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Liaw J, Liaw D, Dave C. Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010-2020. Open Heart 2024; 11:e002515. [PMID: 38302138 PMCID: PMC10831461 DOI: 10.1136/openhrt-2023-002515] [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: 10/06/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND There is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD). SETTING AND METHODS We used the UK Clinical Practice Research Datalink (2010-2020) to conduct a retrospective cohort study to evaluate anticoagulant initiation patterns for older adults (≥65 years) with CKD (N=18 421) and without CKD (N=41 901), categorised by severity of CKD: stages 3a, 3b and 4, and initiation dose by respective direct oral anticoagulant (DOAC). RESULTS Over the study period, warfarin initiations sharply declined and were replaced by DOACs regardless of CKD status or stage. By 2020, patients with CKD were modestly more likely (8.8% difference) to initiate apixaban compared with those without CKD (58.8% vs 50.0%; p<0.01). Among patients with CKD, those with stages 3a and 3b CKD had higher apixaban initiations compared with stage 4 CKD (56.9% and 64.6% vs 52.9%, respectively; p<0.01). Conversely, patients with stage 4 CKD were over three times more likely to initiate warfarin (14.7%) compared with those with stage 3a (2.6%) and 3b (4.0%) CKD (p<0.01). Throughout the study period, there was a rise in the proportion of patients initiating the higher 10 mg daily dose for apixaban, with an increase of 20.6% (from 64.3% in 2013 to 84.9% in 2020; p value for trend <0.01) among patients without CKD, and 21.8% (53.1% to 74.9%; p<0.01), 24.4% (18.8% to 43.2%; p<0.01) and 18.5% (0.0% to 18.2%; p<0.01) among patients with stages 3a, 3b and 4 CKD, respectively. CONCLUSIONS AND RELEVANCE Initiation of DOACs increased regardless of CKD status and stage, although with a reduced magnitude in severe CKD. Apixaban emerged as the preferred agent, with a secular trend towards the higher initiation dose in all subgroups. These findings illuminate evolving trends and priorities in anticoagulant preferences among patients with and without CKD.
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Affiliation(s)
- Julia Liaw
- Centers for Pharmacoepidemiology and Treatment Sciences, Rutgers University, New Brunswick, New Jersey, USA
- Rutgers University, New Brunswick, New Jersey, USA
| | - Deborah Liaw
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Chintan Dave
- Rutgers University, New Brunswick, New Jersey, USA
- Department of Pharmacy Practice and Administration, Rutgers University, New Brunswick, New Jersey, USA
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Zhao M, Chandra A, Xu J, Li J. Factors related to postoperative vitreous hemorrhage after small-gauge vitrectomy in proliferative diabetic retinopathy patients. BMC Ophthalmol 2023; 23:215. [PMID: 37189104 DOI: 10.1186/s12886-023-02940-2] [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: 07/30/2022] [Accepted: 04/23/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND The role of anticoagulation or antiplatelet on post-vitrectomy vitreous hemorrhage (POVH) in patients with proliferative diabetic retinopathy (PDR) is rarely investigated in the small-gauge vitrectomy era. We investigate the relationship between the long-term use of those medications and POVH in a group of PDR patients. METHODS A retrospective cohort study was carried out in a group of PDR patients who underwent small-gauge vitrectomy in our center. The baseline data on diabetes, diabetic complications, long-term use of anticoagulants and antiplatelet agents, ocular findings, and vitrectomy details were collected. The occurrence of POVH was recorded during at least three-month follow-up. Factors related to POVH were analyzed using logistic analysis. RESULTS During a median follow-up of 16 weeks, 5% (11/220) of patients had POVH, and 75 had received antiplatelet or anticoagulation agents before the operation. Factors related to persistent POVH were the use of antiplatelet or anticoagulation agents (5.98, 1.75-20.45, p = 0.004), the presence of myocardial revascularization (130.65, 3.53-4834.50, p = 0.008), the presence of coronary artery disease (CAD) treated with medicine (56.52, 1.99-1604.06, p = 0.018), and younger age (0.86, 0.77-0.96, p = 0.012). For those receiving preoperative antiplatelet or anticoagulation agents, the probability of developing POVH was higher in the patients whose previous therapy was adjusted compared to those with continued therapy (p = 0.02 by Log-rank test). CONCLUSIONS We identified long-term use of anticoagulation or antiplatelet medication, the presence of CAD, and younger age as three independent factors related to POVH. In PDR patients on long-term antiplatelet or anticoagulation medications, particular attention should be given to controlling intraoperative bleeding, and follow-up for POVH should be scheduled.
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Affiliation(s)
- Meng Zhao
- Department of Ophthalmology, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Beijing Tongren Eye Center, Capital Medical University, No1. Dongjiaominxiang street, Dongcheng District, Beijing, 100730, China
| | - Aman Chandra
- Mid & South Essex NHS Foundation Trust (Southend University Hospital) Prittlewell Chase Essex SS00RY, Anglia Ruskin University, Cambridge, UK
| | - Jun Xu
- Department of Ophthalmology, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Beijing Tongren Eye Center, Capital Medical University, No1. Dongjiaominxiang street, Dongcheng District, Beijing, 100730, China
| | - Jipeng Li
- Department of Ophthalmology, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Beijing Tongren Eye Center, Capital Medical University, No1. Dongjiaominxiang street, Dongcheng District, Beijing, 100730, China.
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Hau HM, Eckert M, Laudi S, Völker MT, Stehr S, Rademacher S, Seehofer D, Sucher R, Piegeler T, Jahn N. Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation. J Clin Med 2022; 11:jcm11144025. [PMID: 35887788 PMCID: PMC9319563 DOI: 10.3390/jcm11144025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/22/2022] [Accepted: 07/09/2022] [Indexed: 12/10/2022] Open
Abstract
Objective: Due to the high prevalence and incidence of cardio- and cerebrovascular diseases among dialysis-dependent patients with end-stage renal disease (ERSD) scheduled for kidney transplantation (KT), the use of antiplatelet therapy (APT) and/or anticoagulant drugs in this patient population is common. However, these patients share a high risk of complications, either due to thromboembolic or bleeding events, which makes adequate peri- and post-transplant anticoagulation management challenging. Predictive clinical models, such as the HAS-BLED score developed for predicting major bleeding events in patients under anticoagulation therapy, could be helpful tools for the optimization of antithrombotic management and could reduce peri- and postoperative morbidity and mortality. Methods: Data from 204 patients undergoing kidney transplantation (KT) between 2011 and 2018 at the University Hospital Leipzig were retrospectively analyzed. Patients were stratified and categorized postoperatively into the prophylaxis group (group A)—patients without pretransplant anticoagulation/antiplatelet therapy and receiving postoperative heparin in prophylactic doses—and into the (sub)therapeutic group (group B)—patients with postoperative continued use of pretransplant antithrombotic medication used (sub)therapeutically. The primary outcome was the incidence of postoperative bleeding events, which was evaluated for a possible association with the use of antithrombotic therapy. Secondary analyses were conducted for the associations of other potential risk factors, specifically the HAS-BLED score, with allograft outcome. Univariate and multivariate logistic regression as well as a Cox proportional hazard model were used to identify risk factors for long-term allograft function, outcome and survival. The calibration and prognostic accuracy of the risk models were evaluated using the Hosmer−Lemshow test (HLT) and the area under the receiver operating characteristic curve (AUC) model. Results: In total, 94 of 204 (47%) patients received (sub)therapeutic antithrombotic therapy after transplantation and 108 (53%) patients received prophylactic antithrombotic therapy. A total of 61 (29%) patients showed signs of postoperative bleeding. The incidence (p < 0.01) and timepoint of bleeding (p < 0.01) varied significantly between the different antithrombotic treatment groups. After applying multivariate analyses, pre-existing cardiovascular disease (CVD) (OR 2.89 (95% CI: 1.02−8.21); p = 0.04), procedure-specific complications (blood loss (OR 1.03 (95% CI: 1.0−1.05); p = 0.014), Clavien−Dindo classification > grade II (OR 1.03 (95% CI: 1.0−1.05); p = 0.018)), HAS-BLED score (OR 1.49 (95% CI: 1.08−2.07); p = 0.018), vit K antagonists (VKA) (OR 5.89 (95% CI: 1.10−31.28); p = 0.037), the combination of APT and therapeutic heparin (OR 5.44 (95% CI: 1.33−22.31); p = 0.018) as well as postoperative therapeutic heparin (OR 3.37 (95% CI: 1.37−8.26); p < 0.01) were independently associated with an increased risk for bleeding. The intraoperative use of heparin, prior antiplatelet therapy and APT in combination with prophylactic heparin was not associated with increased bleeding risk. Higher recipient body mass index (BMI) (OR 0.32 per 10 kg/m2 increase in BMI (95% CI: 0.12−0.91); p = 0.023) as well as living donor KT (OR 0.43 (95% CI: 0.18−0.94); p = 0.036) were associated with a decreased risk for bleeding. Regarding bleeding events and graft failure, the HAS-BLED risk model demonstrated good calibration (bleeding and graft failure: HLT: chi-square: 4.572, p = 0.802, versus chi-square: 6.52, p = 0.18, respectively) and moderate predictive performance (bleeding AUC: 0.72 (0.63−0.79); graft failure: AUC: 0.7 (0.6−0.78)). Conclusions: In our current study, we could demonstrate the HAS-BLED risk score as a helpful tool with acceptable predictive accuracy regarding bleeding events and graft failure following KT. The intensified monitoring and precise stratification/assessment of bleeding risk factors may be helpful in identifying patients at higher risks of bleeding, improved individualized anticoagulation decisions and choices of antithrombotic therapy in order to optimize outcome after kidney transplantation.
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Affiliation(s)
- Hans Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.M.H.); (S.R.); (D.S.); (R.S.)
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Markus Eckert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
| | - Maria Theresa Völker
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
| | - Sebastian Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.M.H.); (S.R.); (D.S.); (R.S.)
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.M.H.); (S.R.); (D.S.); (R.S.)
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.M.H.); (S.R.); (D.S.); (R.S.)
| | - Tobias Piegeler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
| | - Nora Jahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany; (M.E.); (S.L.); (M.T.V.); (S.S.); (T.P.)
- Correspondence: ; Tel.: +49-(0)-0341/97-10759; Fax: +49-(0)-0341/97-17709
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Christopoulou A, Ardavanis A, Papandreou C, Koumakis G, Papatsimpas G, Papakotoulas P, Tsoukalas N, Andreadis C, Samelis G, Papakostas P, Aravantinos G, Ziras N, Souggleri M, Kalofonos C, Samantas E, Makrantonakis P, Pentheroudakis G, Athanasiadis A, Stergiou H, Bokas A, Grivas A, Tripodaki ES, Varthalitis I, Timotheadou E, Boukovinas I. Prophylaxis of cancer‑associated venous thromboembolism with low‑molecular‑weight heparin‑tinzaparin: Real world evidence. Oncol Lett 2022; 23:115. [PMID: 35251346 PMCID: PMC8850961 DOI: 10.3892/ol.2022.13235] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/15/2021] [Indexed: 11/05/2022] Open
Abstract
Thromboprophylaxis, as a preventive measure for cancer-associated thrombosis (CAT), may be beneficial for patients with active cancer and high-risk for thrombosis. The present post hoc analysis include a total of 407 patients enrolled in the Greek Management of Thrombosis study, who received thromboprophylaxis with tinzaparin. The objectives of the present analysis were: i) To obtain sufficient evidence for the administration of prophylaxis in patients with active cancer, irrespective of Khorana risk assessment model score; ii) to identify the selection criteria for both dose and duration of tinzaparin; and iii) to evaluate the efficacy and safety of tinzaparin administered for CAT prophylaxis. The main tumor types for the patients included in the present study were as follows: Lung (25.1%), pancreatic (14.3%), breast (9.1%), stomach (8.4%), colorectal (7.9%) and ovarian (7.6%). Furthermore, metastatic disease was observed in 69.5% of the patients. High thrombotic burden agents (HTBAs) were administered to 66.3% of the patients, and 17.4% received erythropoietin. A total of 43.7% of the patients exhibited a Khorana score <2. The results of the present study demonstrated that both the presence of metastatic disease and the use of HTBAs seemed to influence oncologists' decisions for the use of thromboprophylaxis in patients with active cancer, regardless of Khorana score. Tinzaparin, in dose expressed in the standard notation for heparins, i.e., anti-Xa factor international units (Anti-Xa IU), was administered at an intermediate dose (InterD; 8,000-12,000 Anti-Xa IU; once daily) to 52.4% of patients, while the remaining patients received a prophylactic dose (ProD; ≤4,500 Anti-Xa IU; once daily). The average duration of thromoprophylaxis was 5 months. Furthermore, a total of 14 (3.4%) thrombotic events and 6 (1.5%) minor bleeding events were recorded. A total of four thrombotic events were observed following an InterD treatment of tinzaparin, while 10 thrombotic events were observed following ProD treatment. The present study also demonstrated that an InterD of tinzaparin was administered more frequently to patients with a body mass index >30 kg/m2, a history of smoking and a history of metastatic disease, along with administration of erythropoietin. InterD tinzaparin treatment was found to be potentially more efficacious and without safety concerns. The present study is a registered clinical trial (ClinicalTrials.gov code, NCT03292107; registration date, September 25, 2017).
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Affiliation(s)
- Athina Christopoulou
- Oncology/Chemotherapy Department, ‘Saint Andrew’ General Hospital, 26335 Patras, Greece
| | - Alexandros Ardavanis
- 1st Department of Oncology, ‘Agios Savvas’ Anticancer Hospital, 11522 Athens, Greece
| | - Christos Papandreou
- Oncology Department, ‘Papageorgiou’ General Hospital, 56429 Thessaloniki, Greece
| | - Georgios Koumakis
- 1st Department of Oncology, ‘Agios Savvas’ Anticancer Hospital, 11522 Athens, Greece
| | | | - Pavlos Papakotoulas
- 1st Chemotherapy/Oncology Department, ‘Theagenio’ Anticancer Hospital, 54639 Thessaloniki, Greece
| | - Nikolaos Tsoukalas
- Oncology Department, 401 General Military Hospital, 11525 Athens, Greece
| | - Charalambos Andreadis
- 1st Chemotherapy/Oncology Department, ‘Theagenio’ Anticancer Hospital, 54639 Thessaloniki, Greece
| | - Georgios Samelis
- Oncology Department, ‘Ippokrateio’ General Hospital, 11527 Athens, Greece
| | - Pavlos Papakostas
- 2nd Oncology Department, Metropolitan General Hospital, 15562 Athens, Greece
| | - Gerasimos Aravantinos
- 2nd Oncology Department, ‘Agioi Anargyroi’ Anticancer Hospital, 14564 Athens, Greece
| | - Nikolaos Ziras
- Oncology Department, ‘Metaxa’ Anticancer Hospital, 18537 Piraeus, Greece
| | - Maria Souggleri
- Oncology/Chemotherapy Department, ‘Saint Andrew’ General Hospital, 26335 Patras, Greece
| | | | - Epameinondas Samantas
- 2nd Oncology Department, ‘Agioi Anargyroi’ Anticancer Hospital, 14564 Athens, Greece
| | | | | | | | - Helen Stergiou
- Oncology Department, Bioclinic Hospital, 54622 Thessaloniki, Greece
| | - Alexandros Bokas
- 1st Chemotherapy/Oncology Department, ‘Theagenio’ Anticancer Hospital, 54639 Thessaloniki, Greece
| | - Anastasios Grivas
- 1st Department of Oncology, ‘Agios Savvas’ Anticancer Hospital, 11522 Athens, Greece
| | - Elli-Sofia Tripodaki
- 1st Department of Oncology, ‘Agios Savvas’ Anticancer Hospital, 11522 Athens, Greece
| | | | - Eleni Timotheadou
- Oncology Department, ‘Papageorgiou’ General Hospital, 56429 Thessaloniki, Greece
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Wang L, Li S, Mo Y, Hu M, Zhang J, Zeng M, Li H, Zhao H. Gender-Disparities in the in-Hospital Clinical Outcome Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention. Int J Gen Med 2022; 15:593-602. [PMID: 35058710 PMCID: PMC8765440 DOI: 10.2147/ijgm.s343129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The current study was to evaluate the gender-disparities in the in-hospital thrombotic and bleeding events among patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). Patients and Methods Patients with CKD undergoing PCI were retrospectively enrolled. Baseline characteristics, and thrombotic and bleeding events occurred during hospitalization were collected and compared by gender. Results Compared to males (n = 558), females (n = 402) were older and more likely to have diabetes mellitus (37.1% vs 29.7%). Females had a lower estimated glomerular filtration rate (eGFR; 51.2 ± 7.9 vs 54.6 ± 5.1 mL/min/1.73m2) and were more likely to undergo urgent PCI (66.7% vs 60.2%) and use glycoprotein IIb/IIIa inhibitor (15.4% vs 7.5%) at peri-PCI period. Compared to males, females had a higher rate of in-hospital mortality which was due to thrombotic events (9.0% vs 3.4%). Females also had a higher rate of moderate-to-severe hemorrhage (8.0% vs 3.2%). After multivariable adjustment, diabetes mellitus (odds ratio [OR] 1.15 and 95% confidence interval [CI] 1.07–1.29) and acute coronary syndrome (ACS) presentation (OR 1.53 and 95% CI 1.34–1.93) were associated with gender-disparities in composite thrombotic events. Ageing (OR 1.10 and 95% CI 1.02–1.33), diabetes mellitus (OR 1.21 and 95% CI 1.07–1.40) and glycoprotein IIb/IIIa inhibitor use (OR 1.13 and 95% CI 1.02–1.28) were associated with composite bleeding events. Conclusion Females with CKD undergoing PCI had a higher risk of experiencing in-hospital thrombotic and bleeding events than males.
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Affiliation(s)
- Li Wang
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Sha Li
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Yihao Mo
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Mingliang Hu
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Junwei Zhang
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Min Zeng
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Huafeng Li
- Department of Nephrology, People's Hospital of Longhua District, Shenzhen, Guangdong, People's Republic of China
| | - Honglei Zhao
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Science, Shenzhen, Guangdong, People's Republic of China
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Li X, Zuo C, Ji Q, Wang Z, Lv Q. Impact of Renal Function on Effectiveness and Safety Associated With Low Dose Dabigatran in Non-valve Atrial Fibrillation Patients After Catheter Ablation. Front Cardiovasc Med 2021; 8:762872. [PMID: 34778414 PMCID: PMC8581241 DOI: 10.3389/fcvm.2021.762872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 11/28/2022] Open
Abstract
Aim: The purpose of this study is to compare the effectiveness and safety of 110 mg dabigatran in non-valve atrial fibrillation (NVAF) patients with different eGFRs. Methods: We conducted a single-center retrospective cohort study to investigate the effectiveness and safety of 110 mg dabigatran for NVAF patients between January 2017 and December 2018 based on the eGFR category. Results: A total of 560 NVAF patients who treated with 110 mg dabigatran were included for analysis. In 12 months, the Kaplan-Meier survival curves indicated that the lower eGFR subgroups were more likely to experience thrombosis, bleeding, and cumulative events earlier (P = 0.021 for thrombosis; P = 0.026 for bleeding; P = 0.001 for cumulative events). Gastrointestinal bleeding occurred more frequently in the moderate group than in other groups (6.94% in the moderate group vs. 1.54% in the mild group vs. 1.22% in the normal group, P = 0.028). By multivariate analysis, chronic kidney disease (P = 0.043; OR = 4.273, 95% CI 1.043–17.543) and diabetes mellitus (P = 0.023; OR = 2.194, 95% CI 1.114–4.323) were independent predictors of the composite endpoints. A positive linear relationship was observed between eGFR levels and occurrence rate of thrombosis and bleeding under anticoagulation patients with 110 mg dabigatran (R2 = 0.432 and R2 = 0.784, respectively). Conclusions: Impaired renal function was associated with decreased safety and increased thrombosis risks in NVAF patients taking low dose dabigatran.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chengchun Zuo
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiuyi Ji
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature. MEDICINA-LITHUANIA 2021; 57:medicina57090960. [PMID: 34577883 PMCID: PMC8471429 DOI: 10.3390/medicina57090960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and “real-world” studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.
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Zhou P, Wan J, Ran F, Gao F, Yang D, Dai X, Sun Y, Wang P. Development and validation of a prognostic prediction model for antithrombotic-related chronic subdural hematoma in patients with recent acute myocardial infarction. Cardiovasc Diagn Ther 2020; 10:1770-1784. [PMID: 33381422 DOI: 10.21037/cdt-20-763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Antithrombotic therapy is a cornerstone of acute myocardial infarction (AMI) treatment and is thought to be associated with an increased risk of chronic subdural hematoma (CSDH). However, no well-established model exists to predict subsequent antithrombotic treatment outcomes after CSDH in patients with recent AMI. We aimed to identify a prognostic model to predict the 6-month outcome of treatment with antithrombotic therapy. Methods This multicenter retrospective analysis involved 553 patients with recent AMI with antithrombotic-related CSDH. Several candidate clinical variables and biomarkers were examined in the training cohort (Chengdu training cohort; n=368). Patients with unfavorable outcomes had experienced at least 1 of the following: major adverse cardiovascular events (MACE), recurrence, or a modified Rankin scale (mRS) score of 2 to 6. To develop a 6-month outcome prediction model, three approaches were used: (I) a demographic variable model, (II) a clinical marker model and (III) a decision-driven model. A clinical outcome prediction model based on the superior predictors was assessed by logistic regression analysis. The nomogram for the final model was internally validated using a bootstrap procedure and externally validated in an independent cohort (Anhui cohort; n=185). Results Model A produced 7 predictors of unfavorable outcomes, while models B and C yielded 2 and 1 predictors, respectively. The areas under the curve (AUC) increased from 0.743 [model A; 95% confidence interval (CI): 0.680-0.782] to 0.889 (model A + B + C; 95% CI: 0.851-0.916). The final prediction model included age, systolic blood pressure (SBP), body mass index (BMI), the Glasgow Coma Scale (GCS), the estimated glomerular filtration rate (eGFR), the early resumption of antithrombotic therapy, hematoma thickness and the presence of abdominal obesity, frailty and previous bleeding. Internal and external validation of the selected final model revealed adequate C-statistics and calibration slope values (internal validation: 0.81 and 0.78; external validation: 0.80 and 0.76, respectively). Conclusions This model provided a risk stratification tool to predict unfavorable outcomes in patients with recent AMI with antithrombotic-related CSDH. Because the study was based on ten readily practical and available variables, it may be widely applicable to guide management and complement clinical assessment.
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Affiliation(s)
- Peng Zhou
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, Chengdu, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, China
| | - Jindong Wan
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, Chengdu, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, China
| | - Fei Ran
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, Chengdu, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, China
| | - Feng Gao
- Department of Cardiology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Dachun Yang
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Xiaozhen Dai
- School of Biosciences and Technology, Chengdu Medical College, Chengdu, China
| | - Yun Sun
- Department of Party Secretary, The First Affiliated Hospital, Chengdu Medical College, Chengdu, China
| | - Peijian Wang
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, Chengdu, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, China
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9
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Kumar S, Lim E, Covic A, Verhamme P, Gale CP, Camm AJ, Goldsmith D. Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:2204-2215. [PMID: 31648714 DOI: 10.1016/j.jacc.2019.08.1031] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/22/2019] [Accepted: 08/27/2019] [Indexed: 01/22/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist as they share multiple risk factors, including hypertension, diabetes mellitus, and coronary artery disease. Although there is irrefutable evidence supporting anticoagulation in AF in the general population, these data may not be transferable to the setting of advanced CKD, where the decision to commence anticoagulation poses a conundrum. In this cohort, there is a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, complicating the decision to initiate anticoagulation. No definitive clinical guidelines derived from randomized controlled trials exist to aid clinical decision-making, and the findings from observational studies are conflicting. In this review, the authors outline the pathophysiological mechanisms at play and summarize the limited existing data related to anticoagulation in those with concomitant CKD and AF. Finally, the authors suggest how to approach the decision of whether and how to use oral anticoagulation in these patients.
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Affiliation(s)
- Shankar Kumar
- Centre for Medical Imaging, University College London, London, United Kingdom; Imaging Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emma Lim
- Imaging Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - David Goldsmith
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania; Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom; Renal and Transplantation Department, Guys and St. Thomas' Hospitals NHS Foundation Trust, Great Maze Pond, London, United Kingdom.
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10
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Abstract
Advanced age and diabetes represent summative conditions in the determination of cardiovascular risk, and especially for the management of dual antiplatelet therapy (DAPT), often requiring balancing between bleeding and thrombotic complications. However, few studies have so far evaluated the impact of age on platelet reactivity and suboptimal platelet inhibition (high-on treatment platelet reactivity-HRPR) on DAPT among diabetic patients, that was, therefore the aim of the present study. In diabetic patients treated with DAPT (ASA + clopidogrel or ticagrelor) platelet reactivity was assessed at 30-90 days post-discharge for an acute coronary syndrome or elective PCI. Aggregation was assessed by multiple-electrode aggregometry. HRPR was defined for values above the lower limit of normality (in non-treated patients). Elderly patients were considered ≥ 75 years of age. We included 462 patients, among them 149 (32.2%) were ≥ 75 years. Elderly patients were more often females (p = 0.006), with lower body size (p = 0.04), acute coronary syndrome at presentation and renal failure (p < 0.001), non-smokers (p = 0.002), in therapy with insulin (p = 0.02) and diuretics (p < 0.001) and lower rate of betablockers (p = 0.02). Age directly related with C reactive protein (p = 0.01), creatinine levels and inversely with hemoglobin (p < 0.001) and triglycerides (p = 0.003). No association was found at linear regression analysis for platelet reactivity and age with different activating stimuli, but for ASPI test (r = 0.12; p = 0.03). No significant difference in HAPR was found in elderly patients (2.4 vs. 3.2%, p = 0.76, OR[95% CI] = 0.45[0.1-2.11], p = 0.31). HRPR for ADP antagonists was similarly not affected by age (30.1% vs. 35.7%, p = 0.28, adjusted OR[95% CI] = 0.78[0.47-1.29], p = 0.33). Comparable results were obtained when considering separately the DAPT strategies with clopidogrel or ticagrelor, or when adjusting our results according to propensity score values. Among diabetic patients receiving dual antiplatelet therapy for an acute coronary syndrome or elective percutaneous coronary intervention, age does not affect platelet reactivity or the rate of high-on treatment platelet reactivity. Similar results were obtained for ASA and clopidogrel or ticagrelor.
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11
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Burlacu A, Iftene A, Busoiu E, Cogean D, Covic A. Challenging the supremacy of evidence-based medicine through artificial intelligence: the time has come for a change of paradigms. Nephrol Dial Transplant 2019; 35:191-194. [PMID: 31697377 DOI: 10.1093/ndt/gfz203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/02/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Iftene
- Faculty of Computer Science, 'Alexandru Ioan Cuza' University of Iasi, Iasi, Romania
| | - Eugen Busoiu
- Artificial Intelligence Community, Iasi, Romania
| | - Dragos Cogean
- Software Development Gemini CAD Systems, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. Parhon' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
- The Academy of Romanian Scientists (AOSR)
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12
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Valdivielso JM, Rodríguez-Puyol D, Pascual J, Barrios C, Bermúdez-López M, Sánchez-Niño MD, Pérez-Fernández M, Ortiz A. Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol 2019; 39:1938-1966. [PMID: 31412740 DOI: 10.1161/atvbaha.119.312705] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with chronic kidney disease (CKD) are at an increased risk of premature mortality, mainly from cardiovascular causes. The association between CKD on hemodialysis and accelerated atherosclerosis was described >40 years ago. However, more recently, it has been suggested that the increase in atherosclerosis risk is actually observed in early CKD stages, remaining stable thereafter. In this regard, interventions targeting the pathogenesis of atherosclerosis, such as statins, successful in the general population, have failed to benefit patients with very advanced CKD. This raises the issue of the relative contribution of atherosclerosis versus other forms of cardiovascular injury such as arteriosclerosis or myocardial injury to the increased cardiovascular risk in CKD. In this review, the pathophysiogical contributors to atherosclerosis in CKD that are shared with the general population, or specific to CKD, are discussed. The NEFRONA study (Observatorio Nacional de Atherosclerosis en NEFrologia) prospectively assessed the prevalence and progression of subclinical atherosclerosis (plaque in vascular ultrasound), confirming an increased prevalence of atherosclerosis in patients with moderate CKD. However, the adjusted odds ratio for subclinical atherosclerosis increased with CKD stage, suggesting a contribution of CKD itself to subclinical atherosclerosis. Progression of atherosclerosis was closely related to CKD progression as well as to the baseline presence of atheroma plaque, and to higher phosphate, uric acid, and ferritin and lower 25(OH) vitamin D levels. These insights may help design future clinical trials of stratified personalized medicine targeting atherosclerosis in patients with CKD. Future primary prevention trials should enroll patients with evidence of subclinical atherosclerosis and should provide a comprehensive control of all known risk factors in addition to testing any additional intervention or placebo.
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Affiliation(s)
- José M Valdivielso
- From the Vascular & Renal Translational Research Group and UDETMA, IRBLleida. Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain (J.M.V., M.B.-L.)
| | - Diego Rodríguez-Puyol
- Nephrology Unit, Fundación para la investigación del Hospital Universitario Príncipe de Asturias, RedInRen, Alcalá de Henares, Madrid, Spain (D.R.-P.)
| | - Julio Pascual
- Department of Nephrology, Institute Mar for Medical Research, Hospital del Mar, RedInRen, Barcelona, Spain (J.P., C.B.)
| | - Clara Barrios
- Department of Nephrology, Institute Mar for Medical Research, Hospital del Mar, RedInRen, Barcelona, Spain (J.P., C.B.)
| | - Marcelino Bermúdez-López
- From the Vascular & Renal Translational Research Group and UDETMA, IRBLleida. Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain (J.M.V., M.B.-L.)
| | - Maria Dolores Sánchez-Niño
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and RedInRen, Madrid, Spain (M.D.S.-N., A.O.)
| | | | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and RedInRen, Madrid, Spain (M.D.S.-N., A.O.)
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13
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Which anticoagulants should be used for stroke prevention in non-valvular atrial fibrillation and severe chronic kidney disease? Curr Opin Nephrol Hypertens 2018; 27:420-425. [DOI: 10.1097/mnh.0000000000000443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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14
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Covic A, Genovesi S, Rossignol P, Kalra PA, Ortiz A, Banach M, Burlacu A. Practical issues in clinical scenarios involving CKD patients requiring antithrombotic therapy in light of the 2017 ESC guideline recommendations. BMC Med 2018; 16:158. [PMID: 30227855 PMCID: PMC6145111 DOI: 10.1186/s12916-018-1145-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/03/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The choice of the most appropriate antithrombotic regimen that balances ischemic and bleeding risks was addressed by the August 2017 European Society of Cardiologists (ESC)/European Association for Cardio-Thoracic Surgery Focused Update recommendations, which propose new evaluation scores and protocols for patients requiring a coronary stent or patients with an acute coronary syndrome, atrial fibrillation, or a high bleeding risk and indication for oral anticoagulation therapy. DISCUSSION Numerous questions remain regarding antithrombotic regimens and risk management algorithms for both ischemic and hemorrhagic events in patients with chronic kidney disease (CKD) in various clinical scenarios. Limitations of current studies include a general ack of advanced CKD patients in major randomized controlled trials, of evidence on algorithm implementation, and of robust assessment tools for hemorrhagic risk. Herein, we aim to analyze the ESC Update recommendations and the newly implemented risk scores (DAPT, PRECISE-DAPT, PARIS) from the point of view of CKD, providing suggestions on drug choice (which combination has the best evidence), dosage, and duration (the same or different as for non-CKD population) of antithrombotics, as well as to identify current shortcomings and to envision directions of future research. CONCLUSION We provide an evidence-based perspective on the new proposed bleeding management protocol, with focus on the CKD population. Despite previous important steps on antithrombotic therapy of renal patients, there remain many unsolved questions for which our suggestions could fundament new randomized controlled trials and specific protocols.
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Affiliation(s)
- Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Inserm U1116, CHRU Nancy, Nancy, France.,Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Philip A Kalra
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, 'Grigore T. Popa' University of Medicine, Iasi, Romania.
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