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Botto GL, Capranzano P, Colonna P, Fornasari DMM, Sciatti E, Riva L. Use of DOACs in frail elderly patients in light of class genericization. Int J Cardiol 2024; 411:132276. [PMID: 38880419 DOI: 10.1016/j.ijcard.2024.132276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Frailty and comorbidity influence the therapeutic approach in everyday clinical practice. The DOACs genericization opens a reflection on their differences from a pharmacological and bioavailability point of view, particularly in elderly frail patients. The aim of this project was to create a national Delphi consensus on the topic of the use of DOACs for atrial fibrillation (AF) in such patients, in light of the genericization of the class. METHODS AND RESULTS The consensus dealt with 3 main topics: a) efficacy and safety of DOACs in elderly and/or frail patients; b) therapeutic choice in specific frailty scenarios; c) DOACs genericization. 56 cardiologists, two internists and two neurologists from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: uncertain, 4: agree, 5: strongly agree). A positive consensus was reached if the percentage of agreement (vote 1-2, positive consensus) or disagreement (votes 4-5, negative consensus) was >66%; otherwise, no consensus was reached. Results are displayed accordingly. CONCLUSIONS After 10 years of everyday clinical management of DOACs for AF, specific elements differentiating a molecule from another, either for efficacy or for safety, are consolidated. However, some uncertainties still exist in particular contexts, such as chronic kidney disease or cancer patients. Clinicians have an unsure attitude towards generic drugs, because clinical practice is lacking as well as a proper knowledge of the topic. Albeit being an alternative, the choice of the generic drug must remain the responsibility of the clinician.
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Affiliation(s)
- Gian Luca Botto
- Cardiology and Electrophysiology, Department of Medicine, ASST Rhodense, Rho & Garbagnate Hospitals, Italy.
| | - Piera Capranzano
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Italy
| | | | | | | | - Letizia Riva
- Cardiology Department, Maggiore Hospital, Bologna, Italy
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Denas G, Zoppellaro G, Granziera S, Pagliani L, Noventa F, Iliceto S, Pengo V. Very Elderly Patients With Atrial Fibrillation Treated With Edoxaban: Impact of Frailty on Outcomes. JACC. ADVANCES 2023; 2:100569. [PMID: 38939480 PMCID: PMC11198574 DOI: 10.1016/j.jacadv.2023.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/05/2023] [Accepted: 06/24/2023] [Indexed: 06/29/2024]
Abstract
Background Age and frailty are associated with underuse of anticoagulation in elderly patients with atrial fibrillation (AF). Objectives This study aimed at assessing major clinical outcomes in very elderly patients with AF treated with recommended dose edoxaban and look for a possible relation with frailty measured by a validated score. Methods This prospective multicenter cohort study enrolled consecutive very elderly (age ≥80 years) anticoagulation-naïve patients starting recommended doses of edoxaban. Upon entry into the study, patients were categorized into nonfrail, prefrail and frail with the SHARE-FI (Survey of Health, Ageing, and Retirement in Europe-Frailty Index) score. The primary outcome was a composite incidence of stroke/systemic embolism, major bleeding, clinically relevant nonmajor bleeding, and death between frail and fitter patients over 2 years follow-up. Secondary outcomes were frailty-related incidence of the individual components part of the composite outcome. Results Of the 180 screened patients, 176 were enrolled in the study. Of these, 58 (32.9%) were frail, 35 (19.8%) prefrail, and 83 (47.2%) nonfrail. The composite outcome occurred in 49 patients (18.9% per patient-year). No difference in the primary endpoint between frail and fitter patients (incidence rate ratio: 1.2; 95% CI: 0.6-2.2) was observed. On multivariable analysis, anemia was significantly related to the primary outcome (HR: 3.6; 95% CI: 1.8-7.3; P < 0.001), while frailty was not (frail vs nonfrail HR: 0.9; 95% CI: 0.5-1.8). No difference across frailty categories of the individual components of composite events was observed, except for death. Conclusions Anticoagulation with recommended dose edoxaban is feasible in very elderly patients with AF even if frail. (ESCAPE [Edoxaban and Frailty in Senior Individuals]; NCT03524924).
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Affiliation(s)
- Gentian Denas
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Cardiology Clinic, University of Padua, Padua, Italy
- Cardiology Unit, High Specialization Rehabilitation Hospital, Treviso, Italy
| | | | - Serena Granziera
- Department of Physical and Rehabilitation Medicine, “Villa Salus” Hospital, Mestre, Italy
| | - Leopoldo Pagliani
- Cardiology Unit, High Specialization Rehabilitation Hospital, Treviso, Italy
| | | | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Cardiology Clinic, University of Padua, Padua, Italy
| | - Vittorio Pengo
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Cardiology Clinic, University of Padua, Padua, Italy
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Time trends in atrial fibrillation-related stroke during 2001–2020 in Sweden: a nationwide, observational study. Lancet Reg Health Eur 2023; 28:100596. [PMID: 37180742 PMCID: PMC10173271 DOI: 10.1016/j.lanepe.2023.100596] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
Background Great efforts have been made to improve stroke prevention in atrial fibrillation (AF) patients. Meanwhile, incidence of AF is increasing, which may affect the share of AF-related stroke on all strokes. We aimed to examine the temporal trends in the incidence of AF-related ischemic stroke between 2001 and 2020, if it varied by use of novel oral anticoagulant drugs (NOAC), and if the relative risk of ischemic stroke associated with AF changed over time. Methods Data from the total Swedish population aged ≥70 years during the period 2001-2020 were used. Annual incidence rate (IR) was calculated for overall and AF-related ischemic stroke which was defined as first-ever ischemic stroke with AF diagnosed up to 5 years before, on the same day, or within 2 months after the stroke event. Cox regression models were performed to examine if the hazard ratio (HR) between AF and stroke changed over time. Findings While IR of ischemic strokes declined during 2001-2020, IR of AF-related ischemic stroke remained stable between 2001 and 2010 but showed a consistent decline between 2010 and 2020. The HR of ischemic stroke within 3 years from an AF diagnosis came down from 2.39 (95% confidence interval: 2.31-2.48) to 1.54 (1.48-1.61) over the study period, which was largely explained by a substantial increase in the use of NOAC among AF patients after 2012. Yet, by the end of 2020, 24% of all ischemic strokes had a preceding or concurrent AF diagnosis, which is slightly higher than in 2001. Interpretation Even though both the absolute and relative risk of AF-related ischemic stroke declined over the past 20 years, every fourth ischemic stroke in 2020 still had a preceding or concurrent AF diagnosis. This represents a great potential for future gains in stroke prevention among AF patients. Funding Swedish Research Council and Loo and Hans Osterman Foundation for Medical Research.
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Azzoug C, Nuémi G, Menu D, De Maistre E, Boulin M, Putot A, Manckoundia P. Direct Oral Anticoagulants versus Vitamin K Antagonists in Individuals Aged 80 Years and Older: An Overview in 2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1448. [PMID: 36674204 PMCID: PMC9859400 DOI: 10.3390/ijerph20021448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 06/17/2023]
Abstract
Two main types of oral anticoagulants are available in France: vitamin K antagonists (VKA) and, more recently, direct oral anticoagulants (DOAC). The benefit−risk profile appears to be favorable for DOAC, which is as effective as VKA but safer (fewer cases of severe and cerebral bleeding). In a study in 2017, we observed that older adults did not seem to receive the same modalities of oral anticoagulants as younger individuals for various reasons. To assess anticoagulation prescribing practices over time, we repeated this cross-sectional study by comparing very old individuals taking DOAC to those taking VKA. Ambulatory individuals aged 80 years and older were included. They were affiliated with the Mutualité Sociale Agricole of Burgundy and were refunded for a medical prescription of oral anticoagulation in March 2021. The demographic characteristics, registered chronic diseases (RCD), number and types of prescribed drugs, and mortality of the DOAC group and the VKA group were compared. A total of 4275 subjects were included in the study: 67.44% (2883) received DOAC and 32.56% (1392) received VKA. The two groups were similar in age. In the DOAC group, there were more women (54.98% vs. 46.98%) (p < 0.001), fewer RCD (91.47% vs. 93.68%) (p = 0.014), and lower rates of venous thromboembolism (2.53% vs. 6.75%) (p < 0.001), severe heart failure (56.50% vs. 68.03%) (p < 0.001), and severe kidney diseases (1.38% vs. 3.59%) (p < 0.001), but there were more subjects with Alzheimer’s disease (7.49% vs. 4.31%) (p = 0.001). Individuals in the DOAC group had fewer prescriptions of furosemide (48.53% vs. 55.75%) (p < 0.001) and fibrates (2.32% vs. 3.88%) (p = 0.044). They also had more prescriptions of proton pump inhibitors (43.95% vs. 39.44%) (p = 0.006) and antirheumatics (1.60% vs. 0.65%) (p = 0.009) than those in the VKA group. There was no difference in mortality. This study revealed that prescribing practices for DOAC have changed over time.
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Affiliation(s)
- Chana Azzoug
- “Pôle Personnes Âgées”, Hospital of Champmaillot, University Hospital, 21079 Dijon, France
| | - Gilles Nuémi
- Medical Information Department, University Hospital, 21079 Dijon, France
| | - Didier Menu
- “Mutualité Sociale Agricole” of Burgundy Franche Comté, 21000 Dijon, France
| | | | - Mathieu Boulin
- Pharmacy Department, University Hospital, 21079 Dijon, France
| | - Alain Putot
- Department of Internal Medicine and Infectious Diseases, Pays du Mont Blanc Hospital, 74700 Sallanches, France
- Physiopathologie et Épidémiologie Cérébro-Cardiovasculaires (PEC2), EA 7460, University of Burgundy, 21000 Dijon, France
| | - Patrick Manckoundia
- “Pôle Personnes Âgées”, Hospital of Champmaillot, University Hospital, 21079 Dijon, France
- INSERM U-1093, Cognition, Action and Sensorimotor Plasticity, University of Burgundy, 21000 Dijon, France
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Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
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Ehrlinder H, Orsini N, Modig K, Wallén H, Gigante B. Antithrombotic treatment switching in elderly patients with atrial fibrillation and the risk of thromboembolism, bleeding, and cardiac death. Res Pract Thromb Haemost 2022; 6:e12823. [PMID: 36313983 PMCID: PMC9596606 DOI: 10.1002/rth2.12823] [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: 07/12/2022] [Revised: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Background Risks of antithrombotic switching is not investigated in elderly atrial fibrillation patients. Objectives To investigate the effectiveness and safety of antithrombotic treatment and switching of antithrombotic treatment in elderly patients (aged 75 years or older) with atrial fibrillation (AF). Methods We conducted a cohort study of 2943 patients with AF (Carrebean‐elderly), hospitalized during 2010–2017. Cox models were used to estimate the association of antithrombotic treatment (warfarin, direct oral anticoagulants [DOAC] and non–guideline‐recommended therapy [NG], i.e., aspirin and low‐molecular‐weight heparin) at discharge and antithrombotic treatment switching during follow‐up with the risk of a composite and single end points of thromboembolism, bleeding, and cardiac death. Crude and adjusted risk estimates were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). All‐cause death was evaluated, with competing risk regression and estimates expressed as subhazard ratios and 95% CIs. Results We observed an increased risk for the composite end point associated with NG as compared to warfarin at discharge (HR, 1.18; 95% CI, 1.01–1.38) with congruent competing risk regression results, while no significant risk difference was seen for DOACs compared to warfarin (HR, 1.12; 95% CI, 0.92–1.36). Switching from NG to warfarin/DOAC and from warfarin to DOAC occurred in 30.4% and 33.1% of respective antithrombotic treatment groups at discharge and was associated with a decreased risk for the composite end point with an adjusted HR of 0.45 (95% CI, 0.32–0.63) and a HR of 0.50 (95% CI, 0.38–0.65), respectively. Conclusions Antithrombotic treatment switching is common in the elderly AF population. Importantly, switching to guideline‐recommended treatment has a favorable impact on both effectiveness and safety.
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Affiliation(s)
- Hanne Ehrlinder
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden
| | - Nicola Orsini
- Department of Public Health SciencesKarolinska InstitutetStockholmSweden
| | - Karin Modig
- Unit of EpidemiologyInstitute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Håkan Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden,Cardiovascular Medicine Unit, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
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Zeng S, Zheng Y, Jiang J, Ma J, Zhu W, Cai X. Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:907197. [PMID: 35811719 PMCID: PMC9263568 DOI: 10.3389/fcvm.2022.907197] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022] Open
Abstract
Background Patients with atrial fibrillation (AF) and frailty are a considerable group in clinical practice. However, existing studies provide insufficient evidence of anticoagulation strategies for these patients. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of direct oral anticoagulants (DOACs) for these patients. Methods Randomized controlled trials or observational studies reporting the data about the DOACs and warfarin therapy among frail AF patients were included. The search was performed in the PubMed and Embase databases up to March 2022. Frailty was defined using the most widely used claims-based frailty index or the cumulative deficit model-based frailty index. Results A total of 4 studies involving 835,520 patients were included. Compared with warfarin, DOACs therapy reduced the risks of stroke or systemic embolism (HR = 0.79, 95%CI: 0.69–0.90), ischemic stroke (HR = 0.79, 95%CI: 0.71–0.87), hemorrhagic stroke (HR = 0.52, 95%CI: 0.35–0.76), and all-cause death (HR = 0.90, 95%CI: 0.84–0.96). In safety outcomes, DOACs was significantly associated with reduced risks of major bleeding (HR = 0.79, 95%CI: 0.64–0.97) and intracranial hemorrhage (HR = 0.58, 95%CI: 0.52–0.65) compared to warfarin, but there were no statistically differences in gastrointestinal bleeding (HR = 0.97, 95%CI: 0.73–1.29). Conclusions DOACs exerted superior effectiveness and safety outcome than warfarin in AF patients with frailty.
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Affiliation(s)
- Shan Zeng
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Department of Cardiology, First Affiliated Hospital, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Yuxiang Zheng
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xingming Cai
- Department of Geriatric, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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