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Gulilat M, Jandoc R, Jeyakumar N, McArthur E, Garg AX, Kim RB, Tirona RG, Schwarz UI. Association of Sex With Stroke and Bleeding Risk of Apixaban and Rivaroxaban in Elderly Atrial Fibrillation Patients Using Propensity Score Weights. CJC Open 2022; 4:56-64. [PMID: 35072028 PMCID: PMC8767136 DOI: 10.1016/j.cjco.2021.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background Evidence from clinical trials suggests a differential effect of sex on the effectiveness and safety of direct oral anticoagulants (DOACs) for stroke prophylaxis in atrial fibrillation (AF). Methods This population-based cohort study examined the independent effect of sex on hemorrhage and ischemic stroke in 23,884 patients (55% females; age ≥ 66 years) with AF starting apixaban or rivaroxaban treatment in Ontario, Canada. Patients were followed for 90 days after their DOAC prescription. Using female sex as the exposure of interest, differences in baseline characteristics were balanced between sexes using inverse probability weights based on propensity scores. Applying weighted modified Poisson regression, risk ratios (RRs) were estimated for major hemorrhage, ischemic stroke/systemic embolism/transient ischemic attack (hereafter stroke), myocardial infarction, and all-cause mortality, with males as a reference. Results Females were older, had higher predicted stroke risk (based on CHADS2 score), and had fewer comorbidities than did males. Males had a higher prevalence of coronary artery disease, diabetes, and cancer, and similar predicted bleeding risk (based on HAS-BLED score). After weighting, baseline characteristics were well balanced. The 90-day risks for hemorrhage (RR 0.96; 95% confidence interval [CI] 0.80-1.15; P = 0.69) and stroke (RR 1.01; 95% CI 0.86-1.19; P = 0.94) were similar between sexes, which remained true when assessing each DOAC separately by dosing regimen. Compared to males, females had a lower risk for myocardial infarction (RR 0.66; 95% CI 0.52-0.84; P = 0.0008), and for all-cause mortality (RR 0.76; 95% CI 0.67-0.87; P < 0.0001). Conclusions Our findings do not suggest an association of sex with the 90-day risk of hemorrhage or ischemic stroke in older AF patients prescribed apixaban or rivaroxaban.
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Affiliation(s)
- Markus Gulilat
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | | | | | | | - Amit X. Garg
- ICES, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Richard B. Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Rommel G. Tirona
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Ute I. Schwarz
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Corresponding author: Dr Ute I. Schwarz, Western University, London Health Sciences Centre—University Hospital, 339 Windermere Rd, London, Ontario N6A 5A5, Canada. Tel.: +1-519-685-8500; fax: +1-519-663-3090.
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Yi JE, Seo SM, Lim S, Choo EH, Choi IJ, Lee KY, Hwang BH, Kim CJ, Park MW, Kim DB, Her SH, Lee JM, Park CS, Kim PJ, Kim HY, Yoo KD, Jeon DS, Chung WS, Jeong MH, Ahn Y, Chang K. Gender Differences in the Impact of New-Onset Atrial Fibrillation on Long-Term Risk of Ischemic Stroke after Acute Myocardial Infarction. J Clin Med 2021; 10:jcm10215141. [PMID: 34768661 PMCID: PMC8584956 DOI: 10.3390/jcm10215141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 10/27/2021] [Accepted: 10/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) has been identified as a major risk factor for mortality after acute coronary syndrome (ACS). However, the long-term risk of ischemic stroke associated with new-onset atrial fibrillation (NOAF) in ACS remains controversial, and its gender-specific association is unknown. METHODS We analyzed the data of 10,137 ACS survivors included in a multicenter, prospective registry for Korean patients with acute myocardial infarction (AMI) between January 2004 and August 2014. Subjects were categorized into three groups (non-AF vs. NOAF vs. previous AF) based on medical history and electrocardiographic evidence of AF, either at admission or during hospitalization. RESULTS Among the total study population (72.3% men), 370 patients (3.6%) had NOAF and 130 (1.3%) had previous AF. During a median follow-up of 61 months (interquartile range, 38.8 to 89.3 months), 245 (2.4%) patients (218 (2.3%) non-AF vs. 15 (4.1%) NOAF vs. 12 (9.2%) previous AF, p < 0.001) experienced ischemic stroke. After adjustment for confounding variables, both NOAF (adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09-3.24, p = 0.024) and previous AF (adjusted HR 4.00, 95% CI 2.03-7.87, p < 0.001), along with older age, diabetes, current smoker, and previous stroke were independent risk factors of ischemic stroke. In the gender-stratified analysis, men with previous AF but not NOAF had a significantly higher risk of ischemic stroke (adjusted HR 4.14, 95% CI 1.79-9.55, p = 0.001) than those without AF. In women, NOAF (adjusted HR 2.54, 95% CI 1.21-5.35, p = 0.014) as well as previous AF (adjusted HR 3.72, 95% CI 1.16-11.96, p = 0.028) was a strong predictor of ischemic stroke, and the predictive value was comparable to that of previous AF among patients with a CHA2DS2-VASc score ≥ 2. CONCLUSIONS Both NOAF and previous AF were associated with ischemic stroke after AMI, but the impact of NOAF as a risk factor of ischemic stroke was significant only in women.
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Affiliation(s)
- Jeong-Eun Yi
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-E.Y.); (P.-J.K.)
| | - Suk-Min Seo
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-E.Y.); (P.-J.K.)
- Correspondence: ; Tel.: +82-2-2030-2599
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.-J.K.); (J.-M.L.)
| | - Eun-Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.-H.C.); (K.-Y.L.); (B.-H.H.); (W.-S.C.); (K.C.)
| | - Ik-Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.-J.C.); (D.-S.J.)
| | - Kwan-Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.-H.C.); (K.-Y.L.); (B.-H.H.); (W.-S.C.); (K.C.)
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.-H.C.); (K.-Y.L.); (B.-H.H.); (W.-S.C.); (K.C.)
| | - Chan-Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.-J.K.); (J.-M.L.)
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (D.-B.K.); (H.-Y.K.)
| | - Sung-Ho Her
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.-H.H.); (K.-D.Y.)
| | - Jong-Min Lee
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.-J.K.); (J.-M.L.)
| | - Chul-Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Pum-Joon Kim
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-E.Y.); (P.-J.K.)
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (D.-B.K.); (H.-Y.K.)
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.-H.H.); (K.-D.Y.)
| | - Doo-Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.-J.C.); (D.-S.J.)
| | - Wook-Sung Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.-H.C.); (K.-Y.L.); (B.-H.H.); (W.-S.C.); (K.C.)
| | - Myung-Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61748, Korea; (M.-H.J.); (Y.A.)
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61748, Korea; (M.-H.J.); (Y.A.)
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.-H.C.); (K.-Y.L.); (B.-H.H.); (W.-S.C.); (K.C.)
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Takamoto K, Sakamoto JI, Ito S, Kimura T, Manabe E, Shikata T, Asakura M, Ishihara M, Tsujino T. Low Quality of Warfarin Therapy is Associated With Female Gender but Not With Polypharmacy in Patients With Atrial Fibrillation. Front Pharmacol 2021; 12:651799. [PMID: 33981231 PMCID: PMC8110202 DOI: 10.3389/fphar.2021.651799] [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: 01/13/2021] [Accepted: 04/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: We examined the impact of polypharmacy on the quality of the anticoagulation therapy in patients with atrial fibrillation. We also examined the factors that affect the stability of warfarin therapy. Methods and Results: This retrospective study was conducted using data from 157 consecutive outpatients with atrial fibrillation in a single tertiary referral hospital. Patients who were prescribed warfarin continuously and for whom PT-INR was examined at least three times in a year were included in this study. We examined the quality of warfarin therapy using time in the therapeutic INR range (TTR), percentage of PT-INR determinations in range (PINRR), and the coefficient variation (CV) of PT-INR. We found that the number of prescribed medicines was significantly associated with high BMI and low eGFR, but not with TTR, PINRR, and the coefficient variation of PT-INR in patients with atrial fibrillation. We also found that female gender was independently associated with low PINRR in this study population. Conclusion: Polypharmacy did not deteriorate the quality of warfarin therapy in patients with atrial fibrillation treated in the tertiary referral hospital. Female gender was an independent predictor of the low quality of warfarin therapy.
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Affiliation(s)
- Kojiro Takamoto
- Graduate School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan.,Hyogo College of Medicine Sasayama Medical Center, Sasayama, Japan
| | - Jun-Ichi Sakamoto
- Graduate School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan.,Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Satoyasu Ito
- Department of Pharmacy, School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Eri Manabe
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Tsujino
- Graduate School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan.,Department of Pharmacy, School of Pharmacy, Hyogo University of Health Sciences, Kobe, Japan.,Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Zelniker TA, Ardissino M, Andreotti F, O'Donoghue ML, Yin O, Park JG, Murphy SA, Ruff CT, Lanz HJ, Antman EM, Braunwald E, Giugliano RP, Merlini PA. Comparison of the Efficacy and Safety Outcomes of Edoxaban in 8040 Women Versus 13 065 Men With Atrial Fibrillation in the ENGAGE AF-TIMI 48 Trial. Circulation 2021; 143:673-684. [PMID: 33587659 PMCID: PMC7884089 DOI: 10.1161/circulationaha.120.052216] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Female sex is an independent risk factor for stroke and systemic embolic events in patients with atrial fibrillation. This study aimed to examine the efficacy and safety profile of edoxaban in women versus men. Methods: The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) randomly assigned 21 105 patients (8040 women) with atrial fibrillation and CHADS2 score ≥2 either to a higher-dose edoxaban regimen, a lower-dose edoxaban regimen, or warfarin. The primary end points of the trial were the composite of stroke or systemic embolic events (efficacy), and International Society on Thrombosis and Haemostasis–defined major bleeding (safety). Results: In comparison with men, women were older, had lower body weight, were more likely to have hypertension and renal dysfunction, but less likely to smoke, drink alcohol, or have diabetes or coronary artery disease. Pretreatment endogenous factor Xa activity was significantly higher in women than in men (92.5% versus 86.1%, P<0.001). Treatment with edoxaban in women resulted in greater peak edoxaban concentration and inhibition of endogenous factor Xa in comparison with men, resulting in similar endogenous factor Xa activity between the sexes 2 to 4 hours after dose. Treatment with higher-dose edoxaban regimen (versus warfarin) resulted in similar reduction in the risk of stroke/systemic embolic events (women: hazard ratio [HR], 0.87 [0.69–1.11], men: HR, 0.87 [0.71–1.06]; P-interaction=0.97) and major bleeding (women: HR, 0.74 [0.59–0.92], men: HR, 0.84 [0.72–0.99]; P-interaction=0.34) in women and men. However, women assigned to higher-dose edoxaban regimen experienced greater reductions in hemorrhagic stroke (HR, 0.30 [95% CI, 0.15–0.59] versus HR, 0.70 [95% CI, 0.46–1.06]), intracranial bleeding (HR, 0.20 [95% CI, 0.10–0.39] versus HR, 0.63 [95% CI, 0.44–0.89]), and life-threatening or fatal bleeding (HR, 0.25 [95% CI, 0.15–0.42] versus HR, 0.72 [95% CI, 0.54–0.96]) than men (each P-interaction<0.05). Conclusions: Despite many differences in baseline characteristics between women and men and higher baseline endogenous factor Xa levels in women, the intensity of anticoagulation achieved with edoxaban between the sexes was similar. Treatment with higher-dose edoxaban regimen resulted in an even greater reduction in hemorrhagic stroke and several serious bleeding outcomes in women than in men, whereas the efficacy profile was similar between sexes.
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Affiliation(s)
- Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Austria (T.A.Z.)
| | | | - Felicita Andreotti
- Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy (F.A.).,Institute of Cardiology, Catholic University Medical School, Rome, Italy (F.A.)
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Ophelia Yin
- Daiichi Sankyo Inc, Basking Ridge, NJ (O.Y.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Hans J Lanz
- Daiichi Sankyo Europe GmbH, Munich, Germany (H.J.L.)
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
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Risk factors for severe bleeding events during warfarin treatment: the influence of sex, age, comorbidity and co-medication. Eur J Clin Pharmacol 2020; 76:867-876. [PMID: 32222786 PMCID: PMC7239828 DOI: 10.1007/s00228-020-02856-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/05/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE To investigate risk factors for severe bleeding during warfarin treatment, including the influence of sex, age, comorbidity and co-medication on bleeding risk. METHODS Patients initiating warfarin treatment between 2007 and 2011 were identified in the nationwide Swedish Prescribed Drug Register, and diagnoses of severe bleeding were retrieved from the National Patient Register. Hazard ratios (HR) with 95% confidence intervals (CI) for severe bleeding were estimated using multiple Cox regression adjusting for indications and including covariates age, sex, comorbidities and co-medications. Interactions between sex and other covariates were investigated. RESULTS The study cohort included 232,624 patients ≥ 18 years (101,011 women and 131,613 men). The incidence rate of severe bleeding was 37 per 1000 person-years, lower among women than men with an adjusted HR (95% CI) of 0.84 (0.80-0.88). Incidence of bleeding increased with age, HR 2.88 (2.37-3.50) comparing age ≥ 80 to < 40 years, and comorbidities associated with the highest risk of severe bleeding were prior bleeding, HR 1.85 (1.74-1.97); renal failure, HR 1.82 (1.66-2.00); and alcohol dependency diagnosis, HR 1.79 (1.57-2.05). Other comorbidities significantly associated with bleeding events were hypertension, diabetes, peripheral vascular disease, congestive heart failure, liver failure, stroke/TIA, COPD and cancer. CONCLUSION Most of the well-established risk factors were found to be significantly associated with bleeding events in our study. We additionally found that women had a lower incidence of bleeding. Potential biases are selection effects, residual confounding and unmeasured frailty.
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Boriani G, Colella J, Imberti J, Fantecchi E, Vitolo M. Female sex and stroke in atrial fibrillation: an intriguing relationship. Intern Emerg Med 2020; 15:175-179. [PMID: 31396922 DOI: 10.1007/s11739-019-02169-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Cardiology Division, Policlinico di Modena, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125, Modena, Italy.
| | - Jacopo Colella
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Penttilä T, Lehto M, Niiranen J, Mehtälä J, Khanfir H, Lassila R, Raatikainen P. Differences in the risk of stroke, bleeding events, and mortality between female and male patients with atrial fibrillation during warfarin therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 5:29-36. [PMID: 30052822 DOI: 10.1093/ehjcvp/pvy026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 07/20/2018] [Indexed: 01/03/2023]
Abstract
Aims Females with atrial fibrillation (AF) have been suggested to carry a higher risk for thromboembolic events than males. We compared the residual risk of stroke, bleeding events, and cardiovascular and all-cause mortality among female and male AF patients taking warfarin. Methods and results Data from several nationwide registries and laboratory databases were linked with the civil registration number of the patients. A total of 54 568 patients with data on the quality of warfarin treatment (time in therapeutic range) 60 days prior to the events were included (TTR60). Gender differences in the endpoints were reported for the whole population, pre-specified age groups, and different TTR60 groups. During the 3.2 ± 1.6 years follow-up, there were no differences in the adjusted risk of stroke [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.91-1.03, P = 0.304] between the genders. Cardiovascular mortality (HR 0.82, 95% CI 0.78-0.88, P < 0.001) and all-cause mortality (HR 0.79, 95% CI 0.75-0.83, P < 0.001) were lower in women when compared with men. There were no differences in the risk of stroke, cardiovascular mortality, and all-cause mortality between the genders in the TTR60 categories except for those with TTR60 <50%. Bleeding events were less frequent in females (HR 0.52, 95% CI 0.49-0.56, P < 0.001). Conclusion There were no differences in the risk of stroke between female and male AF patients taking warfarin. Cardiovascular mortality, all-cause mortality, and risk of bleeding events were lower in females. Hence, female gender was not a risk marker for adverse outcomes in AF patients with proper warfarin therapy.
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Affiliation(s)
- Tero Penttilä
- Department of Cardiology, Heart Center Co., Tampere University Hospital, Ensitie 4, Tampere, Finland
| | - Mika Lehto
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Jussi Niiranen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Juha Mehtälä
- EPID Research, Metsänneidonkuja 12, Espoo, Finland
| | | | - Riitta Lassila
- Department of Hematology, Comprehensive Cancer Center, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Pekka Raatikainen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
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Lip GYH. The safety of NOACs in atrial fibrillation patient subgroups: A narrative review. Int J Clin Pract 2019; 73:e13285. [PMID: 30334313 DOI: 10.1111/ijcp.13285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/01/2018] [Accepted: 10/14/2018] [Indexed: 12/17/2022] Open
Abstract
AIM Four non-vitamin K oral anticoagulants (NOACs) have been evaluated in clinical trials for the prevention of stroke in patients with atrial fibrillation (AF). Although each of the NOACs have been shown to be at least non-inferior to warfarin for efficacy and safety outcomes, controversy remains over the relative safety of each NOAC inpatient subgroups. This narrative review provides an overview of phase III data on NOAC trials for the prevention of stroke in AF, with a focus on reporting the safety of each agent in key patient subgroups based on age, gender, accumulated risk factors, and primary or secondary prevention of stroke. METHODS A comprehensive literature search was completed and, where data permit, analyses of phase III trials of the NOACs are presented for each patient subgroup. RESULTS Analyses of key safety outcomes from NOAC trials were completed using primary trial data, including major bleeding and all-cause mortality. The safety of NOACs was generally consistent and favourable compared with warfarin according to patient age, gender, previous history of stroke, and the presence of risk factors for stroke. CONCLUSIONS The safety of the NOACs compared with warfarin was generally favourable across different patient subgroups, including those perceived to be at "high risk" for adverse outcomes. However, certain NOACs may be preferable to warfarin in some subgroups, based on indirect analyses.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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9
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Warraich HJ, Califf RM. Differences in Health Outcomes between Men and Women: Biological, Behavioral, and Societal Factors. Clin Chem 2019; 65:19-23. [DOI: 10.1373/clinchem.2018.287334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Haider J Warraich
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Robert M Califf
- Duke Forge, Duke University School of Medicine, Durham, NC
- Department of Medicine, Stanford University, Stanford, CA
- Verily Life Sciences (Alphabet), South San Francisco, CA
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10
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Linde C, Bongiorni MG, Birgersdotter-Green U, Curtis AB, Deisenhofer I, Furokawa T, Gillis AM, Haugaa KH, Lip GYH, Van Gelder I, Malik M, Poole J, Potpara T, Savelieva I, Sarkozy A. Sex differences in cardiac arrhythmia: a consensus document of the European Heart Rhythm Association, endorsed by the Heart Rhythm Society and Asia Pacific Heart Rhythm Society. Europace 2018; 20:1565-1565ao. [PMID: 29961863 DOI: 10.1093/europace/euy067] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital, S-17176 Stockholm, Sweden
| | | | | | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | | | - Anne M Gillis
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute of Alberta, Alberta, Canada
| | - Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Thrombosis Research Unit, Aalborg University, Denmark
| | - Isabelle Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London
| | - Jeannie Poole
- University of Washington Medical center, Seattle, Washington, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Irina Savelieva
- St. George's, University of London, Cranmer Terrace, London, UK
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
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11
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Marzona I, Proietti M, Farcomeni A, Romiti GF, Romanazzi I, Raparelli V, Basili S, Lip GYH, Nobili A, Roncaglioni MC. Sex differences in stroke and major adverse clinical events in patients with atrial fibrillation: A systematic review and meta-analysis of 993,600 patients. Int J Cardiol 2018; 269:182-191. [PMID: 30025657 DOI: 10.1016/j.ijcard.2018.07.044] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/29/2018] [Accepted: 07/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia, which is associated with an increased risk of stroke. Several studies have suggested that female AF patients could have a greater risk for stroke and thromboembolic events (TE). METHODS A systematic literature review update and meta-analysis was conducted using Pubmed. The search used the terms "atrial fibrillation", "gender", "sex", "female", "women", "stroke", "thromboembolism". Main aim of the study was to compare and male AF patients for occurrence of stroke and TE. Secondary outcomes were: major bleeding, cardiovascular (CV) death and all-cause death. RESULTS Forty-four studies were included in the analysis including 993,603 patients (48.9% women). After pooling the data, there was a higher risk of stroke for women vs. male AF patients (hazard ratio [HR]: 1.24; 95% confidence intervals [CIs]: 1.14-1.36). Overall, TE risk was not different between female and male patients, despite sensitivity analysis left some uncertainties. No sex differences were found for major bleeding, CV death and all-cause death. A significant relationship between increasing age and the difference in stroke risk between female and male AF patients was found (Delta HR: 1.01; 95% CI: 1.00-1.03 for each year of age increase). CONCLUSIONS Female patients with AF are at increased risk of stroke compared to men. A significant relationship between increasing age and stroke risk in women compared to men was found, most evident at age > 65 years. Female sex may act as a stroke risk modifier, particularly in elderly and very elderly AF subjects, conferring a significant increase in stroke risk.
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Affiliation(s)
- Irene Marzona
- Department of Cardiovascular Diseases, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neuroscience, IRCCS- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Imma Romanazzi
- Department of Internal Medicine, IRCCS Ca' Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza-University of Rome, Rome, Italy; Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Maria Carla Roncaglioni
- Department of Cardiovascular Diseases, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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12
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Renoux C, Coulombe J, Suissa S. Revisiting sex differences in outcomes in non-valvular atrial fibrillation: a population-based cohort study. Eur Heart J 2018; 38:1473-1479. [PMID: 28073863 DOI: 10.1093/eurheartj/ehw613] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/25/2016] [Indexed: 01/28/2023] Open
Abstract
Aims In patients with non-valvular atrial fibrillation (NVAF), it is uncertain whether the higher risk of ischaemic stroke in women reported in some studies is due to residual confounding. We assessed this association using standard time-fixed and more accurate time-dependent adjustment for confounders. Methods and results Using the computerized databases of the Régie de l'assurance maladie du Québec (RAMQ), we identified a cohort of patients with NVAF during 2000-2009 and RAMQ medication coverage. Cox proportional hazards models were used to estimate the hazard ratio (HR) of ischaemic stroke, death, and bleeding, associated with sex, adjusting for time-fixed covariates at cohort entry. This was compared with adjustment for time-dependent covariates using an age and time-matched nested case-control analysis. The cohort included 147 622 patients. During a mean follow-up of 2.9 years 11 326 patients had a stroke (incidence rate 2.6 per 100 per year). Using time-fixed adjustment for confounders, women had a moderately higher risk of ischaemic stroke than men (HR 1.16 (Confidence interval (CI) 95% 1.11-1.21). Matching on age and using time-dependent adjustment for confounders, women were not at higher risk of stroke than men (Rate Ratio 1.01; 95% CI 0.97-1.05). Mortality and bleeding rates were lower in women compared with men in both analyses. Conclusion In NVAF, women were not at higher risk of thromboembolic events than men in our study. The small increased risk reported in previous studies may be related to residual confounding, in particular from insufficient control for age.
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Affiliation(s)
- Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada.,Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal QC H3A 2B4, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC H3A 1A2, Canada
| | - Janie Coulombe
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC H3A 1A2, Canada
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13
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Abstract
AF is the most common clinical arrhythmia encountered. A wealth of evidence has improved our ability to diagnose and effectively treat AF. An intriguing aspect of this common disease – gender-based differences – is well recognized, but poorly understood. In this brief review, we will explore the accumulating evidence suggesting a gender-based disparity in the prevalence, pathogenesis and management of AF.
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14
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Gómez EA. Trombosis y anticoagulación en la mujer. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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15
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Lobos-Bejarano JM, Castellanos Rodríguez A, Barrios V, Escobar C, Polo-García J, Del Castillo-Rodríguez JC, Vargas-Ortega D, Lopez-Pineda A, Prieto-Valiente L, Lip GYH. Influence of renal function on anticoagulation control in patients with non-valvular atrial fibrillation taking vitamin K antagonists. Int J Clin Pract 2017; 71. [PMID: 28722795 DOI: 10.1111/ijcp.12974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Chronic kidney disease (CKD) has been related to poor anticoagulation control and an increased risk of bleeding. This study aims to evaluate the association between impaired renal function (eGFR <60 mL/min/1.73 m2 ) and anticoagulation control in patients with non-valvular atrial fibrillation (AF) on vitamin K antagonists (VKA) therapy. We also assessed whether the predictive value of the SAMe-TT2 R2 score prevailed for subgroups both with and without CKD. METHODS This is an ancillary analysis of 1381 patients from the PAULA study, which was a cross-sectional, retrospective and nationwide multicenter study. RESULTS A total of 370 patients had eGFR <60 mL/min/1.73 m2 . Anticoagulation control levels progressively worsened across each stage of CKD. Multiple linear regression analysis showed CKD as an independent predictor of time in therapeutic range (TTR). In the subgroup of patients with preserved renal function, female sex, diet affecting INR, polypharmacy and amiodarone were associated with poorer TTR. The SAMe-TT2 R2 score had a significant but modest predictive value for TTR<65% (AUC, area under the curve 0.558, P = .002). In the subgroup of patients with CKD, the SAMe-TT2 R2 (>2 points) showed no significant predictive capacity for TTR (AUC 0.528, P = .354). The average TTR was similar for both sexes (P = .255), but with a higher percentage of males subjects with TTR ≥65% (P = .013). CONCLUSION Chronic kidney disease is associated with poor anticoagulation control in patients with non-valvular AF taking VKA. The SAMe-TT2 R2 score was not predictive of poor TTR in the subgroup with CKD, although a modest predictive value for poor TTR was found in those without CKD.
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Affiliation(s)
| | | | - Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| | | | | | - Diego Vargas-Ortega
- High Resolution Hospitalization Unit, Hospital el Toyo, Hospital de Poniente El Ejido, Almeria, Spain
| | - Adriana Lopez-Pineda
- Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Luis Prieto-Valiente
- Medical Biostatistics, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
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16
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Tamargo J, Rosano G, Walther T, Duarte J, Niessner A, Kaski JC, Ceconi C, Drexel H, Kjeldsen K, Savarese G, Torp-Pedersen C, Atar D, Lewis BS, Agewall S. Gender differences in the effects of cardiovascular drugs. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:163-182. [DOI: 10.1093/ehjcvp/pvw042] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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17
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Ogawa H, Hamatani Y, Doi K, Tezuka Y, An Y, Ishii M, Iguchi M, Masunaga N, Esato M, Chun YH, Tsuji H, Wada H, Hasegawa K, Abe M, Lip GY, Akao M. Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation - The Fushimi AF Registry. Circ J 2017; 81:1403-1410. [PMID: 28539562 DOI: 10.1253/circj.cj-17-0071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Female sex is considered a risk factor for thromboembolism in patients with atrial fibrillation (AF), and is included in the risk stratification scheme, CHA2DS2-VASc score. The purpose of the present study was to investigate the clinical outcomes of female Japanese AF patients.Methods and Results:The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto. Follow-up data were available for 3,878 patients. Female AF patients (n=1,551, 40.0%) were older (77.0 vs. 71.4 years; P<0.001) than male patients (n=2,327, 60.0%). Female patients were more likely to have heart failure (31.1% vs. 23.7%; P<0.001). Previous stroke incidence (19.2% vs. 21.4%; P=0.083) was comparable between male and female patients. During the median follow-up period of 1,102 days, Cox regression analysis demonstrated that female sex was not independently associated with a risk of stroke or systemic embolism (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI]: 0.54-1.00, P=0.051). However, female sex showed an association with a lower risk of intracranial hemorrhage (adjusted HR 0.54; 95% CI: 0.30-0.95, P=0.032) and all-cause death (adjusted HR 0.56; 95% CI: 0.46-0.68, P<0.001). CONCLUSIONS We demonstrated that female sex is not independently associated with an increased risk of thromboembolism, but is associated with a decreased risk of intracranial hemorrhage and all-cause death in Japanese AF patients enrolled in the Fushimi AF Registry.
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Affiliation(s)
- Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yuji Tezuka
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Masahiro Esato
- Department of Arrhythmia, Ijinkai Takeda General Hospital
| | - Yeong-Hwa Chun
- Department of Arrhythmia, Ijinkai Takeda General Hospital
| | | | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Gregory Yh Lip
- Institute of Cardiovascular Sciences, University of Birmingham.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
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18
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Falsetti L, Viticchi G, Buratti L, Balucani C, Marra AM, Silvestrini M. From head to toe: Sex and gender differences in the treatment of ischemic cerebral disease. Pharmacol Res 2017; 121:240-250. [PMID: 28506796 DOI: 10.1016/j.phrs.2017.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 03/27/2017] [Accepted: 05/09/2017] [Indexed: 11/27/2022]
Abstract
Stroke is a major cause of mortality and morbidity, particularly in the older ages. Women have a longer life expectancy and are more likely to experience stroke than men. Interestingly, the increased risk of ischemic stroke in women seems to be independent from age or classical cardiovascular risk factors. Notwithstanding the fact that stroke outcomes and survival are usually poorer in women, current evidence suggests that thrombolysis, antiplatelet and anticoagulant therapies are more beneficial in women than in men. A possible explanation of this paradox might be that females are often undertreated and they have fewer chances to be submitted to an effective and timely treatment for stroke than the male counterpart. The first step in the attempt to solve this obvious discrimination is surely to emphasize any reasons for differences in the therapeutic approach in relation to gender and then to denounce the lack of a sustainable motivation for them. In this article, we aimed to review the existing literature about gender-related differences on efficacy, administration and side effects of the most common drugs used for the treatment of ischemic stroke. The most striking result was the evidence that the therapeutic approach for stroke is often different according to patients' gender with a clear detrimental prognostic effect for women. A major effort is necessary to overcome this problem in order to ensure equal right to treatment without any sexual discrimination.
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Affiliation(s)
- Lorenzo Falsetti
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy; University of Bologna, Cardio-Nephro-Thoracic Sciences PhD School, Italy.
| | - Giovanna Viticchi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Laura Buratti
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Clotilde Balucani
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, New York, United States
| | | | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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19
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Hong Y, Yang X, Zhao W, Zhang X, Zhao J, Yang Y, Ning X, Wang J, An Z. Sex Differences in Outcomes among Stroke Survivors with Non-Valvular Atrial Fibrillation in China. Front Neurol 2017; 8:166. [PMID: 28496431 PMCID: PMC5406396 DOI: 10.3389/fneur.2017.00166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 04/07/2017] [Indexed: 01/19/2023] Open
Abstract
Atrial fibrillation (AF) significantly increases the risk of stroke and disease burden and is an established predictor of poor outcomes after stroke. However, data regarding sex differences in long-term outcomes following stroke in patients with AF are scarce. We thus aimed to assess these differences. We recruited 951 consecutive patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) treated at three hospitals in Tianjin, China, from January 2006 to September 2014. Information regarding stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3, 12, and 36 months after stroke was recorded. The prevalence of NVAF was 8.4% overall, with a higher frequency in women than in men (11.3 vs. 6.9%, P < 0.001). Among patients with NVAF, women were older than men. Women were more likely than men to have severe stroke (38.8 vs. 29.5%, P < 0.001), high levels of total cholesterol and high- and low-density lipoprotein cholesterol (all P < 0.001), hypertension (69.1 vs. 61.2%, P = 0.012), dyslipidemia (29.8 vs. 20.7%, P = 0.001), and obesity (18.5 vs. 11.6%, P = 0.003); they were less likely than men to be current smokers (12.2 vs. 33.6%, P < 0.001) and to consume alcohol (0.9 vs. 13.9%, P < 0.001). There were greater risks of dependency and recurrence at 36 months after stroke in women than in men [odds ratios (95% confidence intervals), 1.64 (1.02–2.64) for dependency, P = 0.043; and 2.03 (1.28–3.20) for recurrence, P = 0.002] after adjustment for stroke subtype, severity, and risk factors. These findings suggest that it is crucial to emphasize the need for individualized stroke prevention education and promotion of healthy lifestyles in order to improve NVAF-related stroke outcomes and reduce disease burden in women.
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Affiliation(s)
- Yan Hong
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Xun Yang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Wenjuan Zhao
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Xianghui Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Junli Zhao
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Yuanju Yang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
| | - Xianjia Ning
- Department of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinghua Wang
- Department of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhongping An
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, Tianjin, China
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20
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Camm AJ, Accetta G, Al Mahmeed W, Ambrosio G, Goldhaber SZ, Haas S, Jansky P, Kayani G, Misselwitz F, Oh S, Oto A, Raatikainen P, Steffel J, van Eickels M, Kakkar AK. Impact of gender on event rates at 1 year in patients with newly diagnosed non-valvular atrial fibrillation: contemporary perspective from the GARFIELD-AF registry. BMJ Open 2017; 7:e014579. [PMID: 28264833 PMCID: PMC5353285 DOI: 10.1136/bmjopen-2016-014579] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/02/2017] [Accepted: 02/08/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) explored the impact of gender, risk factors and anticoagulant (AC) treatment on 1-year outcomes in patients with non-valvular atrial fibrillation (NVAF). DESIGN GARFIELD-AF is a prospective non-interventional registry. SETTING Investigator sites (n=1048) are representative of the care settings/locations in each of the 35 countries. PARTICIPANTS Patients ≥18yrs with newly diagnosed (≤6 weeks' duration) NVAF and ≥1 investigator-determined stroke risk factors. MAIN OUTCOME MEASURES Event rates per 100 person-years were estimated from the Poisson model and HRs and 95% CIs calculated. RESULTS Of 28 624 patients (women 44.4%; men 55.6%) enrolled, there were more elderly (≥75 years) women (46.9%) than men (30.4%). All-cause mortality rates per 100 person-years (95% CI) for women and men were 4.48 (4.12 to 4.87) and 4.04 (3.74 to 4.38), respectively, stroke/systemic embolism (SE) (1.62 (1.41 to 1.87) and 1.17 (1.01 to 1.36)) and major bleeding (0.93 (0.78 to 1.13) and 0.79 (0.66 to 0.95)). After adjustment for baseline risk factors in treated and untreated patients, HRs (95% CI) for women (relative to men) for stroke/SE rates were 1.3-fold higher in women (HR 1.30 (1.04 to 1.63)), and similar for major bleeding (1.13 (0.85 to 1.50)) and all-cause mortality (1.05 (0.92 to 1.19)). Antithrombotic treatment patterns in men and women were almost identical. 63.8% women and 62.9% men received AC± antiplatelets. Relative to no AC treatment, the reduction in stroke/SE rates with AC treatment was greater (p=0.01) in men (HR 0.45 (0.33 to 0.61)) than women 0.77 (0.57 to 1.03). All-cause mortality reduction with AC treatment was similar (women: 0.65 (0.54 to 0.77); men: 0.57 (0.48 to 0.68)). The risk of major bleeding when treated with AC versus no AC was 2.33 (1.41 to 3.84) in men and 1.86 (1.16 to 2.99) in women (p value=0.53). CONCLUSIONS Women have a higher risk of stroke/SE and the reduction in stroke/SE events rates with AC treatment is less in women than in men. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- A John Camm
- St George's University of London, and Imperial College, London, UK
| | | | - Wael Al Mahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | | | | | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Petr Jansky
- Motol University Hospital, Prague, Czech Republic
| | | | | | - Seil Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ali Oto
- Hacettepe University, Ankara, Turkey
| | | | - Jan Steffel
- University Hospital Zurich, Zurich, Switzerland
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK
- University College London, London, UK
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21
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Balancing thromboembolic and bleeding risk with non-vitamin K antagonist oral anticoagulants (NOACs): A systematic review and meta-analysis on gender differences. Pharmacol Res 2017; 117:274-282. [DOI: 10.1016/j.phrs.2017.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 11/23/2022]
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22
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Shah R, Patel MR. Primary and key secondary results from the ROCKET AF trial, and their implications on clinical practice. Ther Adv Cardiovasc Dis 2017; 11:105-120. [PMID: 27555569 PMCID: PMC5942797 DOI: 10.1177/1753944716663156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The safety and efficacy of the oral anticoagulant rivaroxaban were studied in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF trial). A number of subanalyses of the ROCKET AF trial have subsequently analyzed the use of rivaroxaban in special patient populations. METHODS The outcomes of the ROCKET AF trial were reviewed. The use of rivaroxaban in higher risk populations, as determined by the presence of co-morbidities included in the CHADS2 criteria, was analyzed. Requirements for dose adjustment in patients with renal impairment and in East Asian patients were described. Finally, clinical management challenges, including interruptions in therapy, drug discontinuation, management of bleeding events, drug interactions, and management of patients requiring cardioversion/ablation were reviewed. RESULTS Rivaroxaban is efficacious in high-risk populations, including elderly patients, patients with diabetes, heart failure, history of stroke, prior myocardial infarction, or peripheral arterial disease (PAD). Patients with PAD have a higher risk of bleeding with rivaroxaban compared with warfarin. East Asian populations do not require a dose adjustment for rivaroxaban, while a reduced dose of 15 mg daily is required for patients with moderate renal impairment. Rivaroxaban remains effective with temporary interruptions in therapy and in patients requiring cardioversion/ablation. Rates of major bleeding and subsequent outcomes were similar in patients on warfarin and rivaroxaban, although rates of gastrointestinal bleeding were higher with rivaroxaban. Concurrent use of antiarrhythmic therapy was not associated with adverse outcomes. CONCLUSIONS Rivaroxaban represents an efficacious alternative to warfarin in high-risk patients with AF. Dose adjustment is required for patients with moderate renal impairment. Rivaroxaban can be used safely in a number of challenging clinical management scenarios although the concurrent use of amiodarone requires more study.
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Affiliation(s)
- Rohan Shah
- Duke Clinical Research Institute, Durham, NC, USA
| | - Manesh R. Patel
- Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, PO Box 17969, 2400 Pratt St, Durham, NC 27715, USA
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23
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Safety of warfarin in "high-risk" populations: A meta-analysis of randomized and controlled trials. Thromb Res 2016; 150:1-7. [PMID: 27988374 DOI: 10.1016/j.thromres.2016.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/03/2016] [Accepted: 12/07/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Few data are available about safety of vitamin K antagonists (VKAs) in patients with clinical/demographic characteristics predisposing to an increased risk of bleeding. We performed a meta-analysis to evaluate the safety of VKAs in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) in the following subgroups of "high-risk" patients: elderly patients, patients with low body weight and patients with impaired renal function. MATERIALS AND METHODS Major electronic databases were systematically searched to identify randomized controlled trials (RCTs) addressing this issue. Pooled Risk Ratios (RR) and 95% Confidence Intervals (CI) were calculated for each outcome using a random effects model. RESULTS Eleven RCTs for a total of 41,015 patients treated with VKAs (25,901 with AF and 15,114 with VTE) were included. We found a significant association between age>75years and bleeding in patients receiving VKAs (RR: 1.62, 95%CI: 1.28-2.05; P<0.0001). Moreover, the prevalence of bleeding events under VKAs was significantly higher in patients with low body weight (RR: 1.20, 95%CI: 1.03-1.40; P=0.02) and in those with impaired renal function (RR: 1.59, 95%CI: 1.30-1.94; P<0.00001). Results were confirmed when separately analyzing data on AF and VTE. Regression models showed that treatment duration did not impact on the differences found in the safety profile of VKAs in different settings analyzed. CONCLUSIONS Results of our meta-analysis suggest an increased risk of bleeding complications in "high-risk" patients. Although all results are significant, other studies focused on this issue are warranted to further validate these results.
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24
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Ko D, Rahman F, Martins MAP, Hylek EM, Ellinor PT, Schnabel RB, Benjamin EJ, Christophersen IE. Atrial fibrillation in women: treatment. Nat Rev Cardiol 2016; 14:113-124. [PMID: 27786235 DOI: 10.1038/nrcardio.2016.171] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sex-specific differences in the epidemiology, pathophysiology, presentation, prognosis, and treatment of atrial fibrillation (AF) are increasingly recognized. Women with AF generally experience worse symptoms, poorer quality of life, and have higher risk of stroke and death than men with AF. Effective treatment of the arrhythmia in women is critical to reduce the rate of adverse events. We review the current evidence on sex-specific differences in the utilization and outcomes of treatments for AF, including rate-control and rhythm-control strategies, and stroke-prevention therapy. In addition, we provide a critical evaluation of potential disparities and biases in health-care use that might be associated with differences in the outcomes between women and men. We underscore current knowledge gaps that need to be addressed in future studies to improve the management of AF in women. In particular, we suggest several strategies to produce high-quality evidence from randomized clinical trials for women with AF.
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Affiliation(s)
- Darae Ko
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Faisal Rahman
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Maria A P Martins
- Departamento de Produtos Farmacêuticos, Faculdade de Farmácia da Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627 - Pampulha, Belo Horizonte - MG, 31270-901, Brazil.,Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue, Framingham, Massachusetts 01702, USA
| | - Elaine M Hylek
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Oudenarder Strasse 16, D/04 (1. floor), 13347 Berlin, Germany
| | - Emelia J Benjamin
- Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue, Framingham, Massachusetts 01702, USA.,Sections of Cardiovascular Medicine and Preventive Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA.,Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, USA
| | - Ingrid E Christophersen
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA.,Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Sogneprest Munthe-Kaas vei 100, 1346 Gjettum, Norway
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25
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26
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Senoo K, Lip GYH. Female Sex, Time in Therapeutic Range, and Clinical Outcomes in Atrial Fibrillation Patients Taking Warfarin. Stroke 2016; 47:1665-8. [PMID: 27125527 DOI: 10.1161/strokeaha.116.013173] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Female patients have higher risk for stroke than male patients in nonanticoagulated atrial fibrillation patients, but limited data are available on sex differences in stroke and bleeding outcomes among patients with anticoagulated atrial fibrillation on warfarin, especially in relation to quality of anticoagulation control, as reflected by the time in therapeutic range (TTR). METHODS We investigated adverse outcomes in females (n=791) and males (n=1501) among 2292 patients with atrial fibrillation taking warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. RESULTS The combined end point of cardiovascular death and stroke/systemic embolism (SSE) was similar in females versus males. There was no sex differences in either cardiovascular death or SSE. Compared with males, females had a lower risk of major bleeding (hazard ratio, 0.39; 95% confidence interval, 0.18-0.87; P=0.02). No differences were seen in mortality and stroke outcomes between females and males either in the prespecified age subgroups or in relation to TTR categories. TTR was negatively correlated with any clinically relevant bleeding in both females (r=-0.86; P=0.03) and males (r=-0.94; P=0.005). On Cox regression, TTR (but not female sex) emerged as an independent predictor for combined cardiovascular death/SSE and clinically relevant bleeding events. CONCLUSION Anticoagulated female patients with atrial fibrillation had a similar rate of cardiovascular death and SSE, but a lower risk of major bleeding, compared with males. TTR (but not female sex) was an independent predictor for combined cardiovascular death and SSE and clinically relevant bleeding events.
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Affiliation(s)
- Keitaro Senoo
- From the Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Gregory Y H Lip
- From the Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
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27
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Gender Differences of Thromboembolic Events in Atrial Fibrillation. Am J Cardiol 2016; 117:1021-7. [PMID: 26923085 DOI: 10.1016/j.amjcard.2015.12.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 11/20/2022]
Abstract
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and increases the risk of thromboembolism and stroke; however, these risks are not the same for women and men. This review examines the evidence and clinical significance of increased thromboembolic risk in women with AF. The balance of results from over 30 recent studies suggests that female gender is an independent stroke risk factor in AF, and the inclusion of female gender in stroke risk stratification models, such as CHA2DS2-VASc, has improved risk assessment. Reasons for the increased thrombogenicity in women remain incompletely elucidated, but biological factors including increased hypertension, renal dysfunction, and hyperthyroidism in female patients with AF; cardiovascular remodeling; increased hypercoagulability, and estrogen hormone replacement therapy in women have been proposed. More importantly, gender differences exist in medical management of patients with AF, and compared with men, women have been found to have greater thromboembolic risk when not on anticoagulants, but may benefit from greater risk reduction when systemically anticoagulated. In conclusion, increased clinician awareness of these gender differences may help to improve the management of patients with AF.
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28
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Anselmino M, Battaglia A, Gallo C, Gili S, Matta M, Castagno D, Ferraris F, Giustetto C, Gaita F. Atrial fibrillation and female sex. J Cardiovasc Med (Hagerstown) 2015; 16:795-801. [DOI: 10.2459/jcm.0000000000000239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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29
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Avgil Tsadok M, Jackevicius CA, Rahme E, Humphries KH, Pilote L. Sex Differences in Dabigatran Use, Safety, And Effectiveness In a Population-Based Cohort of Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2015; 8:593-9. [DOI: 10.1161/circoutcomes.114.001398] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 09/23/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Meytal Avgil Tsadok
- From the Divisions of Clinical Epidemiology (M.A.T.,E.R., L.P.) and General Internal Medicine (L.P.), McGill University Health Center, Montreal, Quebec, Canada; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, CA (C.A.J.); Institute for Clinical Evaluative Sciences, Toronto, Canada (C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada (C.A.J.); University Health
| | - Cynthia A. Jackevicius
- From the Divisions of Clinical Epidemiology (M.A.T.,E.R., L.P.) and General Internal Medicine (L.P.), McGill University Health Center, Montreal, Quebec, Canada; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, CA (C.A.J.); Institute for Clinical Evaluative Sciences, Toronto, Canada (C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada (C.A.J.); University Health
| | - Elham Rahme
- From the Divisions of Clinical Epidemiology (M.A.T.,E.R., L.P.) and General Internal Medicine (L.P.), McGill University Health Center, Montreal, Quebec, Canada; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, CA (C.A.J.); Institute for Clinical Evaluative Sciences, Toronto, Canada (C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada (C.A.J.); University Health
| | - Karin H. Humphries
- From the Divisions of Clinical Epidemiology (M.A.T.,E.R., L.P.) and General Internal Medicine (L.P.), McGill University Health Center, Montreal, Quebec, Canada; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, CA (C.A.J.); Institute for Clinical Evaluative Sciences, Toronto, Canada (C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada (C.A.J.); University Health
| | - Louise Pilote
- From the Divisions of Clinical Epidemiology (M.A.T.,E.R., L.P.) and General Internal Medicine (L.P.), McGill University Health Center, Montreal, Quebec, Canada; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, CA (C.A.J.); Institute for Clinical Evaluative Sciences, Toronto, Canada (C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada (C.A.J.); University Health
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30
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Senoo K, Lip GY. Relationship of Age With Stroke and Death in Anticoagulated Patients With Nonvalvular Atrial Fibrillation. Stroke 2015; 46:3202-7. [DOI: 10.1161/strokeaha.115.010614] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/04/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The prevalence of atrial fibrillation increases with age, but age-specific data on the incidence of stroke and death in anticoagulated patients with atrial fibrillation are more limited, particularly with regard to comparisons of relative risks of clinical outcomes between the different age strata in relation to quality of anticoagulation control among warfarin users.
Methods—
We investigated the incidence of adverse outcomes between tertiles of age groups (age, <67 [n=722]; age, 67–74 [n=747]; and age, ≥75 [n=824]) in 2293 patients with atrial fibrillation participating in warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. The average time in therapeutic range was calculated as a measure of anticoagulation control and related to clinical outcomes.
Results—
Absolute rates for stroke/systemic embolism (SSE), cardiovascular death, or any clinically relevant bleeding increased with increasing age strata. The combined end point of cardiovascular death and SSE was the highest in the top tertile (adjusted hazard ratio, 2.63; 95% confidence interval, 1.23–5.63) compared with the middle and lowest tertiles (
P
for trend=0.01). For bleeding, there was no significant difference in relative risks between the age strata (
P
for trend=0.55 in the warfarin group and in the warfarin group with time in therapeutic range ≥60%,
P
for trend=0.60). The quality of anticoagulation control (time in therapeutic range) significantly correlated with any clinically relevant bleeding (
r
=−0.91;
P
<0.001) and cardiovascular death/SSE rates (
r
=−0.76;
P
=0.01).
Conclusions—
Elderly patients with atrial fibrillation have higher absolute risks of cardiovascular death, SSE, and bleeding, but relative risks of clinically relevant bleeding are not significantly different with increasing age strata. A significant inverse relationship between time in therapeutic range and bleeding and cardiovascular death/SSE emphasizes the importance of good quality anticoagulation control.
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Affiliation(s)
- Keitaro Senoo
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (K.S., G.Y.H.L.); and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (G.Y.H.L.)
| | - Gregory Y.H. Lip
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (K.S., G.Y.H.L.); and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (G.Y.H.L.)
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31
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Vinereanu D, Stevens SR, Alexander JH, Al-Khatib SM, Avezum A, Bahit MC, Granger CB, Lopes RD, Halvorsen S, Hanna M, Husted S, Hylek EM, Mărgulescu AD, Wallentin L, Atar D. Clinical outcomes in patients with atrial fibrillation according to sex during anticoagulation with apixaban or warfarin: a secondary analysis of a randomized controlled trial. Eur Heart J 2015; 36:3268-75. [PMID: 26371113 DOI: 10.1093/eurheartj/ehv447] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 08/13/2015] [Indexed: 11/14/2022] Open
Abstract
AIM To assess clinical outcomes, efficacy, and safety according to sex during anticoagulation with apixaban compared with warfarin in patients with atrial fibrillation. METHODS AND RESULTS Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) was a randomized, double-blind, placebo-controlled, multicentre trial that included 11 785 (64.7%) men and 6416 (35.3%) women with atrial fibrillation or flutter randomized to receive either warfarin or apixaban. The primary efficacy endpoint was stroke or systemic embolism; secondary efficacy endpoints were death from any cause and cardiovascular death. The primary safety endpoint was major bleeding; secondary safety endpoints were a composite of major bleeding and non-major clinically relevant bleeding. The risk of stroke or systemic embolism was similar in women vs. men [adjusted hazard ratio (adjHR): 0.91; 95% confidence interval (CI): 0.74-1.12; P = 0.38]. However, among patients with history of stroke or transient ischaemic attack, women had a lower risk of recurrent stroke compared with men (adjHR: 0.70; 95% CI: 0.50-0.97; P = 0.036). Women also had a lower risk of all-cause death (adjHR: 0.63; 95% CI: 0.55-0.73; P < 0.0001) and cardiovascular death (adjHR: 0.62; 95% CI: 0.51-0.75; P < 0.0001), and a trend towards less major bleeding (adjHR: 0.86; 95% CI: 0.74-1.01; P = 0.066) and major or non-major clinically relevant bleeding (adjHR: 0.89; 95% CI: 0.80-1.00; P = 0.049). The efficacy and safety benefits of apixaban compared with warfarin were consistent regardless of sex. CONCLUSION In the ARISTOTLE trial, women had a similar rate of stroke or systemic embolism but a lower risk of mortality and less clinically relevant bleeding than men. The efficacy and safety benefits of apixaban compared with warfarin were consistent in men and women. TRIAL REGISTRATION ARISTOTLE ClinicalTrials.gov number, NCT00412984.
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Affiliation(s)
- Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania Department of Cardiology, University and Emergency Hospital of Bucharest, 169 Splaiul Independentei, Sector 5, Bucharest, Romania
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | | | - Steen Husted
- Hospital Unit West and Aarhus University Hospital, Aarhus, Denmark
| | | | - Andrei D Mărgulescu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania Department of Cardiology, University and Emergency Hospital of Bucharest, 169 Splaiul Independentei, Sector 5, Bucharest, Romania
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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32
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Avgil Tsadok M, Gagnon J, Joza J, Behlouli H, Verma A, Essebag V, Pilote L. Temporal trends and sex differences in pulmonary vein isolation for patients with atrial fibrillation. Heart Rhythm 2015; 12:1979-86. [DOI: 10.1016/j.hrthm.2015.06.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Indexed: 10/23/2022]
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Shantsila E, Wolff A, Lip GYH, Lane DA. Gender differences in stroke prevention in atrial fibrillation in general practice: using the GRASP-AF audit tool. Int J Clin Pract 2015; 69:840-5. [PMID: 25752615 DOI: 10.1111/ijcp.12625] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Women represent a large proportion of patients with atrial fibrillation (AF) and tend to have higher risk of stroke. AIMS This study examines gender differences in the utilisation of oral anticoagulation (OAC) and prognosis (i.e. stroke and death) in AF patients in UK general practice. DESIGN Retrospective observational study. METHODS The Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation (GRASP-AF) tool was employed to identify AF patients from 11 general practices in Darlington, England. RESULTS Two thousand two hundred and fifty-nine AF patients (mean±SD age 76 ± 12 years; 46% female) were identified. Based on CHA2 DS2 -VASc score 95% of women and 90% of men were at moderate-high risk of stroke. Women with moderate-high risk of stroke were treated with OAC less frequently than men (47% vs. 52%, p = 0.006). Overall rates of stroke and all-cause mortality were higher among women than men (p = 0.02 and p < 0.001). However, there was no significant gender difference in these outcomes in patients receiving OAC (p = 0.52 for stroke, p = 0.18 for death). Among people not receiving OAC where indicated, female gender was associated with an increased risk of stroke before (p = 0.01), and after (p = 0.04), adjustment for stroke risk factors. Women not receiving OAC had a higher risk of death on univariate regression analysis (p = 0.002), but not after adjustment for stroke risk factors (p = 0.53). CONCLUSION Women with AF are at higher risk of stroke than men without OAC. The gender-related differences in risk of stroke disappear if OAC is used. Despite this, women are more likely not to receive OAC.
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Affiliation(s)
- E Shantsila
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - A Wolff
- Whinfield Medical Practice, Darlington, UK
| | - G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - D A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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34
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Quality of life (QoL) and International Normalized Ratio (INR) control of patients attending anticoagulation clinics. Public Health 2015; 129:954-62. [DOI: 10.1016/j.puhe.2015.05.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/13/2015] [Accepted: 05/13/2015] [Indexed: 11/20/2022]
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Is health-related quality of life a predictor of hospitalization or mortality among women or men with atrial fibrillation? J Cardiovasc Nurs 2015; 29:555-64. [PMID: 24165699 DOI: 10.1097/jcn.0000000000000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Little is known about predictors of mortality or hospitalization in women compared with men in patients with atrial fibrillation (AF). Although there are established gender differences in patients with coronary artery disease (CAD), differences have not been established in AF. OBJECTIVES The aim of this study was to examine clinical and health-related quality of life (HRQOL) predictors of mortality and 1-year hospitalization in women compared with men with AF. METHODS Limited-use data from the National Institutes of Health/National Heart, Lung, and Blood Institute Atrial Fibrillation Follow-up Investigation of Rhythm Management clinical trial provided the sample of 693 patients with AF, 262 women and 431 men. Clinical predictors examined were heart failure (HF), CAD, left ventricular ejection fraction, diabetes, stroke, and age. Predictors of HRQOL included overall HRQOL (Medical Outcomes Study Short Form-36 physical [PCS] and mental component scores) and cardiovascular HRQOL using Quality of Life Index-Cardiac Version. RESULTS Mortality did not differ (women, 11.4%; men, 14.5%; χ(2)1 = 0.437, P = .509) according to gender, with mean 3.5-year follow-up. Different variables independently predicted mortality for women and men. For women, diabetes (hazard ratio [HR], 3.415; P = .003), HF (HR, 2.346; P = .027), stroke (HR, 2.41; P = .032), and age (HR, 1.117; P = .002), and for men, CAD (HR, 1.914; P = 02), age (HR, 1.103, P = < .001), worse PCS (HR, 1.089, P = .001), and worse Quality of Life Index-Cardiac Version score (HR, 1.402, P = .025) independently predicted mortality.One-year hospitalization (women, 38.9%; men, 36.4%) did not differ by gender (χ(2)1 = 0.914, P = .339). Different variables independently predicted 1-year hospitalization-for women: diabetes (odds ratio [OR], 2.359; P = .022), worse PCS (OR, 1.070; P = .003), and rhythm control trial arm (OR, 2.111; P = .006); for men: HF (OR, 2.072; P = .007), worse PCS (OR, 1.045; P = .019), living alone (OR, 1.913; P = .036), and rhythm control trial arm (OR, 2.113; P < .001). CONCLUSION Only clinical status predicted mortality among women; HRQOL and clinical status predicted mortality among men. Both clinical and HRQOL variables predicted hospitalization for women and men. Increased monitoring of HRQOL and interventions designed to target the clinical and HRQOL predictors could impact mortality and hospitalization. Nursing interventions may prove effective for modifying most of the predictors of mortality and hospitalization for women and men with AF.
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36
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Lundberg GP, Volgman AS. Burden of stroke in women. Trends Cardiovasc Med 2015; 26:81-8. [PMID: 26051206 DOI: 10.1016/j.tcm.2015.04.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 12/26/2022]
Abstract
Stroke is the fifth cause of death in the United States and the first cause of disability. While reductions in stroke mortality have occurred, stroke remains a significant burden in women. In addition to traditional cardiovascular risk factors, there are specific risk factors in women that need to be addressed to further reduce deaths in women from stroke. Atrial fibrillation is common in women and needs proper evaluation for anticoagulation for risk reduction. Stroke in women remains a serious cause of preventable deaths, disability, and cost. Implementation of the new guidelines for stroke prevention in women is critical for reducing the burden of stroke in women.
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Affiliation(s)
- Gina Price Lundberg
- Emory Women׳s Heart Center, Atlanta, GA; Emory University School of Medicine, Atlanta, GA; Emory Heart and Vascular Center East Cobb, Marietta, GA.
| | - Annabelle Santos Volgman
- Rush College of Medicine, Rush University Medical Center, Chicago, IL; Rush Heart Center for Women, Rush University Medical Center, Chicago, IL
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Lip GYH, Rushton-Smith SK, Goldhaber SZ, Fitzmaurice DA, Mantovani LG, Goto S, Haas S, Bassand JP, Camm AJ, Ambrosio G, Janský P, Al Mahmeed W, Oh S, van Eickels M, Raatikainen P, Steffel J, Oto A, Kayani G, Accetta G, Kakkar AK. Does sex affect anticoagulant use for stroke prevention in nonvalvular atrial fibrillation? The prospective global anticoagulant registry in the FIELD-Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2015; 8:S12-20. [PMID: 25714828 DOI: 10.1161/circoutcomes.114.001556] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with atrial fibrillation (AF), women are at higher risk of stroke than men. Using prospective cohort data from a large global population of patients with nonvalvular AF, we sought to identify any differences in the use of anticoagulants for stroke prevention in women and men. METHODS AND RESULTS This was a prospective multicenter observational registry with 858 randomly selected sites in 30 countries. A total of 17 184 patients with newly diagnosed (≤6 weeks) nonvalvular AF and ≥1 additional investigator-defined stroke risk factor(s) were recruited (March 2010 to June 2013). The main outcome measure was the use of anticoagulants (vitamin K antagonists, factor Xa inhibitors, and direct thrombin inhibitors) for stroke prevention at AF diagnosis. Of 17 184 patients enrolled, 43.8% were women. More women than men were at moderate-to-high risk of stroke (CHADS2 score ≥2: 65.1% versus 54.7%). Rates of anticoagulant use were not different overall (60.9% of men versus 60.8% of women) and in patients with a CHADS2 score ≥2 (adjusted odds ratio for women versus men, 1.00; 95% confidence interval, 0.92-1.09). In patients at low risk (CHA2DS2-VASc of 0 in men and 1 in women), 41.8% of men and 41.1% of women received an anticoagulant. In patients at high risk (CHA2DS2-VASc score ≥2), 35.4% of men and 38.4% of women did not receive an anticoagulant. CONCLUSIONS These contemporary global data show that anticoagulant use for stroke prevention is no different in men and women with nonvalvular AF. Thromboprophylaxis was, however, suboptimal in substantial proportions of men and women, with underuse in those at moderate-to-high risk of stroke and overuse in those at low risk. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Chapa DW, Akintade B, Thomas SA, Friedmann E. Gender differences in stroke, mortality, and hospitalization among patients with atrial fibrillation: A systematic review. Heart Lung 2015; 44:189-98. [PMID: 25703992 DOI: 10.1016/j.hrtlng.2015.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To conduct a systematic review of gender differences in stroke, mortality, and hospitalization for patients with atrial fibrillation and/or flutter (AF/Afl). METHODS Full texts, published, peer-reviewed, English language articles from 1999 through July 2014 were examined. Articles with populations of patients with AF/Afl were included if they conducted longitudinal analysis of any of three outcomes: stroke, mortality, and hospitalization, and reported or compared at least one of the outcomes according to gender. RESULTS Seventeen articles were included: sixteen on stroke, nine on mortality, and one on hospitalization. In nine articles women had more strokes (RRs 0.89-1.9). Findings about gender differences in mortality (RRs 0.69-2.8) and hospitalizations were equivocal. CONCLUSIONS Few articles examine differences in outcomes between men and women with AF/Afl. Given the prevalence of AF/Afl and health care costs it is vital to determine gender differences to evaluate appropriate therapies to decrease stroke, mortality, and hospitalizations.
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Affiliation(s)
- Deborah W Chapa
- George Washington University, School of Nursing, 2030 M Street NW, Suite 300, Washington, DC 20036, USA.
| | - Bimbola Akintade
- University of Maryland, Baltimore, School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA
| | - Sue A Thomas
- University of Maryland, Baltimore, School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA
| | - Erika Friedmann
- University of Maryland, Baltimore, School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA
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Abstract
Women have a similar lifetime prevalence of non-valvular atrial fibrillation (NVAF) compared with that of men. Given the significant morbidity and potential mortality associated with NVAF, it is crucial to understand gender differences with NVAF. Women can be more symptomatic than men. Despite a higher baseline stroke risk, they are less likely to be on anticoagulation. Women have a greater risk of thromboembolism and a similar rate of bleeding risk compared with men on anticoagulation. Initial experience suggests that novel oral anticoagulants have similar safety and efficacy profile in men and women. Although women can have more adverse reactions from antiarrhythmic therapies, they are often referred later than men for ablation. As a group, a mitigating factor in ablation referral is that women also have a higher incidence of procedural complications from catheter ablation. This review summarizes the available literature highlighting significant gender-based differences and also highlights areas for research to improve NVAF outcomes in women.
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Affiliation(s)
- Nishaki Mehta Oza
- The Ohio State University - Cardiovascular Medicine, Columbus, OH 43210, USA
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40
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Blanco-Molina A, Enea I, Gadelha T, Tufano A, Bura-Riviere A, Di Micco P, Bounameaux H, González J, Villalta J, Monreal M. Sex differences in patients receiving anticoagulant therapy for venous thromboembolism. Medicine (Baltimore) 2014; 93:309-317. [PMID: 25398066 PMCID: PMC4602415 DOI: 10.1097/md.0000000000000114] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In patients with venous thromboembolism (VTE), the outcome during the course of anticoagulant therapy may differ according to the patient's sex. We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to compare the rate of VTE recurrences, major bleeding, and mortality due to these events according to sex.As of August 2013, 47,499 patients were enrolled in RIETE, of whom 24,280 (51%) were women. Women were older, more likely presented with pulmonary embolism (PE), and were more likely to have recent immobilization but less likely to have cancer than men. During the course of anticoagulation (mean duration: 253 d), 659 patients developed recurrent deep vein thrombosis (DVT), 576 recurrent PE, 1368 bled, and 4506 died. Compared with men, women had a lower rate of DVT recurrences (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.67-0.91), a similar rate of PE recurrences (HR: 0.98; 95% CI: 0.83-1.15), a higher rate of major bleeding (HR: 1.21; 95% CI: 1.09-1.35), and higher mortality due to PE (HR: 1.24; 95% CI: 1.04-1.47). On multivariable analysis, any influence of sex on the risk for recurrent DVT (HR: 0.88; 95% CI: 0.75-1.03), major bleeding (HR: 1.10; 95% CI: 0.98-1.24), or fatal PE (HR: 1.01; 95% CI: 0.84-1.22) was no longer statistically significant.In conclusion, women had fewer DVT recurrences and more bleeds than men during the course of anticoagulation. These differences were not due to sex, but very likely to other patient characteristics more common in female patients and differences in treatment choice.
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Affiliation(s)
- Angeles Blanco-Molina
- From Department of Internal Medicine (ABM), Hospital Universitario Reina Sofia, Córdoba, Spain; Department of Emergency Medicine, Ospedale San Sebastiano, Caserta, Italy; Department of Haematology and Hemotherapy (TG), Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; Department of Clinical and Experimental Medicine (AT), Università degli Studi di Napoli Federico II, Naples, Italy; Department of Vascular Medicine (ABR), Hôpital de Rangueil, Toulouse, France; Department of Internal Medicine (PDM), Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy; Division of Angiology and Haemostasis (HB), University Hospital of Geneva, Geneva, Switzerland; Department of Internal Medicine (JG), ALTHAIA, Xarxa Assistencial de Manresa, Spain; Department of Internal Medicine (JV), Hospital Clinic, Barcelona, Spain; and Department of Internal Medicine (MM), Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Gutiérrez-Chico JL, Mehilli J. Gender differences in cardiovascular therapy: focus on antithrombotic therapy and percutaneous coronary intervention. Drugs 2014; 73:1921-33. [PMID: 24155117 DOI: 10.1007/s40265-013-0135-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The epidemiology of coronary artery disease (CAD) differs between women and men: female cardiac patients are older and have poorer risk profiles than their male counterparts. This results in a preferential exclusion of women from participation in clinical trials, reducing their power to detect differences in performance of cardiovascular therapies in women. In general, all the antiplatelet and anticoagulant medications used in cardiac patients are equally effective in men and women, although women tend to experience a higher relative benefit due to their poorer risk profile. In particular, women with CAD benefit the most from interventional treatment combined with modern antithrombotic drugs. No gender-related differences in the reduction of thromboembolic risk with more potent antithrombotic drugs have been reported. On the other hand, a clear trend to a higher incidence of bleeding complications has been consistently reported in women, which might be related to a more frequent over-dosage of antithrombotic treatment in women than in men. Women are therefore one of the subgroups that might benefit the most from careful dose adjustment of available antithrombotic drugs. However, the development of a gender-based dosage guideline remains an unmet need in cardiology.
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Affiliation(s)
- Juan Luis Gutiérrez-Chico
- Munich University Clinic, Cardiology Department, Ludwig-Maximilian University, Marchioninistraße 15, 81377, Munich, DE, Germany
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Mearns ES, Hawthorne J, Song JS, Coleman CI. Measures of vitamin K antagonist control reported in atrial fibrillation and venous thromboembolism studies: a systematic review. BMJ Open 2014; 4:e005379. [PMID: 24951111 PMCID: PMC4067815 DOI: 10.1136/bmjopen-2014-005379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To aid trialists, systematic reviewers and others, we evaluated the degree of standardisation of control measure reporting that has occurred in atrial fibrillation (AF) and venous thromboembolism (VTE) studies since 2000; and attempted to determine whether the prior recommendation of reporting ≥2 measures per study has been employed. DESIGN Systematic review. SEARCH STRATEGY We searched bibliographic databases (2000 to June 2013) to identify AF and VTE studies evaluating dose-adjusted vitamin K antagonists (VKAs) and reporting ≥1 control measure. The types of measures reported, proportion of studies reporting ≥2 measures and mean (±SD) number of measures per study were determined for all studies and compared between subgroups. DATA EXTRACTION Through the use of a standardised data extraction tool, we independently extracted all data, with disagreements resolved by a separate investigator. RESULTS 148 studies were included, 57% of which reported ≥2 control measures (mean/study=2.13±1.36). The proportion of time spent in the target international normalised ratio range (TTR) was most commonly reported (79%), and was frequently accompanied by time above/below range (52%). AF studies more frequently reported ≥2 control measures compared with VTE studies (63% vs 37%; p=0.004), and reported a greater number of measures per study (mean=2.36 vs 1.53; p<0.001). Observational studies were more likely to provide ≥2 measures compared with randomised trials (76% vs 33%; p<0.001) and report a greater number of measures (mean=2.58 vs 1.63; p<0.001). More recent studies (2004-2013) reported ≥2 measures more often than older (2000-2003) studies (59% vs 35%; p=0.05) and reported more measures per study (mean=2.23 vs 1.48; p=0.02). CONCLUSIONS While TTR was often utilised, studies reported ≥2 measures of VKA control only about half of the time and lacked consistency in the types of measures reported. A trend towards studies reporting greater numbers of VKA control measures over time was observed over our review time horizon, particularly, with AF and observational studies.
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Affiliation(s)
- Elizabeth S Mearns
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- The University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, Connecticut, USA
| | - Jessica Hawthorne
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Ju-Sung Song
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- The University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, Connecticut, USA
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43
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Lip GYH, Eikelboom J, Yusuf S, Shestakovska O, Hart RG, Connolly S. Modification of outcomes with aspirin or apixaban in relation to female and male sex in patients with atrial fibrillation: a secondary analysis of the AVERROES study. Stroke 2014; 45:2127-30. [PMID: 24916911 DOI: 10.1161/strokeaha.114.005746] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The main objective of the present analysis was to assess the effect of treatment with aspirin compared with apixaban on ischemic stroke and major bleeding in women compared with men. Female patients with atrial fibrillation are at increased stroke risk compared with male patients, and the underlying reasons for higher risk are uncertain. METHODS Ancillary analysis of the Apixaban Versus Acetylsalicylic Acid [ASA] to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trial, comparing aspirin and apixaban, focused on sex differences. Mean follow-up was 1.1 years. RESULTS Women compared with men tended to be older (aspirin, 71.8 versus 68.8 years; apixaban, 71.4 versus 68.6 years), with a higher proportion of those aged≥75 years. Also, women had less peripheral artery disease (aspirin, 2.4% versus 3.7%; apixaban, 1.4% versus 3.0%), more heart failure, and higher mean CHADS2 (congestive heart failure, hypertension, age of 75 years or older, diabetes [1 point each], stroke or transient ischemic attack [2 points]) scores (aspirin, 2.2 versus 2.0; apixaban, 2.1 versus 2.0). Women compared with men had higher ischemic stroke rates (aspirin, 3.99% versus 2.28%; apixaban, 1.55% versus 0.82%) but similar bleeding rates (aspirin, 1.29% versus 1.22%; apixaban, 1.15% versus 1.36%). The relative effect of apixaban compared with aspirin was similar in men and women for both ischemic stroke (women, 3.99% versus 1.55%; hazard ratio, 0.39; 95% confidence interval, 0.23-0.64; men, 2.28% versus 0.82%; hazard ratio, 0.36; 95% confidence interval, 0.19-0.63; Pint=0.84) and major bleeding (women, 1.29% versus 1.15%; hazard ratio, 1.15; 95% confidence interval, 0.59-2.23; men, 1.36% versus 1.22%; hazard ratio, 1.13; 95% confidence interval, 0.64-2.02; Pint=0.96). CONCLUSIONS Female patients with atrial fibrillation had higher ischemic stroke rates compared with male patients, but the relative effects of apixaban compared with aspirin on both ischemic stroke and bleeding were similar in men and women.
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Affiliation(s)
- Gregory Y H Lip
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.).
| | - John Eikelboom
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.)
| | - Salim Yusuf
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.)
| | - Olga Shestakovska
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.)
| | - Robert G Hart
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.)
| | - Stuart Connolly
- From the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.E., S.Y., O.S., R.G.H., S.C.)
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Halperin JL, Hankey GJ, Wojdyla DM, Piccini JP, Lokhnygina Y, Patel MR, Breithardt G, Singer DE, Becker RC, Hacke W, Paolini JF, Nessel CC, Mahaffey KW, Califf RM, Fox KAA. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation 2014; 130:138-46. [PMID: 24895454 DOI: 10.1161/circulationaha.113.005008] [Citation(s) in RCA: 295] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Nonvalvular atrial fibrillation is common in elderly patients, who face an elevated risk of stroke but difficulty sustaining warfarin treatment. The oral factor Xa inhibitor rivaroxaban was noninferior to warfarin in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). This prespecified secondary analysis compares outcomes in older and younger patients. METHODS AND RESULTS There were 6229 patients (44%) aged ≥75 years with atrial fibrillation and ≥2 stroke risk factors randomized to warfarin (target international normalized ratio=2.0-3.0) or rivaroxaban (20 mg daily; 15 mg if creatinine clearance <50 mL/min), double blind. The primary end point was stroke and systemic embolism by intention to treat. Over 10 866 patient-years, older participants had more primary events (2.57% versus 2.05%/100 patient-years; P=0.0068) and major bleeding (4.63% versus 2.74%/100 patient-years; P<0.0001). Stroke/systemic embolism rates were consistent among older (2.29% rivaroxaban versus 2.85% warfarin per 100 patient-years; hazard ratio=0.80; 95% confidence interval, 0.63-1.02) and younger patients (2.00% versus 2.10%/100 patient-years; hazard ratio=0.95; 95% confidence interval, 0.76-1.19; interaction P=0.313), as were major bleeding rates (≥75 years: 4.86% rivaroxaban versus 4.40% warfarin per 100 patient-years; hazard ratio=1.11; 95% confidence interval, 0.92-1.34; <75 years: 2.69% versus 2.79%/100 patient-years; hazard ratio=0.96; 95% confidence interval, 0.78-1.19; interaction P=0.336). Hemorrhagic stroke rates were similar in both age groups; there was no interaction between age and rivaroxaban response. CONCLUSIONS Elderly patients had higher stroke and major bleeding rates than younger patients, but the efficacy and safety of rivaroxaban relative to warfarin did not differ with age, supporting rivaroxaban as an alternative for the elderly.
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Affiliation(s)
- Jonathan L Halperin
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
| | - Graeme J Hankey
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Daniel M Wojdyla
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Jonathan P Piccini
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Yuliya Lokhnygina
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Manesh R Patel
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Günter Breithardt
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Daniel E Singer
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Richard C Becker
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Werner Hacke
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - John F Paolini
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Christopher C Nessel
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Kenneth W Mahaffey
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Robert M Califf
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Keith A A Fox
- From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
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Sabouret P, Depret-Bixio L, Cotte FE, Marie P, Bedira N, Blin P. Sex differences in stroke prevention in atrial fibrillation in French primary care. Results of the AFIGP (Atrial Fibrillation In General Practice) database. Clin Res Cardiol 2014; 103:887-93. [PMID: 24830515 DOI: 10.1007/s00392-014-0726-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Most of the French patients diagnosed with atrial fibrillation (AF) are managed by general practitioners (GPs). The objective was to evaluate stroke prevention in AF patients ahead of the arrival of the non vitamin K oral anticoagulant in France. METHODS A cross-sectional study using a French GPs database of all patients with a diagnosis of AF consulting their GP between July-2010 and June-2011. Multivariate analyses were used to identify determinants of prevention prescription. RESULTS Among 15,623 AF patients, 42.5 % were ≥75 years and 40.5 % women, 59.2 % had hypertension, 17.2 % diabetes, 11.4 % heart failure, 4.9 % stroke history. CHADS2 score was ≥1 for 83.1 % and ≥2 for 50.9 % of patients (CHA2DS2-VASc score ≥1 for 93.7 % and ≥2 for 82.3 %). Antithrombotic therapies were vitamin K antagonists (VKA) for 50.7 % of patients, followed by aspirin for 19.9 %, clopidogrel ± aspirin for 4.3 % and none for 25.1 %. For patients with CHADS2 scores ≥1, 73.3 % received an antithrombotic and for those with CHADS2 scores ≥2, 54.9 % were treated by a VKA. An age-stratified multivariate analysis showed that women had an odds ratio to be treated with VKA compared to 0.83 (95 % CI: 0.72-0.95) and 0.66 (95 % CI: 0.59-0.74) when aged <75 years and ≥75 years, respectively. CONCLUSIONS Most AF patients followed by French GPs required stroke prevention according to European guidelines, but many of them did not receive the recommended antithrombotic treatment. Women over 75 were a third less likely to be treated with recommended anticoagulants than men of similar age.
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Affiliation(s)
- Pierre Sabouret
- Department of Cardiology, Pitié Salpétrière Hospital, Heart Institute, Pierre and Marie Curie University, Paris, France,
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Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H, Kumagai N, Sakurai M, Kawamura Y, Kubota I, Matsumoto K, Kaneko Y, Ogawa S, Aizawa Y, Chinushi M, Kodama I, Watanabe E, Koretsune Y, Okuyama Y, Shimizu A, Igawa O, Bando S, Fukatani M, Saikawa T, Chishaki A. Impact of gender on the prognosis of patients with nonvalvular atrial fibrillation. Am J Cardiol 2014; 113:957-62. [PMID: 24461771 DOI: 10.1016/j.amjcard.2013.11.057] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/26/2022]
Abstract
Treatment guidelines for atrial fibrillation (AF) used in Western countries describe female gender as a risk factor for thromboembolic events in patients with nonvalvular AF (NVAF). The present study aimed to determine the impact of gender on prognosis of Japanese patients with NVAF. A subanalysis of 7,406 patients with NVAF (mean age 70 years) who were followed-up prospectively for 2 years was performed using data from the J-RHYTHM registry. The primary end points were thromboembolic events, major hemorrhaging, total mortality, and cardiovascular mortality. Compared with male subjects (n = 5,241), female subjects (n = 2,165) were older and displayed greater prevalences of paroxysmal AF, heart failure, and hypertension but less prevalences of diabetes, previous cerebral infarction, and coronary artery disease. Male and female patients had mean CHADS2 (Congestive heart failure, Hypertension, Age of 75 years or more, Diabetes mellitus and prior Stroke or transient ischemic attack) scores of 1.6 and 1.8, respectively (p <0.001). Warfarin was given to 87% of male patients and 86% of female patients (p = 0.760), and the 2 genders displayed similar mean international normalized ratio of prothrombin time values at baseline (1.91 vs 1.90, respectively, p = 0.756). Multivariate logistic regression analysis indicated that male gender was an independent risk factor for major hemorrhaging (odds ratio 1.59, 95% confidence interval 1.05 to 2.40, p = 0.027) and all-cause mortality (odds ratio 1.78, 95% confidence interval 1.25 to 2.55, p <0.002) but not for thromboembolic events (odds ratio 1.24, 95% confidence interval 0.83 to 1.86, p = 0.297) or cardiovascular mortality (odds ratio 0.96, 95% confidence interval 0.56 to 1.66, p = 0.893). In conclusion, female gender is not a risk factor for thromboembolic events among Japanese patients with NVAF who were treated mostly with warfarin. However, male gender is a risk factor for major hemorrhaging and all-cause mortality.
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47
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Pancholy SB, Sharma PS, Pancholy DS, Patel TM, Callans DJ, Marchlinski FE. Meta-analysis of gender differences in residual stroke risk and major bleeding in patients with nonvalvular atrial fibrillation treated with oral anticoagulants. Am J Cardiol 2014; 113:485-90. [PMID: 24315113 DOI: 10.1016/j.amjcard.2013.10.035] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
Studies comparing gender-specific outcomes in patients with atrial fibrillation (AF) have reported conflicting results. Gender differences in cerebrovascular accident/systemic embolism (CVA/SE) or major bleeding outcomes with novel oral anticoagulant (NOAC) use are not known. The goal of this analysis was to perform a systematic review and meta-analysis evaluating gender differences in residual risk of CVA/SE and major bleeding outcomes in patients with nonvalvular AF treated with either warfarin or NOAC. Sixty-four randomized studies were identified using keywords "gender," "AF," and "CVA." Using the Preferred Reporting Items for Systemic Reviews and Meta-analysis method, 6 studies met criteria for inclusion in this meta-analysis. CVA/SE and major bleeding outcomes were separately analyzed in cohorts receiving warfarin and NOAC agents, comparing men with women. Women with AF taking warfarin were at a significantly greater residual risk of CVA/SE compared with men (odds ratio 1.279, 95% confidence interval 1.111 to 1.473, Z = -3.428, p = 0.001). No gender difference in residual risk of CVA/SE was noted in patients with AF receiving NOAC agents (odds ratio 1.146, 95% confidence interval 0.97 to 1.354, p = 0.109). Major bleeding was less frequent in women with AF treated with NOAC. In conclusion, women with AF treated with warfarin have a greater residual risk of CVA/SE and an equivalent major bleeding risk, whereas those treated with NOAC agents deemed superior to warfarin are at equivalent residual risk of CVA/SE and less major bleeding risk compared with men. These results suggest an increased net clinical benefit of NOAC agents compared with warfarin in treating women with AF.
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48
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Ahmad Y, Lip GYH, Apostolakis S. New oral anticoagulants for stroke prevention in atrial fibrillation: impact of gender, heart failure, diabetes mellitus and paroxysmal atrial fibrillation. Expert Rev Cardiovasc Ther 2014; 10:1471-80. [DOI: 10.1586/erc.12.148] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Liu GJ, Wang YF, Chen PY, Chang W, Tu ML, Chang LY, Cheng P, Luo J. The efficacy and safety of novel oral anticoagulants for the preventive treatment in atrial fibrillation patients: a systematic review and meta-analysis. Drug Deliv 2014; 21:436-52. [DOI: 10.3109/10717544.2013.873500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cove CL, Albert CM, Andreotti F, Badimon L, Van Gelder IC, Hylek EM. Female sex as an independent risk factor for stroke in atrial fibrillation: possible mechanisms. Thromb Haemost 2013; 111:385-91. [PMID: 24305974 DOI: 10.1160/th13-04-0347] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 10/11/2013] [Indexed: 11/05/2022]
Abstract
Atrial fibrillation (AF) is an independent risk factor for thromboembolism and stroke. Women with AF are at a higher overall risk for thromboembolic stroke when compared to men with AF. Recent evidence suggests that female sex, after adjusting for stroke risk profile and sex differences in utilisation of anticoagulation, is an independent stroke risk factor in AF. The inclusion of female sex has improved the accuracy of the CHADS2 stroke risk stratification schema (Congestive heart failure, Hypertension, Age 75 years or greater, Diabetes mellitus, and prior Stroke or TIA). The newly revised and validated schema, CHA2DS2-VASc, dichotomises age and incorporates female sex and vascular disease history. The pathophysiological mechanisms to explain this increased risk in women are not well understood. According to Virchow's triad, thrombosis that leads to stroke in AF should arise from three co-existing phenomena: structural abnormalities, blood stasis, and a hypercoagulable state. Herein, we explore the sex differences in the biological processes that lead to thrombus formation as applied to Virchow's Triad. The objective of this review is to describe the potential mechanisms behind the increased risk of stroke in AF associated with female sex.
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Affiliation(s)
- C L Cove
- Christina L. Cove, MD, Crosstown 2075-D, 801 Massachusetts Avenue, Boston, MA 02118, USA, Tel.: +1 617 414 6908, Fax: +1 617 414 4676, E-mail:
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