2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation

Plasmatic variability of direct oral anticoagulants in people with atrial fibrillation and previous gastric surgery: a pilot case series

BACKGROUND

Data on cardioembolic prevention with direct oral anticoagulants (DOAC) in atrial fibrillation (AF) patients with previous gastric surgery are lacking. We report inter- and intra-individual differences in DOAC concentration in people with gastric surgery, to identify potential treatment options.

METHODS

Patients with previous gastric surgery receiving DOAC for AF as stroke secondary prevention, and undergoing peak-trough DOAC plasmatic testing were selected from the regional EDDIE-AF registry. DOAC levels were tested at least 75-102 h after DOAC initiation with Siemens Innovance® assays.

RESULTS

Eight patients with previous gastric surgery were included (mean age 75 years, 50% women). Overall, only 20/36 tests were within range (55.5%; apixaban 75.0%; dabigatran 0%; edoxaban 64.3%; rivaroxaban 33.3%). Rivaroxaban and dabigatran failed to reach therapeutic peak-trough concentrations. Apixaban and edoxaban reached therapeutic levels in 4/6 and 3/7 cases respectively, with marginal out-of-target concentrations in all remaining cases.

CONCLUSIONS

Our data support a consistent variability in DOAC absorption after gastric surgery, suggesting that implementation of DOAC plasmatic testing may help in ensuring therapeutic levels are met whenever DOACs are preferred over warfarin.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Prevalence and prognostic value of dementia in atrial fibrillation patients in emergency departments: Insights from a national-wide multicenter registry study

INTRODUCTION

Atrial fibrillation (AF) and dementia are two common comorbidities in emergency departments (ED) that can significantly affect patients' quality of life. The aim of this study was to evaluate the prevalence and long-term impact of dementia on survival in patients with AF.

METHODS

We conducted a multicenter prospective observational study and consecutively recruited 2016 AF patients from 20 hospitals in China. The primary endpoint was all-cause mortality and the secondary endpoint was stroke. Multivariate logistic regression and odds ratio (OR) were used to identify clinical factors associated with AF patients with dementia. Four multivariate adjusted Cox proportional hazard models were conducted to evaluate the risk factors associated with endpoints.

RESULTS

Totally, 2.2 % of AF patients were found to have dementia in ED. Older age (OR 1.05, 95 % CI 1.02-1.09, P = 0.005), coronary artery disease (OR 2.61, 95 % CI 1.21-6.05, P = 0.019), previous stroke or transient ischemic attack (TIA) (OR 5.67, 95 %CI 2.92-11.26, P < 0.001) and prior major bleeding (OR 3.89, 95 %CI 1.11-11.49, P = 0.021) were independent risk factors for patients with both AF and dementia. During one-year follow-up, Log-rank analysis presented that dementia decreased overall survival (P < 0.001) and had a higher incidence of stroke (P < 0.001). After adjusting age, body mass index, blood pressure, type of AF, comorbidities and treatments, multivariate Cox models showed that dementia was independently associated with increased mortality and increasing risk of stroke.

CONCLUSIONS

Dementia significantly affects the survival and stroke incidence in AF patients. Prioritizing cognitive function screening and comprehensive care in ED is crucial for managing AF effectively.

Non-adherence and non-persistence of Direct Oral Anticoagulants among patients with non-valvular atrial fibrillation: a French retrospective cohort study

Non-adherence and non-persistence of direct oral anticoagulants (DOAC) in patients with non-valvular atrial fibrillation remain major concerns. Most studies on non-persistence and non-adherence during the implementation phase (i.e., from the first to the last dose of DOAC) focus only on new DOAC users. We conducted a retrospective cohort study in France in 2018-2019 using the real-world THIN database to determine non-adherence during the implementation phase, non-persistence, and their associated factors among all DOAC users. Non-adherence was defined as the proportion of days covered < 80% and non-persistence as a supply gap > 30 days. Factors associated with non-adherence or non-persistence were identified using logistic regressions. We included a total of 5,059 DOAC users: 1,358 new users and 3,701 prevalent users. Non-adherence was 18.7% at 6 months and 24.2% at 1 year and non-persistence was 16.1% and 28.4%, respectively. Non-adherence was almost the same in new and prevalent DOAC users and non-persistence was slightly higher in new users. Factors associated with non-adherence and non-persistence were: age < 65 years and having < 5 comedications. Further studies will be needed to quantify the impact of non-adherence or non-persistence.

Safety and Efficacy of Factor Xa Inhibitors in Atrial Fibrillation Patients on Dialysis: Evidence from Four Randomized Controlled Trials

Atrial fibrillation (AF) is prevalent in dialysis-dependent patients, who face higher risks of thromboembolism and bleeding. Although vitamin K antagonists (VKAs) are commonly used for anticoagulation, the benefits of factor Xa (FXa) inhibitors over VKAs in this population are unclear. This systematic review aims to compare the efficacy and safety of VKAs and FXa inhibitors based on randomized controlled trials (RCTs). We conducted a systematic search of PubMed and Embase for RCTs comparing FXa inhibitors and VKAs up to November 2024. The primary safety outcome was major bleeding, and the primary efficacy outcome was stroke or systemic embolism (SSE). Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using random-effects models. This meta-analysis included 486 dialysis-dependent AF patients from 4 RCTs, with a median follow-up of 26 weeks to 1.88 years. FXa inhibitors were associated with a reduced risk of major bleeding compared to VKAs (RR = 0.64, 95% CI = 0.42-0.99; p = 0.04), but no significant difference in SSE (RR = 0.46, 95% CI = 0.20-1.02; p = 0.06). FXa inhibitors also showed a significantly lower risk of intracranial bleeding (RR = 0.40, 95% CI = 0.17-0.96; p = 0.04), but no differences in other outcomes, including gastrointestinal bleeding, hemorrhagic stroke, ischemic stroke, acute coronary syndrome, and mortality. This systematic review and meta-analysis suggest that FXa inhibitors may offer a safer alternative to VKAs for AF patients on dialysis, with a lower risk of bleeding and similar risks of stroke and mortality.

The optimal timing for initiating oral anticoagulant in ischemic stroke combined with non-valvular atrial fibrillation patients: A real-world big data analysis

Oral anticoagulants (OAC) are essential in preventing stroke recurrence in patients with ischemic stroke (IS) and non-valvular atrial fibrillation (NVAF), though they carry a bleeding risk. Balancing the benefits and risks of anticoagulant therapy and determining the optimal timing for initiation are critical. This real-world study investigated optimal timing for OAC initiation post-IS and evaluated drug selection using data from the National Health and Medical Big Data (Eastern) Center, covering IS records from 1564 hospitals in Jiangsu (2018-2021). Using 1:1 propensity score matching (PSM) and Cox model analysis, we compared outcomes between OAC initiators and non-initiators at different time points. Results showed that initiating OAC within 3 days for mild IS (HR, 0.82 [95 ​% CI, 0.71-0.94, p ​= ​0.024]), within 6 days for moderate IS (HR, 0.76 [95 ​% CI, 0.65-0.89, p ​= ​0.004]), and within 11 days for severe IS (HR, 0.89 [95 ​% CI, 0.78-0.97, p ​= ​0.032]) was associated with better outcomes. New oral anticoagulants (NOACs) demonstrated favorable effectiveness and safety profiles compared to warfarin, without increasing bleeding risk (HR, 0.85 [95 ​% CI, 0.73-0.98, p ​= ​0.038]). Based on these observational findings, we suggest considering early NOAC initiation for mild and moderate IS, while carefully assessing stroke progression and bleeding risk before anticoagulation in severe IS.

Hemostasis and Gingival Healing-Polyurethane Adhesive Postextraction Under Rivaroxaban Therapy in a Rodent Model

Objectives: At 31%, the risk of postoperative bleeding after tooth extraction is particularly high in patients who receive rivaroxaban therapy. The aim of this rodent study was to compare the hemostyptic properties and gingival healing between novel polyurethane-based adhesive VIVO and gelatin sponge (GESP) under ongoing rivaroxaban therapy over a period of 10 days. Materials: In total, 120 extractions of the first upper molar were proceeded in rodents treated with rivaroxaban. Of these, 60 postextraction sites were treated with VIVO and 60 with GESP. The duration of the surgical procedure and the clinical parameters of postoperative bleeding and wound evaluation score were recorded. In vivo fluorescence imaging and laser Doppler flowmetry and tissue spectrophotometry (LDF-TS) were performed. Results: GESP provided a faster procedure at 1:06 ± 0:17 min, but postoperative bleeding time was significantly shorter in VIVO sockets at 1:39 ± 0:03 min. Nonsignificant mild bleeding events and comparable wound evaluation scores were recorded in both treatments. LDF-TS showed a significant increase in mean oxygen saturation SO2 (%) and mean blood flow (AU) for both treatments. Only GESP showed a significant increase in relative hemoglobin (rHb). Conclusion: In the context of a rodent study, VIVO showed favorable hemostasis and promising gingival healing properties postextraction under ongoing rivaroxaban therapy.

A Saudi Heart Association Position Statement on the use of DOACs in Patients With Arterial and Venous Thrombosis

Background

Direct oral anticoagulants (DOACs) have emerged as non-inferior and effective alternatives to traditional anticoagulants in managing thromboembolic risks associated with various cardiovascular conditions. This position statement by the Saudi Heart Association (SHA) aims to provide guidance on the use of DOACs in the context of cardiovascular disease, particularly patients with arterial and venous thrombosis.

Methods

A multidisciplinary panel of experts reviewed current evidence and international guidelines on DOACs, considering the local healthcare context in Saudi Arabia. The statement addresses the initiation, maintenance, interruption, and re-initiation of DOAC therapy across different patient populations.

Results

DOACs are effective alternatives to traditional anticoagulants with a comparable or lower risk of bleeding and no requirement for frequent monitoring, making them more convenient for patients. It is important to regularly assess stroke risk (CHA2DS2-VASc score) and bleeding risk (HAS-BLED score) before initiating DOAC therapy and during the course of treatment, particularly in patients with changing clinical conditions. Specific factors warrant careful consideration for the use of DOACs in special patient populations. Recommendations are therefore provided for dosing adjustments in renal and hepatic impairment, alongside considerations for patients in different clinical scenarios such as those undergoing surgery or with malignancies.

Conclusion

DOACs represent a valuable option for clinicians owing to their efficacy, safety and convenience compared to traditional anticoagulants. DOACs should be used based on individualized patient assessment, particularly regarding bleeding risk, stroke risk, and other comorbidities and clinical factors that may affect clinical outcomes. Adherence to the recommendations and guidance provided in this SHA statement is needed to enhance patient care and outcomes in Saudi Arabia.

Biological Variation of Hemostasis Analytes in Atrial Fibrillation Patients Using Dabigatran

BACKGROUND

Analytical criteria for laboratory analysis based on biological variation are considered state-of-the-art. While biological variance should ideally be measured in patient populations for whom the tests are relevant, data are mostly only available from healthy individuals. We determined the biological variance of activated partial thromboplasmin time (APTT), prothrombin time (PT), fibrinogen, and trough dabigatran levels in patients with atrial fibrillation (AF) who were treated with dabigatran.

METHODS

Between 2019 and 2022, patients with AF treated >3 months with dabigatran were included. Blood was collected monthly up to 10 times for the measurement of APTT, PT, fibrinogen, and trough dabigatran levels. Between-subject variance (CVG), within-subject variance (CVI), and analytical variance (CVA) were calculated.

RESULTS

Eighteen participants (median age 65.8 years, 22.2% women) were included, with 130 samples in total. For APTT, the CVG was 11.5%, the CVI 8.8%, and the CVA 1.1%. For PT, these values were 5.2%, 4.0%, and 1.0% and for fibrinogen 13.6%, 11.8%, and 1.6%, respectively. For the dabigatran levels, the percentages were 37.9%, 33.0%, and 3.4%, respectively.

CONCLUSIONS

We assessed the biological variance of APTT, PT, fibrinogen, and dabigatran in a patient population with long-term dabigatran use. The analytical performances of coagulation laboratory tests in patients with AF treated with dabigatran were comparable to those in healthy volunteers.CCMO Registration Number: NL67304.078.18.

Comparison of Risk-Scoring Models to Predict Gastrointestinal Bleeding in Patients With Direct Oral Anticoagulants

BACKGROUND AND AIM

The risk of gastrointestinal bleeding (GIB) remains a concern with the use of direct oral anticoagulants (DOAC). We evaluated the efficacy of four risk-scoring models (HAS-BLED, ATRIA, VTE-BLEED, and ORBIT) in predicting GIB according to the concomitant use of antiplatelet therapy in DOAC users.

METHODS

Patients prescribed DOAC between December 2014 and October 2020 were enrolled in two university-affiliated hospitals. The performance of the four models was compared based on the concomitant use of antiplatelet therapy. The primary outcomes were likelihood ratios and the area under the receiver operating characteristic (AUROC) curve to predict GIB.

RESULTS

A total of 4494 patients were included in the study. The AUROC values for the entire cohort were 0.643 (95% CI: 0.601-0.686) for HAS-BLED, 0.693 (95% CI: 0.649-0.737) for ATRIA, 0.708 (95% CI: 0.665-0.750) for VTE-BLEED, and 0.709 (95% CI: 0.667-0.751) for ORBIT. The AUROC for all scoring models increased in patients without antiplatelet therapy compared to the entire cohort and patients with antiplatelet therapy. The specificity and diagnostic accuracy for all scoring models increased in patients without antiplatelet therapy compared to patients with antiplatelet.

CONCLUSIONS

Our results confirmed that current risk-scoring models for predicting GIB perform better in patients without antiplatelet therapy than in those on concomitant antiplatelet therapy. This suggests that future risk prediction models should consider the concomitant use of antiplatelet therapy for diagnostic accuracy.

Increasing Very Low-Dose Edoxaban Prescription: Effectiveness and Safety Data of Korean AF Patients

BACKGROUND AND OBJECTIVES

Evidence remains limited on the real-world prescription of very low-dose oral anticoagulation among frail patients with atrial fibrillation (AF). We described the practice patterns, effectiveness, and safety of very low-dose edoxaban (15 mg once daily).

METHODS

Patients with AF prescribed edoxaban 15 mg once daily in 2 tertiary hospitals between 2016 and September 2022 were included. Baseline clinical characteristics and clinical outcomes of interest were thromboembolic and bleeding events.

RESULTS

A total of 674 patients were included (mean age 78.3±9.1, 49.7% aged ≥80 years, 49.3% women, median follow-up 1.0±1.2 years). Mean CHA2DS2-VASc score was 3.9±1.6, and the modified HAS-BLED score was 2.0±1.1. Between 2016 and 2022, the number of very low-dose edoxaban prescriptions increased. The main reasons for the prescription of very low-dose were low body weight (55.5% below 60 kg), anaemia (62.8%), chronic kidney disease (40.2%), active cancer (15.3%), concomitant anti-platelet use (26.7%), and prior major bleeding (19.7%). During a median follow-up duration of 8 (interquartile range 3-16) months, overall thromboembolic and bleeding events occurred in 16 (2.3%) and 88 (13.1%) patients, respectively. Compared to the expected event rates on the established risk scoring systems, patients receiving very low-dose edoxaban demonstrated a 61% reduction in ischemic stroke, a 68% reduction of ischemic stroke/transient ischemic attack/systemic embolism, whereas a 49% increase in major bleeding.

CONCLUSIONS

The prescription of very low-dose edoxaban was increased over time, attributable to various clinical factors. The use of very low-dose edoxaban reduced the expected risk of thromboembolic events.

Anticoagulants: From chance discovery to structure-based design

Taking a historical perspective, we review the discovery, pharmacology, and clinical evaluation of the old and new anticoagulants that have been approved for clinical use. The drugs are discussed chronologically, starting in the 1880s, and progressing through to 2024. The innovations in technology used to develop novel anticoagulants came in fits and starts and reflected the advances in science and technology over these decades, whereas the shift from anecdote to evidence-based use of anticoagulants was delayed until the principles of epidemiology and biostatistics were introduced into clinical trial design and to the approval process. Hirudin, heparin, and vitamin K antagonists were discovered by chance, and were used clinically before their mechanism of action was elucidated and before their net clinical benefits were evaluated in randomized clinical trials. Subsequent anticoagulants were designed based on a better understanding of the structure and function of coagulation proteins, including antithrombin, thrombin, and factor Xa, and underwent more rigorous preclinical and clinical evaluation before regulatory approval. By simplifying oral anticoagulation, the direct oral anticoagulants have revolutionized anticoagulation care and have enhanced the uptake of anticoagulation, but bleeding has not been eliminated and there is a need for more effective and convenient anticoagulants for thrombosis triggered by the contact pathway of coagulation. The newly developed factor XIa and XIIa inhibitors have the potential to address these unmet clinical needs and are undergoing clinical evaluation for several indications. SIGNIFICANCE STATEMENT: Anticoagulant therapy is the cornerstone of treatment and prevention of thrombosis, which remains a leading cause of morbidity and mortality worldwide. Elucidation of the structure and function of coagulation enzymes, their cofactors, and inhibitors, coupled with advances in structure-based design led to the discovery of more convenient, safer, and more effective anticoagulants that have revolutionized the management of thrombotic disorders.

Use of Direct Anticoagulants in Kidney Transplant Recipients: Review of the Current Evidence and Emerging Perspectives

Thromboembolic events and atrial fibrillation are common among kidney transplant recipients (KTRs), and these conditions typically require anticoagulation. Traditionally, vitamin K antagonists were used for management, but the use of direct oral anticoagulants (DOACs) has increased in KTRs. In the general population, DOACs are recommended over warfarin, but the applicability of these recommendations to KTRs is unclear because of risk-benefit concerns. There is some hesitancy to use DOACs in KTRs because of their dependence on renal clearance for elimination, potential drug-drug interactions, and limited data. To date, studies of DOACs in KTRs have demonstrated that they are efficient in thromboembolic events, major bleeding is rare, and drug-drug interactions appear rare. However, no guidance yet exists about the use of DOACs, reversal of DOAC action, and the pre- and post-kidney transplant management of DOACs in KTRs, and the evidence base is scarce. Thus, decisions on DOAC use in KTRs are based on expert opinion and the resources and experiences of individual transplant centers. This review summarizes 10 published studies on the use of DOACs in 741 KTRs, evaluating the side effects, efficacy, drug-drug interactions, and perioperative management compared with those of 1320 KTRs using vitamin K antagonists. Although current data are limited, DOACs appear to be relatively safe and effective in KTRs, with some studies suggesting lower bleeding rates and better kidney function than with vitamin K antagonists. However, more research with larger patient groups is needed to draw definitive conclusions.

Part 1: Management of antithrombotic medications in dermatologic surgery

Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic adverse events including cerebrovascular accidents, myocardial infarction, pulmonary embolism, deep vein thrombosis, and retinal artery occlusion. Conversely, continuation of antithrombotic therapy during surgical procedures has associated bleeding risks. Currently, no guidelines exist regarding management of antithrombotic agents in the perioperative period for cutaneous surgeries and practice differs by surgeon. Here, we review the data on antithrombotic medications in patients undergoing cutaneous surgery including medication-specific surgical and postoperative bleeding risk if the medications are continued, and thromboembolic risk if the medications are interrupted. Specifically, we focus on vitamin K antagonist (warfarin), direct-acting oral anticoagulants (rivaroxaban, apixaban, edoxaban, dabigatran), antiplatelet medications (aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole), unfractionated heparin, low molecular weight heparin (enoxaparin and dalteparin), fondaparinux, bruton tyrosine kinase inhibitors (ibrutinib, acalabrutinib), and dietary supplements (ie, garlic, ginger, gingko).

Early vs later non-vitamin K antagonist oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation: A meta-analysis and systematic review of randomized trials

BACKGROUND

There are conflicting published data on the optimal timing of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with acute ischemic stroke.

OBJECTIVE

To compare the efficacy and safety of early initiation of NOACs with later initiation of NOACs in those patients, we conducted a meta-analysis of phase 3 or phase 4 randomized controlled trials.

METHODS

We systematically searched the Cochrane Library, PubMed, and Embase databases. A random effects model was selected to pool the effect measurement estimates (risk ratios [RRs] and 95% confidence intervals [CIs]).

RESULTS

Three randomized controlled trials with 6442 enrolled patients with AF and acute ischemic stroke were included. Compared with later NOAC therapy, early NOAC therapy was associated with nonsignificant reductions in the risk of primary outcomes (RR, 0.82; 95% CI, 0.65-1.05). Subgroup analysis found that in reducing risk of primary outcomes, early anticoagulation may benefit female patients more than male patients (0.54 [0.35-0.83] vs 0.97 [0.63-1.50]; P for interaction, .06). Numerically lower rates of recurrent ischemic stroke (RR, 0.80; 95% CI, 0.56-1.15), death (RR, 0.96; 95% CI, 0.81-1.15), and systemic embolism (RR, 0.43; 95% CI, 0.16-1.11) were observed in early initiation of NOACs in comparison with later initiation of NOACs. There was no difference in major bleeding (RR, 0.98; 95% CI, 0.55-1.74), symptomatic intracranial hemorrhage (RR, 0.93; 95% CI, 0.43-1.96), or major extracranial bleeding (RR, 0.73; 95% CI, 0.28-1.95) between groups.

CONCLUSION

In AF patients with acute ischemic stroke, early initiation of NOACs is not inferior to later initiation of NOACs in reducing composite events, without increased hazard of bleeding, especially in female patients.

Management of heart disease in renal transplant recipients: a national Delphi survey-based SET/SEC/SEN consensus document

Renal transplantation improves the survival and quality of life of patients with end-stage renal disease. Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients. The bidirectional relationship between renal and heart disease creates a unique clinical scenario that demands a comprehensive and personalized approach. This expert consensus, drafted by the Spanish Society of Transplantation, the Spanish Society of Cardiology, and the Spanish Society of Nephrology, aims to assess current practices and propose strategies for the management of heart disease in renal transplant recipients. A panel of Spanish nephrologists and cardiologists with expertise in renal and heart transplantation reviewed the scientific evidence concerning the current management of heart disease in renal transplant recipients. Subsequently, consensus statements were created through a 2-round Delphi methodology, resulting in 30 statements covering key topics such as the identification of renal transplant candidates, the management of heart disease in renal transplant recipients, and eligibility for combined heart-kidney transplantation in patients with both end-stage renal disease and cardiac disease. These consensus statements provide expert guidance for the management of heart disease in renal transplant recipients, an area where published clinical evidence remains limited.

Plasma Concentrations of Direct Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation and Different Degrees of Obesity

BACKGROUND

Atrial fibrillation (AF) has multiple cardio-metabolic comorbidities, including obesity. The use of direct oral anticoagulants (DOACs) in patients with AF and obesity is still uncertain owing to the concern of possible ineffective DOAC plasma concentration. We evaluated the peak and trough plasma concentrations of DOACs in AF patients with different degrees of obesity.

METHODS

Observational single-center study including patients with obesity and AF, between April 2022 and April 2024. Obesity was defined as body mass index (BMI) ≥ 30.0 kg/m2. The 2-hour peak and trough DOAC plasma concentrations were assessed. Intake of DOAC was verified on site. Multivariable logistic regression analysis was used to assess the odds ratio (OR) and 95% confidence interval (95% CI) of factors associated with below-range trough concentration (BRTC) and below-range peak concentration (BRPC).

RESULTS

In total, 160 patients (33.8% women) with a mean age of 73.2 ± 9.1 years were included. The median BMI was 32.3 kg/m2. DOACs prescribed were apixaban (46.8%), rivaroxaban (21.8%), dabigatran (16.4%), and edoxaban (15.0%); 18.1% and 14.4% had BRTC and BRPC concentrations, respectively. Patients with BRTC were more frequently treated with edoxaban and dabigatran and had a higher BMI. On multivariable logistic regression analysis, dabigatran [hazard ratio (HR) 3.039, 95% CI 1.155-7.999, p = 0.024) and BMI ≥ II class (OR 2.625, 95% CI 1.087-6.335, p = 0.032] were associated with BRTC. Dabigatran (OR 4.296, 95% CI 1.523-12.120, p = 0.006) and apixaban (OR 0.277, 95% CI 0.096-0.802, p = 0.018) were directly and inversely associated with BRPC, respectively.

CONCLUSIONS

A nonnegligible proportion of patients with obesity and AF have below-range plasma concentrations of DOACs. Assessment of DOAC plasma concentration in obesity class ≥ II may be useful in these patients.

Effectiveness and Safety in Patients with Non-Valvular Atrial Fibrillation Who Switched from Warfarin to Direct Oral Anticoagulants in Medicare Population

INTRODUCTION

Atrial fibrillation (AF), a common heart rhythm abnormality, is linked to a higher risk of stroke. Traditionally, warfarin has been the primary anticoagulation treatment for reducing the stroke risk. The new standard of treatment by direct oral anticoagulants (DOACs) offers greater benefits including improved efficacy and fewer adverse effects with reduced monitoring. This study aims to evaluate the risk of stroke/systemic embolism (SE) and major bleeding (MB) among patients with AF who switched from warfarin to DOACs.

METHODS

This study utilized Medicare data to conduct a retrospective analysis of patients with non-valvular atrial fibrillation (NVAF) who switched from warfarin to DOACs between January 1, 2012, and December 31, 2019. Patients with NVAF aged 65 and older who switched from warfarin and had continuous health plan enrollment were included. Descriptive statistics, propensity score matching (PSM), and Cox proportional hazard (PH) models were utilized to compare the outcomes and assess risks of SE and MB across the DOAC cohorts.

RESULTS

Among 1,843,495 patients with NVAF on warfarin, 171,700 switched to DOACs within 90 days of discontinuation (apixaban: 90,850; rivaroxaban: 67,698; dabigatran: 12,900). The mean follow-up period across DOAC cohorts ranged from 552 to 628 days. After PSM, apixaban showed significantly lower rates of stroke/SE compared to dabigatran (2.99% vs. 3.98%, p < 0.0001) and rivaroxaban (3.08% vs. 3.80%, p < 0.0001). MB rates were also lower with apixaban versus dabigatran (4.29% vs. 5.57%, p < 0.0001) and rivaroxaban (4.07% vs. 6.35%, p < 0.0001). Cox PH models confirmed these findings, with apixaban demonstrating lower risks of stroke/SE [hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.72-0.96 vs. dabigatran; HR 0.91, 95% CI 0.85-0.96 vs. rivaroxaban] and MB (HR 0.79, 95% CI 0.71-0.89 vs. dabigatran; HR 0.68, 95% CI 0.65-0.72 vs. rivaroxaban).

CONCLUSION

The risk of stroke/SE and MB varies significantly among patients with NVAF switching from warfarin to different DOACs, with apixaban presenting the lowest risk compared to dabigatran and rivaroxaban.

Cardiology involvement and mortality in adult patients with advanced solid cancer complicated by atrial fibrillation

BACKGROUND

The association between comorbid atrial fibrillation (AF) and survival in adult patients with advanced solid cancer, as well as the impact of cardiology involvement in such patients, remains unclear.

METHODS

This retrospective cohort study included adult patients diagnosed with advanced solid cancers. We calculated prevalence of AF in different cancer types and compared all-cause mortality between patients with and without AF. We further examined the association between cardiology involvement and mortality in the subset of participants with AF.

RESULTS

Among the 1,349 adult patients with advanced solid cancer, 122 (9.0%) had AF. The risk of AF was the highest in lung and mediastinal cancer (15.6%). AF was associated with higher all-cause mortality, which became neutral after adjustment for age, sex, comorbidities, cancer types and cancer treatments (crude hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.11-1.75, p =  0.004; adjusted HR 1.08, 95%CI 0.84-1.39, p =  0.552). In those with AF, cardiology involvement was independently associated with lower all-cause mortality (age, sex, comorbidities, cancer types and cancer treatments-adjusted HR 0.50 [95%CI 0.28-0.88], p =  0.017), though the cumulative incidence of neither cardiovascular nor non-cardiovascular death differed significantly between patients who received cardiology care and those who did not.

CONCLUSIONS

In adult patients with advanced solid cancer, AF per se was not independently associated with increased mortality. Cardiology involvement in patients with advanced solid cancer and AF was linked to a better overall survival, but with low certainty that this finding is not attributable to unmeasured confounding.

Clinical and Economic Impact of a First Major Bleeding Event in Non-Anticoagulated Patients in Spain: A 3-Year Retrospective Observational Cohort Study

Objective: To analyze clinical characteristics of non-anticoagulated subjects with major bleeding, and to determine the incidence of adverse events, healthcare resource utilization (HCRU) and associated costs following a major bleeding event. Methods: Retrospective observational cohort study that analyzed secondary data from electronic health records in Spain. Non-anticoagulated patients with a first major bleeding during the study period (between January 2013 and December 2022) were analyzed for 3 years. Results: A total of 4089 patients (mean age 57.26 (12.87) years, 58.47% female) were included. A proportion of 27.63% presented with genitourinary bleeding, 22.43% with gastrointestinal bleeding, 5.16% with respiratory bleeding and 3.11% with intracranial hemorrhage. At the end of the first major bleeding event, 0.56% of patients died (5.51% after intracranial hemorrhage, 3.23% in case of trauma-related bleeding). The incidence rates of clinical outcomes per 100 person-years within the first 3 months of the major bleeding were death from any cause 7.51 (95% CI 6.70-8.32), cardiovascular death 1.80 (95% CI 1.39-2.21), acute myocardial infarction 4.53 (95% CI 3.89-5.17), and ischemic stroke 3.52 (95% CI 2.96-4.08), and decreased over time. At year 3, mean overall major bleeding cost per patient was EUR 13,310.00 (5153.05), of which EUR 7648.20 (2674.46) (57.46%) accounted for in-hospital costs to treat the major bleeding event. Conclusions: Among non-anticoagulated patients presenting with a first major bleeding, <1% of patients died during index hospitalization. However, these patients had a substantial risk of adverse clinical events during the follow-up, as well as high associated HCRU and costs.

Outcomes and Disease Management in Patients With Atrial Fibrillation ≥80 Years: Data From a Consecutive 11-Year Real-World Registry

BACKGROUND

As the population ages, atrial fibrillation (AF) prevalence increases, but data on optimal oral anticoagulation (OAC) in patients ≥80 years remain limited. This study tested whether direct OACs offer comparable benefits to vitamin K antagonists in patients ≥80 years with AF presenting to the emergency department.

METHODS

This single-center retrospective all-comer study used data from the Heidelberg Registry of Atrial Fibrillation, including patients with AF presenting to the emergency department of the University Hospital of Heidelberg from June 2009 until March 2020. Data were analyzed by age for outcomes and risk factors for predefined end points.

RESULTS

Patients ≥80 years comprised 32.2% of AF cases. Hazard ratios (HRs) for the primary end point (all-cause mortality, stroke, or myocardial infarction) and secondary end point (including major bleeding) were 3.09 (95% CI, 2.73-3.21) and 2.96 (95% CI, 2.73-3.21) for patients ≥80 years, compared with younger patients. Anticoagulation rates were slightly lower in patients ≥80 years (67.9% versus 70.5%, P=0.0070). OAC use, particularly the use of direct OACs, increased over time. Patients ≥80 years without OACs had higher HRs for primary (3.48 [95% CI, 3.07-3.94]) and secondary end points (3.23 [95% CI, 2.86-3.64]) compared with those with OACs. Vitamin K antagonist use was linked to higher HR for stroke or major bleeding events (HR, 1.25 [95% CI, 1.05-1.50]), rising to 1.64 (95% CI, 1.34-2.01) after excluding reduced direct OAC doses.

CONCLUSIONS

Our data highlight patients ≥80 years as an important and vulnerable subpopulation of patients with AF, where evidence for optimal OAC therapy remains conflicting.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05995561.

Hypertrophic cardiomyopathy and atrial fibrillation: the Cardiomyopathy/Myocarditis Registry of the EURObservational Research Programme of the European Society of Cardiology

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is commonly associated with atrial fibrillation (AF), but its impact on outcomes in real-world practice is uncertain. The aim of the study was to evaluate the clinical profile and prognosis of patients with HCM and AF.

METHODS

Overall, 1739 adult patients with HCM (40.9% women; median age: 55.5 years) were enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy/Myocarditis Registry. Clinical characteristics at baseline and cardiovascular endpoints at 1 year were prospectively assessed.

RESULTS

At baseline, AF was present in 478 (27.5%) patients; an additional 48 patients (2.8%) developed AF at 1-year follow-up. Oral anticoagulants (OAC) were administered at baseline in 69.5% of the patients. Patients with AF were older and more symptomatic, had higher body mass index, more prevalent cardiovascular risk factors, a history of sustained ventricular tachycardia and implantable cardioverter-defibrillator, lower left ventricular ejection fraction (LVEF), larger left atria (LA) and more advanced LV diastolic dysfunction (pp<0.001 for all). Age at enrolment (OR=1.068, p<0.001), symptom: palpitations (OR=2.191, p<0.001), LVEF (OR=0.978, p<0.001) and LA diameter (OR=1.094, p<0.001) were independent predictors of AF in HCM population. Patients with AF had a higher annual incidence of stroke/transient ischaemic attack (2.6 vs 0.9%, p=0.009) and a trend towards increased all-cause mortality in comparison to the non-AF cohort (3.4 vs 1.7%, p=0.053).

CONCLUSIONS

AF affects nearly one-third of patients with HCM and is associated with higher symptom burden, increased prevalence of comorbidities, myocardial remodelling and increased annual risk of cerebral ischaemic events. In spite of this, the utilisation of OAC was suboptimal.

Increased Mortality Associated with Amiodarone Compared to Other Antiarrhythmic Drugs in New-Onset Atrial Fibrillation

Background and Aims: Antiarrhythmic drugs (AADs) are the primary treatment for maintaining sinus rhythm in patients with atrial fibrillation (AF). While amiodarone is mainly used in patients with structural heart disease, its effects on all-cause mortality compared to other AADs remain unclear. Methods: This study utilized nationwide healthcare insurance data involving patients with new-onset AF from 2013 to 2019. We identified patients who were prescribed with AADs ≥ six months within the first year of diagnosis (medication possession ratio ≥ 0.5). All-cause mortality was assessed between amiodarone and other AAD users up to three years post-AAD-prescription. Results: Among 770,977 new-onset AF patients, 12,243 were amiodarone users and 33,036 were prescribed with other AADs. Significant differences in mean age and prevalence of medical conditions such as heart failure, myocardial infarction, chronic kidney disease, diabetes, and dyslipidemia were noted. After propensity score matching, 12,017 amiodarone users were compared to an equal number of other AAD users with similar baseline characteristics. Multivariate analysis indicated a 2.9-fold increase in all-cause mortality for amiodarone users (hazard ratio = 2.88; 95% confidence interval = 2.64-3.15; p < 0.001). This increased risk was more pronounced among women compared with men (hazard ratio = 3.38 vs. 2.56; p for interaction = 0.004). Amiodarone was associated with increased mortality in AF patients with heart failure and myocardial infarction. Conclusions: Amiodarone, compared with non-amiodarone AADs, was associated with increased risk of all-cause mortality in AAD-naive new-onset AF patients. Increased all-cause mortality associated with amiodarone was consistent throughout various subgroups. Significant interaction was observed with the sex category, with women being more vulnerable to amiodarone.

Direct oral anticoagulant use in oral surgery: insights from a systematic review

PURPOSE

The increasing use of direct oral anticoagulants (DOACs) in patients undergoing oral surgery highlights the need for well-defined, evidence-based recommendations on perioperative and postoperative bleeding management. This review aims to evaluate bleeding risks and strategies to optimize the management of patients treated with DOACs undergoing oral surgical procedures.

METHODS

A systematic review identified 628 articles, of which 17 met the inclusion criteria. These studies focused exclusively on patients treated with DOACs-Dabigatran, Rivaroxaban, Apixaban, and Edoxaban-undergoing oral surgical procedures, such as tooth extractions, dental implants, and soft tissue surgical procedures. Articles involving other anticoagulants or combined therapies were excluded to ensure precision in evaluating DOAC-specific outcomes.

RESULTS

The findings revealed that minor to moderate bleeding events were relatively common, while severe bleeding requiring hospitalization was rare. Bleeding events were effectively managed using standard local hemostatic measures in most cases. This review highlights the importance of scheduling procedures when DOAC levels are at their lowest, as this minimizes the risk of excessive bleeding. Furthermore, the continuation of DOAC therapy during oral surgery was deemed safe, with effective local management strategies mitigating bleeding risks.

CONCLUSION

This review offers practical, evidence-based recommendations for the management of patients on DOAC therapy undergoing oral surgical procedures. The findings simplify clinical decision-making and improve patient safety by emphasizing the importance of timing and perioperative strategies. The exclusive focus on DOACs underscores the clinical significance of this work in guiding oral and maxillofacial surgeons.

A Pilot Study to Evaluate an International Normalized Ratio-Derived Formula in Combination with Heparin-Calibrated Anti-Xa Activity in Calculating a Plasma Edoxaban Level

Introduction: A drug-specific chromogenic assay is not immediately available, so it hampers the treatment of patients who present in a clinical emergency. In this pilot study, we aimed to create a formula to predict a plasma edoxaban level based on the international normalized ratio (INR) and heparin-calibrated anti-Xa activity and derive a novel workflow for routine laboratory diagnosis. Method: Forty-two patients prescribed edoxaban were recruited and randomized to a testing or validation cohort. Plasma levels from the testing cohort were used to create a prediction formula that was then validated in a validation cohort and real-world clinical requests. Results: The INR-derived formula had high sensitivity (95.8-100%) to predict the plasma edoxaban level > 50 ng/mL and >100 ng/mL but with low specificity. However, the specificity of predicting the plasma edoxaban level of ≥100 ng/mL was 100% by using an INR ≥ 1.5 as cut-off. Heparin-calibrated anti-Xa-derived formula had a high sensitivity (90.9-100%) and specificity (93.8-100%) in real clinical situations. A two-tier approach of combining INR-derived and heparin-calibrated anti-Xa-derived formulae can overcome the low specificity and utilize the advantages of wide availability and a short turnaround time of the INR-derived formula. Conclusions: Both INR-derived and heparin-calibrated anti-Xa-derived formulae can be applied to calculate the plasma edoxaban level. A two-tier workflow of combining these two formulae greatly helps streamline the treatment of patients prescribed edoxaban who present in a clinical emergency. Adoption of this framework is feasible for routine diagnostic laboratories.

Prothrombin complex concentrate for reversal of oral anticoagulants in patients with oral anticoagulation-related critical bleeding: a systematic review of randomised clinical trials

BACKGROUND

Swift reversal of oral anticoagulation is deemed essential for the outcome of patients with anticoagulation-related critical bleeding. The aim of this systematic review was to evaluate the benefits and harms of prothrombin complex concentrate (PCC) in patients with oral anticoagulants-related critical bleeding.

METHODS

For this systematic review CENTRAL, MEDLINE, Embase, LILACS, BIOSIS, Web of Science, and clinical trial registries were systematically searched. Clinical study reports were also requested from competent authorities. Eligible for inclusion were randomised clinical trials comparing PCC versus no intervention, placebo, or other reversal interventions in participants with critical bleeding related to ongoing treatment with vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC). Pre-specified primary outcomes were all-cause mortality, health-related quality of life, and serious adverse events for which meta-analyses, Trial Sequential Analysis, and GRADE assessments were conducted.

RESULTS

Three trials, randomising a total of 291 participants, evaluated PCC against two different active comparators in participants with VKA-related critical bleeding, and two trials, randomising a total of 534 participants, evaluated PCC against two different active comparators in participants with factor Xa-related critical bleeding. Among participants with VKA-related critical bleeding, meta-analyses showed no evidence of a difference between PCC versus fresh frozen plasma (FFP) when assessing all-cause mortality (risk ratio [RR] 1.05; 95% confidence interval (CI) 0.27 to 4.05; low certainty), health-related quality of life (mean difference 1.04; 95% CI - 0.94 to 3.02; very low certainty), and serious adverse events (RR 1.33; 95% CI 0.94 to 1.88; very low certainty), but information is currently sparse. Among participants with factor Xa-related critical bleeding, PCC could not be shown superior or inferior to other reversal strategies (FFP or andexanet alfa) on any patient-relevant outcome, but information is currently sparse.

CONCLUSION

Among participants with VKA or DOAC-related critical bleeding, evidence from randomised clinical trials is currently insufficient to establish if PCC is superior or inferior versus other interventions in decreasing the risk of undesirable patient-relevant outcomes or improving health-related quality of life.

Perioperative Factor Xa Inhibitor Discontinuation for Patients Undergoing Procedures With Minimal or Low Bleeding Risk

Importance

Discontinuation of oral anticoagulant treatment is common in clinical practice due to concerns about bleeding, even for procedures with minimal to low bleeding risk.

Objective

To explore whether perioperative discontinuation of factor Xa inhibitors is associated with major bleeding and thromboembolic events in patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk.

Design, Setting, and Participants

This prospective, multicenter, single-arm cohort study conducted in Korea included patients with AF who planned to undergo a procedure with minimal to low bleeding risk between September 25, 2020, and April 5, 2024.

Exposure

The PERIXa (Perioperative Factor Xa Inhibitor Discontinuation in Patients With Atrial Fibrillation Undergoing Minimal to Low Bleed Risk Procedures) protocol recommending giving the last dose of factor Xa inhibitor (ie, apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure (ie, endoscopy, dental procedure, or ocular surgery) and restarting treatment with the inhibitor the next day.

Main Outcomes and Measures

The primary outcome was major bleeding, and the secondary outcome included a composite of thromboembolic events 30 days after the index procedure with minimal to low bleeding risk.

Results

In total, 1902 patients were included in the modified intention-to-treat analysis set encompassing all patients who underwent the intended procedure (mean [SD] age, 70.4 [8.8] years; 1135 [59.7%] male; mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex; range, 0-9, with higher scores indicating higher risk of stroke] score, 2.8 [1.3]; mean [SD] HAS-BLED [hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65 years, and drug or alcohol use; range, 0-9, with higher scores indicating higher risk of bleeding] score, 1.6 [0.7]). Among them, 921 (48.4%) were receiving apixaban, 616 (32.4%) were receiving edoxaban, and 365 (19.2%) were receiving rivaroxaban. Of the total procedures, 948 (49.8%) were endoscopy, 820 (43.1%) were dental procedures, and 120 (6.3%) were ocular surgery. The 30-day event rate of major bleeding was 0.1% (n = 2), and there were no composite thromboembolic events. The results were consistent in the per-protocol analysis, and no differences were observed by procedure category or factor Xa inhibitor type.

Conclusions and Relevance

In this cohort study, patients with AF receiving a factor Xa inhibitor and undergoing a procedure with minimal to low bleeding risk had low rates of major bleeding and thromboembolism when following the standardized PERIXa protocol for perioperative management of oral anticoagulant treatment, suggesting that this may be a safe and reasonable option for this patient population.

Drug-Drug Interactions Between DAAs and Anticoagulants or Antiplatelets: A Position Paper of the Italian Anticoagulation Clinics

The natural history of chronic hepatitis C virus (HCV) infection has changed after the introduction of direct-acting antiviral agents (DAAs). Screening programs have been ongoing to reach the World Health Organisation's goal of HCV elimination by 2030, and most infected people are eligible for treatment. Given the increased cardiovascular risk in people with HCV infection and the metabolic pathways of DAAs, it is not uncommon to face the issue of drug-drug interactions (DDIs) with antiplatelet or anticoagulant drugs. In the absence of clinical trials, we offer suggestions to deal with DDIs in case of treatment of patients with DAAs who are also receiving antiplatelet or anticoagulant drugs, based on the best available evidence from pharmacodynamics and pharmacokinetics studies in conjunction with clinical experience in the field of haemostasis and thrombosis.

A Real-World, Prospective, Observational Study of Rivaroxaban on Prevention of Stroke and Non-Central Nervous Systemic Embolism in Renally Impaired Korean Patients With Non-Valvular Atrial Fibrillation: XARENAL

BACKGROUND AND OBJECTIVES

Several real-world studies have been done in patients with nonvalvular atrial fibrillation (NVAF); however, information on its safety profile in patients with renal impairment is limited. XARENAL, a real-world study, aimed to prospectively investigate the safety profile of rivaroxaban in patients with NVAF with renal impairment (creatinine clearance [CrCl], 15-49 mL/min).

METHODS

XARENAL is an observational single-arm cohort study in renal impairment NVAF patients. Patients were followed up approximately every 3 months for 1 year or until 30 days following early discontinuation. The primary endpoint was major bleeding events. All adverse events, symptomatic thromboembolic events, treatment duration, and renal function change from baseline were the secondary endpoints.

RESULTS

XARENAL included 888 patients from 29 study sites. Overall, 713 (80.3%) had moderate renal impairment (CrCl, 30-49 mL/min), and 175 (19.7%) had severe renal impairment (CrCl, 15-29 mL/min) with a mean estimated glomerular filtration rate (eGFR) of 45.2±13.0 mL/min/1.73 m². The mean risk scores were 3.3±1.4 and 1.7±0.9 for CHA₂DS₂-VASc score and HAS-BLED score, respectively. An incidence proportion of 5.6% (6.2 events per 100 patient-years) developed major bleeding; however, fatal bleeding occurred in 0.5% (0.5 events per 100 patient-years). The mean change in the eGFR was 2.22±26.47 mL/min/1.73 m² per year.

CONCLUSIONS

XARENAL observed no meaningful differences in major bleeding events from other previous findings as well as renal function changes in rivaroxaban-treated NVAF patients with renal impairment, which is considered to be acceptable in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03746301.

Direct Oral Anticoagulants Versus Vitamin K Antagonists in Chronic Kidney Disease Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Chronic kidney disease (CKD) complicates anticoagulation in transcatheter aortic valve replacement (TAVR) patients in some cases. The aim of this review was to compare the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in this group. We conducted a meta-analysis of 13 studies (32,508 patients) from databases like PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, and Cochrane Library up to September 2024, focusing on all-cause mortality and major bleeding as primary outcomes, with stroke and intracranial hemorrhage as secondary outcomes. DOACs were found associated with reduced mortality (risk ratio (RR): 0.90, 95%CI: 0.81-0.99, p=0.04), particularly in moderate CKD (RR: 0.94, 95%CI: 0.90-0.98, p=0.01). Major bleeding was significantly lower with DOACs in moderate CKD (RR: 0.70, 95%CI: 0.50-0.98, p=0.03), alongside decreased stroke (RR: 0.42, 95%CI: 0.18-0.97) and intracranial hemorrhage (RR: 0.58, 95%CI: 0.36-0.94). DOACs demonstrate superior efficacy in reducing mortality and comparable safety to VKAs in CKD patients post TAVR, especially in moderate CKD. These findings advocate for DOACs as a preferable anticoagulation strategy, with cautious application in severe CKD pending further research.

Renal function and adverse clinical events in anticoagulated patients with atrial fibrillation: insights from the GLORIA-AF Registry Phase III

Renal function, assessed by creatinine clearance (CrCl), affects the efficacy and safety of oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). To investigate the association between CrCl and the risk of clinical adverse events and compare the safety profiles of vitamin K antagonists (VKA) and non-vitamin K antagonist oral anticoagulants (NOAC). Patients with newly diagnosed AF (< 3 months before baseline visit) were collected from the prospective Global Registry on Long-Term Oral Anti-Thrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) registry Phase III. Clinical events assessed included the composite outcome (all-cause death, thromboembolism, and major bleeding), cardiovascular (CV) death, myocardial infarction (MI), and other single outcomes. 10,594 AF patients (mean age 70.35 ± 9.92 years; 55% male; 73% on NOAC) were included. Increasing CrCl was associated with decreased risks of all cause death, composite outcomes and CV-death with in patients with CrCl < 80 mL/min. Multivariate Cox models indicated that compared to VKA, NOAC was associated with lower risks of all cause death (adjusted hazard ratio [aHR] 0.68, 95% CI 0.58-0.78), composite outcomes (aHR 0.77, 95% CI 0.69-0.86), CV-death (aHR 0.70, 95% CI 0.56-0.87), and major bleeding (aHR 0.74, 95% CI 0.61-0.91) in AF patients. For CrCl < 30 mL/min, lower risks of all-cause death, composite outcomes and CV death were related to NOAC therapy. In this large prospective global registry, NOACs were associated with better outcomes compared with VKA for patients with normal or impaired renal function.

Impact of Banhabaekchulcheonmatang (Banxia Baizhu Tianma Tang) and Hwangryeonhaedoktang (Huang Lian Jie Du Tang) on edoxaban: Herb-drug interaction study in healthy subjects

ETHNOPHARMACOLOGICAL RELEVANCE

Concurrent use of traditional herbal medicines and conventional drugs, particularly for stroke treatment, is widespread, raising concerns about potential drug interactions.

AIM OF THE STUDY

This clinical study aimed to investigate interactions between edoxaban, a direct oral anticoagulant, and two traditional herbal medicines commonly used for stroke: Banhabaekchulcheonmatang (BBCT) and Hwangryeonhaedoktang (HRHDT).

MATERIALS AND METHODS

Korean healthy volunteers participated in a randomized, open-label, three-period, three-treatment, two-sequence clinical study. Treatments consisted of a single oral dose of edoxaban tablet (60 mg) in the presence or absence of multiple doses of BBCT or HRHDT three times daily for six days. Pharmacokinetic and pharmacodynamic parameters of edoxaban and its active metabolite M4 were assessed following administration of edoxaban alone or in co-administration with BBCT or HRHDT.

RESULTS

When edoxaban was co-administered with BBCT or HRHDT, the area under the curve (AUC) of edoxaban remained unaffected. However, its peak concentrations (Cmax) were decreased by 18.5%-28.1%. Similarly, co-administration of edoxaban with BBCT or HRHDT slightly decreased the AUC of M4 and reduced its Cmax by 16.8%-27.1%. Results revealed that BBCT and HRHDT had a minor impact on pharmacokinetics of edoxaban and M4. Despite alterations in systemic exposures, all pharmacodynamic parameters of edoxaban derived from activated partial thromboplastin time and prothrombin time were equivalent irrespective of herbal medicine co-administration.

CONCLUSIONS

These findings contribute to our understanding of potential interactions between conventional anticoagulants and traditional herbal medicines, highlighting the need for comprehensive evaluation in clinical practice.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition)

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy reviews the published evidence since 2018 and provides guidance to help avoid this potentially catastrophic complication.The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy uses similar methodology as previous editions but is reorganized and significantly condensed. Therefore, the clinicians are encouraged to review the earlier texts for more detailed descriptions of methods, clinical trials, case series and pharmacology. It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade. In previous versions, the anticoagulant doses were described as prophylactic and therapeutic. In this version, we will be using 'low dose' and 'high dose,' which will allow us to be consistent with other published guidelines and more accurately describe the dose in the setting of specific patient characteristics and indications. For example, the same 'high' dose may be used in one patient as a treatment for deep venous thrombosis (DVT) and in another patient as prophylaxis for recurrent DVT. Due to the increasing ability to obtain drug-specific assays, we have included suggestions for when ordering these tests may be helpful and guide practice. Like previous editions, at the end of each recommendation the authors have clearly noted how the recommendation has changed from previous editions.

10-Year Trends of Antithrombotic Therapy Status and Clinical Outcomes in Patients With Atrial Fibrillation and Renal Dysfunction - The Fushimi AF Registry

BACKGROUND

Anticoagulation therapy for atrial fibrillation (AF) has undergone major changes following the introduction of direct oral anticoagulants (DOAC) in 2011. However, the transition of anticoagulation therapy for AF patients with severe renal dysfunction remains to be elucidated.

METHODS AND RESULTS

Follow-up data, including creatinine clearance (CrCl), were available for 3,706 patients in the Fushimi AF Registry. We divided patients into 3 groups based on CrCl as follows: (1) CrCl ≥50 mL/min; (2) 50 mL/min>CrCl≥30 mL/min; and (3) CrCl <30 mL/min. In patients with CrCl ≥50 mL/min and 50>CrCl≥30 mL/min, prescription of oral anticoagulants increased year-by-year from 2011 to 2021 with a growing proportion of DOAC; however, the prescription of oral anticoagulants remained almost unchanged in those with CrCl <30 mL/min. In patients with CrCl ≥50 mL/min and 50 mL/min>CrCl≥30 mL/min, the incidence of adverse events, including stroke/systemic embolism and major bleeding, was lower among patients enrolled after 2014 than before 2013. However, these trends were not seen in patients with CrCl <30 mL/min.

CONCLUSIONS

Despite the increased use of DOAC in patients with AF since 2011, anticoagulation therapy for AF patients with severe renal dysfunction has largely remained unchanged, and a reduction in adverse events in those patients has not been observed.

"Evaluating the efficacy and safety of direct oral anticoagulants compared to warfarin in very morbidly obese patients with non-valvular atrial fibrillation: A retrospective cohort study"

•DOACs are effective and safe in very morbidly obese AF patients (BMI ≥50 kg/m2).•DOACs show similar stroke and bleeding risks as warfarin in this population.•Findings support DOACs in anticoagulation guidelines for very morbidly obese patients.

Peak and trough concentrations of apixaban and rivaroxaban in adult patients: a systematic review and meta-analysis

BACKGROUND

Apixaban and rivaroxaban are activated factor X (FXa) inhibitors commonly used for treatment of venous thromboembolism and stroke prevention in patients with atrial fibrillation. While routine monitoring of their concentrations is not recommended, but it may be beneficial in certain situations. Expected peak and trough concentrations remain poorly understood, with most data derived from small studies.

OBJECTIVES

To establish the average peak and trough concentrations of apixaban and rivaroxaban from real-world studies.

METHODS

PubMed, Scopus, and Web of Science were searched until October 2023 for observational studies reporting apixaban and rivaroxaban concentrations. Meta-regression was used to examine factors influencing these concentrations.

RESULTS

Sixteen studies involving 1054 apixaban and 1321 rivaroxaban patients were pooled using random-effects model. Mean apixaban peak concentrations were 157 ng/mL (95% CI, 127-187) for 2.5 mg and 228 ng/mL (95% CI, 204-252) for 5 mg, with trough concentrations of 77 ng/mL (95% CI, 56-98) and 113 ng/mL (95% CI, 101-124), respectively. Mean rivaroxaban peak concentrations were 168 ng/mL (95% CI, 104-232) for 10 mg, 225 ng/mL (95% CI, 192-257) for 15 mg, and 229 ng/mL (95% CI, 193-264) for 20 mg, with trough concentrations of 23 ng/mL (95% CI, 13-32), 31 ng/mL (95% CI, 26-36), and 36 ng/mL (95% CI, 25-47), respectively. Meta-regression revealed age and creatinine clearance correlated with apixaban peak concentrations. Creatinine clearance correlated with apixaban and rivaroxaban trough concentrations.

CONCLUSION

The pooled mean concentrations align with expected concentration ranges reported in different pharmacokinetic studies.

Efficacy and safety of anticoagulants on venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials

Background

Anticoagulants are the primary means for the treatment and prevention of venous thromboembolism (VTE), but their clinical standardized application still remains controversial. The present study intends to comprehensively compare the efficacy and safety of various anticoagulants in VTE.

Methods

Medline, Embase, and Cochrane Library from their inception up to August 2023 were searched to compare the efficacy and safety of various anticoagulants in VTE. We extracted data on study settings, baseline characteristics, interventions, and outcomes, applying the intention-to-treat principle. Two researchers assessed study bias using the Cochrane tool, resolving disagreements through discussion or third-party adjudication. Network meta-analyses were performed based on Bayesian generalized linear models, and a frequentist framework with multivariate random effects was used to fit the model.

Results

In terms of treatment, 58 trials with 119,417 patients proved eligible, while 125 trials with 225,414 patients were included in terms of prevention. All anticoagulants were found to reduce the recurrence or incidence of VTE compared with Placebo, of which high-level evidence indicated that direct thrombin inhibitors (TIs) and novel oral anticoagulants (NOACs) were the two most effective drugs. For treatment, low molecular weight heparin (LMWH), unfractionated heparin (UFH), and vitamin K antagonists (VKAs) significantly increased the risk of major bleeding in comparison to Placebo. For prevention, only UFH (OR 2.0, 95% CI 1.2-3.3) and NOACs (OR 1.8, 95% CI 1.2-2.6) showed significant increased risks in major bleeding. Additionally, after an exhaustive analysis of NOACs, analysis showed that apixaban (RR 0.5, 95%CI 0.17-1.46) had a superior performance in major bleeding compared to rivaroxaban (RR 3.87, 95%CI 1.48-10.09).

Conclusion

TIs and NOACs were superior in efficacy with minimal side effects, making them pivotal choices for both prevention and treatment of VTE. Clinical practitioners must carefully weigh drug characteristics, indications, and contraindications to optimize treatment outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=466775.

Quality of Oral Anticoagulation Control with Warfarin According to Sex: A Cross-Sectional Study

Evidence indicates a difference between men and women in oral anticoagulation control, but the results were discrepant. This study investigated the association of sex with oral anticoagulation control in patients on warfarin assisted by anticoagulation clinics (ACs) in Brazil. The cross-sectional study included patients on warfarin recruited at three public ACs in southeast Brazil (2014-2015). The quality of oral anticoagulation was estimated by the time in therapeutic range (TTR). Univariable and multivariable linear regression models were built to examine the association of sociodemographic, behavior, clinical, and drug therapy variables with TTR. Overall, 801 participants were studied (455; 56.8% women), with a mean age of 65.0 (13.4) years. The female sex was associated with lower TTR than the male sex (Beta (95% CI) = -17.01 (-30.25; -3.76), p = 0.012), however, this difference decreased with increasing age, becoming null after age 60. Smoking patients had a lower TTR than non-smokers (-5.18 (-10.02; -0.34), p = 0.036). The results showed that the association of sex with oral anticoagulation control is dependent on age. Women have lower TTR than men, but this difference is null in older patients. Knowledge of these factors may be useful for developing strategies to improve care for these patients.

High-risk percutaneous coronary intervention in patients with reduced left ventricular ejection fraction deemed not suitable for surgical revascularisation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the ESC Working Group on Cardiovascular Surgery

This clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions was developed in association with the European Society of Cardiology Working Group on Cardiovascular Surgery. It aims to define procedural and contemporary technical requirements that may improve the efficacy and safety of percutaneous coronary intervention (PCI), both in the acute phase and at long-term follow-up, in a high-risk cohort of patients on optimal medical therapy when clinical and anatomical high-risk criteria are present that entail unacceptable surgical risks, precluding the feasibility of coronary artery bypass grafting (CABG). This document pertains to patients with surgical contraindication according to the Heart Team, in whom medical therapy has failed (e.g., residual symptoms), and for whom the Heart Team estimates that revascularisation may have a prognostic benefit (e.g., left main, last remaining vessel, multivessel disease with large areas of ischaemia); however, there is a lack of data regarding the size of this patient population. This document aims to guide interventional cardiologists on how to proceed with PCI in such high-risk patients with reduced left ventricular ejection fraction after the decision of the Heart Team is made that CABG - which overall is the guideline-recommended option for revascularisation in these patients - is not an option and that PCI may be beneficial for the patient. Importantly, when a high-risk PCI is planned, a multidisciplinary decision by interventional cardiologists, cardiac surgeons, anaesthetists and non-invasive physicians with expertise in heart failure management and intensive care should be agreed upon after careful consideration of the possible undesirable consequences of PCI, including futility, similar to the approach for structural interventions.

Effectiveness and Safety of Dose-Specific DOACs in Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis

Background: Dose adjustments of direct-acting oral anticoagulants (DOACs) for atrial fibrillation are based on pivotal clinical trials assessing their effectiveness and safety in controlled settings. However, the appropriateness of these dosing strategies in real-world practice is uncertain. The purpose of this study is to compare the effectiveness and safety of dose-specific DOACs with those of warfarin. Methods: This study retrieved articles from MEDLINE, Embase, and CENTRAL until March 5, 2024. Primary outcomes were the incidence of stroke/systemic embolisms (S/SEs) and major bleeding (MB). Direct pairwise meta-analyses compared each dose-specific DOAC with warfarin. Heterogeneity was assessed using Higgin's I 2 and Q statistics, while publication bias was evaluated through funnel plots and Begg's and Egger's tests, with adjusted pooled estimates calculated via trim-and-fill and precision-effect estimate with standard error (PET-PEESE) methods. A network analysis was conducted, with additional comparisons made using a Bayesian random-effects model for indirect evidence. Results: A total of 32 studies with 2,332,770 patients were included. Both standard-dose (SD) and low-dose (LD) DOACs significantly reduced S/SE, except for LD apixaban and LD edoxaban. Rivaroxaban did not show significant difference in MB compared to warfarin. In East Asian patients, all doses of DOACs exhibited lower hazard ratios (HRs) for S/SE and MB than those observed in the primary analysis, with LD rivaroxaban significantly reducing MB, a finding not observed in the primary analysis. Rank probability analysis indicated that the dose-specific DOACs had different safety profiles and small but meaningful differences in effectiveness. SD apixaban (S/SE: second, MB: second) and edoxaban (S/SE: first, MB: fourth) and LD edoxaban (S/SE: fourth, MB: first) had high ranks. LD apixaban had the most significant difference in rank for S/SE from SD apixaban, ranking eighth compared to second. Conclusions: This study found that all DOACs provided comparable or superior effectiveness and safety to warfarin. SD apixaban, SD edoxaban, and LD edoxaban achieved a favorable balance between preventing S/SE and MB risk.

Comparative Effectiveness and Safety of Off-Label Underdosed Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: A Systematic Review and Meta-analysis

INTRODUCTION

Off-label underdosed direct oral anticoagulants (DOACs) are commonly utilised in Asian patients with atrial fibrillation (AF) since they are prone to bleeding with OACs. However, the efficacy and safety of off-label underdosing DOACs are controversial. This study aimed to compare the effectiveness and safety of off-label underdosed DOACs in Asian patients with AF.

METHODS

PubMed, Embase, Cochrane library, and ClinicalTrials.gov were searched from 2010 to July 5, 2024, for randomised controlled trials or observational studies that compared off-label DOACs and on-label/warfarin in Asian patients with AF. The primary outcomes included ischaemic stroke or systemic embolism (ISSE) and major bleeding (MB), while secondary outcomes included all-cause death, gastrointestinal bleeding (GIB), intracranial haemorrhage (ICH), and myocardial infarction (MI). Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using random-effects models.

RESULTS

Twenty observational studies were included. Seventeen studies compared off-label underdosed DOACs versus on-label DOACs, whereas five studies compared off-label underdosed DOACs versus warfarin. Off-label underdosed DOACs were associated with higher risk of ISSE (pooled HR [pHR] = 1.17; 95% CI: 1.00-1.38, p = 0.048) and ICH (pHR = 1.27; 95% CI: 1.06-1.52, p = 0.010) versus on-label. Subgroup analysis demonstrated increased ISSE risk with off-label underdosed rivaroxaban compared to on-label (pHR = 1.49; 95% CI: 1.07-2.08). Compared to warfarin, off-label underdosed DOACs were associated with decreased risk of MB (pHR = 0.46; 95% CI: 0.32-0.65, p < 0.001), GIB (pHR = 0.52; 95% CI: 0.29-0.93, p = 0.028), ICH (pHR = 0.60; 95% CI: 0.42-0.86, p = 0.005), and all-cause death (pHR = 0.70; 95% CI: 0.56-0.87, p = 0.001), while illustrating similar ISSE risk.

CONCLUSIONS

Off-label underdosed DOACs, particularly rivaroxaban, was associated with increased ISSE risk but did not decrease bleeding compared to on-label. Adherence to appropriate DOAC doses should be emphasised to achieve the best clinical outcomes for Asian patients with AF.

Treatment appropriateness of direct oral anticoagulants in patients with atrial fibrillation for stroke prevention: A real-world prospective study

INTRODUCTION

Inappropriate use of direct oral anticoagulants (DOACs) is common, affecting up to 30% of atrial fibrillation (AF) population receiving treatment for stroke prevention. This study assessed appropriateness of anticoagulation in anticoagulation-naive AF patients treated with DOACs during a 12-month prospective follow-up.

METHODS

This prospective cohort study included all anticoagulation-naive AF patients referred for anticoagulation for stroke prevention at a tertiary cardiovascular center. Participants were prospectively followed through phone call interviews by a dedicated nurse at 1, 3, 6, 9, and 12 months after enrollment.

RESULTS

Of 403 anticoagulation-naive AF patients, rivaroxaban was prescribed for 325 patients (80.7%) and apixaban for 78 (19.3%). Inappropriate therapy was observed in 23% (76/325) and 46% (36/78) of patients treated with rivaroxaban and apixaban, respectively. Undertreatment was predominant scenario for both drugs, detected in 78.5% (78/112) of patients treated inappropriately, and was more frequently observed with apixaban versus rivaroxaban (44.8% vs 16.3%). During 12 months, inappropriate treatment was corrected in only 13% of all patients. The multivariate regression model identified creatinine clearance ≤ 49 mL/min (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.12 to 4.21), female sex (OR, 1.81; 95% CI, 1.11 to 2.97), and age ≥ 80 years (OR, 1.85; 95% CI, 1.22 to 2.83) as independent covariates associated with inappropriate dosing.

CONCLUSIONS

Inappropriate therapy with DOACs for stroke prevention in patients with AF is common, and the dosage were corrected in few patients during the 12-month follow-up. Our findings highlight the persistent lack of knowledge regarding appropriate DOAC dosage and need for continuous education.

Atrial fibrillation management in older hospitalized patients: Evidence of a poor oral anticoagulants prescriptive attitude from the Italian REPOSI registry

Atrial fibrillation (AF) prevalence increases in older patients which also show a high thromboembolic risk. Oral anticoagulants (OACs) are recommended to prevent cardioembolic events and direct oral anticoagulants (DOACs) improved anti-thrombotic treatment. However, the benefits/risks of anticoagulant in older patients still need to be completely defined. This retrospective observational study aimed to describe the treatment with OACs in older AF hospitalized patients, and to identify factors influencing OAC therapy or discontinuation using the REgistro Politerapie SIMI. Univariate and multivariate logistic regression models were applied to identify predictors of OACs treatment and discontinuation. Cox proportional hazards models were performed to evaluate one-year mortality by treatment groups. AF patients were 1,128(26.5 %) at discharge and 1,098(97.3 %) required OAC treatment; about half of them (N = 528;48.1 %) were no-OACs users; 236(21.5 %) and 334(30.4 %) used DOACs and VKA, respectively. Increasing DOACs use was observed during the study period. Predictors of OACs treatment were: BMI (OR:1.04; 95 %CI:1.01-1.07), Barthel index (OR:1.01; 95 %CI:1.01-1.02), medications number (OR:1.07; 95 %CI:1.01-1.13). Conversely, a lower probability was found in patients with a high CIR.S (OR:0.59; 95 %CI:0.36-0.97) and neoplasm (OR:0.57; 95 %CI:0.37-0.88). Hospital stay (OR:1.02; 95 %CI:1.01-1.05), neoplasm (OR:2.25; 95 %CI:1.07-4.70) and INR (OR:1.21; 95 %CI:1.05-1.40) increased OACs discontinuation. A lower discontinuation was observed in dyslipidemic patients (OR:0.18; 95 %CI:0.04-0.82) and heart failure (OR:0.38; 95 %CI:0.21-0.70). Among AF patients, 157(14.3 %) died during the follow-up year. Age (HR = 1.05; 95 %CI = 1.03-1.08) and CIR.S (HR = 2.54; 95 %CI = 1.53-4.21) were associated with a greater mortality risk. In conclusion, critical issues related to the underuse and discontinuation of OACs therapy in hospitalized older patients were highlighted.

[Cerebrolysin and the optimal timing of anticoagulation resumption in stroke: combined post hoc survival analysis of the CEREHETIS trial]

OBJECTIVE

To evaluate the effect of Cerebrolysin on hazard dynamics of hemorrhagic transformation (HT) and identify optimal anticoagulation therapy (AT) resumption timing in stroke patients, stratified by the Hemorrhagic Transformation Index (HTI).

MATERIAL AND METHODS

A post hoc survival analysis of the CEREHETIS trial (ISRCTN87656744) included patients with middle cerebral artery infarctions. The intervention group (IG, n=91) received Cerebrolysin with intravenous thrombolysis (IVT) and standard care, while the control group (CG, n=147) received IVT and standard care alone. Additionally, a validation cohort (VC, n=248) from an observational study was analyzed. Patients were stratified into low-risk (HT=0), high-risk (HTI=1-4), and very-high-risk (HTI=5-8, VC only) groups. Symptomatic HT and any HT within 14 days post-stroke were defined as failure events. Hazard dynamics were modeled using a Gompertz parametric survival approach, with a hazard threshold (0.6% per day) estimating safe AT resumption timing.

RESULTS

Cerebrolysin significantly reduced risk of symptomatic HT (HR 0.245; 95% CI 0.072-0.837; p=0.02) and any HT (HR 0.543; 95% CI 0.297-0.991; p=0.032). The compounding effect peaked on day 1 and persisted through days 7-10 in very-high-risk patients (HTI=5-8). In high-risk patients (HTI=1-4), Cerebrolysin mitigated the compounding effect and reduced hazard levels to the threshold by day 2, compared to days 3-5 in the CG and VC. The hazardous period extended to day 10 in HTI=5-8. In low-risk patients (HTI=0), hazard levels remained below the threshold from day 1, with no measurable impact of Cerebrolysin on HT.

CONCLUSION

AT may be safely resumed within 48 h in low-risk patients (HTI=0), on days 3-5 in high-risk patients (HTI=1-4), and on day 10 in very-high-risk patients (HTI=5-8) without symptomatic HT. Cerebrolysin mitigates the compounding effect, reduces HT risk, and facilitates earlier, safer AT resumption in high-risk patients (HTI=1-4) by day 2 post-stroke, supporting its role in personalized stroke management.

Phenotypes of Patients with Direct Oral Anticoagulant (DOAC) Underdosing in Atrial Fibrillation: Results from the ARENA Registry

BACKGROUND AND OBJECTIVES

Oral anticoagulation in patients with atrial fibrillation is crucial to prevent thrombus formation in the heart, a major cause of ischemic stroke. The appropriate dose of direct oral anticoagulants (DOAC) - either standard or reduced dose - must be chosen individually in accordance with defined patient characteristics. However, a significant proportion of patients receive inappropriately low DOAC doses (underdosing). With a novel medication-based approach, this study aims to facilitate the identification of patients at risk of DOAC underdosing.

METHODS

The prospective ARENA registry is a multi-centre study on patients with atrial fibrillation in Germany. Patients gave detailed information on medication, including over-the-counter preparations. Medication data were grouped according to the Anatomical Therapeutic Chemical (ATC) classification. In a bivariate analysis, the characteristics of patients on an appropriate versus inappropriate dose were compared (n = 866). To further evaluate variables for their association with underdosing, a model based on ATC third level medication data complemented with dose-adjustment criteria and validated clinical scores in all patients with complete information was built (n = 504).

RESULTS

In 15% of patients, an inappropriately low dose was found. The number of DOAC drug interactions, concomitant antiplatelet therapy and the total drug count were the most important predictors of DOAC underdosing. Mineral supplements and better health-related quality of life (HrQoL) were predictive of correct DOAC dosing, among others.

CONCLUSIONS

Medication-related data showed to be predictive of DOAC underdosing. Clinicians should check for inappropriately reduced DOAC doses, especially in patients undergoing antiplatelet therapy, polypharmacy and reduced HrQoL.

TRIAL REGISTRATION NUMBER

NCT02978248; date of registration: 30 November 2016.