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Kwun JS, Lee JH, Park BE, Park JS, Kim HJ, Kim SH, Jeon KH, Cho HW, Kang SH, Lee W, Youn TJ, Chae IH, Yoon CH. Diagnostic Value of a Wearable Continuous Electrocardiogram Monitoring Device (AT-Patch) for New-Onset Atrial Fibrillation in High-Risk Patients: Prospective Cohort Study. J Med Internet Res 2023; 25:e45760. [PMID: 37721791 PMCID: PMC10546264 DOI: 10.2196/45760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/07/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND While conventional electrocardiogram monitoring devices are useful for detecting atrial fibrillation, they have considerable drawbacks, including a short monitoring duration and invasive device implantation. The use of patch-type devices circumvents these drawbacks and has shown comparable diagnostic capability for the early detection of atrial fibrillation. OBJECTIVE We aimed to determine whether a patch-type device (AT-Patch) applied to patients with a high risk of new-onset atrial fibrillation defined by the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, sex scale (CHA2DS2-VASc) score had increased detection rates. METHODS In this nonrandomized multicenter prospective cohort study, we enrolled 320 adults aged ≥19 years who had never experienced atrial fibrillation and whose CHA2DS2-VASc score was ≥2. The AT-Patch was attached to each individual for 11 days, and the data were analyzed for arrhythmic events by 2 independent cardiologists. RESULTS Atrial fibrillation was detected by the AT-Patch in 3.4% (11/320) of patients, as diagnosed by both cardiologists. Interestingly, when participants with or without atrial fibrillation were compared, a previous history of heart failure was significantly more common in the atrial fibrillation group (n=4/11, 36.4% vs n=16/309, 5.2%, respectively; P=.003). When a CHA2DS2-VASc score ≥4 was combined with previous heart failure, the detection rate was significantly increased to 24.4%. Comparison of the recorded electrocardiogram data revealed that supraventricular and ventricular ectopic rhythms were significantly more frequent in the new-onset atrial fibrillation group compared with nonatrial fibrillation group (3.4% vs 0.4%; P=.001 and 5.2% vs 1.2%; P<.001), respectively. CONCLUSIONS This study detected a moderate number of new-onset atrial fibrillations in high-risk patients using the AT-Patch device. Further studies will aim to investigate the value of early detection of atrial fibrillation, particularly in patients with heart failure as a means of reducing adverse clinical outcomes of atrial fibrillation. TRIAL REGISTRATION ClinicalTrials.gov NCT04857268; https://classic.clinicaltrials.gov/ct2/show/NCT04857268.
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Affiliation(s)
- Ju-Seung Kwun
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Bo Eun Park
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jong Sung Park
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Hyeon Jeong Kim
- Department of Internal Medicine, Sihwa Medical Center, Siheung-si, Republic of Korea
| | - Sun-Hwa Kim
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Ki-Hyun Jeon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Hyoung-Won Cho
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Si-Hyuck Kang
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Wonjae Lee
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Tae-Jin Youn
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - In-Ho Chae
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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Shen J, Li M, Cao S, Lu Z, Xia Y, Chen S, Bi Y, Cai Z, Hu B, Cao F. Neurologists' attitudes and options for anticoagulation therapy in central China. Int J Clin Pract 2021; 75:e14305. [PMID: 33930249 DOI: 10.1111/ijcp.14305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 04/27/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS We aim to find out the factors affecting the use of anticoagulants and the intensity of their choices, and to establish a basis for improving neurologists' effective implementation of the guidelines. METHODS A cross-sectional study is conducted in Hubei province in central China. Each neurologist completes a standard-structured anonymous questionnaire through face-to-face interviews. The problems include the attitude and options about anticoagulant therapy. RESULTS A total of 611 neurologists from 38 hospitals respond to this survey. For the best treatment of atrial fibrillation, more than 80% of physicians choose anticoagulant therapy. For patients with atrial fibrillation and cerebral infarction, physicians think that Warfarin is the preferred drug as high as 93.8%. Among the anticoagulant drugs ever used by clinicians, the use rate of Warfarin is 93.8%, but the use rate of direct oral anticoagulants is insufficient. The use of direct oral anticoagulants is related to the educational level and the geographical location of the hospital. Bleeding risk is the first reason influencing clinicians' choice of Warfarin, accounts for 88.9%. 97.7% of the clinicians recommend patients with Warfarin to regularly monitor the INR, but the frequency of monitoring is inconsistent. Clinicians have a high willingness to learn about AF, but the proportion of hospitals that carry out appropriate training is low. CONCLUSIONS There are still some gaps with the guidelines on the choice of anticoagulant drugs. Neurologists have positive attitude towards anticoagulant therapy and a strong willingness to learn, but the corresponding training is lacking. Continuous professional training is necessary.
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Affiliation(s)
- Jing Shen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Man Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiyi Cao
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zuxun Lu
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanpeng Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shengcai Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuoyuan Cai
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Cao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gao L, Scuffham P, Ball J, Stewart S, Byrnes J. Long-term cost-effectiveness of a disease management program for patients with atrial fibrillation compared to standard care - a multi-state survival model based on a randomized controlled trial. J Med Econ 2021; 24:87-95. [PMID: 33406944 DOI: 10.1080/13696998.2020.1860371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM To assess the long-term cost-effectiveness of an atrial fibrillation disease management program (i.e. the SAFETY program) from the Australian healthcare system perspective. METHODS A multistate Markov model was developed based on patient-level data from the SAFETY randomized controlled trial. Predicted long-term survival, dependent on hospital admission history, was estimated by extrapolating parametric survival models. Quality-adjusted life years (QALY) and life years (LY) were the primary and secondary outcome measures used to estimate the incremental cost-utility/effectiveness ratio (ICUR/ICER). Both deterministic and probabilistic sensitivity analyses (PSA) were undertaken. RESULTS The SAFETY program was associated with both higher costs ($94,953 vs. $78,433) and benefits [QALY (3.99 vs 3.60); LY (5.86 vs 5.24)], with an ICUR of $42,513/QALY or ICER of $26,356/LY, compared to standard care. Due to the extended survival, the SAFETY was associated with a greater number of hospitalizations (14.85 vs 11.65) and higher costs for medications ($25,084 vs $22,402) and outpatient care ($12,904 vs $11,524). The cost per hospitalization for an average length of stay, analytical time horizon, and cost of medication are key determinants of ICUR. The PSA showed that the intervention has a 70.4% probability of being cost-effective at a threshold of $50,000/QALY. CONCLUSIONS The SAFETY program has a high probability of being cost-effective for patients with atrial fibrillation. It is associated with uncertainty that further research could potentially eliminate; implementation with further evidence collection is recommended.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Paul Scuffham
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Jocasta Ball
- Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Australia
| | | | - Joshua Byrnes
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
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Cho IY. Using non-vitamin K oral anticoagulants in specific patient populations: a study of Korean cases. Ther Clin Risk Manag 2019; 15:1183-1206. [PMID: 31632045 PMCID: PMC6790210 DOI: 10.2147/tcrm.s204377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/27/2019] [Indexed: 12/19/2022] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) are increasingly used as alternatives to conventional therapies and have considerable accumulated real-world clinical data in patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). However, it is not easy to make a complete changeover to NOACs in real-world clinical practice because NOACs still have challenges in specific patient populations (eg, Asian patients, NVAF patients presenting with acute coronary syndrome [ACS], dialysis patients with NVAF, patients with cancer-associated VTE, etc.). Clinical data on the optimal dose of NOACs in Asian patients with NVAF are not sufficient. The intensity of NOAC and antiplatelet treatment and the duration of antiplatelet treatment should be adjusted according to the bleeding and thrombotic risk profiles of the individual NVAF patient presenting with ACS. Increased bleeding risk and unclear efficacy of NOACs in dialysis patients with NVAF should be considered when making decisions on whether to give NOACs for these patients. If dialysis patients with NVAF require anticoagulant for stroke prevention, then apixaban could be considered while awaiting more clinical efficacy and safety data. Additional studies are needed to determine the utility of continuing treatment with reduced-dose NOACs for long-term therapy after VTE. We have enough experiences in using NOACs in cancer patients showing the benefit of antithrombotic treatment counterbalanced the bleeding risk; however, some challenges of cancer-associated VTE management exist due to differences in cancer types or chemotherapy regimens and comorbidities. Different dosing regimens among NOACs may impact on medication adherence; thus, individual patient preference should be considered in choosing a particular NOAC. A significant proportion of patients remain on warfarin because of the high price of NOACs and variability in reimbursement coverage. To compensate clinical-evidence and achieve optimal use of NOACs, we should pay attention to the outcomes of ongoing studies and evaluate more real-world data.
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Affiliation(s)
- Il Young Cho
- College of Pharmacy, Ewhawomans University, Seoul, Republic of Korea
- Pharmaceutical Safety Bureau, Ministry of Food and Drug Safety, Cheongju-si, Republic of Korea
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Relationship Between Anticoagulant Medication Adherence and Satisfaction in Patients With Stroke. J Neurosci Nurs 2019; 51:229-234. [DOI: 10.1097/jnn.0000000000000463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Zado ES, Pammer M, Parham T, Lin D, Frankel DS, Dixit S, Marchlinski FE. "As Needed" nonvitamin K antagonist oral anticoagulants for infrequent atrial fibrillation episodes following atrial fibrillation ablation guided by diligent pulse monitoring: A feasibility study. J Cardiovasc Electrophysiol 2019; 30:631-638. [PMID: 30706975 DOI: 10.1111/jce.13859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/13/2019] [Accepted: 01/13/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION After atrial fibrillation (AF) ablation, oral anticoagulation (OAC) is recommended if stroke risk as assessed by CHA2 DS 2 -VASc score is high. However, patients without AF are often reluctant to take daily OAC. We describe outcome using as needed nonvitamin K antagonist (NOACs) guided by pulse monitoring to detect AF following successful ablation. METHODS AND RESULTS We identified 99 patients (84% male, age 64 ± 8 years), CHA2 DS 2 -VASc score greater than or equal to 1 in men and greater than or equal to 2 in women (median 2, range 1-6), capable of pulse assessment twice daily and no AF on extended monitoring after AF ablation. All patients were instructed to start NOAC if AF >1 hour or recurrent shorter episodes. Duration of NOAC use after restart was typically 2 to 4 weeks. After 30 ± 14 months (total 244 patient-years), 22 patients (22%) transitioned to daily NOAC because of noncompliance with pulse assessment or patient preference (six patients) or because of suspected or documented AF episode(s) in 16 (16%) patients. Of the remaining 77 (78%), 14 (14%) used NOACs but did not transition back to daily use, most (10 patients) with single use (seven patients) or non-AF rhythm (three patients) documented. There was only one thromboembolic event (0.4%/yr of follow-up) in patient without AF and one mild bleeding event (epistaxis). CONCLUSION The use of as needed NOACs when AF is suspected with pulse monitoring is effective and safe to maintain low risk of stroke and bleeding after successful ablation. Transition back to daily NOAC use should be anticipated in about one quarter of patients.
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Affiliation(s)
- Erica S Zado
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monica Pammer
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tara Parham
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Smet L, Heggermont WA, Goossens E, Eeckloo K, Vander Stichele R, De Potter T, De Backer T. Adherence, knowledge, and perception about oral anticoagulants in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation. J Adv Nurs 2018; 74:2577-2587. [PMID: 29944735 DOI: 10.1111/jan.13780] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 04/17/2018] [Accepted: 05/01/2018] [Indexed: 01/08/2023]
Abstract
AIMS This study aimed to: (a) determine adherence rates to oral anticoagulants in atrial fibrillation patients with a high risk for thromboembolic events postradiofrequency ablation; (b) evaluate patients' knowledge and perceptions towards oral anticoagulants; and (c) explore the impact of patients' knowledge and perceptions on treatment adherence. BACKGROUND Atrial fibrillation is a common arrhythmia associated with an increased risk of developing thromboembolic events such as stroke. Although adherence to oral anticoagulants is crucial to prevent such complications, the relationship between adherence, knowledge and patient perceptions is poorly understood in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation. DESIGN A cross-sectional observational survey study was performed in a single centre. METHODS The levels of adherence, knowledge, and perception towards oral anticoagulants were assessed using the 8-item Morisky Medication Adherence Scale, Knowledge of Oral Anticoagulation Tool, Perception of Anticoagulant Treatment Questionnaire and Benefit-Risk Perception Tool, respectively. Results from these self-reported tools were analysed descriptively. A multivariable binary logistic regression model was used to identify factors associated with levels of adequate adherence. RESULTS Adequate treatment adherence was found in three-quarters of patients. The total mean knowledge score was low. Participants expressed high ease of use and low burden of treatment. Higher total knowledge and satisfaction scores were significant factors associated with higher levels of adherence. CONCLUSION There remains a huge unmet need to follow-up and educate patients with atrial fibrillation, focusing on good knowledge and correct perception of the advantages and disadvantages of oral anticoagulants. Our results suggest that increased knowledge and satisfaction rates might have a positive impact on adherence to oral anticoagulants.
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Affiliation(s)
- Lily Smet
- Department of Public Health, Ghent University, Ghent, Belgium.,Department of Cardiology, Cardiovascular Research Center Aalst, OLV Hospital Aalst, Aalst, Belgium
| | - Ward A Heggermont
- Department of Cardiology, Cardiovascular Research Center Aalst, OLV Hospital Aalst, Aalst, Belgium
| | - Eva Goossens
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Foundation Flanders (FWO), Brussels, Belgium.,Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Kristof Eeckloo
- Department of Public Health, Ghent University, Ghent, Belgium.,University Hospital Ghent, Ghent, Belgium
| | | | - Tom De Potter
- Department of Cardiology, Cardiovascular Research Center Aalst, OLV Hospital Aalst, Aalst, Belgium
| | - Tine De Backer
- Department of Public Health, Ghent University, Ghent, Belgium.,University Hospital Ghent, Ghent, Belgium.,Department of Cardiovascular Diseases, University Hospital Ghent, Ghent, Belgium
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8
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[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article]. Rev Esp Geriatr Gerontol 2018; 53:344-355. [PMID: 30072184 DOI: 10.1016/j.regg.2018.04.450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 12/31/2022]
Abstract
Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.
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Lane DA, Meyerhoff J, Rohner U, Lip GYH. Patients' Perceptions of Atrial Fibrillation, Stroke Risk, and Oral Anticoagulation Treatment: An International Survey. TH OPEN 2018; 2:e233-e241. [PMID: 31249947 PMCID: PMC6524879 DOI: 10.1055/s-0038-1666803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022] Open
Abstract
Background Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juliane Meyerhoff
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Ute Rohner
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J 2018; 38:860-868. [PMID: 26848150 DOI: 10.1093/eurheartj/ehw069] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 12/11/2022] Open
Abstract
The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension. In addition, we discuss adherence and compliance. Finally, we present a summary of treatment suggestions. In specific subgroups of patients with AF, evidence supports the use of particular NOACs and/or particular doses of anticoagulant. The appropriate choice of treatment for these subgroups will help to promote optimal clinical outcomes.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: Specific Situation and High Risk Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Proietti M, Laroche C, Opolski G, Maggioni AP, Boriani G, Lip GYH. 'Real-world' atrial fibrillation management in Europe: observations from the 2-year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase. Europace 2018; 19:722-733. [PMID: 27194538 DOI: 10.1093/europace/euw112] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/30/2016] [Indexed: 12/13/2022] Open
Abstract
Aims Atrial fibrillation (AF) is commonly associated with a high risk of stroke, thromboembolism, and mortality. The 1-year follow-up of the EURObservational Research Programme-Atrial Fibrillation (EORP-AF) Pilot Registry demonstrated a high mortality but good outcomes with European Society of Cardiology guideline-adherent therapy. Whether these 'real-world' observations on patients managed by European cardiologists extend to 2 years remains uncertain. Methods and results In this report from the EORP-AF General Registry Pilot Phase, we provide data on the 2-year follow-up outcomes. Consistent with the 1-year follow-up report, only a small proportion of patients were symptomatic (24.9%), with minor differences between the different AF subtypes. Persistence of oral anticoagulant (OAC) therapy remains high at 2-years, with ∼80% of patients treated with OAC. The prescribing rates of non-vitamin K antagonist oral anticoagulants are progressively increasing (13.7% at 2 years). Rate and rhythm control approaches remained consistent across the entire follow-up observation. Overall mortality rates remained high, with 5.0% of patients dead during the 2-year follow-up, mostly due to cardiovascular causes (61.8%). Atrial fibrillation readmissions were frequent, particularly related to arrhythmias and heart failure. On multivariate analyses, any cardiovascular reason for admission rather than AF was significantly associated with increased mortality during the 2-year follow-up. Conclusion In this 2-year follow-up report from EORP-AF, mortality rates with AF remain high from cardiovascular causes, despite the high prevalent use of OAC. Improved management strategies to reduce major adverse outcomes in AF patients are needed.
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Affiliation(s)
- Marco Proietti
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Dudley Road, B18 7QH Birmingham, UK
| | - Cécile Laroche
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aldo P Maggioni
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France.,ANMCO Research Center, Firenze, Italy
| | - Giuseppe Boriani
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Dudley Road, B18 7QH Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Stephenson JJ, Shinde MU, Kwong WJ, Fu AC, Tan H, Weintraub WS. Comparison of claims vs patient-reported adherence measures and associated outcomes among patients with nonvalvular atrial fibrillation using oral anticoagulant therapy. Patient Prefer Adherence 2018; 12:105-117. [PMID: 29391782 PMCID: PMC5769561 DOI: 10.2147/ppa.s148697] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare oral anticoagulant (OAC) adherence among patients with nonvalvular atrial fibrillation (NVAF) using patient-reported and claims-based measures, and to evaluate the effect of OAC adherence on health care costs and patient satisfaction with OAC therapy. METHODS This was a hybrid US observational study consisting of a longitudinal cohort survey followed by linkage and analysis of respondents' administrative claims data. Patients with NVAF receiving warfarin, dabigatran, rivaroxaban, or apixaban completed an initial survey and follow-up surveys at 4, 8, and 12 months. Patient-reported adherence was measured at each survey by Morisky Medication Adherence Scale (MMAS-8) and pharmacy claims-determined adherence by the proportion of days covered (PDC) for the 12-month period following the initial survey date; adherence was defined as MMAS-8 score =8 and PDC ≥80%. Patient satisfaction with OAC therapy was assessed by the Duke Anticoagulation Satisfaction Scale (DASS). RESULTS Overall, 675 patients completed at least the initial survey (warfarin, n=271; dabigatran, n=266; rivaroxaban, n=128; apixaban, n=10). Fewer than half (47.9%) were PDC adherent, 37.2% were MMAS-8 adherent, and 19.4% were adherent by both measures. Total medical costs of PDC-adherent patients were significantly lower vs PDC-nonadherent patients (US$640 vs $993 per-patient per-month, respectively, p<0.05). MMAS-8-adherent patients reported higher treatment satisfaction; total DASS score was significantly lower among MMAS-8-adherent than MMAS-8-nonadherent patients (37.3 vs 42.9, respectively, p<0.001). CONCLUSION Using claims-based or patient-reported methods to measure OAC adherence may lead to different results when assessing impact on health care costs and satisfaction with anticoagulation medication. These results underscore the importance of considering both claims-based and patient-reported measures when evaluating treatment adherence in real-world settings.
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Affiliation(s)
- Judith J Stephenson
- HealthCore, Inc., Wilmington, DE
- Correspondence: Judith J Stephenson, HealthCore, Inc., 123 Justison Street, Suite 200, Wilmington, DE 19801, USA, Tel +1 302 230 2142, Fax +1 302 230 2020, Email
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14
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Moss AS, Dimitropoulous G, Lip GYH. Clinical implications, benefits and pitfalls of using and reversing non-vitamin K antagonist oral anticoagulants. Expert Rev Hematol 2017; 10:833-845. [PMID: 28741391 DOI: 10.1080/17474086.2017.1358085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The use of non-Vitamin K antagonist oral anticoagulant (NOAC) drugs is increasingly common in clinical practice. As compared to vitamin K antagonists they are more straightforward to initiate, require no hematological monitoring and offer potentially more stable therapeutic indices. Concern has been raised with regard to their safety profiles particularly in the context of acute reversal in major bleeding. Further issues pertain to patient concordance. Areas covered: This review article aims to provide an overview of the current evidence relating to NOAC safety as well as the management of NOAC-related major bleeding with particular emphasis on reversal agents in use and in development following a selective literature review. Second, the effects of medication concordance and dosing regimens on NOAC efficacy will be considered. Expert commentary: The short half-lives and low overall bleeding risk of NOACs is likely to mean that specific reversal agents in development are infrequently required and costly with associated practicality issues with their use in clinical emergencies. Concern regarding patient concordance can be practicably addressed with appropriate medication, dosing regimen and patient selection and continuous education with active, informed patient involvement in the decision-making process.
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Affiliation(s)
- Alexandra Sophie Moss
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gerasimos Dimitropoulous
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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15
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Rivera-Caravaca JM, Esteve-Pastor MA, Roldán V, Marín F, Lip GY. Non-vitamin K antagonist oral anticoagulants: impact of non-adherence and discontinuation. Expert Opin Drug Saf 2017; 16:1051-1062. [DOI: 10.1080/14740338.2017.1351542] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- José Miguel Rivera-Caravaca
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Gregory Y.H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Sørensen R, Jamie Nielsen B, Langtved Pallisgaard J, Ji-Young Lee C, Torp-Pedersen C. Adherence with oral anticoagulation in non-valvular atrial fibrillation: a comparison of vitamin K antagonists and non-vitamin K antagonists. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:151-156. [DOI: 10.1093/ehjcvp/pvw048] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/03/2017] [Indexed: 11/12/2022]
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