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Whitlock RP, Bhatt DL, Eikelboom JW. Reduced-Intensity Anticoagulation for Mechanical Aortic Valve Prostheses. J Am Coll Cardiol 2019; 71:2727-2730. [PMID: 29903345 DOI: 10.1016/j.jacc.2018.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Richard P Whitlock
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics and Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Deepak L Bhatt
- Brigham and Women's Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBHATTMD
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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2
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Antiplatelet Drugs in the Management of Venous Thromboembolism, Cardioembolism, Ventricular Assist Devices, and Pregnancy Complications. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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3
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Manckoundia P, Buzens JB, Mahmoudi R, d'Athis P, Martin I, Laborde C, Menu D, Putot A. The prescription of antiplatelet medication in a very elderly population: An observational study in 15 141 ambulatory subjects. Int J Clin Pract 2017; 71. [PMID: 28940596 DOI: 10.1111/ijcp.13020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/02/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Despite the frequent use of antiplatelet medication (AM) in the elderly patients, very few studies have investigated its prescription. We describe AM prescription through retrospective study in ambulatory elderly patients. METHOD All subjects aged over 80 years with a medical prescription delivered in March 2015 and affiliated to the Mutualité Sociale Agricole de Bourgogne. Subjects with prescriptions for AM were compared with those without. RESULTS A total of 15 141 ambulatory elderly patients (83-89 years, 61.3% of women) were included and 4412 (29.14%) had a prescription for AM. The latter were more frequently men than those without AM (43% vs 36.93%, P < .0001) and more frequently had chronic comorbidities (77.24% vs 64.65%, P < .0001). Compared with ambulatory subjects without AM, those with AM more frequently had coronary heart disease (35.15% vs 14.49%), severe hypertension (30% vs 25.65%), diabetes (27.42% vs 20.64%), peripheral arterial diseases (16.28% vs 5.96%) and disabling stroke (9% vs 5.56% (all P < .0001). In addition, they had more prescriptions of beta-blockers (45.24% vs 36.90%), angiotensin conversion enzyme inhibitor (31.35% vs 25.44%), calcium channel blockers (33.34% vs 27.90%), nitrate derivatives (10.6% vs 6.03%) or hypolipidemic agents (HA; 49.81% vs 29.72%) (all P < .0001) than those without AM. CONCLUSION In this study, which is very interested for its size and the advanced age of the subjects, long-course AM was prescribed in one third of ambulatory elderly patients. Coronary heart disease, severe hypertension and diabetes were more frequent in AM subjects. However, the low percentage of declared strokes was surprising. We provide additional data to doctors following subjects with AM.
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Affiliation(s)
- Patrick Manckoundia
- Pôle Personnes Âgées, Hospital of Champmaillot, University Hospital, Dijon, France
- UMR Inserm/U1093 Cognition, Action Sensorimotor Plasticity, University of Burgundy Franche Comté, Dijon, France
| | - Jean-Baptiste Buzens
- Pôle Personnes Âgées, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Rachid Mahmoudi
- Department of Geriatrics, University Hospital, Reims, France
| | - Philippe d'Athis
- Department of Biostatistics and Medical Information, François Mitterrand Hospital, University Hospital, Dijon, France
| | - Isabelle Martin
- Pôle Personnes Âgées, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Caroline Laborde
- Pôle Personnes Âgées, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Didier Menu
- Mutualité Sociale Agricole of Burgundy, Dijon, France
| | - Alain Putot
- Pôle Personnes Âgées, Hospital of Champmaillot, University Hospital, Dijon, France
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4
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Lip GYH, Collet JP, Caterina RD, Fauchier L, Lane DA, Larsen TB, Marin F, Morais J, Narasimhan C, Olshansky B, Pierard L, Potpara T, Sarrafzadegan N, Sliwa K, Varela G, Vilahur G, Weiss T, Boriani G, Rocca B, Gorenek B, Savelieva I, Sticherling C, Kudaiberdieva G, Chao TF, Violi F, Nair M, Zimerman L, Piccini J, Storey R, Halvorsen S, Gorog D, Rubboli A, Chin A, Scott-Millar R. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017; 19:1757-1758. [DOI: 10.1093/europace/eux240] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 01/08/2023] Open
Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (Chair, representing EHRA)
| | - Jean Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut De Cardiologie, Groupe Hôpital Pitié-Salpetrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Faculté de Medicinde, Université François Rabelais, Tours, France
| | - Deirdre A Lane
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Torben B Larsen
- Thrombosis Research Unit,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | | | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Leiria, Portugal
| | | | | | - Luc Pierard
- Department of Cardiology, University Hospital Sart-Tilman, Liege, Belgium
| | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Center (WHO Collaborating Center), Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, South Africa; and Mary McKillop Institute, ACU, Melbourne, Australia
| | - Gonzalo Varela
- Servicio de Electrofisiología, Centro Cardiovascular Casa de Galicia, Hidalgos, Uruguay
| | - Gemma Vilahur
- Cardiovascular Science Institute - ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
| | - Thomas Weiss
- Medical Department For Cardiology and Intensive Care, Wilhelminenhospital, and Medical Faculty Sigmund Freud University, Vienna, Austria
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy (Co-Chair, representing ESC Working Group on Thrombosis)
| | - Bulent Gorenek
- Eskisehir Osmangazi University, Eskisehir, Turkey (Reviewer Coordinator)
| | - Irina Savelieva
- Molecular and Clinical Sciences Institute, St George's University of London, London, UK
| | | | | | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (APHRS reviewer)
| | | | - Mohan Nair
- Department of Cardiology, Max Super Specialty Hospital, New Delhi, India
| | - Leandro Zimerman
- Hospital de Cl쭩cas de Porto Alegre, Federal University of Rio Grande do Sul, Brasil (SOLAECE reviewer)
| | - Jonathan Piccini
- Duke University Medical Center, Duke Clinical Research Institute, Durham, USA (HRS reviewer)
| | - Robert Storey
- Department of Cardiovascular Sciences, University of Sheffield, Sheffield, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Diana Gorog
- National Heart and Lung Institute, Imperial College, London, and Postgraduate Medicine, University of Hertfordshire, Hertfordshire, UK
| | - Andrea Rubboli
- Ospedale Maggiore, Division of Cardiology, Bologna, Italy (Working Group of Thrombosis reviewer)
| | - Ashley Chin
- Electrophysiology and Pacing, Groote Schuur Hospital, University of Cape Town, South Africa (CASSA reviewer)
| | - Robert Scott-Millar
- Department of Medicine, Division of Cardiology, University of Cape Town, South Africa (SAHeart reviewer)
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5
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Frouws MA, van Herk-Sukel MPP, Maas HA, Van de Velde CJH, Portielje JEA, Liefers GJ, Bastiaannet E. The mortality reducing effect of aspirin in colorectal cancer patients: Interpreting the evidence. Cancer Treat Rev 2017; 55:120-127. [PMID: 28359968 DOI: 10.1016/j.ctrv.2016.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Abstract
In 1971 the first study appeared that suggested a relationship between aspirin and cancer. Currently publications on the subject of aspirin and cancer are numerous, with both a beneficial effect of aspirin on cancer incidence and a beneficial effect on cancer survival. This review focusses on the relation between the use of aspirin and improved survival in colorectal cancer patients. Various study designs have been used, with the main part being observational studies and post hoc meta-analyses of cancer outcomes in cardiovascular prevention trials. The results of these studies are unambiguously pointing towards an effect of aspirin on colorectal cancer survival, and several randomised controlled trials are currently ongoing. Some clinicians feel that the current evidence is conclusive and that the time has come for aspirin to be prescribed as adjuvant therapy. However, until this review, not much attention has been paid to the specific types of bias associated with these studies. One of these biases is confounding by indication, because aspirin is indicated for patients as secondary prevention for cardiovascular disease. This review aims to provide perspective on these biases and provide tools for the interpretation of the current evidence. Albeit promising, the current evidence is not sufficient to already prescribe aspirin as adjuvant therapy for colorectal cancer.
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Affiliation(s)
- Martine A Frouws
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands.
| | - Myrthe P P van Herk-Sukel
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30/40, 3528 AE Utrecht, The Netherlands
| | - Huub A Maas
- Department of Geriatric Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Cornelis J H Van de Velde
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Haga Hospital, Leyweg 275, 2545 CH The Hague, The Netherlands
| | - Gerrit-Jan Liefers
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
| | - Esther Bastiaannet
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
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Karlsson WK, Jensen JS, Jakobsen JC. Antiplatelet therapy for preventing stroke in people with atrial fibrillation. Hippokratia 2016. [DOI: 10.1002/14651858.cd012428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- William K Karlsson
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Jakob S Jensen
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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7
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El-Hamamsy MH, Elsisi GH, Eldessouki R, Elmazar MM, Taha AS, Awad BF, Elmansy H. Economic Evaluation of the Combined Use of Warfarin and Low-dose Aspirin Versus Warfarin Alone in Mechanical Valve Prostheses. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:431-440. [PMID: 27028445 DOI: 10.1007/s40258-016-0238-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The use of combined therapy of antiplatelet and anticoagulant versus anticoagulant alone to reduce instances of thromboembolic events in patients with heart valve prostheses is an established standard of care in many countries but not in Egypt. A previous Markov model cost-effectiveness study on Egyptian patients aged 50-60 years demonstrated that the combined therapy reduces the overall treatment cost. However, due to the lack of actual real-world data on cost-effectiveness and the limitation of the Markov model study to 50- to 60-year-old patients, the Egyptian medical community is still questioning whether the added benefit is worth the cost. OBJECTIVE To assess, from the perspective of the Egyptian health sector, the cost-effectiveness of the combined use of warfarin and low-dose aspirin (75 mg) versus that of warfarin alone in patients with mechanical heart valve prostheses who began therapy between the age of 15 and 50 years. METHODS An economic evaluation was conducted alongside a randomized, controlled trial to assess the cost-effectiveness of the combined therapy in patients with mechanical valve prostheses. A total of 316 patients aged between 15 and 50 years were included in the study and randomly assigned to a group treated with both warfarin and aspirin or a group treated with warfarin alone. RESULTS The patients in the combined therapy group exhibited a significantly longer duration of protection against the first event. Fewer primary events were observed in the patients treated with warfarin plus aspirin than in those treated with warfarin alone (1.4 %/year, vs. 4.8 %/year), and a higher mean quality-adjusted life-years (QALYs) value over 4 years was obtained for the group treated with warfarin plus aspirin (difference 0.058; 95 % CI 0.013-0.118), although this difference did not reach a conventional level of statistical significance. The total costs over a 4-year period were lower with the combined therapy (difference -US$244; 95 % CI -US$483.1 to -US$3.8), which yielded an incremental cost-effectiveness ratio of -US$4206 per QALY gained. Thus, the combined therapy was dominant. All costs were reported in US dollars (USD) for the financial year 2014. CONCLUSIONS The results of this analysis indicate that from the perspective of the Egyptian health sector, the addition of aspirin to the typical warfarin therapy is more effective and less costly for patients with mechanical valve prostheses than treatment with warfarin alone. This combined strategy could be adopted to prevent the complications of mechanical valve prostheses. Our study adds to the body of evidence supporting the option of warfarin-plus-aspirin therapy for patients with mechanical valve prostheses.
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Affiliation(s)
| | - Gihan H Elsisi
- Faculty of Pharmacy, German University in Cairo, Cairo, Egypt.
- Pharmacoeconomic Unit, Central Administration for Pharmaceutical Affairs, Cairo, Egypt.
| | | | - Mohamed M Elmazar
- Faculty of Pharmacy, The British University in Egypt (BUE), Cairo, Egypt
| | - Ahmed S Taha
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Cardiothoracic Surgery Unit, Ain Shams University Hospitals, Cairo, Egypt
| | - Basma F Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Cardiothoracic Surgery Unit, Ain Shams University Hospitals, Cairo, Egypt
| | - Hossam Elmansy
- Faculty of Business Administration, Canadian International College, Cairo, Egypt
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8
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Getachew H, Bhagavathula AS, Abebe TB, Belachew SA. Inappropriate prescribing of antithrombotic therapy in Ethiopian elderly population using updated 2015 STOPP/START criteria: a cross-sectional study. Clin Interv Aging 2016; 11:819-27. [PMID: 27382265 PMCID: PMC4920226 DOI: 10.2147/cia.s107394] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Inappropriate use of antiplatelets and anticoagulants among elderly patients increases the risk of adverse outcomes. The aim of this study was to assess the prevalence of inappropriate prescribing of antithrombotic therapy in hospitalized elderly patients. Methods A retrospective cross-sectional, single-center study was conducted at the Gondar University Hospital. A total of 156 hospitalized elderly patients fulfilling the inclusion/exclusion criteria were included in the study. The Screening Tool for Older Person’s Prescription/Screening Tool to Alert doctors to Right Treatment criteria version 2 were applied to patients’ data to identify the total number of inappropriate prescribing (IPs) including potentially inappropriate medications and potential prescribing omissions. Results A total of 70 IPs were identified in 156 patients who met the inclusion criteria. Of these, 36 (51.4%) were identified as potentially inappropriate medications by the Screening Tool for Older Person’s Prescription criteria. The prevalence of IP per patient indicated that 58 of the 156 (37.2%) patients were exposed to at least one IP. Of these, 32 (55.2%) had at least one potentially inappropriate medication and 33 (56.9%) had at least one potential prescribing omission. Patients hospitalized due to venous thromboembolism (adjusted odds ratio [AOR] =29.87, 95% confidence interval [CI], 1.26–708.6), stroke (AOR =7.74, 95% CI, 1.27–47.29), or acute coronary syndrome (AOR =13.48, 95% CI, 1.4–129.1) were less likely to be exposed to an IP. An increase in Charlson comorbidity index score was associated with increased IP exposure (AOR =0.60, 95% CI, 0.39–0.945). IPs were about six times more likely to absent in patients prescribed with antiplatelet only therapy (AOR =6.23, 95% CI, 1.90–20.37) than those receiving any other groups of antithrombotics. Conclusion IPs are less common in elderly patients primarily admitted due to venous thromboembolism, stroke, and acute coronary syndrome, and those elderly patients prescribed with only antiplatelet. Patients with higher Charlson comorbidity index were, however, associated with increased IPs exposure. Our study may guide further research to reduce high-risk prescription of antithrombotics in the elderly.
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Affiliation(s)
- Henok Getachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Akshaya Srikanth Bhagavathula
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tamrat Befekadu Abebe
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Sewunet Admasu Belachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Patient-Centred Care of Older Adults With Cardiovascular Disease and Multiple Chronic Conditions. Can J Cardiol 2016; 32:1097-107. [PMID: 27378591 DOI: 10.1016/j.cjca.2016.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 12/21/2022] Open
Abstract
Multimorbidity, defined as the presence of 2 or more chronic conditions, is common among older adults with cardiovascular disease. These individuals are at increased risk for poor health outcomes and account for a large proportion of health care utilization. Clinicians are challenged with the heterogeneity of this population, the complexity of the treatment regimen, limited high-quality evidence, and fragmented health care systems. Each treatment recommended by a clinical practice guideline for a single cardiovascular disease might be rational, but the combination of all evidence-based recommendations can be impractical or even harmful to individuals with multimorbidity. These challenges can be overcome with a patient-centred approach that incorporates the individual's preferences, relevant evidence, the overall and condition-specific prognosis, clinical feasibility of treatments, and interactions with other treatments and coexisting chronic conditions. The ultimate goal is to maximize benefits and minimize harms by optimizing adherence to the most essential treatments, while acknowledging trade-offs between treatments for different health conditions. It might be necessary to discontinue therapies that are not essential or potentially harmful to decrease the risk of drug-drug and drug-disease interactions from polypharmacy. A decision to initiate, withhold, or stop a treatment should be on the basis of the time horizon to benefits vs the individual's prognosis. In this review, we illustrate how cardiologists and general practitioners can adopt a patient-centred approach to focus on the aspects of cardiovascular and noncardiovascular health that have the greatest effect on functioning and quality of life in older adults with cardiovascular disease and multimorbidity.
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10
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Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement. ACTA ACUST UNITED AC 2014; 34:902-906. [DOI: 10.1007/s11596-014-1371-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 10/18/2014] [Indexed: 10/24/2022]
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11
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Elsisi GH, Eldessouki R, Kalo Z, Elmazar MM, Taha AS, Awad BF, El-Hamamsy MH. Cost-Effectiveness of the Combined Use of Warfarin and Low-Dose Aspirin versus Warfarin Alone in Egyptian Patients with Aortic Valve Replacements: A Markov Model. Value Health Reg Issues 2014; 4:24-30. [PMID: 29702802 DOI: 10.1016/j.vhri.2014.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The combination of antiplatelet and anticoagulant therapy significantly reduces the rate of thromboembolic events in patients with heart valves compared with anticoagulant therapy alone. Cost-effectiveness of this therapy in Egypt, however, has not yet been established. OBJECTIVE The aim of the present study was to evaluate the cost-effectiveness of the combined use of warfarin and low-dose aspirin (100 mg) versus warfarin alone in patients with mechanical aortic heart valve prostheses who began therapy at the age of 50 to 60 years over a 5-year period from the perspective of the medical providers. METHODS A cohort Markov process model with five health states (recovery, reoperation, bleeding, thromboembolism, and death) based on Egyptian clinical practice was derived from published sources. The clinical parameters were derived from meta-analyses of randomized controlled trials of patients with mechanical valve prostheses. The quality of life of the health states was derived using the available published data. Direct medical costs were obtained from four top-rated governmental cardiology hospitals in Egypt. All costs and effects were discounted at 3.5% annually. All costs were converted using the purchasing power parity rate and are reported in US $ for the financial year of 2013. RESULTS The total quality-adjusted life-years (QALYs) were estimated to be 1.1616 and 1.1199 for the warfarin plus aspirin group and the warfarin group, respectively, which resulted in a difference of 0.0416 QALYs. The total costs for the warfarin plus aspirin group and the warfarin group were US $307.33 and US $315.25, respectively (the difference was US $7.92), which yielded an incremental cost-effectiveness ratio of -190.38 for the warfarin plus aspirin group. Thus, the combined therapy was dominant. Various one-way sensitivity analyses indicated that probabilities of reoperation and bleeding in the recovery state had the greatest effects on incremental costs. The model parameters that had the greatest effects on incremental QALYs were the relative risk reduction of death and the utility value in the recovery state. CONCLUSIONS The present study is the first cost-utility analysis to conclude that, from the perspective of Egyptian medical providers, combined therapy is more effective and less costly than warfarin alone for patients with mechanical aortic valve prostheses. For clinicians and patients who choose to focus on minimizing thromboembolic risk, these results suggest that combined therapy offers the best protection. This study helps to inform decisions about the allocation of health care system resources and to achieve better health in the Egyptian population.
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Affiliation(s)
- Gihan H Elsisi
- Pharmacoeconomic Unit, Central Administration for Pharmaceutical Affairs, Cairo, Egypt.
| | - Randa Eldessouki
- Scientific and Health Policy Initiatives, International Society for Pharmacoeconomics and Outcomes Research, NJ, USA; Faculty of Medicine, Fayoum University, Al Fayoum, Egypt
| | - Zoltan Kalo
- Health Economics Research Centre, Eötvös Loránd University, Budapest, Hungary
| | - Mohamed M Elmazar
- Faculty of Pharmacy, The British University in Egypt (BUE), El Sherouk, Cairo, Egypt
| | - Ahmed S Taha
- Faculty of Medicine, Ain Shams University, Cairo, Egypt; Cardiothoracic Surgery Unit, Ain Shams University Hospitals, Cairo, Egypt
| | - Basma F Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt; Cardiothoracic Surgery Unit, Ain Shams University Hospitals, Cairo, Egypt
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McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Bonet LA, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Flachskampf FA, Guida GF, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Ørn S, Parissis JT, Ponikowski P. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur J Heart Fail 2014; 14:803-69. [PMID: 22828712 DOI: 10.1093/eurjhf/hfs105] [Citation(s) in RCA: 1818] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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13
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Mahan CE, Spyropoulos AC, Fisher MD, Fields LE, Mills RM, Stephenson JJ, Fu AC, Klaskala W. Antithrombotic medication use and bleeding risk in medically ill patients after hospitalization. Clin Appl Thromb Hemost 2013; 19:504-12. [PMID: 23324537 DOI: 10.1177/1076029612470967] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Hospitalized medically ill patients receiving antithrombotic medications experience increased risk of bleeding. We examined antithrombotic use, bleeding rates, and associated risk factors at 30 days post discharge. METHODS This retrospective database analysis included nonsurgical patients aged ≥40 years hospitalized for ≥2 days during 2005 to 2009. Previously cited, validated International Classification of Diseases, Ninth Revision, Clinical Modification codes for major bleeding were used to define clinically relevant bleeding. RESULTS Of the 327,578 patients, 9.1% received antithrombotic medications, of which 3.7% were anticoagulants. Rates of major and minor bleeding were 1.8% and 7.1%, respectively. Preindex gastroduodenal ulcer, thromboembolic stroke, blood dyscrasias, liver disease, and rehospitalization were the strongest predictors of major bleeding. Other risk factors included increasing age, male gender, and hospital stay of ≥3 days. CONCLUSIONS Careful consideration of these demonstrated bleed-associated comorbidities before initiating anticoagulation or combining antithrombotic medications in medically ill patients may improve strategies for prevention of postdischarge thromboembolism.
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Affiliation(s)
- Charles E Mahan
- 1Department of Outcomes Research, New Mexico Heart Institute, Albuquerque, NM, USA
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14
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McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez Sanchez MA, Jaarsma T, Køber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, h T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Almenar Bonet L, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Arnold Flachskampf F, Francesco Guida G, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Ørn S, Parissis JT, Ponikowski P. Guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica 2012. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2012.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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15
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McMurray JJV, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GYH, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Bonet LA, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Flachskampf FA, Guida GF, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Orn S, Parissis JT, Ponikowski P. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787-847. [PMID: 22611136 DOI: 10.1093/eurheartj/ehs104] [Citation(s) in RCA: 3482] [Impact Index Per Article: 290.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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16
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McMurray JJV, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Kober L, Lip GYH, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Ronnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Bonet LA, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Flachskampf FA, Guida GF, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Orn S, Parissis JT, Ponikowski P. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012. [DOI: 78495111110.1093/eurheartj/ehs104' target='_blank'>'"<>78495111110.1093/eurheartj/ehs104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [78495111110.1093/eurheartj/ehs104','', '10.1111/j.1525-1497.2004.30419.x')">Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
78495111110.1093/eurheartj/ehs104" />
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17
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Evaluation of drug-drug interaction screening software combined with pharmacist intervention. Int J Clin Pharm 2012; 34:547-52. [PMID: 22535491 DOI: 10.1007/s11096-012-9642-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 04/14/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND Drug-drug interactions (DDI) in hospitalized patients are highly prevalent and an important source of adverse drug reactions. DI computerized screening system can prevent the occurrence of some of these events. OBJECTIVE To evaluate the impact of drug-drug interaction (DDI) screening software combined with active intervention in preventing drug interactions. SETTING The study was conducted at General Hospital of Vitória da Conquista (HGVC), Brazil. METHOD A quasi-experimental study was used to evaluate the impact of IM-Pharma, a locally developed drug-drug interaction screening system, coupled with pharmacist intervention on adverse drug events in the hospital setting. MAIN OUTCOME MEASURE The proportion of patients co-prescribed two interacting drugs were measured in two phases, prior the implementation of IM-Pharma and during the intervention period. DDI rates per 100 patient days were calculated before and after implementation. Risk ratios were estimated by Poisson regression models. RESULTS A total of 6,834 instances of drug-drug interactions were identified; there was an average of 3.3 DDIs per patient in phase one and 2.5 in phase two, a reduction of 24 % (P = 0.03). There was a 71 % reduction in high-severity drug-drug interaction (P < 0.01). The risk for all DDIs decreased 50 % after the implementation of IM-Pharma (P < 0.01), and for those with high-severity, the reduction was 81 % (P < 0.01). CONCLUSION The performance of IM-Pharma combined with pharmacist intervention was positive with an expressive reduction in the risk of DDIs.
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18
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Anticoagulation Review. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2012. [DOI: 10.1177/1084822311432336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anticoagulants, also known as antithrombotics, are among the most commonly prescribed medications in the United States. Understanding how these medications work, the propensity for interactions with other drugs, dietary factors, and disease states is important for clinicians assessing and providing care to patients in all environments. In this review, we seek to provide essential information for the home health care provider for evaluating patients receiving anticoagulants commonly prescribed in the home health care setting. The low-molecular-weight heparins and vitamin K antagonists are the most commonly used agents for outpatient anticoagulation. New agents, such as the direct factor Xa inhibitors and direct thrombin inhibitors have recently been approved with additional new agents in the approval process and development pipeline. We seek to review the most pertinent information for each of these classes of medications providing information on pharmacology, interactions with other drugs, diet, and diseases and important clinical information.
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19
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Tamura T, Sakaeda T, Kadoyama K, Okuno Y. Aspirin- and clopidogrel-associated bleeding complications: data mining of the public version of the FDA adverse event reporting system, AERS. Int J Med Sci 2012; 9:441-6. [PMID: 22859904 PMCID: PMC3410363 DOI: 10.7150/ijms.4549] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/22/2012] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Adverse event reports (AERs) submitted to the US Food and Drug Administration (FDA) were reviewed to assess the bleeding complications induced by the administration of antiplatelets and to attempt to determine the rank-order of the association. METHODS After a deletion of duplicated submissions and the revision of arbitrary drug names, AERs involving warfarin, aspirin, cilostazol, clopidogrel, ethyl icosapentate, limaprost alfadex, sarpogrelate, and ticlopidine were analyzed. Authorized pharmacovigilance tools were used for the quantitative detection of signals, i.e., drug-associated adverse events, including the proportional reporting ratio, the reporting odds ratio, the information component given by a Bayesian confidence propagation neural network, and the empirical Bayes geometric mean. RESULTS Based on 22,017,956 co-occurrences, i.e., drug-adverse event pairs, found in 1,644,220 AERs from 2004 to 2009, 736 adverse events were listed as warfarin-associated adverse events, and 147 of the 736 were bleeding complications, including haemorrhage and haematoma. Both aspirin and clopidogrel were associated with haemorrhage, but the association was more noteworthy for clopidogrel. As for bleeding complications related to the gastrointestinal system, e.g., melaena and haematochezia, the statistical metrics suggested a stronger association for aspirin than clopidogrel. The total number of co-occurrences was not large enough to compare the association with bleeding complications for the other 5 antiplatelets. CONCLUSIONS The data strongly suggest the necessity of well-organized clinical studies with respect to antiplatelet-associated bleeding complications.
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20
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Anticoagulation therapy with combined low dose aspirin and warfarin following mechanical heart valve replacement. Thromb Res 2011; 128:e91-4. [DOI: 10.1016/j.thromres.2011.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 11/23/2022]
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21
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Leiria TLL, Lopes RD, Williams JB, Katz JN, Kalil RAK, Alexander JH. Antithrombotic therapies in patients with prosthetic heart valves: guidelines translated for the clinician. J Thromb Thrombolysis 2011; 31:514-22. [PMID: 21327503 PMCID: PMC3699194 DOI: 10.1007/s11239-011-0574-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with prosthetic heart valves require chronic oral anticoagulation. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Currently, only vitamin K antagonists are approved for this indication. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients.
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Affiliation(s)
- Tiago L. L. Leiria
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | - Renato D. Lopes
- Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, Box 3850, Durham, NC 27710, UK
| | - Judson B. Williams
- Duke Clinical Research Institute, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, UK
| | - Jason N. Katz
- Division of Cardiology & Division of Pulmonary/Critical Care Medicine, University of North Carolina Center for Heart and Vascular Care, Chapel Hill, NC, UK
| | - Renato A. K. Kalil
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil. Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - John H. Alexander
- Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, Box 3850, Durham, NC 27710, UK
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Effectiveness and safety of combined antiplatelet and anticoagulant therapy: a critical review of the evidence from randomized controlled trials. Blood Rev 2011; 25:123-9. [PMID: 21354678 DOI: 10.1016/j.blre.2011.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Antiplatelet and anticoagulant drugs are effective for the prevention of arterial and venous thrombosis but patients continue to experience major cardiovascular events despite their use. Strategies to improve the effectiveness of antithrombotic therapies include selecting the optimal drug and dosing regimen, the use of combinations of antiplatelet and anticoagulant drugs and the development of new more effective drugs to replace existing therapies. Evidence from randomized controlled trials indicates that the combination of aspirin and an anticoagulant is more effective than aspirin alone for the prevention of recurrent cardiovascular events in patients with acute coronary syndrome and is more effective than anticoagulation alone for the prevention of thromboembolic events in patients with mechanical heart valves, but at a cost of increased bleeding. Randomized controlled trials provide no evidence for improved effectiveness of combination therapy compared with antiplatelet therapy alone for the prevention of recurrent cardiovascular events in patients with non-cardioembolic stroke or peripheral artery disease, or compared with anticoagulant therapy alone for the prevention of stroke in patients with atrial fibrillation. Despite lack of evaluation in randomized controlled trials, combination therapy is commonly used in patients with separate indications for antiplatelet therapy (e.g., acute coronary syndrome, recent coronary artery stent) and anticoagulant therapy (e.g., atrial fibrillation with at least one additional risk factor for stroke). Randomized trials are urgently required to evaluate the effectiveness and safety of combining antiplatelet and anticoagulant therapy in these settings.
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Sun JCJ, Davidson MJ, Lamy A, Eikelboom JW. Antithrombotic management of patients with prosthetic heart valves: current evidence and future trends. Lancet 2009; 374:565-76. [PMID: 19683642 DOI: 10.1016/s0140-6736(09)60780-7] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over 4 million people worldwide have received a prosthetic heart valve, and an estimated 300,000 valves are being implanted every year. Prosthetic heart valves improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thrombotic complications in valve recipients poses challenges for clinicians and patients. Here, we review antithrombotic therapies for patients with prosthetic heart valves and management of thromboembolic complications. Advances in antithrombotic therapy and valve technologies are likely to improve the management of patients with prosthetic heart valves in developed countries, but the most important unmet need and potential for benefit from these new therapies is in developing countries where a massive and rapidly increasing burden of valvular heart disease exists.
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Affiliation(s)
- Jack C J Sun
- Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada.
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24
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Furlan AJ. Does the Combination of Warfarin and Aspirin Have a Place in Secondary Stroke Prevention? Stroke 2009; 40:1942-3. [DOI: 10.1161/strokeaha.108.537662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony J. Furlan
- From the Department of Neurology, Neurological Institute Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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25
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Johnson S. Known knowns and known unknowns: risks associated with combination antithrombotic therapy. Thromb Res 2008; 123 Suppl 1:S7-11. [PMID: 18829070 DOI: 10.1016/j.thromres.2008.08.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Use of antiplatelet therapy in combination with oral anticoagulants remains controversial. The purpose of this article is to review current consensus recommendations for antithrombotic therapy, to evaluate risks for bleeding among patients taking combination antithrombotic therapy, and lastly to review single-center data from Kaiser Permanente Colorado detailing clinical outcomes associated with combination therapy. METHODS This was a retrospective, longitudinal pharmacoepidemiologic review. Adult patients receiving warfarin managed by a clinical pharmacy service who had documented antiplatelet (aspirin, clopidogrel, and/or dipyridamole) use (combination therapy cohort) or non-use (monotherapy cohort) were identified as of September 30, 2005. Utilizing integrated, electronic medical records, anticoagulation-related adverse events (death, hemorrhage, thrombosis) and coronary events were identified during a six-month follow-up (October 2005 through March 2006). Proportions of events were compared between cohorts. Independent associations between the cohorts and the outcomes were assessed with adjustment for potential confounding factors. RESULTS Data from 2,560 monotherapy and 1,623 combination therapy patients were analyzed. Patients in the combination therapy cohort were more likely to have had anticoagulation-related hemorrhages (4.2% vs. 2.0%, unadjusted p<0.001). With adjustment, combined warfarin and antiplatelet use was independently associated with hemorrhagic (OR=2.75; 95% CI 1.44, 5.28) but not coronary (OR=0.99; 95% CI 0.37, 2.62) events. CONCLUSIONS At the population level, the hemorrhagic risk associated with warfarin therapy combined with antiplatelet therapy appears to outweigh the benefits. These findings suggest that clinicians carefully consider risks and benefits when prescribing antiplatelet therapy for patients taking warfarin who do not meet evidence-based criteria for that approach.
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Affiliation(s)
- S Johnson
- Clinical Pharmacy Services, Rock Creek Medical Center, Kaiser Permanente Colorado, Denver, CO, USA.
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Concomitant antiplatelet and anticoagulation therapy: indications, controversies and practical advice. Thromb Res 2008; 123 Suppl 1:S11-5. [PMID: 18822448 DOI: 10.1016/j.thromres.2008.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The use of combination antiplatelet and anticoagulant therapy is commonly encountered in clinical practice and is often a source of clinical controversy in regards to the efficacy versus the safety of this regimen. The benefit of combination therapy relates to the probable additive effect of suppressing both platelet and coagulation factor activities. The risk of dual therapy is the potential for increased hemorrhagic events which may outweigh the clinical benefit. This review will focus on the clinical evidence that has demonstrated greater efficacy with combination therapy over either antiplatelet or anticoagulant therapy alone. Clinicians should consider the importance of documentation of combination therapy use in their patients in an effort to target those patients with the greatest benefit, and to avoid unnecessary complications.
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Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis. CMAJ 2008; 179:235-44. [PMID: 18663203 DOI: 10.1503/cmaj.080171] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients taking oral anticoagulant therapy balance the risks of hemorrhage and thromboembolism. We sought to determine the association between anticoagulation intensity and the risk of hemorrhagic and thromboembolic events. We also sought to determine how under-or overanticoagulation would influence patient outcomes. METHODS We reviewed the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL databases to identify studies involving patients taking anticoagulants that reported person-years of observation and the number of hemorrhages or thromboemboli in 3 or more discrete ranges of international normalized ratios. We estimated the overall relative and absolute risks of events specific to anticoagulation intensity. RESULTS We included 19 studies. The risk of hemorrhage increased significantly at high international normalized ratios. Compared with the therapeutic ratio of 2-3, the relative risk (RR) of hemorrhage (and 95% confidence intervals [CIs]) were 2.7 (1.8-3.9; p < 0.01) at a ratio of 3-5 and 21.8 (12.1-39.4; p < 0.01) at a ratio greater than 5. The risk of thromboemboli increased significantly at ratios less than 2, with a relative risk of 3.5 (95% CI 2.8-4.4; p < 0.01). The risk of hemorrhagic or thromboembolic events was lower at ratios of 3-5 (RR 1.8, 95% CI 1.2-2.6) than at ratios of less than 2 (RR 2.4, 95% CI 1.9-3.1; p = 0.10). We found that a ratio of 2-3 had the lowest absolute risk (AR) of events (AR 4.3%/yr, 95% CI 3.0%-6.3%). CONCLUSIONS The risks of hemorrhage and thromboemboli are minimized at international normalized ratios of 2-3. Ratios that are moderately higher than this therapeutic range appear safe and more effective than subtherapeutic ratios.
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Affiliation(s)
- Natalie Oake
- Department of Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ont
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Johnson SG, Rogers K, Delate T, Witt DM. Outcomes Associated With Combined Antiplatelet and Anticoagulant Therapy. Chest 2008; 133:948-54. [DOI: 10.1378/chest.07-2627] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Garcia DA, Khamashta MA, Crowther MA. How we diagnose and treat thrombotic manifestations of the antiphospholipid syndrome: a case-based review. Blood 2007; 110:3122-7. [PMID: 17644740 DOI: 10.1182/blood-2006-10-041814] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Antiphospholipid antibodies including anticardiolipin antibodies, lupus anticoagulants, and anti–β2 glycoprotein-1–specific antibodies may identify patients at elevated risk of first or recurrent venous or arterial thromboembolism. Traditionally, published case series supplemented by anecdotal experience have formed the basis of management of patients with these autoantibodies. Over the past several years, studies have described the management of patients with key clinical manifestations of antiphospholipid antibodies, including patients with antiphospholipid antibody syndrome. As a result, evidence-based treatment recommendations are possible for selected patients with, or at risk of, thrombosis in the setting of antiphospholipid antibodies. Unfortunately, most patients encountered in clinical practice do not correspond directly with those enrolled in clinical trials. For such patients, treatment recommendations are based on experience, extrapolation, and less rigorous evidence. This article proposes 5 cases typical of those found in clinical practice and provides recommendations for therapy focused on a series of clinical questions. Whenever possible, the recommendations are based on evidence; however, in many cases, insufficient evidence exists, so the recommendation is experiential.
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Affiliation(s)
- David A Garcia
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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Eikelboom JW, Hirsh J. Combined antiplatelet and anticoagulant therapy: clinical benefits and risks. J Thromb Haemost 2007; 5 Suppl 1:255-63. [PMID: 17635734 DOI: 10.1111/j.1538-7836.2007.02499.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The combination of anticoagulant and antiplatelet therapy is more effective than antiplatelet therapy alone for the initial and long-term management of acute coronary syndromes but increases the risk of bleeding. Antiplatelet therapy is often combined with oral anticoagulants in patients with an indication for warfarin therapy (e.g. atrial fibrillation) who also have an indication for antiplatelet therapy (e.g. coronary artery disease) but the appropriateness of such an approach is unresolved. Anticoagulation appears to be as effective as antiplatelet therapy for long-term management of acute coronary syndrome and stroke, and possibly peripheral artery disease, but causes more bleeding. Therefore, in such patients who develop atrial fibrillation, switching from antiplatelet therapy to anticoagulants might be all that is required. The combination of anticoagulant and antiplatelet therapy has only been proven to provide additional benefit over anticoagulants alone in patients with prosthetic heart valves. The combination of aspirin and clopidogrel is not as effective as oral anticoagulants in patients with atrial fibrillation, whereas the combination of aspirin and clopidogrel is more effective than oral anticoagulants in patients with coronary stents. Whether the benefits of triple therapy outweigh the risks in patients with atrial fibrillation and coronary stents requires evaluation in randomized trials.
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Affiliation(s)
- J W Eikelboom
- Thrombosis Service, Hamilton General Hospital, Hamilton, ON, Canada.
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31
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Oake N, Fergusson DA, Forster AJ, van Walraven C. Frequency of adverse events in patients with poor anticoagulation: a meta-analysis. CMAJ 2007; 176:1589-94. [PMID: 17515585 PMCID: PMC1867836 DOI: 10.1503/cmaj.061523] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients taking anticoagulants orally over the long term have international normalized ratios (INRs) outside the individual therapeutic range more than one-third of the time. Improved anticoagulation control will reduce hemorrhagic and thromboembolic event rates. To gauge the potential effect of improved anticoagulation control, we undertook to determine the proportion of anticoagulant-associated events that occur when INRs are outside the therapeutic range. METHODS We conducted a meta-analysis of all studies that assigned hemorrhagic and thromboembolic events in patients taking anticoagulants to discrete INR ranges. We identified studies using the MEDLINE (1966-2006) and EMBASE (1980-2006) databases. We included studies reported in English if the majority of patients taking oral anticoagulants had an INR range with a lower limit between 1.8 and 2 and an upper limit between 3 and 3.5, and their INR at the time of the hemorrhagic or thromboembolic event was recorded. RESULTS The final analysis included results from 45 studies (23 that reported both hemorrhages and thromboemboli; 14 that reported hemorrhages only; and 8, thromboemboli only) involving a median of 208 patients (limits of interquartile range [25th-75th percentile] 131-523 subjects; total n = 71 065). Of these studies, 64% were conducted at community practices; the remainder, at anticoagulation clinics. About 69% of the studies were classed as having moderate or high quality. Overall, 44% (95% confidence interval [CI] 39%-49%) of hemorrhages occurred when INRs were above the therapeutic range, and 48% (95% CI 41%-55%) of thromboemboli took place when below it. The mean proportion of events that occurred while the patient's INR was outside the therapeutic range was greater for studies with a short mean follow-up (< 1 yr). Between-study heterogeneity was significant (p < 0.001). INTERPRETATION Improved anticoagulation control could decrease the likelihood of almost half of all anticoagulant-associated adverse events.
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Affiliation(s)
- Natalie Oake
- Department of Medicine, University of Ottawa, Ottawa, Ont.
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Biyik I, Mercan I, Ergene O, Oto O. Ocular bleeding related to warfarin anticoagulation in patients with mechanical heart valve and atrial fibrillation. J Int Med Res 2007; 35:143-9. [PMID: 17408066 DOI: 10.1177/147323000703500116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We investigated the incidence of ocular bleeding in patients taking anticoagulant therapy (warfarin) and its association with other related factors. We examined 210 patients taking warfarin and 210 gender- and age-matched controls for ocular bleeding. Patients and controls were examined by external ocular examination and fundoscopic examination. The incidence of ocular bleeding was 11.4% in patients and 3.8% in controls. It was five times higher in patients with hypertension than in other patients. The incidence of ocular bleeding was higher in older than in younger patients. No association was found between ocular bleeding and factors such as gender, international normalized ratio, duration of warfarin therapy, concomitant aspirin use and diabetes mellitus. Thus, warfarin therapy increases the frequency of ocular bleeding. The higher incidence of ocular bleeding in the patients with hypertension and advanced age should be kept in mind and this subgroup of patients taking warfarin should be monitored closely.
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Affiliation(s)
- I Biyik
- Department of Cardiology, Uşak State Hospital, Uşak, Turkey.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004. [DOI: 10.1002/pds.925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Understanding the frequency, risk factors, and management of anticoagulant-induced adverse events will assist clinicians in optimizing patient outcomes. The most frequent adverse event of all anticoagulants is major bleeding. Risk factors for major bleeding have been identified with the heparin compounds, the direct thrombin inhibitors (DTIs), fondaparinux, and warfarin therapy. Understanding these risk factors can help prevent bleeding events. For cases of clinically significant bleeding, reversal agents exist primarily for heparin and warfarin. Although less common, nonbleeding adverse events of anticoagulant therapy can also be life threatening. The heparin compounds are associated with the development of heparin-induced thrombocytopenia (HIT) and osteoporosis. HIT can result in life-threatening thrombosis and is usually managed with a DTI. Nonbleeding adverse events with warfarin therapy include skin reactions and the development of venous limb gangrene. Appropriate initiation of warfarin therapy may decrease the risk of venous limb gangrene.
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Affiliation(s)
- Maureen A. Smythe
- Department of Pharmacy Practice, Wayne State University, Detroit, Michigan, William Beaumont Hospital, Royal Oak, Michigan,
| | - William E. Dager
- University of California, Davis, Medical Center, University of California, San Francisco, School of Pharmacy
| | - Nima M. Patel
- Temple University School of Pharmacy, Philadelphia, Pennsylvania
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