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Kengkla K, Nathisuwan S, Sripakdee W, Saelue P, Sengnoo K, Sookprasert A, Subongkot S. Trends in Anticoagulant Utilization and Clinical Outcomes for Cancer-Associated Thrombosis: A Multicenter Cohort Study in Thailand's Upper-Middle-Income Country Setting. JCO Glob Oncol 2024; 10:e2300353. [PMID: 38422463 PMCID: PMC10914243 DOI: 10.1200/go.23.00353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 03/02/2024] Open
Abstract
PURPOSE To evaluate anticoagulant trends and clinical outcomes in the management of cancer-associated thrombosis (CAT) within Thailand, an upper-middle-income country (UMIC). METHODS This multicenter retrospective cohort study included adult patients with cancer diagnosed with venous thromboembolism (VTE) hospitalized in Thailand from 2017 to 2021. Anticoagulants were classified as low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and warfarin. Prescription trends were assessed, and patients were followed for 1 year, or until 2022 to evaluate outcomes. The primary effectiveness outcome was recurrent VTE, whereas the primary safety outcome was major bleeding. Secondary outcomes included net clinical benefit and all-cause mortality. Treatment effects were examined using inverse probability of treatment weighting (IPTW) Cox proportional hazards models. RESULTS Among 1,611 patients (61.3% female; mean age, 58.8 years; standard deviation, 13.1 years), 86% received LMWH, 10% warfarin, and 4% DOACs. In the study cohort, LMWH prescriptions remained consistent, warfarin use declined, and DOAC prescriptions notably increased. In IPTW analysis, DOACs showed comparable rates of VTE recurrence (weighted hazard ratio [HR], 0.77 [95% CI, 0.22 to 2.70]; P = .679) and major bleeding (weighted HR, 0.62 [95% CI, 0.15 to 2.55]; P = .506) with LMWH. Warfarin had a higher risk of major bleeding (weighted HR, 2.74 [95% CI, 1.12 to 6.72]; P = .028) but a similar rate of VTE recurrence (weighted HR, 1.46 [95% CI, 0.75 to 2.84]; P = .271) compared with LMWH. Secondary outcomes were consistent across groups. CONCLUSION LMWH remains the primary treatment for CAT, in line with current guidelines. The study highlights the challenges faced in these settings with the continuous use of warfarin. The comparable efficacy and safety of DOACs with LMWH suggest a potential shift in CAT management within UMICs.
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Affiliation(s)
- Kirati Kengkla
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
- The College of Pharmacotherapy of Thailand, Nonthaburi, Thailand
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Warunsuda Sripakdee
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Pirun Saelue
- Hematology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Aumkhae Sookprasert
- Medical Oncology Unit, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Suphat Subongkot
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
- The College of Pharmacotherapy of Thailand, Nonthaburi, Thailand
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2
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Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, Kamiya Y, Shigeta K, Okubo S, Hayakawa M, Ishii N, Koguchi Y, Takigawa T, Inoue M, Naito H, Ota T, Hirano T, Kato N, Ueda T, Iguchi Y, Akaji K, Tsuruta W, Miki K, Fujimoto S, Higashida T, Iwasaki M, Aoki J, Nishiyama Y, Otsuka T, Kimura K. The impact of SAH finding on CT to the clinical outcome after mechanical thrombectomy for large vessel occlusion. J Neurol Sci 2023; 453:120797. [PMID: 37703704 DOI: 10.1016/j.jns.2023.120797] [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: 07/02/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND PURPOSE Whether subarachnoid haemorrhage (SAH) after mechanical thrombectomy affects the clinical outcomes of patients with acute large-vessel occlusion remains unclear. This study aimed to investigate the clinical impact of SAH on computed tomography (CT) after mechanical thrombectomy. METHODS The SKIP study was an investigator-initiated, multicentre, randomised, open-label clinical trial. This study was performed in 23 hospital networks in Japan from January 1, 2017, to July 31, 2019. Among the 204 patients, seven were excluded because they did not undergo mechanical thrombectomy (MT) and had a modified Rankin scale (mRS) score > 2. The main outcome was the association between SAH within 36 h after mechanical thrombectomy and the clinical outcome at 90 days. RESULTS Among 197 patients, the median age was 74 (67-79) years, 62.9% were male. Moreover, 26 (13.2%) patients had SAH (seven isolated SAH) on CT within 36 h. The SAH rate did not differ according to IV rt-PA administration (p = 0.4). The rate of favourable clinical outcomes tended to be lower in patients with SAH rather than patients without SAH (11 [42%] vs. 106 [62%], p = 0.08). Among the seven patients with isolated SAH, 6 showed favourable outcomes at 90 days. In the multivariate regression analysis, the presence of SAH within 36 h from onset was not associated with clinical outcome (Odd ratio, 0.59; 95% confidence interval, 0.18-1.95; p = 0.38). CONCLUSIONS Among patients with acute stroke treated with MT, SAH, especially isolated SAH findings on CT, were not associated with poor clinical outcomes after 90 days. TRIAL REGISTRATION NUMBER UMIN000021488.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | | | - Yohei Takayama
- Department of Neurology, Akiyama Neurosurgical Hospital, Kanagawa, Japan
| | - Yuki Kamiya
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Norihiro Ishii
- Department of Neurosurgery, New Tokyo Hospital, Chiba, Japan
| | - Yorio Koguchi
- Department of Neurology and Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Masato Inoue
- Department of Neurosurgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiromichi Naito
- Department of Neurosurgery, Funabashi Municipal Medical Center, Chiba, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Ibaraki, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kanagawa, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine, Tokyo, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Kazunori Miki
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Mitsuhiro Iwasaki
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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3
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Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, Sanmartin Fernández M, Arribas F, Masjuan J, Barrios V, Cosin-Sales J, Freixa-Pamias R, Recalde E, Pérez-Cabeza AI, Manuel Vázquez Rodríguez J, Ràfols Priu C, Anguita Sánchez M, Lip GYH, Marin F. Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:38-46. [PMID: 36318457 DOI: 10.1093/ehjcvp/pvac060] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study. METHODS AND RESULTS EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2 ± 9.7 (44.5% female). Mean HAS-BLED score was 1.6 ± 1.0 and ORBIT score was 1.1 ± 1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P <0.001] and AUC 0.765 (95% CI 0.672-0.858; P <0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P = 0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P = 0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients. CONCLUSION In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.
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Affiliation(s)
- María A Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - José M Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, IMIB-Arrixaca, 30008 Murcia, Spain
| | | | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigacion Sanitaria Hospital 12 de Octubre (IMAS 12); CIBERCV, 28041 Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Juan Cosin-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, 46015 Valencia, Spain
| | | | - Esther Recalde
- Department of Cardiology, Hospital Universitario de Basurto, 48013 Bilbao, Spain
| | - Alejandro I Pérez-Cabeza
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, CIBERCV, 29010 Málaga, Spain
| | | | | | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Reina Sofía Córdoba, IMIBIC, University of Cordoba, 14004 Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, L69 7TX Liverpool, UK.,Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
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4
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Shami JJP, Zhao J, Pathadka S, Wan EYF, Blais JE, Vora P, Soriano-Gabarró M, Cheung KS, Leung WK, Wong ICK, Chan EW. Safety and effectiveness of low-dose aspirin for the prevention of gastrointestinal cancer in adults without atherosclerotic cardiovascular disease: a population-based cohort study. BMJ Open 2022; 12:e050510. [PMID: 35121597 PMCID: PMC8819826 DOI: 10.1136/bmjopen-2021-050510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the association between low-dose aspirin and the incidence of colorectal cancer (CRC), gastric cancer (GC), oesophageal cancer (EC) and gastrointestinal bleeding (GIB) in adults without established atherosclerotic cardiovascular disease. DESIGN Cohort study with propensity score matching of new-users of aspirin to non-users. SETTING Clinical Data Analysis and Reporting System database, Hong Kong. PARTICIPANTS Adults ≥40 years with a prescription start date of either low-dose aspirin (75-300 mg/daily) or paracetamol (non-aspirin users) between 1 January 2004 to 31 December 2008 without a history of atherosclerotic cardiovascular disease. MAIN OUTCOME MEASURES The primary outcome was the first diagnosis of gastrointestinal cancer (either CRC, GC or EC) and the secondary outcome was GIB. Individuals were followed from index date of prescription until the earliest occurrence of an outcome of interest, an incident diagnosis of any type of cancer besides the outcome, death or until 31 December 2017. A competing risk survival analysis was used to estimate HRs and 95% CIs with death as the competing risk. RESULTS After matching, 49 679 aspirin and non-aspirin users were included. The median (IQR) follow-up was 10.0 (6.4) years. HRs for low-dose aspirin compared with non-aspirin users were 0.83 for CRC (95% CI, 0.76 to 0.91), 0.77 for GC (95% CI, 0.65 to 0.92) and 0.88 for EC (95% CI, 0.67 to 1.16). Patients prescribed low-dose aspirin had an increased risk of GIB (HR 1.15, 95% CI, 1.11 to 1.20), except for patients prescribed proton pump inhibitors or histamine H2-receptor antagonists (HR 1.03, 95% CI, 0.96 to 1.10). CONCLUSION In this cohort study of Chinese adults, patients prescribed low-dose aspirin had reduced risks of CRC and GC and an increased risk of GIB. Among the subgroup of patients prescribed gastroprotective agents at baseline, however, the association with GIB was attenuated.
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Affiliation(s)
- Jessica J P Shami
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Jiaxi Zhao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Digital and Data Innovation, AstraZeneca Global R&D (China) Co., Ltd, Shanghai, China
| | - Swathi Pathadka
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Eric Yuk Fai Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Department of Family Medicine and Primary Care, University of Hong Kong, Hong Kong
| | - Joseph Edgar Blais
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Pareen Vora
- Epidemiology, Bayer AG, Leverkusen, Nordrhein-Westfalen, Germany
| | | | | | - W K Leung
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
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5
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Zawawi NA, Abdul Halim Zaki I, Ming LC, Goh HP, Zulkifly HH. Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation. Front Cardiovasc Med 2021; 8:736143. [PMID: 34869639 PMCID: PMC8635010 DOI: 10.3389/fcvm.2021.736143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022] Open
Abstract
Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.
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Affiliation(s)
- Nur Azyyati Zawawi
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Izzati Abdul Halim Zaki
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hui Poh Goh
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hanis Hanum Zulkifly
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
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6
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Wattanaruengchai P, Nathisuwan S, Karaketklang K, Wongcharoen W, Phrommintikul A, Lip GYH. Comparison of the HAS-BLED versus ORBIT scores in predicting major bleeding among Asians receiving direct-acting oral anticoagulants. Br J Clin Pharmacol 2021; 88:2203-2212. [PMID: 34783372 DOI: 10.1111/bcp.15145] [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: 08/23/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS This study aimed to evaluate the performance of HAS-BLED and ORBIT scores in predicting bleeding risk among Asian patients with nonvalvular atrial fibrillation (NVAF) using direct-acting oral anticoagulants (DOACs). METHODS A retrospective chart review was conducted among adult patients receiving DOACs for ≥6 months during January 2013 to December 2017 in 10 tertiary care hospitals in Thailand. The area under the receiver operating curve (AUROC) method or C-statistic was used to test the diagnostic accuracy for bleeding risk classification of HAS-BLED and ORBIT scores. The predictive performances of the two scores were compared using DeLong's method. RESULTS A total of 961 NVAF patients, 52.5% warfarin-naïve and 47.5% warfarin-experienced, with mean age of 74.25 ± 10.08 years, were included in the analysis. Mean HAS-BLED and ORBIT scores of the cohort were 1.98 ± 1.10 and 2.37 ± 1.71, respectively. During the mean follow-up time of 1.55 ± 1.13 years, 34 patients experienced major bleeding (2.28 events/100 patient-year). For the overall cohort, both the HAS-BLED and ORBIT scores showed similarly moderate predictive performance on bleeding with C-statistic (95% confidence interval) of 0.65 (0.57-0.74) and 0.64 (0.56-0.71), respectively. There was no statistical significance between the two scores (P = .62). Analysis based on the status of previous warfarin use was consistent with the overall cohort. Based on the calibration analysis, both HAS-BLED and ORBIT scores possessed moderate ability to identify those who experienced major bleeding from those who did not. CONCLUSION Both HAS-BLED and ORBIT bleeding risk scores had moderate predictive performance in Asian NVAF patients receiving DOACs.
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Affiliation(s)
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Khemajira Karaketklang
- Department of Medicine, Faculty of Medicine at Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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7
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Tan JWC, Chew DP, Brieger D, Eikelboom J, Montalescot G, Ako J, Kim BK, Quek DK, Aitken SJ, Chow CK, Chour S, Tse HF, Kaul U, Firdaus I, Kubo T, Liew BW, Chong TT, Sin KY, Yeh HI, Buddhari W, Chunhamaneewat N, Hasan F, Fox KA, Nguyen QN, Lo ST. 2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome. Eur Cardiol 2021; 16:e26. [PMID: 34249148 PMCID: PMC8251506 DOI: 10.15420/ecr.2020.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - David Brieger
- Concord Repatriation General Hospital, University of Sydney Sydney, Australia
| | | | - Gilles Montalescot
- Sorbonne University Paris, France.,ACTION Study Group France.,Pitié-Salpêtrière University Hospital (AP-HP) Paris, France
| | - Junya Ako
- Kitasato University and Hospital Kanagawa, Japan
| | | | | | | | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney Sydney, Australia.,Westmead Hospital Sydney, Australia
| | - Sok Chour
- Calmette Hospital Phnom Penh, Cambodia
| | - Hung Fat Tse
- Queen Mary Hospital, University of Hong Kong Hong Kong, China
| | - Upendra Kaul
- Batra Hospital and Medical Research Center New Delhi, India
| | - Isman Firdaus
- Faculty of Medicine, University of Indonesia Jakarta, Indonesia
| | | | | | | | | | - Hung-I Yeh
- MacKay Memorial Hospital, MacKay Medical College Taipei, Taiwan
| | | | | | - Faisal Hasan
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates
| | | | - Quang Ngoc Nguyen
- Hanoi Medical University, Vietnam National Heart Institute Hanoi, Vietnam
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8
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Guo Y, Lane DA, Chen Y, Lip GYH. Regular Bleeding Risk Assessment Associated with Reduction in Bleeding Outcomes: The mAFA-II Randomized Trial. Am J Med 2020; 133:1195-1202.e2. [PMID: 32289310 DOI: 10.1016/j.amjmed.2020.03.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The mobile atrial fibrillation application (mAFA-II) randomized trial reported that a holistic management strategy supported by mobile health reduced atrial fibrillation-related adverse outcomes. The present study aimed to assess whether regular reassessment of bleeding risk using the Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol (HAS-BLED) score would improve bleeding outcomes and oral anticoagulant (OAC) uptake. METHODS Bleeding risk (HAS-BLED score) was monitored prospectively using mAFA, and calculated as 30 days, days 31-60, days 61-180, and days 181-365. Clinical events and OAC changes in relation to the dynamic monitoring were analyzed. RESULTS We studied 1793 patients with atrial fibrillation (mean, standard deviation, age 64 years, 24 years, 32.5% female). Comparing baseline and 12 months, the proportion of atrial fibrillation patients with HAS-BLED ≥3 decreased (11.8% vs 8.5%, P = .008), with changes in use of concomitant nonsteroidal antiinflammatory drugs/antiplatelets, renal dysfunction, and labile international normalized ratio contributing to the decreased proportions of patients with HAS-BLED ≥3 (P < .05). Among 1077 (60%) patients who had 4 bleeding risk assessments, incident bleeding events decreased significantly from days 1-30 to days 181-365 (1.2% to 0.2%, respectively, P < .001). Total OAC usage increased from 63.4% to 70.2% (Ptrend < .001). Compared with atrial fibrillation patients receiving usual care (n = 1136), bleeding events were significantly lower in atrial fibrillation patients with dynamic monitoring of their bleeding risk (mAFA vs usual care, 2.1%, 4.3%, P = .004). OAC use decreased significantly by 25% among AF patients receiving usual care, when comparing baseline to 12 months (P < .001). CONCLUSION Dynamic risk monitoring using the HAS-BLED score, together with holistic App-based management using mAFA-II reduced bleeding events, addressed modifiable bleeding risks, and increased uptake of OACs.
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Affiliation(s)
- Yutao Guo
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Yundai Chen
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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9
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Xiong Q, Wang C, Liu H, Tan Z, Chen C, Li J, Lip GYH, Hong K. Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Asians With Nonvalvular Atrial Fibrillation: A Network Meta-Analysis. Clin Appl Thromb Hemost 2020; 25:1076029619885188. [PMID: 31718263 PMCID: PMC7019404 DOI: 10.1177/1076029619885188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
There are few head-to-head trials directly comparing non-vitamin K antagonist oral anticoagulants (NOACs) against one other. A network meta-analysis (NMA) was performed to examine the indirect comparisons among NOACs in Asians with nonvalvular atrial fibrillation (NVAF). STATA 15.0 and ADDIS 1.16.8 softwares were used to perform the statistical analysis. Odds ratios with 95% credible intervals were applied to evaluate the end points. The probabilities of treatment rank were used to understand which interventions are more effective and safe, and the total rank probability was 1. In our NMA, the rank probabilities of apixaban in the case of stroke or systemic embolism, death from any cause, major bleeding, and intracranial hemorrhage (ICH) were 0.47, 0.49, 0.42, and 0.51, respectively. For cases of myocardial infarction, the rank probabilities of rivaroxaban were 0.40. This NMA indirectly compares the main efficacy and safety end points among NOACs in Asians with NVAF, and the rank probability analysis showed that apixaban likely performs best in cases of stroke or systemic embolism, death from any cause, and ICH; rivaroxaban may have the best performance for myocardial infarction.
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Affiliation(s)
- Qinmei Xiong
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Cen Wang
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Hualong Liu
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhaochong Tan
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Chen Chen
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Juxiang Li
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kui Hong
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China.,Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
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10
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Chang G, Xie Q, Ma L, Hu K, Zhang Z, Mu G, Cui Y. Accuracy of HAS-BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta-analysis. J Thromb Haemost 2020; 18:791-801. [PMID: 31782613 DOI: 10.1111/jth.14692] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preventing thrombosis is an important part of atrial fibrillation (AF) treatment. However, it may increase the risk of bleeding, and bleeding risk assessment tools' predictive value remains unclear. This network meta-analysis investigated the sensitivity and specificity of HAS-BLED, and other bleeding risk assessment tools, to predict major bleeding events in AF patients. METHODS The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched using keywords, including "AF," "bleeding," and "HAS-BLED," for results published through 30 November 2018. The predictive sensitivity and specificity of each bleeding risk assessment tool was analyzed by network meta-analysis. RESULTS Our analysis included 18 studies, recruiting a total of 321 888 people. The bleeding risk assessment tools analyzed in this study included the ABC-bleeding score, ATRIA, European score, GARFIELD-AF, HAS-BLED, HEMORR2HAGES, ORBIT, Shireman, and mOBRI. A comprehensive analysis of sensitivity and specificity, based on an inconsistency model, showed that European score, ABC, and mOBRI have relatively high-sensitivity but low-specificity tools, whereas HAS-BLED and HEMORR2HAGES have balanced sensitivity and specificity. ORBIT, ATRIA, Shireman, and GARFIELD-AF had relatively high specificity but low sensitivity. A consistency model analysis showed similar results. CONCLUSIONS HAS-BLED is a balanced bleeding risk assessment tool in terms of sensitivity and specificity, whereas the European score, ABC, and mOBRI are high-sensitivity tools and ORBIT, ATRIA, Shireman, and GARFIELD-AF are high-specificity tools.
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Affiliation(s)
- Guodong Chang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Beijing Protgen Biotechnology Co. Ltd, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhuo Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
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11
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Should Every Patient With Atrial Fibrillation and a CHA2DS2-VASc Score of 1 Be Anticoagulated? A Systematic Review of 37,030 Patients. Cardiol Rev 2019; 27:249-255. [DOI: 10.1097/crd.0000000000000246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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12
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Priksri W, Rattanavipanon W, Saejear W, Tanyasaensook K, Phrommintikul A, Chulavatnatol S, Nathisuwan S. Incidence, risk factors, and outcomes of warfarin-associated major bleeding in Thai population. Pharmacoepidemiol Drug Saf 2019; 28:942-950. [DOI: 10.1002/pds.4781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | - Wipharak Rattanavipanon
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy; Mahidol University; Bangkok Thailand
| | - Wiwat Saejear
- Division of Cardiology, Department of Medicine; Chonburi Hospital; Chonburi Thailand
| | - Krittika Tanyasaensook
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy; Mahidol University; Bangkok Thailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Suvatna Chulavatnatol
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy; Mahidol University; Bangkok Thailand
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy; Mahidol University; Bangkok Thailand
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13
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Pallazola VA, Kapoor RK, Kapoor K, McEvoy JW, Blumenthal RS, Gluckman TJ. Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review. Vasc Med 2019; 24:141-152. [PMID: 30755150 DOI: 10.1177/1358863x18819816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.
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Affiliation(s)
- Vincent A Pallazola
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Rishi K Kapoor
- 2 Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, Essex County, NJ, USA
| | - Karan Kapoor
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - John W McEvoy
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Roger S Blumenthal
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Ty J Gluckman
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA.,3 Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Multnomah County, OR, USA
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14
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The Association Between Atrial Fibrillation and Poststroke Seizures is Influenced by Ethnicity and Environmental Factors. J Stroke Cerebrovasc Dis 2018; 27:2755-2760. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 05/28/2018] [Indexed: 12/31/2022] Open
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15
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Lip GYH, Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, Halvorsen S, Lau D, Lopez-Cabanillas N, Lettino M, Marin F, Obel I, Rubboli A, Storey RF, Valgimigli M, Huber K, Potpara T, Blomström Lundqvist C, Crijns H, Steffel J, Heidbüchel H, Stankovic G, Airaksinen J, Ten Berg JM, Capodanno D, James S, Bueno H, Morais J, Sibbing D, Rocca B, Hsieh MH, Akoum N, Lockwood DJ, Gomez Flores JR, Jardine R. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2018; 21:192-193. [DOI: 10.1093/europace/euy174] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Jean-Phillippe Collet
- Sorbonne Université Paris 6, ACTION Study Group (www.action-coeur.org), Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS, Paris, France
| | - Michael Haude
- Städtische Kliniken Neuss Lukaskrankenhaus Gmbh Kardiologie, Nephrologie, Pneumologie, Neuss, Germany
| | - Robert Byrne
- Deutsches Herzzentrum Muenchen, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Eugene H Chung
- University of North Carolina at Chapel Hill, Medicine, Cardiology, Electrophysiology, Chapel Hill, NC, USA
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Faculté de Médecine—Université François Rabelais, Tours, France
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dennis Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Maddalena Lettino
- Cardiology Department, Humanitas Research Hospital, Rozzano, MI, Italy
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Israel Obel
- Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital Vienna, Vienna, Austria
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Harry Crijns
- Cardiology Department, Maastricht UMC+, Maastricht, Netherlands
| | - Jan Steffel
- University Heart Center Zurich, Zurich, Switzerland
| | - Hein Heidbüchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Juhani Airaksinen
- Turku University Hospital, Cardiology, Department of Internal Medicine, Turku, Finland
| | | | - Davide Capodanno
- Ferrarotto Hospital, Azienda Ospedaliero-Univ, Policlinico-Vittorio Emanuele, University of Catania, Cardiologia Department, University of Catania, Catania, Italy
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Senior Interventional Cardiologist, Uppsala University Hospital, Uppsala, Sweden
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro, Madrid, Spain
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Portugal
| | - Dirk Sibbing
- Oberarzt, Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität (LMU), Campus Großhadern, München, Germany
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | | | - Nazem Akoum
- Cardiology Department, University of Washington, Seattle, USA
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Guo Y, Wang Y, Li X, Shan Z, Shi X, Xi G, Lip GYH. Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry: protocol for a prospective, observational nationwide cohort study. BMJ Open 2018; 8:e020191. [PMID: 29730624 PMCID: PMC5942423 DOI: 10.1136/bmjopen-2017-020191] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a worldwide healthcare burden that is associated with the ageing population. Elderly patients with AF with multiple comorbidities usually present with a high risk of thromboembolism and bleeding. Limited prospective data are available from Asian cohorts on the epidemiology and complications of AF. The present prospective cohort study aims to explore contemporary antithrombotic strategies among the elderly Chinese population in the new era of non-vitamin K antagonist oral anticoagulants and to compare the clinical characteristics and outcomes between Chinese and European AF populations. METHODS AND ANALYSIS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry will recruit 5000 patients with AF over 65 years of age in China. AF-related risks, including stroke/systemic thromboembolism and bleeding outcomes, will be assessed. Medical history, risk factors, demographic information and management will be collected at baseline, and clinical events during 1 year follow-up will be recorded. Follow-up will be conducted for at least 1 year and then annually thereafter. As our registry has a common protocol to the European Society of Cardiology EURObservational Research Programme AF general registry programme, preplanned analyses comparing the clinical profiles and outcomes will be performed. The ChiOTEAF registry offers an opportunity to provide a better understanding of the clinical profiles and adverse outcomes of patients with AF in China and allow for comparisons with a contemporary European population. ETHICS AND DISSEMINATION Ethics approval was granted by the Central Medical Ethic Committee of Chinese PLA General Hospital (approval no S2014-065-01). The (inter)national research presentations, peer-reviewed publications and media coverage of the research will be sued for dissemination of the results.
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Affiliation(s)
- Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yutang Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Li
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Zaoliang Shan
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiangmin Shi
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Guorong Xi
- Health Division of Guard Bureau, Chinese PLA General Staff Department, Beijing, China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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17
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Guo Y, Zhu H, Chen Y, Lip GYH. Comparing Bleeding Risk Assessment Focused on Modifiable Risk Factors Only Versus Validated Bleeding Risk Scores in Atrial Fibrillation. Am J Med 2018; 131:185-192. [PMID: 28943382 DOI: 10.1016/j.amjmed.2017.09.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is uncertainty whether a focus on modifiable bleeding risk factors offers better prediction of major bleeding than other existing bleeding risk scores. METHODS This study compared a score based on numbers of the modifiable bleeding risk factors recommended in the 2016 European guidelines ("European risk score") versus other published bleeding risk scores that have been derived and validated in atrial fibrillation subjects (HEMORR2HAGES, HAS-BLED, ATRIA, and ORBIT) in a large hospital-based cohort of Chinese inpatients with atrial fibrillation. RESULTS The European score had modest predictive ability for major bleeding (c-index 0.63, 95% confidence interval 0.56-0.69) and intracranial hemorrhage (0.72, 0.65-0.79) but nonsignificantly (and poorly) predicted extracranial bleeding (0.55, 0.54-0.56; P = .361). The HAS-BLED score was superior to predict bleeding events compared with the European score, with the differences between c-indexes of 0.10-0.12 (Delong test, all P < .05), net reclassification improvement values of 13.0%-34.5% (all P < .05), and integrated discrimination improvement values of 0.7%-1.4% (all P < .05). The European score had similar predictive value to other bleeding risk schemes (HEMORR2HAGES, ATRIA, and ORBIT) for major bleeding and intracranial hemorrhage (all P > .05). Decision curve analysis clearly shows that HAS-BLED had better net benefit of predicting major bleeding compared with the European score. CONCLUSIONS Relying on bleeding risk assessment using modifiable bleeding risk factors alone is an inferior strategy for predicting atrial fibrillation patients for major bleeding. Our observations reaffirm the Asian guideline recommendations with HAS-BLED for bleeding risk assessment in patients with atrial fibrillation.
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Affiliation(s)
- Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China.
| | - Hang Zhu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark.
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18
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Li YG, Lee SR, Choi EK, Lip GY. Stroke Prevention in Atrial Fibrillation: Focus on Asian Patients. Korean Circ J 2018; 48:665-684. [PMID: 30073805 PMCID: PMC6072666 DOI: 10.4070/kcj.2018.0190] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia conferring a fivefold increased risk of stroke. Stroke prevention is the cornerstone of management of patients with AF. Asians have a generally higher incidence of AF-related risks of stroke and bleeding (particularly intracranial bleeding), compared with non-Asians. Despite the well-documented efficacy and relative safety of oral anticoagulation for stroke prevention among Asians, the suboptimal use of oral anticoagulation remains common. The current narrative review aims to provide a summary of the available evidence on stroke prevention among patients with AF focused on the Asia region, regarding stroke and bleeding risk evaluation, the performance of oral anticoagulation, and current use of thromboprophylaxis.
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Affiliation(s)
- Yan Guang Li
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Chinese PLA Medical School, Beijing, China
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital Seoul, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Gregory Yh Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Chinese PLA Medical School, Beijing, China.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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19
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Beshir SA, Aziz Z, Yap LB, Chee KH, Lo YL. Evaluation of the predictive performance of bleeding risk scores in patients with non-valvular atrial fibrillation on oral anticoagulants. J Clin Pharm Ther 2017; 43:209-219. [PMID: 29030869 DOI: 10.1111/jcpt.12634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/07/2017] [Indexed: 12/11/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Bleeding risk scores (BRSs) aid in the assessment of oral anticoagulant-related bleeding risk in patients with atrial fibrillation. Ideally, the applicability of a BRS needs to be assessed, prior to its routine use in a population other than the original derivation cohort. Therefore, we evaluated the performance of 6 established BRSs to predict major or clinically relevant bleeding (CRB) events associated with the use of oral anticoagulant (OAC) among Malaysian patients. METHODS The pharmacy supply database and the medical records of patients with non-valvular atrial fibrillation (NVAF) receiving warfarin, dabigatran or rivaroxaban at two tertiary hospitals were reviewed. Patients who experienced an OAC-associated major or CRB event within 12 months of follow-up, or who have received OAC therapy for at least 1 year, were identified. The BRSs were fitted separately into patient data. The discrimination and the calibration of these BRSs as well as the factors associated with bleeding events were then assessed. RESULTS A total of 1017 patients with at least 1-year follow-up period, or those who developed a bleeding event within 1 year of OAC use, were recruited. Of which, 23 patients experienced a first major bleeding event, whereas 76 patients, a first CRB event. Multivariate logistic regression results show that age of 75 or older, prior bleeding and male gender are associated with major bleeding events. On the other hand, prior gastrointestinal bleeding, a haematocrit value of less than 30% and renal impairment are independent predictors of CRB events. All the BRSs show a satisfactory calibration for major and CRB events. Among these BRSs, only HEMORR2 HAGES (C-statistic = 0.71, 95% CI 0.60-0.82, P < .001) and ATRIA score (C-statistic = 0.70, 95% CI 0.58-0.82, P < .001) show acceptable discrimination performance for major bleeding events. All the 6 BRSs, however, lack acceptable predictive performance for CRB events. WHAT IS NEW AND CONCLUSION To the best of our knowledge, this is the first evaluation study of the predictive performance of these 6 BRSs on clinically relevant bleeding events applied to the same cohort consisting of mainly Asian novel oral anticoagulant users. These BRSs show poor to acceptable predictive performance on OAC-induced major or CRB events. An improvement in the existing BRSs for OAC users is warranted.
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Affiliation(s)
- S A Beshir
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - L B Yap
- National Heart Institute, Kuala Lumpur, Malaysia
| | - K H Chee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Y L Lo
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Pharmacy Practice, School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Importance of time in therapeutic range on bleeding risk prediction using clinical risk scores in patients with atrial fibrillation. Sci Rep 2017; 7:12066. [PMID: 28935868 PMCID: PMC5608893 DOI: 10.1038/s41598-017-11683-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/28/2017] [Indexed: 01/08/2023] Open
Abstract
Bleeding risk with vitamin K antagonists (VKAs) is closely related to the quality of anticoagulation in atrial fibrillation (AF) patients, reflected by time in therapeutic range (TTR). Here we compared the discrimination performance of different bleeding risk scores and investigated if adding TTR would improve their predictive value and clinical usefulness. We included 1361 AF patients stables on VKA for at least 6 months. Bleeding risk was assessed by the HAS-BLED, ATRIA, ORBIT and HEMORR2HAGES scores. Major bleeding events were recorded after a median of 6.5 years follow-up. In this period 250 patients suffered major bleeds. Comparison of receiver operating characteristic (ROC) curves demonstrated that HAS-BLED had the best discrimination performance, but adding the ‘labile INR’ criteria (i.e. TTR <65%) to ATRIA, ORBIT and HEMORR2HAGES increased their ability of discrimination and predictive value, with significant improvements in reclassification and discriminatory performance. Decision curve analyses (DCA) showed improvements of the clinical usefulness and a net benefit of the modified risk scores. In summary, in AF patients taking VKAs, the HAS-BLED score had the best predictive ability. Adding ‘labile INR’ to ATRIA, ORBIT and HEMORR2HAGES improved their predictive value for major bleeding leading to improved clinical usefulness compared to the original scores.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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Wang C, Yu Y, Zhu W, Yu J, Lip GYH, Hong K. Comparing the ORBIT and HAS-BLED bleeding risk scores in anticoagulated atrial fibrillation patients: a systematic review and meta-analysis. Oncotarget 2017; 8:109703-109711. [PMID: 29312640 PMCID: PMC5752553 DOI: 10.18632/oncotarget.19858] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/25/2017] [Indexed: 02/03/2023] Open
Abstract
Background The HAS-BLED and ORBIT scores have been proposed to assess bleeding risk in anticoagulated atrial fibrillation patients. We performed a systematic review and meta-analysis to compare the predictive ability by using these two scores. Materials and Methods We searched the Cochrane Library, Elsevier and PubMed databases for related studies. Statistical analysis was performed with Revman 5.3 Manager software. We chose the C-statistic to reflect the diagnostic value. Results In our seven selected studies, the pooled C- statistic of continuous variables for major bleeding was 0.65 (0.60,0.69) for ORBIT and 0.63 (0.60,0.66) for HAS-BLED. Compared with HAS-BLED, more anticoagulated AF patients (88.45% versus 32.59%) and major bleeding events (75.57% versus 25.57%) were categorized as low risk. The ORBIT score had a 1.21, 1.73 and 1.44-fold elevated risk of major bleeding in the low, intermediate and high risk strata respectively. Calibration analysis demonstrated that the ORBIT score under-predicted major bleeding in the low, intermediate, and high risk stratifications, where a odds ratio of 0.64 (0.37-1.10), 0.63 (0.38-1.05) and 0.64 (0.38-1.06), respectively. Conclusions Compared with HAS-BLED , the ORBIT score does not perform better in predicting major bleeding events in anticoagulated atrial fibrillation patients. More anticoagulated AF patients and major bleeding events were categorized as low risk when using ORBIT.
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Affiliation(s)
- Cen Wang
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Ye Yu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Wengen Zhu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Jianhua Yu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Kui Hong
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Jiangxi, China.,The Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
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