prescribed an inappropriately lower dose.
Conclusion:
The study demonstrated no significant differences in the risk of ischaemic stroke or NGIB between rivaroxaban and warfarin groups in newly diagnosed NVAF patients. However, rivaroxaban users were found to have a significantly higher risk of GIB. Rivaroxaban was appropriately prescribed to the majority of the patients, and only a small proportion of the group received an inappropriately lower dose of rivaroxaban.
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22
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Hanna-Rivero N, Tu SJ, Elliott AD, Pitman BM, Gallagher C, Lau DH, Sanders P, Wong CX. Anemia and iron deficiency in patients with atrial fibrillation. BMC Cardiovasc Disord 2022; 22:204. [PMID: 35508964 PMCID: PMC9066804 DOI: 10.1186/s12872-022-02633-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia and has a rising global prevalence. Given the increasing burden of AF-related symptoms and complications, new approaches to management are required. Anemia and iron deficiency are common conditions in patients with AF. Furthermore, emerging evidence suggests that the presence of anemia may be associated with worse outcome in these patients. The role of anemia and iron deficiency has been extensively explored in other cardiovascular states, such as heart failure and ischemic heart disease. In particular, the role of iron repletion amongst patients with heart failure is now an established treatment modality. However, despite the strong bidirectional inter-relationship between AF and heart failure, the implications of anemia and iron-deficiency in AF have been scarcely studied. This area is of mechanistic and clinical relevance given the potential that treatment of these conditions may improve symptoms and prognosis in the increasing number of individuals with AF. In this review, we summarise the current published literature on anemia and iron deficiency in patients with AF. We discuss AF complications such as stroke, bleeding, and heart failure, in addition to AF-related symptoms such as exercise intolerance, and the potential impact of anemia and iron deficiency on these. Finally, we summarize current research gaps on anemia, iron deficiency, and AF, and underscore potential research directions.
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Affiliation(s)
- Nicole Hanna-Rivero
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Samuel J Tu
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Bradley M Pitman
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia.
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia.
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Polidocanol foam sclerotherapy in the treatment of hemorrhoidal disease in patients with bleeding disorders: a multicenter, prospective, cohort study. Tech Coloproctol 2022; 26:615-625. [PMID: 35217937 PMCID: PMC8879173 DOI: 10.1007/s10151-022-02600-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023]
Abstract
Background The management of hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. Polidocanol foam sclerotherapy (PFS) is associated with a low rate of bleeding complications. The aim of this study was to compare the efficacy and safety of PFS in the treatment of HD in patients with and without BD. Methods This prospective, multicenter, cohort study enrolled patients with (group B) and without (group A) BD, with symptomatic internal HD grades I–III over an 18-month period. All patients were treated with PFS. Patients with congenital BD did not undergo prior replacement therapy and those with acquired BD due to antithrombotic drugs, did not discontinue therapy. Efficacy outcomes included therapeutic success and HD recurrence during a 1-year follow-up period. To evaluate safety the complications related to PFS were recorded. Results We included 228 patients (group A: 155, group B: 73; male/female: 114/114; mean age: 59.4 ± 15.9 years). The baseline hemorrhoidal disease bleeding grade (p < 0.001) and Sodergren hemorrhoidal symptom severity score (p = 0.019) were higher for group B. The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51 ± 0.74, significantly higher for group B (1.68 ± 0.86 vs 1.43 ± 0.65, p = 0.013). Complications occurred in 11.4% of the patients, with bleeding reported in 4.8%. The majority of complications were mild (96.2%). No significant differences between the two groups were observed for therapeutic success, recurrence, or complication rate. Conclusions Patients with BD may have more symptomatic HD at baseline. Even so, PSF showed similar effectiveness and safety in patients with BD compared to patients without BD. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02600-5.
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Lai Y, Masatoshi H, Ma Y, Guo Y, Zhang B. Role of Vitamin K in Intestinal Health. Front Immunol 2022; 12:791565. [PMID: 35069573 PMCID: PMC8769504 DOI: 10.3389/fimmu.2021.791565] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Intestinal diseases, such as inflammatory bowel diseases (IBDs) and colorectal cancer (CRC) generally characterized by clinical symptoms, including malabsorption, intestinal dysfunction, injury, and microbiome imbalance, as well as certain secondary intestinal disease complications, continue to be serious public health problems worldwide. The role of vitamin K (VK) on intestinal health has drawn growing interest in recent years. In addition to its role in blood coagulation and bone health, several investigations continue to explore the role of VK as an emerging novel biological compound with the potential function of improving intestinal health. This study aims to present a thorough review on the bacterial sources, intestinal absorption, uptake of VK, and VK deficiency in patients with intestinal diseases, with emphasis on the effect of VK supplementation on immunity, anti-inflammation, intestinal microbes and its metabolites, antioxidation, and coagulation, and promoting epithelial development. Besides, VK-dependent proteins (VKDPs) are another crucial mechanism for VK to exert a gastroprotection role for their functions of anti-inflammation, immunomodulation, and anti-tumorigenesis. In summary, published studies preliminarily show that VK presents a beneficial effect on intestinal health and may be used as a therapeutic drug to prevent/treat intestinal diseases, but the specific mechanism of VK in intestinal health has yet to be elucidated.
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Affiliation(s)
- Yujiao Lai
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Hori Masatoshi
- Department of Veterinary Pharmacology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Yanbo Ma
- Department of Animal Physiology, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, China
| | - Yuming Guo
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Bingkun Zhang
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
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25
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Liu PH, Liu ZH, Niu MH, Chen P, Shi YB, He F, Guo R. A Comparative Study of the Clinical Benefits of Rivaroxaban and Warfarin in Patients With Non-valvular Atrial Fibrillation With High Bleeding Risk. Front Cardiovasc Med 2022; 9:803233. [PMID: 35252386 PMCID: PMC8888829 DOI: 10.3389/fcvm.2022.803233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo compare the clinical benefits of rivaroxaban and warfarin in patients with non-valvular atrial fibrillation (NVAF) with high bleeding risk.MethodsA retrospective study was conducted on patients with high bleeding risk NVAF who were hospitalized at the First Affiliated Hospital of Zhengzhou University between May 31, 2016 and May 31, 2019 and took at least rivaroxaban and warfarin. The clinical benefits of both drugs were assessed by efficacy benefit and safety risk. The primary efficacy benefit was a composite end point for stroke (both ischemic and hemorrhagic) and systemic embolism. The secondary efficacy end points were death and myocardial infarction (MI). The principal safety end point was the composite end point of fatal bleeding and critical organ bleeding.ResultsA total of 1,246 patients with high bleeding risk were enrolled, including 787 patients in the rivaroxaban group and 459 patients in the warfarin group. Results of the primary efficacy benefit endpoint were obtained from 104 patients (13.2%) in the rivaroxaban group and 88 (19.2%) patients in the warfarin group (hazard ratio [HR]: 0.681; 95% confidence interval [CI]: 0.512–0.906; P < 0.001 for non-inferiority). The principal safety end points were observed in 49 (6.23%) patients in the rivaroxaban group and in 55 (11.98%) patients in the warfarin group (HR: 0.469 in the rivaroxaban group; 95% CI: 0.314–0.702; P < 0.001). With respect to secondary efficacy and benefit endpoints, 28 (3.56%) patients in the rivaroxaban group and 22 (4.79%) patients in the warfarin group died, with an HR of 0.760 (95% CI: 0.435–1.329; P = 0.336); 32 (4.07%) patients in the rivaroxaban group; and 26 (5.66%) patients in the warfarin group had MI, with an HR of 1.940 (95% CI: 0.495–1.069, P = 0.254) in the rivaroxaban group.ConclusionsRivaroxaban is non-inferior to warfarin in the prevention of stroke and systemic embolism in patients with high blood NVAF. Rivaroxaban is superior to warfarin in reducing fatal bleeding and bleeding in critical organs.Clinical Trial RegistrationChinese Clinical Trials Registry, identifier ChiCTR2100052454.
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Affiliation(s)
- Peng-Hui Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ze-Hua Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming-Hui Niu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ping Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan-Bin Shi
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei He
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Fei He
| | - Rong Guo
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Rong Guo
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Lau LH, Guo CL, Yip TC, Mak JW, Wong SH, Lam KL, Wong GL, Ng SC, Chan FK. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut 2022; 71:100-110. [PMID: 33619167 DOI: 10.1136/gutjnl-2020-323600] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND There were limited data on the risk of post-polypectomy bleeding (PPB) in patients on direct oral anticoagulants (DOAC). We aimed to evaluate the PPB and thromboembolic risks among DOAC and warfarin users in a population-based cohort. METHODS We performed a territory-wide retrospective cohort study involving patients in Hong Kong from 2012 to 2020. Patients who received an oral anticoagulant and had undergone colonoscopy with polypectomy were identified. Propensity-score models with inverse probability of treatment weighting were developed for the warfarin-DOAC and between-DOAC comparisons. The primary outcome was clinically significant delayed PPB, defined as repeat colonoscopy requiring haemostasis within 30 days. The secondary outcomes were 30-day blood transfusion requirement and new thromboembolic event. RESULTS Apixaban was associated with lower PPB risk than warfarin (adjusted HR (aHR) 0.39, 95% CI 0.24 to 0.63, p<0.001). Dabigatran (aHR 2.23, 95% CI 1.04 to 4.77, adjusted p (ap)=0.035) and rivaroxaban (aHR 2.72, 95% CI 1.35 to 5.48, ap=0.002) were associated with higher PPB risk than apixaban. In subgroup analysis, apixaban was associated with lower PPB risk in patients aged ≥70 years and patients with right-sided colonic polyps.For thromboembolic events, apixaban was associated with lower risk than warfarin (aHR 0.22, 95% CI 0.11 to 0.45, p<0.001). Dabigatran (aHR 2.60, 95% CI 1.06 to 6.41, ap=0.033) and rivaroxaban (aHR 2.96, 95% CI 1.19 to 7.37, ap =0.013) were associated with higher thromboembolic risk than apixaban. CONCLUSIONS Apixaban was associated with a significantly lower risk of PPB and thromboembolism than warfarin, dabigatran and rivaroxaban, particularly in older patients with right-sided polyps.
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Affiliation(s)
- Louis Hs Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Cosmos Lt Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Terry Cf Yip
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Joyce Wy Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Kelvin Ly Lam
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Grace Lh Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Siew C Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Francis Kl Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR .,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
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27
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Belenkov YN, Popova LV, Ilgisonis SI. [Management of patients with atrial fibrillation and minor bleeding during therapy with direct oral anti-coagulants]. KARDIOLOGIIA 2021; 61:72-81. [PMID: 35057724 DOI: 10.18087/cardio.2021.12.n1872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/10/2021] [Accepted: 10/29/2021] [Indexed: 06/14/2023]
Abstract
The recommended tactics for prevention of thromboembolic complications of atrial fibrillation (AF) is the oral anticoagulant (OAC) treatment. The drugs of choice for preventing stroke for most patients with AF, excluding some valvular defects, are direct OACs (DOACS). Regardless of the drug class, all anticoagulants, even at appropriate doses, increase the risk of bleeding. However, the development of minor bleedings is not an absolute indication for DOAC withdrawal. This review presents a tactics for management of patients with minor bleeding associated with the DOAC treatment.
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Affiliation(s)
- Yu N Belenkov
- I.M. Sechenov First Moscow State Medical University, Moscow
| | - L V Popova
- I.M. Sechenov First Moscow State Medical University, Moscow
| | - S I Ilgisonis
- I.M. Sechenov First Moscow State Medical University, Moscow
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation. JAMA 2021; 326:2395-2404. [PMID: 34932078 PMCID: PMC8693217 DOI: 10.1001/jama.2021.21222] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The comparative effectiveness of rivaroxaban and apixaban, the most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation, is uncertain. OBJECTIVE To compare major ischemic and hemorrhagic outcomes in patients with atrial fibrillation treated with rivaroxaban or apixaban. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using computerized enrollment and claims files for US Medicare beneficiaries 65 years or older. Between January 1, 2013, and November 30, 2018, a total of 581 451 patients with atrial fibrillation began rivaroxaban or apixaban treatment and were followed up for 4 years, through November 30, 2018. EXPOSURES Rivaroxaban (n = 227 572) and apixaban (n = 353 879), either standard or reduced dose. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of major ischemic (stroke/systemic embolism) and hemorrhagic (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding) events. Secondary outcomes were nonfatal extracranial bleeding and total mortality (fatal ischemic/hemorrhagic event or other death during follow-up). Rates, hazard ratios (HRs), and rate differences (RDs) were adjusted for baseline differences in comorbidity with inverse probability of treatment weighting. RESULTS Study patients (mean age, 77.0 years; 291 966 [50.2%] women; 134 393 [23.1%] receiving reduced dose) had 474 605 person-years of follow-up (median [IQR] of 174 [62-397] days). The adjusted primary outcome rate for rivaroxaban was 16.1 per 1000 person-years vs 13.4 per 1000 person-years for apixaban (RD, 2.7 [95% CI, 1.9-3.5]; HR, 1.18 [95% CI, 1.12-1.24]). The rivaroxaban group had increased risk for both major ischemic events (8.6 vs 7.6 per 1000 person-years; RD, 1.1 [95% CI, 0.5-1.7]; HR, 1.12 [95% CI, 1.04-1.20]) and hemorrhagic events (7.5 vs 5.9 per 1000 person-years; RD, 1.6 [95% CI, 1.1-2.1]; HR, 1.26 [95% CI, 1.16-1.36]), including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; RD, 0.4 [95% CI, 0.2-0.7]; HR, 1.41 [95% CI, 1.18-1.70]). Patients receiving rivaroxaban had increased risk of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years; RD, 21.1 [95% CI, 20.0-22.3]; HR, 2.07 [95% CI, 1.99-2.15]), fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years; RD, 1.2 [95% CI, 0.8-1.6]; HR, 1.34 [95% CI, 1.21-1.48]), and total mortality (44.2 vs 41.0 per 1000 person-years; RD, 3.1 [95% CI, 1.8-4.5]; HR, 1.06 [95% CI, 1.02-1.09]). The risk of the primary outcome was increased for rivaroxaban in both those receiving the reduced dose (27.4 vs 21.0 per 1000 person-years; RD, 6.4 [95% CI, 4.1-8.7]; HR, 1.28 [95% CI, 1.16-1.40]) and the standard dose (13.2 vs 11.4 per 1000 person-years; RD, 1.8 [95% CI, 1.0-2.6]; HR, 1.13 [95% CI, 1.06-1.21]) groups. CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville Campus
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
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Averkov OV, Mishchenko LN. Gastrointestinal Bleeding: a Cardiologist's Point of View. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-10-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oral anticoagulant therapy is widely used in different patients for the prevention and treatment of thromboembolic events: in atrial fibrillation, deep vein thrombosis/pulmonary embolism, acute coronary syndrome, in the early postoperative period after orthopedic surgery. Nowadays it is possible to use vitamin K antagonists (warfarin) as well as direct oral anticoagulants (DOAC): dabigatran, rivaroxaban, apixaban and edoxaban. The mai complication of any anticoagulant therapy is bleeding (gastrointestinal, intracranial, etc.), which seriously limits its usage. In this review the incidence of gastrointestinal bleeding (GIB) associated with oral anticoagulants intake was analyzed according to the results of both large randomized and postregistration trials. Furthermore, the effect of age on the risk of GIB development is discussed, and also aspects of the pathophysiology of gastrointestinal mucosa lesions in patients taking DOAC are considered.
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Affiliation(s)
- O. V. Averkov
- Moscow City Clinical Hospital №15 n.a. O. M. Filatova
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Ingason AB, Hreinsson JP, Ágústsson AS, Lund SH, Rumba E, Pálsson DA, Reynisson IE, Guðmundsdóttir BR, Önundarson PT, Björnsson ES. Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study. Ann Intern Med 2021; 174:1493-1502. [PMID: 34633836 DOI: 10.7326/m21-1474] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) rates for direct oral anticoagulants (DOACs) and warfarin have been extensively compared. However, population-based studies comparing GIB rates among different DOACs are limited. OBJECTIVE To compare rates of GIB among apixaban, dabigatran, and rivaroxaban. DESIGN Nationwide population-based cohort study. SETTING Landspítali-The National University Hospital of Iceland and the 4 regional hospitals in Iceland. PATIENTS New users of apixaban, dabigatran, and rivaroxaban from 2014 to 2019. MEASUREMENTS Rates of GIB were compared using inverse probability weighting, Kaplan-Meier survival estimates, and Cox regression. RESULTS In total, 2157 patients receiving apixaban, 494 patients receiving dabigatran, and 3217 patients receiving rivaroxaban were compared. For all patients, rivaroxaban had higher overall rates of GIB (3.2 vs. 2.5 events per 100 person-years; hazard ratio [HR], 1.42 [95% CI, 1.04 to 1.93]) and major GIB (1.9 vs. 1.4 events per 100 person-years; HR, 1.50 [CI, 1.00 to 2.24]) compared with apixaban. Rivaroxaban also had higher GIB rates than dabigatran, with similar point estimates, although the CIs were wider and included the possibility of a null effect. When only patients with atrial fibrillation were included, rivaroxaban was associated with higher rates of overall GIB than apixaban (HR, 1.40 [CI, 1.01 to 1.94]) or dabigatran (HR, 2.04 [CI, 1.17 to 3.55]). Dabigatran was associated with lower rates of upper GIB than rivaroxaban in both analyses. LIMITATIONS Unmeasured confounding and small subgroup analyses. CONCLUSION Rivaroxaban was associated with higher GIB rates than apixaban and dabigatran regardless of treatment indication. PRIMARY FUNDING SOURCE Icelandic Centre for Research and Landspítali-The National University Hospital of Iceland.
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Affiliation(s)
- Arnar B Ingason
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | - Jóhann P Hreinsson
- University of Gothenburg and Sahlgrenska Academy, Gothenburg, Sweden (J.P.H.)
| | - Arnar S Ágústsson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | | | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland (E.R., D.A.P.)
| | - Daníel A Pálsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland (E.R., D.A.P.)
| | | | | | - Páll T Önundarson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
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Risk factors and one-year mortality in patients with direct oral anticoagulant-associated gastrointestinal bleeding. Thromb Res 2021; 208:138-144. [PMID: 34773747 DOI: 10.1016/j.thromres.2021.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Risk factors and mortality in patients with DOACs-associated gastrointestinal bleeding (GIB) are not completely defined. Aims of this study were to identify risk factors for bleeding and evaluate one-year mortality in patients with DOACs-associated GIB. METHODS We conducted a case-control study. Cases were patients with DOACs-associated GIB admitted to the Perugia Hospital, Italy between 2013 and 2019. Controls were derived from the prospective database of patients with DOACs referred to the ambulatory service. Cases and controls were matched by a 1:2 ratio for type and dose of DOAC, indication for anticoagulation and gender. Univariate and multivariable analyses were performed to identify risk factors. Hazard Ratio with 95% confidence interval was used to calculate mortality. RESULTS We included 324 patients, of which 108 with DOACs-associated GIB. Mean age was 81.9 ± 7.2 years and 78.9 ± 8.7 years, respectively. The most frequent indication for anticoagulation was atrial fibrillation. Reduced doses of DOACs were prescribed in 186 patients (56.4%). At multivariable analysis, active cancer (OR:7.26; 95%CI 3.10-16.96), renal impairment (OR:4.26; 95%CI 1.98-9.17), bleeding predisposition (OR:3.66; 95%CI 2.00-6.68), COPD (OR:2.12; 95%CI 1.08-4.16) and uncontrolled hypertension (OR:1.86; 95%CI 1.07-3.23) were found to be predictors for DOACs-associated GIB. Adjusted one-year mortality was significantly higher in patients who experienced GIB compared with those who did not experience GIB (OR: 7.04; 95%CI 3.82-14.31). CONCLUSIONS Predictors of DOACs-associated GIB included active cancer, renal impairment, bleeding predisposition, COPD and uncontrolled hypertension. The adjusted one-year-mortality was significantly increased in patients with DOACs-associated GIB in comparison to DOACs patients without GIB.
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Xu Y, Siegal DM. Anticoagulant-associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants. J Thromb Haemost 2021; 19:2383-2393. [PMID: 34273241 DOI: 10.1111/jth.15466] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Abstract
Gastrointestinal (GI) bleeding is the most frequent single site of oral anticoagulant (OAC)-associated major bleeding. Patients with major GI bleeding experience morbidity and a substantial risk of short-term all-cause mortality up to 10%. While OACs are frequently discontinued during acute bleeding, there is substantial uncertainty about whether, when, and how OACs should be resumed after bleeding has resolved. Limited evidence suggests a lower risk of thromboembolism and death, and a higher risk of recurrent bleeding with OAC resumption. However, the absolute risks and optimal timing of anticoagulation remain uncertain based on these observational studies at risk of bias, particularly due to baseline confounding. In addition to an individualized approach to determining the benefits and harms of treatment decisions informed by the best available evidence about thrombosis and recurrent bleeding, discussions should meaningfully incorporate patient values and preferences. The objective of this review is to provide a framework for decision-making by summarizing the epidemiology and clinical outcomes of OAC-associated GI bleeding, providing an approach for assessment and risk stratification for OAC resumption and its timing, and outlining strategies for the prevention of recurrent GI bleeding.
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Affiliation(s)
- Yan Xu
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Carabineanu A, Zaharia C, Blidisel A, Ilina R, Miclaus C, Ardelean O, Preda M, Mazilu O. Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment. ACTA ACUST UNITED AC 2021; 57:medicina57101003. [PMID: 34684040 PMCID: PMC8539967 DOI: 10.3390/medicina57101003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 11/19/2022]
Abstract
Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79–14.06) than the others of being identified postoperatively with more advanced lesions.
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Affiliation(s)
- Adrian Carabineanu
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
| | - Claudia Zaharia
- Department of Mathematics, Faculty of Mathematics and Computer Science, West University of Timisoara, 300223 Timisoara, Romania;
| | - Alexandru Blidisel
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
- Correspondence:
| | - Razvan Ilina
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
| | - Codruta Miclaus
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
| | - Ovidiu Ardelean
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
| | - Marius Preda
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
| | - Octavian Mazilu
- First Department of Surgery, Second Discipline of Surgical Semiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.C.); (R.I.); (C.M.); (O.A.); (M.P.); (O.M.)
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Jiang H, Jiang Y, Ma H, Zeng H, Lv J. Effects of rivaroxaban and warfarin on the risk of gastrointestinal bleeding and intracranial hemorrhage in patients with atrial fibrillation: Systematic review and meta-analysis. Clin Cardiol 2021; 44:1208-1215. [PMID: 34302375 PMCID: PMC8427974 DOI: 10.1002/clc.23690] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/26/2021] [Accepted: 07/01/2021] [Indexed: 01/29/2023] Open
Abstract
To assess the risk of gastrointestinal bleeding and intracranial hemorrhage in patients with atrial fibrillation (AF) after the use of rivaroxaban or warfarin. To investigate the effects of rivaroxaban and warfarin on gastrointestinal and intracranial hemorrhage in patients with AF, we searched PubMed, Embase, and Medline from the establishment of databases up to 2020. We finally included 38 observational studies involving 1 312 609 patients for the assessment of intracranial hemorrhage, and 33 observational studies involving 1 332 956 patients for the assessment of gastrointestinal bleeding. The rates of intracranial hemorrhage were 0.55% in the rivaroxaban group versus 0.91% in the warfarin group (OR 0.59; 95% CI 0.53-0.66; p < .00001, I2 = 78%). The rates of gastrointestinal bleeding were 2.63% in patients with rivaroxaban versus 2.48% in those with warfarin (OR 1.06; 95% CI 0.96-1.17; p < .00001, I2 = 94%). Rivaroxaban could significantly reduce the risk of intracranial hemorrhage in patients with AF than warfarin, but the risk of gastrointestinal bleeding remained controversy due to no statistical significant difference. Notably, a subgroup analysis demonstrated that patients in rivaroxaban group with severe chronic renal diseases or undergoing hemodialysis exposed to less gastrointestinal hemorrhage risk than the group from warfarin.
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Affiliation(s)
- Hongcheng Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yue Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Haotian Ma
- The First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hesong Zeng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiagao Lv
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Impact of Fall Risk and Direct Oral Anticoagulant Treatment on Quality-Adjusted Life-Years in Older Adults with Atrial Fibrillation: A Markov Decision Analysis. Drugs Aging 2021; 38:713-723. [PMID: 34235644 DOI: 10.1007/s40266-021-00870-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVE The decision to initiate anticoagulation in older adults with atrial fibrillation is complicated by the benefit of ischemic stroke prevention vs the risk of falls resulting in major bleeds. The objective of this study was to assess the impact of different treatments including direct oral anticoagulants on quality-adjusted life-years (QALYs) in patients aged 75 years and older with atrial fibrillation in the context of falls. METHODS A Markov decision process was constructed for older patients with atrial fibrillation taking no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban. Input probabilities for clinical events were estimated from the available literature. One-way and two-way sensitivity analyses were performed by measuring the impact of varying input probabilities of clinical events on QALY outcomes. RESULTS The base-case scenario estimated that older adults treated with no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban had QALYs of 8.03, 8.69, 10.38, 11.02, and 11.56, respectively. The sensitivity analysis estimated that an older adult would need to fall over 45 (rivaroxaban) and 458 (apixaban) times per year for the QALY of a direct oral anticoagulant to be lower than that of aspirin. CONCLUSIONS Older adults with atrial fibrillation benefit from stroke protection of anticoagulants, especially direct oral anticoagulants, even if they are at high risk of falls. Clinicians should not consider fall risk as a deciding factor for withholding anticoagulation in this population of patients.
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Zappulla P, Calvi V. Gastrointestinal Bleeding and Direct Oral Anticoagulants among Patients with Atrial Fibrillation: Risk, Prevention, Management, and Quality of Life. TH OPEN 2021; 5:e200-e210. [PMID: 34151138 PMCID: PMC8208840 DOI: 10.1055/s-0041-1730035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/09/2021] [Indexed: 02/08/2023] Open
Abstract
A significant problem for patients undergoing oral anticoagulation therapy is gastrointestinal bleeding (GIB), a problem that has become increasingly urgent following the introduction of direct oral anticoagulants (DOACs). Furthermore, in recent years a greater focus has been placed on the quality of life (QOL) of patients on long-term oral anticoagulant therapy, which necessitates changes in lifestyle, as well as posing an increased risk of bleeding without producing objective symptomatic relief. Here, we examine current evidence linked to GIB associated with oral anticoagulants, with a focus on randomized control trials, meta-analyses, and postmarketing observational studies. Rivaroxaban and dabigatran (especially the 150-mg bis-in-die dose) appeared to be linked to an increased risk of GIB. The risk of GIB was also greater when edoxaban was used, although this was dependent on the dose. Apixaban did not pose a higher risk of GIB in comparison with warfarin. We provided a summary of current knowledge regarding GIB risk factors for individual anticoagulants, prevention strategies that lower the risk of GIB and management of DOAC therapy after a GIB episode.
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Affiliation(s)
- Paolo Zappulla
- Division of Cardiology, Centro alte specialità e trapianti (C.A.S.T.), Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Valeria Calvi
- Division of Cardiology, Centro alte specialità e trapianti (C.A.S.T.), Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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Benamouzig R, Guenoun M, Deutsch D, Fauchier L. Review Article: Gastrointestinal Bleeding Risk with Direct Oral Anticoagulants. Cardiovasc Drugs Ther 2021; 36:973-989. [PMID: 34143317 DOI: 10.1007/s10557-021-07211-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared with vitamin K antagonists (VKAs) remains controversial. Accordingly, we aimed to provide a focused overview of the risk of gastrointestinal bleeding associated with dabigatran, rivaroxaban, apixaban and edoxaban and its management. METHODS We reviewed published studies reporting on DOACs with gastrointestinal bleeding as an outcome, including randomised controlled trials (RCTs), retrospective database studies and large-scale prospective cohort studies. RESULTS Cumulative evidence confirms no notable difference in major gastrointestinal bleeding risk between DOACs and VKAs. Moreover, gastrointestinal bleeding in DOAC-treated patients seems less severe and requires less intensive management. The main cause of upper gastrointestinal bleeding in DOAC-treated patients appears to be gastroduodenal ulcers, whereas lower gastrointestinal bleedings are mainly due to diverticula followed by angiodysplasia and haemorrhoids. The lack of head-to-head RCTs with DOACs precludes drawing conclusions on the DOAC with the lowest gastrointestinal bleeding risk. Prescribing physicians should be aware of risk factors for DOAC-related gastrointestinal bleeding (e.g. age > 65, heavy alcohol use, uncontrolled hypertension, hepatic or renal dysfunction, active cancer, anaemia) and adopt preventive measures accordingly. Management of DOAC-associated major gastrointestinal bleeding involves temporary discontinuation of the DOAC, investigation of the bleeding source and treatment of bleeding with fluid resuscitation combined with transfusion and endoscopic haemostasis. CONCLUSION DOACs as a class do not increase the risk of major gastrointestinal bleeding compared to VKAs, which supports their continued use for different anticoagulant indications.
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Affiliation(s)
- Robert Benamouzig
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France.
| | - Maxime Guenoun
- Department of Cardiology, Clinique Bouchard, Marseille, France
| | - David Deutsch
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France
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Korpallová B, Samoš M, Bolek T, Kühnelová L, Škorňová I, Kubisz P, Staško J, Mokáň M. ROTEM Testing for Direct Oral Anticoagulants. Semin Thromb Hemost 2021; 47:815-823. [PMID: 34130343 DOI: 10.1055/s-0041-1726372] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used worldwide for the prevention of stroke in patients with atrial fibrillation and to prevent or treat venous thromboembolism. In situations such as serious bleeding, the need for urgent surgery/intervention or the management of a thromboembolic event, the laboratory measurement of DOACs levels or anticoagulant activity may be required. Rotational thromboelastometry (ROTEM) is a viscoelastic hemostatic assay (VHA) which has been used in emergencies (trauma and obstetrics), and surgical procedures (cardiac surgery and liver transplants), but experience with this assay in DOACs-treated patients is still limited. This article reviews the use of ROTEM in the setting of DOACs therapy, focusing on DOACs-associated bleeding and the use of this VHA for the management of reversal strategies for DOACs-associated anticoagulation.
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Affiliation(s)
- Barbora Korpallová
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Linda Kühnelová
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ingrid Škorňová
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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Zhu YJ, Zhou YP, Wei YP, Xu XQ, Yan XX, Liu C, Zhu XJ, Liu ZY, Sun K, Hua L, Jiang X, Jing ZC. Association Between Anticoagulation Outcomes and Venous Thromboembolism History in Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:628284. [PMID: 34095244 PMCID: PMC8175786 DOI: 10.3389/fcvm.2021.628284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The association between anticoagulation outcomes and prior history of venous thromboembolism (VTE) in chronic thromboembolic pulmonary hypertension (CTEPH) has not been established. This study aimed to compare the efficacy and safety of anticoagulation treatment in CTEPH patients with and without prior history of VTE. Methods: A total of 333 CTEPH patients prescribed anticoagulants were retrospectively included from May 2013 to April 2019. The clinical characteristics were collected at their first admission. Incidental recurrent VTE and clinically relevant bleeding were recorded during follow-up. The Cox proportional regression models were used to identify potential factors associated with recurrent VTE and clinically relevant bleeding. Results: Seventy patients (21%) without a prior history of VTE did not experience recurrent VTE during anticoagulation. Compared to CTEPH patients without a prior history of VTE, those with a prior history of VTE had an increased risk of recurrent VTE [2.27/100 person-year vs. 0/100 person-year; hazard ratio (HR), 8.92; 95% confidence interval (CI), 1.18–1142.00; P = 0.029] but a similar risk of clinically relevant bleeding (3.90/100 person-year vs. 4.59/100 person-year; HR, 0.83; 95% CI, 0.38–1.78; P = 0.623). Multivariate Cox analyses suggested that a prior history of VTE and interruption of anticoagulation treatments were significantly associated with an increased risk of recurrent VTE, while anemia and glucocorticoid use were significantly associated with a higher risk of clinically relevant bleeding. Conclusions: This study is the first to reveal that a prior history of VTE significantly increases the risk of recurrent VTE in CTEPH patients during anticoagulation treatment. This finding should be further evaluated in prospective studies.
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Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Jie Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Yi Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Dave M, Kumar A, Majmundar M, Adalja D, Shariff M, Shah P, Desai R, Patel K, Jagirdhar GSK, Vallabhajosyula S, Gullapalli N, Doshi R. Frequency, Trend, Predictors, and Impact of Gastrointestinal Bleeding in Atrial Fibrillation Hospitalizations. Am J Cardiol 2021; 146:29-35. [PMID: 33529616 DOI: 10.1016/j.amjcard.2021.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/18/2022]
Abstract
Anticoagulation alone or in combination with other treatment strategies are implemented to reduce the risk of stroke in patients with atrial fibrillation (AF). Gastrointestinal bleeding (GIB) is a common complication of oral anticoagulation with a prevalence of 1% to 3% in patients on long term oral anticoagulation. We analyzed the national inpatient sample database from the year 2005 to 2015 to report evidence on the frequency, trends, predictors, clinical outcomes, and economic burden of GIB among AF hospitalizations. A total of 34,260,000 AF hospitalizations without GIB and 1,846,259 hospitalizations with GIB (5.39%) were included. The trend of AF hospitalizations with GIB per 100 AF hospitalizations remained stable from the year 2005 to 2015 (p value = 0.0562). AF hospitalizations with GIB had a higher frequency of congestive heart failure, long term kidney disease, long term liver disease, anemia, and alcohol abuse compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a higher odds of in-hospital mortality (Odds ratio (OR) 1.47; 95% Confidence interval (CI): 1.46 to 1.48, p-value <0.0001), mechanical ventilation (OR 1.69; 95% CI: 1.68 to 1.70, p-value <0.0001), and blood transfusion (OR 7.2; 95% CI: 7.17 to 7.22, P-value <0.0001) compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a lower odds of stroke (OR 0.51; 95% CI: 0.51 to 0.52, p-value <0.0001) compared with AF hospitalizations without GIB. Further, AF hospitalizations with GIB had a higher median length of stay and cost of hospitalization compared with AF hospitalizations without GIB. In conclusion, the frequency of GIB is 5.4% in AF hospitalizations and the frequency of GIB remained stable in the last decade as shown in this analysis. When GIB occurs, it is associated with higher resource utilization. This study addresses a significant knowledge gap highlighting national temporal trends of GIB and associated outcomes in AF hospitalizations.
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Affiliation(s)
- Mihir Dave
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada
| | - Ashish Kumar
- Department of Critical Care Medicine, St John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Monil Majmundar
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Devina Adalja
- Department of Medicine, GMERS Gotri Medical College, Vadodara, Gujarat, India
| | - Mariam Shariff
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Palak Shah
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Rupak Desai
- Department of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
| | - Krunalkumar Patel
- Department of Internal Medicine, St. Mary Medical Center, Langhorn, Pennsylvania
| | | | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada.
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Calsolaro V, Okoye C, Antognoli R, Dell'Agnello U, Calabrese AM, Monzani F. Long-term effectiveness and safety of anticoagulation therapy in oldest old, frail people with atrial fibrillation. Eur J Intern Med 2021; 86:91-97. [PMID: 33551290 DOI: 10.1016/j.ejim.2021.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Atrial Fibrillation (AF) represents a major cause of mortality and morbidity in older people; however, oldest-old frail patients are usually excluded from clinical trials. Aim of the study is to evaluate the impact of oral anticoagulation (OAC) therapy on long-term overall survival and clinically relevant bleedings in a large cohort of hospitalised frail, oldest-old patients with AF. PATIENTS AND METHODS Prospective, observational, cohort study, evaluating patients consecutively hospitalized for acute illnesses in our Geriatrics Unit (January 2013-July 2017). Participants were divided in two groups, AF and sinus rhythm (SR). Besides recording demographic characteristics and clinical history, comprehensive geriatric assessment (CGA) was obtained. RESULTS AF patients [1808/5093 (35.5%), 58.5% women] were older, with higher burden of comorbidity than those with SR. At discharge, HAS-BLED [OR 0.77 (95%CI 0.67-0.90), cognitive impairment [OR 0.92 (95%CI 0.90-0.95)], malnutrition [OR 0.74 (95%CI 0.57-0.97)] and CHA2DS2VASc [OR 1.33 (95%CI 1.20-1.47)] emerged as significant independent predictors of anticoagulant prescription. AF patients showed significantly reduced overall survival (OS) than those with SR (11.4 vs 19.4 months, p<.001). However, anticoagulated AF patients (75.2%) had three-times longer OS than those not anticoagulated (15.0 vs 5.6 months, p<.001), comparable to SR patients after adjustment for potential confounders [HR 1.04 (95%CI 0.99-1.10)]. ED readmittance risk for clinically relevant bleeding did not differ between AF patients receiving or not anticoagulation [HR 1.04 (95%CI 0.76-1.14)] CONCLUSION: anticoagulation therapy was associated with significant increase of long-term OS without increased risk of clinically relevant bleeding. CGA resulted an useful tool in OAC therapy decision-making.
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Affiliation(s)
- Valeria Calsolaro
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Umberto Dell'Agnello
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Alessia Maria Calabrese
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy.
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Weaver J, Shoaibi A, Truong HQ, Larbi L, Wu S, Wildgoose P, Rao G, Freedman A, Wang L, Yuan Z, Barnathan E. Comparative Risk Assessment of Severe Uterine Bleeding Following Exposure to Direct Oral Anticoagulants: A Network Study Across Four Observational Databases in the USA. Drug Saf 2021; 44:479-497. [PMID: 33651368 PMCID: PMC7994226 DOI: 10.1007/s40264-021-01060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Antithrombotic therapies are associated with an increased bleeding risk. Abnormal uterine bleeding data have been reported in clinical trials of patients with venous thromboembolism (VTE), but data are limited for patients with atrial fibrillation (AF). OBJECTIVE Using real-world data from four US healthcare databases (October 2010 to December 2018), we compared the occurrence of severe uterine bleeding among women newly exposed to rivaroxaban, apixaban, dabigatran, and warfarin stratified by indication. METHODS To reduce potential confounding, patients in comparative cohorts were matched on propensity scores. Treatment effect estimates were generated using Cox proportional hazard models for each indication, in each database, and only for pairwise comparisons that met a priori study diagnostics. If estimates were homogeneous (I2 < 40%), a meta-analysis across databases was performed and pooled hazard ratios reported. RESULTS Data from 363,919 women newly exposed to a direct oral anticoagulant or warfarin with a prior diagnosis of AF (60.8%) or VTE (39.2%) were analyzed. Overall incidence of severe uterine bleeding was low in the populations exposed to direct oral anticoagulants, although relatively higher in the younger VTE population vs the AF population (unadjusted incidence rates: 2.8-33.7 vs 1.9-10.0 events/1000 person-years). In the propensity score-matched AF population, a suggestive, moderately increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [hazard ratios and 95% confidence intervals from 0.83 (0.27-2.48) to 2.84 (1.32-6.23) across databases with significant heterogeneity], apixaban [pooled hazard ratio 1.45 (0.91-2.28)], and dabigatran [2.12 (1.01-4.43)], which were sensitive to the time-at-risk period. In the propensity score-matched VTE population, a consistent increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [2.03 (1.19-3.27)] and apixaban [2.25 (1.45-3.41)], which were insensitive to the time-at-risk period. CONCLUSIONS For women who need antithrombotic therapy, personalized management strategies with careful evaluation of benefits and risks are required. CLINICALTRIALS. GOV REGISTRATION NCT04394234; registered in May 2020.
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Affiliation(s)
- James Weaver
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Azza Shoaibi
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Huy Q Truong
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Leila Larbi
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Shujian Wu
- Janssen Research & Development, LLC, Horsham, PA, USA
| | - Peter Wildgoose
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Gowtham Rao
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Amy Freedman
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Lu Wang
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
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Kobalava ZD, Shavarov AA, Vatsik-Gorodetskaya MV. Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Renal Dysfunction. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation and renal dysfunction often coexist, each disorder may predispose to the other and contribute to worsening prognosis. Both atrial fibrillation and chronic kidney disease are associated with increased risk of stroke and thromboembolic complications. Oral anticoagulation for stroke prevention is therefore recommended in patients with atrial fibrillation and decreased renal function. Each direct oral anticoagulant has unique pharmacologic properties of which clinician should be aware to optimally manage patients. The doses of direct oral anticoagulants require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault equation, should be used to estimate glomerular filtration rate in patients with atrial fibrillation treated with direct oral anticoagulants. Our review tries to find arguments for benefit of direct oral anticoagulants in patients with renal dysfunction.
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Affiliation(s)
- Z. D. Kobalava
- Peoples Friendship University of Russia (RUDN University)
| | - A. A. Shavarov
- Peoples Friendship University of Russia (RUDN University)
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Harada H, Miyaoka Y, Yuki T, Iwaki T, Maeda G, Nakahara R, Murakami D, Ujihara T, Katsuyama Y, Hayasaka K, Kushiyama Y, Fujishiro H, Amano Y. Postpolypectomy bleeding of colorectal polyps in patients with continuous warfarin and short-term interruption of direct oral anticoagulants. Gastrointest Endosc 2021; 93:691-698. [PMID: 33022270 DOI: 10.1016/j.gie.2020.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Postpolypectomy bleeding (PPB) is the most common adverse event after colorectal polypectomy. Use of anticoagulants is an important risk factor for PPB. This study aimed to evaluate PPB in patients receiving treatment with warfarin and direct oral anticoagulants (DOACs). METHODS Between August 2017 and July 2019, 5449 patients with 12,601 polyps who underwent endoscopic snare resection of colorectal polyps were enrolled. Endoscopic snare resection was performed in patients receiving continuous warfarin (C-warfarin) and in patients who experienced 1 day cessation of (O-) of DOACs in accordance with the Japanese Gastroenterological Endoscopy Society guidelines. RESULTS The PPB rate in the group receiving anticoagulants was statistically higher than that in the group without anticoagulants (8.5% [33/387] vs 1.2% [63/5,062], respectively; P < .001). By multivariate logistic regression analysis, male gender (odds ratio [OR], 2.17; P = .007), warfarin (OR, 4.64; P < .001), DOACs (OR, 6.59; P < .001), and multipolyp removal (OR, 1.77; P = .007) were significant risk factors for PPB. PPB was observed in 9 and 21 patients in the C-warfarin and O-DOACs groups, respectively: C-warfarin (8.0% [9/113]), O-dabigatran (6.1% [2/33]), O-rivaroxaban (14.8% [9/61]), O-apixaban (9.8% [9/92]), and O-edoxaban (1.8% [1/56]). The PPB rate with the O-edoxaban group was significantly lower than that with the O-rivaroxaban group (P < .05). CONCLUSIONS Use of anticoagulant therapy was an independent risk factor for PPB. The rates of PPB in patients receiving C-warfarin and O-DOACs were also higher than those in patients not receiving anticoagulants. Edoxaban may be safe through short-term withdrawal in patients undergoing endoscopic snare resection of colorectal polyps.
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Affiliation(s)
- Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Youichi Miyaoka
- Department of Endoscopy, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Takafumi Yuki
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Tomoyuki Iwaki
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Gen Maeda
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Ryotaro Nakahara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Tetsuro Ujihara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | | | - Kenji Hayasaka
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | | | - Hirofumi Fujishiro
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, Chiba, Japan
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Giehm-Reese M, Johansen MN, Kronborg MB, Jensen HK, Gerdes C, Kristensen J, Johannessen A, Jacobsen PK, Djurhuus MS, Hansen PS, Riahi S, Nielsen JC. Discontinuation of oral anticoagulation and risk of stroke and death after ablation for typical atrial flutter: A nation-wide Danish cohort study. Int J Cardiol 2021; 333:110-116. [PMID: 33647366 DOI: 10.1016/j.ijcard.2021.02.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/02/2021] [Accepted: 02/19/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Oral anticoagulation (OAC) is indicated for patients with atrial fibrillation (AF) and atrial flutter (AFL) with a CHA2DS2-VASc score ≥ 2 for men and ≥3 for women. This is regardless of successful catheter ablation for their arrhythmia. Studies have mainly focused on AF, and little is known regarding use of OAC in AFL patients following catheter ablation. PURPOSE To describe discontinuation of OAC in a national cohort of patients who have undergone first-time cavo-tricuspid isthmus ablation (CTIA) for AFL. METHODS We identified patients undergoing first-time CTIA during the period 2010-2016 using the Danish National Ablation Registry. Information on comorbidities and OAC use were gathered using the Danish National Patient Registry and the Danish National Prescription Registry. Patients were followed until March 1st, 2018. RESULTS We identified 2409 consecutive patients. Median age was 66 (IQR 58-72) years, and 1952 (81%) were men. During mean follow-up of 4 ± 1.7 years, 723 (30%) patients discontinued OAC. Patients discontinuing OAC were younger, had less comorbidity, and a lower CHA2DS2-VASc score. During follow-up, 252 (10%) patients died, and 112 (5%) patients had a stroke. Incidence of both these events increased with increasing age and CHA2DS2-VASc score. In adjusted analysis, we observed higher mortality (p < 0.0001) in patients discontinuing OAC, while stroke rate was not significantly higher (p = 0.21). CONCLUSION In this national cohort of patients who have undergone first-time CTIA, patients discontinuing OAC treatment were younger and had less comorbidities. Patients remain at elevated risk of death and stroke/TIA, increasing with their age and CHA2DS2-VASc score.
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Affiliation(s)
| | | | | | | | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Arne Johannessen
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
| | - Peter Karl Jacobsen
- Department of Cardiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | | | | | - Sam Riahi
- AF Study Group, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Yang KT, Sun WC, Tsai TJ, Tsay FW, Chen WC, Cheng JS. The Risk of Gastrointestinal Bleeding between Non-Vitamin K Antagonist Oral Anticoagulants and Vitamin K Antagonists in the Asian Atrial Fibrillation Patients: A Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010137. [PMID: 33375495 PMCID: PMC7795910 DOI: 10.3390/ijerph18010137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 05/04/2023]
Abstract
Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used to prevent atrial fibrillation (AF) patients from thromboembolic events than vitamin K antagonists (VKAs). However, the gastrointestinal bleeding (GIB) risk in the Asian AF patients associated with NOACs in comparison with VKAs remained unaddressed. Materials and Methods: A systematic search of studies on NOACs and VKAs in the Asian AF patients was conducted in PubMed, Cochrane Library, and ClinicalTrials.gov. The primary outcome was the hazard ratio (HR) of any GIB associated with NOACs versus VKAs. The secondary outcome was the GIB risks in different kinds of NOACs compared with VKAs. Results: This meta-analysis included two randomized controlled trials (RCTs) and four retrospective studies, comprising at least 200,000 patients in total. A significantly lower HR of GIB risks was found in all kinds of NOACs than VKAs in the Asian AF patients (HR: 0.633; 95% confidence interval: 0.535-0.748; p < 0.001). Additionally, the GIB risks of different NOACs were apixaban (HR: 0.392), edoxaban (HR: 0.603), dabigatran (HR: 0.685), and rivaroxaban (HR: 0.794), respectively. Conclusions: NOACs significantly reduced the risk of GIB in the Asian AF patients compared with VKAs. In the four NOACs compared with VKAs, apixaban probably had a trend of the least GIB risk. We need further head-to-head studies of different NOACs to confirm which NOAC is the most suitable for Asian AF patients and to know the optimal dosage regimen of different NOACs.
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Affiliation(s)
- Kuang-Tsu Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
- Department of Chemistry, College of Science, National Kaohsiung Normal University, Kaohsiung 80201, Taiwan
- Correspondence: ; Tel.: +886-7-346-8078; Fax: +886-7-346-8237
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
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47
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Sun X, Ze B, Zhang LJ, BaiMa YZ, Zuo W, Zhao B, GeSang LB. Hemorrhage Risk Profiles among Different Antithrombotic Regimens: Evidence from a Real-World Analysis of Postmarketing Surveillance Data. Cardiovasc Drugs Ther 2020; 36:103-112. [PMID: 33226545 DOI: 10.1007/s10557-020-07110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of direct oral anticoagulants (DOACs) has been reported in patients with atrial fibrillation (AF), there is currently no consensus on the occurrence or characteristics of the hemorrhage risk in different antithrombotic regimens. METHODS Disproportionality and Bayesian analyses were performed in mining data of suspected hemorrhagic events after antithrombotic drug use from the FDA Adverse Event Reporting System (FAERS) from January 2004 to September 2019. The time to onset and fatality rate of hemorrhage following different antithrombotic regimens were also compared. RESULTS A total of 84,998 reports of hemorrhage-related adverse events with the use of antithrombotic drugs were identified. The patients included were mostly from the Americas (80.87%) and Europe (13.22%), with most data submitted by nonhealthcare professionals. Among the seven antithrombotic drug monotherapies, betrixaban had the highest association with hemorrhage based on the highest reporting odds ratio (ROR, 829.95; 95% CI = 113.61-6063.15), proportional reporting ratio (PRR, 24.68, χ2 = 804.24), and multi-item gamma Poisson shrinker (MGPS, 24.68, 95% one-sided CI = 4.67). The combination therapies of clopidogrel plus new oral anticoagulants had higher RORs, PRRs, and empirical Bayesian geometric means (EBGMs) than the antithrombotic drug monotherapies. Hemorrhage associated with rivaroxaban plus clopidogrel appeared to have an earlier onset (171 days vs 219 days, 95% two-sided CI =68.68-27.34, p < 0.0001) and a lower fatality rate (15.30% vs 17.74%, p<0.05) than that associated with rivaroxaban monotherapy. CONCLUSION This study provides a relevant overview of the hemorrhagic complications/fatalities associated with different antithrombotic regimens in their real-world use. Among the combination therapies, clopidogrel plus DOACs were found to have stronger associations with hemorrhage than traditional dual antithrombotic therapies. Rivaroxaban showed a stronger association with hemorrhage than other antithrombotic drug monotherapies, and apixaban monotherapy appeared to have weaker associations with hemorrhage than others.
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Affiliation(s)
- Xue Sun
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Bi Ze
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Ling-Jun Zhang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| | - Yang-Zhong BaiMa
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Wei Zuo
- Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bin Zhao
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China. .,Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Luo-Bo GeSang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
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48
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Raposeiras Roubín S, Abu Assi E, Barreiro Pardal C, Cespón Fernandez M, Muñoz Pousa I, Cobas Paz R, Parada JA, Represa Montenegro M, Melendo Miu M, Blanco Prieto S, Rosselló X, Ibañez B, Íñiguez Romo A. New Cancer Diagnosis After Bleeding in Anticoagulated Patients With Atrial Fibrillation. J Am Heart Assoc 2020; 9:e016836. [PMID: 33140676 PMCID: PMC7763724 DOI: 10.1161/jaha.120.016836] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Background Bleeding is frequent in patients with atrial fibrillation (AF) treated with oral anticoagulant therapy, and may be the first manifestation of underlying cancer. We sought to investigate to what extent bleeding represents the unmasking of an occult cancer in patients with AF treated with oral anticoagulants. Methods and Results Using data from CardioCHUVI-AF (Retrospective Observational Registry of Patients With Atrial Fibrillation From Vigo's Health Area), 8753 patients with AF aged ≥75 years with a diagnosis of AF between 2014 and 2017 were analyzed. Of them, 2171 (24.8%) experienced any clinically relevant bleeding, and 479 (5.5%) were diagnosed with cancer during a follow-up of 3 years. Among 2171 patients who experienced bleeding, 198 (9.1%) were subsequently diagnosed with cancer. Patients with bleeding have a 3-fold higher hazard of being subsequently diagnosed with new cancer compared with those without bleeding (4.7 versus 1.4 per 100 patient-years; adjusted hazard ratio [HR], 3.2 [95% CI, 2.6-3.9]). Gastrointestinal bleeding was associated with a 13-fold higher hazard of new gastrointestinal cancer diagnosis (HR, 13.4; 95% CI, 9.1-19.8); genitourinary bleeding was associated with an 18-fold higher hazard of new genitourinary cancer diagnosis (HR, 18.1; 95% CI, 12.5-26.2); and bronchopulmonary bleeding was associated with a 15-fold higher hazard of new bronchopulmonary cancer diagnosis (HR, 15.8; 95% CI, 6.0-41.3). For other bleeding (nongastrointestinal, nongenitourinary, nonbronchopulmonary), the HR for cancer was 2.3 (95% CI, 1.5-3.6). Conclusions In patients with AF treated with oral anticoagulant therapy, any gastrointestinal, genitourinary, or bronchopulmonary bleeding was associated with higher rates of new cancer diagnosis. These bleeding events should prompt investigation for cancers at those sites.
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Affiliation(s)
- Sergio Raposeiras Roubín
- Hospital Universitario Álvaro CunqueiroVigoSpain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)MadridSpain
| | | | | | | | | | | | | | | | | | | | - Xavier Rosselló
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)MadridSpain
- Department of CardiologyHealth Research Institute of the Balearic Islands (IdISBa)University Hospital Son EspasesPalmaSpain
| | - Borja Ibañez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)MadridSpain
- Hospital Fundación Jiménez DíazMadridSpain
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49
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Bouget J, Viglino D, Yvetot Q, Oger E. Major gastrointestinal bleeding and antithrombotics: Characteristics and management. World J Gastroenterol 2020; 26:5463-5473. [PMID: 33024397 PMCID: PMC7520611 DOI: 10.3748/wjg.v26.i36.5463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic.
AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events.
METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified.
RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations (P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use (P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents.
CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).
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Affiliation(s)
- Jacques Bouget
- EA 7449 REPERES, Pharmacoepidemiology and Health Services Research, Univ Rennes, Rennes 35000, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit-HP2 Laboratory INSERM U1042, University Grenoble Alps, La Tronche 38700, France
| | | | - Emmanuel Oger
- EA 7449 REPERES, Université de Rennes 1, Rennes 35000, France
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50
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Fanning L, Wong ICK, Li X, Chan EW, Mongkhon P, Man KKC, Wei L, Leung WK, Darzins P, Bell JS, Ilomaki J, Lau WCY. Gastrointestinal bleeding risk with rivaroxaban vs aspirin in atrial fibrillation: A multinational study. Pharmacoepidemiol Drug Saf 2020; 29:1550-1561. [PMID: 32936997 DOI: 10.1002/pds.5130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/19/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022]
Abstract
PURPOSE Comparative gastrointestinal bleeding (GIB) risk between rivaroxaban and low-dose aspirin is unknown in patients with atrial fibrillation (AF). This study investigated GIB risk with rivaroxaban vs aspirin among two separate AF cohorts in Hong Kong and the United Kingdom, using a common protocol approach. METHODS This was a population-based cohort study using separate data from the Clinical Data Analysis and Reporting System (CDARS) of the Hong Kong Hospital Authority (2010-2018) and The Health Improvement Network (THIN) database in the United Kingdom (2011-2017). Patients with AF newly prescribed aspirin or rivaroxaban were included. Cox proportional hazards regression was used to compare GIB risks for rivaroxaban vs aspirin, accounting for confounders using propensity score fine stratification approach. RESULTS In CDARS, 29 213 patients were included; n = 1052 (rivaroxaban), n = 28 161 (aspirin). Crude GIB event rates per 100 patient-years in CDARS were 3.0 (aspirin) and 2.6 (rivaroxaban). No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.04, 95%CI = 0.76-1.42), and in dose-stratified analyses (HR = 1.21, 95%CI = 0.84-1.74 [20 mg/day]; HR = 0.80, 95%CI = 0.44-1.45 [≤15 mg/day]). In THIN, 11 549 patients were included, n = 3496 (rivaroxaban) and n = 8053 (aspirin). Crude GIB event rates were 1.3 (aspirin) and 2.4 (rivaroxaban) per 100 patient-years. No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.40, 95%CI = 1.00-1.98) and low-dose rivaroxaban (≤15 mg/day) (HR = 1.00, 95%CI = 0.56-1.30), but increased GIB risk was observed for rivaroxaban 20 mg/day vs aspirin (HR = 1.57, 95%CI = 1.08-2.29). CONCLUSION In patients with AF, GIB risk was comparable between aspirin and rivaroxaban ≤15 mg/day. GIB risk for rivaroxaban 20 mg/day vs aspirin remains uncertain and warrants further investigation.
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Affiliation(s)
- Laura Fanning
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ian C K Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - Xue Li
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China.,Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.,Department of Social Work and Social Administration, Faculty of Science, University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China.,The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
| | - Pajaree Mongkhon
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Faculty of Pharmacy, Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, Thailand.,School of Pharmaceutical Sciences, University of Phayao, Muang, Thailand
| | - Kenneth K C Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Wai K Leung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Peteris Darzins
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jenni Ilomaki
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
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