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Kreutz R, Kloss S, Enders D, Abdelgawwad K, Häckl D, Schmedt N, Bonnemeier H. Comparative effectiveness of factor Xa non-vitamin K antagonist oral anticoagulants versus phenprocoumon in patients with non-valvular atrial fibrillation. Int J Cardiol 2024; 404:131894. [PMID: 38437952 DOI: 10.1016/j.ijcard.2024.131894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) have largely supplanted vitamin K antagonists (VKAs) for oral anticoagulation in non-valvular atrial fibrillation (NVAF). However, data on the real-world effectiveness of NOACs vs. phenprocoumon, a VKA widely used in Germany, are limited. The RELOADED study aimed to compare effectiveness of factor Xa NOACs and phenprocoumon in NVAF in clinical practice. METHODS Patients who started on a factor Xa NOAC or phenprocoumon for NVAF during the study period were enrolled from the Institute for Applied Healthcare Research Berlin. Patients were followed from first prescription until the end of exposure or available data. Primary outcomes were analyzed by Cox proportional hazard regression models and included ischemic stroke and systemic embolism for effectiveness, and intracranial hemorrhage (ICH) for safety. Subgroups of interest were patients with diabetes and patients with renal impairment. RESULTS The total study population was 64,920; 36.3% of patients initiated phenprocoumon, 34.4% initiated rivaroxaban, 25.0% apixaban, and 4.4% edoxaban. Treatment with phenprocoumon is associated with a similar risk of ischemic stroke/systemic embolism as treatment with rivaroxaban or apixaban; while rivaroxaban (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.43-0.75) and apixaban (adjusted HR 0.43, 95% CI 0.31-0.6) were associated with a lower risk of ICH compared to phenprocoumon in NVAF patients. The use of rivaroxaban and apixaban was associated with a lower risk of developing kidney failure in patients with diabetes or renal impairment in comparison to those treated with phenprocoumon. CONCLUSION The factor Xa NOACs rivaroxaban and apixaban demonstrated similar effectiveness and lower rates of ICH compared with phenprocoumon in this study.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Charitéplatz 1, 10117 Berlin, Germany.
| | | | - Dirk Enders
- InGef - Institute for Applied Health Research Berlin, Spittelmarkt 12, 10117 Berlin, Germany
| | | | - Dennis Häckl
- University Leipzig, Health Economics and Management, Grimmaische Straße 12, 04109 Leipzig, Germany; WIG2 - Scientific Institute for Health Economics and Health System Research, Markt 8, 04109 Leipzig, Germany
| | - Niklas Schmedt
- InGef - Institute for Applied Health Research Berlin, Spittelmarkt 12, 10117 Berlin, Germany
| | - Hendrik Bonnemeier
- University Medical Center Schleswig-Holstein, Department of Electrophysiology and Rhythmology, Arnold-Heller-Straße 3, 24105 Kiel, Germany
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2
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Zahoor MM, Mazhar S, Azhar A, Mand Khan F, Anees U, Vohra RR, Ejaz U, Jawad S. Factor Xa inhibitors versus warfarin in patients with non-valvular atrial fibrillation and diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. Ann Med Surg (Lond) 2024; 86:986-993. [PMID: 38333250 PMCID: PMC10849443 DOI: 10.1097/ms9.0000000000001621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/03/2023] [Indexed: 02/10/2024] Open
Abstract
Background Patients with non-valvular atrial fibrillation with diabetes face increased stroke and cardiovascular risks. This study compares factor Xa inhibitors and warfarin using data from randomized controlled trials (RCTs). Methods MEDLINE, Embase, and Cochrane CENTRAL databases were searched for RCTs comparing the risk of efficacy and safety of any factor Xa inhibitors with dose-adjusted warfarin by diabetes status. Incidence of stroke/systemic embolism, major bleeding, intracranial hemorrhage, ischemic stroke, all-cause mortality, risk of hemorrhagic stroke, and myocardial infarction were among the outcomes of interest. A generic inverse-weighted random-effects model was used to calculate hazard ratios (HRs) with 95 percent confidence intervals (CIs). Results After applying exclusion criteria, four RCTs containing 19 818 patients were included in the analysis. Compared with warfarin, meta-analysis showed statistically significant reduction in incidence of stroke/systemic embolism (HR 0.80 [95% CI 0.69-0.92]; P=0.002), intracranial hemorrhage (HR 0.49 [95% CI 0.37-0.65]; P<0.001), and risk of hemorrhagic stroke (HR 0.37 [95% CI 0.20-0.66]; P=0.001) in patients on factor Xa inhibitors. However, there was no discernible difference between two treatment arms in incidence of major bleeding (HR 0.93 [95% CI 0.84-1.04]; P=0.19), ischemic stroke (risk ratio (RR) 0.90 [95% CI 0.73-1.12; P=0.34), myocardial infarction (RR 0.88 [95% CI 0.67-1.15]; P=0.35), and all-cause mortality (RR 0.89 [95% CI 0.79-1.01]; P=0.06). Conclusion Factor Xa inhibitors show a favorable balance between efficacy and safety compared with warfarin, which is consistent across a wide range of patients with atrial fibrillation known to be at high risk for both ischemic and bleeding events.
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Affiliation(s)
| | - Saad Mazhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Fasih Mand Khan
- Department of Surgery, Fatima Memorial College of Medicine and Dentistry, Lahore
| | - Usama Anees
- Department of Medicine, Quad-e-Azam Medical College, Bahawalpur
| | - Rimsha R. Vohra
- Department of Medicine, Dow University of Health Sciences, Karachi
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi, Pakistan
| | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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3
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Ton MT, Quang Ho TH, Nguyen VL, Pham HM, Hoang SV, Vo NT, Nguyen TQ, Pham LT, Mai TD, Nguyen TH. Selection of Non-vitamin K Antagonist Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Based on Patient Profile: Perspectives from Vietnamese Experts. Part 2. Eur Cardiol 2023; 18:e62. [PMID: 38174218 PMCID: PMC10762676 DOI: 10.15420/ecr.2023.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/18/2023] [Indexed: 01/05/2024] Open
Abstract
Part 1 of this review provided an overview of AF in Vietnam, with a particular focus on primary and secondary stroke prevention. Part 2 explores the management of AF in special, high-risk and clinically common patient populations, including those with renal impairment, diabetes, the elderly, and those with coronary artery disease. Furthermore, Part 2 addresses the challenges posed by patients with AF who have a bioprosthetic valve, a group situated in a grey area of consideration. Managing AF in these patient groups presents unique clinical challenges that require careful consideration. Physicians are tasked with addressing specific clinical questions to identify the optimal anticoagulation strategy for each individual. To inform these decisions, subgroup analyses from pivotal studies are presented alongside real-world data derived from clinical practice. By synthesising available information and considering the nuanced clinical context, the aim is to provide informed perspectives that align with current medical knowledge and contribute to the enhancement of patient care in these challenging scenarios.
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Affiliation(s)
| | | | | | - Hung Manh Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
- Hanoi Medical UniversityHanoi, Vietnam
| | - Sy Van Hoang
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh CityHo Chi Minh City, Vietnam
| | - Nhan Thanh Vo
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- Cardiovascular Center, Vinmec HospitalHo Chi Minh City, Vietnam
| | | | - Linh Tran Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
| | - Ton Duy Mai
- Hanoi Medical UniversityHanoi, Vietnam
- Stroke Center, Bach Mai HospitalHanoi, Vietnam
- VNU-University of Medicine and PharmacyHanoi, Vietnam
| | - Thang Huy Nguyen
- Cerebrovascular Disease Department, People's 115 Hospital
- Pham Ngoc Thach University of MedicineHo Chi Minh City, Vietnam
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4
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Derosa G, Rizzo M, Brunetti ND, Raddino R, Gavazzoni M, Pasini G, Gaudio G, Maggi A, D'Angelo A, De Gennaro L, Maffioli P. ORal anticoaGulants in diAbetic and Nondiabetic patients with nOn-valvular atrial fibrillatioN (ORGANON). J Diabetes Complications 2023; 37:108512. [PMID: 37390799 DOI: 10.1016/j.jdiacomp.2023.108512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Diabetes represents a pro-thrombotic condition. OBJECTIVES The primary objective was to evaluate the effects of Vitamin K Antagonist (VKA) compared to direct oral anticoagulants (DOACs) in diabetic and nondiabetic patients with non-valvular atrial fibrillation, newly diagnosed. The secondary objective was to evaluate the effects on the risk of bleeding. METHODS We enrolled 300 patients with newly diagnosed atrial fibrillation. One hundred and sixteen patients were taking warfarin, 31 acenocumarol, 22 dabigatran, 80 rivaroxaban, 34 apixaban, and 17 edoxaban. We evaluated: anthropometric parameters, glycated hemoglobin (HbA1c), fasting and post-prandial glucose (FPG, and PPG), lipid profile, Lp(a), small and dense low-density lipoprotein (SD-LDL), oxidized LDL (Ox-LDL), I-troponin (I-Tn), creatinine, transaminases, iron, red blood cells (RBC); hemoglobin (Hb), platelets (PLT), fibrinogen, D-dimer, anti-thrombin III, C-reactive protein (Hs-CRP), Metalloproteinases-2 (MMP-2), Metalloproteinases-9 (MMP-9), and incidence of bleeding. RESULTS We did not record any differences among nondiabetic patients between VKA and DOACs. However, when we considered diabetic patients, we found a slight, but significant improvement of triglycerides and SD-LDL. As regards incidence of bleeding, minor bleeding was more frequent in VKA diabetic group compared to DOACs diabetic group; furthermore, the incidence of major bleeding was higher with VKA in nondiabetic and diabetic group, compared to patients with DOACs. Among DOACs, we recorded a higher incidence of bleeding (minor and major) with dabigatran compared to rivaroxaban, apixaban and edoxaban in nondiabetic and diabetic patients. CONCLUSION DOACs seem to be metabolically favourable in diabetic patients. Regarding incidence of bleeding, DOACs with the exception of dabigatran, seem better than VKA in diabetic patients.
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Affiliation(s)
- Giuseppe Derosa
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Laboratory of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | | | - Riccardo Raddino
- Cardiology Department, University of Brescia, Spedali Civili of Brescia, Brescia, Italy
| | - Mara Gavazzoni
- Cardiology Department, University of Brescia, Spedali Civili of Brescia, Brescia, Italy
| | - Gianfranco Pasini
- Cardiologic Unit, Presidio Ospedaliero di Gavardo, Gavardo, Brescia, Italy
| | - Giovanni Gaudio
- Internal Medicine Division, Ospedale Angelo Bellini, Somma Lombardo, Varese, Italy
| | - Antonio Maggi
- Cardiologic Unit, Poliambulanza Foundation, Brescia, Italy
| | - Angela D'Angelo
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Laboratory of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Pamela Maffioli
- Centre of Diabetes and Metabolic Diseases, Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Escobar-Cervantes C, Díez-Villanueva P, Bonanad Lozano C, Reino AP, Almendro-Delia M, Facila L, Valle A, Suárez C. Vascular protection with rivaroxaban in the comprehensive management of atrial fibrillation. Expert Rev Cardiovasc Ther 2023; 21:791-802. [PMID: 37933665 DOI: 10.1080/14779072.2023.2276893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION In addition to an increased risk of thromboembolic complications, patients with atrial fibrillation (AF) are at risk for vascular events. Consequently, complete vascular protection is warranted in these patients. AREAS COVERED A narrative search was conducted on PubMed (MEDLINE), using the MeSH terms [Rivaroxaban] + [Atrial fibrillation] + [Cardiovascular] + [Vascular] + [Treatment]. Original data from clinical trials, prospective and retrospective studies, useful reviews and experimental studies, were selected. EXPERT OPINION The ROCKET-AF trial showed that rivaroxaban is effective in reducing the risk of stroke, with a lower risk of fatal and intracranial bleeding compared to warfarin. Remarkably, experimental data have provided a number of pathogenic mechanisms through which rivaroxaban could provide beneficial vascular properties beyond its antithrombotic activity. Moreover, in the AF population, additional to its ability to reduce the risk of thromboembolic complications, rivaroxaban is associated with a lower risk of myocardial infarction, major adverse cardiac and limb events, and vascular mortality in patients with diabetes, also attenuating renal impairment during follow-up. These findings suggest that rivaroxaban may provide a comprehensive vascular protection in patients with AF.
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Affiliation(s)
| | | | - Clara Bonanad Lozano
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (INCLIVA), Spain
| | - Antonio Pose Reino
- Hypertension and Vascular Risk Unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia Valencia, Spain
| | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Carmen Suárez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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6
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Jia X, Yin Z, Zhang W, Du S, Kang J. Efficacy and safety of novel oral anticoagulants in patients with atrial nonvalvular atrial fibrillation and diabetes mellitus: a systematic review and meta-analysis. J Transl Med 2022; 20:441. [PMID: 36180856 PMCID: PMC9524066 DOI: 10.1186/s12967-022-03652-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/18/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study incorporates the results of subgroup analyses of currently published randomized controlled trials (RCTs) and real-world cohort studies to compare the effectiveness and safety of new direct oral anticoagulants (NOACs) and warfarin among nonvalvular atrial fibrillation patients with diabetes. METHODS The PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov databases were searched. Five retrospective cohort studies and four subgroup analyses of RCTs were included in this meta-analysis. RESULTS A meta-analysis of the data of 26,7272 patients showed that for patients with nonvalvular atrial fibrillation and diabetes, NOACs can significantly reduce the incidence of stroke/systemic embolism (SSE), ischaemic stroke, and haemorrhagic stroke compared with warfarin, with no significant difference in major bleeding and all-cause mortality. Additionally, NOACs were superior to warfarin in the incidence of intracranial bleeding, gastrointestinal bleeding, myocardial infarction, and vascular death. CONCLUSIONS Among nonvalvular atrial fibrillation patients with diabetes, NOACs were associated with a lower risk of SSE versus warfarin, with no significant difference in major bleeding. Therefore, NOACs may be a better clinical choice.
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Affiliation(s)
- Xuedong Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, 43 North University Road, Zhengzhou City, 450052, Henan Province, China.
| | - Zhao Yin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, 43 North University Road, Zhengzhou City, 450052, Henan Province, China
| | - Wan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, 43 North University Road, Zhengzhou City, 450052, Henan Province, China
| | - Shuzhang Du
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, 43 North University Road, Zhengzhou City, 450052, Henan Province, China
| | - Jian Kang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, 43 North University Road, Zhengzhou City, 450052, Henan Province, China.
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7
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Camm AJ, Sabbour H, Schnell O, Summaria F, Verma A. Managing thrombotic risk in patients with diabetes. Cardiovasc Diabetol 2022; 21:160. [PMID: 35996159 PMCID: PMC9396895 DOI: 10.1186/s12933-022-01581-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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8
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Yildiz M, Lavie CJ, Morin DP, Oktay AA. The complex interplay between diabetes mellitus and atrial fibrillation. Expert Rev Cardiovasc Ther 2022; 20:707-717. [PMID: 35984314 DOI: 10.1080/14779072.2022.2115357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
INTRODUCTION : A growing body of evidence suggests that diabetes mellitus (DM) is associated with an increased risk of new-onset atrial fibrillation (AF) and contributes to suboptimal arrhythmia control and poor prognosis in patients with AF. The high prevalence of AF among patients with DM is primarily attributed to common risk factors, shared pathophysiological mechanisms, and associated atrial remodeling and autonomic dysfunction. AREAS COVERED : This comprehensive review covers the current data on the role of DM in the development and prognosis of AF. In addition, we review the impact of anti-DM medications on AF prevention and the role of anticoagulation in patients with coexisting DM and AF. EXPERT OPINION : DM is independently associated with new-onset AF, and the coexistence of these two conditions contributes to poor outcomes, from reduced quality of life to increased risks of thromboembolic events, heart failure, and mortality. Despite this strong link, the current evidence is insufficient to recommend routine screening for AF in patients with DM. Although some observations exist on preventing AF with anti-DM medications, randomized controlled trials are warranted to explore the proposed benefits of novel anti-DM medicines in reducing the risk of incident AF.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Ahmet Afsin Oktay
- The Heart and Vascular Institute, Rush University Medical Center, Chicago, IL
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9
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Roy Chowdhury K, Michaud J, Yu OHY, Yin H, Azoulay L, Renoux C. Effectiveness and safety of apixaban vs. rivaroxaban in patients with atrial fibrillation and type 2 diabetes mellitus. Thromb Haemost 2022; 122:1794-1803. [PMID: 35292949 DOI: 10.1055/a-1798-2116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS To evaluate the effectiveness and safety of apixaban vs. rivaroxaban among patients with non-valvular atrial fibrillation (NVAF) and type 2 diabetes mellitus (T2DM). METHODS AND RESULTS Using the United Kingdom's Clinical Practice Research Datalink linked to the Hospital Episode Statistics repository, and the Office for National Statistics database, we identified a cohort of patients with NVAF and T2DM newly treated with apixaban or rivaroxaban between 2013 and 2020. Propensity scores with standardised mortality ratio weighting were used to control for confounding. We used weighted Cox proportional hazards models to estimate separately the hazard ratios (HRs) with 95% confidence intervals (CIs) of ischemic stroke, major bleeding, and major adverse limb events associated with use of apixaban compared with rivaroxaban. We also evaluated whether the risk was modified by age, sex, duration of diabetes, microvascular and macrovascular complications of diabetes, nephropathy, CHA2DS2-VASc and HAS-BLED scores, and by dose (standard vs low dose). RESULTS The cohort included 11,561 apixaban and 8,265 rivaroxaban users. Apixaban was associated with a similar risk of stroke (HR 0.99, 95% CI 0.79-1.23), and a 32% reduced risk of major bleeding (HR 0.68, 95% CI 0.59-0.78), compared with rivaroxaban. The risk of major adverse limb events was similar between apixaban and rivaroxaban (HR 0.75, 95% CI 0.54-1.04). Overall, the risk of ischemic stroke and major bleeding was consistent in stratified analyses. CONCLUSIONS Among patients with NVAF and T2DM, apixaban was associated with a similar risk of stroke, and a lower risk of major bleeding compared with rivaroxaban.
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Affiliation(s)
- Krishna Roy Chowdhury
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Jonathan Michaud
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Oriana Hoi Yun Yu
- Division of Endocrinology, Jewish General Hospital, Montreal, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Christel Renoux
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Canada.,Neurology and Neurosurgery, McGill University, Montreal, Canada
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10
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Magnocavallo M, Vetta G, Trivigno S, Mariani MV, DI Lullo L, Bellasi A, Della Rocca DG, Severino P, Piro A, Giunta G, Quaglione R, Lavalle C. The Connubium among diabetes, chronic kidney disease and atrial fibrillation. Minerva Cardiol Angiol 2022; 70:393-402. [PMID: 35212508 DOI: 10.23736/s2724-5683.22.05891-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The burden of cardiovascular comorbid conditions was significantly higher in patients with Atrial Fibrillation (AF); most of them are affected by hypertension, Chronic Kidney Disease (CKD) and/or Diabetes Mellitus (DM). DM represents a well-known risk factor for the development and maintenance of AF; the coexistence of DM and AF is also associated with an increased risk of mortality and stroke. Moreover, DM is currently the main cause of renal impairment and the leading cause of dialysis in the world. The hyperglycemia is responsible for inducing redox imbalance and both systemic and intrarenal inflammation, playing a critical role in the pathogenesis of diabetic kidney disease. Long-term thromboembolic preventive therapy in AF patients with DM and CKD may be more challenging because both DM and CKD have been independently associated with an increased thromboembolic and bleeding risk, which results from the prothrombotic and pro-inflammatory status. Vitamin K Antagonists (VKAs) are characterized by numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavourable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. On the other hand, Direct Oral Anticoagulants (DOACs) are currently contraindicated in dialysis patients even if mounting evidence suggests that they may have a nephroprotective role in AF patients with DM and CKD. Consequently, the choice of anticoagulant therapy in this setting of patient seems to be very challenging. The aim of this review is to investigate the role of DOACs in diabetic patients and its nephroprotective role by reviewing the current literature.
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Affiliation(s)
- Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Vetta
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Sara Trivigno
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco V Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Luca DI Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Roma, Italy
| | - Antonio Bellasi
- Innovation and Brand Reputation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Giunta
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Raffaele Quaglione
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy -
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11
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Alwafi H, Alotaibi B, Naser AY, Salawati E, Qadus S, Sweiss K, Dairi MS, Hassouneh L, Aldalameh Y, Samannodi M. The safety and efficacy of the use of oral anticoagulant medications in patients with diabetes mellitus: A systematic review. Saudi Pharm J 2022; 29:1374-1382. [PMID: 35002374 PMCID: PMC8720821 DOI: 10.1016/j.jsps.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
Aims Diabetes mellitus (DM) and atrial fibrillation (AF) commonly co-exist. Oral anticoagulants (OACs) are widely used in patients with DM. This review aims to summarise the available literature on the safety (hypoglycaemia or bleeding) and efficacy (stroke or systemic embolism) of the use of OACs in patients with DM. Methods We searched the Medline, the Excerpta Medica dataBASE (Embase) and Cochrane databases up to the 10th of December 2020. The search strategy was conducted using both keywords and MeSH terms. We included randomised controlled trials (RCTs) and observational studies that reported on the safety and efficacy of the use of OACs in patients with diabetes from all age groups. Study selection, data extraction and quality assessment were conducted independently by two reviewers. Results A total of 3,976 articles were identified through the search process, of which seven studies met the inclusion criteria of the systematic review: four observational studies and three studies that were randomised controlled trials, with a total of 703,855 patients. Two observational studies reported that the use of warfarin was associated with a higher risk of hypoglycaemic events, specifically with sulfonylurea. One observational study and three randomised controlled trials reported that the use of warfarin compared to other oral anticoagulants was associated with a higher risk of bleeding. In addition, three randomised controlled trials reported that the use of warfarin compared to other oral anticoagulants was associated with a lower risk of stroke or systemic embolism. Conclusions This systematic review found that DOACs had a better efficacy outcome and safer clinical outcomes in comparison to warfarin in patients with diabetes.
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Affiliation(s)
- Hassan Alwafi
- Faculty of Medicine, Umm Alqura University, Mecca, Saudi Arabia.,Alnoor Specialist Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Basil Alotaibi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdallah Y Naser
- Department of Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Emad Salawati
- Department of Family Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sami Qadus
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Kanar Sweiss
- Department of Basic Pharmaceutical Sciences, Faculty of Pharmacy, Isra University, Amman, Jordan
| | | | - Loay Hassouneh
- Department of Basic Pharmaceutical Sciences, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Yousef Aldalameh
- Department of Basic Pharmaceutical Sciences, Faculty of Pharmacy, Isra University, Amman, Jordan
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12
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Fauchier L, Boriani G, de Groot JR, Kreutz R, Rossing P, Camm AJ. Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus. Europace 2021; 23:1873-1891. [PMID: 34411235 DOI: 10.1093/europace/euab184] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF), type 2 diabetes mellitus (DM), and chronic kidney disease (CKD) are three global epidemics with significant effects on morbidity and mortality. Diabetes is a risk factor for AF, and a risk factor for thromboembolism, comorbidity, and mortality when AF is present. The pathophysiology of diabetes-related AF and interrelationships with cardiovascular events and renal events is not fully understood but is in part related to structural, electrical, electromechanical, and autonomic remodelling. The current practice guidelines offer limited recommendations on the management of patients with AF (or risk of AF) and diabetes with its own heterogeneity for the prevention of cardiovascular and renal events. This document discusses possible clinical approaches for these patients. In the last decade, there have been major improvements for the prevention of stroke in AF patients with direct oral anticoagulants, which are preferable to vitamin K antagonists for stroke prevention in DM. Because of the increased risk rate for several cardiovascular adverse events in diabetic patients, a similar relative risk reduction generally translates into greater absolute risk reduction in the diabetic population. Recent trials with non-insulin diabetes drugs using glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors showed a significant reduction for the risk of major adverse cardiovascular events in patients with type 2 DM. Sodium-glucose cotransporter-2 inhibitors also showed a large reduction in hospitalization for heart failure and renal events, which need to be more completely evaluated in patients with AF. Mechanisms, risks, and optimal management of AF patients with DM who have or are under risk of developing heart failure or CKD are also discussed in this document. The benefits of medical therapies for these patients still need to be put into perspective, and gaps in evidence on some of these issues are likely to be addressed in future years.
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Affiliation(s)
- Laurent Fauchier
- Department of Cardiology, Centre Hospitalier Universitaire Trousseau et Université de Tours, Tours 37044, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Joris R de Groot
- Department of Cardiology, Amsterdam University Medical Centres/University of Amsterdam, Amsterdam, The Netherlands
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Clinical Pharmacology and Toxicology, Charité University Medicine, Berlin, Germany
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A John Camm
- Cardiology Clinical Academic Group Molecular and Clinical Sciences Institute, St George's University of London, London, UK
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13
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Drogkaris S, Thomopoulos C, Kalos T, Manta E, Tsioufis C. Net clinical benefit of direct oral anticoagulants in atrial fibrillation patients with or without diabetes mellitus: A meta-analysis of outcome trials. Diabetes Res Clin Pract 2021; 182:109147. [PMID: 34793880 DOI: 10.1016/j.diabres.2021.109147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the net clinical benefit following direct oral anticoagulants (DOACs) vs warfarin by diabetes status in patients with non-valvular atrial fibrillation. METHODS We searched 3 electronic databases through end-February 2021 to identify relevant outcome trials in patients with and without diabetes mellitus (DM). All-cause death, non-fatal stroke/systemic embolism and major bleedings defined net clinical benefit. Outcome risk ratios and 95% confidence interval (CI), and absolute risk outcome reduction per 1000 treated patients were assessed. RESULTS Four trials of DOACs vs warfarin compared 22,087 patients with DM to 49,592 patients without DM. CHADS2 and 10-year fatal cardiovascular risk were higher in patients with vs those without DM (3.7 vs 2.5 and 28.4% vs 23.4%, respectively). DOACs were associated with more favorable net clinical benefit compared to warfarin in patients with and without DM (relative risk reduction, 0.85 [95% CI, 0.81-0.89] and 0.87 [95% CI, 0.79-0.96]; absolute risk reduction per 1000 patients treated, -33 [95% CI, -45, -21]) and -24 [95% CI, -43, -5]), but interaction test was not significant by relative and absolute numbers (P = 0.68 and P = 0.44, respectively). CONCLUSION Net clinical benefit following DOACs was not different between patients with and without DM over a period of 2.2 years.
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Affiliation(s)
- Sotirios Drogkaris
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Theodoros Kalos
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Manta
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Costas Tsioufis
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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14
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Jin H, Zhu K, Wang L, Zhi H. A network meta-analysis of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and diabetes mellitus. Acta Cardiol 2021; 76:960-969. [PMID: 33432890 DOI: 10.1080/00015385.2020.1869671] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE With the aim of recommending proper anticoagulation for patients with atrial fibrillation (AF) and diabetes mellitus, we performed the network meta-analysis comparing the non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in terms of efficacy (stroke or systemic embolism) and safety (major bleeding) outcome. METHODS A systematic search of PubMed, EMBASE, Web of Science and Cochrane Library was performed with the items "dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, AF and diabetes mellitus". On the basis of R (version 3.5.1, R Foundation for Statistical Computing) and JAGS (version 4.3.0) to perform the network meta-analysis, our work was also conducted with the help of NetMetaXL (version1.6.1) and winBUGS (version1.4.3) to obtain the cumulative ranking curve (SUCRA) of treatments. RESULTS With respect to the most effective drug for preventing systemic embolism or stroke, there was a high probability that dabigatran150 (SUCRA 0.88) would ranked first, followed by apixaban (SUCRA 0.63), dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.51). In comparison, probability of ranking the safest drug for preventing major bleeding was edoxaban (SUCRA 0.94), followed by dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.52). CONCLUSION In patients suffering from AF and diabetes, dabigatran 110 mg (bid) was more likely to become the choice for its performance on preventing systemic embolism or stroke and major bleeding, followed by rivaroxaban 20 mg (QD).
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Affiliation(s)
- Hao Jin
- School of Medicine, Southeast University, Nanjing, China
| | - Kongbo Zhu
- Department of Cardiology, Affiliated ZhongDa Hospital of Southeast University (HZ), Nanjing, China
| | - Lina Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University, Nanjing, China
| | - Hong Zhi
- Department of Cardiology, Affiliated ZhongDa Hospital of Southeast University (HZ), Nanjing, China
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15
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Cao B, Yao X, Zhang L, Hu X, Chen M, Shen M, Xu L. Efficacy and Safety of Direct Oral Anticoagulants in Patients with Diabetes and Nonvalvular Atrial Fibrillation: Meta-Analysis of Observational Studies. Cardiovasc Ther 2021; 2021:5520027. [PMID: 34729079 PMCID: PMC8523231 DOI: 10.1155/2021/5520027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND This meta-analysis was performed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for stroke prevention in real-world patients with diabetes and nonvalvular atrial fibrillation (NVAF) through observational studies. METHODS PubMed, Embase, and Web of Science databases were searched up to August 2020 for eligible studies. Outputs were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs) by using a random-effect model. RESULTS Seven observational studies involving 249,794 diabetic NVAF patients were selected. Compared with VKAs, the use of DOACs was associated with significantly reduced risks of stroke (RR = 0.56, 95% CI 0.45-0.70; p < 0.00001), ischemic stroke (RR = 0.61, 95% CI 0.48-0.78; p < 0.0001), stroke or systemic embolism (SSE) (RR = 0.81, 95% CI 0.68-0.95; p = 0.01), myocardial infarction (RR = 0.69, 95% CI 0.55-0.88; p = 0.002), major bleeding (RR = 0.75, 95% CI 0.63-0.90; p = 0.002), intracranial hemorrhage (RR = 0.50, 95% CI 0.44-0.56; p < 0.00001), and major gastrointestinal bleeding (RR = 0.77, 95% CI 0.62-0.95; p = 0.02), and a borderline significant decrease in major adverse cardiac events (RR = 0.87, 95% CI 0.75-1.00; p = 0.05) in NVAF patients with diabetes. CONCLUSION For patients with NVAF and diabetes in real-world clinical settings, DOACs showed superior efficacy and safety profile over VKAs and significantly reduced risks of stroke, ischemic stroke, SSE, myocardial infarction, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding.
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Affiliation(s)
- Bo Cao
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Xingcan Yao
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Lifang Zhang
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Xiaobo Hu
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Min Chen
- Department of Cardiovascular Medicine, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Mingfeng Shen
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Lan Xu
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
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16
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Gach O, Pierard LA. Atrial fibrillation, diabetes and anticoagulation with direct oral anticoagulants: time to reconsider duration of the disease to evaluate the bleeding risk? Acta Cardiol 2021; 76:461-463. [PMID: 33435835 DOI: 10.1080/00015385.2020.1870194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Atrial fibrillation and diabetes: time to reconsider duration of the disease to evaluate the bleeding risk? Impact of diabetes status in patients suffering of non-valvular atrial fibrillation requiring anticoagulation have been analysed previously and risk/benefit balance of NOACs have been confirmed in these patients. The implication of that pathology in the evaluation of the thrombotic risk is discussed but more importantly bleeding risk in this growing population is analysed, perhaps neglected until now.
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Affiliation(s)
- Olivier Gach
- Université de Liège. Service de Cardiologie, CHC MontLégia, Liège, Belgium
| | - Luc A. Pierard
- Faculté de Médecine. Département des sciences cliniques, Université de Liège, Liège, Belgium
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17
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Ajjan RA, Kietsiriroje N, Badimon L, Vilahur G, Gorog DA, Angiolillo DJ, Russell DA, Rocca B, Storey RF. Antithrombotic therapy in diabetes: which, when, and for how long? Eur Heart J 2021; 42:2235-2259. [PMID: 33764414 PMCID: PMC8203081 DOI: 10.1093/eurheartj/ehab128] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.
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Affiliation(s)
- Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK
| | - Noppadol Kietsiriroje
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Endocrinology and Metabolism Unit, Internal Medicine Department, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Lina Badimon
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Cardiovascular Research Chair, Universidad Autónoma Barcelona (UAB), Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Diana A Gorog
- University of Hertfordshire, College Lane Campus Hatfield, Hertfordshire AL10 9AB, UK.,National Heart and Lung Institute, Guy Scadding Building, Dovehouse St, London SW3 6LY, UK
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, 655 West, 8th Street, Jacksonville, FL 32209, USA
| | - David A Russell
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK
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18
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Diabetes and Thrombosis: A Central Role for Vascular Oxidative Stress. Antioxidants (Basel) 2021; 10:antiox10050706. [PMID: 33946846 PMCID: PMC8146432 DOI: 10.3390/antiox10050706] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
Diabetes mellitus is the fifth most common cause of death worldwide. Due to its chronic nature, diabetes is a debilitating disease for the patient and a relevant cost for the national health system. Type 2 diabetes mellitus is the most common form of diabetes mellitus (90% of cases) and is characteristically multifactorial, with both genetic and environmental causes. Diabetes patients display a significant increase in the risk of developing cardiovascular disease compared to the rest of the population. This is associated with increased blood clotting, which results in circulatory complications and vascular damage. Platelets are circulating cells within the vascular system that contribute to hemostasis. Their increased tendency to activate and form thrombi has been observed in diabetes mellitus patients (i.e., platelet hyperactivity). The oxidative damage of platelets and the function of pro-oxidant enzymes such as the NADPH oxidases appear central to diabetes-dependent platelet hyperactivity. In addition to platelet hyperactivity, endothelial cell damage and alterations of the coagulation response also participate in the vascular damage associated with diabetes. Here, we present an updated interpretation of the molecular mechanisms underlying vascular damage in diabetes, including current therapeutic options for its control.
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19
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Korgaonkar S, Yang Y, Banahan B, Bentley JP. Comparative effectiveness and safety of non-vitamin-K antagonist oral anticoagulants and warfarin in older adults with atrial fibrillation and diabetes. Curr Med Res Opin 2021; 37:343-356. [PMID: 33327796 DOI: 10.1080/03007995.2020.1865748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate comparative effectiveness and safety of non-vitamin-K antagonist oral anticoagulants (NOACs) versus warfarin in Medicare beneficiaries with non-valvular atrial fibrillation (NVAF) and comorbid diabetes mellitus (DM). METHODS A retrospective cohort study using 2014-2016 5% national Medicare data was undertaken. NVAF patients with DM aged ≥65 years having at least one prescription for NOACs or warfarin between July 2014 and December 2015 were included in the study. Propensity score matching was used to balance demographic and baseline clinical characteristics of patients in two treatment groups. Cardiovascular outcomes including stroke/systemic embolism (SE) and myocardial infarction (MI) were evaluated to measure effectiveness. Assessment of safety outcomes included intracranial hemorrhage (ICH), major gastrointestinal bleeding (MGB), bleeding from other sites (OB) and all-cause mortality. Stratified Cox proportional hazards models were used to estimate hazard ratios for the outcomes in the matched cohort. RESULTS The matched sample consisted of 4582 patients (2291 pairs). Compared to warfarin, NOACs had a significantly lower risk of stroke/SE (hazard ratio (HR): 0.373, 95% confidence interval (CI): 0.247-0.564, p < .001) and all-cause mortality (HR: 0.783, CI: 0.656-0.873, p = .007). NOACs were found to significantly reduce the risk of ICH (HR: 0.500, CI: 0.300-0.834, p = .008) and OB (HR: 0.608, CI: 0.424-0.870, p = .007), but no difference was observed in the risk of MGB (HR: 0.862, CI: 0.640-1.160, p = .326) between NOACs and warfarin. The composite outcome demonstrated superior overall effectiveness and safety of NOAC therapy compared to warfarin therapy (HR: 0.685, CI: 0.587-0.801, p < .001). CONCLUSION Oral anticoagulation therapy with NOACs was found to be more effective than warfarin therapy among older adults with NVAF and comorbid DM.
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Affiliation(s)
- Siddhi Korgaonkar
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| | - Yi Yang
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
| | - Benjamin Banahan
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
| | - John P Bentley
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
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20
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Camm AJ, Atar D. Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects. Thromb Haemost 2021; 121:716-730. [PMID: 33412613 DOI: 10.1055/s-0040-1721665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,University of Oslo, Oslo, Norway
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21
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De Caterina R, Patti G, Westerbergh J, Horowitz J, Ezekowitz JA, Lewis BS, Lopes RD, McMurray JJV, Atar D, Bahit MC, Keltai M, López-Sendón JL, Ruzyllo W, Granger CB, Alexander JH, Wallentin L. Heterogeneity of diabetes as a risk factor for major adverse cardiovascular events in anticoagulated patients with atrial fibrillation: an analysis of the ARISTOTLE trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:227-235. [PMID: 33367487 DOI: 10.1093/ehjcvp/pvaa140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/14/2020] [Accepted: 12/07/2020] [Indexed: 12/11/2022]
Abstract
AIMS Whether diabetes without insulin therapy is an independent cardiovascular (CV) risk factor in atrial fibrillation (AF) has recently been questioned. We investigated the prognostic relevance of diabetes with or without insulin treatment in patients in the ARISTOTLE trial. METHODS AND RESULTS Patients with AF and increased stroke risk randomized to apixaban vs. warfarin were classified according to diabetes status: no diabetes; diabetes on no diabetes medications; diabetes on non-insulin antidiabetic drugs only; or insulin-treated. The associations between such patient subgroups and stroke/systemic embolism (SE), myocardial infarction (MI), and CV death were examined by Cox proportional hazard regression, both unadjusted and adjusted for other prognostic variables. Patients with diabetes were younger and had a higher body mass index. Median CHA2DS2VASc score was 4.0 in patients with diabetes and 3.0 in patients without diabetes. We found no significant difference in stroke/SE incidence across patient subgroups. Compared with no diabetes, only insulin-treated diabetes was significantly associated with higher risk. When adjusted for clinical variables, compared with no diabetes, the hazard ratios (HRs) for MI (95% confidence intervals) were for diabetes on no medication: 1.15 (0.62-2.14); for diabetes on non-insulin antidiabetic drugs: 1.32 (0.90-1.94); for insulin-treated diabetes: 2.34 (1.43-3.82); interaction P = 0.008. HRs for CV death were for diabetes on no medication: 1.19 (0.86-166); for diabetes on non-insulin antidiabetic drugs: 1.12 (0.88-1.42); for insulin-treated diabetes 1.85 (1.36-2.53), interaction P = 0.001. CONCLUSION In anticoagulated patients with AF, a higher risk of MI and CV death is largely confined to diabetes treated with insulin.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa, and Cardiovascular Division, Pisa University Hospital, Via Paradisa 2, 56126 Pisa, Italy.,Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Italy
| | | | - Johan Westerbergh
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval and Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Argentina
| | - Matyas Keltai
- Hungarian Institute of Cardiology, Semmelweis University, Budapest, Hungary
| | | | | | | | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital ingång 40, 751 85 Uppsala, Sweden
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22
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Rustem Gulluoglu F, Souverein PC, van den Ham HA, de Boer A, Komen J. Comparative effectiveness and safety of direct oral anticoagulants versus warfarin in UK patients with atrial fibrillation and type 2 diabetes: A retrospective cohort study. Pharmacoepidemiol Drug Saf 2020; 30:1293-1320. [PMID: 33314401 PMCID: PMC8451809 DOI: 10.1002/pds.5181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/09/2020] [Accepted: 12/07/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE To estimate the effectiveness and safety of direct oral anticoagulants (DOACs) compared with warfarin in AF patients with type 2 diabetes (T2DM). METHODS A retrospective cohort study was designed, using the UK Clinical Practice Research Datalink (August 2011-June 2018). Participants were 1-year naïve users of DOACs or warfarin, followed from the date of first prescription of an oral anticoagulant until the end of the study period, death, discontinuation of treatment, switching to another anticoagulant, or an outcome of interest, whichever came first. Cox regression analysis was performed to estimate the hazard ratio (HR) adjusted for potential confounders. RESULTS A total of 8555 patients were identified. No significant differences were found between DOACs and warfarin in the risk of stroke (adjusted HR 1.15; 95% CI 0.82-1.60), ischemic and unspecified stroke (adjusted HR 1.23; 95% CI 0.86-1.76) or haemorrhagic stroke (adjusted HR 0.75; 95% CI 0.30-1.85), and myocardial infarction (adjusted HR 1.39;95% CI 0.99-1.97). DOAC and warfarin users were comparable with respect to risk of major bleed (adjusted HR 0.83; 95% CI 0.68-1.03), intracranial bleeding (HR 0.66; 95% CI 0.34-1.30), gastrointestinal bleeding (HR 0.88; 95% CI 0.60-1.30), and bleeding on other clinically relevant sites (HR 0.89; 95% CI 0.60-1.31). In the subgroup analyses stratified by gender and diabetes severity, the risk for stroke and bleeding remained consistent. CONCLUSION DOACs are effective and safe alternatives to warfarin for the prevention of stroke in AF patients with T2DM.
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Affiliation(s)
- Fatma Rustem Gulluoglu
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Joris Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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23
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Kreutz R, Camm AJ, Rossing P. Concomitant diabetes with atrial fibrillation and anticoagulation management considerations. Eur Heart J Suppl 2020; 22:O78-O86. [PMID: 33380946 PMCID: PMC7753879 DOI: 10.1093/eurheartj/suaa182] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia. It is associated with numerous co mobilities. Approximately 30% of diabetic patients have atrial fibrillation and 15% of atrial fibrillation regulation patients have diabetes mellitus. Diabetes increases the likelihood of the development of atrial fibrillation and contributes to the high risk of thromboembolism seen in patients with both diabetes and atrial fibrillation. Chronic kidney disease is often a consequence of diabetes and presents an additional challenge to the management of patients with both atrial fibrillation and diabetes. All non-vitamin K oral anticoagulants are partially eliminated via the kidney and must be carefully prescribed according to strict dosing schedules to avoid anticoagulation overdose. However, NOACs have the advantage of being associated with less progressive impairment of renal function compared with vitamin K antagonist therapy in both diabetics and non-diabetics. Otherwise, diabetic patients benefit from NOAC therapy as opposed to vitamin K antagonists to a similar extent as patients without diabetes. This review deals with anticoagulation treatment in patients with fibrillation and diabetes mellitus, often complicated by progressive renal impairment.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - A John Camm
- Cardiac Clinical Academic Group, St George’s University of London, Cranmer Terrace, London SW19 0RE, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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24
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Abdool M, Kunutsor SK, Khunti K, Seidu S. Does the presence of diabetes mellitus confer an increased risk of stroke in patients with atrial fibrillation on direct oral anticoagulants? A systematic review and meta-analysis. Diabetes Metab Syndr 2020; 14:1725-1733. [PMID: 32916556 DOI: 10.1016/j.dsx.2020.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/13/2020] [Accepted: 08/30/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS There is limited data on clinical outcomes in high risk groups such as patients with diabetes mellitus (DM) with atrial fibrillation (AF) on direct-acting oral anticoagulants (DOACs). Using a systematic review and meta-analysis of published studies, we aimed to determine the risk of stroke and other clinical outcomes in patients with AF on DOACs, with or without DM. METHODS Observational cohort studies reporting clinical outcomes in patients with AF on DOACs, with or without DM were identified from MEDLINE, Embase, Web of Science, the Cochrane Library, and search of bibliographies to April 2020. Summary measures of effect were relative risks with 95% confidence intervals (CIs). RESULTS Eight studies comprising of 4 observational cohorts (n = 76,260 participants) and 4 randomised controlled trials (RCTs) (n = 71,683 participants) were included. In RCTs, DOACs compared with warfarin reduced the risk of the composite outcome of stroke and systemic embolism, CVD death and intracranial bleeding in patients with DM: RRs (95% CIs) of 0.75 (0.62-0.90), 0.84 (0.72-0.97), and 0.57 (0.40-0.81) respectively. The corresponding estimates for patients without DM were 0.81 (0.68-0.96), 0.93 (0.80-1.08), and 0.47 (0.31-0.70) respectively. There was no evidence of interactions between DM status and effects of DOACs. The absolute reduction in clinical outcomes with DOACs compared to warfarin was greater in DM than without DM. Regardless of treatment strategy, interventional and observational evidence indicate that patients with DM had higher rates of stroke or systemic embolism, mortality and major bleeding compared to patients without DM. CONCLUSIONS Patients with AF and DM have increased risk of vascular events, which is reduced with the use of DOACs. The use of DOACs should be considered as an option in reducing the risk of stroke in these populations. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2020: CRD42020157196.
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Affiliation(s)
- Mohammad Abdool
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, UK
| | - Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, UK
| | - Samuel Seidu
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, UK.
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25
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Plitt A, Zelniker TA, Park JG, McGuire DK, Ruff CT, Antman EM, Braunwald E, Giugliano RP. Patients with diabetes mellitus and atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants: meta-analysis of eight outcomes in 58 634 patients across four randomized controlled trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f40-f49. [PMID: 33063112 DOI: 10.1093/ehjcvp/pvaa120] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/31/2020] [Accepted: 09/30/2020] [Indexed: 12/29/2022]
Abstract
AIMS Concomitant atrial fibrillation (AF) and diabetes mellitus (DM) increases the risk of stroke and systemic embolic events (SEE). This meta-analysis assessed the benefit/risk balance of non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin, and explored whether there was effect modification by DM or heterogeneity in outcomes between NOACs in patients with and without DM. METHODS AND RESULTS We performed a meta-analysis of 58 634 patients from four Phase 3 trials of NOAC vs. warfarin in patients with AF, comparing the primary outcomes of efficacy and safety and six other secondary outcomes in patients stratified by the presence of DM. Interaction testing was used to assess for heterogeneity of treatment effects. A meta-regression was performed to evaluate the influence of baseline characteristics. NOACs reduced the risk of stroke/SEE in 18 134 patients with DM [hazard ratio (HR) 0.80; 95% confidence interval (CI) (0.69-0.93), I2 3.90] to a similar degree as in 40 500 patients without DM [HR 0.82; 95% CI (0.74-0.91), I2 16.33; P-int 0.81]. There was no effect modification of DM on the relative reduction with NOACs vs. warfarin in major bleeding (DM: 0.95, 95% CI 0.75-1.20, I2 43.83; no DM: 0.83, 95% CI 0.55-1.24; I2 87.90; P-int 0.37). Intracranial haemorrhage (HRs 0.51 and 0.47, P-int 0.70) and cardiovascular death (HRs 0.87 and 0.90, P-int 0.70) were significantly reduced by NOACs in the presence or absence of DM. CONCLUSION Non-vitamin K antagonist oral anticoagulants are more effective and safer than warfarin in AF patients with or without DM. Absent contraindications, NOACs should be the anticoagulation treatment choice in patients with diabetes.
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Affiliation(s)
- Anna Plitt
- Mount Sinai Heart, 1190 5th Ave, New York, NY, USA
| | - Thomas A Zelniker
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA.,Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, 5323 Harry Hines Blvd., TX 75390, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
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26
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Obrezan AG, Kulikov NV. [Atrial Fibrillation and Diabetes Mellitus: the Control of Thromboembolic Risk]. KARDIOLOGIYA 2020; 60:108-114. [PMID: 33155949 DOI: 10.18087/cardio.2020.7.n1146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/30/2020] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation is one of the most common concomitant diseases in patients with diabetes mellitus (DM). Meta-analyses of multiple studies have shown that the risk of AF is higher for diabetic patients with impaired glucose homeostasis than for patients without DM. Patients with AF and DM were younger, more frequently had arterial hypertension, chronic kidney disease, heart failure, and ischemic heart disease, and stroke and were characterized with a more severe course of AF. The article discusses possible mechanisms of the mutually aggravating effects of DM and AF, scales for evaluating the risk of bleeding (CHADS2, CHA2DS2‑VASc, HAS-BLED), and the role of anticoagulants. A meta-analysis of 16 randomized clinical studies, including 9 874 patients, has demonstrated the efficacy of oral anticoagulants in prevention of stroke with an overall decrease in the relative risk by 62 % compared to placebo (95% confidence interval, from 48 to 72 ). For prevention of complications in patients with AF and DM, current antithrombotic therapies can be used, specifically the oral factor Xa inhibitor, rivaroxaban, which is the best studied in patients with AF and DM and represents a possible alternative to warfarin in such patients.
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Affiliation(s)
- A G Obrezan
- Saint-Petersburg University, Saint-Petersburg; SOGAZ MEDI-CINE Clinic Group
| | - N V Kulikov
- Saint-Petersburg University, Saint-Petersburg
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27
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Paolillo S, Ruocco G, Filardi PP, Palazzuoli A, Tocchetti CG, Nodari S, Lombardi C, Metra M, Correale M. Direct oral anticoagulants across the heart failure spectrum: the precision medicine era. Heart Fail Rev 2020; 27:135-145. [PMID: 32583229 DOI: 10.1007/s10741-020-09994-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Heart failure (HF) is characterized by a pro-thrombotic state, which might aggravate its morbidity and, consequently, mortality. Several and commonly observed comorbidities, such as coronary artery disease, atrial fibrillation (AF), renal dysfunction, and diabetes often complicate HF, increasing the thromboembolic risk. In the past decade, direct oral anticoagulants (DOACs) have been approved for the treatment and prevention of stroke and embolic events in patients with nonvalvular AF. Due to their lower bleeding risk, these drugs are frequently used instead of warfarin; however, some controversies exist on their use in HF patients with or without comorbidities. Indeed, the management of anticoagulation in HF patients with underlying conditions is poorly investigated since these patients are underrepresented or excluded from randomized controlled trials. The aim of this research is to review current evidence on the use of DOACs in HF patients, also discussing their specific use in different clinical scenarios. Graphical abstract.
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Affiliation(s)
- Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Gaetano Ruocco
- Division of Cardiology, Regina Montis Regalis Hospital, ASLCN-1, Via S. Rocchetto, 99, 12084, Mondovì, CN, Italy.
| | | | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy
| | | | - Savina Nodari
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Carlo Lombardi
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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28
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Chan YH, Lee HF, Li PR, Liu JR, Chao TF, Wu LS, Chang SH, Yeh YH, Kuo CT, See LC, Lip GYH. Effectiveness, safety, and major adverse limb events in atrial fibrillation patients with concomitant diabetes mellitus treated with non-vitamin K antagonist oral anticoagulants. Cardiovasc Diabetol 2020; 19:63. [PMID: 32404168 PMCID: PMC7222472 DOI: 10.1186/s12933-020-01043-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/09/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Evidence of adverse clinical outcomes for non-vitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation (AF) and diabetes mellitus are limited. We investigated the effectiveness, safety, and major adverse limb events for NOACs versus warfarin among diabetic AF patients. METHODS In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, we identified a total of 20,967 and 5812 consecutive AF patients with diabetes taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. We used propensity-score stabilized weighting to balance covariates across study groups. RESULTS NOAC was associated with a lower risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio (aHR):0.88; [95% confidential interval (CI) 0.78-0.99]; P = 0.0283), major adverse limb events (MALE) (aHR:0.72;[95% CI 0.57-0.92]; P = 0.0083), and major bleeding (aHR:0.67;[95% CI 0.59-0.76]; P < 0.0001) compared to warfarin. NOACs decreased MACE in patients of ≥ 75 but not in those aged < 75 years (P interaction = 0.01), and in patients with ischemic heart disease (IHD) compared to those without IHD (P interaction < 0.01). For major adverse limb events, the advantage of risk reduction for NOAC over warfarin persisted in high risk subgroups including age ≥ 75 years, chronic kidney disease, IHD, peripheral artery disease, or use of concomitant antiplatelet drugs. CONCLUSION Among diabetic AF patients, NOACs were associated with a lower risk of thromboembolism, major bleeding, and major adverse limb events than warfarin. Thromboprophylaxis with NOACs should be considered in the diabetic AF population with a high atherosclerotic burden.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng branch, Taiwan), Taipei, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan. .,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan. .,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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29
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Lip GYH, Keshishian AV, Kang AL, Li X, Dhamane AD, Luo X, Balachander N, Rosenblatt L, Mardekian J, Nadkarni A, Pan X, Di Fusco M, Garcia Reeves AB, Yuce H, Deitelzweig SB. Effectiveness and Safety of Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation and Diabetes Mellitus. Mayo Clin Proc 2020; 95:929-943. [PMID: 32370854 DOI: 10.1016/j.mayocp.2019.05.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/17/2019] [Accepted: 05/24/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To address gaps in the data comparing non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin among patients with nonvalvular atrial fibrillation (NVAF) and diabetes. PATIENTS AND METHODS A retrospective study was conducted on patients with NVAF and diabetes newly initiating apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with Medicare data from the US Centers for Medicare & Medicaid Services and 4 other US commercial claims databases. One-to-one propensity score matching was completed between NOACs and warfarin and between NOACs in each database, and the results were pooled. Cox proportional hazards models were used to evaluate the risk of stroke/systemic embolism (SE) and major bleeding (MB). RESULTS A total of 154,324 patients were included in the 6 matched cohorts, with a mean follow-up time of 6 to 8 months. Compared with warfarin, apixaban (hazard ratio [HR], 0.67; 95% CI, 0.57-0.77) and rivaroxaban (HR, 0.79; 95% CI, 0.71-0.89) were associated with a lower risk of stroke/SE; dabigatran (HR, 0.84; 95% CI, 0.67-1.07) was associated with a similar risk of stroke/SE. Apixaban (HR, 0.60; 95% CI, 0.56-0.65) and dabigatran (HR, 0.78; 95% CI, 0.69-0.88) were associated with a lower risk of MB; rivaroxaban (HR, 1.02; 95% CI, 0.94-1.10) was associated with a similar risk of MB compared with warfarin. Compared with dabigatran and rivaroxaban, apixaban was associated with a lower risk of MB. Compared with rivaroxaban, dabigatran was associated with a lower risk of MB. CONCLUSION This study-the largest observational study to date of patients with NVAF and diabetes taking anticoagulants-found that NOACs were associated with variable rates of stroke/SE and MB compared with warfarin. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03087487.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, at the Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Allison V Keshishian
- Health Economics and Outcomes Research, SIMR, LLC, Ann Arbor, MI; Department of Mathematics, New York City College of Technology, City University of New York, New York
| | - Amiee L Kang
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Xiaoyan Li
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Amol D Dhamane
- Health Economics & Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Xuemei Luo
- Global Research and Development, Pfizer Inc., Groton, CT
| | - Neeraja Balachander
- Worldwide Cardiovascular Department, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Lisa Rosenblatt
- Worldwide Cardiovascular Department, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | | | - Anagha Nadkarni
- Health Economics & Outcomes Research, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Xianying Pan
- Center for Observational Research & Data Sciences, Bristol-Myers Squibb Company, Lawrenceville, NJ
| | | | - Alessandra B Garcia Reeves
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Huseyin Yuce
- Department of Mathematics, New York City College of Technology, City University of New York, New York
| | - Steven B Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA; Queensland School of Medicine, University of Queensland School of Medicine, New Orleans, LA
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30
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Glycemic status and risks of thromboembolism and major bleeding in patients with atrial fibrillation. Cardiovasc Diabetol 2020; 19:30. [PMID: 32156277 PMCID: PMC7063754 DOI: 10.1186/s12933-020-01005-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 02/24/2020] [Indexed: 12/17/2022] Open
Abstract
Background Studies specifically examining the association between glycated hemoglobin A1c (HbA1c) levels and ischemic stroke/systemic thromboembolism (IS/SE) risk in atrial fibrillation (AF) patients are limited. Here, we investigated the association between HbA1c levels and the risk of IS/SE, as well as major bleeding, among AF patients with or without oral anticoagulants (OACs). We also compared the effectiveness and safety of warfarin and direct oral anticoagulants (DOACs) in different HbA1c categories. Methods We utilized medical data from a multi-center healthcare provider in Taiwan, which included 34,036 AF patients with serum HbA1c data available within 3 months after AF being diagnosed. Patients were divided into seven study groups according to their HbA1c levels: < 5.4%, 5.4%–5.6%, 5.7%–5.9%, 6.0%–6.4%, 6.5%–6.9%, 7.0%–7.9%, and ≥ 8.0%. The risks of IS/SE and major bleeding were compared among the groups after adjusting for baseline stroke and bleeding risk factors. Results Compared with the patients with HbA1c level < 5.4%, IS/SE risk significantly increased at HbA1c levels higher than 6.5% [adjusted hazard ratio (HR): 1.20, 95% confidence interval (CI): 1.00–1.43 for HbA1c level 6.5%–6.9%; 1.32, (95% CI 1.11–1.57) for HbA1c level 7.0%–7.9%; and 1.48 (95% CI 1.25–1.76) for HbA1c level ≥ 8.0%]. These results were generally consistent in AF patients without OACs (n = 24,931). However, among 9105 patients receiving OACs, IS/SE risk was not higher for patients having higher HbA1c levels. The risk of major bleeding was comparable across all HbA1c categories. Compared with warfarin, DOACs were associated with lower risks of IS/SE (adjusted HR: 0.61, 95% CI 0.49–0.75) and major bleeding (adjusted HR: 0.30, 95% CI 0.21–0.42) without interactions across different HbA1c categories (all P interactions > 0.05). Conclusion For AF patients, IS/SE risk significantly increased once HbA1c levels exceeded 6.5%, and OACs may attenuate these associations. Compared with warfarin, DOACs were more effective and safer across broad HbA1c categories. Therefore, in addition to prescribing DOACs when indicated, more aggressive glycemic control to achieve an HbA1c level < 6.5% may be considered for eligible AF patients and should be tested in further prospective studies.
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Plitt A, Ruff CT, Goudev A, Morais J, Ostojic MC, Grosso MA, Lanz HJ, Park JG, Antman EM, Braunwald E, Giugliano RP. Efficacy and safety of edoxaban in patients with diabetes mellitus in the ENGAGE AF-TIMI 48 trial. Int J Cardiol 2020; 304:185-191. [PMID: 32008850 DOI: 10.1016/j.ijcard.2020.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/30/2019] [Accepted: 01/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diabetes mellitus is an independent risk factor for stroke and atrial fibrillation. Therefore, the risk/benefit profile of the oral factor Xa inhibitor edoxaban stratified by diabetes is of clinical interest. METHODS 21,105 patients enrolled in ENGAGE AF-TIMI 48 were stratified into 2 pre-specified groups: without (N = 13,481) and with diabetes (N = 7,624). RESULTS On average, patients with diabetes were younger, and had a higher body mass index, CHA2DS2-VASc score and baseline endogenous Factor Xa activity. After multivariate adjustments, patients with diabetes had a similar rate of stroke and systemic embolism compared to those without diabetes (adjusted hazard ratio (HRadj) 1.08; 95% confidence interval (CI) 0.94-1.24; p = 0.28). However, the risk of major bleeding was significantly higher in patients with diabetes (HRadj 1.28; 95% CI 1.14-1.44; p < 0.001). The treatment effect of edoxaban (vs warfarin) was not modified by diabetes (all p-interactions > 0.05), a finding supported by the preserved edoxaban concentrations and inhibition of Factor Xa regardless of diabetes. The HRs of stroke and systemic embolism in patients receiving the higher-dose edoxaban regimen vs warfarin were 0.93 and 0.84 (p-interaction = 0.54) in those with and without diabetes respectively. The higher-dose edoxaban regimen reduced major bleeding (by 19-21%) and cardiovascular death (by 7-17%) regardless of diabetes (p-interactions = 0.81 and 0.33 respectively). CONCLUSION Patients with diabetes in ENGAGE AF-TIMI 48 had higher bleeding risk, but after adjustment similar stroke risk, compared to those without diabetes. The higher-dose edoxaban regimen had similar efficacy compared to warfarin, while reducing bleeding and cardiovascular mortality, irrespective of diabetes.
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Affiliation(s)
- Anna Plitt
- Mount Sinai Heart, New York, NY, United States of America
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Assen Goudev
- UMHAT "Tzaritza Yoanna-ISUL" EAD Clinic of Cardiology, Sofia, Bulgaria
| | - Joao Morais
- Santo Andre's Hospital, Cardiology Division, Leiria, Portugal
| | | | - Michael A Grosso
- Daiichi Sankyo Inc., Basking Ridge, NJ, United States of America
| | | | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States of America.
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Prídavková D, Samoš M, Bolek T, Škorňová I, Žolková J, Kubisz P, Staško J, Mokáň M. Type 2 Diabetes, Atrial Fibrillation, and Direct Oral Anticoagulation. J Diabetes Res 2019; 2019:5158308. [PMID: 31886279 PMCID: PMC6925766 DOI: 10.1155/2019/5158308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/27/2019] [Indexed: 02/06/2023] Open
Abstract
Type 2 diabetes (T2D) is an independent risk factor of stroke and systemic embolism in patients with atrial fibrillation (AF), and T2D patients with AF-associated stroke seem to have worse clinical outcome and higher risk of unfavorable clinical course compared to individuals without this metabolic disorder. Long-term anticoagulation is indicated in majority of T2D patients with AF to prevent adverse AF-associated embolic events. Direct oral anticoagulants (DOACs), direct oral thrombin inhibitor dabigatran, and direct oral factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have emerged as a preferred choice for long-term prevention of stroke in AF patients offering potent and predictable anticoagulation and a favorable pharmacology with low risk of interactions. This article reviews the current data regarding the use of DOACs in individuals with T2D and AF.
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Affiliation(s)
- Dana Prídavková
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Ingrid Škorňová
- National Center of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jana Žolková
- National Center of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Peter Kubisz
- National Center of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Ján Staško
- National Center of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Pomero F, Dentali F, Mumoli N, Salomone P, Tangianu F, Desideri G, Mastroiacovo D. The continuous challenge of antithrombotic strategies in diabetes: focus on direct oral anticoagulants. Acta Diabetol 2019; 56:1247-1258. [PMID: 31552542 DOI: 10.1007/s00592-019-01426-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/17/2019] [Indexed: 12/16/2022]
Abstract
Direct oral anticoagulants (DOACs) include dabigatran, which inhibits thrombin, and apixaban, edoxaban, and rivaroxaban, which inhibit factor Xa. They have been extensively studied in large trials involving patients affected by the most common cardiovascular diseases. As the presence of diabetes leads to peculiar changes in primary and secondary hemostasis, in this review we highlight the current evidence regarding DOAC use in diabetic patients included in the majority of recently conducted studies. Overall, in trials involving patients with atrial fibrillation, data seem to confirm at least a similar efficacy and safety of DOACs compared to warfarin in patients with or without diabetes. Furthermore, in diabetic patients, treatment with DOACs is associated with a significant relative reduction in vascular death compared to warfarin. In trials enrolling patients undergoing percutaneous coronary intervention, results concerning bleeding events are consistent in patients with or without diabetes. With regards to the COMPASS study, in patients with diabetes (n = 10,241), addition of rivaroxaban 2.5 mg to aspirin resulted in a significantly lower incidence of major adverse cardiovascular events (HR 0.74, 95% CI 0.61-0.90; interaction p = 0.68) with higher rates of major bleeding expected (HR 1.70, 95% CI 1.25-2.31). The 3287 patients with peripheral artery disease and diabetes receiving rivaroxaban plus aspirin had a twofold higher absolute reduction in the composite endpoint (cardiovascular death, myocardial infarction, and stroke) than patients without diabetes. Finally, we report the involvement of cytochromes or P-glycoprotein on the metabolism of the most commonly prescribed glucose-lowering drugs. No clinically relevant interactions are expected during the concomitant use of DOACs and anti-diabetic agents.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, S. Lazzaro Hospital, Alba, CN, Italy.
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Fornaroli, Magenta, Italy
| | - Pietro Salomone
- Specialty Training in Internal Medicine, University of Turin, Turin, Italy
| | - Flavio Tangianu
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Science, San Salvatore Hospital, University of L'Aquila, Building Delta 6, L'Aquila, Italy
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Guimarães PO, Peterson ED, Stevens SR, Lokhnygina Y, Green JB, McGuire DK, Holman RR, Lopes RD. Antithrombotic treatment gap among patients with atrial fibrillation and type 2 diabetes. Int J Cardiol 2019; 289:58-62. [PMID: 31079973 DOI: 10.1016/j.ijcard.2019.04.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/09/2019] [Accepted: 04/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND We investigated the use of different antithrombotic therapies at baseline among patients with a history of atrial fibrillation (AF), type 2 diabetes, and established atherosclerotic cardiovascular disease (ASCVD) enrolled in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). METHODS TECOS participants with a history of AF were stratified by CHA2DS2-VASc score and their antithrombotic use evaluated. Cox proportional hazards models were employed to explore possible associations between history of AF and prespecified clinical outcomes after adjusting for key baseline characteristics. RESULTS Of the 14,671 TECOS participants, 1167 (8%) had a history of AF, of whom 51.6% were using vitamin K antagonists (VKA); 31.2% used VKA alone, 16.9% used aspirin plus VKA, 1.8% used clopidogrel plus VKA, and 1.7% used aspirin and clopidogrel plus VKA. Aspirin was used by 56.8%: 30.9% used aspirin alone and 7.3% aspirin plus clopidogrel. Clopidogrel alone was used by 2.9%, and 7.3% were not using any antithrombotic medication. Participants with a history of AF had a higher risk of cardiovascular events, including hospitalization for heart failure and all-cause mortality, than those without AF. White, older men with prior myocardial infarction, heart failure, peripheral artery disease, or prior stroke were more likely to develop new-onset AF than others without these characteristics. CONCLUSIONS Almost half of high-risk AF patients with diabetes and established ASCVD in TECOS were not treated with anticoagulation therapy despite clear guideline recommendations for such therapy, highlighting the challenge and potential for clinical improvements in managing these patients in clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00790205.
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Affiliation(s)
- Patrícia O Guimarães
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
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Alexander KP, Brouwer MA, Mulder H, Vinereanu D, Lopes RD, Proietti M, Al-Khatib SM, Hijazi Z, Halvorsen S, Hylek EM, Verheugt FWA, Alexander JH, Wallentin L, Granger CB. Outcomes of apixaban versus warfarin in patients with atrial fibrillation and multi-morbidity: Insights from the ARISTOTLE trial. Am Heart J 2019; 208:123-131. [PMID: 30579505 DOI: 10.1016/j.ahj.2018.09.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) often have multi-morbidity, defined as ≥3 comorbid conditions. Multi-morbidity is associated with polypharmacy, adverse events, and frailty potentially altering response to anticoagulation. We sought to describe the prevalence of multi-morbidity among older patients with AF and determine the association between multi-morbidity, clinical outcomes, and the efficacy and safety of apixaban compared with warfarin. METHODS In this post-hoc subgroup analysis of the ARISTOTLE trial, we studied enrolled patients age ≥ 55 years (n = 16,800). Patients were categorized by the number of comorbid conditions at baseline: no multi-morbidity (0-2 comorbid conditions), moderate multi-morbidity (3-5 comorbid conditions), and high multi-morbidity (≥6 comorbid conditions). Association between multi-morbidity and clinical outcomes were analyzed by treatment with a median follow-up of 1.8 (1.3-2.3) years. RESULTS Multi-morbidity was present in 64% (n = 10,713) of patients; 51% (n = 8491) had moderate multi-morbidity, 13% (n = 2222) had high multi-morbidity, and 36% (n = 6087) had no multi-morbidity. Compared with the no multi-morbidity group, the high multi-morbidity group was older (74 vs 69 years), took twice as many medications (10 vs 5), and had higher CHA2DS2-VASc scores (4.9 vs 2.7) (all P < .001). Adjusted rates per 100 patient-years for stroke/systemic embolism, death, and major bleeding increased with multi-morbidity (Reference no multi-morbidity; moderate multi-morbidity 1.42 [1.24-1.64] and high multi-morbidity 1.92 [1.59-2.31]), with no interaction in relation to efficacy or safety of apixaban. CONCLUSIONS Multi-morbidity is prevalent among the population with AF; efficacy and safety of apixaban is preserved in this subgroup supporting extension of trial results to the most complex AF patients.
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Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Marc A Brouwer
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marco Proietti
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | | | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Yamagishi SI. Concerns about clinical efficacy and safety of warfarin in diabetic patients with atrial fibrillation. Cardiovasc Diabetol 2019; 18:12. [PMID: 30691466 PMCID: PMC6348611 DOI: 10.1186/s12933-019-0818-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/21/2019] [Indexed: 01/07/2023] Open
Abstract
Atrial fibrillation (AF) is one of the most common arrhythmias in elderly people. The risk of thromboembolic stroke is increased in AF patients, especially those with diabetes. Anticoagulant therapy, such as warfarin and non-vitamin K oral anticoagulants (NOACs), is recommended for diabetic patients with AF. However, recent guidelines do not preferentially recommend NOACs over warfarin for diabetic patients. Variability of glycemic control in diabetic patients could affect the pharmacokinetics and anticoagulant activity of warfarin, therefore, the risk-benefit balance of warfarin is prone to be compromised in diabetic patients with AF. Furthermore, since warfarin inhibits the vitamin K-dependent gamma-glutamyl carboxylation of proteins, including osteocalcin and matrix Gla protein, use of warfarin may increase the risk of osteoporotic bone fracture and vascular calcification, both of which are the leading causes of morbidity that diminish the quality of life in diabetic patients. Even though the cost of NOACs is high, NOACs may be preferable to warfarin for the treatment of diabetic patients with AF.
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Affiliation(s)
- Sho-Ichi Yamagishi
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume, 830-0011, Japan.
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Lowenstern A, Al-Khatib SM, Sharan L, Chatterjee R, Allen LaPointe NM, Shah B, Borre ED, Raitz G, Goode A, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski AS, Sanders GD. Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med 2018; 169:774-787. [PMID: 30383133 PMCID: PMC6825839 DOI: 10.7326/m18-1523] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The comparative safety and effectiveness of treatments to prevent thromboembolic complications in atrial fibrillation (AF) remain uncertain. PURPOSE To compare the effectiveness of medical and procedural therapies in preventing thromboembolic events and bleeding complications in adults with nonvalvular AF. DATA SOURCES English-language studies in several databases from 1 January 2000 to 14 February 2018. STUDY SELECTION Two reviewers independently screened citations to identify comparative studies of treatments to prevent stroke in adults with nonvalvular AF who reported thromboembolic or bleeding complications. DATA EXTRACTION Two reviewers independently abstracted data, assessed study quality and applicability, and rated strength of evidence. DATA SYNTHESIS Data from 220 articles were included. Dabigatran and apixaban were superior and rivaroxaban and edoxaban were similar to warfarin in preventing stroke or systemic embolism. Apixaban and edoxaban were superior and rivaroxaban and dabigatran were similar to warfarin in reducing the risk for major bleeding. Treatment effects with dabigatran were similar in patients with renal dysfunction (interaction P > 0.05), and patients younger than 75 years had lower bleeding rates with dabigatran (interaction P < 0.001). The benefit of treatment with apixaban was consistent in many subgroups, including those with renal impairment, diabetes, and prior stroke (interaction P > 0.05 for all). The greatest bleeding risk reduction was observed in patients with a glomerular filtration rate less than 50 mL/min/1.73 m2 (P = 0.003). Similar treatment effects were observed for rivaroxaban and edoxaban in patients with prior stroke, diabetes, or heart failure (interaction P > 0.05 for all). LIMITATION Heterogeneous study populations, interventions, and outcomes. CONCLUSION The available direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular AF. The DOACs had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular AF. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069999).
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Affiliation(s)
- Angela Lowenstern
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Sana M Al-Khatib
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Lauren Sharan
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Ranee Chatterjee
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Nancy M Allen LaPointe
- Duke University School of Medicine, Durham, and Premier, Charlotte, North Carolina (N.M.A.)
| | - Bimal Shah
- Duke University School of Medicine, Durham, North Carolina, and Livongo, Mountain View, California (B.S.)
| | - Ethan D Borre
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Giselle Raitz
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Adam Goode
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | | | | | - Kathryn Lallinger
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Robyn Schmidt
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Andrzej S Kosinski
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Gillian D Sanders
- Duke University School of Medicine and Duke University, Durham, North Carolina (G.D.S.)
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Papp J, Zima E, Bover R, Karaliute R, Rossi A, Szymanski C, Troccoli R, Schneider J, Fagerland MW, Camm AJ, Atar D. Changes in oral anticoagulation for elective cardioversion: results from a European cardioversion registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 3:147-150. [PMID: 28329309 PMCID: PMC5843131 DOI: 10.1093/ehjcvp/pvx003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/09/2017] [Indexed: 12/21/2022]
Abstract
Aims In patients with atrial fibrillation (AF) pharmacological or electrical cardioversion may be performed to restore sinus rhythm. The procedure is associated with an increased risk of thromboembolic events, which can be significantly reduced by adequate anticoagulation (OAC). Our aim was to create a partly prospective, partly retrospective cardioversion registry, particularly focusing on OAC strategies in different European countries, and on emerging choice of OAC over time. Methods From September 2014 to October 2015, cardioversions due to AF performed in six European city hospitals in five European countries (Hungary: Budapest-1 and -2; Italy: Bari and Pisa; France: Amiens; Spain: Madrid; and Lithuania: Kaunas) were recorded in the registry. Results A total of 1101 patients (retrospective/prospective: 679/422, male/female: 742/359, mean age: 67.3 years ± 11.2) were registered. Most of the cardioversions were electrical (97%). Oral anticoagulants were administered in 87% of the patient, the usage of non-VKA oral anticoagulants (NOACs) vs Vitamin K antagonists (VKA) was 31.5% vs 68.5%, respectively. Seventy seven percent of the patients were given oral anticoagulants more than 3 weeks prior to the procedure, and 86% more than 4 weeks after the procedure. When using VKA, international normalized ratio (INR) at cardioversion was above 2.0 in 76% of the cases. A decline in VKA usage (P = 0.033) in elective cardioversion over approximately 1 year was observed. During the observation period, there was an increase in apixaban (P < 0.001), a slight increase in rivaroxaban (P = 0.028) and no changes in dabigatran (P = 0.34) usage for elective cardioversion. There were differences in use of OAC between the countries: Spain used most VKA (89%), while France used least VKA (39%, P < 0.001). Conclusion According to current AF guidelines, NOACs are adequate alternatives to VKA for thromboembolic prevention in AF patients undergoing elective cardioversion. Our results indicate that NOAC use is increasing and there is a significant decrease in VKA use.
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Affiliation(s)
- Judit Papp
- Department of Cardiology, Medical Center Hungarian Defence Forces, 44 Robert Karoly Krt., 1134 Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 68 Varosmajor u., 1122 Budapest, Hungary
| | - Ramon Bover
- Cardiology Department, University Hospital Clinico San Carlos, Profesor Martin Lagos s/n, 28040 Madrid, Spain
| | - Rasa Karaliute
- Lithuanian University of Health Sciences, Cardiology Clinic, 2 Eiveniu str., 50161 Kaunas, Lithuania
| | - Andrea Rossi
- Cardiothoracic Department, Tuscany Foundation Gabriele Monasterio, 1 Via G. Moruzzi, 56124 Pisa, Italy
| | - Catherine Szymanski
- Cardiology Department, Amiens University Hospital, Avenue Rene Laennec, 80000 Salouel Amiens, France
| | - Rossella Troccoli
- Cardiologia Ospedaliera Polyclinic of Bari, 11 Piazza Giulio Cesare, 70124 Bari, Italy
| | | | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
| | - A John Camm
- Molecular and Clinical Research Institute and Cardiology Clinical Academic Group, St. George's University of London and Imperial College, London SW17 0RE, UK
| | - Dan Atar
- Cardiology Department B and Faculty of Medicine, Oslo University Hospital, University of Oslo, 166 Kirkeveien, Building 3-A, 0407 Oslo, Norway
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Stacy ZA, Richter SK. Direct oral anticoagulants for stroke prevention in atrial fibrillation: treatment outcomes and dosing in special populations. Ther Adv Cardiovasc Dis 2018; 12:247-262. [PMID: 30081727 DOI: 10.1177/1753944718787384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND To review data from the pivotal phase III trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) versus warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), and to summarize the major findings with regards to patient subgroups that are at an increased risk for stroke or bleeding. METHODS A PubMed literature search (January 2009 to January 2017) was performed using the terms 'dabigatran', 'rivaroxaban', 'apixaban', 'edoxaban', 'atrial fibrillation', 'RE-LY', 'ROCKET AF', 'ARISTOTLE', and 'ENGAGE AF-TIMI 48'. All primary publications and secondary analyses in special populations at increased risk of stroke or bleeding from the pivotal phase III clinical trials were evaluated. RESULTS Available secondary analyses indicate no treatment interactions with regards to stroke or systemic embolic event (SEE) prevention for any of the DOACs in the patient subgroups, including patients with advanced age, impaired renal function, diabetes, prior stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD). Although higher bleeding incidence was reported with dabigatran and rivaroxaban in patients aged 75 years and over with apixaban in patients with diabetes, and with rivaroxaban in patients with previous MI or PAD, no changes in dosing are recommended. CONCLUSIONS Overall, results of secondary analyses indicate that the recommended dosing strategy for each of the DOACs produces a consistent anticoagulant effect across a diverse patient population, including those at increased risk of stroke or bleeding.
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Affiliation(s)
- Zachary A Stacy
- Division of Acute Care Pharmacy, Pharmacy Practice Department, St Louis College of Pharmacy, 4588 Parkview Place, St Louis, MO 63110-1088, USA
| | - Sara K Richter
- Division of Acute Care Pharmacy, Pharmacy Practice Department, St Louis College of Pharmacy, St Louis, MO, USA
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Itzhaki Ben Zadok O, Eisen A. Use of non-vitamin K oral anticoagulants in people with atrial fibrillation and diabetes mellitus. Diabet Med 2018; 35:548-556. [PMID: 29438571 DOI: 10.1111/dme.13600] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 11/30/2022]
Abstract
AIMS To examine the efficacy and safety of non-vitamin K oral anticoagulants in people with both atrial fibrillation and diabetes mellitus. METHODS We reviewed efficacy and safety data from the warfarin-controlled phase III non-vitamin K oral anticoagulants trials (ARISTOTLE, RE-LY, ROCKET-AF, ENGAGE AF-TIMI 48) and their post hoc analyses with regard to diabetes status. We also reviewed the updated literature regarding this population. RESULTS At baseline 20-40% of the participants in the phase III non-vitamin K oral anticoagulants trials had diabetes mellitus at baseline. This population, in comparison with those without diabetes, was more likely to have other comorbidities, such as hypertension and coronary artery disease; thus, their cardiovascular risk was higher. Participants with diabetes had higher rates of stroke and systemic embolism than participants without diabetes. This risk was decreased using non-vitamin K oral anticoagulants, with no significant interaction by diabetic status or the specific drug used. Overall, compared with warfarin, non-vitamin K oral anticoagulants were safe and reduced the incidence of major bleeding in people with atrial fibrillation and diabetes, although the results varied with the different non-vitamin K oral anticoagulants. CONCLUSIONS The efficacy and safety of non-vitamin K oral anticoagulants compared with warfarin generally extend to participants with diabetes mellitus, although dedicated randomized trials or real-world data are lacking.
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Affiliation(s)
- O Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Eisen
- Department of Cardiology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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42
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Scridon A, Perian M, MĂrginean A, Huţanu A, Gherţescu D, Vântu A, FişcĂ PC, Chevalier P, Şerban RC, Dobreanu D. Plasma lipids affect dabigatran etexilate anticoagulation in rats with unbalanced diabetes mellitus. J Diabetes 2018; 10:240-248. [PMID: 28671757 DOI: 10.1111/1753-0407.12580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/12/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Dabigatran etexilate (DE) has similar stroke prevention efficacy in patients with and without diabetes mellitus (DM). However, the benefit of reducing major bleeding was not seen in diabetics. Thus, this study investigated anticoagulant responses to DE and the biological predictors of this response in a DM model. METHODS Experiments were performed in six control (C), eight DE-treated control (CD), five diabetic (D), and eight DE-treated diabetic (DD) rats. Dabigatran etexilate (50 mg/kg/day) was administered in chow for 12 weeks. At the end of the study, plasma glucose, triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), and plasma creatinine were measured. Correlations were ascertained with the diluted thrombin time (dTT). RESULTS When corrected for similar DE intake, dTT was significantly higher in DD than CD rats (P < 0.001). There was a significant negative correlation between creatinine clearance (CCr) and dTT (r = -0.91, P < 0.01) in DD rats. In addition, dTT was positively correlated with TC (r = 0.96, P < 0.01), LDL-C (r = 0.75, P = 0.04), and glucose (r = 0.83, P = 0.02). In multiple regression analysis, CCr (r = -0.81, P = 0.01), TC (r = 0.93, P < 0.001), and LDL-C (r = 0.74, P < 0.01) remained the only independent predictors of dTT. CONCLUSIONS The results show a significantly more intense DE-induced anticoagulation in diabetic rats that does not seem to be solely related to altered kidney function, and demonstrate that plasma cholesterol can significantly affect DE anticoagulation in this setting.
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Affiliation(s)
- Alina Scridon
- Laboratory of Functional Explorations, Center for Advanced Medical and Pharmaceutical Research, Tîrgu Mureş, Romania
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Marcel Perian
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Alina MĂrginean
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Department of Medical Laboratory, Emergency Military Hospital "Dr. Constantin Papilian,", Cluj-Napoca, Romania
| | - Adina Huţanu
- Laboratory of Functional Explorations, Center for Advanced Medical and Pharmaceutical Research, Tîrgu Mureş, Romania
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Department of Medical Laboratory, Emergency Clinical County Hospital, Tîrgu Mureş, Romania
| | - Doina Gherţescu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Adriana Vântu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Paul C FişcĂ
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | | | - Răzvan C Şerban
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Laboratory of Cardiac Catheterization, Angiography, and Electrophysiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureş, Romania
| | - Dan Dobreanu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Laboratory of Cardiac Catheterization, Angiography, and Electrophysiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureş, Romania
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43
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Ioannou A, Tsappa I, Metaxa S, Missouris CG. Non-valvular atrial fibrillation: impact of apixaban on patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2017; 8:121-131. [PMID: 29138609 PMCID: PMC5680948 DOI: 10.2147/prom.s117549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.
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Affiliation(s)
- Adam Ioannou
- Cardiology Department, Royal Free NHS Foundation Trust, London, UK
| | - Irene Tsappa
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Sofia Metaxa
- Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
| | - Constantinos G Missouris
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus.,Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
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44
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Echouffo-Tcheugui JB, Shrader P, Thomas L, Gersh BJ, Kowey PR, Mahaffey KW, Singer DE, Hylek EM, Go AS, Peterson ED, Piccini JP, Fonarow GC. Care Patterns and Outcomes in Atrial Fibrillation Patients With and Without Diabetes. J Am Coll Cardiol 2017; 70:1325-1335. [DOI: 10.1016/j.jacc.2017.07.755] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 01/02/2023]
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Moss AS, Dimitropoulos G, Connolly DL, Lip GYH. Considerations and treatment options for patients with comorbid atrial fibrillation and diabetes mellitus. Expert Opin Pharmacother 2017; 18:1101-1114. [PMID: 28669216 DOI: 10.1080/14656566.2017.1350647] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) and diabetes mellitus (DM) are common worldwide and their incidence is increasing, representing a significant public health and economic burden as well as an increase in individual increased morbidity and mortality risk profiles. Both conditions are closely related, as patients with DM are at increased risk of incident AF, and AF patients with DM are at higher risk of cardiovascular events compared to non-AF patients. Areas covered: This review article aims to provide an overview of the current evidence linking DM and AF, as well as the impact of obesity, weight loss and stroke on these coexisting conditions. Second, the effects of new oral anti hyperglycaemic medications on cardiovascular risk will be considered. Expert opinion: In conclusion, coexisting AF and DM represent a high risk population of patients requiring aggressive risk factor identification and treatment optimisation. The multifactorial interplay between these conditions requires individual assessment of patient risk profiles with the aim of minimising the impact of each modifiable risk factor.
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Affiliation(s)
- Alexandra Sophie Moss
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gerasimos Dimitropoulos
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Derek L Connolly
- b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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46
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Shaul AA, Eisen A. Novel oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) and diabetes-Good or excellent? Diabetes Metab Res Rev 2017; 33. [PMID: 28258654 DOI: 10.1002/dmrr.2893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 03/01/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Aviv A Shaul
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:365-379. [PMID: 27896543 PMCID: PMC5337242 DOI: 10.1007/s11239-016-1446-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.
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Affiliation(s)
- Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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48
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Patti G, Di Gioia G, Cavallari I, Nenna A. Safety and efficacy of nonvitamin K antagonist oral anticoagulants versus warfarin in diabetic patients with atrial fibrillation: A study-level meta-analysis of phase III randomized trials. Diabetes Metab Res Rev 2017; 33. [PMID: 28029216 DOI: 10.1002/dmrr.2876] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 11/01/2016] [Accepted: 12/14/2016] [Indexed: 11/09/2022]
Abstract
In patients with atrial fibrillation (AF), the safety and efficacy of nonvitamin K antagonist oral anticoagulants (NOACs) vs warfarin according to diabetes mellitus (DM) status are not completely characterized. We performed a meta-analysis to clarify whether in these patients the strategy of oral anticoagulation should be tailored to diabetes status. In this study-level meta-analysis, we included 4 randomized phase III trials comparing NOACs and warfarin in patients with nonvalvular AF; a total of 18 134 patients with DM and 40 454 without DM were overall considered. Incidence of the following outcome measures was evaluated during the follow-up: stroke or systemic embolism, ischemic stroke, major bleeding, intracranial bleeding, and vascular death. Use of NOACs compared with warfarin reduced stroke/systemic embolism in diabetic (Risk Ratios [RR] 0.80, 95% CI 0.68-0.93; P = .004) and nondiabetic patients (RR 0.83, 0.73-0.93; P = .001) (P for interaction .72). No interaction between diabetes status and benefits of NOACs was found for the occurrence of ischemic stroke, major bleeding, or intracranial bleeding (P for interaction >.05 for each comparison). Reduction of vascular death rates with NOACs was significant in diabetic patients (4.97% vs 5.99% with warfarin; RR 0.83, 0.72-0.96; P = .01), in whom absolute the reduction of this outcome measure was higher than in nondiabetics (1.02% vs 0.27%), although no interaction was present (P = .23). Results of this meta-analysis support the safety and efficacy of NOACs compared with warfarin in diabetic patients with nonvalvular AF.
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Affiliation(s)
- Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Giuseppe Di Gioia
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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Hu PT, Lopes RD, Stevens SR, Wallentin L, Thomas L, Alexander JH, Hanna M, Lewis BS, Verheugt FWA, Granger CB, Jones WS. Efficacy and Safety of Apixaban Compared With Warfarin in Patients With Atrial Fibrillation and Peripheral Artery Disease: Insights From the ARISTOTLE Trial. J Am Heart Assoc 2017; 6:JAHA.116.004699. [PMID: 28096100 PMCID: PMC5523640 DOI: 10.1161/jaha.116.004699] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background We studied (1) the rates of stroke or systemic embolism and bleeding in patients with atrial fibrillation and peripheral artery disease (PAD) and (2) the efficacy and safety of apixaban versus warfarin in patients with atrial fibrillation with and without PAD. Methods and Results The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial randomized 18 201 patients with atrial fibrillation to apixaban or warfarin for stroke/systemic embolism prevention; 884 (4.9%) patients had PAD at baseline. Patients with PAD had higher unadjusted rates of stroke and systemic embolism (hazard ratio [HR] 1.73, 95% CI 1.22–2.45; P=0.002) and major bleeding (HR 1.34, 95% CI 1.00–1.81; P=0.05), but after adjustment, no differences existed in rates of stroke and systemic embolism (HR 1.32, 95% CI 0.93–1.88; P=0.12) and major bleeding (HR 1.03, 95% CI 0.76–1.40; P=0.83) compared with patients without PAD. The risk of stroke or systemic embolism was similar in patients assigned to apixaban and warfarin with PAD (HR 0.63, 95% CI 0.32–1.25) and without PAD (HR 0.80, 95% CI 0.66–0.96; interaction P=0.52). Patients with PAD did not have a statistically significant reduction in major or clinically relevant nonmajor bleeding with apixaban compared with warfarin (HR 1.05, 95% CI 0.69–1.58), whereas those without PAD had a statistically significant reduction (HR 0.65, 95% CI 0.58–0.73; interaction P=0.03). Conclusions Patients with PAD in ARISTOTLE had a higher crude risk of stroke or systemic embolism compared with patients without PAD that was not present after adjustment. The benefits of apixaban versus warfarin for stroke and systemic embolism were similar in patients with and without PAD. These findings highlight the need to optimize the treatment of patients with atrial fibrillation and PAD. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.
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Affiliation(s)
- Peter T Hu
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Department of Medicine, Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - John H Alexander
- Department of Medicine, Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Basil S Lewis
- Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine of the Technion, Haifa, Israel
| | | | - Christopher B Granger
- Department of Medicine, Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - W Schuyler Jones
- Department of Medicine, Duke University Medical Center, Durham, NC .,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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50
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Cardiovascular pharmacotherapy. Int J Cardiol 2016; 224:412-415. [PMID: 27690338 DOI: 10.1016/j.ijcard.2016.09.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/16/2016] [Indexed: 11/21/2022]
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