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Sterne JA, Bodalia PN, Bryden PA, Davies PA, López-López JA, Okoli GN, Thom HH, Caldwell DM, Dias S, Eaton D, Higgins JP, Hollingworth W, Salisbury C, Savović J, Sofat R, Stephens-Boal A, Welton NJ, Hingorani AD. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2018; 21:1-386. [PMID: 28279251 DOI: 10.3310/hta21090] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Warfarin is effective for stroke prevention in atrial fibrillation (AF), but anticoagulation is underused in clinical care. The risk of venous thromboembolic disease during hospitalisation can be reduced by low-molecular-weight heparin (LMWH): warfarin is the most frequently prescribed anticoagulant for treatment and secondary prevention of venous thromboembolism (VTE). Warfarin-related bleeding is a major reason for hospitalisation for adverse drug effects. Warfarin is cheap but therapeutic monitoring increases treatment costs. Novel oral anticoagulants (NOACs) have more rapid onset and offset of action than warfarin, and more predictable dosing requirements. OBJECTIVE To determine the best oral anticoagulant/s for prevention of stroke in AF and for primary prevention, treatment and secondary prevention of VTE. DESIGN Four systematic reviews, network meta-analyses (NMAs) and cost-effectiveness analyses (CEAs) of randomised controlled trials. SETTING Hospital (VTE primary prevention and acute treatment) and primary care/anticoagulation clinics (AF and VTE secondary prevention). PARTICIPANTS Patients eligible for anticoagulation with warfarin (stroke prevention in AF, acute treatment or secondary prevention of VTE) or LMWH (primary prevention of VTE). INTERVENTIONS NOACs, warfarin and LMWH, together with other interventions (antiplatelet therapy, placebo) evaluated in the evidence network. MAIN OUTCOME MEASURES Efficacy Stroke, symptomatic VTE, symptomatic deep-vein thrombosis and symptomatic pulmonary embolism. Safety Major bleeding, clinically relevant bleeding and intracranial haemorrhage. We also considered myocardial infarction and all-cause mortality and evaluated cost-effectiveness. DATA SOURCES MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library, reference lists of published NMAs and trial registries. We searched MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library. The stroke prevention in AF review search was run on the 12 March 2014 and updated on 15 September 2014, and covered the period 2010 to September 2014. The search for the three reviews in VTE was run on the 19 March 2014, updated on 15 September 2014, and covered the period 2008 to September 2014. REVIEW METHODS Two reviewers screened search results, extracted and checked data, and assessed risk of bias. For each outcome we conducted standard meta-analysis and NMA. We evaluated cost-effectiveness using discrete-time Markov models. RESULTS Apixaban (Eliquis®, Bristol-Myers Squibb, USA; Pfizer, USA) [5 mg bd (twice daily)] was ranked as among the best interventions for stroke prevention in AF, and had the highest expected net benefit. Edoxaban (Lixiana®, Daiichi Sankyo, Japan) [60 mg od (once daily)] was ranked second for major bleeding and all-cause mortality. Neither the clinical effectiveness analysis nor the CEA provided strong evidence that NOACs should replace postoperative LMWH in primary prevention of VTE. For acute treatment and secondary prevention of VTE, we found little evidence that NOACs offer an efficacy advantage over warfarin, but the risk of bleeding complications was lower for some NOACs than for warfarin. For a willingness-to-pay threshold of > £5000, apixaban (5 mg bd) had the highest expected net benefit for acute treatment of VTE. Aspirin or no pharmacotherapy were likely to be the most cost-effective interventions for secondary prevention of VTE: our results suggest that it is not cost-effective to prescribe NOACs or warfarin for this indication. CONCLUSIONS NOACs have advantages over warfarin in patients with AF, but we found no strong evidence that they should replace warfarin or LMWH in primary prevention, treatment or secondary prevention of VTE. LIMITATIONS These relate mainly to shortfalls in the primary data: in particular, there were no head-to-head comparisons between different NOAC drugs. FUTURE WORK Calculating the expected value of sample information to clarify whether or not it would be justifiable to fund one or more head-to-head trials. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005324, CRD42013005331 and CRD42013005330. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Jonathan Ac Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Pritesh N Bodalia
- University College London Hospitals, NHS, London, UK.,Royal National Orthopaedic Hospital, NHS, London, UK
| | - Peter A Bryden
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Philippa A Davies
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jose A López-López
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - George N Okoli
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Howard Hz Thom
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Deborah M Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Julian Pt Higgins
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jelena Savović
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Reecha Sofat
- University College London, London, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Aroon D Hingorani
- University College London, London, UK.,London School of Hygiene and Tropical Medicine, London, UK
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Sergie Z, Gukathasan N, Yu JJ, Mehran R. The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations. Interv Cardiol Clin 2012; 1:441-451. [PMID: 28581962 DOI: 10.1016/j.iccl.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.
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Affiliation(s)
- Ziad Sergie
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Nilusha Gukathasan
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Jennifer J Yu
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA; Cardiovascular Research Foundation, 111 East 59th Street, New York, NY 10022, USA.
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Ndrepepa G, Schuster T, Hadamitzky M, Byrne RA, Mehilli J, Neumann FJ, Richardt G, Schulz S, Laugwitz KL, Massberg S, Schömig A, Kastrati A. Validation of the Bleeding Academic Research Consortium Definition of Bleeding in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention. Circulation 2012; 125:1424-31. [DOI: 10.1161/circulationaha.111.060871] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Bleeding Academic Research Consortium (BARC) has recently proposed a unified definition of bleeding in patients receiving antithrombotic therapy. We investigated the relationship between bleeding events as defined by BARC and 1-year mortality in patients undergoing percutaneous coronary intervention (PCI) and assessed whether the BARC bleeding definition is superior to existing bleeding definitions in regard to mortality prediction in patients after PCI procedures.
Methods and Results—
This study represents a patient-level pooled analysis of 12 459 patients recruited in 6 randomized trials of patients undergoing PCI. Bleeding events were assessed with the use of BARC, Thrombolysis in Myocardial Infarction (TIMI), and Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) trial criteria. The primary outcome was 1-year mortality. Bleeding occurred in 1233 patients (9.9%) according to BARC (679 patients or 5.4% with BARC class ≥2 bleeding), in 374 patients (3.0%) according to TIMI, and in 491 patients (3.9%) according to REPLACE-2 criteria. There were 340 deaths (2.7%) over the first year after PCI. BARC class ≥2 bleeding was associated with a significant increase in 1-year mortality (adjusted hazard ratio 2.72; 95% confidence interval, 2.03–3.63). The predictivity of a multivariable model for 1-year mortality was significantly improved after inclusion of bleeding defined according to BARC to an extent comparable to that provided by TIMI and REPLACE-2 criteria.
Conclusions—
The present study demonstrated a close association between bleeding events defined according to BARC and 1-year mortality after PCI.
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Affiliation(s)
- Gjin Ndrepepa
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Tibor Schuster
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Martin Hadamitzky
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Robert A. Byrne
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Julinda Mehilli
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Franz-Josef Neumann
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Gert Richardt
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Stefanie Schulz
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Karl-Ludwig Laugwitz
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Steffen Massberg
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Albert Schömig
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
| | - Adnan Kastrati
- From the Deutsches Herzzentrum München, München (G.N., M.H., R.A.B., J.M., S.S., S.M., A.S., A.K.); Institution für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Üniversität, München (T.S.); Herz-Zentrum, Bad Krozingen (F.N.); Herzzentrum der Segeberger Kliniken, Bad Segeberg (G.R.); and Medizinische Klinik rechts der Isar, Technische Üniversität, München (K.L., A.S.), Germany
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