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Martins AS, Monteiro C, Duarte AP. Risks of oral anticoagulants: Analysis of adverse drug reactions reported to the Portuguese National Pharmacovigilance System. Pharmacol Res Perspect 2024; 12:e1235. [PMID: 39291726 PMCID: PMC11409200 DOI: 10.1002/prp2.1235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/28/2024] [Accepted: 06/22/2024] [Indexed: 09/19/2024] Open
Abstract
Cardiovascular diseases are the leading cause of death globally, making the use of oral anticoagulants for prevention increasingly important. Historically, warfarin has played a significant role in this context. In recent years, introduction of new oral anticoagulants, such as rivaroxaban, apixaban, dabigatran, and edoxaban, has been seen. This study evaluates the risk associated with the use of oral anticoagulants by analyzing spontaneous adverse drug reactions reported to the Portuguese Pharmacovigilance System from 2012 to 2021. The study includes 951 adverse drug reactions reports, with the majority (n = 770; 80.97%) classified as serious. Of the 770 serious adverse drug reactions reports, the most commonly reported seriousness criterion was "Clinically Important" (n = 350; 45.45%). In terms of demographics, there was a higher reporting rate among the elderly population, with a greater prevalence of females. The System Organ Class group with the highest number of adverse drug reactions was "Gastrointestinal disorders," with the most commonly reported Preferred Term being "Gastrointestinal hemorrhage," and dabigatran was the most frequently reported drug. In summary, oral anticoagulants have adverse drug reactions that require continuous monitoring. Accurate identification and monitorization of adverse drug reactions is an important starting point to improve drug safety in population.
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Affiliation(s)
| | - Cristina Monteiro
- UFBI‐ Pharmacovigilance Unit of Beira InteriorUniversity of Beira InteriorCovilhãPortugal
- CISCS‐UBI‐ Health Sciences Research CentreUniversity of Beira InteriorCovilhãPortugal
| | - Ana Paula Duarte
- UFBI‐ Pharmacovigilance Unit of Beira InteriorUniversity of Beira InteriorCovilhãPortugal
- CISCS‐UBI‐ Health Sciences Research CentreUniversity of Beira InteriorCovilhãPortugal
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2
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Lavalle C, Magnocavallo M, Vetta G, Piro A, Borrelli A, Grimaldi M, Rossillo A, Notarstefano P, Carreras G, Addonisio L, Dello Russo A, Perna F, Castro A, Grossi S, Pandozi C, Pappalardo A, Sgarito G, Forleo GB. Rationale and study design of the Italian Registry in the setting of Atrial Fibrillation Ablation with Rivaroxaban - IRIS. Minerva Cardiol Angiol 2023; 71:91-99. [PMID: 35080355 DOI: 10.23736/s2724-5683.21.05832-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Catheter ablation (CA) of atrial fibrillation (AF) is used routinely to establish rhythm control. There is mounting evidence that CA procedures should be performed during continuous oral anticoagulation and direct oral anticoagulants (DOACs) are considered the first anticoagulation strategy. Few real-life data are now available and even less in the Italian panorama. METHODS IRIS is an Italian multicenter, non-interventional, prospective study which will be enrolled consecutive AF patients eligible for CA and treated with Rivaroxaban; patients in treatment with Rivaroxaban proceeded directly to CA while Rivaroxaban-naive patients were scheduled for CA after 4 weeks of uninterrupted anticoagulation unless the exclusion of atrial thrombi. Rivaroxaban was uninterrupted or shortly uninterrupted (<24 hours) prior CA, in line with routinely practice of each operator. Patients will be followed on continuous anticoagulation for 1 month after the ablation. The primary efficacy outcome is the cumulative incidence of all-cause death and systemic embolism while the primary safety outcome is the incidence of major bleeding events. The secondary outcomes are represented by non-major bleeding events. All events must be occurred within the first 30 days after the procedure. RESULTS Two hundred fifty patients are expected to be enrolled and the study is estimated to be completed by the end of 2022. Up to now 56 patients have been enrolled. CONCLUSIONS This study is the first large Italian prospective study on the management of Rivaroxaban in patients undergoing CA of AF. It aims to depict a comprehensive view of anticoagulation strategy prior CA in several Italian electrophysiology labs.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy -
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Giampaolo Vetta
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | | | - Massimo Grimaldi
- Department of Cardiology, F. Miulli Regional General Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | | | - Giovanni Carreras
- Department of Cardiology, S. Maria University Hospital, Terni, Italy
| | - Luigi Addonisio
- Department of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Department of Biomedical Science and Public Health, Ospedali Riuniti University Hospital, Marche Polytechnic University, Ancona, Italy
| | - Francesco Perna
- Department of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | | | - Stefano Grossi
- Division of Cardiology, Mauriziano Umberto I Hospital, Turin, Italy
| | - Claudio Pandozi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Augusto Pappalardo
- Division of Cardiology, Unit of Cardiac Arrhythmias, San Camillo Hospital, Rome, Italy
| | - Giuseppe Sgarito
- Division of Cardiology, ARNAS Benfratelli Civic Hospital, Palermo, Italy
| | - Giovanni B Forleo
- Unit of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
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3
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Treatment strategy of dabigatran etexilate following the availability of idarucizumab in Japanese patients with non-valvular atrial fibrillation: J-Dabigatran Surveillance 2. J Cardiol 2022; 80:255-260. [PMID: 35717283 DOI: 10.1016/j.jjcc.2022.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Idarucizumab, a dabigatran-specific reversal agent, was launched in Japan in 2016. The J-Dabigatran Surveillance 2 study was designed to assess the characteristics and outcomes of dabigatran-treated patients after the launch of idarucizumab. METHODS Patient characteristics and outcomes, including thromboembolic and bleeding events, of dabigatran-naïve patients with non-valvular atrial fibrillation (NVAF) who received dabigatran etexilate [110 mg or 150 mg twice-daily (b.i.d.)] for the prevention of ischemic stroke and systemic embolism were investigated and presented descriptively. Absolute standardized differences (ASD) in baseline characteristics compared with the first J-Dabigatran Surveillance (J-Dabi1; 2011-2013) study were included. RESULTS In total, 5660 patients were enrolled and 5436 were analyzed in this study; 3516 and 1898 received 110 mg b.i.d. and 150 mg b.i.d. dabigatran, respectively; 22 received other doses. The overall duration of follow-up (mean ± standard deviation) was 287 ± 179 days. Baseline characteristics, including stroke/bleeding-risk scores, were typical of this patient population. Overall, paroxysmal, persistent, permanent, and symptomatic atrial fibrillation were observed for 53.2%, 27.1%, 13.7%, and 53.9% of patients, respectively (J-Dabi1 ASD: 0.2, 0.0, 0.3, and 0.2, respectively). Catheter ablation was selected in 27.9% of patients (J-Dabi1 ASD: 0.6). Rates of clinical outcomes were low in the study (mostly <2%/year). The incidence rate of major bleeding was 1.1%/year (n = 46) and stroke/transient ischemic attack/systemic embolism was 1.7%/year (n = 71). Twelve (0.2%) patients received idarucizumab, commonly for serious bleeding events, and most recovered. CONCLUSIONS Dabigatran continues to be safe and well tolerated in patients with NVAF for stroke and systemic embolism prevention and continues to be prescribed appropriately. Treatment outcomes have not changed since the availability of idarucizumab. Since the J-Dabi1 study, treatment guidelines for anticoagulation use in NVAF have been updated based on emerging clinical evidence, accounting for differences in patient characteristics, and making dabigatran a preference for distinct patient populations.
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Lavalle C, Mariani MV, Piro A, Magnocavallo M, Vetta G, Trivigno S, Forleo GB, Della Rocca DG, Uguccioni M, Russo V, Summaria F, Di Lullo L. Five Years of Direct Oral Anticoagulants Use in Italy: Adverse Drug Reactions from the Italian National Pharmacovigilance Network. J Clin Med 2022; 11:3207. [PMID: 35683593 PMCID: PMC9181424 DOI: 10.3390/jcm11113207] [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: 05/07/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the preferred anticoagulant drugs for the prevention of atrial fibrillation (AF)-related thromboembolic complications and for the treatment and the prevention of recurrences of venous thromboembolism (VTE). The evaluation of self-reported adverse drug reactions (ADRs) available from databases of drug-regulatory agencies such as the Italian Medicines Agency (AIFA) pharmacovigilance database represents a novel aid to guide decision making. OBJECTIVE To assess the safety profile of DOACs by analyzing ADR rates in the real-world Italian scenario. METHODS Post-marketing surveillance data recorded by the National Pharmacovigilance Network were retrieved for the time period 2017-2021 from the AIFA online site. The following data were collected for each DOAC: total ADR number, serious ADR number, gastrointestinal (GI) ADR, intracranial hemorrhage events (ICH ADR), and more frequently reported ADR for the study year. The safety profile was expressed by the risk index (RI). RESULTS Rivaroxaban use was associated with consistent and stable low rates of serious ADR, GI ADR, and ICH ADR across the 5-year study period. Rivaroxaban and apixaban showed the lowest RI for serious ADR and GI ADR, while rivaroxaban use was associated with significantly lower ICH events as compared to apixaban. Dabigatran was related to the highest RIs for every ADR class, in particular GI ADRs. CONCLUSIONS DOACs presented an acceptable safety profile in the current post-market analysis. However, rivaroxaban and apixaban were associated with more favorable safety profiles as compared to dabigatran, while rivaroxaban provoked statistically significantly fewer ICH events as compared to apixaban.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Giampaolo Vetta
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Sara Trivigno
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (M.V.M.); (A.P.); (M.M.); (G.V.); (S.T.)
| | - Giovanni Battista Forleo
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy;
| | | | | | - Vincenzo Russo
- Department of Medical Transational Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy;
| | | | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Piazza Aldo Moro 1, 00034 Rome, Italy;
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Magnocavallo M, Vetta G, Trivigno S, Mariani MV, DI Lullo L, Bellasi A, Della Rocca DG, Severino P, Piro A, Giunta G, Quaglione R, Lavalle C. The Connubium among diabetes, chronic kidney disease and atrial fibrillation. Minerva Cardiol Angiol 2022; 70:393-402. [PMID: 35212508 DOI: 10.23736/s2724-5683.22.05891-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The burden of cardiovascular comorbid conditions was significantly higher in patients with Atrial Fibrillation (AF); most of them are affected by hypertension, Chronic Kidney Disease (CKD) and/or Diabetes Mellitus (DM). DM represents a well-known risk factor for the development and maintenance of AF; the coexistence of DM and AF is also associated with an increased risk of mortality and stroke. Moreover, DM is currently the main cause of renal impairment and the leading cause of dialysis in the world. The hyperglycemia is responsible for inducing redox imbalance and both systemic and intrarenal inflammation, playing a critical role in the pathogenesis of diabetic kidney disease. Long-term thromboembolic preventive therapy in AF patients with DM and CKD may be more challenging because both DM and CKD have been independently associated with an increased thromboembolic and bleeding risk, which results from the prothrombotic and pro-inflammatory status. Vitamin K Antagonists (VKAs) are characterized by numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavourable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. On the other hand, Direct Oral Anticoagulants (DOACs) are currently contraindicated in dialysis patients even if mounting evidence suggests that they may have a nephroprotective role in AF patients with DM and CKD. Consequently, the choice of anticoagulant therapy in this setting of patient seems to be very challenging. The aim of this review is to investigate the role of DOACs in diabetic patients and its nephroprotective role by reviewing the current literature.
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Affiliation(s)
- Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Vetta
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Sara Trivigno
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco V Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Luca DI Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Roma, Italy
| | - Antonio Bellasi
- Innovation and Brand Reputation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Giunta
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Raffaele Quaglione
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy -
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6
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Magnocavallo M, Vetta G, Della Rocca DG, Gianni C, Mohanty S, Bassiouny M, Di Lullo L, Del Prete A, Cirone D, Lavalle C, Chimenti C, Al-Ahmad A, Burkhardt JD, Gallinghouse GJ, Sanchez JE, Horton RP, Di Biase L, Natale A. Prevalence, Management, and Outcome of Atrial Fibrillation and Other Supraventricular Arrhythmias in COVID-19 Patients. Card Electrophysiol Clin 2022; 14:1-9. [PMID: 35221076 PMCID: PMC8783208 DOI: 10.1016/j.ccep.2021.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Michele Magnocavallo
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Vetta
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA.
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Mohamed Bassiouny
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Roma, Italy
| | | | | | - Carlo Lavalle
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Cristina Chimenti
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - G Joseph Gallinghouse
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA; Department of Cardiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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7
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Chimenti C, Lavalle C, Magnocavallo M, Alfarano M, Mariani MV, Bernardini F, Della Rocca DG, Galardo G, Severino P, Di Lullo L, Miraldi F, Fedele F, Frustaci A. A proposed strategy for anticoagulation therapy in noncompaction cardiomyopathy. ESC Heart Fail 2021; 9:241-250. [PMID: 34918480 PMCID: PMC8788052 DOI: 10.1002/ehf2.13694] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/19/2021] [Accepted: 10/25/2021] [Indexed: 12/23/2022] Open
Abstract
Noncompaction cardiomyopathy (NCCM) is a rare condition characterized by prominent trabeculae, deep intertrabecular recesses, and a left ventricular myocardium with a two‐layered structure, characterized by a spongy endocardial layer and a thinner and compacted epicardial one. NCCM can be isolated or associated with other congenital heart diseases and complex syndromes involving neuromuscular disorders and facial dysmorphisms. To date, more than 40 genes coding for sarcomeric, cytoskeletal, ion channels, and desmosomal proteins have been identified. Clinical presentation is also highly variable, ranging from no symptoms to end‐stage heart failure (HF), lethal arrhythmias, sudden cardiac death, or thromboembolic events. In particular, the prevalence of thromboembolism in NCCM patients appears to be higher than that of a similar, age‐matched population without NCCM. Thromboembolism has a multifactorial aetiology, which is linked to genetic, as well as traditional cardiovascular risk factors. In previous studies, atrial fibrillation (AF) was observed in approximately 25–30% of adult NCCM patients and embolism had a cardiac source in ~63–69% of cases; therefore, AF represents a strong predictor of adverse events, especially if associated to HF and neuromuscular disorders. Left ventricular dysfunction is another risk factor for thromboembolism, as a result of blood stagnation and local myocardial injury. Moreover, it is not completely clarified if the presence of deep intertrabecular recesses causing stagnant blood flow can constitute per se a thrombogenic substrate even in absence of ventricular dysfunction. For the clinical management of NCCM patients, an appropriate stratification of the thromboembolic risk is of utmost importance for a timely initiation of anticoagulant therapy. The aim of the present study is to review the available literature on NCCM with particular attention on thromboembolic risk stratification and prevention and the current evidence for oral anticoagulation therapy. The use of direct oral anticoagulants vs. vitamin K antagonists is also discussed with important implications for patient treatment and prognosis.
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Affiliation(s)
- Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.,Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Federico Bernardini
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | | | - Gioacchino Galardo
- Medical Emergency Unit, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Italy
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.,Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
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New evidence of direct oral anticoagulation therapy on cardiac valve calcifications, renal preservation and inflammatory modulation. Int J Cardiol 2021; 345:90-97. [PMID: 34688719 DOI: 10.1016/j.ijcard.2021.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/25/2021] [Accepted: 10/15/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Rivaroxaban is a direct inhibitor of activated Factor X (FXa), an anti-inflammatory protein exerting a protective effect on the cardiac valve and vascular endothelium. We compare the effect of Warfarin and Rivaroxaban on inflammation biomarkers and their contribution to heart valve calcification progression and renal preservation in a population of atrial fibrillation (AF) patients with chronic kidney disease (CKD) stage 3b - 4. METHODS This was an observational, multicenter, prospective study enrolling 347 consecutive CKD stage 3b - 4 patients newly diagnosed with AF: 247 were treated with Rivaroxaban and 100 with Warfarin. Every 12 months, we measured creatinine levels and cardiac valve calcification via standard trans-thoracic echocardiogram, while plasma levels of inflammatory mediators were quantified by ELISA at baseline and after 24 months. RESULTS Over a follow-up of 24 months, long-term treatment with Rivaroxaban was associated with a significative reduction of cytokines. Patients treated with Rivaroxaban experienced a more frequent stabilization/regression of valve calcifications comparing with patients treated with Warfarin. Rivaroxaban use was related with an improvement in kidney function in 87.4% of patients, while in those treated with Warfarin was reported a worsening of renal clearance in 98% of cases. Patients taking Rivaroxaban experienced lower adverse events (3.2% vs 49%, p-value <0.001). CONCLUSIONS Our findings suggest that Rivaroxaban compared to Warfarin is associated with lower levels of serum markers of inflammation. The inhibition of FXa may exert an anti-inflammatory effect contributing to reduce the risk of cardiac valve calcification progression and worsening of renal function.
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Mariani MV, Di Lullo L, Lavalle C. Direct oral anticoagulants and chronic kidney disease: it is time to be brave. J Nephrol 2021; 34:1419-1420. [PMID: 34357570 DOI: 10.1007/s40620-021-01137-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/24/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034, Colleferro, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Roberti R, Iannone LF, Palleria C, Curcio A, Rossi M, Sciacqua A, Armentaro G, Vero A, Manti A, Cassano V, Russo E, De Sarro G, Citraro R. Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice. Front Pharmacol 2021; 12:684638. [PMID: 34122113 PMCID: PMC8188985 DOI: 10.3389/fphar.2021.684638] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 12/21/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are a more manageable alternative than vitamin K antagonists (VKAs) to prevent stroke in patients with nonvalvular atrial fibrillation and to prevent and treat venous thromboembolism. Despite their widespread use in clinical practice, there are still some unresolved issues on optimizing their use in particular clinical settings. Herein, we reviewed the current clinical evidence on uses of DOACs from pharmacology and clinical indications to safety and practical issues such as drugs and food interactions. Dabigatran is the DOAC most affected by interactions with drugs and food, although all DOACs demonstrate a favorable pharmacokinetic profile. Management issues associated with perioperative procedures, bleeding treatment, and special populations (pregnancy, renal and hepatic impairment, elderly, and oncologic patients) have been discussed. Literature evidence shows that DOACs are at least as effective as VKAs, with a favorable safety profile; data are particularly encouraging in using low doses of edoxaban in elderly patients, and edoxaban and rivaroxaban in the treatment of venous thromboembolism in oncologic patients. In the next year, DOAC clinical indications are likely to be further extended.
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Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Luigi Francesco Iannone
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonio Curcio
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Marco Rossi
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Angela Sciacqua
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Armentaro
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Ada Vero
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonia Manti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Velia Cassano
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
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11
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Barbieri MA, Cutroneo PM, Baratelli C, Cicala G, Battaglia A, Santoro V, Andò G, Spina E. Adverse drug reactions with oral anticoagulants: data from sicilian spontaneous reporting system database. J Clin Pharm Ther 2021; 46:1027-1040. [PMID: 33646603 DOI: 10.1111/jcpt.13391] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/07/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Direct oral anticoagulants (DOACs) were developed to avoid the limitations of vitamin K antagonists (VKAs). DOACs are associated with a greater incidence of gastrointestinal bleeding and a smaller number of intracranial haemorrhages than VKAs. Therefore, it is important to deepen our knowledge of their safety profiles. The aim of this study was thus to analyse adverse drug reaction (ADR) reports on DOACs and VKAs using the Sicilian Spontaneous Reporting System (SRS) database. METHODS All ADR reports with DOACs and VKAs as suspected drugs that were entered into the Sicilian SRS database during the period 2001-2019 were selected. In detail, all reports with the following single active substances were included: dabigatran etexilate, rivaroxaban, apixaban and edoxaban; acenocoumarol and warfarin were included as a comparator group. Descriptive statistical methodology was used to evaluate characteristics of the reported cases with a case-by-case assessment. RESULTS AND DISCUSSION Out of 521 reports related to anticoagulants, 444 (85.2%) and 77 (14.8%) involved DOACs and VKAs, respectively. DOAC-related reports were mainly of gastrointestinal disorders. In contrast, VKAs were mostly associated with blood and lymphatic system disorders, injury, investigations and vascular disorders. Many more cases of ADRs in the form of gastrointestinal disorders concerned dabigatran etexilate (n = 179, 73.7%) than the other DOACs, while ADRs in the form of blood disorders were mainly associated with acenocoumarol (n = 27, 57.4%). The most commonly reported Preferred Terms for DOACs were dyspepsia (n = 89, 17.1%), upper abdominal pain (n = 41, 9.2%) and pruritus (n = 26, 5.8%), whereas for VKAs, they were anaemia (n = 21, 27.3%) and hypocoagulable state (n = 18, 3.5%). Potentially interacting concomitant medications particularly included antithrombotic agents (n = 19, 4.3%) for DOACs and proton-pump inhibitors (PPIs) (n = 37, 48.1%) and antithrombotic agents (n = 13, 16.9%) for VKAs. CONCLUSION The ADRs most commonly associated with DOACs, especially dabigatran, were gastrointestinal disorders, particularly gastrointestinal bleeding. Our study also highlights the potential role of drug-drug interactions in the ADRs. The cases of gastrointestinal bleeding highlight the need for careful prescribing of DOACs and use of potentially interacting concomitant drugs.
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Affiliation(s)
| | - Paola Maria Cutroneo
- Sicilian Regional Pharmacovigilance Centre, University Hospital of Messina, Messina, Italy
| | - Chiara Baratelli
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Battaglia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenza Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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12
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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