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Kefale AT, Bezabhe WM, Peterson GM. Clinical outcomes of oral anticoagulant discontinuation in atrial fibrillation: a systematic review and meta-analysis. Expert Rev Clin Pharmacol 2023; 16:677-684. [PMID: 37309076 DOI: 10.1080/17512433.2023.2223973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Oral anticoagulants (OACs) should generally be continued lifelong in patients with atrial fibrillation (AF) to ensure optimal benefits, unless contraindications arise. However, discontinuation of OACs might occur for various reasons, potentially affecting clinical outcomes. In this review, we synthesized evidence on the clinical outcomes following OAC discontinuation in patients with AF. METHODS We conducted a systematic review and meta-analysis using PubMed, Embase and Scopus. Cohort or case-control studies were included if data were available on clinical outcomes of OAC discontinuation, compared with continuation, in patients with AF. A random-effect meta-analyses were conducted for key outcomes of stroke, mortality, and major bleeding. RESULTS Eighteen observational studies having a total of 283,418 patients were included. Discontinuation significantly increased the risk of stroke (hazard ratio [HR] 1.88; 95% confidence interval [CI] 1.58-2.23), all-cause (HR 1.90; 95% CI 1.40-2.59) and cardiovascular (HR 1.83; 95% CI 1.06-3.18) mortality. The risk of major bleeding was not significantly different between the discontinued and continued groups (HR 1.04; 95% CI 0.72-1.52). CONCLUSIONS Discontinuation of OAC therapy was associated with an increased risk of stroke and mortality, with no difference in the risk of major bleeding. Acknowledging heterogeneity among the studies, the findings underline the need to ensure continuity of OAC therapy in patients with AF to prevent thrombotic complications and associated mortality. PROSPERO REGISTRATION NUMBER CRD42020186116.
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Affiliation(s)
- Adane Teshome Kefale
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
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Lee WK, Woo SI, Hyun DK, Jung SY, Kim MS, Lee J. Impact of treatment adherence on the effectiveness and safety of oral anticoagulants in patients with atrial fibrillation: a retrospective cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:216-226. [PMID: 35533394 DOI: 10.1093/ehjqcco/qcac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/24/2022] [Accepted: 05/03/2022] [Indexed: 05/17/2023]
Abstract
AIMS The impact of adherence to oral anticoagulation has not been reported in terms of absolute risk, which would enhance patients' understanding and treatment adherence. METHODS AND RESULTS This retrospective cohort study analysed data from the National Health Insurance Database of Korea, from January 2010 to December 2018, on 84 227 patients with non-valvular atrial fibrillation (NVAF). The participants were analysed according to their overall adherence to oral anticoagulants (OACs) and further divided into four groups: non-vitamin K antagonist oral anticoagulant (NOAC) adherent, vitamin K antagonist (VKA) adherent, NOAC non-adherent, and VKA non-adherent. The incidence of ischaemic stroke, major bleeding, and death was compared between the four groups using risk difference, number needed to treat and number needed to harm. Among the participants, 50 178 were adherent to (OACs), while 34 049 were non-adherent. The incidence of major bleeding was higher in the adherent group (4.49%; 95% confidence interval, 4.11-4.85%) than in the non-adherent group (3.61%; 3.16-4.06%), and the incidence of ischaemic stroke was higher in the non-adherent group (7.68%; 7.08-8.33%) than in the adherent group (5.61%; 5.17-6.07%). In terms of risk difference, adherence to OACs increased the risk of major bleeding by 0.87% and decreased the risk of ischaemic stroke by 2.08%. This finding suggests that one additional major bleeding event occurred for every 115 adherent patients, and one additional ischaemic stroke event was prevented for every 48 adherent patients. CONCLUSION The benefits of OAC adherence in NVAF patients for ischaemic stroke prevention exceeding the risk of bleeding are shown more clearly in terms of absolute risk.
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Affiliation(s)
- Won Kyung Lee
- Department of Prevention and Management, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
| | - Seong Ill Woo
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
- Department of Internal Medicine, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
| | - Dong Keun Hyun
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
- Department of Neurosurgery, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Mi-Sook Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Republic of Korea
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Esteve-Pastor MA, Rivera-Caravaca JM, Ruiz-Ortiz M, Muñiz J, Roldán-Rabadán I, Otero D, López-Gálvez R, Cequier Á, Bertomeu-Martínez V, Badimón L, Anguita M, Lip GYH, Marín F. A comparison of front-line oral anticoagulants for the treatment of non-valvular atrial fibrillation: Effectiveness and safety of direct oral anticoagulants in the FANTASIIA registry. Expert Opin Pharmacother 2022; 23:1457-1465. [PMID: 35924672 DOI: 10.1080/14656566.2022.2109961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION For a long time, vitamin K antagonists (VKA) were the only oral anticoagulation therapy available to reduce adverse events in atrial fibrillation (AF) patients. Direct-acting oral anticoagulants (DOAC) are at least as effective and safe as VKA with few drug interactions, rapid onset and short half-life. Four DOACs, dabigatran, apixaban, rivaroxaban and edoxaban have demonstrated efficacy and safety for treatment in AF patients. AREAS COVERED The purpose of this review article is to analyze the current evidence in clinical trials and in real-world populations and performed a new analysis with the estimated effect of those DOACs over the VKA population from the FANTASIIA registry. We present in this manuscript original data analysis from FANTASIIA population as well as data obtained through a search of PubMed for the clinical trials comparing DOAC in the main randomized trials of each DOAC and observational data of the real-world effects of DOACs compared to VKAs. EXPERT OPINION In the absence of randomized, controlled head-to-head comparisons between DOACs, high-quality observational data can provide useful information on the comparative effectiveness of DOACs. Current clinical guidelines recommend the management of oral anticoagulation in AF patients with DOACs over VKA for stroke prevention; however, many guidelines generally do not suggest a specific DOAC choice in clinical practice. The revised evidence in this manuscript and our real experience reflects that apixaban and dabigatran show the best efficacy and safety profile.
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Affiliation(s)
- María Asunción Esteve-Pastor
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Maimonides Institute for Biomedical Research of Cordoba, IMIBIC, Córdoba, Spain
| | - Javier Muñiz
- Universidade da Coruña, Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica de A Coruña (INIBIC), La Coruña, CIBERCV, Spain
| | | | | | - Raquel López-Gálvez
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Ángel Cequier
- Department of Cardiology, Hospital de Bellvitge, CIBERCV, Barcelona, Spain
| | | | - Lina Badimón
- Cardiovascular Research Center (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, CIBERCV, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Maimonides Institute for Biomedical Research of Cordoba, IMIBIC, Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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Binding C, Olesen JB, Lee CJY, Lip GYH, Sindet-Pedersen C, Gislason G, Bonde AN. Discontinuation of direct oral anticoagulants among patients with atrial fibrillation according to gender and cohabitation status: a nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:353-362. [PMID: 34415024 DOI: 10.1093/ehjcvp/pvab065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 08/18/2021] [Indexed: 06/13/2023]
Abstract
AIMS The aim of this study was to evaluate the risk of discontinuing treatment with direct oral anticoagulants (DOACs) among patients with atrial fibrillation (AF) according to cohabitation status and gender. METHODS AND RESULTS Using the Danish national registers, we identified 32 364 patients with AF aged 40-90 years undergoing treatment with DOACs. The study period was from 2013 to 2017, and patients were followed for 2 years, or until death, outcome, or emigration. The main outcome was discontinuation of DOAC treatment for at least 30 days. The absolute 2-year risk of DOAC discontinuation was highest among men living alone [35.7%, 95% confidence interval (CI): 37.3-34.1%]. Men living alone had a 4.6% (95% CI: 6.4-2.8%) higher absolute risk of discontinuation and a 12% [hazard ratio (HR): 1.12, 95% CI: 1.04-1.20] higher relative risk of discontinuation compared with men living with a partner. Female patients living alone likewise had a higher absolute risk of DOAC discontinuation (2.6%, 95% CI: 4.4-0.09%) compared with female patients living with a partner, yet no statistically significant difference in relative risk. In an analysis evaluating gender, we found male gender to be associated with a significantly higher relative risk of DOAC discontinuation (HR: 1.33, 95% CI: 1.26-1.40) compared with female gender (P-value for interaction with cohabitant status = 0.5996). CONCLUSION In this nationwide population study, male gender and living alone were associated with a higher risk of DOAC discontinuation among patients with AF.
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Affiliation(s)
- Casper Binding
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Post 635, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
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Cools F, Johnson D, Camm AJ, Bassand J, Verheugt FWA, Yang S, Tsiatis A, Fitzmaurice DA, Goldhaber SZ, Kayani G, Goto S, Haas S, Misselwitz F, Turpie AGG, Fox KAA, Pieper KS, Kakkar AK. Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: Results from the GARFIELD-AF Registry. J Thromb Haemost 2021; 19:2322-2334. [PMID: 34060704 PMCID: PMC8390436 DOI: 10.1111/jth.15415] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral anticoagulation (OAC) in atrial fibrillation (AF) reduces the risk of stroke/systemic embolism (SE). The impact of OAC discontinuation is less well documented. OBJECTIVE Investigate outcomes of patients prospectively enrolled in the Global Anticoagulant Registry in the Field-Atrial Fibrillation study who discontinued OAC. METHODS Oral anticoagulation discontinuation was defined as cessation of treatment for ≥7 consecutive days. Adjusted outcome risks were assessed in 23 882 patients with 511 days of median follow-up after discontinuation. RESULTS Patients who discontinued (n = 3114, 13.0%) had a higher risk (hazard ratio [95% CI]) of all-cause death (1.62 [1.25-2.09]), stroke/systemic embolism (SE) (2.21 [1.42-3.44]) and myocardial infarction (MI) (1.85 [1.09-3.13]) than patients who did not, whether OAC was restarted or not. This higher risk of outcomes after discontinuation was similar for patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) (p for interactions range = 0.145-0.778). Bleeding history (1.43 [1.14-1.80]), paroxysmal vs. persistent AF (1.15 [1.02-1.29]), emergency room care setting vs. office (1.37 [1.18-1.59]), major, clinically relevant nonmajor, and minor bleeding (10.02 [7.19-13.98], 2.70 [2.24-3.25] and 1.90 [1.61-2.23]), stroke/SE (4.09 [2.55-6.56]), MI (2.74 [1.69-4.43]), and left atrial appendage procedures (4.99 [1.82-13.70]) were predictors of discontinuation. Age (0.84 [0.81-0.88], per 10-year increase), history of stroke/transient ischemic attack (0.81 [0.71-0.93]), diabetes (0.88 [0.80-0.97]), weeks from AF onset to treatment (0.96 [0.93-0.99] per week), and permanent vs. persistent AF (0.73 [0.63-0.86]) were predictors of lower discontinuation rates. CONCLUSIONS In GARFIELD-AF, the rate of discontinuation was 13.0%. Discontinuation for ≥7 consecutive days was associated with significantly higher all-cause mortality, stroke/SE, and MI risk. Caution should be exerted when considering any OAC discontinuation beyond 7 days.
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Affiliation(s)
| | - Dana Johnson
- Department of StatisticsNorth Carolina State UniversityRaleighNCUSA
| | - Alan J. Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research InstituteSt. George’s University of LondonLondonUK
| | | | | | - Shu Yang
- North Carolina State UniversityRaleighNCUSA
| | | | | | | | | | - Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | - Sylvia Haas
- Formerly Department of MedicineTechnical University of MunichMunichGermany
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
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Chao TF, Chan YH, Chiang CE, Tuan TC, Liao JN, Chen TJ, Lip GYH, Chen SA. Continuation or discontinuation of oral anticoagulants after HAS-BLED scores increase in patients with atrial fibrillation. Clin Res Cardiol 2021; 111:23-33. [PMID: 33704551 DOI: 10.1007/s00392-021-01816-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/02/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND The bleeding risk profile of patients with atrial fibrillation (AF) may change over time, and the increment of HAS-BLED score is perceived to result in discontinuations of oral anticoagulants (OACs). OBJECTIVES To investigate the changes of HAS-BLED scores of AF patients initially with a low bleeding risk. The associations between continuation or discontinuation of OACs and clinical outcomes after patients' bleeding risk profile worsened (ie HAS-BLED increased) were studied. METHODS The present study used Taiwan nationwide health insurance research database. From year 2000 to 2015, a total of 24,990 AF patients aged ≥ 20 years with a CHA2DS2-VASc score ≥ 1 (males) or ≥ 2 (females) having an HAS-BLED score of 0-2 who were treated with OACs were identified and followed up for changes of the HAS-BLED scores. Patients who did not refill OACs within 90 days after their HAS-BLED scores increased to ≥ 3 were defined as discontinuations of OACs. The risks of clinical outcomes were compared between patients who continued or stopped OACs once their HAS-BLED scores increased to ≥ 3. RESULTS Mean HAS-BLED score of study population increased from 1.54 to 3.33. At end of 1 year, 5,229 (20.9%) patients had an increment of their HAS-BLED scores to ≥ 3, mainly due to newly diagnosed hypertension, stroke, bleeding, and concomitant drug therapies. Among 4777 patients who consistently had an HAS-BLED score ≥ 3, 1,062 (22.2%) stopped their use of OACs. Patients who kept on OACs (n = 3715; 77.8%) even after their HAS-BLED scores increased to ≥ 3 were associated with a lower risk of ischemic stroke (aHR 0.60, 95%CI 0.53-0.69), major bleeding (aHR 0.78, 95%CI 0.67-0.91), all-cause mortality (aHR 0.88, 95%CI 0.79-0.97), and any adverse events (aHR 0.75, 95%CI 0.68-0.82) adjusted for age, sex, heart failure, and HAS-BLED score. These results were consistent among the cohorts after propensity matching. CONCLUSIONS For patients whose HAS-BLED scores increased to ≥ 3, the continuation of OACs was associated with better clinical outcomes. An increased HAS-BLED score in anticoagulated AF patients may not be the only reason to withhold OACs, but reminds physicians to correct modifiable bleeding risk factors and follow up patients more closely. Associations between Continuation or Discontinuation of Oral Anticoagulants and Risks of Clinical Outcomes after HAS-BLED Scores Increased AF atrial fibrillation; aHR adjusted hazard ratio; ICH intra-cranial hemorrhage; OACs oral anticoagulants.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. .,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chern-En Chiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Domek M, Gumprecht J, Li YG, Proietti M, Rashed W, Al Qudaimi A, Gumprecht J, Zubaid M, Lip GYH. Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry. Eur J Clin Invest 2021; 51:e13385. [PMID: 32810282 DOI: 10.1111/eci.13385] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/19/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple strategy of integrated approach of AF management: A-Avoid stroke; B-Better symptom control; C-Cardiovascular comorbidity risk management. AIMS Evaluation of the AF treatment compliance to ABC pathway in DM patients in the Middle East. Assessment of the impact of ABC pathway adherence on all-cause mortality and the composite outcome of stroke/systemic embolism, all-cause death and cardiovascular hospitalisations. METHODS From 2043 patients in the Gulf SAFE registry, 603 patients (mean age 63; 48% male) with DM were included in an analysis of ABC pathway compliance: A-appropriate use of anticoagulation according to CHA2 DS2 -VASc score; B-AF symptoms management according to the European Heart Rhythm Association (EHRA) scale; C-Optimised cardiovascular comorbidities management. RESULTS 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC group vs non-ABC (5.8% vs 15.9%, P = .0014, respectively). On multivariate analysis, ABC compliance was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI: 0.42-0.75 and OR 0.54; 95% Cl: 0.30-1.00, respectively) and at 1 year (OR 0.30; 95% Cl: 0.11-0.76 and OR 0.57; 95% Cl: 0.33-0.97, respectively) vs the non-ABC group. CONCLUSIONS Compliance with the ABC pathway care was independently associated with the reduced risk of all-cause death and the composite outcome in DM patients with AF, highlighting the importance of an integrated approach to AF management.
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Affiliation(s)
- Magdalena Domek
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Jakub Gumprecht
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Yan-Guang Li
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca'Granda, Ospendale Maggiore Policlinico, Milan, Italy
| | - Wafa Rashed
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait.,Division of Cardiology, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
| | | | - Janusz Gumprecht
- Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Mohammad Zubaid
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait.,Division of Cardiology, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait.,Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
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9
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Menichelli D, Del Sole F, Di Rocco A, Farcomeni A, Vestri A, Violi F, Pignatelli P, Lip GYH, Pastori D. Real-world safety and efficacy of direct oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of 605 771 patients. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:f11-f19. [PMID: 33493255 DOI: 10.1093/ehjcvp/pvab002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/10/2020] [Accepted: 01/08/2021] [Indexed: 01/05/2023]
Abstract
AIMS To analyse the safety and efficacy of direct oral anticoagulants (DOACs) in real-world studies including atrial fibrillation (AF) patients. METHODS AND RESULTS Systematic review and meta-analysis of observational studies including AF patients on DOACs. Primary endpoints: any, major, gastrointestinal (GI), intracranial haemorrhage (ICH), and haemorrhagic stroke (HS). Secondary endpoints: ischaemic stroke (IS), systemic embolism (SE), myocardial infarction (MI), and all-cause of death. A set of pair-wise meta-analyses using a random effect model and a random effect network meta-analysis under a Bayesian framework were performed. Prospero registration number: CRD42019137111. We included 21 studies with 605 771 AF patients. Apixaban was associated with lower major and GI bleeding compared with Rivaroxaban [hazard ratio (HR) 2.0, 95% confidence interval (CI) 1.6-2.5] and Dabigatran (HR 1.6, 95% CI 1.3-2.1). The latter drug performed better than Rivaroxaban (HR 1.2, 95% CI 1.0-1.5). Dabigatran and Apixaban had a similar association with HS, but Apixaban performed better than Rivaroxaban (HR 1.8, 95% CI 1.1-3.0). Apixaban had a similar association with Rivaroxaban and Dabigatran for ICH, the latter drug performing better than Rivaroxaban (HR 1.3, 95% CI 1.0-1.7). Rankograms showed that Apixaban was likely to be the first-choice treatment in relation to any (65%) major (100%) and GI bleeding (100%) followed by Dabigatran (46%, 100%, 99%, respectively). Dabigatran and Apixaban had similar rank as first choice for ICH (44% and 55%) and HS (52% and 48%). DOACs showed similar association with IS/SE, MI, all-cause of death. CONCLUSIONS Analysis of real-world studies shows significant differences for safety among DOACs.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Francesco Del Sole
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome Tor Vergata, Via Columbia, 2, Rome 00133, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Søndre Skovvej 15, Forskningens Hus. 9000 Aalborg, Denmark
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, 6 West Derby Street, Liverpool L7 8TX, UK
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Statin use and mortality in atrial fibrillation: A systematic review and meta-analysis of 100,287 patients. Pharmacol Res 2021; 165:105418. [PMID: 33450384 DOI: 10.1016/j.phrs.2021.105418] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/06/2020] [Accepted: 01/03/2021] [Indexed: 01/24/2023]
Abstract
Statins are effective for reducing cardiovascular disease in patients at risk or with cardiovascular disease. The benefit of statin therapy on adverse cardiovascular outcomes in patients with non-valvular atrial fibrillation (AF) is not clear. We performed a systematic review and meta-analysis of studies retrieved from MEDLINE via PubMed and Cochrane (CENTRAL) database of studies investigating the efficacy of statins in AF patients. The principal endpoint was all-cause mortality. Other endpoints were cardiovascular mortality, ischemic stroke, composite endpoints and any bleeding. We included 14 studies (2 post-hoc analysis of randomized clinical trials, 8 prospective and 4 retrospective) with 100,287 AF patients, of whom 23,228 were on statins. The pooled hazard ratio (HR) for all-cause mortality was 0.59 (95 % Confidence Interval [CI] 0.54-0.65). This association was consistent by aging, sex and prevalent cardiovascular or cerebrovascular disease. and the beneficial effect was evident already after 12 months of therapy. The absolute risk reduction for all-cause mortality in patients treated with statins was 10 % (95 % CI 9-10). The pooled HR for statins against cardiovascular mortality was 0.75 (95 % CI 0.58-0.96). No association was found with other secondary endpoints. Regarding bleeding events, the pooled HR for statin use was 0.60 (95 % CI 0.48-0.76). Our meta-analysis shows that in AF patients, statin therapy was associated with a reduction in all-cause and cardiovascular mortality are reduced by 41 % and 25 %, respectively. Randomized clinical trials in AF patients are necessary, as well as clarity on AF-specific LDL cholesterol targets.
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11
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García Rodríguez LA, Cea Soriano L, Munk Hald S, Hallas J, Balabanova Y, Brobert G, Vora P, Sharma M, Gaist D. Discontinuation of oral anticoagulation in atrial fibrillation and risk of ischaemic stroke. Heart 2020; 107:heartjnl-2020-317887. [PMID: 33310887 PMCID: PMC7958105 DOI: 10.1136/heartjnl-2020-317887] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate associations between oral anticoagulant (OAC) discontinuation and risk of ischaemic stroke (IS) among patients with atrial fibrillation (AF). METHODS We undertook a population-based cohort study with nested case-control analysis using UK primary care electronic health records (IQVIA Medical Research Data-UK) and linked registries from the Region of Southern Denmark (RSD). Patients with AF (76 882 UK, 41 526 RSD) were followed to identify incident IS cases during 2016-2018. Incident IS cases were matched by age and sex to controls. Adjusted ORs for OAC discontinuation (vs current OAC use) were calculated using logistic regression. RESULTS We identified 616 incident IS cases in the UK and 643 in the RSD. ORs for IS with any OAC discontinuation were 2.99 (95% CI 2.31 to 3.86, UK) and 2.30 (95% CI 1.79 to 2.95, RSD), for vitamin K antagonist discontinuation they were 2.38 (95% CI 1.72 to 3.30, UK) and 1.83 (95% CI 1.34 to 2.49, RSD), and for non-vitamin K antagonist oral anticoagulant discontinuation they were 4.59 (95% CI 2.97 to 7.08, UK) and 3.37 (95% CI 2.35 to 4.85, RSD). ORs were unaffected by time since discontinuation and duration of use. Annually, up to 987 IS cases in the UK and 132 in Denmark could be preventable if OAC therapy is not discontinued. CONCLUSIONS Our results suggest that patients with AF who discontinue OAC therapy have a significant twofold to threefold higher risk of IS compared with those who continue therapy. Addressing OAC discontinuation could potentially result in a significant reduction in AF-attributed IS.
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Affiliation(s)
| | | | | | | | | | | | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada
| | - David Gaist
- University of Southern Denmark, Odense, Denmark
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12
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Dietz N, Ruff C, Giugliano RP, Mercuri MF, Antman EM. Pharmacogenetic-guided and clinical warfarin dosing algorithm assessments with bleeding outcomes risk-stratified by genetic and covariate subgroups. Int J Cardiol 2020; 317:159-166. [DOI: 10.1016/j.ijcard.2020.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
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13
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Domek M, Gumprecht J, Ding WY, Lip GYH, Lane DA. Practice-derived data on non-vitamin K antagonist oral anticoagulant therapy to complement observations from randomized trials. Eur Heart J Suppl 2020; 22:I1-I12. [PMID: 33093817 PMCID: PMC7556745 DOI: 10.1093/eurheartj/suaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Anticoagulation is fundamental in the management of patients with atrial fibrillation (AF). The study aims to provide a comparative review of the major phase III randomized clinical trials (RCTs) and real-world data (RWD) from reliable, high-grade Phase IV studies that assess the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) vs. vitamin K antagonists (VKAs). Observational studies based on nationwide or health insurance database records on the use of NOACs vs. VKAs in patients with AF were included. We performed a comparison of the efficacy and safety characteristics associated with NOACs vs. VKAs in RCTs and RWD. Although RCTs provide strong support for evidence-based practice, RWD may be used to reflect the broader picture of various clinical settings, provide supplementary insight and fulfil knowledge gaps. Both study types confirmed the safety and efficacy of NOACs in preventing stroke and thromboembolism in patients with AF. In comparison to VKAs, NOACs were associated with reduced risk of ischaemic events and lower rates of adverse events such as major bleeding or intracranial haemorrhage. Administration of NOACs might be associated with increased risk of dose-related gastrointestinal bleeding and myocardial ischaemic events, especially in the early treatment period after switching from VKAs. Special care should be taken in challenging clinical situations like severe renal or hepatic impairment when the treatment regimen needs to be considered individually. Randomized clinical trial and RWD studies are complementary and present comparable findings, affirming that NOACs are safe and effective for anticoagulation of patients with AF in daily clinical practice.
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Affiliation(s)
- Magdalena Domek
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Jakub Gumprecht
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Pastori D, Menichelli D, Lip GYH, Sciacqua A, Violi F, Pignatelli P. Family History of Atrial Fibrillation and Risk of Cardiovascular Events: A Multicenter Prospective Cohort Study. Circ Arrhythm Electrophysiol 2020; 13:e008477. [PMID: 32718257 DOI: 10.1161/circep.120.008477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND To investigate the association between family history of atrial fibrillation (AF) with cardiovascular events (CVEs), major adverse cardiac events (MACE), and cardiovascular mortality. METHODS Multicenter prospective observational cohort study including 1722 nonvalvular AF patients from February 2008 to August 2019 in Italy. Family history of AF was defined as the presence of AF in a first-degree relative: mother, father, sibling, or children. Primary outcome was a composite of CVEs including fatal/nonfatal ischemic stroke and myocardial infarction, and cardiovascular death. Second, we analyzed the association with major adverse cardiac event. RESULTS Mean age was 74.6±9.4 years; 44% of women. Family history of AF was detected in 368 (21.4%) patients, and 3.5% had ≥2 relatives affected by AF. Age of AF onset progressively decreased from patients without family history of AF, compared with those with single and multiple first-degree affected relatives (P<0.001). During a mean follow-up of 23.7 months (4606 patients/y) 145 CVEs (3.15%/y), 98 major adverse cardiac event (2.13%/y), and 57 cardiovascular deaths (0.97%/y) occurred. After adjustment for cardiovascular risk factors, family history of AF was associated with a higher risk of CVEs (hazard ratio, 1.524 [95% CI, 1.021-2.274], P=0.039), major adverse cardiac event (hazard ratio, 1.917 [95% CI, 1.207-3.045], P=0.006), and cardiovascular mortality (hazard ratio, 2.008 [95% CI, 1.047-3.851], P=0.036). Subgroup analysis showed that this association was modified by age, sex, and prior ischemic heart disease. CONCLUSIONS In a cohort of elderly patients with a high atherosclerotic burden, family history of AF is evident in >20% of patients and was associated with an increased risk for CVEs and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01882114.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.).,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (D.P., G.Y.H.L.)
| | - Danilo Menichelli
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (D.P., G.Y.H.L.)
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy (A.S.)
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
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15
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Escobar C, Borrás X, Bover Freire R, González-Juanatey C, Morillas M, Muñoz AV, Gómez-Doblas JJ. A Delphi consensus on the management of oral anticoagulation in patients with non-valvular atrial fibrillation in Spain: ACOPREFERENCE study. PLoS One 2020; 15:e0231565. [PMID: 32479502 PMCID: PMC7263623 DOI: 10.1371/journal.pone.0231565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 03/26/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain. MATERIALS AND METHODS A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1. RESULTS A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2. CONCLUSIONS This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
- * E-mail:
| | - Xavier Borrás
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ramón Bover Freire
- Cardiology Department, Hospital Clínico San Carlos, CIBERCV, Madrid, Spain
| | | | - Miren Morillas
- Cardiology Department, Hospital de Galdakao, Galdakao, Bizkaia, Spain
| | | | - Juan José Gómez-Doblas
- Cardiology Department, Hospital Universitario Virgen de la Victoria, CIBERCV, Málaga, Spain
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16
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Martinez C, Wallenhorst C, Rietbrock S, Freedman B. Ischemic Stroke and Transient Ischemic Attack Risk Following Vitamin K Antagonist Cessation in Newly Diagnosed Atrial Fibrillation: A Cohort Study. J Am Heart Assoc 2020; 9:e014376. [PMID: 31937194 PMCID: PMC7033838 DOI: 10.1161/jaha.119.014376] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background In nonvalvular atrial fibrillation (AF), oral anticoagulants prevent ischemic strokes and transient ischemic attacks (TIAs), but nonpersistence with vitamin K antagonist (VKA) oral anticoagulant therapy (20-50% at 1 year) is problematic. The precise risk of stroke/TIA after VKA cessation and its time course during extended follow-up is unknown. Methods and Results The study cohort of incident AF in patients receiving initial VKA between 2001 and 2013 was identified from the UK Clinical Practice Research Datalink (linked hospitalizations and causes of death). Using a nested case-control analysis, patients with incident stroke/TIA were matched to patients without stroke/TIA (controls). Relative risk with time since VKA cessation compared with current VKA use was approximated from conditional logistic regression. We studied 16 696 patients with incident AF and initial VKA treatment. There were 489 stroke/TIA cases matched to 2137 controls (mean CHA2DS2-VASc score 4.3). Compared with current VKA use, the excess incidence rate of stroke/TIA following VKA cessation in the first year after AF diagnosis was 2.29 (95% CI, 0.98-3.90) per 100 person-years of VKA cessation or 1 additional stroke/TIA per 43 patients per year discontinuing VKA, compared with 1.43 (95% CI, 0.97-1.88) per 100 person-years corresponding to 1 additional stroke/TIA per 70 patients per year, when VKA was discontinued more than 1 year after AF diagnosis. Conclusions VKA cessation is associated with a continuous excess thromboembolic stroke/TIA risk. Increasing oral anticoagulant persistence, especially in the year after AF diagnosis, should be a therapeutic target to reduce stroke/TIA in AF.
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Affiliation(s)
- Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | | | - Stephan Rietbrock
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | - Ben Freedman
- Heart Research InstituteCharles Perkins CentreUniversity of SydneyAustralia
- Department of Cardiology and Anzac Research InstituteConcord HospitalSydneyAustralia
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17
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Pastori D, Menichelli D, Gingis R, Pignatelli P, Violi F. Tailored Practical Management of Patients With Atrial Fibrillation: A Risk Factor-Based Approach. Front Cardiovasc Med 2019; 6:17. [PMID: 30915342 PMCID: PMC6422871 DOI: 10.3389/fcvm.2019.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/12/2019] [Indexed: 12/25/2022] Open
Abstract
The management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization).
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Affiliation(s)
| | | | | | | | - Francesco Violi
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
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18
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The Basics of Antithrombotic Medications. TOPICS IN GERIATRIC REHABILITATION 2019. [DOI: 10.1097/tgr.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Boriani G, Proietti M, Laroche C, Diemberger I, Popescu MI, Riahi S, Shantsila A, Dan GA, Tavazzi L, Maggioni AP, Lip GY. Changes to oral anticoagulant therapy and risk of death over a 3-year follow-up of a contemporary cohort of European patients with atrial fibrillation final report of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) pilot general registry. Int J Cardiol 2018; 271:68-74. [DOI: 10.1016/j.ijcard.2018.05.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/22/2018] [Accepted: 05/10/2018] [Indexed: 12/20/2022]
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20
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Real-world comparison of bleeding risks among non-valvular atrial fibrillation patients prescribed apixaban, dabigatran, or rivaroxaban. PLoS One 2018; 13:e0205989. [PMID: 30383768 PMCID: PMC6211674 DOI: 10.1371/journal.pone.0205989] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
Limited real-world data are available regarding the comparative safety of non-vitamin K antagonist oral anticoagulants (NOACs). The objective of this retrospective claims observational cohort study was to compare the risk of bleeding among non-valvular atrial fibrillation (NVAF) patients prescribed apixaban, dabigatran, or rivaroxaban. NVAF patients aged ≥18 years with a 1-year baseline period were included if they were new initiators of NOACs or switched from warfarin to a NOAC. Cox proportional hazards modelling was used to estimate the adjusted hazard ratios of any bleeding, clinically relevant non-major (CRNM) bleeding, and major inpatient bleeding within 6 months of treatment initiation for rivaroxaban and dabigatran compared to apixaban. Among 60,227 eligible patients, 8,785 were prescribed apixaban, 20,963 dabigatran, and 30,529 rivaroxaban. Compared to dabigatran or rivaroxaban patients, apixaban patients were more likely to have greater proportions of baseline comorbidities and higher CHA2DS2-VASc and HAS-BLED scores. After adjusting for baseline clinical and demographic characteristics, patients prescribed rivaroxaban were more likely to experience any bleeding (HR: 1.35, 95% confidence interval [CI]: 1.26–1.45), CRNM bleeding (HR: 1.38, 95% CI: 1.27–1.49), and major inpatient bleeding (HR: 1.43, 95% CI: 1.17–1.74), compared to patients prescribed apixaban. Dabigatran patients had similar bleeding risks as apixaban patients. In conclusion, NVAF patients treated with rivaroxaban appeared to have an increased risk of any bleeding, CRNM bleeding, and major inpatient bleeding, compared to apixaban patients. There was no significant difference in any bleeding, CRNM bleeding, or inpatient major bleeding risks between patients treated with dabigatran and apixaban.
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21
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Mahmood M, Lip GY. Anticoagulantes orales no dependientes de la vitamina K para pacientes con fibrilación auricular e insuficiencia renal grave. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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22
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Gorenek B, Pelliccia A, Benjamin EJ, Boriani G, Crijns HJ, Fogel RI, Van Gelder IC, Halle M, Kudaiberdieva G, Lane DA, Larsen TB, Lip GYH, Løchen ML, Marín F, Niebauer J, Sanders P, Tokgozoglu L, Vos MA, Van Wagoner DR, Fauchier L, Savelieva I, Goette A, Agewall S, Chiang CE, Figueiredo M, Stiles M, Dickfeld T, Patton K, Piepoli M, Corra U, Marques-Vidal PM, Faggiano P, Schmid JP, Abreu A. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Europace 2018; 19:190-225. [PMID: 28175283 DOI: 10.1093/europace/euw242] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | - Harry J Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Martin Halle
- Prevention and Sports Medicine, Technical University Munich, München, Germany
| | | | | | | | | | - Maja-Lisa Løchen
- University of Birmingham, Birmingham, UK.,Aalborg University Hospital, Aalborg, Denmark
| | | | - Josef Niebauer
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ugo Corra
- Irccs Rehabilitation Medical Center, Veruno, Italy
| | | | | | | | - Ana Abreu
- Hospital de Santa Marta, Lisboa, Portugal
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Pastori D, Farcomeni A, Saliola M, Del Sole F, Pignatelli P, Violi F, Lip GYH. Temporal trends of time in therapeutic range and incidence of cardiovascular events in patients with non-valvular atrial fibrillation. Eur J Intern Med 2018; 54:34-39. [PMID: 29655807 DOI: 10.1016/j.ejim.2018.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/03/2018] [Accepted: 04/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Optimal time in therapeutic range (TTR) of vitamin K antagonists (VKAs) is crucial for cardiovascular events (CVEs) prevention in non-valvular atrial fibrillation (NVAF). The relationship between temporal changes of TTR and the incidence of CVEs has been poorly investigated. We investigated 1) temporal trends of TTR in a long-term follow-up of NVAF patients; 2) the incidence of CVEs according to changes of TTR. METHODS Prospective observational study including 1341 NVAF outpatients (mean age 73.5 years, 42.5% male) starting VKAs. Patients were divided into 4 groups: Group 0: Optimal TTR, consistently ≥70% (n = 241); Group 1: Temporally worsening TTR, from above to below 70% (n = 263); Group 2: Temporally improving TTR, from below to above 70% (n = 270); Group 3: Suboptimal TTR, consistently <70% (n = 567). RESULTS In a mean follow-up of 37.7 months (4214.2 patient-years), 108 CVEs occurred (2.6%/year). Survival analysis showed a graded increased risk of CVEs in relation to temporal changes in TTR, with the worst outcomes in Groups 1 and 3 (log-rank test p = 0.013). Multivariable Cox proportional hazards regression analysis showed that Group 1 vs. 0 (HR: 2.096; 95%CI 1.061-4.139, p = 0.033), Group 3 vs. 0 (HR: 2.292; 95%CI 1.205-4.361, p = 0.011), CHA2DS2VASc score (HR:1.316; 95%CI 1.153-1.501, p < 0.001) and PPIs (HR:0.453; 95%CI 0.285-0.721, p = 0.001) were independently associated with CVEs. CONCLUSION A decrease of TTR <70% over time is observed in almost 20% of NVAF patients. Patients with worsening TTR temporally (ie. from initially above 70% to below 70%) have similar risk of CVEs of patients with consistently suboptimal anticoagulation.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases Sapienza University of Rome, Rome, Italy
| | - Mirella Saliola
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Del Sole
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Nonvitamin K Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Renal Dysfunction. ACTA ACUST UNITED AC 2018; 71:847-855. [PMID: 29958809 DOI: 10.1016/j.rec.2018.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
Both atrial fibrillation (AF) and chronic kidney disease (CKD) are highly prevalent, especially with increasing age and associated comorbidities, such as hypertension, diabetes, heart failure, and vascular disease. The relationship between both AF and CKD seems to be bidirectional: CKD predisposes to AF while onset of AF seems to lead to progression of CKD. Stroke prevention is the cornerstone of AF management, and AF patients with CKD are at higher risk of stroke, mortality, cardiac events, and bleeding. Stroke prevention requires use of oral anticoagulants, which are either vitamin K antagonists (eg, warfarin), or the nonvitamin K antagonist oral anticoagulants (NOACs). While NOACs have been shown to be effective in mild-to-moderate renal dysfunction, there are a paucity of data regarding NOACs in severe and end-stage renal dysfunction. This review first discusses the evidence for NOACs in CKD. Second, we summarize the current knowledge regarding the efficacy and safety of NOACs to prevent AF-related stroke and systemic embolism in severe and end-stage renal disease.
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Li YG, Pastori D, Lip GYH. Fitting the right non-vitamin K antagonist oral anticoagulant to the right patient with non-valvular atrial fibrillation: an evidence-based choice. Ann Med 2018; 50:288-302. [PMID: 29608110 DOI: 10.1080/07853890.2018.1460489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia and is associated with an increased risk of ischemic stroke (IS) and systemic embolism (SE). Stroke prevention is a key element for the overall management of AF patients. The non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, apixaban and edoxaban, are at least as effective as warfarin in reducing IS/SE with a lower rate of major bleeding. Various analyses from the large Phase III randomized trials demonstrated different efficacy and safety of NOACs in specific subgroups of patients. The randomized trials are supplemented by effectiveness and safety data from real-world observational cohorts following the availability of these drugs for use in everyday clinical practice. Given the clinical heterogeneity of AF patients, the available data from trials and real-world studies allow us to fit the right NOAC to the particular patient's characteristics, with the aim of optimizing outcomes for the individual patient. This review article aims to provide a summary of the evidence on the performance of NOACs in AF patients with specific clinical characteristics. Evidence-based suggestions are presented to provide a simple and viable strategy for clinicians for the choice of a particular NOAC. KEY MESSAGE Given the different performance of the new-oral anticoagulants in patients with the different clinical situation, evidence-based choice of fitting the right new-oral anticoagulants to the patients is provided in this review article.
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Affiliation(s)
- Yan-Guang Li
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Department of Cardiology , Chinese PLA General Hospital, Chinese PLA Medical School , Beijing , China
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome, Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J 2018; 38:852-859. [PMID: 26848149 DOI: 10.1093/eurheartj/ehv643] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 01/05/2023] Open
Abstract
Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA2DS2VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Antiagregación doble frente a simple, con o sin anticoagulación, tras reemplazo percutáneo de válvula aórtica: comparación indirecta y metanálisis. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.06.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: Specific Situation and High Risk Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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29
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Estimated absolute effects on efficacy and safety outcomes of using non-vitamin K antagonist oral anticoagulants in ‘real-world’ atrial fibrillation patients: A comparison with optimally acenocoumarol anticoagulated patients. Int J Cardiol 2018; 254:125-131. [DOI: 10.1016/j.ijcard.2017.11.087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/25/2017] [Accepted: 11/26/2017] [Indexed: 11/23/2022]
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30
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Impact of quality of anticoagulation control on outcomes in patients with atrial fibrillation taking aspirin: An analysis from the SPORTIF trials. Int J Cardiol 2018; 252:96-100. [DOI: 10.1016/j.ijcard.2017.10.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/09/2017] [Accepted: 10/23/2017] [Indexed: 11/23/2022]
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31
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Ammentorp B, Darius H, De Caterina R, Schilling R, Schmitt J, Zamorano JL, Kirchhof P, Le Heuzey JY. Differences among western European countries in anticoagulation management of atrial fibrillation. Thromb Haemost 2017; 111:833-41. [DOI: 10.1160/th13-12-1007] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/20/2014] [Indexed: 11/05/2022]
Abstract
SummaryDue to improved implementation of guidelines, new scoring approaches to improve risk categorisation, and introduction of novel oral anticoagulants, medical management of patients with atrial fibrillation (AF) is continuously improving. The PREFER in AF registry enrolled 7,243 consecutive patients with ECG-confirmed AF in seven European countries in 2012–2013 (mean age: 71.5 ± 10.7 years; 60.1% males; mean CHA2DS 2 -VASc score: 3.4). While patient characteristics were generally homogeneous across countries, anticoagulation management showed important differences: the proportion of patients taking vitamin K antagonists (VKAs) varied between 86.0% (in France) and 71.4% (in Italy). Warfarin was used predominantly in the UK and Italy (74.9% and 62.0%, respectively), phenprocoumon in Germany (74.1%), acenocoumarol in Spain (67.3%), and fluindione in France (61.8 %). The major sites for international normalised ratio (INR) measurements were biology laboratories in France anticoagulation clinics in Italy, Spain, and the UK, and physicians’ offices or self-measurement in Germany. Temporary VKA discontinuation and bridging with other anticoagulants was frequent (at least once in the previous 12 months for 22.9% of the patients, on average; ranging from 29.7% in Germany to 14.9% in the UK). Time in therapeutic range (TTR), defined as at least two of the last three available INR values between 2.0–3.0 prior to enrolment, ranged from 70.3% in Spain to 81.4% in Germany. TTR was constantly overestimated by physicians. While the type and half-lives of VKA as well as the mode of INR surveillance differed, overall quality of anticoagulation management by TTR was relatively homogenous in AF patients across countries.
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Larsen T, Rasmussen L, Lip GYH, Skjøth F. Efficacy and safety of edoxaban in comparison with dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation. Thromb Haemost 2017; 111:981-8. [DOI: 10.1160/th14-02-0118] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 02/18/2014] [Indexed: 01/16/2023]
Abstract
SummaryLarge Phase 3 clinical trials for stroke prevention in atrial fibrillation (AF) have compared non-vitamin K antagonist oral anticoagulants (NOACs) against warfarin, with the edoxaban trial only recently reported. In the absence of head to head trials directly comparing these NOACs against each other, we compared the efficacy and safety of edoxaban to other agents by an indirect comparison analysis. We performed an indirect comparison analysis of edoxaban (2 dose strategies) against apixaban (1 dose), dabigatran etexilate (2 doses) and rivaroxaban (1 dose), for their relative efficacy and safety against each other. For high-dose edoxaban vs apixaban, there were no significant differences in efficacy endpoints, mortality, myocardial infarction and major bleeding. Apixaban was associated with less major or clinically relevant non-major bleeding (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.70–0.90) and gastrointestinal bleeding (HR 0.72; 95% CI 0.53–0.99). For dabigatran 110 mg twice daily, there were no significant differences in the main efficacy or safety endpoints. Dabigatran 150 mg bid was associated with lower stroke/systemic embolism (SE) (HR 0.75; 95% CI 0.56–0.99), stroke (HR 0.73; 95% CI 0.55–0.96) and haemorrhagic stroke (HR 0.48; 95% CI 0.23–0.99). There were no significant differences between high-dose edoxaban vs rivaroxaban for efficacy endpoints or mortality, but rivaroxaban had more major and/or clinically relevant non-major bleeding. When compared to low-dose edoxaban, apixaban was associated with lower stroke/SE (HR 0.70; 95% CI 0.55–0.89), stroke (HR 0.70; 95% CI 0.55–0.92) and ischaemic stroke (HR 0.65; 95% CI 0.50–0.89), but more major bleeding (HR 1.47; 95% CI 1.20–1.80). For dabigatran 110 mg bid, there were no significant differences in the efficacy endpoints, but dabigatran 110 mg bid had higher major (and gastrointestinal) bleeding. Dabigatran 150 mg bid and rivaroxaban were associated with lower stroke/SE and ischaemic stroke, but higher bleeding rates. In the present analysis, we have provided for the first time, comparisons of efficacy and safety of edoxaban against other NOACs. Notwithstanding the significant limitations of an indirect comparison analysis, some differential effects are evident with the NOACs for stroke prevention, allowing us to allow the prescriber a ‘choice’ to be able to fit the drug to the patient clinical profile (and vice versa).Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Wang KL, Lip GYH, Chiang CE. Stroke prevention in atrial fibrillation: An Asian perspective. Thromb Haemost 2017; 111:789-97. [PMID: 24500243 DOI: 10.1160/th13-11-0948] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 01/16/2014] [Indexed: 01/27/2023]
Abstract
SummaryAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia. In 2050, it is estimated that there will be 72 million AF patients in Asia, accounting for almost 2.9 million patients suffering from AF-associated stroke. Asian AF patients share similar risk factor profiles as non-Asians, except that more Asians have a history of previous stroke. Clinical challenges are evident in the field of stroke prevention in AF, amongst Asians. Existing stroke and bleeding risk scores have not been well-validated in Asians. Asians are prone to bleeding when treated with warfarin, and the optimal international normalised ratio (INR) for warfarin use is yet to be determined in Asians, though Asian physicians tend to keep it in a lower range (e.g. INR 1.6–2.6) for elderly patients despite limited evidence to justify this. In general, warfarin is ‘difficult’ to use in Asians due to higher risk of bleeding and higher stroke rate in Asians than in non-Asians, as shown in randomised controlled trials. Excess of bleeding was not found in Asians when novel oral anticoagulants (NOACs) were used. Besides, the superiority of NOACs to warfarin in reducing thromboembolism was maintained in Asians. Therefore NOACs are preferentially indicated in Asians in terms of both efficacy and safety. Also, some preliminary data suggest that Asian patients with AF might not be the same. Future prospective randomised trials are needed for the selection of NOACs according to different ethnic background.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.
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Bertomeu V, Cequier Á, Marín F, Anguita M, Ruiz-Ortiz M. Validation of the SAMe-TT2R2 score in a nationwide population of nonvalvular atrial fibrillation patients on vitamin K antagonists. Thromb Haemost 2017; 114:695-701. [DOI: 10.1160/th15-02-0169] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/20/2015] [Indexed: 11/05/2022]
Abstract
SummaryThe SAMe-TT2R2 score has been proposed to identify patients with non valvular atrial fibrillation (AF) who maintain a high average time in therapeutic range (TTR) on vitamin K antagonists treatment (VKA). This score has been validated in several studies, either monocentric or including very selected populations in a specialised setting. Our objective was to validate this score in a nationwide cohort of AF patients. From November 2013 to March 2014 we included in this study the first 10 patients with AF on VKA consecutively seen in 120 outpatient cardiology clinics in Spain. The SAMe-TT2R2 score was calculated for each patient and TTR in the preceding six months was estimated by Rosendaal method. A total of 1,056 patients were recruited (mean age 73.6 ± 9.8 years, 42 % female). Mean value of TTR was 63.8 ± 25.9 % (median 66.8 %, interquartile range 45.6 %-85.4 %). We found a progressive decline in mean TTR from a score of 0 (67.5 % ± 24.6 %) to4 (52.7 ± 28.7 %, p< 0.01). The score was able to discriminate which patients had a good anticoagulation control (TTR65 %) with a C-statistic of 0.57 (95 %CI 0.53–0.60, p< 0.0005). A SAMe-TT2R2 score of 0–1 was associated with a good anticoagulation control with a sensitivity, specificity, positive and negative predictive values of 64 %, 48 %, 58 % and 54 %, respectively; and the odds ratio of having a TTR< 65 % if the score was2 was 1.64 (95 % confidence interval 1.33–1.95, p< 0.001). In conclusion, in this nationwide population with AF on VKA, the SAMe-TT2R2 score had a significant, although moderate, ability to identify patients with a good anticoagulation control.
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Poli D, Olshansky B, Fauchier L. The SAMe-TT2R2 score and quality of anticoagulation in AF: Can we predict which patient benefits from anticoagulation? Thromb Haemost 2017; 114:657-9. [DOI: 10.1160/th15-06-0518] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/26/2015] [Indexed: 12/30/2022]
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Belley-Cote E, Hanif H, D’Aragon F, Eikelboom J, Anderson J, Borgman M, Jonas D, Kimmel S, Manolopoulos V, Baranova E, Maitland-van der Zee A, Pirmohamed M, Whitlock R. Genotype-guided versus standard vitamin K antagonist dosing algorithms in patients initiating anticoagulation. Thromb Haemost 2017; 114:768-77. [DOI: 10.1160/th15-01-0071] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/03/2015] [Indexed: 01/01/2023]
Abstract
SummaryVariability in vitamin K antagonist (VKA) dosing is partially explained by genetic polymorphisms. We performed a meta-analysis to determine whether genotype-guided VKA dosing algorithms decrease a composite of death, thromboembolic events and major bleeding (pri-mary outcome) and improve time in therapeutic range (TTR). We searched MEDLINE, EMBASE, CENTRAL, trial registries and conference proceedings for randomised trials comparing genotype-guided and standard (non genotype-guided) VKA dosing algorithms in adults initiating anticoagulation. Data were pooled using a random effects model. Of the 12 included studies (3,217 patients), six reported all components of the primary outcome of mortality, thromboembolic events and major bleeding (2,223 patients, 87 events). Our meta-analysis found no significant difference between groups for the primary outcome (relative risk 0.85, 95 % confidence interval [CI] 0.54–1.34; heterogeneity X2=4.46, p=0.35, I2=10 %). Based on 10 studies (2,767 patients), TTR was significantly higher in the genotype-guided group (mean difference (MD) 4.31 %; 95 % CI 0.35, 8.26; heterogeneity X2=43.31, p< 0.001, I2=79 %). Pre-specified exploratory analyses demonstrated that TTR was significantly higher when geno-type-guided dosing was compared with fixed VKA dosing (6 trials, 997 patients: MD 8.41 %; 95 % CI 3.50,13.31; heterogeneity X2=15.18, p=0.01, I2=67 %) but not when compared with clinical algorithm-guided dosing (4 trials, 1,770 patients: MD –0.29 %; 95 % CI –2.48,1.90; heterogeneity X2=1.53, p=0.68, I2=0 %; p for interaction=0.002). In conclusion, genotype-guided compared with standard VKA dosing algorithms were not found to decrease a composite of death, thromboembolism and major bleeding, but did result in improved TTR. An improvement in TTR was observed in comparison with fixed VKA dosing algorithms, but not with clinical algorithms.
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients. Thromb Haemost 2017; 117:1448-1454. [DOI: 10.1160/th16-12-0961] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
SummaryOral anticoagulation (OAC) is highly effective preventing stroke and mortality in AF, but withdrawal is common in the elderly, when high bleeding risk and when are difficulties achieving an optimal time in therapeutic range (TTR). We analysed the rate of OAC cessation, predisposing factors to cessation and the relation to clinical outcomes in a large ‘real world’ cohort of AF patients over a long follow-up period. Consecutive non-valvular AF outpatients clinically stables for six months were recruited. Rates of cardiovascular events, major bleeding and mortality were recorded and related to OAC cessation. We included 1361 patients (48.7 % male; aged 76, IQR 71–81), followed-up for a median of 6.5 years. During follow-up, 244 patients suffered thrombotic events, 250 suffered from major bleeding and 551 patients died. 10 % of patients stopped OAC. After OAC withdrawal, there were 36 thromboembolic events (22 strokes), 10 major bleedings and 75 deaths. OAC cessation was independently associated with adverse cardiovascular events (HR 1.45; 95 % CI 1.01–2.08), stroke/TIA (HR 1.85; 1.17–2.94) and all-cause mortality (HR 1.30; 1.02–1.67). Independent predictors of OAC cessation were age ≥80 (HR 2.29; 1.60–3.29), previous coronary artery disease (HR 0.32; 0.15–0.71), major bleeding (HR 5.00; 3.49–7.15), heart failure (HR 2.38; 1.26–4.47), cancer (HR 5.24; 3.25–8.44) and renal impairment developed during follow-up (HR 2.70; 1.26–5.75). In conclusion, in non-valvular AF patients, cessation of OAC was independently associated with the risk of stroke, adverse cardiovascular events and mortality. Bleeding events and some variables associated with higher bleeding risk are responsible for OAC cessation.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Marín F, Vanessa R. The importance of excellence in the quality of anticoagulation control whilst taking vitamin K antagonists. Thromb Haemost 2017; 113:671-3. [DOI: 10.1160/th14-12-1087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 01/18/2015] [Indexed: 12/11/2022]
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Zulkifly H, Lip GYH, Lane DA. Use of the SAMe-TT 2R 2 score to predict anticoagulation control in atrial fibrillation and venous thromboembolism patients receiving vitamin K antagonists: A review. Heart Rhythm 2017; 15:615-623. [PMID: 29180122 DOI: 10.1016/j.hrthm.2017.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Indexed: 10/18/2022]
Abstract
Identifying patients who are likely to achieve and maintain a therapeutic international normalized ratio when prescribed a vitamin K antagonist for stroke prevention in atrial fibrillation (AF) and venous thromboembolism (VTE) is challenging. The SAMe-TT2R2 score was developed on the basis of common clinical factors that can highlight patients who may be unable to achieve and maintain good anticoagulation control and for whom a "trial of warfarin" would be inadvisable. This review summarizes the main published prospective and retrospective studies that have validated the SAMe-TT2R2 score in patients with AF and VTE treated with a vitamin K antagonist and how the SAMe-TT2R2 score could aid clinical decision making; 19 studies were included. Taken together, validation studies suggest that the SAMe-TT2R2 score is able to predict good or poor anticoagulation control in patients with AF and VTE, although data on patients with VTE are limited (3 studies). The available evidence suggests that the SAMe-TT2R2 score may be a useful tool to aid clinical decision making for oral anticoagulants in patients with AF and VTE.
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Affiliation(s)
- Hanis Zulkifly
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Nijenhuis VJ, Bennaghmouch N, Kuijk JPV, Capodanno D, ten Berg JM. Antithrombotic treatment in patients undergoing transcatheter aortic valve implantation (TAVI). Thromb Haemost 2017; 113:674-85. [DOI: 10.1160/th14-10-0821] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/27/2014] [Indexed: 12/31/2022]
Abstract
SummaryTranscatheter aortic valve implantation (TAVI) is an established treatment option for symptomatic patients with severe aortic valvular disease who are not suitable for conventional surgical aortic valve replacement. Despite improving experience and techniques, ischaemic and bleeding complications after TAVI remain prevalent and impair survival in this generally old and comorbid-rich population. Due to changing aetiology of complications over time, antiplatelet and anticoagulant therapy after TAVI should be carefully balanced. Empirically, a dual antiplatelet strategy is generally used after TAVI for patients without an indication for oral anticoagulation (OAC; e. g. atrial fibrillation, mechanical mitral valve prosthesis), including aspirin and a thienopyridine. For patients on OAC, a combination of OAC and aspirin or thienopyridine is generally used. This review shows that current registries are unfit to directly compare antithrombotic regimens. Small exploring studies suggest that additional clopidogrel after TAVI only affects bleeding and not ischemic complications. However, these studies are lack in quality in terms of Cochrane criteria. Currently, three randomised controlled trials are recruiting to gather more knowledge about the effects of clopidogrel after TAVI.
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Bellesini M, Minno MNDD, Mumoli N, Pomero F, Franchini M, Fantoni C, Lupoli R, Brondi B, Borretta V, Bonfanti C, Ageno W, Dentali F, Riva N. Poor predictive value of contemporary bleeding risk scores during long-term treatment of venous thromboembolism. Thromb Haemost 2017; 112:511-21. [DOI: 10.1160/th14-01-0081] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 04/17/2014] [Indexed: 11/05/2022]
Abstract
SummaryBleeding is a common and feared complication of oral anticoagulant therapy. Several prediction models have been recently developed, but there is a lack of evidence in patients with venous thromboembolism (VTE). The aim of this study was to validate currently available bleeding risk scores during long-term oral anticoagulation for VTE. We retrospectively included adult patients on vitamin K antagonists for VTE secondary prevention, followed by five Italian Anticoagulation Clinics (Cuneo, Livorno, Mantova, Napoli, Varese), between January 2010 and August 2012. All bleeding events were classified as major bleeding (MB) or clinically-relevant-non-major-bleeding (CRNMB). A total of 681 patients were included (median age 63 years; 52.0% female). During a mean follow-up of 8.82 (± 3.59) months, 50 bleeding events occurred (13 MB and 37 CRNMB), for an overall bleeding incidence of 9.99/100 patient-years. The rate of bleeding was higher in the first three months of treatment (15.86/100 patient-years) than afterwards (7.13/100 patient-years). The HAS-BLED showed the best predictive value for bleeding complications during the first three months of treatment (area under the curve [AUC] 0.68, 95% confidence interval [CI] 0.59–0.78), while only the ACCP score showed a modest predictive value after the initial three months (AUC 0.61, 95%CI 0.51–0.72). These two scores had also the highest sensitivity and the highest negative predictive value. None of the scores predicted MB better than chance. Currently available bleeding risk scores had only a modest predictive value for patients with VTE. Future studies should aim at the creation of a new prediction rule, in order to better define the risk of bleeding of VTE patients.
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Importance of time in therapeutic range on bleeding risk prediction using clinical risk scores in patients with atrial fibrillation. Sci Rep 2017; 7:12066. [PMID: 28935868 PMCID: PMC5608893 DOI: 10.1038/s41598-017-11683-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/28/2017] [Indexed: 01/08/2023] Open
Abstract
Bleeding risk with vitamin K antagonists (VKAs) is closely related to the quality of anticoagulation in atrial fibrillation (AF) patients, reflected by time in therapeutic range (TTR). Here we compared the discrimination performance of different bleeding risk scores and investigated if adding TTR would improve their predictive value and clinical usefulness. We included 1361 AF patients stables on VKA for at least 6 months. Bleeding risk was assessed by the HAS-BLED, ATRIA, ORBIT and HEMORR2HAGES scores. Major bleeding events were recorded after a median of 6.5 years follow-up. In this period 250 patients suffered major bleeds. Comparison of receiver operating characteristic (ROC) curves demonstrated that HAS-BLED had the best discrimination performance, but adding the ‘labile INR’ criteria (i.e. TTR <65%) to ATRIA, ORBIT and HEMORR2HAGES increased their ability of discrimination and predictive value, with significant improvements in reclassification and discriminatory performance. Decision curve analyses (DCA) showed improvements of the clinical usefulness and a net benefit of the modified risk scores. In summary, in AF patients taking VKAs, the HAS-BLED score had the best predictive ability. Adding ‘labile INR’ to ATRIA, ORBIT and HEMORR2HAGES improved their predictive value for major bleeding leading to improved clinical usefulness compared to the original scores.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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Kondratieva TB, Popova LV, Bokarev IN. Non-vitamin K antagonist oral anticoagulants for heart diseases. TERAPEVT ARKH 2017; 89:120-127. [DOI: 10.17116/terarkh2017899120-127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NОАСs) are highly effective drugs that prevent venous thrombosis and stroke in atrial fibrillation. Their use has difficulties that are associated with the need for laboratory control and with the influence of many factors on the activity of these medications. The emerged direct oral anticoagulants have some advantages over NOACs. Nevertheless, there are a number of pathological conditions, in which NOACs remain first-line drugs. These include prosthetic mechanical heart valves, a glomerular filtration rate less than 60 mL/min/1.73 m2, and left atrial thrombus.
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Liu J, Wang N, Qin L, Liu J, Xi S, Wang X, Li X, Zhang Y, Yin T. Integrating genotypes in the SAMe-TT 2R 2 score for the prediction of anticoagulation control in Chinese patients with atrial fibrillation on warfarin. Int J Cardiol 2017; 241:358-363. [PMID: 28479094 DOI: 10.1016/j.ijcard.2017.04.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/07/2017] [Accepted: 04/26/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The SAMe-TT2R2 score has been proposed to predict whether patients with atrial fibrillation (AF) would be well anti-coagulated with warfarin or not. However, it might over-estimate the number of patients under suboptimal warfarin treatment in non-Caucasians. This study was designed to modify the SAMe-TT2R2 score with genotypes and validate it in Chinese AF patients treated with warfarin. MATERIAL AND METHODS Consented Chinese-Han patients (n=510) with AF under the treatment of warfarin for at least 3months were randomly divided into a derivation (n=310) and a validation cohort (n=200). For each patient, CYP2C9*3 and VKORC1 -1639 A/G genotyping was performed, and the time in therapeutic range (TTR) was calculated over this period. RESULTS The modified SAMe-TT2R2 score was established by adding "warfarin genotype bins" to replace "the non-white race" variable. In the validation cohort, the discrimination performance of the modified score for good anticoagulation control (TTR≥70%) was significantly improved (c- index increased from 0.60 to 0.67). Significantly increased risks of major bleedings (HR: 4.91; 95% CI: 1.03-23.37; adjusted p=0.04) and all bleedings (HR: 1.93; 95% CI: 1.14-3.25; adjusted p=0.01) were found in patients with modified scores ≥2, as compared with patients with modified scores of 0-1. CONCLUSIONS The modified SAMe-TT2R2 score could improve the ability for the identification of good anticoagulation control, and the prediction of major bleeding events in Chinese patients with AF treated by warfarin.
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Affiliation(s)
- Jia Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Nina Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Liuan Qin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jun Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Shaozhi Xi
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xuyun Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoqi Li
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yuxiao Zhang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Tong Yin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China.
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Potpara TS, Trendafilova E, Dan GA, Goda A, Kusljugic Z, Manola S, Music L, Gjini V, Pojskic B, Popescu MI, Georgescu CA, Dimitrova ES, Kamenova D, Ekmeciu U, Mrsic D, Nenezic A, Brusich S, Milanov S, Zeljkovic I, Lip GYH. The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey. Adv Ther 2017; 34:2043-2057. [PMID: 28795332 PMCID: PMC5565662 DOI: 10.1007/s12325-017-0589-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Data on management of atrial fibrillation (AF) in the Balkan Region are scarce. To capture the patterns in AF management in contemporary clinical practice in the Balkan countries a prospective survey was conducted between December 2014 and February 2015, and we report results pertinent to the use of non-vitamin K antagonist oral anticoagulants (NOACs). METHODS A 14-week prospective, multicenter survey of consecutive AF patients seen by cardiologists or internal medicine specialists was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania, and Serbia (a total of about 50 million inhabitants). RESULTS Of 2712 enrolled patients, 2663 (98.2%) had complete data relevant to oral anticoagulant (OAC) use (mean age 69.1 ± 10.9 years, female 44.6%). Overall, OAC was used in 1960 patients (73.6%) of whom 338 (17.2%) received NOACs. Malignancy [odds ratio (OR), 95% confidence interval (CI) 2.06, 1.20-3.56], rhythm control (OR 1.64, 1.25-2.16), and treatment by cardiologists were independent predictors of NOAC use (OR 2.32, 1.51-3.54) [all p < 0.01)], whilst heart failure and valvular disease were negatively associated with NOAC use (both p < 0.01). Individual stroke and bleeding risk were not significantly associated with NOAC use on multivariate analysis. CONCLUSIONS NOACs are increasingly used in AF patients in the Balkan Region, but NOAC use is predominantly guided by factors other than evidence-based decision-making (e.g., drug availability on the market or reimbursement policy). Efforts are needed to establish an evidence-based approach to OAC selection and to facilitate the optimal use of OAC, thus improving the outcomes in AF patients in this large region.
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Affiliation(s)
- Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia.
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia.
| | | | - Gheorghe-Andrei Dan
- Medicine University "Carol Davila", Colentina University Hospital, Bucharest, Romania
| | - Artan Goda
- Clinic of Cardiology, University Hospital Centre Mother Theresa, Tirana, Albania
| | - Zumreta Kusljugic
- Cardiology Department, Clinic for Internal Diseases, Tuzla, Bosnia and Herzegovina
| | - Sime Manola
- Clinical Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Ljilja Music
- University Clinical Centre Podgorica, Podgorica, Montenegro
| | | | - Belma Pojskic
- General Hospital Zenica, Zenica, Bosnia and Herzegovina
| | | | | | - Elena S Dimitrova
- Medicine University "Carol Davila", Colentina University Hospital, Bucharest, Romania
| | | | - Uliks Ekmeciu
- Clinic of Cardiology, University Hospital Centre Mother Theresa, Tirana, Albania
| | - Denis Mrsic
- Cardiology Department, Clinic for Internal Diseases, Tuzla, Bosnia and Herzegovina
| | - Ana Nenezic
- University Clinical Centre Podgorica, Podgorica, Montenegro
| | | | | | - Ivan Zeljkovic
- Clinical Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Gregory Y H Lip
- School of Medicine, Belgrade University, Belgrade, Serbia
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, UK
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Verdoia M, Barbieri L, Nardin M, Suryapranata H, De Luca G. Dual Versus Single Antiplatelet Regimen With or Without Anticoagulation in Transcatheter Aortic Valve Replacement: Indirect Comparison and Meta-analysis. ACTA ACUST UNITED AC 2017; 71:257-266. [PMID: 28734880 DOI: 10.1016/j.rec.2017.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES There is uncertainty on the correct management of antithrombotic therapies after transcatheter aortic valve replacement (TAVR), with dual antiplatelet therapy (DAPT) being currently recommended on an empirical basis. The aim of the present meta-analysis was to assess the safety and effectiveness of DAPT in patients undergoing TAVR. METHODS Studies comparing different antithrombotic regimens after TAVR were included. The primary endpoint was 30-day overall mortality. RESULTS We included 9 studies, 5 comparing DAPT with aspirin monotherapy and 4 comparing DAPT with monoantiplatelet therapy (MAPT) + oral anticoagulation. Among 7991 patients, 72% were on DAPT. The median follow-up was 3.5 months. Mortality was significantly lower in the DAPT group (12.2% vs 14.4%; OR, 0.81; 95%CI, 0.70-0.93; P = .003; Phet = .93), with similar benefits compared with aspirin monotherapy (OR, 0.80; 95%CI, 0.69-0.93; P = .004; Phet = .60), which were not statistically significant when compared with MAPT + oral anticoagulation (OR, 0.86; 95%CI, 0.55-1.35; P = .51; Phet = .97). A similar trend for DAPT was observed for stroke (OR, 0.83 95%CI, 0.63-1.10; P = .20; Phet = .67), with no increase in the rate of major bleedings (OR, 1.69; 95%CI, 0.86-3.31; P = .13; Phet< .0001). On indirect comparison analysis, no benefit in survival, stroke, or bleedings was identified for additional oral anticoagulation. CONCLUSIONS The present meta-analysis supports the use of DAPT after TAVR, reducing mortality and offering slight benefits in stroke, with no increase in major bleedings compared with MAPT. The strategy of aspirin + oral anticoagulation did not provide significant benefits compared with MAPT or DAPT.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Department of Cardiology, Ospedale S. Andrea, Vercelli, Italy
| | - Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Department of Medicine, ASST "Spedali Civili", University of Brescia, Brescia, Italy
| | - Harry Suryapranata
- Department of Cardiology, University Medical Centre St Radboud, Nijmegen, The Netherlands
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Pastori D, Carnevale R, Nocella C, Novo M, Santulli M, Cammisotto V, Menichelli D, Pignatelli P, Violi F. Gut-Derived Serum Lipopolysaccharide is Associated With Enhanced Risk of Major Adverse Cardiovascular Events in Atrial Fibrillation: Effect of Adherence to Mediterranean Diet. J Am Heart Assoc 2017; 6:e005784. [PMID: 28584074 PMCID: PMC5669181 DOI: 10.1161/jaha.117.005784] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/12/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gut microbiota is emerging as a novel risk factor for atherothrombosis, but the predictive role of gut-derived lipopolysaccharide (LPS) is unknown. We analyzed (1) the association between LPS and major adverse cardiovascular events (MACE) in atrial fibrillation (AF) and (2) its relationship with adherence to a Mediterranean diet (Med-diet). METHODS AND RESULTS This was a prospective single-center study including 912 AF patients treated with vitamin K antagonists (3716 patient-years). The primary end point was a composite of MACE. Baseline serum LPS, adherence to Med-diet (n=704), and urinary excretion of 11-dehydro-thromboxane B2 (TxB2, n=852) were investigated. Mean age was 73.5 years; 42.9% were women. A total of 187 MACE (5.0% per year) occurred: 54, 59, and 74 in the first, second, and third tertile of LPS, respectively (log-rank test P=0.004). Log-LPS (hazard ratio 1.194, P=0.009), age (hazard ratio 1.083, P<0.001), and previous cerebrovascular (hazard ratio 1.634, P=0.004) and cardiac events (hazard ratio 1.822, P<0.001) were predictors of MACE. In the whole cohort, AF (versus sinus rhythm) (β 0.087, P=0.014) and low-density lipoprotein cholesterol (β 0.069, P=0.049) were associated with circulating LPS. Furthermore, Med-diet score (β -0.137, P<0.001) was predictive of log-LPS, with fruits (β -0.083, P=0.030) and legumes (β -0.120, P=0.002) negatively associated with log-LPS levels. Log-LPS and log-TxB2 were highly correlated (r=0.598, P<0.001). Log-LPS (β 0.574, P<0.001) and Med-diet score (β -0.218, P<0.001) were significantly associated with baseline urinary excretion of TxB2. CONCLUSIONS In this cohort of AF patients, LPS levels were predictive of MACE and negatively affected by high adherence to Med-diet. LPS may contribute to MACE incidence in AF by increasing platelet activation.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Italy
| | - Roberto Carnevale
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Cristina Nocella
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Marta Novo
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Maria Santulli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Vittoria Cammisotto
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Danilo Menichelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
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Geographical differences in thromboembolic and bleeding risks in patients with non-valvular atrial fibrillation: An ancillary analysis from the SPORTIF trials. Int J Cardiol 2017; 236:244-248. [DOI: 10.1016/j.ijcard.2017.02.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 02/24/2017] [Indexed: 01/08/2023]
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Atrial Fibrillation and End Stage Renal Failure in Patients Receiving Dialysis: Balancing the Risks and Benefits of Stroke Prevention. Can J Cardiol 2017; 33:705-707. [DOI: 10.1016/j.cjca.2017.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/23/2017] [Accepted: 02/23/2017] [Indexed: 01/10/2023] Open
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Balancing thromboembolic and bleeding risk with non-vitamin K antagonist oral anticoagulants (NOACs): A systematic review and meta-analysis on gender differences. Pharmacol Res 2017; 117:274-282. [DOI: 10.1016/j.phrs.2017.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 11/23/2022]
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