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Perike S, Gonzalez-Gonzalez FJ, Abu-Taha I, Damen FW, Hanft LM, Lizama KS, Aboonabi A, Capote AE, Aguilar-Sanchez Y, Levin B, Han Z, Sridhar A, Grand J, Martin J, Akar JG, Warren CM, Solaro RJ, Sang-Ging O, Darbar D, McDonald KS, Goergen CJ, Wolska BM, Dobrev D, Wehrens XH, McCauley MD. PPP1R12C Promotes Atrial Hypocontractility in Atrial Fibrillation. Circ Res 2023; 133:758-771. [PMID: 37737016 PMCID: PMC10616980 DOI: 10.1161/circresaha.123.322516] [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: 01/11/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Atrial fibrillation (AF)-the most common sustained cardiac arrhythmia-increases thromboembolic stroke risk 5-fold. Although atrial hypocontractility contributes to stroke risk in AF, the molecular mechanisms reducing myofilament contractile function remain unknown. We tested the hypothesis that increased expression of PPP1R12C (protein phosphatase 1 regulatory subunit 12C)-the PP1 (protein phosphatase 1) regulatory subunit targeting MLC2a (atrial myosin light chain 2)-causes hypophosphorylation of MLC2a and results in atrial hypocontractility. METHODS Right atrial appendage tissues were isolated from human patients with AF versus sinus rhythm controls. Western blots, coimmunoprecipitation, and phosphorylation studies were performed to examine how the PP1c (PP1 catalytic subunit)-PPP1R12C interaction causes MLC2a dephosphorylation. In vitro studies of pharmacological MRCK (myotonic dystrophy kinase-related Cdc42-binding kinase) inhibitor (BDP5290) in atrial HL-1 cells were performed to evaluate PP1 holoenzyme activity on MLC2a. Cardiac-specific lentiviral PPP1R12C overexpression was performed in mice to evaluate atrial remodeling with atrial cell shortening assays, echocardiography, and AF inducibility with electrophysiology studies. RESULTS In human patients with AF, PPP1R12C expression was increased 2-fold versus sinus rhythm controls (P=2.0×10-2; n=12 and 12 in each group) with >40% reduction in MLC2a phosphorylation (P=1.4×10-6; n=12 and 12 in each group). PPP1R12C-PP1c binding and PPP1R12C-MLC2a binding were significantly increased in AF (P=2.9×10-2 and 6.7×10-3, respectively; n=8 and 8 in each group). In vitro studies utilizing drug BDP5290, which inhibits T560-PPP1R12C phosphorylation, demonstrated increased PPP1R12C binding with both PP1c and MLC2a and dephosphorylation of MLC2a. Mice treated with lentiviral PPP1R12C vector demonstrated a 150% increase in left atrial size versus controls (P=5.0×10-6; n=12, 8, and 12), with reduced atrial strain and atrial ejection fraction. Pacing-induced AF in mice treated with lentiviral PPP1R12C vector was significantly higher than in controls (P=1.8×10-2 and 4.1×10-2, respectively; n=6, 6, and 5). CONCLUSIONS Patients with AF exhibit increased levels of PPP1R12C protein compared with controls. PPP1R12C overexpression in mice increases PP1c targeting to MLC2a and causes MLC2a dephosphorylation, which reduces atrial contractility and increases AF inducibility. These findings suggest that PP1 regulation of sarcomere function at MLC2a is a key determinant of atrial contractility in AF.
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Affiliation(s)
- Srikanth Perike
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
- Jesse Brown VA Medical Center, Chicago, IL
| | - Francisco J. Gonzalez-Gonzalez
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
- Jesse Brown VA Medical Center, Chicago, IL
| | - Issam Abu-Taha
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Germany
| | - Frederick W. Damen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | - Laurin M. Hanft
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia
| | - Ken S. Lizama
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
- Jesse Brown VA Medical Center, Chicago, IL
| | - Anahita Aboonabi
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
| | - Andrielle E. Capote
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
| | - Yuriana Aguilar-Sanchez
- Department of Integrative Physiology and The Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
| | | | - Zhenbo Han
- Department of Pharmacology and Regenerative Medicine, College of Medicine,University of Illinois at Chicago
| | - Arvind Sridhar
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
| | - Jacob Grand
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
| | | | | | - Chad M. Warren
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
| | - R. John Solaro
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
| | - Ong Sang-Ging
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Pharmacology and Regenerative Medicine, College of Medicine,University of Illinois at Chicago
| | - Dawood Darbar
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
- Jesse Brown VA Medical Center, Chicago, IL
| | - Kerry S. McDonald
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia
| | - Craig J. Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | - Beata M. Wolska
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Germany
- Department of Integrative Physiology and The Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
- Department of Medicine, Montréal Heart Institute and Université de Montréal, Montréal, Canada
| | - Xander H.T. Wehrens
- Department of Integrative Physiology and The Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
| | - Mark D. McCauley
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, University of Illinois at Chicago
- Jesse Brown VA Medical Center, Chicago, IL
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Perike S, Gonzalez-Gonzalez FJ, Abu-Taha I, Damen FW, Lizama KS, Aboonabi A, Capote AE, Aguilar-Sanchez Y, Levin B, Han Z, Sridhar A, Grand J, Martin J, Akar JG, Warren CM, Solaro RJ, Ong SG, Darbar D, Goergen CJ, Wolska BM, Dobrev D, Wehrens XHT, McCauley MD. Myosin Light Chain Dephosphorylation by PPP1R12C Promotes Atrial Hypocontractility in Atrial Fibrillation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.19.537590. [PMID: 37131731 PMCID: PMC10153354 DOI: 10.1101/2023.04.19.537590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, increases thromboembolic stroke risk five-fold. Although atrial hypocontractility contributes to stroke risk in AF, the molecular mechanisms reducing myofilament contractile function remain unknown. We tested the hypothesis that increased expression of PPP1R12C, the PP1 regulatory subunit targeting atrial myosin light chain 2 (MLC2a), causes hypophosphorylation of MLC2a and results in atrial hypocontractility. Methods Right atrial appendage tissues were isolated from human AF patients versus sinus rhythm (SR) controls. Western blots, co-immunoprecipitation, and phosphorylation studies were performed to examine how the PP1c-PPP1R12C interaction causes MLC2a de-phosphorylation. In vitro studies of pharmacologic MRCK inhibitor (BDP5290) in atrial HL-1 cells were performed to evaluate PP1 holoenzyme activity on MLC2a. Cardiac-specific lentiviral PPP1R12C overexpression was performed in mice to evaluate atrial remodeling with atrial cell shortening assays, echocardiography, and AF inducibility with EP studies. Results In human patients with AF, PPP1R12C expression was increased two-fold versus SR controls ( P =2.0×10 -2 , n=12,12 in each group) with > 40% reduction in MLC2a phosphorylation ( P =1.4×10 -6 , n=12,12 in each group). PPP1R12C-PP1c binding and PPP1R12C-MLC2a binding were significantly increased in AF ( P =2.9×10 -2 and 6.7×10 -3 respectively, n=8,8 in each group). In vitro studies utilizing drug BDP5290, which inhibits T560-PPP1R12C phosphorylation, demonstrated increased PPP1R12C binding with both PP1c and MLC2a, and dephosphorylation of MLC2a. Lenti-12C mice demonstrated a 150% increase in LA size versus controls ( P =5.0×10 -6 , n=12,8,12), with reduced atrial strain and atrial ejection fraction. Pacing-induced AF in Lenti-12C mice was significantly higher than controls ( P =1.8×10 -2 and 4.1×10 -2 respectively, n= 6,6,5). Conclusions AF patients exhibit increased levels of PPP1R12C protein compared to controls. PPP1R12C overexpression in mice increases PP1c targeting to MLC2a and causes MLC2a dephosphorylation, which reduces atrial contractility and increases AF inducibility. These findings suggest that PP1 regulation of sarcomere function at MLC2a is a key determinant of atrial contractility in AF.
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Jansson M, Själander S, Sjögren V, Björck F, Renlund H, Norrving B, Själander A. Reduced dose direct oral anticoagulants compared with warfarin with high time in therapeutic range in nonvalvular atrial fibrillation. J Thromb Thrombolysis 2023; 55:415-425. [PMID: 36607464 PMCID: PMC10110706 DOI: 10.1007/s11239-022-02763-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 01/07/2023]
Abstract
Direct oral anticoagulants (DOACs) used in nonvalvular atrial fibrillation (NVAF) are dose-reduced in elderly and patients with impaired renal function. Only reduced dose dabigatran is concluded as having similar stroke risk reduction and lower risk of major bleeding than warfarin in the pivotal studies. In clinical practice, reduced dose is prescribed more often than expected making this an important issue. The objective of this study was to compare effectiveness and safety between reduced dose DOACs and high TTR warfarin treatment (TTR ≥ 70%) in NVAF. A Swedish anticoagulation registry was used in identifying eligible patients from July 2011 to December 2017. The study cohort consisted of 40,564 patients with newly initiated DOAC (apixaban, dabigatran, or rivaroxaban) (11,083 patients) or warfarin treatment (29,481 patients) after exclusion of 374,135 patients due to not being warfarin or DOAC naïve, not being prescribed reduced dose, having previous mechanical heart valve (MHV), or being under 18 years old. The median durations of follow up were 365, 419, 432 and 473 days for apixaban, dabigatran, rivaroxaban and warfarin, respectively. Warfarin TTR identified from Auricula was 70.0%. Endpoints (stroke and major bleeding) and baseline characteristics were collected from hospital administrative registers using ICD-10 codes. Cohorts were compared using weighted adjusted Cox regression after full optimal matching based on propensity scores. DOACs are associated with lower risk of major bleeding (HR with 95% CI) 0.85 (0.78-0.93), intracranial bleeding HR 0.64 (0.51-0.80), hemorrhagic stroke HR 0.68 (0.50-0.92), gastrointestinal bleeding HR 0.81 (0.69-0.96) and all-cause stroke HR 0.87 (0.76-0.99), than warfarin. Apixaban and dabigatran are associated with lower risk of major bleeding, HR 0.70 (0.63-0.78) and HR 0.80 (0.69-0.94), and rivaroxaban is associated with lower risk of ischemic stroke, HR 0.73 (0.59-0.96), with higher major bleeding risk, HR 1.31 (1.15-1.48), compared to warfarin. Apixaban is associated with higher all-cause mortality compared to warfarin, HR 1.12 (1.03-1.21). DOACs are associated with lower risk of major bleeding and all-cause stroke, than high quality warfarin treatment, with exception of rivaroxaban that carried higher risk of major bleeding and lower risk of stroke or systemic embolism. In this large observational registry-based NVAF cohort, DOACs are preferred treatment in patients with indication for DOAC dose reduction, even in a high TTR setting.
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Affiliation(s)
- M Jansson
- Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden. .,Cardiology Department, Sundsvall Hospital, 856 43, Sundsvall, Sweden.
| | - S Själander
- Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden
| | - V Sjögren
- Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden
| | - F Björck
- Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden
| | - H Renlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - B Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - A Själander
- Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden
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Jansson M, Själander S, Sjögren V, Renlund H, Norrving B, Själander A. Direct comparisons of effectiveness and safety of treatment with Apixaban, Dabigatran and Rivaroxaban in atrial fibrillation. Thromb Res 2020; 185:135-141. [DOI: 10.1016/j.thromres.2019.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/29/2022]
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Profiles of Clinical Need Among Homeless Individuals with Dual Diagnoses. Community Ment Health J 2019; 55:1305-1312. [PMID: 31236735 DOI: 10.1007/s10597-019-00432-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
This study explored patterns of clinical need among homeless individuals with dual diagnoses, and explored whether certain profiles are characteristic of different demographic groups. Data were drawn from two larger studies conducted with dually diagnosed, homeless individuals (n = 373). Hierarchical cluster analysis identified four subgroups: (1) Clinically least severe, characterized by less frequent psychological symptoms and no history of physical or sexual abuse; (2) Moderate clinical needs, including shorter history of substance use and less frequent psychological symptoms, but symptoms consistent with severe mental illness; (3) Clinically severe, with frequent anxiety, depression, past and recent physical or sexual abuse, and long history of substance use; (4) Least frequent psychological symptoms, but frequent history of physical or sexual abuse and long history of drug use. Women veterans were mostly likely to be classified in cluster 3, and male civilians in cluster 2. Subgroups of homeless individuals with dual diagnoses demonstrated different clusters of clinical needs, having implications for service delivery to the population.
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Verdecchia P, Vedovati MC, Conti S, Giustozzi M, Aita A, Molini G, Angeli F, Turturiello D, Becattini C, Cavallini C, Agnelli G. Long-term outcome in patients with non-valvular atrial fibrillation on dabigatran: a prospective cohort study. Expert Opin Drug Saf 2018; 17:1063-1069. [PMID: 30260252 DOI: 10.1080/14740338.2018.1529166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Most studies on thromboembolic and bleeding risk in patients with non-valvular atrial fibrillation (NVAF) exposed to non-vitamin K oral anticoagulants stem from interrogation of insurance databases. Areas covered: We studied 742 consecutive patients with NVAF who started treatment with dabigatran in three hospitals in Italy. Average follow-up was 1.80 years. Mean age was 76.2 years. CHA2DS2VASc score was 0-1 in 37 (5%), 2 in 97 (13%) and ≥ 3 in 604 (82%) patients. NVAF was permanent in 349 (48%). Overall, 76% of patients remained on treatment over the entire follow-up period. Among 180 patients who discontinued permanently, the most frequent reasons were dyspepsia (33.9%), bleeding (17.8%), and renal worsening (12.1%). About 48% and 74% of permanent discontinuations occurred during the first 6 and 12 months of treatment, respectively. Rates of major events (per 100 patient-years) were 0.75 for stroke, 0.31 for myocardial infarction, 1.50 for all-cause death, and 1.80 for major bleedings. The rate of intracranial bleedings was 0.45 and that of major gastrointestinal bleedings was 0.75. Expert opinion: This prospective cohort study confirms the low incidence of stroke, major bleeding and intracranial bleeding, and a 76% persistence with treatment, in patients with NVAF treated with dabigatran over about 2 years.
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Affiliation(s)
- Paolo Verdecchia
- a Division of Cardiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Maria Cristina Vedovati
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Serenella Conti
- c Division of Cardiology , S. Matteo degli Infermi Hospital , Spoleto , Italy
| | - Michela Giustozzi
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Adolfo Aita
- d Department of Medicine , Hospital of Assisi , Assisi , Italy
| | | | - Fabio Angeli
- e Division of Cardiology and Cardiovascular Pathophysiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Dario Turturiello
- e Division of Cardiology and Cardiovascular Pathophysiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Cecilia Becattini
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Claudio Cavallini
- a Division of Cardiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Giancarlo Agnelli
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
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Abstract
Direct oral anticoagulants (DOACs) have been introduced within the last years as alternative to vitamin K antagonists (VKAs) as oral anticoagulant drugs (OAC). The mean/median age of the patients included in DOAC-investigating trials was 70-72 years. The age-pattern of patients to whom DOAC are prescribed in clinical settings is largely unknown. Thus, aim of the study was to assess the age-pattern of patients who received OAC in the years 2011-2014 in Austria. The data analysis refers to the accounting data of the 13 major health insurance funds, covering >97 % of the Austrian population. The number of patients who received OAC in 2011-2014 increased by 43 % (182,464-261,347). Patients who received DOACs increased nearly fivefold (20,927-96,247), whereas patients who received VKAs increased by only 2 % (161,537-165,100). In 2011, the age of patients receiving VKAs was higher than DOACs (72 vs. 68 years), whereas in 2014, the age of the patients receiving VKAs was lower than DOACs (73 vs. 74 years). The proportion of patients ≥80 years receiving VKAs declined from 26 to 21 % of all OAC, receiving DOACs increased from 1 to 12 %. Among nonagenarians, the proportion of patients receiving VKAs remained 2 % (3316-5858), whereas the proportion of patients receiving DOACs increased 40-fold (91-4296). DOACs are prescribed to patients ≥80 years, although there are is a lack of data about efficacy and safety. There is an urgent need for data about this patient group. Since a randomized trial is rather unlikely in this specific age group we suggest subgroup analyses about octo-and nonagenarians, in case they have been included in previously completed or still ongoing trials or registries for OAC.
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Prisco D, Ageno W, Becattini C, D'Angelo A, Davì G, De Cristofaro R, Dentali F, Di Minno G, Falanga A, Gussoni G, Masotti L, Palareti G, Pignatelli P, Santi RM, Santilli F, Silingardi M, Tufano A, Violi F. Italian intersociety consensus on DOAC use in internal medicine. Intern Emerg Med 2017; 12:387-406. [PMID: 28191610 DOI: 10.1007/s11739-017-1628-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/02/2017] [Indexed: 12/15/2022]
Abstract
The direct oral anticoagulants (DOACs) are drugs used in clinical practice since 2009 for the prevention of stroke or systemic embolism in non-valvular atrial fibrillation, and for the treatment and secondary prevention of venous thromboembolism. The four DOACs, including the three factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and one direct thrombin inhibitor (dabigatran) provide oral anticoagulation therapy alternatives to Vitamin K antagonists (VKAs). Despite their clear advantages, the DOACs require on the part of the internist a thorough knowledge of their pharmacokinetic and pharmacodynamic characteristics to ensure their correct use, laboratory monitoring and the appropriate management of adverse events. This document represents a consensus paper on the use of DOACs by representatives of three Italian scientific societies: the Italian Society of Internal Medicine (SIMI), the Federation of the Associations of Hospital Managers (FADOI), and the Society for the Study of Haemostasis and Thrombosis (SISET). This document formulates expert opinion guidance for pragmatic managing, monitoring and reversing the anticoagulant effect of DOACs in both chronic and emergency settings. This practical guidance may help the internist to create adequate protocols for patients hospitalized ion internal medicine wards, where patients are often elderly subjects affected by poly-morbidities and renal insufficiency, and, thus, require particular attention to drug-drug interactions and peri-procedural protocols.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Giovanni Davì
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Raimondo De Cristofaro
- Institute of Internal Medicine and Geriatrics, Center for Haemorrhagic and Thrombotic Diseases, Haematology, Foundation Policlinico universitario "Agostino Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giovanni Di Minno
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, and the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto M Santi
- Haemostasis and Thrombosis Unit, Haematology, Az. Osp. "SS.Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | - Francesca Santilli
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Mauro Silingardi
- Internal Medicine Unit A - Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Antonella Tufano
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
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Abstract
The prevalence and embolic risk of atrial fibrillation (AF) increase with age. Vitamin K antagonists (VKAs) or direct-acting oral anticoagulants (DOACs) reduce the risk of stroke or embolism. The aim of this review was to summarize the paucity of information regarding the safety and efficacy of DOACs in AF patients aged 90 years or older. The maximum age of included patients is not listed in any of the available DOAC investigating trials and registries, thus it is unclear if nonagenarians were included. Additionally, we could not find any subgroup analysis addressing this issue. There is an urgent need to collect more information on the safety and efficacy of oral anticoagulants in nonagenarians, especially regarding the role of DOACs, which are increasingly prescribed to this group of patients despite the lack of data. The best solution to this problem would be a prospective, randomized trial in this group of patients, however that would require a large investment of time, effort, and funds. In the meantime, we suggest subgroup analyses addressing the effects and safety of VKAs versus DOACs in nonagenarians, in case they have been included in previously completed or ongoing trials or registries. This could be feasible and would be desirable in view of the large amount of data already accumulated. Irrespective of age, anemia in patients receiving DOACs should be carefully investigated to rule out occult blood loss. With their known interaction profile and the possibility of monitoring these drugs, VKAs should be favored over DOACs in nonagenarians until more data are available regarding the safety of DOACs.
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Cayla G, Leclercq F, Schmutz L, Cornillet L, Ledermann B, Messner P, Lattuca B. Syndrome coronaire aigu : y a-t-il une place pour les anticoagulants oraux directs ? Presse Med 2016; 45:919-925. [DOI: 10.1016/j.lpm.2016.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/10/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022] Open
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Plitt A, Ruff CT, Giugliano RP. Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation. Hematol Oncol Clin North Am 2016; 30:1019-34. [DOI: 10.1016/j.hoc.2016.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Martins RP, Galand V, Colette E, Behar N, Pavin D, Leclercq C, Daubert JC, Mabo P. Defining nonvalvular atrial fibrillation: A quest for clarification. Am Heart J 2016; 178:161-7. [PMID: 27502864 DOI: 10.1016/j.ahj.2016.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/25/2016] [Indexed: 12/17/2022]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are currently recommended for patients with nonvalvular atrial fibrillation since the publication of the 4 major pivotal trials evaluating the efficacy and safety of factor IIa and factor Xa inhibitors. The definition of nonvalvular atrial fibrillation is unclear, varying from one trial to another and even between North American and European guidelines, which is a source of uncertainties in clinical practice. However, many patients with atrial fibrillation present signs of valvular involvement, and clarification of this term is needed to not deny NOACs to patients based on the wrong perception that they may have valvular atrial fibrillation. The currently unique contraindications to NOACs are patients with mechanical heart valves and those with moderate-to-severe mitral stenosis, as stated by the recent 2015 position paper of the European Heart Rhythm Association. Patients with native heart valve involvement, regardless of their severity, are suitable for NOAC therapy. Patients with bioprosthetic heart valves and mitral valve repair may be suitable for NOACs except for the first 3 and the first 3-6 months postoperatively, respectively. Patients with transaortic valve implantation or percutaneous transluminal aortic valvuloplasty are also considered as being eligible for NOACs, although the bleeding risk has to be carefully considered in this population often requiring a combination with antiplatelet therapy. Future studies are warranted to increase the level of evidence of use of NOACs, particularly in patients with transaortic valve implantation and valvular surgery, and to determine whether they could be used in the future in the only 2 remaining contraindications.
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Appelmann I, Kreher S, Parmentier S, Wolf HH, Bisping G, Kirschner M, Bergmann F, Schilling K, Brümmendorf TH, Petrides PE, Tiede A, Matzdorff A, Griesshammer M, Riess H, Koschmieder S. Diagnosis, prevention, and management of bleeding episodes in Philadelphia-negative myeloproliferative neoplasms: recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society of Thrombosis and Hemostasis Research (GTH). Ann Hematol 2016; 95:707-18. [PMID: 26916570 DOI: 10.1007/s00277-016-2621-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/31/2022]
Abstract
Philadelphia-negative myeloproliferative neoplasms (Ph-negative MPN) comprise a heterogeneous group of chronic hematologic malignancies. The quality of life, morbidity, and mortality of patients with MPN are primarily affected by disease-related symptoms, thromboembolic and hemorrhagic complications, and progression to myelofibrosis and acute leukemia. Major bleeding represents a common and important complication in MPN, and the incidence of such bleeding events will become even more relevant in the future due to the increasing disease prevalence and survival of MPN patients. This review discusses the causes, differential diagnoses, prevention, and management of bleeding episodes in patients with MPN, aiming at defining updated standards of care in these often challenging situations.
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Affiliation(s)
- Iris Appelmann
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Stephan Kreher
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Stefani Parmentier
- Department of Hematology, Oncology, and Palliative Medicine, Rems-Murr-Klinikum Winnenden, Winnenden, Germany
| | - Hans-Heinrich Wolf
- Department of Internal Medicine IV, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, Rheine, Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Frauke Bergmann
- Medizinisches Versorgungszentrum Wagnerstibbe, Hannover, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Petro E Petrides
- Hematology Oncology Centre, Ludwig Maximilians University of Munich Medical School, Munich, Germany
| | - Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem-Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Axel Matzdorff
- Clinic for Internal Medicine II, Dept. of Hematology, Oncology, Asklepios Clinic Uckermark, Schwedt/Oder, Germany
| | | | - Hanno Riess
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany.
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14
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Zoppellaro G, Granziera S, Padayattil Jose S, Denas G, Bracco A, Iliceto S, Pengo V. Minimizing the risk of hemorrhagic stroke during anticoagulant therapy for atrial fibrillation. Expert Opin Drug Saf 2015; 14:683-95. [DOI: 10.1517/14740338.2015.1024222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Giacomo Zoppellaro
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
| | - Serena Granziera
- 2University of Padua, Geriatric Clinic, Department of Medicine - DIMED, Padua, Italy
| | - Seena Padayattil Jose
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
| | - Gentian Denas
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
| | - Alessia Bracco
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
| | - Sabino Iliceto
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
| | - Vittorio Pengo
- 1University of Padua, Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, Padua, Italy ;
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