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Elshafei MN, El-Bardissy A, Salem M, Abdelmoneim MS, Khalil A, Elhadad S, Danjuma M. Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2024; 24:255-271. [PMID: 38386247 PMCID: PMC10973089 DOI: 10.1007/s40256-024-00628-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION oral anticoagulant (DOAC) agents are becoming the anticoagulation strategy of choice for most clinical risks for which they are indicated. However, residual uncertainty remains regarding their use in preventing stroke in patients with low bodyweight [< 60 kg or body mass index (BMI) < 18 kg/m2]. We have carried out pooled systematic analyses of published studies to determine the efficacy and safety of these agents compared with warfarin in stroke prevention in patients with low bodyweight. METHODS We carried out a comprehensive search of electronic databases from inception to June 2023 for eligible studies reporting on the efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. These include PubMed, EMBASE, the Cochrane Database of Systematic Reviews, the Science Citation Index, and the Database of Abstracts of Reviews of Effectiveness. Using the random effects model, derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes in patient cohorts exposed to direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. RESULTS Nine studies (n = 159,514 patients) were included in our meta-analysis. DOAC analogs were associated with lower stroke recurrence compared with warfarin [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.49-0.9]; however, there was no significant difference in the composite outcome (OR 0.81, 95% CI 0.59-1.09) and mortality (OR 0.82, 95% CI 0.48-1.41). Additionally, DOAC analogs showed a significant reduction in major bleeding events by 30% compared with warfarin (OR 0.70, 95% CI 0.62-0.80). CONCLUSION In this pooled meta-analytical synthesis of studies comprising both real-world and randomized controlled data, the use of DOAC analogs in patients with atrial fibrillation and low bodyweight (< 60 kg or BMI < 18 kg/m2) was associated with a significant reduction in risks of stroke and major bleeding compared with patient cohorts stabilized on warfarin-based therapy. There was uncertainty regarding the composite outcome and mortality point estimate between these two anticoagulation strategies. This finding helps to resolve the uncertainty associated with the use of DOACs in this cohort. Additionally, it suggests the need for confirmatory non-inferiority randomized controlled trials evaluating DOACs versus warfarin in this cohort of patients.
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Affiliation(s)
- Mohamed Nabil Elshafei
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar.
- Department of Pharmacy, Hamad Medical Corporation (HMC), P.O.3050, Doha, Qatar.
| | - Ahmed El-Bardissy
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Salem
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Khalil
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammed Danjuma
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
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Russo V, Falco L, Tessitore V, Mauriello A, Catapano D, Napolitano N, Tariq M, Caturano A, Ciccarelli G, D’Andrea A, Giordano A. Anti-Inflammatory and Anticancer Effects of Anticoagulant Therapy in Patients with Malignancy. Life (Basel) 2023; 13:1888. [PMID: 37763292 PMCID: PMC10532829 DOI: 10.3390/life13091888] [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: 08/14/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Optimizing the anticoagulation therapy is of pivotal importance in patients with a malignant tumor, as venous thromboembolism (VTE) has become the second-leading cause of death in this population. Cancer can highly increase the risk of thrombosis and bleeding. Consequently, the management of cancer-associated VTE is complex. In recent years, translational research has intensified, and several studies have highlighted the role of inflammatory cytokines in cancer growth and progression. Simultaneously, the pleiotropic effects of anticoagulants currently recommended for VTE have emerged. In this review, we describe the anti-inflammatory and anticancer effects of both direct oral anticoagulants (DOACs) and low-molecular-weight heparins (LWMHs).
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
| | - Luigi Falco
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Viviana Tessitore
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Alfredo Mauriello
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Dario Catapano
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Nicola Napolitano
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Moiz Tariq
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, 80138 Naples, NA, Italy (A.D.)
| | - Giovanni Ciccarelli
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80126 Naples, NA, Italy
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
| | - Antonello D’Andrea
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, 80138 Naples, NA, Italy (A.D.)
- Cardiology Unit, Umberto I Hospital, 84014 Nocera Inferiore, SA, Italy
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
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Falco L, Tessitore V, Ciccarelli G, Malvezzi M, D'Andrea A, Imbalzano E, Golino P, Russo V. Antioxidant Properties of Oral Antithrombotic Therapies in Atherosclerotic Disease and Atrial Fibrillation. Antioxidants (Basel) 2023; 12:1185. [PMID: 37371915 DOI: 10.3390/antiox12061185] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The thrombosis-related diseases are one of the leading causes of illness and death in the general population, and despite significant improvements in long-term survival due to remarkable advances in pharmacologic therapy, they continue to pose a tremendous burden on healthcare systems. The oxidative stress plays a role of pivotal importance in thrombosis pathophysiology. The anticoagulant and antiplatelet drugs commonly used in the management of thrombosis-related diseases show several pleiotropic effects, beyond the antithrombotic effects. The present review aims to describe the current evidence about the antioxidant effects of the oral antithrombotic therapies in patients with atherosclerotic disease and atrial fibrillation.
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Affiliation(s)
- Luigi Falco
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Viviana Tessitore
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Giovanni Ciccarelli
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Marco Malvezzi
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | | | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Paolo Golino
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
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Carbone A, Bottino R, Attena E, Parisi V, Conte M, D'Andrea A, Imbalzano E, Golino P, Russo V. Clinical impact of oral anticoagulation among octogenarians with atrial fibrillation and anaemia. J Thromb Thrombolysis 2023; 55:222-227. [PMID: 36472719 DOI: 10.1007/s11239-022-02740-3] [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] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Our study aimed to describe the efficacy and safety of oral anticoagulation (OAC) use in elderly patients (> or = 80 years-old) with atrial fibrillation (AF) and concomitant anaemia. Data for this study were sourced from AF Research Database (NCT03760874). AF patients aged ≥ 80 who received OAC treatment, both direct oral anticoagulant (DOAC) and vitamin K antagonist (VKA) were selected. Participants were categorized as anaemic and non-anaemic. The primary outcome was the occurrence of overall bleeding. The primary effectiveness outcome was the occurrence of thromboembolic events (a composite of ischemic stroke, transient ischemic attack and systemic embolism). The secondary safety and effectiveness outcomes were major, minor bleedings and mortality, respectively. A total of 958 patients were included in the study, 120 (12.5%) were anaemic; among them, 93 patients (76.6%) were treated with VKAs and 28 (23.3%) with DOAC. Kaplan-Meier curves for major bleedings showed significant differences between anemic- and non-anemic groups (log-rank p = 0.005). In multivariate analysis, among patients on OAC, anaemia was independently associated with major bleeding (HR 2.36; 95% IC 1.2-4.4; p = 0.006), intracranial hemorrhages (HR 3.81; 95% IC 1.35-10.7; p = 0.01) and minor bleedings (HR 2.40; 95%IC 1.1-5.2; p = 0.02); these associations were not confirmed in the DOACs subgroup. No difference in survival was shown between anaemic- and non-anaemic groups and among anaemic patients, between DOAC and VKAs subgroups. Anaemic octogenarians with AF on OAC therapy showed a significantly increased risk of major bleedings, in particular ICH, and mortality compared to non-anaemic.
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Affiliation(s)
- Andreina Carbone
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberta Bottino
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Emilio Attena
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Valentina Parisi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Maddalena Conte
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolo Golino
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"- Monaldi Hospital, P.zzale Ettore Ruggeri, 80131, Naples, Italy.
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Gender Differences in Atrial Fibrillation: From the Thromboembolic Risk to the Anticoagulant Treatment Response. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020254. [PMID: 36837457 PMCID: PMC9963174 DOI: 10.3390/medicina59020254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with an increased thromboembolic risk. The impact of the female sex as an independent risk factor for thromboembolic events in AF is still debated. Background and Objectives: The aim of this review is to evaluate the gender-related differences in cardioembolic risk and response to anticoagulants among AF patients. Materials and Methods: The PubMed database is used to review the reports about gender differences and thromboembolic risk in atrial fibrillation. Results: Non-vitamin K oral anticoagulants (NOACs) represent the gold standard for thromboembolic risk prevention in patients with non-valvular atrial fibrillation (NVAF). Despite a similar rate of stroke and systemic embolism (SE) among men and women in NOACs or vitamin K antagonists (VKAs) treatment, the use of NOACs in AF women is associated with a lower risk of intracranial bleeding, major bleeding, and all-cause mortality than in men. Conclusions: The female sex can be defined as a stroke risk modifier rather than a stroke risk factor since it mainly increases the thromboembolic risk in the presence of other risk factors. Further studies about the efficacy and safety profile of NOACs according to sex are needed to support clinicians in performing the most appropriate and tailored anticoagulant therapy, either in male or female AF patients.
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Carbone A, Bottino R, D’Andrea A, Russo V. Direct Oral Anticoagulants for Stroke Prevention in Special Populations: Beyond the Clinical Trials. Biomedicines 2023; 11:biomedicines11010131. [PMID: 36672639 PMCID: PMC9856013 DOI: 10.3390/biomedicines11010131] [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: 11/17/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Currently, direct oral anticoagulants (DOACs) are the first-line anticoagulant strategy in patients with non-valvular atrial fibrillation (NVAF). They are characterized by a more favorable pharmacological profile than warfarin, having demonstrated equal efficacy in stroke prevention and greater safety in terms of intracranial bleeding. The study population in the randomized trials of DOACs was highly selected, so the results of these trials cannot be extended to specific populations such as obese, elderly, frail, and cancer patients, which, on the other hand, are sub-populations widely represented in clinical practice. Furthermore, due to the negative results of DOAC administration in patients with mechanical heart valves, the available evidence in subjects with biological heart valves is still few and often controversial. We sought to review the available literature on the efficacy and safety of DOACs in elderly, obese, underweight, frail, cancer patients, and in patients with bioprosthetic heart valves with NVAF to clarify the best anticoagulant strategy in these special and poorly studied subpopulations.
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Affiliation(s)
- Andreina Carbone
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Roberta Bottino
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Antonello D’Andrea
- Unit of Cardiology and Intensive Coronary Care, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy
| | - Vincenzo Russo
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Monaldi Hospital, P.zzale Ettore Ruggeri, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-5665144
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Taoutel R, Ezekowitz MD, Chaudhry UA, Weber C, Hassan D, Gracely EJ, Kamareddine MH, Horn BI, Harper GR. Retrospective Comparison of Patients ≥ 80 Years With Atrial Fibrillation Prescribed Either an FDA-Approved Reduced or Full Dose Direct-Acting Oral Anticoagulant. IJC HEART & VASCULATURE 2022; 43:101130. [PMID: 36246771 PMCID: PMC9556913 DOI: 10.1016/j.ijcha.2022.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 11/21/2022]
Abstract
Direct-acting oral anticoagulants (DOACs) represent the standard for preventing stroke and systemic embolization (SSE) in patients with atrial fibrillation (AF). There is limited information for patients ≥ 80 years. We report a retrospective analysis of AF patients ≥ 80 years prescribed either a US Food and Drug Administration (FDA)-approved reduced (n = 514) or full dose (n = 199) DOAC (Dabigatran, Rivaroxaban, or Apixaban) between January 1st, 2011 (first DOAC commercially available) and May 31st, 2017. The following multivariable differences in baseline characteristics were identified: patients prescribed a reduced dose DOAC were older (p < 0.001), had worse renal function (p = 0.001), were more often prescribed aspirin (p = 0.004) or aspirin and clopidogrel (p < 0.001), and more often had new-onset AF (p = 0.001). SSE and central nervous system (CNS) bleed rates were low and not different (1.02 vs 0 %/yr and 1.45 vs 0.44 %/yr) for the reduced and full dose groups, respectively. For non-CNS bleeds, rates were 10.89 vs 4.15 %/yr (p < 0.001, univariable) for the reduced and full doses, respectively. The mortality rate was 6.24 vs 1.75 %/yr (p = 0.001, univariable) for the reduced and full doses. Unlike the non-CNS bleed rate, mortality rate differences remained significant when adjusted for baseline characteristics. Thus, DOACs in patients ≥ 80 with AF effectively reduce SSE with a low risk of CNS bleeding, independent of DOAC dose. The higher non-CNS bleed rate and not the mortality rate is explained by the higher risk baseline characteristics in the reduced DOAC dose group. Further investigation of the etiology of non-CNS bleeds and mortality is warranted.
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Key Words
- A2.5, Apixaban 2.5 mg twice daily
- A5, Apixaban 5 mg twice daily
- AF, atrial fibrillation
- Atrial fibrillation
- BMMSA, Bryn Mawr Medical Specialists Association
- CKD, chronic kidney disease
- CNS, central nervous system
- CrCl, creatinine clearance
- D110, Dabigatran 110 mg twice daily
- D150, Dabigatran 150 mg twice daily
- D75, Dabigatran 75 mg twice daily
- DOAC
- DOACs, direct-acting oral anticoagulants
- Direct-acting oral anticoagulants
- ESRD, end-stage renal disease
- Elderly
- FDA, Food and Drug Administration
- R15, Rivaroxaban 15 mg daily
- R20, Rivaroxaban 20 mg daily
- SSE, stroke and systemic embolization
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Affiliation(s)
- Roy Taoutel
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Michael D. Ezekowitz
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA,Bryn Mawr Hospital Main Line Health, Bryn Mawr, PA, USA,Sidney Kimmel Medical College at Jefferson University, Philadelphia, PA, USA,Corresponding author at: 214 N Ithan Ave, Villanova, PA 19085, USA.
| | - Usman A. Chaudhry
- Bryn Mawr Hospital Main Line Health, Bryn Mawr, PA, USA,Sidney Kimmel Medical College at Jefferson University, Philadelphia, PA, USA
| | - Carly Weber
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Dana Hassan
- Lankenau Medical Center Main Line Health, Wynnewood, PA, USA
| | - Ed J. Gracely
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
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Russo V, Attena E, Baroni M, Trotta R, Manu MC, Kirchhof P, De Caterina R. Clinical Performance of Oral Anticoagulants in Elderly with Atrial Fibrillation and Low Body Weight: Insight into Italian Cohort of PREFER-AF and PREFER-AF Prolongation Registries. J Clin Med 2022; 11:jcm11133751. [PMID: 35807032 PMCID: PMC9267647 DOI: 10.3390/jcm11133751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Elderly patients are at high risk of both ischaemic and bleeding events, and the low body weight is considered a risk factor for major bleeding in atrial fibrillation (AF) patients on anticoagulation therapy. The aim of our study was to compare the safety and effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) versus well-controlled vitamin-K antagonists (VKA) therapy among AF patients aged >75 years and with a body weight <60 kg in a prospective registry setting. Methods: Data for this study were sourced from the Italian cohorts of PREFER in AF and PREFER in AF PROLONGATION registries. The occurrence of a composite of stroke, transient ischemic attack and systemic embolism (thromboembolic events) was the primary effectiveness endpoint. The occurrence of major bleeding was the primary safety endpoint. All-cause hospitalizations and all-cause death were the secondary endpoints. The net clinical benefit (NCB) was calculated in order to obtain an integrated assessment of the anti-thromboembolic and pro-haemorrhagic effects of NOACs vs. VKA. Results: Overall, 522 patients were included; 225 were on treatment with NOACs and 317 patients with VKA. The NOAC group more frequently featured a higher BMI and a higher prevalence of history of stroke/TIA and insulin-requiring diabetes; conversely, heart failure and chronic liver disease were less frequent in the NAOC group. In the unmatched study population, 18 patients (3.6% in the NOAC vs. 3.2% in the VKA group, p = 0.79) experienced thromboembolic events; 19 patients (1.78% in the NOAC vs. 4.73% in the VKA group, p = 0.06) experienced major bleeding events; and 68 patients were hospitalized during the follow-up (9.3% vs. 14.8%, p = 0.06). After balancing for potential confounders by using the 1:1 propensity score matching technique, 426 patients (213 on NOAC and 213 on VKA) were selected. We found no significant differences in terms of thromboembolic events (3.76% vs. 4.69%, p = 0.63), major bleeding events (n: 1.88% vs. 4.22%, p = 0.15) and hospitalizations (9.9% vs. 16.9%, p = 0.06) between NOAC vs. VKA matched population. Based on these incidences, we found a positive net clinical benefit (+1.6) of NOACs vs. VKAs. Conclusions: These real-world data suggest the safety and effectiveness of using NOACs in elderly patients with low body weight.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”-Monaldi Hospital, 80131 Naples, Italy;
- Correspondence:
| | - Emilio Attena
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”-Monaldi Hospital, 80131 Naples, Italy;
| | - Matteo Baroni
- Cardiologia 3–A. De Gasperis Cardio Center, ASST GOM Niguarda Ca’Granda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Roberta Trotta
- Medical Affairs Department, Daiichi Sankyo, 00142 Rome, Italy;
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK;
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa, Italy;
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Carbone A, Santelli F, Bottino R, Attena E, Mazzone C, Parisi V, D'Andrea A, Golino P, Nigro G, Russo V. Prevalence and clinical predictors of inappropriate direct oral anticoagulant dosage in octagenarians with atrial fibrillation. Eur J Clin Pharmacol 2022; 78:879-886. [PMID: 35138442 PMCID: PMC9005392 DOI: 10.1007/s00228-022-03286-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/30/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Older age is associated with inappropriate dose prescription of direct oral anticoagulants. The aim of our study was to describe the prevalence and the clinical predictors of inappropriate DOACs dosage among octogenarians in real-world setting. METHODS Data for this study were sourced from the multicenter prospectively maintained Atrial Fibrillation (AF) Research Database (NCT03760874). Of the AF patients aged ≥ 80 who received DOACs treatment, 253 patients were selected. Participants were categorized as appropriate dosage, overdosage, or underdosage. Underdosage and overdosage were, respectively, defined as administration of a lower or higher DOAC dose than recommended in the EHRA consensus. RESULTS A total of 178 patients (71%) received appropriate DOACs dose and 75 patients (29%) inappropriate DOACs dose; among them, 19 patients (25.6%) were overdosed and 56 (74.4%) were underdosed. Subgroup analysis demonstrated that underdosage was independently associated with male gender [OR = 3.15 (95% IC; 1.45-6.83); p < 0.001], coronary artery disease [OR = 3.60 (95% IC 1.45-9.10); p < 0.001] and body mass index [OR = 1.27 (1.14-1.41); p < 0.001]. Overdosage was independently associated with diabetes mellitus [OR = 18 (3.36-96); p < 0.001], with age [OR = 0.76 (95% IC; 0.61-0.96; p = 0.045], BMI [OR = 0.77 (95% IC; 0.62-0.97; p = 0.043] and with previous bleedings [OR = 6.40 (0.7; 1.43-28); p = 0.039]. There wasn't significant difference in thromboembolic, major bleeding events and mortality among different subgroups. Underdosage group showed a significatively lower survival compared with appropriate dose group (p < 0.001). CONCLUSION In our analysis, nearly one-third of octogenarians with AF received an inappropriate dose of DOAC. Several clinical factors were associated with DOACs' overdosage (diabetes mellitus type II, previous bleeding) or underdosage (male gender, coronary artery disease, and higher body mass index). Octogenarians with inappropriate DOACs underdosage showed less survival.
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Affiliation(s)
- Andreina Carbone
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, P.Zzale Ettore Ruggeri, 80131, Naples, Italy
| | - Francesco Santelli
- Department of Political Sciences, University of Naples Federico II, Naples, Italy
| | - Roberta Bottino
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, P.Zzale Ettore Ruggeri, 80131, Naples, Italy
| | - Emilio Attena
- Department of Cardiology, Health Authority Naples 2 North, Naples, Italy
| | | | - Valentina Parisi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, P.Zzale Ettore Ruggeri, 80131, Naples, Italy
| | - Gerardo Nigro
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, P.Zzale Ettore Ruggeri, 80131, Naples, Italy
| | - Vincenzo Russo
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, P.Zzale Ettore Ruggeri, 80131, Naples, Italy.
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Bezabhe WM, Bereznicki LR, Radford J, Wimmer BC, Curtain C, Salahudeen MS, Peterson GM. Factors influencing oral anticoagulant use in patients newly diagnosed with atrial fibrillation. Eur J Clin Invest 2021; 51:e13457. [PMID: 33222261 DOI: 10.1111/eci.13457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF. METHODS Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice. RESULTS A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA2 DS2 -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001). CONCLUSIONS The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia.
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Affiliation(s)
| | - Luke R Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Jan Radford
- Launceston Clinical School, Tasmanian School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Barbara C Wimmer
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Colin Curtain
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | | | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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11
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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12
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Russo V, Cassini R, Caso V, Donno C, Laezza A, Naddei M, Fiorelli A, Golino P, Nigro G. Nursing Teleconsultation for the Outpatient Management of Patients with Cardiovascular Disease during COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042087. [PMID: 33669951 PMCID: PMC7924875 DOI: 10.3390/ijerph18042087] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
Introduction: During the COVID-19 outbreak, non-urgent clinic visits or cardiac interventional procedures were postponed to a later date, and the implementation of telemedicine has guaranteed continuity of care for patients with chronic diseases. The aim of our study was to describe the medical interventions following nursing teleconsultation for the outpatient management of patients with cardiovascular diseases during the COVID-19 pandemic. Materials and Methods: All patients who did not attend the follow-up visit from 4 to 15 April 2020 at our institution and who were re-scheduled due to the COVID-19 lockdown were selected to be enrolled in the study. Each patient was followed by a semi-structured telephonic interview performed by a nurse. The outcomes of our study were to assess the patients' adherence to nursing teleconsultation and the usefulness of nursing teleconsultation to detect clinical conditions in need of medical intervention. Results: In total, 203 patients (81%) underwent nursing teleconsultation in a mean time of 7 ± 3 days from the outpatient visit lost due to the COVID-19 lockdown. Furthermore, 53 patients (26%) showed poor adherence to nursing teleconsultation. Among the 150 patients (mean age 67 ± 10 years; 68% male) who completed the telephonic interview, the nursing teleconsultation revealed the need of medical intervention in 69 patients (46%), who were more likely at very high cardiovascular risk (77% vs. 48%; p < 0.0003) and who showed a higher prevalence of dyslipidemia (97% vs. 64%; p < 0.0001) and coronary artery disease (75% vs. 48%, p < 0.0008) compared to those not in need of any intervention. The up-titration of the lipid-lowering drugs (n: 32, 74%) was the most frequent medical intervention following the nursing teleconsultation. The mean time between the nursing teleconsultation and the date of the rescheduled in-person follow-up visit was 164 ± 36 days. Conclusions: Nursing teleconsultation is a simple and well-tolerated strategy that ensures the continuity of care and outpatient management for patients with cardiovascular diseases during the COVID-19 pandemic.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli” , Monaldi Hospital, 80131 Naples, Italy; (R.C.); (P.G.); (G.N.)
- Correspondence:
| | - Roberta Cassini
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli” , Monaldi Hospital, 80131 Naples, Italy; (R.C.); (P.G.); (G.N.)
| | - Valentina Caso
- Cardiac Diagnostic Unit, Monaldi Hospital, 80131 Naples, Italy; (V.C.); (C.D.); (A.L.)
| | - Chiara Donno
- Cardiac Diagnostic Unit, Monaldi Hospital, 80131 Naples, Italy; (V.C.); (C.D.); (A.L.)
| | - Annunziata Laezza
- Cardiac Diagnostic Unit, Monaldi Hospital, 80131 Naples, Italy; (V.C.); (C.D.); (A.L.)
| | - Maria Naddei
- Day Hospital Surgery Unit, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
| | - Paolo Golino
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli” , Monaldi Hospital, 80131 Naples, Italy; (R.C.); (P.G.); (G.N.)
| | - Gerardo Nigro
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli” , Monaldi Hospital, 80131 Naples, Italy; (R.C.); (P.G.); (G.N.)
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13
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Grymonprez M, De Backer TL, Steurbaut S, Boussery K, Lahousse L. Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) Versus Warfarin in Patients with Atrial Fibrillation and (Morbid) Obesity or Low Body Weight: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther 2021; 36:749-761. [PMID: 33428092 DOI: 10.1007/s10557-020-07122-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Oral anticoagulants are crucial for preventing systemic thromboembolism in atrial fibrillation (AF), with guidelines preferring non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) in the general AF population. However, as NOACs are administered in fixed doses, concerns of unintentional underdosing in morbidly obese patients and unintentional overdosing in underweight patients have emerged. Therefore, a critical appraisal of the benefit-risk profile of NOACs in AF patients across the body weight spectrum is needed. METHODS AND RESULTS After searching Medline, this systematic review discusses the impact of body weight on the risk-benefit profile of NOACs versus VKAs. The meta-analysis demonstrated that NOAC use in obese and class III obese AF patients (body mass index (BMI) ≥ 30 and ≥ 40 kg/m2, respectively) was associated with significantly lower stroke/systemic embolism (stroke/SE) risks (RR 0.82, 95%CI [0.71-0.96] and RR 0.75, 95%CI [0.64-0.87], respectively), similar to lower major bleeding risks (RR 0.83, 95%CI [0.69-1.00] and RR 0.74, 95%CI [0.57-0.95], respectively) and similar mortality risks (RR 0.92, 95%CI [0.73-1.15] and RR 1.17, 95%CI [0.83-1.64], respectively) compared to VKAs. In AF patients ≤ 60 kg, significantly lower stroke/SE (RR 0.63, 95%CI [0.56-0.71]) and major bleeding risks (RR 0.71, 95%CI [0.62-0.80]), but similar mortality risks (RR 0.68, 95%CI [0.42-1.10]), were observed for NOAC- versus VKA-treated patients. CONCLUSION The benefit-risk profile of NOACs seems preserved in (morbidly) obese AF patients and patients with low body weight. However, more data are needed on underweight AF patients (BMI < 18.5 kg/m2) and on differences between NOACs in these patients.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015, Rotterdam, The Netherlands
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14
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Santos IS, Goulart AC, Olmos RD, Thomas GN, Lip GYH, Lotufo PA, Benseñor IM. Atrial fibrillation in low- and middle-income countries: a narrative review. Eur Heart J Suppl 2020; 22:O61-O77. [PMID: 33380945 PMCID: PMC7753884 DOI: 10.1093/eurheartj/suaa181] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA2DS2-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.
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Affiliation(s)
- Itamar S Santos
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.,Internal Medicine Deparment, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Alessandra C Goulart
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.,Internal Medicine Deparment, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo D Olmos
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.,Internal Medicine Deparment, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - G Neil Thomas
- Institute for Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute for Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Paulo A Lotufo
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.,Internal Medicine Deparment, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Isabela M Benseñor
- Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.,Internal Medicine Deparment, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
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