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Elling T, Hak E, Bos JH, Tichelaar VYIG, Veeger NJGM, Meijer K. Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC. Thromb Haemost 2024; 124:778-790. [PMID: 37673103 PMCID: PMC11259495 DOI: 10.1055/a-2168-9378] [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: 04/25/2023] [Accepted: 09/03/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Current guideline suggests a switch from vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) in patients with low time in therapeutic range (TTR < 70%). Poor international normalized ratio (INR) control may be the result of poor compliance, and might therefore be associated with subsequent DOAC intake. Therefore, this study evaluates the effect of previous TTR and other measures of INR control on DOAC nonadherence and nonpersistence, in patients who switched from VKA to DOAC. METHODS A total of 437 patients who switched from VKA to DOAC between 2012 and 2019 were included using data from Certe Thrombosis Service, IADB.nl pharmacy community database University Groningen, and Statistics Netherlands. DOAC prescriptions were used to determine nonadherence and nonpersistence. INR control (i.e., TTR, time under therapeutic range [TUR], and INR variability) was assessed during the last 180 days of VKA use. Multivariable regression models were applied to determine the association between INR control and DOAC nonpersistence/nonadherence. RESULTS On VKA, 67.7% of the patients had a TTR below 70%. DOAC nonpersistence was 39.8% (95% confidence interval [CI]: 33.4-45.5%) during a median follow-up of 34.4 months (interquartile range: 19.1-49.2). Approximately 80% of persistent patients were DOAC-adherent. Low TTR was not associated with DOAC nonpersistence (hazard ratio: 1.14, 95% CI: 0.69-1.87) and DOAC nonadherence (odds ratio: 1.38, 95% CI: 0.67-2.84), nor were TUR and INR variability. CONCLUSION Previous INR control during VKA therapy is not associated with subsequent DOAC nonadherence and nonpersistence. This study suggests that INR control on VKA cannot, and therefore should not, be used for predicting DOAC adherence or persistence.
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Affiliation(s)
- Tessa Elling
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economy, University of Groningen, Groningen, The Netherlands
| | - Jens H. Bos
- Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economy, University of Groningen, Groningen, The Netherlands
| | - Vladimir Y. I. G. Tichelaar
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Certe Thrombosis Service, Groningen, The Netherlands
| | - Nic J. G. M. Veeger
- Department of Epidemiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Gulizia MM, Turazza FM, Ameri P, Alings M, Collins R, De Luca L, Di Nisio M, Lucci D, Gabrielli D, Janssens S, Parrini I, Pinto FJ, Zamorano J, Colivicchi F. Characteristics and Management of Patients With Cancer and Atrial Fibrillation: The BLITZ-AF Cancer Registry. JACC. ADVANCES 2024; 3:100991. [PMID: 39130025 PMCID: PMC11312304 DOI: 10.1016/j.jacadv.2024.100991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/06/2023] [Accepted: 02/14/2024] [Indexed: 08/13/2024]
Abstract
Background Atrial fibrillation (AF) is a frequent cardiovascular (CV) comorbidity in cancer. Objectives The purpose of this study was to examine clinical characteristics and contemporary management of patients with AF and cancer with a specific focus on antithrombotic treatments. Methods This was a prospective, multicenter, observational study of patients with a recent cancer diagnosis and electrocardiographically confirmed AF (the BLITZ-AF Cancer Registry). CHA2DS2VASc scores were calculated for study participants. Results Overall, 1,514 individuals were enrolled from June 2019 to September 2021 (mean age 74 ± 9 years, 47.5% of participants >75 years of age; 63.5% males). CV diseases were common: 20.9% had heart failure, 18.1% had coronary artery disease, 38.5% had valvular heart disease, and 9.8% had peripheral artery disease. Previous thromboembolic and hemorrhagic events occurred in 13.9% and 10.4% of subjects, respectively. The most common cancer types were lung (14.9%), colorectal (14.1%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%). In total, 41.5% of the patients had a CHA2DS2VASc score ≥4. Before admission or prior to cardiologist consultation, 16.6% of subjects were not taking any antithrombotic therapy and 22.7% were receiving antiplatelet agents and/or low-molecular-weight heparin. At discharge or after cardiologic assessment, these percentages dropped to 7.7% and 16.6%, respectively. This trend was paralleled by an increase in the use of direct-acting oral anticoagulant, while the proportion of vitamin K antagonist declined. Conclusions This study demonstrates that there is underuse of appropriate antithrombotic therapy for AF in cancer patients highlighting the need to integrate early CV assessment in the management of these patients. (Non-interventional Study on Patients With Atrial Fibrillation and Cancer [BLITZ-AF Cancer]; NCT03909386).
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Affiliation(s)
- Michele Massimo Gulizia
- Cardiology Division, Garibaldi-Nesima Hospital, Catania, Italy
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Fabio Maria Turazza
- Cardiology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Pietro Ameri
- Cardiac, Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Ronan Collins
- Age-Related Health Care Department, Tallaght University Hospital/Trinity College, Dublin, Ireland
| | - Leonardo De Luca
- Cardiology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Donata Lucci
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Domenico Gabrielli
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Rome, Italy
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Iris Parrini
- Cardiology Department, Mauriziano Umberto I Hospital, Torino, Italy
| | - Fausto J. Pinto
- Faculdade de Medicina, Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Universidade de Lisboa, Lisboa, Portugal
| | - Jose Zamorano
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), University Hospital Ramón y Cajal, Madrid, Spain
| | - Furio Colivicchi
- Clinical and Rehabilitation Unit, San Filippo Neri Hospital, Rome, Italy
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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [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: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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Han X, Yang X, Hidru TH, Wang C, Xia Y. Patterns of Anticoagulation Use and All-Cause of Mortality in Cancer Patients with Atrial Fibrillation. Cancer Epidemiol Biomarkers Prev 2024; 33:244-253. [PMID: 38088911 DOI: 10.1158/1055-9965.epi-23-0866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/23/2023] [Accepted: 11/13/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND There is uncertainty regarding the clinical benefit of anticoagulant (AC) treatment in patients with cancer with atrial fibrillation (AF). We aimed to evaluate the distribution and patterns of AC use and its impact on all-cause mortality in cancer patients with AF. METHODS A total of 1,653 patients with cancer diagnosed with AF were included in this retrospective cohort analysis. Multivariable logistic regression was applied to identify the clinical predictors of anticoagulant prescription. Kaplan-Meier curve with a log-rank test was used to compare the probability of survival between the AC and non-AC groups. Multivariate Cox proportional hazard regression models were implemented to evaluate the influences of various variables on all-cause death. RESULTS Of 1,653 patients with cancer with AF, 971 (58.7%) did not receive a prescription for AC. Among patients with CHA2DS2-VASC ≥2 in men or ≥3 in women and HAS-BLED <3, 56.5% were not prescribed AC. Rivaroxaban and warfarin are more frequently used than dabigatran, mainly in patients with lung and breast cancer. Over a median follow-up of 36 months, 776 deaths were identified. The Kaplan-Meier curve suggested that patients with AC prescriptions had better clinical outcomes. On multivariate Cox proportional risk regression analysis, AC prescription was significantly associated with a lower risk of all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = 0.002). CONCLUSIONS The prescription of anticoagulants in patients with cancer with AF was suboptimal. AC prescription at discharge was associated with a decreased risk of all-cause mortality. IMPACT This study highlights the importance of AC prescriptions in patients with cancer with AF.
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Affiliation(s)
- Xu Han
- Health Management Center, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xiaolei Yang
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Tesfaldet H Hidru
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Chengfang Wang
- Health Management Center, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yunlong Xia
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Patti G, Wang R, Marston XL, Yeh YC, Zimmermann L, Ye X, Gao X, Brüggenjürgen B. Anticoagulant Treatment Adherence and Persistence in German Patients with Atrial Fibrillation. Cardiol Ther 2023; 12:371-391. [PMID: 37138193 DOI: 10.1007/s40119-023-00315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION Treatment adherence and persistence impact the effectiveness of edoxaban for the prevention of thromboembolism in patients with atrial fibrillation (AF). The objective of this analysis was to assess adherence and persistence of edoxaban vs. other non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs). METHODS Utilizing a German claims database, adults with AF with the first pharmacy claim identified for edoxaban, apixaban, dabigatran, rivaroxaban, or VKAs from January 2013 to December 2017 were included in a propensity score-matched analysis. The first pharmacy claim was the index claim. Adherence (i.e., proportion of days covered [PDC]) and persistence (proportion of patients who continued therapy) were compared between edoxaban and other therapies. Patients receiving once-daily (QD) vs. twice-daily (BID) NOAC were also analyzed. RESULTS Overall, 21,038 patients were included (1236 edoxaban, 6053 apixaban, 1306 dabigatran, 7013 rivaroxaban, and 5430 VKA). After matching, baseline characteristics were well balanced across cohorts. Adherence was significantly higher for edoxaban vs. apixaban, dabigatran, and VKAs (all P < 0.0001). Significantly more edoxaban patients continued therapy vs. rivaroxaban (P = 0.0153), dabigatran (P < 0.0001), and VKAs (P < 0.0001). Time to discontinuation was significantly longer for edoxaban vs. dabigatran, rivaroxaban, and VKAs (all P < 0.0001). More patients receiving NOACs QD had a PDC ≥ 0.8 compared with those receiving NOACs BID (65.3 vs. 49.6%, respectively; P < 0.05); persistence rates were comparable between QD and BID groups. CONCLUSIONS Patients with AF receiving edoxaban had significantly higher adherence and persistence compared with those receiving VKAs. This trend was also seen in NOAC QD regimens vs. NOAC BID regimens for adherence. These results provide insight into how adherence and persistence may contribute to the effectiveness of edoxaban for stroke prevention in patients with AF in Germany.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
| | - Rosa Wang
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | | | | | | | - Xin Ye
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | - Xin Gao
- OPEN Health, Bethesda, MD, USA
| | - Bernd Brüggenjürgen
- Orthopedic Department, Medical School Hannover at DIAKOVERE Annastift Hospital, Hannover, Germany
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Siegal DM, Leong DP. Evaluating Anticoagulant Strategies for Atrial Fibrillation in Patients With Cancer: Challenges and Opportunities. JACC CardioOncol 2022; 4:351-353. [PMID: 36213364 PMCID: PMC9537084 DOI: 10.1016/j.jaccao.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Deborah M. Siegal
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darryl P. Leong
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
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