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Yu D, Brown J, David Strain W, Simmons D. Real-world evidence that among atrial fibrillation patients warfarin is associated with reduced nonelective admissions compared with those on DOACs. Clin Cardiol 2023; 46:1544-1553. [PMID: 37681472 PMCID: PMC10716333 DOI: 10.1002/clc.24146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Randomized trials show inconsistent estimates on risks of direct-acting oral anticoagulants (DOACs) versus warfarin in bleeding and mortality for atrial fibrillation (AF) patients. Trials are confounded by additional DOAC adherence support, while warfarin has a low time in therapeutic range. Few real-world studies compared emergency hospitalization risk between DOAC and warfarin users in AF. This study aimed to determine emergency hospitalization risk for AF patients on DOACs or warfarin in real-world settings. METHODS A tapered-matched real-world cohort extracted data from 412 English general practices' primary care records linked with emergency department (ED) and hospitalization data from the ECLIPSE database. AF patients with new DOAC or warfarin prescriptions were included. The primary outcome was all-cause ED attendance; the secondary outcomes were ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months. Weighted Cox regression estimated relative risk difference. RESULTS 39 201 DOAC patients were matched with 13 145 warfarin patients. DOAC patients had a 25% higher likelihood of attending ED (odds ratio 1.25; 95% confidence interval [CI] 1.01-1.55). DOAC use also associated with higher ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months: 1.41 (95% CI 1.00-1.98), 1.26 (1.00-1.57), and 1.54 (1.01-2.34), respectively, with p-values < .05. CONCLUSIONS DOACs for AF thromboprophylaxis are associated with the increased risk of ED attendance, recurrent hospitalization, and numerical rise in ED re-attendance and first nonelective hospitalization compared to warfarin. However, these real-world data cannot establish if this difference results from medication adherence, lack of regular DOAC clinic monitoring, unmeasured confounders, or fundamental agent efficacy disparities.
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Affiliation(s)
- Dahai Yu
- Primary Care Centre Versus Arthritis, School of Medicine, Faculty of Medicine & Health Sciences, Keele UniversityKeeleUK
| | | | - W. David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science and College of Medicine and Health, University of ExeterExeterUK
| | - David Simmons
- Macarthur Clinical School, School of MedicineWestern Sydney UniversitySydneyNew South WalesAustralia
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Cao Y, Zheng Y, Li S, Liu F, Xue Z, Yin K, Luo J. An Updated Meta-Analysis of DOACs vs. VKAs in Atrial Fibrillation Patients With Bioprosthetic Heart Valve. Front Cardiovasc Med 2022; 9:899906. [PMID: 35783817 PMCID: PMC9248967 DOI: 10.3389/fcvm.2022.899906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Current guidelines recommend the utilization of direct-acting oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (AF). However, the optimal anticoagulation strategy for AF patients with bioprosthetic heart valves (BPHV) remains controversial. Therefore, we conducted this meta-analysis to explore the effect of DOACs versus vitamin K antagonists (VKAs) in this population. Methods We systematically searched the PubMed and Embase databases until November 2021 for studies reporting the effect of DOACs versus VKAs in AF patients with BPHV. Adjusted risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using the random-effects model with an inverse variance method. Results We selected four randomized clinical trials and seven observational studies (2236 DOAC- and 6403 VKAs-users). Regarding the effectiveness outcomes, there were no significant differences between DOACs and VKAs in stroke or systemic embolism (RR = 0.74, 95%CI: 0.50–1.08), ischemic stroke (RR = 1.08, 95%CI: 0.76–1.55), all-cause death (RR = 0.98, 95%CI: 0.86–1.12), and cardiovascular death (RR = 0.85, 95%CI: 0.40–1.80). In terms of the safety outcomes, DOACs was associated with lower risks of major bleeding (RR = 0.70, 95%CI: 0.59–0.82) and intracranial bleeding (RR = 0.42, 95%CI: 0.26–0.70), but the risks of any bleeding (RR = 0.85, 95%CI: 0.65–1.13) and gastrointestinal bleeding (RR = 0.92, 95%CI: 0.73–1.17) are not significantly different when compared with VKAs. The subgroup analysis with follow-up as a covariate revealed that the DOACs had lower risks of SSE (RR = 0.59, 95%CI: 0.37–0.94) and major bleeding (RR = 0.69, 95%CI: 0.58–0.81) in patients with a mean follow-up of more than 24 months, but no statistical differences were found in patients with the follow-up less than 24 months (SSE: RR = 1.10, 95%CI: 0.92–1.32; major bleeding: RR = 0.91, 95%CI: 0.42–2.01). Conclusions In AF with BPHV, patients on DOACs experienced a reduced risk of major bleeding and intracranial bleeding compared with VKAs, while the risks of stroke, cardiovascular death, and all-cause mortality were similar.
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Affiliation(s)
- Yalin Cao
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Yuxiang Zheng
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Siyuan Li
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Fuwei Liu
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- *Correspondence: Fuwei Liu
| | - Zhengbiao Xue
- Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Kang Yin
- Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jun Luo
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
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Ng TP, Wong C, Leong ELE, Tan BY, Chan MYY, Yeo LL, Yeo TC, Wong RC, Leow AS, Ho JSY, Sia CH. Simultaneous cardio-cerebral infarction: a meta-analysis. QJM 2022; 115:374-380. [PMID: 34051098 DOI: 10.1093/qjmed/hcab158] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 05/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/INTRODUCTION Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse. AIM We aimed to summarize the reported cardio-cerebral infarction cases in the literature. DESIGN Meta-analysis. METHODS Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors. RESULTS A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported. DISCUSSION/CONCLUSION The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.
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Affiliation(s)
- T P Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - E L E Leong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10 , 119228, Singapore
| | - B Y Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road , NUHS Tower Block Level 10, 119228, Singapore
- Division of Neurology, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - M Y-Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road, 119074, Singapore
| | - L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Division of Neurology, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - T-C Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road, 119074, Singapore
| | - R C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road , 119074, Singapore
| | - A S Leow
- Internal Medicine Residency, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - J S-Y Ho
- Academic Foundation Programme, North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX, UK
| | - C-H Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore , 5 Lower Kent Ridge Road, 119074, Singapore
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Scarano Pereira JP, Owen E, Martinino A, Akmal K, Abouelazayem M, Graham Y, Weiner S, Sakran N, Dekker LR, Parmar C, Pouwels S. Epicardial adipose tissue, obesity and the occurrence of atrial fibrillation: an overview of pathophysiology and treatment methods. Expert Rev Cardiovasc Ther 2022; 20:307-322. [PMID: 35443854 DOI: 10.1080/14779072.2022.2067144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Obesity is a chronic disease, which has significant health consequences and is a staggering burden to health care systems. Obesity can have harmful effects on the cardiovascular system, including heart failure, hypertension, coronary heart disease, and atrial fibrillation (AF). One of the possible substrates might be epicardial adipose tissue (EAT), which can be the link between AF and obesity. EAT is a fat deposit located between the myocardium and the visceral pericardium. Numerous studies have demonstrated that EAT plays a pivotal role in this relationship regarding atrial fibrillation. AREAS COVERED This review will focus on the role of obesity and the occurrence of atrial fibrillation (AF) and examine the connection between these and epicardial adipose tissue (EAT). The first part of this review will explain the pathophysiology of EAT and its association with the occurrence of AF. Secondly, we will review bariatric and metabolic surgery and its effects on EAT and AF. EXPERT COMMENTARY In this review, the epidemiology, pathophysiology, and treatments methods of AF are explained. Secondly the effects on EAT were elucidated. Due to the complex pathophysiological link between EAT, AF, and obesity, it is still uncertain which treatment strategy is superior.
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Affiliation(s)
| | - Eloise Owen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Kiran Akmal
- Faculty of Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Mohamed Abouelazayem
- Department of Surgery, Royal Free London Hospitals NHS Foundation, London, United Kingdom
| | - Yitka Graham
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, United Kingdom.,Facultad de Psucologia, Universidad Anahuac Mexico, Mexico City, Mexico
| | - Sylvia Weiner
- Department of Bariatric and Metabolic Surgery, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Nasser Sakran
- Department of Surgery, Holy Family Hospital, Nazareth, Israel.,Azrieli, Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Lukas R Dekker
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Chetan Parmar
- Department of Surgery, Whittington Health NHS Trust, London, United Kingdom
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Song D, Zhou J, Fan T, Chang J, Qiu Y, Zhuang Z, Ma J, Zeng L. Decision aids for shared decision-making and appropriate anticoagulation therapy in patients with atrial fibrillation: a systematic review and meta-analysis. Eur J Cardiovasc Nurs 2021; 21:97-106. [PMID: 34550376 DOI: 10.1093/eurjcn/zvab085] [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] [Received: 03/31/2021] [Revised: 06/23/2021] [Accepted: 09/03/2021] [Indexed: 11/12/2022]
Abstract
AIMS Underuse of oral anticoagulants (OACs) is commonly observed among patients with atrial fibrillation (AF), which hinders stroke prevention in AF. Shared decision-making (SDM) can help enhance adherence by minimizing patients' misunderstanding of treatment and aligning care with their preferences. Decision aids (DAs) have been developed to facilitate the SDM process. This study aimed to: (i) evaluate the effects of DAs on AF patients' knowledge, decisional conflict, OAC uptake, and adherence and on the incidence of stroke and bleeding; and (ii) explore characterizing factors associated with enhanced DA effectiveness. METHODS AND RESULTS Five databases were searched. Meta-analysis was conducted using RevMan 5.3 when data were available. Comparative analysis between effective and ineffective DAs was conducted to determine the DA designs associated with better effects. Ten studies were included. Pooling results indicated that DAs reduce decisional conflict related to warfarin use [mean difference = -0.10; 95% confidence interval (CI): -0.18 to -0.02; P = 0.01] and enhance OAC uptake [risk ratio: 1.03; 95% CI: 1.01-1.05; P = 0.004]. The effects of DAs on adherence and incidence of stroke and bleeding were unclear. Comparative analysis revealed that DAs with key elements of SDM (situation diagnosis, choice awareness, option clarification, benefits and disadvantages, and patient's preference) and pre-consultation delivery are more likely to be effective in promoting SDM and OAC uptake. CONCLUSIONS DAs are promising in promoting SDM and OAC uptake in patients with AF. The evidence on adherence and incidence of stroke and bleeding remains uncertain. More trials with rigorous study design and longer follow-up are necessary to obtain evidence.
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Affiliation(s)
- Dan Song
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Jie Zhou
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Tianli Fan
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Jing Chang
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Yuzhen Qiu
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Zexiang Zhuang
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Juanjuan Ma
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Li Zeng
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
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Otto CM. Heartbeat: higher risk of COVID-19 infection in younger patients with cardiovascular disease. Heart 2021; 107:345-347. [PMID: 33574131 DOI: 10.1136/heartjnl-2021-319052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, WA 98195, USA
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