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Haller PM, Kazem N, Agewall S, Borghi C, Ceconi C, Dobrev D, Cerbai E, Grove EL, Kaski JC, Lewis BS, Niessner A, Rocca B, Rosano G, Savarese G, Schnabel RB, Semb AG, Sossalla S, Wassmann S, Sulzgruber P. Oral anticoagulation in patients with left ventricular thrombus: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:444-453. [PMID: 38845369 DOI: 10.1093/ehjcvp/pvae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/17/2024] [Accepted: 06/05/2024] [Indexed: 08/15/2024]
Abstract
AIMS Direct oral anticoagulants (DOACs) are increasingly used off-label to treat patients with left ventricular thrombus (LVT). We analysed available meta-data comparing DOACs and vitamin K antagonists (VKAs) for efficacy and safety. METHODS We conducted a systematic search and meta-analysis of observational and randomized data comparing DOACs vs. VKAs in patients with LVT. Endpoints of interest were stroke or systemic embolism, thrombus resolution, all-cause death, and a composite bleeding endpoint. Estimates were pooled using a random-effects model meta-analysis, and their robustness was investigated using sensitivity and influential analyses. RESULTS We identified 22 articles (18 observational studies, 4 small randomized clinical trials) reporting on a total of 3587 patients (2489 VKA vs. 1098 DOAC therapy). The pooled estimates for stroke or systemic embolism [odds ratio (OR): 0.81; 95% confidence interval (CI): 0.57, 1.15] and thrombus resolution (OR: 1.12; 95% CI: 0.86, 1.46) were comparable, and there was low heterogeneity overall across the included studies. The use of DOACs was associated with lower odds of all-cause death (OR: 0.65; 95% CI: 0.46, 0.92) and a composite bleeding endpoint (OR: 0.67; 95% CI: 0.47, 0.97). A risk of bias was evident particularly for observational reports, with some publication bias suggested in funnel plots. CONCLUSION In this comprehensive analysis of mainly observational data, the use of DOACs was not associated with a significant difference in stroke or systemic embolism, or thrombus resolution, compared with VKA therapy. The use of DOACs was associated with a lower rate of all-cause death and fewer bleeding events. Adequately sized randomized clinical trials are needed to confirm these findings, which could allow a wider adoption of DOACs in patients with LVT.
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Affiliation(s)
- Paul M Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Building O50, Empore, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg 20246, Germany
| | - Niema Kazem
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stefan Agewall
- Division of Clinical Science, Danderyd hospital, Karolinska Institute, Stockholm 171 77, Sweden
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40126, Italy
| | - Claudio Ceconi
- Cardiovascular Institute, Azienda Ospedaliera Universitaria S. Anna, Ferrara 44124, Italy
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen 45122, Germany
- Montréal Heart Institute, Université de Montréal, Montréal, Québec H1T 1C8, Canada
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Elisabetta Cerbai
- Department of Preclinical and Clinical Pharmacology, University of Florence, Florence 50121, Italy
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus 8200, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus 8200, Denmark
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London SW17 ORE, UK
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and Technion-Israel Institute of Technology, Haifa 3436212, Israel
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Bianca Rocca
- Department of Preclinical and Clinical Pharmacology, University of Florence, Florence 50121, Italy
- Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome 00168, Italy
| | - Giuseppe Rosano
- St George's Hospital Medical School, London SW17 0RE, UK
- IRCCS San Raffaele Roma, Rome 00163, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm 171 77, Sweden
- Heart and Vascular and Neurology Theme, Karolinska University Hospital, Stockholm 171 77, Sweden
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Building O50, Empore, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg 20246, Germany
| | - Anne Grete Semb
- Division of Research and Innovation, REMEDY, Centre for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo 0319, Norway
| | - Samuel Sossalla
- Department of Medicine I, Cardiology, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen, Gießen 35392, Germany
- Abteilung für Kardiologie, Kerckhoff-Klinik GmbH, Bad Nauheim 61231, Germany
| | - Sven Wassmann
- Cardiology Pasing, Munich, and Faculty of Medicine, University of the Saarland, Homburg/Saar 66123, Germany
| | - Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA 2024:2822177. [PMID: 39133476 DOI: 10.1001/jama.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Importance Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, New York
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Galli M, Occhipinti G, Ortega-Paz L, Franchi F, Rollini F, Brugaletta S, Capodanno D, Sciarretta S, Angiolillo DJ. Therapeutic Potential of FXI Inhibitors: Hype or Hope? Drugs 2024:10.1007/s40265-024-02049-w. [PMID: 39073551 DOI: 10.1007/s40265-024-02049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 07/30/2024]
Abstract
Significant advancements have shaped the landscape of anticoagulant therapy in the past two decades, including the introduction of direct oral anticoagulants (DOACs), characterized by favorable safety and efficacy profiles and reduced drug-to-drug or food interaction resulting in excellent patient compliance. However, residual concerns still exist with standard-of-care anticoagulant therapy, including the inability to use DOACs in several clinical settings and the need to further reduce the risk of bleeding. Recent improvements in the understanding of the mechanisms behind thrombus formation have led to the awareness that the intrinsic pathway of the coagulation cascade may play an important role in pathological thrombosis, but not in hemostasis. This has represented the rationale for targeting this pathway with factor XI (FXI) inhibitors, with the aim of uncoupling hemostasis and thrombosis. Clinical evidence from patients with FXI deficiency further supports this concept. A number of compounds with different mechanisms of action have been developed to target FXI (i.e., asundexian, abelacimab, Ionis-FXIRx, milvexian, osocimab, and Xisomab 3G). To date, the majority of available trials have not gone beyond completion of phase 2 and results are conflictive making it difficult to appraise the clinical benefit of these compounds in the different clinical settings where they have been tested (i.e., atrial fibrillation, acute ischemic stroke, acute myocardial infarction, end-stage renal disease, total knee arthroplasty). Moreover, the largest phase 3 randomized trial designed to test the efficacy of asundexian over apixaban in patients with atrial fibrillation, the OCEANIC-AF, has been prematurely stopped as a result of the inferior efficacy of asundexian. In this review we discuss the pharmacological properties and available evidence generated thus far for factor XI inhibitors, providing a perspective on the current state of these drugs.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giovanni Occhipinti
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- IRCCS NeuroMed, Pozzilli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
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Luo L, Cai Q, Liu X, Yun Z, Li X, Yan R, Li C. Characteristics and prognosis of elderly-onset antiphospholipid syndrome: An observational cohort study. Lupus 2024:9612033241266875. [PMID: 39033374 DOI: 10.1177/09612033241266875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is an autoimmune disease mainly affecting young individuals. Testing for antiphospholipid antibodies is recommended for young patients who are suspected to have APS. Yet, it is hard to differentiate APS from other acquired thrombophilia disorders in elderly-onset APS patients. This study aim to investigate the characteristics and prognosis of elderly-onset APS. METHODS This is an observational cohort study. Thrombotic APS patients who underwent follow-ups between 2009 and 2022 were included. Elderly-onset APS patients (onset age ≥60 years) were compared to non-elderly-onset APS patients (onset age <60 years) and matched cases of elderly non-APS patients (age ≥60 years with thrombosis). RESULTS A total of 161 APS patients were included in this study, 45 (28.0%) were elderly-onset APS. Stroke (35.6% vs. 18.1%, p = .018) was more common at disease onset in elderly-onset APS patients. Compared to non-elderly-onset patients, elderly-onset APS patients were associated with a higher number of cardiovascular risk factors. Elderly-onset APS patients showed significantly lower positive rate (51.1% vs. 71.6%, p = .014) and ratios [1.24 (1.01-1.38) vs. 1.37 (1.16-1.77), p = .004] of lupus anticoagulant. Elderly-onset APS patients had a significantly higher 10-years cumulative all-cause mortality (p < .001) and APS-related mortality than non-elderly-onset patients (p = .002) and elderly non-APS patients (p = .040). CONCLUSIONS Elderly-onset APS patients have unique disease characteristics with higher 10-years cumulative all-cause mortality and APS-related mortality. Early recognition and control of comorbidities may reduce the recurrence of thrombosis and mortality in elderly-onset APS patients.
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Affiliation(s)
- Liang Luo
- Department of Chinese Medicine, The People's Hospital of Yubei District of Chongqing City, Chongqing, China
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Qingmeng Cai
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xiangjun Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Zelin Yun
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xuerong Li
- Department of Rheumatology and Immunology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Rui Yan
- Department of Rheumatology and Immunology, Beijing Shunyi Hospital, Beijing, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
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Celia AI, Galli M, Mancuso S, Alessandri C, Frati G, Sciarretta S, Conti F. Antiphospholipid Syndrome: Insights into Molecular Mechanisms and Clinical Manifestations. J Clin Med 2024; 13:4191. [PMID: 39064231 PMCID: PMC11277906 DOI: 10.3390/jcm13144191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/12/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Antiphospholipid syndrome (APS) is a complex systemic autoimmune disorder characterized by a hypercoagulable state, leading to severe vascular thrombosis and obstetric complications. The 2023 ACR/EULAR guidelines have revolutionized the classification and understanding of APS, introducing broader diagnostic criteria that encompass previously overlooked cardiac, renal, and hematologic manifestations. Despite these advancements, diagnosing APS remains particularly challenging in seronegative patients, where traditional tests fail, yet clinical symptoms persist. Emerging non-criteria antiphospholipid antibodies offer promising new diagnostic and management avenues for these patients. Managing APS involves a strategic balance of cardiovascular risk mitigation and long-term anticoagulation therapy, though the use of direct oral anticoagulants remains contentious due to varying efficacy and safety profiles. This article delves into the intricate pathogenesis of APS, explores the latest classification criteria, and evaluates cutting-edge diagnostic tools and therapeutic strategies.
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Affiliation(s)
- Alessandra Ida Celia
- Rheumatology, Department of Clinical Internal, Anesthesiological e Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (A.I.C.); (S.M.); (C.A.); (F.C.)
| | - Mattia Galli
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (G.F.); (S.S.)
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Silvia Mancuso
- Rheumatology, Department of Clinical Internal, Anesthesiological e Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (A.I.C.); (S.M.); (C.A.); (F.C.)
| | - Cristiano Alessandri
- Rheumatology, Department of Clinical Internal, Anesthesiological e Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (A.I.C.); (S.M.); (C.A.); (F.C.)
| | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (G.F.); (S.S.)
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (G.F.); (S.S.)
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Fabrizio Conti
- Rheumatology, Department of Clinical Internal, Anesthesiological e Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (A.I.C.); (S.M.); (C.A.); (F.C.)
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Iov DE, Floria M, Tanase DM. Patent foramen oval and ESUS in cryptogenic stroke: Still a complex puzzle. Echocardiography 2024; 41:e15778. [PMID: 38353336 DOI: 10.1111/echo.15778] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Diana-Elena Iov
- Faculty of Medicine, Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa,", Iasi, Romania
- Emergency Clinical Hospital "Saint Spiridon,", Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Mariana Floria
- Faculty of Medicine, Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa,", Iasi, Romania
- Emergency Clinical Hospital "Saint Spiridon,", Internal Medicine Clinic, Iasi, Romania
| | - Daniela Maria Tanase
- Faculty of Medicine, Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa,", Iasi, Romania
- Emergency Clinical Hospital "Saint Spiridon,", Internal Medicine Clinic, Iasi, Romania
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