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García-Escobar A, Lázaro-García R, Goicolea-Ruigómez J, González-Casal D, Fontenla-Cerezuela A, Soto N, González-Panizo J, Datino T, Pizarro G, Moreno R, Cabrera JÁ. Red Blood Cell Distribution Width is a Biomarker of Red Cell Dysfunction Associated with High Systemic Inflammation and a Prognostic Marker in Heart Failure and Cardiovascular Disease: A Potential Predictor of Atrial Fibrillation Recurrence. High Blood Press Cardiovasc Prev 2024:10.1007/s40292-024-00662-0. [PMID: 39031283 DOI: 10.1007/s40292-024-00662-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/12/2024] [Indexed: 07/22/2024] Open
Abstract
At the beginning of the 21st century, approximately 2.3 million US adults had atrial fibrillation (AF), and there has been a 60% increase in hospital admissions for AF. Given that the expectancy is a continuous increase in incidence, it portends a severe healthcare problem. Considerable evidence supports the immune system and inflammatory response in cardiac tissue, and circulatory processes are involved in the physiopathology of AF. In this regard, finding novel inflammatory biomarkers that predict AF recurrence after catheter ablation (CA) is a prime importance global healthcare problem. Many inflammatory biomarkers and natriuretic peptides came out and were shown to have predictive capabilities for AF recurrence in patients undergoing CA. In this regard, some studies have shown that red blood cell distribution width (RDW) is associated with the risk of incident AF. This review aimed to provide an update on the evidence of the RDW as a biomarker of red cell dysfunction and its association with high systemic inflammation, and with the risk of incident AF. Through the literature review, we will highlight the most relevant studies of the RDW related to AF recurrence after CA. Many studies demonstrated that RDW is associated with all cause-mortality, heart failure, cardiovascular disease, and AF, probably because RDW is a biomarker of red blood cell dysfunction associated with high systemic inflammation, reflecting an advanced heart disease with prognostic implications in heart failure and cardiovascular disease. Thus, suggesting that could be a potential predictor for AF recurrence after CA. Moreover, the RDW is a parameter included in routine full blood count, which is low-cost, quick, and easy to obtain. We provided an update on the evidence of the most relevant studies of the RDW related to AF recurrence after CA, as well as the mechanism of the high RDW and its association with high systemic inflammation and prognostic marker in cardiovascular disease and heart failure.
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Affiliation(s)
- Artemio García-Escobar
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain.
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain.
| | - Rosa Lázaro-García
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Javier Goicolea-Ruigómez
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - David González-Casal
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Adolfo Fontenla-Cerezuela
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Nina Soto
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Jorge González-Panizo
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Tomás Datino
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Gonzalo Pizarro
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
| | - Raúl Moreno
- Cardiology Department, La Paz University Hospital, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - José Ángel Cabrera
- Cardiology Department, Quirónsalud University Hospital Madrid, Calle Diego de Velázquez, 1, 28223, Pozuelo de Alarcón, Madrid, Spain
- Cardiology Department, Ruber Juan Bravo Quirónsalud University Hospital, Calle de Juan Bravo, 49, 28006, Madrid, Spain
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Kang W, Peng K, Yan VK, Al-Badriyeh D, Lee SF, Yiu HHE, Wei Y, Li STH, Ye X, El Helali A, Lam KO, Lee VHF, Wong ICK, Chan EW. Direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer-associated venous thrombosis: a cost-effectiveness analysis. J Pharm Policy Pract 2024; 17:2375269. [PMID: 39027009 PMCID: PMC11257015 DOI: 10.1080/20523211.2024.2375269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
Background Direct oral anticoagulants (DOACs) have demonstrated clinical benefits and better patient adherence over low-molecular-weight heparin (LMWH) in treating patients with cancer-associated venous thrombosis (CAT). We aimed to compare the cost-effectiveness of DOACs against LMWH in patients with CAT from the perspective of the Hong Kong healthcare system. Methods A Markov state-transition model was performed to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) for DOACs and LMWH in a hypothetical cohort of 10,000 patients with CAT over a 5-year lifetime horizon. The model was primarily based on the health states of no event, recurrent venous thromboembolism, bleeding, and death. Transition probabilities, relative risks, and utilities were derived from the literature. Resource cost data were obtained from the Hong Kong Hospital Authority. Deterministic and probabilistic sensitivity analyses tested the robustness of the results. Results Relative to LMWH, DOACs were associated with increased QALYs (1.52 versus 1.50) at a lower medical cost of USD 2,232 versus 8,224 in five years. The cost of LMWH was the main contributor to the outcome. Out of 10,000 simulated cases, DOACs were dominant in 15.8% and cost-effective in 42.1%, at the willingness-to-pay threshold of USD 148,392 per additional QALY. Conclusions DOACs were associated with greater QALY improvements and lower overall costs compared to LMWH. Accounting for uncertainty, DOACs were between cost-effective and dominant in 57.9% of cases. DOACs are a cost-effective alternative to LMWH in the management of CAT in Hong Kong.
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Affiliation(s)
- Wei Kang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Kuan Peng
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Vincent K.C. Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | | | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Hei Hang Edmund Yiu
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Yue Wei
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Silvia T. H. Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Xuxiao Ye
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Aya El Helali
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Ka On Lam
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Victor H. F. Lee
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, People’s Republic of China
- School of Pharmacy, Aston University, Birmingham, UK
- School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Macau SAR, People’s Republic of China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, People’s Republic of China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, People’s Republic of China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
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Nam KW, Kwon HM, Lee YS, Won SH, Moon HS, Park JH. Outcomes of non-vitamin K oral anticoagulants for secondary prevention in ischemic stroke with atrial fibrillation. Sci Rep 2024; 14:9838. [PMID: 38684879 PMCID: PMC11058194 DOI: 10.1038/s41598-024-60660-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 04/25/2024] [Indexed: 05/02/2024] Open
Abstract
Previous studies have rarely investigated the role of non-vitamin K oral anticoagulants (NOAC) and warfarin in the secondary prevention of ischemic stroke patients with nonvalvular atrial fibrillation (NVAF). In this study, we compared the effectiveness and safety of NOAC and warfarin for secondary prevention in Korean ischemic stroke patients with NVAF. Based on the Korean National Health Insurance Service Database, this study included 21,064 oral anticoagulants-naïve acute ischemic stroke patients with NVAF between July 2015 and June 2019. The main study outcomes included ischemic stroke, systemic embolism, major bleeding, and death. During the observational periods, NOAC users had a significantly decreased risk of ischemic stroke + systemic embolism (adjusted hazard ratio [aHR] 0.86; 95% confidence interval [CI] 0.78-0.95), ischemic stroke (aHR 0.89; 95% CI 0.81-0.99), major bleeding (aHR 0.78; 95% CI 0.68-0.89), and all-cause death (aHR 0.87; 95% CI 0.81-0.93). Standard-dose NOAC users had a lower risk of ischemic stroke, systemic embolism, and major bleeding events than warfarin users. In contrast, low-dose NOAC users did not differ in risk from warfarin users for all outcomes. In conclusion, NOACs were associated with a lower risk of secondary thromboembolic events and bleeding complications in Korean ischemic stroke patients with NVAF than warfarin.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Sung-Ho Won
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Hye-Sung Moon
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Jong-Ho Park
- Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
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Poonchuay N, Saokaew S, Incomenoy S. SAMe-TT 2R 2 Score to Predict Time in Therapeutic Range of Vitamin K Antagonists in Asian and Non-Asian patients: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2024; 24:211-240. [PMID: 38252269 DOI: 10.1007/s40256-023-00623-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Sex, age, medical history, treatment, tobacco use, and race (SAMe-TT2R2) score helps detect patients at risk of suboptimal anticoagulation control. A score above two suggests poor control; however, non-Caucasian status being assigned two points might hinder the recognition of poor control in patients of other races. OBJECTIVE To evaluate the SAMe-TT2R2 score's ability to predict poor anticoagulation control [defined as time in therapeutic range (TTR) < 60-70%] in Asian and non-Asian populations on vitamin K antagonists (VKAs). METHODS We searched PubMed, Cochrane Library, Scopus, SpringerLink, and Web of Science using the keyword "SAMe-TT2R2." Articles published before April 2022 were screened. We gathered mean TTR and diagnostic accuracy data for different SAMe-TT2R2 thresholds and conducted meta-analyses using random-effects models. RESULTS A total of 30 studies were included (N = 36,690). The overall mean TTR differences were - 4.88 and - 6.41 for the cutoffs of ≥ 3 and ≥ 4, respectively. For non-Asian patients, the mean TTR differences were - 3.86, - 5.12, and - 8.09 for the cutoffs ≥ 2, ≥ 3, and ≥ 4, respectively. For Asian patients, the mean TTR differences were - 3.99 and - 4.07 for the cut-offs ≥ 3 and ≥ 4, respectively. The highest positive likelihood ratio (LR+) for the Asian subgroup was 1.17 [95% confidence interval (CI): 1.06-1.28; I2 = 0%, p heterogeneity = 0.500] at cutoff ≥ 4 and for the non-Asian subgroup, at cut-off ≥ 3, the LR+ was 1.24 (95% CI 1.14-1.34; I2 = 0% p heterogeneity = 0.455). The lowest LR- was found at a lower cutoff for both races (at cutoff ≥ 3 and ≥ 2 for Asian and non-Asian subgroups, respectively). The pooled results of other accuracy parameters were modest at all cutoffs, except for the sensitivity at cutoff ≥ 3 in the Asian subgroup (83.05%). CONCLUSION Our study results suggest that a higher SAMe-TT2R2 score resulted in a greater reduction of TTR among Asian and all races. The accuracy parameters showed the highest sensitivity for poor TTR at the SAMe-TT2R2 cutoff of ≥ 3 for Asian patients. However, the ability to identify patients likely to have poor TTR was limited. Further research is needed to enhance the risk assessment for poor anticoagulation control with VKAs. REGISTRATION The protocol of this systematic review was registered in the International Prospective Register of Scientific Reviews: PROSPERO, registration number CRD42021291865.
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Affiliation(s)
- Natnicha Poonchuay
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Tha Sala, Nakhon Si Thammarat, 80160, Thailand
- Drug and Cosmetics Excellence Center, Walailak University, Tha Sala, Nakhon Si Thammarat, 80161, Thailand
| | - Surasak Saokaew
- Division of Social and Administrative Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
- Unit of Excellence On Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
| | - Supatcha Incomenoy
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Tha Sala, Nakhon Si Thammarat, 80160, Thailand.
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Basu Roy P, Tejani VN, Dhillon SS, Damarlapally N, Winson T, Usman NUB, Panjiyar BK. Efficacy and Safety of Novel Oral Anticoagulants in Atrial Fibrillation: A Systematic Review. Cureus 2023; 15:e46385. [PMID: 37927673 PMCID: PMC10620341 DOI: 10.7759/cureus.46385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
In recent times, novel oral anticoagulants (NOACs)/direct oral anticoagulants (DOACs) have emerged as an alternative to the traditionally used Vitamin K oral antagonists (VKA) like warfarin for the treatment of atrial fibrillation (AF). This systematic review and meta-analysis aims to evaluate the efficacy and safety of NOACs in patients with AF and, thus, the related thromboembolic risks and sequelae. Of the 131 published articles we examined, 11 were included in an in-depth systematic review. The articles we reviewed were from the past ten years, from 2013 onward. The analysis derived the efficacy and safety of NOACs in patients with AF and also included different patients' baseline characteristics and subgroups. This systematic review reiterates previous research findings of superior efficacy and safety of the use of NOACs in the AF population and also illuminates certain head-to-head comparisons of individual NOACs with warfarin. It digressed into subgroups of patients with different baseline characteristics to provide evidence and support the existing guidelines for the use of NOACs in the treatment of AF. Overall, there is marked efficacy and safety of NOACs in patients with AF, be they elderly or Asian, with decreased renal function, or with other comorbidities. Adherence to NOACs was also satisfactory. Despite such a review, there needs to be more research on vast subgroups and also on reversal antidotes like andexanet alfa and idarucizumab, as well as more head-to-head analysis between NOACs over a long duration of study, which would provide more answers and pinpoint reasons as to the differences that exist between demographics and subgroups in the usage of NOACs.
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Affiliation(s)
- Prithvi Basu Roy
- Medicine, KPC (Kali Pradip Chaudhuri) Medical College and Hospital, Kolkata, West Bengal, India, Kolkata, IND
| | - Vitrag N Tejani
- Medicine, Parul Institute of Medical Sciences and Research, Vadodara, IND
| | - Sukhmeet S Dhillon
- Internal Medicine, Baba Farid University of Health Sciences, Faridkot, IND
| | - Nanush Damarlapally
- Health Sciences, Houston Community College - Coleman College for Health Sciences, Houston, USA
| | | | | | - Binay K Panjiyar
- Global Clinical Scholars Research Training, Harvard Medical School, Boston, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Diaz AB, Chow J, Hoo FK, Koh KW, Lee GCK, Teo WS, Venketasubramanian N, Wang CC, Mehta R. Early experiences with edoxaban for stroke prevention in atrial fibrillation in the Southeast Asia region. Drugs Context 2023; 12:2023-3-3. [PMID: 37711730 PMCID: PMC10499367 DOI: 10.7573/dic.2023-3-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023] Open
Abstract
Edoxaban, a once-daily, direct-acting oral anticoagulant, is approved to prevent stroke or systemic embolism in non-valvular atrial fibrillation (NVAF) and treat venous thromboembolism. The clinical benefit of edoxaban for stroke prevention in Asian patients with NVAF has been demonstrated in clinical and real-world studies. We share early clinical experiences with once-daily edoxaban and discuss its evidence-based use in patients with NVAF in Southeast Asia through several cases of patients at high risk, including frail patients, elderly patients with multiple comorbidities and patients with increased bleeding risk. These cases demonstrate the effectiveness and safety of once-daily edoxaban in patients with NVAF in Southeast Asia.
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Affiliation(s)
| | - Jeremy Chow
- Asian Heart & Vascular Centre, Singapore, Singapore
| | - Fan Kee Hoo
- University Putra Malaysia, Serdang, Malaysia
| | - Kok Wei Koh
- Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | | | - Wee Siong Teo
- Mount Elizabeth Medical Centre, Singapore, Singapore
| | | | - Chun-Chieh Wang
- Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan
| | - Radhika Mehta
- A. Menarini Asia-Pacific Pte Ltd, Singapore, Singapore
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Kim H, Song TJ, Yee J, Kim DH, Park J, Gwak HS. ABCG2 Gene Polymorphisms May Affect the Bleeding Risk in Patients on Apixaban and Rivaroxaban. Drug Des Devel Ther 2023; 17:2513-2522. [PMID: 37641689 PMCID: PMC10460569 DOI: 10.2147/dddt.s417096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose Direct oral anticoagulants (DOACs) are widely used for stroke prevention in atrial fibrillation. However, they have a bleeding complication. Breast cancer resistance protein, encoded by ABCG2, is known to be an efflux transporter of apixaban and rivaroxaban among DOACs. This study aimed to investigate the association between gene variants and bleeding complications during treatment with ABCG2 substrates (apixaban and rivaroxaban). Patients and Methods Patients treated with apixaban and rivaroxaban were enrolled from June 2018 to December 2021. Five single nucleotide polymorphisms (SNPs) of ABCG2 were selected. Previously studied genes (ABCB1, CYP3A4, and CYP3A5) were further analyzed as possible confounders. Finally, a total of 16 SNPs were examined in this case-control study. The outcome was defined as major bleeding and clinically relevant non-major bleeding. Two models were constructed using the multivariable analysis. Results Among 293 patients, 64 were cases. The mean age of the patients was 68.8 years, and males comprised 62.5% of the study population. Model I revealed that a history of bleeding, concurrent use of proton pump inhibitor (PPI), ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with bleeding complications; the AORs (95% CI) were 6.209 (2.210-17.442), 2.385 (1.064-5.349), 2.188 (1.156-4.142), and 3.243 (1.371-7.671), respectively. Model II showed that modified HAS-BLED score, concurrent use of PPI, ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with bleeding complications. Conclusion The modified HAS-BLED score, a history of bleeding, concurrent use of PPI, ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with the risk of bleeding complications in patients on apixaban and rivaroxaban, after adjusting for other confounders. These findings can be used to develop individualized treatment strategies for patients taking apixaban and rivaroxaban.
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Affiliation(s)
- Hamin Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Dong-Hyeok Kim
- Department of Cardiology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
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8
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Grymonprez M, Vanspranghe K, Steurbaut S, De Backer TL, Lahousse L. Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Versus Warfarin in Patients with Atrial Fibrillation Using P-gp and/or CYP450-Interacting Drugs: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2023; 37:781-791. [PMID: 34637052 DOI: 10.1007/s10557-021-07279-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Non-vitamin K antagonist oral anticoagulants (NOACs) are excreted by P-glycoprotein (P-gp) and some are metabolized by CYP450 enzymes such as CYP3A4. Although fewer drug interactions are present with NOACs, it is unclear whether NOACs should also be preferred over vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) using pharmacokinetically interacting drugs. Therefore, the benefit-risk profile of NOACs versus VKAs was investigated in AF patients treated with P-gp and/or CYP450-interacting drugs. METHODS Using PubMed and Embase, randomized controlled trials and observational studies on the effectiveness and safety of NOACs versus VKAs in AF patients using P-gp and/or CYP450-interacting drugs were included. A meta-analysis was performed, calculating relative risks (RR) and 95% confidence intervals (CI) with the Mantel-Haenszel method. RESULTS Twelve studies were included, investigating 10,793 NOAC and 10,096 VKA users treated with P-gp/CYP3A4 inhibitors, whereas no studies on P-gp and/or CYP450-inducing drugs were identified. Compared to VKAs, NOACs were associated with a borderline non-significantly lower stroke or systemic embolism (stroke/SE) risk (RR 0.85, 95%CI (0.72-1.01)), significantly lower intracranial bleeding (RR 0.47, 95%CI (0.34-0.65)) and all-cause mortality risks (RR 0.87, 95%CI (0.79-0.95), but significantly higher gastrointestinal bleeding risk (RR 1.74, 95%CI (1.06-2.86)). Among AF patients using amiodarone, NOACs were associated with significantly lower stroke/SE (RR 0.71, 95%CI (0.54-0.93)) and intracranial bleeding risks (RR 0.51, 95%CI (0.29-0.88)), but significantly higher gastrointestinal bleeding risk (RR 2.15, 95%CI (1.24-3.72)) than VKAs. CONCLUSION The benefit-risk profile of NOACs compared to VKAs was preserved in AF patients using P-gp/CYP3A4 inhibitors, including amiodarone.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
| | - Kevin Vanspranghe
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015, Rotterdam, The Netherlands
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9
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Yildirim S, Aslan O. Comparison of bleeding risk scores and evaluation of major bleeding predictive factors in patients with major bleeding due to vitamin K antagonist use. Heliyon 2023; 9:e19079. [PMID: 37636426 PMCID: PMC10448070 DOI: 10.1016/j.heliyon.2023.e19079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023] Open
Abstract
Background Major bleeding in the treatment of atrial fibrillation is closely associated with an increased risk of death and major adverse outcomes in both the short and long term, but all bleeding events are associated with a reduced quality of life. Bleeding events are also known to reduce medication adherence. In this sense, bleeding risk scores are important tools to help predict major bleeding. However, it is not clear which scoring system is superior. Aim In this study, our aim was to compare bleeding risk scores and to examine the factors associated with bleeding in patients with major bleeding while using vitamin K antagonists. Methods In this retrospective and single-center study, scoring, laboratory and demographic data were analyzed with SPSS 20.0 statistical program. Results The mean age of a total of 1434 patients included in our study was 68.2 ± 11.3 years, range was 39-93 years and 769 (53.6%) of these patients were male. Of 588 patients with major bleeding, 93 (15.8%) had intracranial hemorrhage. Logistic regression analysis comparing the scoring systems among themselves revealed that the GARFIELD-AF scoring system had a predictive effect on major bleeding independent of the effect of other scoring systems (OR: 1.532, 95% CI 1.348-1.741, p < 0.001). The area under the curve (AUC) for GARFIELD-AF was 0.690 (0.662-0.718) as a result of the ROC analysis considering the best cut-off point of 3.2% calculated for 2 years. AUC 0.659 (0.630-0.687) for HAS-BLED, AUC 0.636 (0.606-0.665) for ORBIT and AUC 0.611 (0.5810.642) for ATRIA. When we compare the patient group with the control group, it can be said that intracranial hemorrhage occurred independently of INR and TTR values, unlike in the major bleeding group (p:0.129, p:0.545). Conclusion In patients using vitamin K antagonists for atrial fibrillation, the GARFIELD-AF risk score was found to be superior to important bleeding risk scores such as HAS-BLED, ORBIT and ATRIA in terms of predicting major bleeding. It is an important result that intracranial hemorrhages, which have a special place among major hemorrhages, were independent of INR and TTR levels. It is noteworthy that 8.2% of patients with major bleeding had a history of minor bleeding in the last year.
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Affiliation(s)
- Sinan Yildirim
- Department of Emergency Medicine, Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Onur Aslan
- Department of Cardiology, Tarsus State Hospital, Mersin, Turkey
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10
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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: 0] [Impact Index Per Article: 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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11
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Scridon A, Balan AI. Challenges of Anticoagulant Therapy in Atrial Fibrillation-Focus on Gastrointestinal Bleeding. Int J Mol Sci 2023; 24:ijms24086879. [PMID: 37108042 PMCID: PMC10138869 DOI: 10.3390/ijms24086879] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
The rising prevalence and the complexity of atrial fibrillation (AF) pose major clinical challenges. Stroke prevention is accompanied by non-negligible risks, making anticoagulant treatment an ongoing challenge for the clinician. Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in most AF patients, mainly due to the ease of their use. However, assessing the bleeding risk in patients receiving oral anticoagulants remains-particularly in the case of DOACs-highly challenging. Using dose-adjusted warfarin increases threefold the risk of gastrointestinal bleeding (GIB). Although the overall bleeding risk appears to be lower, the use of DOACs has been associated with an increased risk of GIB compared to warfarin. Accurate bleeding (including GIB-specific) risk scores specific for DOACs remain to be developed. Until then, the assessment of bleeding risk factors remains the only available tool, although the extent to which each of these factors contributes to the risk of bleeding is unknown. In this paper, we aim to provide a comprehensive review of the bleeding risk associated with oral anticoagulant therapy in AF patients, with a highlight on the latest insights into GIB associated with oral anticoagulation; we emphasize questions that remain to be answered; and we identify hotspots for future research.
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Affiliation(s)
- Alina Scridon
- Physiology Department, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Târgu Mureș, 540142 Târgu Mureș, Romania
| | - Alkora Ioana Balan
- Physiology Department, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Târgu Mureș, 540142 Târgu Mureș, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation of Târgu Mureș, 540136 Târgu Mureș, Romania
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12
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Zhou Q, Liu X, Yang X, Huang XH, Wu YZ, Tao YY, Wei M. Efficacy and safety of anticoagulation in atrial fibrillation patients with intracranial hemorrhage: A systematic review and meta-analysis. Front Pharmacol 2023; 14:1122564. [PMID: 36969833 PMCID: PMC10033967 DOI: 10.3389/fphar.2023.1122564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
Background: The benefits and risks of starting anticoagulation therapy, such as direct oral anticoagulations (DOACs) or warfarin, in atrial fibrillation (AF) patients with a history of intracranial hemorrhage (ICH) remain controversial. We performed a systematic review and meta-analysis to compare the safety and efficacy of starting oral anticoagulation (OAC) and non-oral anticoagulation in these patients.Methods: PubMed, Cochrane Library, and Embase were searched from inception to 01 May 2022 for randomized controlled trials and cohort studies, reporting effectiveness and safety outcomes for anticoagulation therapy in atrial fibrillation patients with intracranial hemorrhage. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration tool were used to evaluate bias risks for all randomized controlled trials (RCTs) and cohort studies. An effects model was applied to calculate adjusted hazard ratios (aHRs) for randomized controlled trials and cohort studies.Results: We analyzed data from two randomized controlled trials (304 patients) and seven Cohort studies (17,477 patients). Compared to non-oral anticoagulation, starting oral anticoagulation therapy reduced the risk of Ischemic Stroke/Systemic Embolism (SE) (aHR: 0.64, 95% CI: 0.55–0.57) and all-cause death (aHR: 0.53, 95% CI: 0.35–0.80) in atrial fibrillation patients and a prior history intracranial hemorrhage. Starting oral anticoagulation therapy did not increase the risk of recurrent intracranial hemorrhage (aHR: 1.07, 95% CI: 0.66–1.74), but increased the risk of major bleeding (aHR: 1.38, 95% CI: 1.00–1.91) than no oral anticoagulation therapy. The DOACs had a lower risk of Ischemic Stroke/SE (aHR: 0.84, 95% CI: 0.70–1.00), recurrent intracranial hemorrhage (aHR: 0.63, 95% CI: 0.49–0.82), and all-cause death (aHR: 0.65, 95% CI: 0.48–0.88) compared to warfarin. According to subgroup analyses, starting oral anticoagulation therapy have a higher risk of recurrent intracranial hemorrhage than non-oral anticoagulation therapy (aHR: 1.57, 95% CI: 1.36–1.81) for Asians.Conclusion: After intracranial hemorrhage in atrial fibrillation patients, restarting or initiating oral anticoagulation therapy decreased the risk of Ischemic Stroke/SE and all-cause death but did not increase the risk for recurrent intracranial hemorrhage. Direct oral anticoagulations have better efficacy and safety than warfarin if oral anticoagulation therapy is started. However, starting oral anticoagulation increases the risk for recurrent intracranial hemorrhage in the Asian region.
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Affiliation(s)
- Qiang Zhou
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiang Liu
- Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China
| | - Xian Yang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiao-Hui Huang
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yan-Zi Wu
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ying-Ying Tao
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Meng Wei
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- *Correspondence: Meng Wei,
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13
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Wang C, Du Z, Ye N, Liu S, Geng D, Sun Y. Prevalence and prognosis of atrial fibrillation in a hypertensive population: A prospective cohort study. J Clin Hypertens (Greenwich) 2023; 25:335-342. [PMID: 36866435 PMCID: PMC10085811 DOI: 10.1111/jch.14643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 03/04/2023]
Abstract
Identifying risk factors for atrial fibrillation (AF) and evaluating their impact are essential to avoid the occurrence of adverse events. However, few studies to date have explored the prevalence, risk factors, and prognosis of AF in hypertensive patients. The objective of this study was to investigate the epidemiology of AF in a hypertensive population and determine the relationship between AF and all-cause mortality. At baseline, a total of 8541 Chinese patients with hypertension were enrolled from the Northeast Rural Cardiovascular Health Study. A logistic regression model was established to assess the relationship between blood pressure and AF, and Kaplan-Meier survival curve analysis and multivariate Cox regression were used to explore the relationship between AF and all-cause mortality. Meanwhile, subgroup analyses illustrated the robustness of results. This study found that the overall prevalence rate of AF was 1.4% in its Chinese hypertensive population. After adjusting for the confounding factors, every standard deviation increase in diastolic blood pressure (DBP) was associated with a 37% increase in the prevalence of AF (95% confidence interval: 1.152-1.627, p < .001). Compared to hypertensive patients without AF, those with AF had an increased risk of all-cause mortality (hazard ratio = 1.866, 95% confidence interval: 1.117-3.115, p = .017) in the adjusted model. The results show that the burden of AF is quite large in rural-dwelling Chinese hypertensive patients. Focusing on the control of DBP to prevent the occurrence of AF can be helpful. Meanwhile, AF increases risk of all-cause mortality in hypertensive patients. Our results indicated a huge burden of AF. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals and given their high risk of mortality, long-term interventions, including AF education, timely screening, and widespread use of anticoagulant drugs, should be emphasized in hypertensive populations.
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Affiliation(s)
- Chang Wang
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhi Du
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ning Ye
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Songyue Liu
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Danxi Geng
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yingxian Sun
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang, Liaoning, China
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14
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McQuilten ZK, Venkatesh B, Jha V, Roberts J, Morpeth SC, Totterdell JA, McPhee GM, Abraham J, Bam N, Bandara M, Bangi AK, Barina LA, Basnet BK, Bhally H, Bhusal KR, Bogati U, Bowen AC, Burke AJ, Christopher DJ, Chunilal SD, Cochrane B, Curnow JL, Das SK, Dhungana A, Di Tanna GL, Dotel R, DSouza H, Dummer J, Dutta S, Foo H, Gilbey TL, Giles ML, Goli K, Gordon A, Gyanwali P, Haksar D, Hudson BJ, Jani MK, Jevaji PR, Jhawar S, Jindal A, John MJ, John M, John FB, John O, Jones M, Joshi RD, Kamath P, Kang G, Karki AR, Karmalkar AM, Kaur B, Koganti KC, Koshy JM, Krishnamurthy MS, Lau JS, Lewin SR, Lim LL, Marschner IC, Marsh JA, Maze MJ, McGree JM, McMahon JH, Medcalf RL, Merriman EG, Misal AP, Mora JM, Mudaliar VK, Nguyen V, O'Sullivan MV, Pant S, Pant P, Paterson DL, Price DJ, Rees MA, Robinson JO, Rogers BA, Samuel S, Sasadeusz J, Sharma D, Sharma PK, Shrestha R, Shrestha SK, Shrestha P, Shukla U, Shum O, Sommerville C, Spelman T, Sullivan RP, Thatavarthi U, Tran HA, Trask N, Whitehead CL, Mahar RK, Hammond NE, McFadyen JD, Snelling TL, Davis JS, Denholm JT, Tong SYC. Anticoagulation Strategies in Non-Critically Ill Patients with Covid-19. NEJM EVIDENCE 2023; 2:EVIDoa2200293. [PMID: 38320033 DOI: 10.1056/evidoa2200293] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Optimal thromboprophylaxis for hospitalized patients with coronavirus disease 2019 (Covid-19) is uncertain. METHODS: In an open-label, adaptive platform trial, we randomly assigned hospitalized adults with Covid-19 to low-dose low-molecular-weight heparin thromboprophylaxis or intermediate-dose or low-dose plus aspirin. In response to external evidence, the aspirin intervention was discontinued and a therapeutic-dose arm added. The primary end point was death or the requirement for new organ support by day 28, analyzed with a Bayesian logistic model. Enrolment was closed as a result of operational constraints. RESULTS: Between February 2021 and March 2022, 1574 patients were randomly assigned. Among 1526 participants included in the analysis (India, n=1273; Australia and New Zealand, n=138; and Nepal, n=115), the primary outcome occurred in 35 (5.9%) of 596 in low-dose, 25 (4.2%) of 601 in intermediate-dose, 20 (7.2%) of 279 in low-dose plus aspirin, and 7 (14%) of 50 in therapeutic-dose anticoagulation. Compared with low-dose thromboprophylaxis, the median adjusted odds ratio for the primary outcome for intermediate-dose was 0.74 (95% credible interval [CrI], 0.43 to 1.27; posterior probability of effectiveness [adjusted odds ratio<1; Pr], 86%), for low-dose plus aspirin 0.88 (95% CrI, 0.47 to 1.64; Pr, 65%), and for therapeutic-dose anticoagulation 2.22 (95% CrI, 0.77 to 6.20; Pr, 7%). Overall thrombotic and bleeding rates were 0.8% and 0.4%, respectively. There were 10 serious adverse reactions related to anticoagulation strategy, of which nine were grade 1 or 2 across study interventions and one grade 4 episode of retroperitoneal hematoma in a patient receiving intermediate-dose anticoagulation. CONCLUSIONS: In hospitalized non–critically ill adults with Covid-19, compared with low-dose, there was an 86% posterior probability that intermediate-dose, 65% posterior probability that low-dose plus aspirin, and a 7% posterior probability that therapeutic-dose anticoagulation reduced the odds of death or requirement for organ support. No treatment strategy met prespecified stopping criteria before trial closure, precluding definitive conclusions. (Funded by Australian National Health and Medical Research Council or Medical Research Future Fund Investigator and Practitioner Grants and others; ClinicalTrials.gov number, NCT04483960.)
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Affiliation(s)
- Zoe K McQuilten
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Balasubramanian Venkatesh
- University of Queensland, Brisbane, Australia
- The George Institute for Global Health, Sydney, Australia
- The George Institute for Global Health, Delhi, Delhi, India
- The Wesley Hospital, Brisbane, Queensland, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, Delhi, Delhi, India
- Imperial College, London, England, United Kingdom
| | - Jason Roberts
- University of Queensland, Brisbane, Australia
- Metro North Health, Brisbane, Queensland, Australia
| | | | - James A Totterdell
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Grace M McPhee
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - John Abraham
- Christian Medical College, Ludhiana, Punjab, India
| | - Niraj Bam
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - Methma Bandara
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Ashpak K Bangi
- Jivanrekha Multispeciality Hospital, Pune, Maharashtra, India
| | - Lauren A Barina
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Bhupendra K Basnet
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Hasan Bhally
- North Shore Hospital, Auckland, North Island, New Zealand
| | - Khema R Bhusal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Umesh Bogati
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrew J Burke
- University of Queensland, Brisbane, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Sanjeev D Chunilal
- Monash University, Melbourne, Australia
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Belinda Cochrane
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
| | - Jennifer L Curnow
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Santa Kumar Das
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Ashesh Dhungana
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | | | - Hyjel DSouza
- The George Institute for Global Health, Delhi, Delhi, India
| | - Jack Dummer
- University of Otago, Dunedin, Otago, New Zealand
- Dunedin Hospital, Dunedin, Otago, New Zealand
| | - Sourabh Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Hong Foo
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Timothy L Gilbey
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
| | - Michelle L Giles
- Monash University, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Kasiram Goli
- Aditya Multi-speciality Hospital, Guntur, Andhra Pradesh, India
| | - Adrienne Gordon
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Newborn Care, Melbourne, Victoria, Australia
| | - Pradip Gyanwali
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | | | | | | | | | | | - Aikaj Jindal
- Satguru Partap Singh Hospitals, Ludhiana, Punjab, India
| | | | - Mary John
- Christian Medical College, Ludhiana, Punjab, India
| | | | - Oommen John
- The George Institute for Global Health, Delhi, Delhi, India
- Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Mark Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh D Joshi
- The George Institute for Global Health, Delhi, Delhi, India
| | | | | | - Achyut R Karki
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | - Baldeep Kaur
- The George Institute for Global Health, Sydney, Australia
| | | | - Jency M Koshy
- Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | | | - Jillian S Lau
- Eastern Health, Melbourne, Victoria, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Sharon R Lewin
- Monash Health, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Ian C Marschner
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Julie A Marsh
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | | | - James M McGree
- Queensland University of Technology, Brisbane, Queensland, Australia
| | | | | | | | | | - Jocelyn M Mora
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Vi Nguyen
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Matthew V O'Sullivan
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Suman Pant
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Pankaj Pant
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - David L Paterson
- National Institute of Singapore, Singapore, Singapore, Singapore
| | - David J Price
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan A Rees
- Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - James O Robinson
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Benjamin A Rogers
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | | | - Joe Sasadeusz
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Deepak Sharma
- Maharaja Agrasen Superspeciality Hospital, Delhi, Delhi, India
| | | | - Roshan Shrestha
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Sailesh K Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Prajowl Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Urvi Shukla
- Symbiosis University Hospital & Research Centre, Pune, Maharashtra, India
| | - Omar Shum
- The Wollongong Hospital, Wollongong, New South Wales, Australia
- University of Wollongong, Wollongong, New South Wales, Australia
| | - Christine Sommerville
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Tim Spelman
- Karolinska Institute, Solna, Stockholm, Sweden
- Burnet Institute, Melbourne, Victoria, Australia
| | - Richard P Sullivan
- St. George Hospital, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Huyen A Tran
- Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nanette Trask
- Chartered Accountants Australia and New Zealand, Perth, Western Australia, Australia
| | - Clare L Whitehead
- The Royal Women's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Robert K Mahar
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Perth, Western Australia, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James D McFadyen
- The Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas L Snelling
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Joshua S Davis
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Justin T Denholm
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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15
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Lee H, Hong JH, Seo KD. Long-term stroke and major bleeding risk in patients with non-valvular atrial fibrillation: A comparative analysis between non-vitamin K antagonist oral anticoagulants and warfarin using a clinical data warehouse. Front Neurol 2023; 14:1058781. [PMID: 36793489 PMCID: PMC9923348 DOI: 10.3389/fneur.2023.1058781] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Non-vitamin K antagonist oral anticoagulants (NOACs) has been the drug of choice for preventing ischemic stroke in patients with atrial fibrillation (AF) since 2014. Many studies based on claim data revealed that NOACs had comparable effect to warfarin in preventing ischemic stroke with fewer hemorrhagic side effects. We analyzed the difference in clinical outcomes according to the drugs in patients with AF based on the clinical data warehouse (CDW). Methods We extracted data of patients with AF from our hospital's CDW and obtained clinical information including test results. All claim data of the patients were extracted from National Health Insurance Service, and dataset was constructed by combining it with CDW data. Separately, another dataset was constructed with patients who could obtain sufficient clinical information from the CDW. The patients were divided NOAC and warfarin groups. The occurrence of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and death were confirmed as clinical outcome. The factors influencing the risk of clinical outcomes were analyzed. Results The patients who were diagnosed AF between 2009 and 2020 were included in the dataset construction. In the combined dataset, 858 patients were treated with warfarin, 2,343 patients were treated with NOACs. After the diagnosis of AF, the incidence of ischemic stroke during follow-up was 199 (23.2%) in the warfarin group, 209 (8.9%) in the NOAC group. Intracranial hemorrhage occurred in 70 patients (8.2%) among the warfarin group, 61 (2.6%) of the NOAC group. Gastrointestinal bleeding occurred in 69 patients (8.0%) in the warfarin group, 78 patients (3.3%) in the NOAC group. NOAC's hazard ratio (HR) of ischemic stroke was 0.479 (95% CI 0.39-0.589, p < 0.0001), HR of intracranial hemorrhage was 0.453 (95% CI 0.31-0.664, p < 0.0001), and HR of gastrointestinal bleeding was 0.579 (95% CI 0.406-0.824, p = 0.0024). In the dataset constructed using only CDW, the NOAC group also had a lower risk of ischemic stroke and intracranial hemorrhage than warfarin group. Conclusions In this CDW based study, NOACs are more effective and safer than warfarin in patients with AF even with long-term follow-up. NOACs should be used to prevent ischemic stroke in patients with AF.
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Affiliation(s)
- Hancheol Lee
- Department of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Jung Hwa Hong
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea,Department of Neurology, Graduate School of Medicine, Kangwon National University, Chuncheon, Republic of Korea,*Correspondence: Kwon-Duk Seo ✉
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Zhai M, Yang J, Cao X, Li Y, Xu H, Wang Y. Determinants of 1-Year Unfavorable Outcomes of Intravenous Alteplase Thrombolysis for Acute Ischemic Stroke. Clin Appl Thromb Hemost 2023; 29:10760296231187616. [PMID: 37461226 DOI: 10.1177/10760296231187616] [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] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE Intravenous thrombolytic therapy has become the standard of treatment for eligible patients with ischemic stroke. However, outcomes after receiving intravenous thrombolytic therapy vary widely. This study aims to investigate determinants of 1-year clinical outcomes of intravenous thrombolytic therapy for patients with acute ischemic stroke. METHODS In a prospective, observational study, patients with acute ischemic stroke treated with intravenous thrombolysis were consecutively included, and clinical information and laboratory data were collected. The patients were followed up for 12 months after onset, and the 1-year clinical outcome was evaluated using modified Rankin Scale scores. A score ≥ 3 was defined as unfavorable functional outcome. Univariate and multivariate logistic regressions were used to assess the determinants of the 1-year clinical outcomes of intravenous thrombolysis for acute ischemic stroke. RESULTS A total of 222 patients with intravenous thrombolysis were enrolled, and we identified 58 patients (26.1%) had unfavorable functional outcomes. Multivariate logistic regression analysis revealed that mean platelet volume-to-lymphocyte ratio (MPVLR) (odds ratio [OR] = 1.114, 95% confidence interval [CI]: 1.024-1.211, P = .012), atrial fibrillation (OR = 2.553, 95% CI: 1.086-6.002, P = .032), symptomatic stenosis occlusion (OR = 2.547, 95% CI: 1.269-5.110, P = .009), and baseline National Institutes of Health Stroke Scale (NIHSS) score (OR = 1.141, 95% CI: 1.074-1.212, P < .001) were independent predictors of unfavorable functional outcomes at 1 year. CONCLUSIONS In patients receiving intravenous thrombolysis, we found that MPVLR, atrial fibrillation, symptomatic stenosis occlusion, and baseline NIHSS score were significant predictors of unfavorable functional outcomes at 1 year.
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Affiliation(s)
- Mingfeng Zhai
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Jinwei Yang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoyan Cao
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Anhui Public Health Clinical Center, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Yingying Li
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Hui Xu
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Romiti GF, Proietti M, Bonini N, Ding WY, Boriani G, Huisman MV, Lip GY. Adherence to the Atrial Fibrillation Better Care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: A post-hoc analysis from the prospective GLORIA-AF Registry. EClinicalMedicine 2023; 55:101757. [PMID: 36457650 PMCID: PMC9706520 DOI: 10.1016/j.eclinm.2022.101757] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The 'Atrial fibrillation Better Care' (ABC) pathway has been proposed to streamline a more holistic or integrated care approach to atrial fibrillation (AF) management. We aimed to analyse the impact of adherence to the ABC pathway on the risk of major adverse outcomes in a contemporary prospective global cohort of patients with AF. METHODS Patients enrolled Phase II and III of the GLORIA-AF Registry with complete data on ABC pathway adherence and follow-up were included in this post-hoc analysis between November 2011 and December 2014 for Phase II, and between January 2014 and December 2016 for Phase III. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Multivariable Cox-regression and delay of event (DoE) analyses were used to evaluate the association between adherence to the ABC pathway and the risk of outcomes. FINDINGS We included 24,608 patients in this analysis (mean age: 70.2 (10.3) years, 10,938 (44.4%) females). Adherence to the ABC pathway was associated with a significant risk reduction for the primary outcome, with greatest magnitude observed for full ABC pathway adherence (adjusted Hazard Ratio [aHR] 0.54, 95% Confidence Interval [CI]: 0.44-0.67, p < 0.0001). ABC pathway adherence was also associated with reduced risk of mortality (aHR: 0.89, 95% CI: 0.79-1.00, p = 0.048), thromboembolism (aHR: 0.78, 95% CI: 0.65-0.94, p = 0.0078), and MACE (aHR: 0.82, 95% CI: 0.71-0.95, p = 0.0071). An increasing number of ABC criteria attained was associated with longer event-free survival in the DoE analysis. INTERPRETATION Adherence to the ABC pathway in patients with AF was associated with a reduced risk of major adverse events, including mortality, thromboembolism and MACE. This underlines the importance of using the ABC pathway in the clinical care of patients with AF. FUNDING This study was funded by Boehringer Ingelheim.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Corresponding author. Liverpool Centre for Cardiovascular Science, University of Liverpool, William Henry Duncan Building, 6 West Derby St, Liverpool L7 8TX, United Kingdom.
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18
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Shim CY, Seo J, Kim YJ, Lee SH, De Caterina R, Lee S, Hong GR. Efficacy and safety of edoxaban in patients early after surgical bioprosthetic valve implantation or valve repair: A randomized clinical trial. J Thorac Cardiovasc Surg 2023; 165:58-67.e4. [PMID: 33726903 DOI: 10.1016/j.jtcvs.2021.01.127] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early warfarin anticoagulation is recommended in patients undergoing surgical bioprosthetic valve implantation or valve repair. It is unclear whether non-vitamin K antagonist oral anticoagulants can be a full alternative to warfarin. This study aimed to compare efficacy and safety of edoxaban with warfarin in patients early after surgical bioprosthetic valve implantation or valve repair. METHODS The Explore the Efficacy and Safety of Edoxaban in Patients after Heart Valve Repair or Bioprosthetic Valve Replacement study was a prospective, randomized (1:1), open-label, clinical trial conducted from December 2017 to September 2019. Patients were randomly assigned to receive edoxaban (60 mg or 30 mg once daily) or warfarin for the first 3 months after surgical bioprosthetic valve implantation or valve repair. The primary efficacy outcome was a composite of death, clinical thromboembolic events, or asymptomatic intracardiac thrombosis. The primary safety outcome was the occurrence of major bleeding. RESULTS Of 220 participants, 218 (109 per group) were included in the modified intention-to-treat analysis. The primary efficacy outcome occurred in 4 patients (3.7%) taking warfarin and none taking edoxaban (risk difference, -0.0367; 95% confidence interval, -0.0720 to -0.0014; P < .001 for noninferiority). The primary safety outcome occurred in 1 patient (0.9%) taking warfarin and 3 patients (2.8%) taking edoxaban (risk difference, 0.0183; 95% confidence interval, -0.0172 to 0.0539; P = .013 for noninferiority). CONCLUSIONS Edoxaban is noninferior to warfarin for preventing thromboembolism and is potentially comparable for risk of major bleeding during the first 3 months after surgical bioprosthetic valve implantation or valve repair.
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Affiliation(s)
- Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Raffaele De Caterina
- Cardio-Thoracic and Vascular Department, Pisa University Hospital and University of Pisa, Pisa, Italy
| | - Sak Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Liu D, Han X, Zhang Z, Tse G, Shao Q, Liu T. Role of Heat Shock Proteins in Atrial Fibrillation: From Molecular Mechanisms to Diagnostic and Therapeutic Opportunities. Cells 2022; 12:cells12010151. [PMID: 36611952 PMCID: PMC9818491 DOI: 10.3390/cells12010151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Heat shock proteins (HSPs) are endogenous protective proteins and biomarkers of cell stress response, of which examples are HSP70, HSP60, HSP90, and small HSPs (HSPB). HSPs protect cells and organs, especially the cardiovascular system, against harmful and cytotoxic conditions. More recent attention has focused on the roles of HSPs in the irreversible remodeling of atrial fibrillation (AF), which is the most common arrhythmia in clinical practice and a significant contributor to mortality. In this review, we investigated the relationship between HSPs and atrial remodeling mechanisms in AF. PubMed was searched for studies using the terms "Heat Shock Proteins" and "Atrial Fibrillation" and their relevant abbreviations up to 10 July 2022. The results showed that HSPs have cytoprotective roles in atrial cardiomyocytes during AF by promoting reverse electrical and structural remodeling. Heat shock response (HSR) exhaustion, followed by low levels of HSPs, causes proteostasis derailment in cardiomyocytes, which is the basis of AF. Furthermore, potential implications of HSPs in the management of AF are discussed in detail. HSPs represent reliable biomarkers for predicting and staging AF. HSP inducers may serve as novel therapeutic modalities in postoperative AF. HSP induction, either by geranylgeranylacetone (GGA) or by other compounds presently in development, may therefore be an interesting new approach for upstream therapy for AF, a strategy that aims to prevent AF whilst minimizing the ventricular proarrhythmic risks of traditional anti-arrhythmic agents.
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Affiliation(s)
- Daiqi Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Xuyao Han
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Zhiwei Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, Hong Kong, China
- Kent and Medway Medical School, Canterbury CT2 7NZ, UK
| | - Qingmiao Shao
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Correspondence: (Q.S.); or (T.L.)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Correspondence: (Q.S.); or (T.L.)
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20
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Chan YH, Chao TF, Chen SW, Lee HF, Chen WM, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. Development of Interstitial Lung Disease Among Patients With Atrial Fibrillation Receiving Oral Anticoagulants in Taiwan. JAMA Netw Open 2022; 5:e2243307. [PMID: 36413365 PMCID: PMC9682427 DOI: 10.1001/jamanetworkopen.2022.43307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE There are emerging concerns from case reports and pharmacovigilance analyses of a possible risk of interstitial lung disease (ILD) associated with the use of factor Xa (FXa) inhibitors. OBJECTIVE To evaluate the risk of incident ILD associated with the use of oral anticoagulants (OACs) in patients with nonvalvular atrial fibrillation (NVAF). DESIGN, SETTING, AND PARTICIPANTS This nationwide retrospective cohort study used data from the Taiwan National Health Insurance Research Database. Patients with NVAF without preexisting lung disease who received OACs from June 1, 2012, to December 31, 2017, were included. Propensity score stabilized weighting (PSSW) was used to balance covariates across the medication groups (FXa inhibitors, dabigatran, and warfarin, with warfarin as the reference). Patients were followed up from the drug index date until the onset of ILD, death, or end of the study (December 31, 2019), whichever occurred first. Data were analyzed from September 11, 2021, to August 3, 2022. EXPOSURES Patients with NVAF were treated with FXa inhibitors, dabigatran, or warfarin. MAIN OUTCOMES AND MEASURES New-onset idiopathic ILD. RESULTS Among the 106 044 patients (mean [SD] age, 73.4 [11.9] years; 59 995 men [56.6%]) included in the study, 64 555 (60.9%) received FXa inhibitors (apixban [n = 15 386], edoxaban [n = 12 413], and rivaroxaban [n = 36 756]), 22 501 (21.2%) received dabigatran, and 18 988 (17.9%) received warfarin at baseline. The FXa inhibitors were associated with a higher risk of incident ILD (0.29 vs 0.17 per 100 patient-years; hazard ratio, 1.54 [95% CI, 1.22-1.94]; P < .001), whereas dabigatran was associated with a nonsignificant difference in risk of incident ILD compared with warfarin (reference) after PSSW. The higher risk of incident ILD for FXa inhibitors vs warfarin was consistent with several high-risk subgroups. CONCLUSIONS AND RELEVANCE Results of this study suggest that FXa inhibitors were associated with lung injury among patients with NVAF who were treated with OACs. Physicians should be vigilant in monitoring for any potential adverse lung outcomes associated with the use of these drugs.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- New Taipei City Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Tucheng Branch, New Taipei City, Taiwan
| | - Wei-Min Chen
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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21
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Shin J, Han K, Jung JH, Park HJ, Kim W, Huh Y, Kim YH, Kim DH, Kim SM, Choi YS, Cho KH, Nam GE. Age at menopause and risk of heart failure and atrial fibrillation: a nationwide cohort study. Eur Heart J 2022; 43:4148-4157. [PMID: 36239217 DOI: 10.1093/eurheartj/ehac364] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 05/13/2022] [Accepted: 06/23/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS This study aimed to examine the association of premature menopause and age at menopause with the risk of heart failure (HF) and atrial fibrillation (AF). METHODS AND RESULTS A total of 1 401 175 postmenopausal women, who had undergone health examination provided by the Korean National Health Insurance Service, were included, and their reproductive histories were collected. Multivariable Cox proportional hazard models were performed to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HF and AF, according to the history of premature menopause and age at menopause. At a mean follow-up of 9.1 years, there were 42 699 (3.0%) and 44 834 (3.2%) new cases of HF and AF, respectively. Women with history of premature menopause had an increased risk of HF (HR: 1.33, 95% CI: 1.26-1.40) and AF (HR: 1.09, 95% CI: 1.02-1.16), compared to women without the history. Compared with women aged ≥50 years at menopause, those aged 45-49, 40-44, and <40 years at menopause showed a significantly increased trend in HRs for the incident risk of both HF and AF (P for trend <0.001). The robustness of the results of a series of sensitivity analyses further strengthens the main findings. CONCLUSION Our findings suggest that postmenopausal women with a history of premature menopause or early menopausal age may have an increased risk of HF and AF. These reproductive factors need to be considered for preventing the future risk of HF and AF.
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Affiliation(s)
- Jean Shin
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jin Park
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Wonsock Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea.,Department of Family Medicine, Uijeongbu Eulji Medical Center, Eulji Unversity, Gyeonggi-do, Republic of Korea
| | - Youn Huh
- Department of Family Medicine, Uijeongbu Eulji Medical Center, Eulji Unversity, Gyeonggi-do, Republic of Korea
| | - Yang-Hyun Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Do-Hoon Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seon Mee Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Cho
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ga Eun Nam
- Department of Family Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Beier L, Lu S, França LR, Marler S, Lip GYH, Huisman MV, Teutsch C, Halperin JL, Zint K, Diener HC, Baker L, Ma CS, Paquette M, Bartels DB, Dubner SJ, Lyrer P, Senges J, Rothman KJ. Evolution of antithrombotic therapy for patients with atrial fibrillation: The prospective global GLORIA-AF registry program. PLoS One 2022; 17:e0274237. [PMID: 36201473 PMCID: PMC9536607 DOI: 10.1371/journal.pone.0274237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/16/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To assess baseline characteristics and antithrombotic treatment (ATT) prescription patterns in patients enrolled in the third phase of the GLORIA-AF Registry Program, evaluate predictors of treatment prescription, and compare results with phase II. Methods GLORIA-AF is a large, global, prospective registry program, enrolling patients with newly diagnosed nonvalvular atrial fibrillation (AF) at risk of stroke. Patients receiving dabigatran were followed for two years in phase II, and all patients were followed for 3 years in phase III. Phase II started when dabigatran became available; phase III started when the characteristics of patients receiving dabigatran became roughly comparable with those receiving vitamin K antagonists (VKAs). Results Between 2014 and 2016, 21,241 patients were enrolled in phase III. In total, 82% of patients were prescribed oral anticoagulation ([OAC]; 59.5% novel/nonvitamin K oral anticoagulants [NOACs], 22.7% VKAs). A further 11% of patients were prescribed antiplatelets without OAC and 7% were prescribed no ATT. A high stroke risk was the main driver of OAC prescription. Factors associated with prescription of VKA over NOAC included type of site, region, physician specialty, and impaired kidney function. Conclusion Over the past few years, data from phase III of GLORIA-AF show that OACs have become the standard treatment option, with most newly diagnosed AF patients prescribed a NOAC. However, in some regions a remarkable proportion of patients remain undertreated. In comparison with phase II, more patients received NOACs in phase III while the prescription of VKA decreased. VKAs were preferred over NOACs in patients with impaired kidney function.
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Affiliation(s)
- Lea Beier
- Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Shihai Lu
- Takeda Pharmaceuticals, Inc., Cambridge, Massachusetts, United States of America
| | | | - Sabrina Marler
- Takeda Pharmaceuticals, Inc., Cambridge, Massachusetts, United States of America
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | | | - Christine Teutsch
- Department of CardioMetabolism and Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Jonathan L. Halperin
- Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Kristina Zint
- Department of CardioMetabolism and Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | | | - Chang-Sheng Ma
- Atrial Fibrillation Center, Beijing Anzhen Hospital, Beijing, People’s Republic of China
| | | | - Dorothee B. Bartels
- Hannover Medical School, Hannover, Germany
- UCB Biosciences GmbH, Monheim, Germany
| | | | - Philippe Lyrer
- University Hospital Basel, Stroke Center Neurology, and University of Basel, Basel, Switzerland
| | | | - Kenneth J. Rothman
- RTI Health Solutions, Research Triangle Institute, Research Triangle Park, North Carolina, United States of America
- * E-mail:
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23
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Srikajornlarp S, Amnueypol M, Vathesatogkit P, Numthavaj P, Ungkanont A, Likittanasombat K, Pattanaprateep O, Angchaisuksiri P, Boonyawat K. Effectiveness and Safety of Direct Oral Anticoagulants in Thai Patients with Atrial Fibrillation: A Real-World Retrospective Cohort Study. Clin Appl Thromb Hemost 2022; 28:10760296221130058. [PMID: 36198021 PMCID: PMC9537480 DOI: 10.1177/10760296221130058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) are commonly used to prevent stroke and
systemic embolism in patients with atrial fibrillation (AF). However,
studies into their effectiveness and safety in the Thai population have so
far been limited. Objectives To study the effectiveness and safety of warfarin and DOACs among Thai AF
patients Methods A retrospective cohort study was conducted on AF patients at Ramathibodi
Hospital from 2013 to 2018. All patients were followed for at least 1 year.
Relevant clinical information was collected and compared between AF patient
groups receiving warfarin, dabigatran, rivaroxaban, and apixaban. The
primary outcome was a composite of major bleeding, ischemic stroke, and
systemic thromboembolism. The secondary outcomes were all-cause mortality
and disease-specific mortality caused by major bleeding, ischemic stroke,
and systemic thromboembolism. Results A total of 1680 AF patients were enrolled in the study (warfarin 1193,
apixaban 140, dabigatran 193, rivaroxaban 114). The estimated incidence of
composite outcome was 16% [95% CI, 14−18%] and 12.4% [95% CI, 9.4−15.3%] in
the warfarin and DOAC group, respectively, given a number needed to treat of
28 [95% CI, 3−52]. Compared with warfarin, DOACs were associated with both
lower rate of all-cause mortality (4.9% [22/447] vs 8% [98/1193]) and lower
disease-specific mortality (0.4% [2/447] and 1% [12/1193]). Conclusions This study suggests DOACs were associated with a lower risk of major
bleeding, ischemic stroke, and systemic thromboembolism compared to warfarin
in Thai patients with AF. Patients receiving DOAC also had a lower rate of
all-cause mortality and disease-specific mortality.
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Affiliation(s)
- Saowaluk Srikajornlarp
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Montawatt Amnueypol
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Artit Ungkanont
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Samut Prakan, Thailand
| | - Khanchit Likittanasombat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
| | - Kochawan Boonyawat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand,Kochawan Boonyawat, Department of Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama sixth
Road, Rachathewi, Bangkok, 10400, Thailand.
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24
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Integrated Analysis of the microRNA–mRNA Network Predicts Potential Regulators of Atrial Fibrillation in Humans. Cells 2022; 11:cells11172629. [PMID: 36078037 PMCID: PMC9454849 DOI: 10.3390/cells11172629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF) is a form of sustained cardiac arrhythmia and microRNAs (miRs) play crucial roles in the pathophysiology of AF. To identify novel miR–mRNA pairs, we performed RNA-seq from atrial biopsies of persistent AF patients and non-AF patients with normal sinus rhythm (SR). Differentially expressed miRs (11 down and 9 up) and mRNAs (95 up and 82 down) were identified and hierarchically clustered in a heat map. Subsequently, GO, KEGG, and GSEA analyses were run to identify deregulated pathways. Then, miR targets were predicted in the miRDB database, and a regulatory network of negatively correlated miR–mRNA pairs was constructed using Cytoscape. To select potential candidate genes from GSEA analysis, the top-50 enriched genes in GSEA were overlaid with predicted targets of differentially deregulated miRs. Further, the protein–protein interaction (PPI) network of enriched genes in GSEA was constructed, and subsequently, GO and canonical pathway analyses were run for genes in the PPI network. Our analyses showed that TNF-α, p53, EMT, and SYDECAN1 signaling were among the highly affected pathways in AF samples. SDC-1 (SYNDECAN-1) was the top-enriched gene in p53, EMT, and SYDECAN1 signaling. Consistently, SDC-1 mRNA and protein levels were significantly higher in atrial samples of AF patients. Among negatively correlated miRs, miR-302b-3p was experimentally validated to suppress SDC-1 transcript levels. Overall, our results suggested that the miR-302b-3p/SDC-1 axis may be involved in the pathogenesis of AF.
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25
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1). JACC. ASIA 2022; 2:395-411. [PMID: 36339361 PMCID: PMC9627863 DOI: 10.1016/j.jacasi.2022.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - 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
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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26
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Hiramori S, Yamashita Y, Morimoto T, Kadota K, Takase T, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Inoko M, Tada T, Izumi T, Chen PM, Murata K, Tsuyuki Y, Saga S, Nishimoto Y, Sasa T, Matsuda M, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Nakagawa Y, Kato T, Ono K, Ando K, Kimura T. Optimal quality of vitamin K antagonist therapy in Japanese patients with venous thromboembolism. J Cardiol 2022; 80:487-494. [PMID: 35882615 DOI: 10.1016/j.jjcc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/20/2022] [Accepted: 07/01/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Vitamin K antagonist (VKA) remains an essential option for venous thromboembolism (VTE), although direct oral anticoagulants have become available. However, there is a paucity of data on the optimal intensity and quality of control for VKA in Japanese. METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1938 patients who received VKA with prothrombin time-international normalized ratio (PT-INR) measurement >5 times. The primary outcome measure was a composite of symptomatic VTE recurrence or major bleeding at 1 year. The presumed optimal quality of VKA therapy was defined as the combination of PT-INR range and time in therapeutic range (TTR) with the numerically lowest event rate. RESULTS The group with TTR ≥70 % based on PT-INR range ≥1.5 and <2.0 showed the lowest cumulative incidence rate. The cumulative 1-year incidence and the adjusted risk for the primary outcome measure were significantly lower in the optimal quality group than in the non-optimal quality group (5.2 % vs. 11.7 %, p = 0.001, and HR 0.49, 95%CI 0.28-0.81). Similarly, the cumulative 1-year incidences of a recurrent VTE, major bleeding, and all-cause death were significantly lower in the optimal quality group (recurrent VTE: 2.5 % vs. 6.0 %, p = 0.02; major bleeding: 2.8 % vs. 7.0 %, p = 0.008; and all-cause death: 2.8 % vs. 12.6 %, p < 0.0001). The lower risk of the optimal quality group relative to non-optimal quality group for the clinical outcomes was consistent regardless of the etiology of VTE (active cancer, transient risk factor, and unprovoked). CONCLUSIONS The current VTE registry showed the optimal intensity of VKA therapy was target PT-INR range ≥1.5 and <2.0, which could support the current Japanese guideline recommendation, and the good quality of control for VKA therapy of TTR ≥70 % was independently associated with better outcomes.
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Affiliation(s)
- Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan.
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Toshiaki Izumi
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Mitsuo Matsuda
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Yoshihisa Nakagawa
- Department of Internal Medicine, Division of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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27
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Pimentel RC, Rahai N, Maccioni S, Khanna R. DIFFERENCES IN OUTCOMES AMONG PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING CATHETER ABLATION WITH VERSUS WITHOUT INTRACARDIAC ECHOCARDIOGRAPHY. J Cardiovasc Electrophysiol 2022; 33:2015-2047. [PMID: 35711034 PMCID: PMC9544828 DOI: 10.1111/jce.15599] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/18/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022]
Abstract
Background Intracardiac echocardiography (ICE) use can lead to early detection of periprocedural complications and may improve patient outcomes by providing real‐time visualization of catheter location and the treatment area during cardiac ablation (CA) for atrial fibrillation (AF). Objective Examine complications and 12‐month healthcare use among patients with AF undergoing CA with versus without ICE use during the procedure in a real‐world setting. Methods The 2015–2020 IBM MarketScan® Database was used to identify non‐elderly adults (age 18–64 years) undergoing CA for AF. Patients were classified into ICE/non‐ICE groups based on the presence or absence of ICE procedure codes. Patients in each group were matched on study covariates using propensity scores. Peri‐procedural complications, 12‐month cardiovascular (CV) or AF‐related inpatient admission, repeat CA, and cardioversion were compared using a Cox proportional hazard model. Results 1371 patients were identified in each study cohort (ICE and non‐ICE) after propensity matching. Patients who had CA with ICE had a significantly lower rate of complications than those without (2.9% vs. 5.8%; p < .001). The risk of complications was 50% lower with ICE use (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.34–0.72). For assessment of 12‐month healthcare utilization, 1250 patients were identified in each cohort after propensity matching. ICE use was associated with a 36% lower risk of 12‐month repeat ablation (HR 0.64; 95% CI 0.49–0.83). No differences in CV‐ or AF‐related inpatient admission and cardioversion were observed. Conclusion Among patients with AF, the use of ICE during an ablation procedure was associated with lower incidence of complications and repeat ablation.
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Affiliation(s)
- R C Pimentel
- The University of Kansas Health System, Kansas City, KS, USA
| | - N Rahai
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - S Maccioni
- Franchise Health Economics and Market Access, Johnson & Johnson, Irvine, CA, USA
| | - R Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
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28
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Oka H, Homma Y, Nishino Y, Suemori K, Sato N, Sakurai Y, Sekimoto M, Ando S, Iwamoto S, Iwamoto T, Kondo M, Kamimura T, Nakano T, Kitazono T. Retroperitoneal Hemorrhage in Patients with COVID-19 Undergoing Hemodialysis: Three Case Reports. Intern Med 2022; 61:1869-1876. [PMID: 35400699 PMCID: PMC9259805 DOI: 10.2169/internalmedicine.8976-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] Open
Abstract
A 73-year-old man receiving hemodialysis and antiplatelets was admitted with a mild case of COVID-19. Heparin was added, and iliopsoas hemorrhage developed. He was successfully treated by interventional radiology. A 76-year-old man receiving hemodialysis and antiplatelets was admitted with mild COVID-19. Heparin was added, and iliacus hemorrhage developed. Despite heparin discontinuation, he died of worsening pneumonia. A 74-year-old man undergoing hemodialysis was admitted with severe COVID-19. Gastrointestinal bleeding developed during continuous hemodiafiltration with heparin. Upon switching to nafamostat and increasing the dose, iliopsoas hemorrhage developed. Despite interventional radiology, he died of infectious complications. Attention to hemorrhagic complications is therefore needed in patients with COVID-19.
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Affiliation(s)
- Hideaki Oka
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Yoshito Homma
- Department of Infectious Diseases, Ehime Prefectural Central Hospital, Japan
| | - Yuki Nishino
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University, Graduate School of Medicine, Japan
| | - Koichiro Suemori
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University, Graduate School of Medicine, Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Japan
| | - Yuko Sakurai
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Mizuki Sekimoto
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Shota Ando
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Saki Iwamoto
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Takaki Iwamoto
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Mika Kondo
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Taro Kamimura
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
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29
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Arashi H, Yamaguchi J, Hagiwara N, Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Nakamura M, Miyauchi K, Kimura K, Hirayama A, Matsui K, Ogawa H. Rivaroxaban Underdose for Atrial Fibrillation with Stable Coronary Disease: The AFIRE Trial Findings. Thromb Haemost 2022; 122:1584-1593. [PMID: 35697255 PMCID: PMC9420554 DOI: 10.1055/s-0042-1744543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
Rivaroxaban monotherapy was noninferior to combination therapy (rivaroxaban plus antiplatelet therapy) in efficacy but superior in safety in the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial. Among 2,215 patients with atrial fibrillation (AF) and stable coronary artery disease (CAD), 1,378 had baseline creatinine clearance (CrCl) ≥50 mL/min and received 10 (underdose) or 15 mg/d (standard-dose) rivaroxaban. We aimed to assess the effects of rivaroxaban underdose on clinical outcomes.
Methods
We assessed efficacy endpoint (a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause) and major bleeding in the subgroup of patients with preserved renal function in the AFIRE trial.
Results
Age ≥75 years, female sex, lower CrCl, heart failure, and percutaneous coronary intervention history were associated with the underdose prescription. The underdose group had a similar incidence of the efficacy endpoint (3.62 vs. 3.51% per patient-year;
p
= 0.871) and significantly lower incidence of major bleeding (0.82 vs. 2.17% per patient-year;
p
= 0.022) than the standard-dose group. In patients receiving monotherapy, the incidences of efficacy endpoint and major bleeding were similar between the groups, whereas in those receiving combination therapy, the incidence of major bleeding was significantly lower in the underdose group than that in the standard-dose group.
Conclusion
In patients with AF, stable CAD, and preserved renal function, rivaroxaban underdose was associated with similar rates of thrombotic events but a lower incidence of hemorrhagic events than the standard dose.
Clinical Trial Registration
AFIRE UMIN Clinical Trials Registry (
https://www.umin.ac.jp/ctr/
), number UMIN000016612, and ClinicalTrials.gov, number NCT02642419.
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Affiliation(s)
- Hiroyuki Arashi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan.,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center, Kanagawa, Japan
| | | | - Kunihiko Matsui
- Department of General Medicine and Primary Care, Kumamoto University Hospital, Kumamoto, Japan
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30
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Chueh HH, Huang ST, Chang SH, Lin SY, Hsiao FY. Comparative effectiveness and safety of different combinations of antithrombotic regimens in atrial fibrillation patients with stent insertions. Clin Pharmacol Ther 2022; 112:864-872. [PMID: 35680555 DOI: 10.1002/cpt.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/28/2022] [Indexed: 11/10/2022]
Abstract
This study aims to compare the risks of major adverse cardiac events (MACEs), including cardiovascular death, myocardial infarction, ischemic stroke and transient ischemic attack, and major bleeding across different antithrombotic regimens in Asian atrial fibrillation (AF) patients with stent insertions. We conducted a retrospective cohort study using Taiwan's National Health Insurance Research Database and National Mortality Registry. A total of 10,208 nonvalvular AF patients who had undergone percutaneous coronary intervention (PCI) with stents for the first time in 2007-2017 were identified. Most patients (68.4%) were prescribed dual antiplatelet therapy (DAPT) at discharge. During follow-up, the use of anticoagulants increased, and double therapy (an antiplatelet plus an anticoagulant) was the most frequently prescribed therapy. The risks of MACEs were comparable in double therapy and had a similar risk of MACEs compared to DAPT (aHR 0.86; 95% CI 0.67-1.11). Triple therapy (DAPT plus an anticoagulant) also had similar effectiveness to double therapy (1.23; 0.84-1.80) or DAPT (1.06; 0.77-1.45). However, triple therapy was associated with a nearly twofold higher major bleeding risk than DAPT and double therapy (1.97; 1.31-2.94 and 1.80; 1.10-2.95, respectively). DAPT was the most frequently prescribed antithrombotic regimen at discharge for Asian AF patients who had undergone stent insertions. DAPT and double and triple therapy had comparable effectiveness, but triple therapy had a significantly higher major bleeding risk than either DAPT or double therapy.
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Affiliation(s)
- Han-Hsin Chueh
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shih-Tsung Huang
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shang-Hung Chang
- Department of Cardiology, Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Medicine, Chang Gung University, Linkou, Taiwan
| | - Shin-Yi Lin
- School of Pharmacy, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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31
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Lee MY, Han S, Bang OY, On YK, Jang SW, Han S, Ryu J, Park YJ, Kang S, Suh HS, Kim YH. Drug Utilization Pattern of Oral Anticoagulants in Patients with Atrial Fibrillation: A Nationwide Population-Based Study in Korea. Adv Ther 2022; 39:3112-3130. [PMID: 35524839 DOI: 10.1007/s12325-022-02151-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/28/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Treatment persistence for anticoagulant therapy is important in preventing thromboembolism in nonvalvular atrial fibrillation (NVAF) patients. Understanding drug utilization pattern and treatment changes in oral anticoagulant (OAC) users may facilite better NVAF management. Thus, our study aimed to examine OAC treatment patterns preceding events leading to switch or discontinuation and medication adherence in Korean NVAF patients. METHODS We conducted a drug utilization study on all Korean patients with atrial fibrillation (AF) newly prescribed OACs between July 2015 and November 2016 using the national claims data. We assessed treatment changes such as switching and discontinuation from index OAC and relevant events preceding the change and examined patient characteristics as predictors of changes that occurred among OAC users. Medication adherence was compared among OAC users by calculating the medication possession ratio (MPR). RESULTS A total of 48,389 NVAF patients were identified who initiated OACs within the study period. Most initiated nonvitamin K antagonist oral anticoagulants (NOACs) (22% apixaban, 24% dabigatran, 37% rivaroxaban), and 18% initiated warfarin. The frequency of switch to another OAC was 8.8% for apixaban, 16.1% for dabigatran, 6.6% for rivaroxaban, and 19.1% for warfarin. The frequency of discontinuation was lower for apixaban (22.9%), dabigatran (26.3%), and rivaroxaban (25.7%) than warfarin (31.6%). Compared to warfarin, NOAC users were less likely to switch treatment. Thromboembolic event was the most common clinical event preceding switch from warfarin to NOAC and from NOAC to warfarin. Discontinuation of OAC was often preceded by a bleeding event. Patients who initiated apixaban showed significantly higher mean MPR compared to those on dabigatran and warfarin. CONCLUSION In real-world practice in Korea, we have observed treatment change to be common in OAC users. Our results indicate better medication adherence with NOACs than with warfarin. (ClinicalTrials.gov registration number NCT03572972).
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Kim TH, Kim SY, Jung YK, Yim HJ, Jung JM, Seo WK. FIB-4 index and liver fibrosis are risk factors for long-term outcomes in atrial fibrillation-related stroke. Clin Neurol Neurosurg 2022; 217:107235. [DOI: 10.1016/j.clineuro.2022.107235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
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Nishimoto Y, Yachi S, Takeyama M, Tsujino I, Nakamura J, Yamamoto N, Nakata H, Ikeda S, Umetsu M, Aikawa S, Hayashi H, Satokawa H, Okuno Y, Iwata E, Ogihara Y, Ikeda N, Kondo A, Iwai T, Yamada N, Ogawa T, Kobayashi T, Mo M, Yamashita Y. The current status of thrombosis and anticoagulation therapy in patients with COVID-19 in Japan: From the CLOT-COVID study. J Cardiol 2022; 80:285-291. [PMID: 35430141 PMCID: PMC8979768 DOI: 10.1016/j.jjcc.2022.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/25/2022] [Indexed: 02/06/2023]
Abstract
Background Data on thrombosis and current real-world management strategies for anticoagulation therapy are scarce but important for understanding current issues and unmet needs of an optimal management of patients with coronavirus disease 2019 (COVID-19). Method The CLOT-COVID Study (thrombosis and antiCoaguLatiOn Therapy in patients with COVID-19 in Japan Study: UMIN000045800) was a retrospective, multicenter cohort study enrolling consecutive hospitalized patients with COVID-19 among 16 centers in Japan from April 2021 to September 2021, and we tried to capture the status of the patients in the fourth and fifth waves of the COVID-19 infections in Japan. We enrolled consecutive hospitalized patients who were diagnosed with COVID-19 and had a positive polymerase chain reaction test obtained from the hospital databases. Results Among 2894 patients with COVID-19, 1245 (43%) received pharmacological thromboprophylaxis. The proportion of pharmacological thromboprophylaxis increased according to the severity of the COVID-19 in 9.8% with mild COVID-19, 61% with moderate COVID-19, and 97% with severe COVID-19. The types and doses of anticoagulants varied widely across the participating centers. During the hospitalization, 38 patients (1.3%) and 126 (4.4%) underwent ultrasound examinations for the lower extremities and contrast-enhanced computed tomography examinations, respectively, and 55 (1.9%) developed thrombosis, mostly venous thromboembolism (71%). The incidence of thrombosis increased according to the severity of the COVID-19 in 0.2% with mild COVID-19, 1.4% with moderate COVID-19, and 9.5% with severe COVID-19. Major bleeding occurred in 57 patients (2.0%) and 158 (5.5%) died, and 81% of them were due to respiratory failure from COVID-19 pneumonia. Conclusions In the present large-scale observational study, pharmacological thromboprophylaxis for hospitalized patients with COVID-19 was common especially in patients with severe COVID-19, and management strategies varied widely across the participating centers. The overall incidence of thrombosis was substantially low with an increased incidence according to the severity of the COVID-19.
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Zhao N, Liu Z, Xie Q, Wang Z, Sun Z, Xiang Q, Cui Y. A Combined Pharmacometrics Analysis of Biomarker Distribution Under Treatment With Standard- or Low-Dose Rivaroxaban in Real-World Chinese Patients With Nonvalvular Atrial Fibrillation. Front Pharmacol 2022; 13:814724. [PMID: 35370683 PMCID: PMC8971662 DOI: 10.3389/fphar.2022.814724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The rivaroxaban dose regimen for patients with nonvalvular atrial fibrillation (NVAF) is complex in Asia. Given the high interindividual variability and the risk of bleeding caused by rivaroxaban in Asians, the influencing factors and the relationship between outlier biomarkers and bleeding events need exploration. Methods: The integrated pharmacokinetics (PK)/pharmacodynamics (PD) models were characterized based on rich PK/PD data from 304 healthy volunteers and sparse PD [anti-factor Xa activity (anti-Xa) and prothrombin (PT)] data from 223 patients with NVAF. The correlations between PD biomarkers and clinically relevant bleedings in 1 year were explored. The final integrated PK/PD model was used to evaluate the influence of dosage and individual covariates on PD parameters. Results: A two-compartment, linear model with sequential zero-order and first-order absorption was adopted. The dose-specific relative bioavailability (F1), diet status, creatinine clearance, and body mass index (BMI) improved the model fit. The apparent systemic clearance was 7.39 L/h, and the central and peripheral volumes were 10.9 and 50.9 L, respectively. The linear direct-effects model with shape factor plus the additive (and/or proportional) error model described the correlation between anti-Xa/PT and plasma concentration. Bodyweight, total cholesterol (TCHO), and diet status were selected as the covariates of the anti-Xa/PT model. Anti-Xa was more sensitive to the increase in rivaroxaban exposure compared with PT. An elevated bleeding tendency was seen with higher peak anti-Xa and PT. For a typical Chinese patient, the peak anti-Xa value (median (5%–95% PI)) of 20 and 15 mg were 309 ng/ml (139–597 ng/ml) and 296 ng/ml (138–604 ng/ml), both median values were within the expected range. For patients with CrCL 30–49 ml/min, the median peak anti-Xa with recommended 10 mg other than 15 mg were within the expected range. Conclusion: Fixed doses of rivaroxaban could be prescribed for patients with NVAF without adjustment for bodyweight, BMI, and TCHO. Randomized studies should be performed to evaluate the efficacy and safety of low-dose rivaroxaban in Chinese patients with NVAF.
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Affiliation(s)
- Nan Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhongyi Sun
- Shanghai Qiangshi Information Technology Co., Ltd, Shanghai, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- Institute of Clinical Pharmacology, Peking University, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
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Matsumoto C, Ogawa H, Saito Y, Okada S, Soejima H, Sakuma M, Masuda I, Nakayama M, Doi N, Jinnouchi H, Waki M, Morimoto T. Incidence of atrial fibrillation in elderly patients with type 2 diabetes mellitus. BMJ Open Diabetes Res Care 2022; 10:10/2/e002745. [PMID: 35361621 PMCID: PMC8971791 DOI: 10.1136/bmjdrc-2021-002745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/13/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION The incidence of atrial fibrillation (AF), a significant risk factor for cardiovascular disease (CVD), is increasing worldwide. Type 2 diabetes mellitus (T2D) and advanced age are recognized as major risk factors for AF, but herein, we evaluated the incidence of AF in elderly patients with T2D and compared the prognosis between these patients with/without AF. RESEARCH DESIGN AND METHODS The Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD2) study is a follow-up cohort study of the JPAD trial, a randomized controlled clinical trial initiated in 2002 in 2535 Japanese patients with T2D, to examine whether low-dose aspirin prevents CVD. After completion of that trial, we followed up the patients until 2019 and evaluated the incidence of AF. We also compared the incidence of cerebral cardiovascular events in elderly patients with T2D with/without AF. RESULTS During the median follow-up period of 10.9 years, 132 patients developed AF (incidence rate: 5.14/1000 person-years). The adjusted HRs for cerebral cardiovascular events, stroke, coronary artery disease, heart failure, and all-cause death in elderly patients with T2D with versus without AF were 1.65 (95% CI 1.03 to 2.66), 1.54 (95% CI 0.81 to 2.93), 1.96 (95% CI 1.03 to 3.73), 5.17 (95% CI 2.46 to 10.89), and 1.82 (95% CI 1.24 to 2.67), respectively. CONCLUSIONS Annually, 1 in 200 elderly Japanese patients with T2D are estimated to develop AF. Because elderly patients with T2D with AF are at an elevated risk for CVD, careful follow-up of this patient subgroup is necessary. TRIAL REGISTRATION NUMBER NCT00110448.
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Affiliation(s)
- Chisa Matsumoto
- Department of Cardiology, Center for Health Surveillance and Preventive Medicine, Tokyo Medical University Hospital, Shinjuku, Japan
| | | | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Nara, Japan
| | - Hirofumi Soejima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Health Care Center, Kumamoto University, Kumamoto, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Izuru Masuda
- Takeda Hospital Medical Examination Center, Kyoto, Japan
| | | | - Naofumi Doi
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Nara, Japan
| | - Hideaki Jinnouchi
- Department of Internal Medicine, Jinnouchi Hospital Diabetes Care Center, Kumamoto, Japan
| | - Masako Waki
- Food Safety Commission of Japan, Tokyo, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
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The Rate of Clinical Outcomes in Atrial Fibrillation according to Antithrombotic Strategy: The COOL-AF Registry. Cardiovasc Ther 2022; 2022:5797257. [PMID: 35284003 PMCID: PMC8885252 DOI: 10.1155/2022/5797257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background Ischemic stroke/transient ischemic attack (TIA), major bleeding, and death are common outcomes in atrial fibrillation (AF) patients, so appropriate antithrombotic therapy is crucial. The objective of this study was to investigate the rate of ischemic stroke/TIA, major bleeding, and death compared among AF patients who received oral anticoagulant (OAC) alone, antiplatelet alone, or OAC plus antiplatelet. Methods Prospective data from the COOL-AF Registry (Thailand's largest multicenter nationwide AF registry) were analyzed. Clinical, laboratory, and medication data were collected at baseline and during follow-up. Clinical outcomes, including ischemic stroke/TIA, major bleeding, and death, were collected. Results There were 3,148 patients included. Mean age was 68.1 ± 10.8 years and 1,826 (57.7%) were male. AF was paroxysmal in 998 (31.7%), persistent in 603 (19.2%), and permanent in 1,547 (49.1%). The mean follow-up duration was 25.7 ± 10.6 months. The median rates of ischemic stroke/TIA, major bleeding, and death were 1.49 (1.21-1.81), 2.29 (1.94-2.68), and 3.89 (3.43-4.40) per 100 person-years. Antiplatelet alone, OAC plus antiplatelet, and OAC alone were used in 582 (18.5%), 308 (9.8%), and 2,258 (71.7%) patients, respectively. Antiplatelet alone significantly increased the risk of ischemic stroke/TIA and death compared to OAC alone. OAC plus antiplatelet significantly increased the risk of death compared to OAC alone. Conclusions Antiplatelet was used in 890 (28.3%) AF, of whom 582 (18.5%) received antiplatelet alone, and 308 (9.8%) received antiplatelet and OAC. OAC plus antiplatelet significantly increased the risk of death without additional stroke prevention benefit. Antiplatelet alone should not be used in patients with AF.
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Azahar SN, Sulong S, Wan Zaidi WA, Muhammad N, Kamisah Y, Masbah N. Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:1078. [PMID: 35162102 PMCID: PMC8834259 DOI: 10.3390/ijerph19031078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia. METHODS This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin. RESULTS The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25. CONCLUSIONS The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.
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Affiliation(s)
- Siti Norain Azahar
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (S.N.A.); (N.M.); (Y.K.)
| | - Saperi Sulong
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia;
| | - Wan Asyraf Wan Zaidi
- Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia;
| | - Norliza Muhammad
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (S.N.A.); (N.M.); (Y.K.)
| | - Yusof Kamisah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (S.N.A.); (N.M.); (Y.K.)
| | - Norliana Masbah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (S.N.A.); (N.M.); (Y.K.)
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Zhao D, Yao C. Pragmatic Clinical Studies: An Emerging Clinical Research Discipline for Improving Evidence-Based Practice of Cardiovascular Diseases in Asia. Korean Circ J 2022; 52:401-413. [PMID: 35656900 PMCID: PMC9160648 DOI: 10.4070/kcj.2022.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022] Open
Abstract
Pragmatic clinical studies, as an emerging clinical research discipline, include a wide range of studies that are largely embedded with routine clinical practice aiming to evaluate comparative effectiveness and safety of different clinical intervention strategies. In this review, we described the evolution of the conceptual framework of pragmatic clinical studies, shared perspectives on the importance of pragmatic clinical studies for cardiovascular diseases as a complement to conventional randomized controlled trials, as well as highlighted the specific importance of pragmatic clinical research in improving evidence-based practice for cardiovascular disease managements in Asia. Pragmatic clinical studies, an emerging clinical research discipline, include a wide range of studies that are largely embedded with routine clinical practice and aim to evaluate the comparative effectiveness and safety of different clinical intervention strategies. Increased availability and quality of electronic medical/health records drives the development of pragmatic clinical studies. In this review, we describe evolution of the conceptual framework of pragmatic clinical studies and share perspectives on the importance of pragmatic clinical studies in evidence-based practice for cardiovascular diseases, as a complement to conventional randomized controlled trials. We also highlight specific needs of pragmatic clinical studies in improving evidence-based practice for cardiovascular disease in Asian countries. The main challenges of pragmatic clinical studies are discussed briefly in this review.
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Affiliation(s)
- Dong Zhao
- Capital Medical University Beijing Anzhen Hospital-Beijing Institute of Heart, Lung & Blood Vessel Diseases, Beijing, China
| | - Chen Yao
- Peking University Clinical Research Institute. Peking University First Hospital, Beijing, China
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Zawawi NA, Abdul Halim Zaki I, Ming LC, Goh HP, Zulkifly HH. Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation. Front Cardiovasc Med 2021; 8:736143. [PMID: 34869639 PMCID: PMC8635010 DOI: 10.3389/fcvm.2021.736143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022] Open
Abstract
Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.
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Affiliation(s)
- Nur Azyyati Zawawi
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Izzati Abdul Halim Zaki
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hui Poh Goh
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Hanis Hanum Zulkifly
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia.,Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam, Malaysia
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Lu W, Wang Y, Chen L, Li Y, Zhang R, Chen Z, Yan J, Yang M, Han B, Wang Z, He S, Chen L, Wu X, Zeng H, Ma L, Shi G, Yin J, Chen J, Ma G. Antithrombotic Therapy With Ticagrelor in Atrial Fibrillation Subjects After Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:745549. [PMID: 34712714 PMCID: PMC8545975 DOI: 10.3389/fcvm.2021.745549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Warfarin, along with aspirin and clopidogrel, has long been recommended for patients with atrial fibrillation (AF) who are undergoing percutaneous coronary intervention with a drug-eluting stent (PCI-DES). However, this triple therapy has been known to increase the risk of bleeding complications. Meanwhile, there is no evidence from prospective trials on the use of ticagrelor in a dual therapy. We here aimed to compare the antiplatelet drug ticagrelor as a dual antithrombotic agent to aspirin and clopidogrel in bleeding events. Methods: In this multicenter, active-controlled, open-label, randomized trial, patients with AF taking warfarin who had undergone PCI-DES were randomly assigned to the ticagrelor therapy group (Dual group) or the clopidogrel plus aspirin therapy group (Triple group). The primary and secondary endpoints were overall bleeding events and major bleeding events, respectively, according to the Thrombolysis in Myocardial Infarction (TIMI) criteria at 6 months. Cardiovascular events [re-PCI, surgical bypass, myocardial infarction (MI), heart failure, rehospitalization due to angina pectoris, stent thrombosis and death due to cardiovascular causes] at 6 months were also recorded. Results: A total of 296 patients from 12 medical centers in China were randomized after PCI-DES to either the Dual therapy group (n = 148) or the Triple group (n = 146) for 6 months. The overall incidence of bleeding events at 6 months was 36.49% in the Dual therapy group and 35.62% in the Triple group [hazard ratio, 0.930; 95% confidence interval (CI), 0.635 to 1.361; P = 0.7088]. The incidence of the secondary endpoint over 6 months was 4.73% in the Dual therapy group and 1.37% in the Triple group (hazard ratio, 0.273; 95% CI, 0.057 to 1.315; P = 0.1056). Cardiovascular event occurrence was also comparable in both groups at 6 months (18.24 vs. 16.44%; hazard ratio, 0.845; 95% CI, 0.488 to 1.465; P = 0.5484). Conclusions: The incidence of total bleeding events in AF patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 month; Meanwhile, the incidence of cardiovascular events were also comparable between the groups. Clinical Trial Registration: MANJUSRI, ClinicalTrials.gov# NCT02206815, 2014, August 1st
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Affiliation(s)
- Wenbin Lu
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yu Wang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yongjun Li
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Rui Zhang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Zhongpu Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Jinchuan Yan
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Jiangsu, China
| | - Mingming Yang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Bing Han
- Department of Cardiology, Central Hospital of Xuzhou City, Xuzhou, China
| | - Zhirong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shenghu He
- Department of Cardiology, Northern Jiangsu People's Hospital Affiliated With Yangzhou University, Yangzhou, China
| | - Lianglong Chen
- Department of Cardiology, Union Hospital Affiliated With Fujian Medical University, Fuzhou, China
| | - Xiang Wu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hesong Zeng
- Department of Cardiology, Tongji Hospital Affiliated With Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Likun Ma
- Department of Cardiology, Anhui Provincial Hospital, Hefei, China
| | - Guoping Shi
- Department of Cardiology, Rugao People's Hospital, Nantong, China
| | - Jianrong Yin
- Department of Cardiology, Pizhou People's Hospital Affiliated With Xuzhou Medical University, Xuzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong, China
| | - GenShan Ma
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
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Krittayaphong R, Pumprueg S, Ratanasumawong K, Sairat P, Lip GYH. Average Systolic Blood Pressure and Clinical Outcomes in Patients with Atrial Fibrillation: Prospective Data from COOL-AF Registry. Clin Interv Aging 2021; 16:1835-1846. [PMID: 34675498 PMCID: PMC8520416 DOI: 10.2147/cia.s335321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/23/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose Hypertension is associated with incident atrial fibrillation (AF) and AF-related complications. We investigated the associations between average systolic blood pressure (SBP) and outcomes in a nationwide cohort of Asian patients with non-valvular atrial fibrillation (NVAF). Patients and Methods A multicenter nationwide registry of patients with NVAF in Thailand was conducted during 2014–2017. Clinical data, including blood pressure, were recorded at baseline and then every 6 months. Average SBP was calculated from the average of SBP from every visit. Cox regression models were used to calculate the rate of clinical outcomes of interest, ie ischemic stroke or transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and all-cause death. Average SBP was categorized into three groups: <120, 120–140, and ≥140 mmHg. Results A total of 3402 patients were included, and the mean age was 67.4±11.3 years. The mean (±SD) baseline and average SBPs were 128.5±18.5 and 128.0±13.4 mmHg, respectively. The mean follow-up duration was 25.7±10.6 months. The median rate of ischemic stroke/TIA, ICH, and all-cause death was 1.43 (1.17–1.74), 0.70 (0.52–0.92), and 3.77 (3.33–4.24) per 100 person-years, respectively. The rate of ischemic stroke/TIA and ICH was lowest in patients with average SBP <120 mmHg, and highest among those with average SBP ≥140 mmHg. The death rates were consistent with a J-curve effect, being lowest in patients with an average SBP 120–140 mmHg. Sustained SBP control is more important than the SBP from a single visit. Conclusion Sustained control of SBP was significantly associated with a reduction in adverse clinical outcomes in patients with NVAF.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satchana Pumprueg
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory Y H Lip
- 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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Zhang C, Pan MM, Wang N, Wang WW, Li Z, Gu ZC, Lin HW. Feasibility and usability of a mobile health tool on anticoagulation management for patients with atrial fibrillation: a pilot study. Eur J Clin Pharmacol 2021; 78:293-304. [PMID: 34671819 DOI: 10.1007/s00228-021-03236-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Appropriate prescription of oral anticoagulants (OACs) and good patient adherence are essential to ensure optimal anticoagulation in patients with atrial fibrillation (AF). The aim of this study is to develop a mobile health tool to aid both clinicians and patients with AF in anticoagulation therapy. METHODS In this study, a novel anticoagulation management model integrating decision support and patient follow-up, the I-Anticoagulation, was developed based on a WeChat Mini Program. With this tool, the risks of stroke and bleeding in AF patients can automatically be calculated according to their characteristics. Anticoagulation regimens were recommended based on a trade-off analysis that balances stroke and bleeding risks according to recent clinical guidelines. A shared decision can be made with full communication between medical professionals and patients. Moreover, follow-up was also conducted using I-Anticoagulation. RESULTS A total of 120 AF patients receiving anticoagulants (40 received warfarin and 80 received non-vitamin K antagonist oral anticoagulants [NOACs]) were included in the pilot study. The incidence of thromboembolic events was 2.5% and 1.3%, and the rates of bleeding events were 22.5% and 13.8% in the warfarin and NOAC groups, respectively. Generally, self-reported adherence was high, and the satisfaction with anticoagulation was good in all patients with AF. CONCLUSION Overall, the anticoagulation management model developed in this study could be involved in the full process of anticoagulation therapy in AF patients to improve rationality, adherence, and satisfaction in both medical professionals and patients. However, the usability, feasibility, and acceptability of the I-Anticoagulant-based anticoagulation management model need to be further assessed through well-designed random clinical trials.
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Affiliation(s)
- Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.,School of Medicine, Tongji University, Shanghai, 200092, China.,Shanghai Pharmaceutical Association, Shanghai Anticoagulation Pharmacist Alliance, Shanghai, 200040, China
| | - Mang-Mang Pan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Wei-Wei Wang
- Department of S/4HANA Research & Development, SAP (China) Co., Ltd, Shanghai, 201203, China
| | - Zheng Li
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China. .,Shanghai Pharmaceutical Association, Shanghai Anticoagulation Pharmacist Alliance, Shanghai, 200040, China.
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.,School of Medicine, Tongji University, Shanghai, 200092, China.,Shanghai Pharmaceutical Association, Shanghai Anticoagulation Pharmacist Alliance, Shanghai, 200040, China
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Escobar C, Barrios V, Lip GYH, Amin AN, Auladell-Rispau A, Santero M, Salazar J, Requeijo C. Effectiveness and Safety of Dabigatran Compared to Vitamin K Antagonists in Non-Asian Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis. Clin Drug Investig 2021; 41:941-953. [PMID: 34643934 DOI: 10.1007/s40261-021-01091-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Real-life data about the use of dabigatran in patients with non-valvular atrial fibrillation are warranted. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of dabigatran, globally and stratified by dose (110/150 mg twice daily), vs vitamin K antagonists in non-Asian patients with non-valvular atrial fibrillation from "real-world" studies. METHODS A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement) statement. The ROBINS-I tool was used to assess bias risk. MEDLINE and EMBASE, from inception up to May 2021, using appropriate controlled vocabulary and free search terms, were searched. RESULTS: A total of 34 studies, corresponding to 37 articles involving 1,600,722 participants (1,154,283 exposed to vitamin K antagonists and 446,439 to dabigatran) were eligible for this review. Dabigatran 150 mg reduced the risk of ischemic stroke compared with vitamin K antagonists, with a 14% risk reduction (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.74-0.98). Globally, dabigatran reduced the risk of all-cause mortality compared with vitamin K antagonists (HR 0.76, 95% CI 0.69-0.84), with a greater effect observed with dabigatran 150 mg (HR 0.65, 95% CI 0.58-0.73). There was a trend towards a lower risk of myocardial infarction with dabigatran 150 mg (HR 0.86, 95% CI 0.71-1.04). Regarding the primary safety outcomes, dabigatran (either at a dose of 150 mg or 110 mg) reduced the risk of major bleeding compared with vitamin K antagonists (HR 0.77, 95% CI 0.70-0.83), as well as the risk of intracranial bleeding (HR 0.44, 95% CI 0.39-0.50) and fatal bleeding (HR 0.76, 95% CI 0.60-0.95), but with a slight increase in gastrointestinal bleeding risk (HR 1.16, 95% CI 1.08-1.26). CONCLUSIONS Dabigatran has a favorable impact on effectiveness and safety outcomes compared with vitamin K antagonists in real-world populations.
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Affiliation(s)
- Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
| | - Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest, Liverpool, UK
| | - Alpesh N Amin
- Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Ariadna Auladell-Rispau
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Marilina Santero
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Josefina Salazar
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Carolina Requeijo
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
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Thomson VS, Aaron S, Samson D N, Krupa J, Prabhakar AT, Jose J, George P, George OK, Joseph G, Yadav BK. Patent foramen ovale closure in India; Feasibility, challenges and mid-term outcomes. Indian Heart J 2021; 73:656-659. [PMID: 34627589 PMCID: PMC8514405 DOI: 10.1016/j.ihj.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 10/25/2022] Open
Abstract
Patent foramen ovale closure (PFO) is an underutilized therapy, and our study explored the challenges and feasibility of PFO closure in the Indian setting. Eighty patients with Embolic Stroke of Undetermined Source (ESUS) were screened by transcranial Doppler (TCD) for PFO. Twenty-nine patients underwent successful closure. High-risk features of a long tunnel, inter-atrial septal aneurysm, and large defect were present in 31%, 28%, and 59%. Transcranial Doppler had a sensitivity and specificity of 78% and 53% (p = 0.02) to detect PFO. Anticoagulation was withdrawn in 85% of patients post closure. Two patients had residual shunts at follow-up of 19 (9,34) months.
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Affiliation(s)
- Viji S Thomson
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India.
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Nathaniel Samson D
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Jesu Krupa
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - A T Prabhakar
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - John Jose
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Paul George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Oommen K George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - George Joseph
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Bijesh Kumar Yadav
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, 632004, India
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Han S, Han S, Suh HS, Bang OY, On YK, Lee MY, Jang SW, Won MM, Park YJ, Lee JM, Kang S, Kim YH. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: A nationwide, population-based study in Korea. J Arrhythm 2021; 37:1240-1249. [PMID: 34621422 PMCID: PMC8485801 DOI: 10.1002/joa3.12607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/25/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF), this retrospective study was conducted using the Korean Health Insurance Review & Assessment Service (HIRA) claims database. METHODS Patients with AF who initiated NOACs (apixaban, dabigatran, and rivaroxaban) from July 1, 2015 to November 30, 2016 were included. We applied inverse probability of treatment weighting (IPTW) method using propensity score to make weighted populations having similar characteristics between groups. Hazard ratio (HR) of S/SE and MB were estimated by Cox proportional hazard model. RESULTS Of the 39 783 patients with AF, 10 564; 11 418; and 17 801 used apixaban, dabigatran, and rivaroxaban, respectively. The mean CHA2DS2-VASc and HAS-BLED scores were 4.59 ~ 4.69 and 3.58 ~ 3.62, respectively, among all patients after applying IPTW. For S/SE, there were no significant differences between NOACs (HR [95% confidence interval (CI)]): apixaban vs dabigatran (0.99 [0.87-1.13]), apixaban vs rivaroxaban (0.95 [0.84-1.07]), and dabigatran vs rivaroxaban (0.96 [0.85-1.08]). For MB (HR [95% CI]), both apixaban (0.77 [0.68-0.86]) and dabigatran (0.88 [0.79-0.98]) had a significantly lower risk compared with rivaroxaban. Apixaban also had a significantly lower risk of MB compared with dabigatran (0.87 [0.76-0.99]). CONCLUSIONS In real-world practice among Korean AF patients with relatively high risk of stroke and bleeding, there were no significant differences in the risk of S/SE between all NOAC comparisons. Apixaban was associated with lower risk of MB than dabigatran and rivaroxaban.
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Affiliation(s)
- Seongwook Han
- Division of Cardiology Department of Internal Medicine Dongsan Hospital Keimyung University School of Medicine Daegu South Korea
| | - Sola Han
- Pharmaceutical Economics Big Data Analysis & Policy College of Pharmacy Kyung Hee University Seoul South Korea
| | - Hae Sun Suh
- Pharmaceutical Economics Big Data Analysis & Policy College of Pharmacy Kyung Hee University Seoul South Korea
| | - Oh Young Bang
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Young Keun On
- Department of Cardiology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Myung-Yong Lee
- Division of Cardiology Department of Internal Medicine Dankook University Chung Nam South Korea
| | - Sung-Won Jang
- Division of Cardiology Department of Internal Medicine Catholic University of Korea Seoul South Korea
| | | | | | | | | | - Young-Hoon Kim
- Division of Cardiology Department of Internal Medicine Korea University Seoul South Korea
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Hsieh HL, Kao CW, Cheng SM, Chang YC. A Web-Based Integrated Management Program for Improving Medication Adherence and Quality of Life, and Reducing Readmission in Patients With Atrial Fibrillation: Randomized Controlled Trial. J Med Internet Res 2021; 23:e30107. [PMID: 34550084 PMCID: PMC8495568 DOI: 10.2196/30107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/17/2021] [Accepted: 07/26/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is related to a variety of chronic diseases and life-threatening complications. It is estimated that by 2050, there will be 72 million patients with AF in Asia, of which 2.9 million will have AF-associated stroke. AF has become a major issue for health care systems. OBJECTIVE We aimed to evaluate the effects of a web-based integrated management program on improving coping strategies, medication adherence, and health-related quality of life (HRQoL) in patients with AF, and to detect the effect on decreasing readmission events. METHODS The parallel-group, single-blind, prospective randomized controlled trial recruited patients with AF from a medical center in northern Taiwan and divided them randomly into intervention and control groups. Patients in the intervention group received the web-based integrated management program, whereas those in the control group received usual care. The measurement tools included the Brief Coping Orientation to Problems Experienced (COPE) scale, Medication Adherence Rating Scale (MARS), the three-level version of the EuroQoL five-dimension self-report questionnaire (EQ-5D-3L), and readmission events 2 years after initiating the intervention. Data were collected at 4 instances (baseline, 1 month, 3 months, and 6 months after initiating the intervention), and analyzed with generalized estimating equations (GEEs). RESULTS A total of 231 patients were recruited and allocated into an intervention (n=115) or control (n=116) group. The mean age of participants was 73.08 (SD 11.71) years. Most participants were diagnosed with paroxysmal AF (171/231, 74%), and the most frequent comorbidity was hypertension (162/231, 70.1%). Compared with the control group, the intervention group showed significantly greater improvement in approach coping strategies, medication adherence, and HRQoL at 1, 3, and 6 months (all P<.05). In addition, the intervention group showed significantly fewer readmission events within 2 years (OR 0.406, P=.03), compared with the control group. CONCLUSIONS The web-based integrated management program can significantly improve patients' coping strategy and medication adherence. Therefore, it can empower patients to maintain disease stability, which is a major factor in improving their HRQoL and reducing readmission events within 2 years. TRIAL REGISTRATION ClinicalTrials.gov NCT04813094; https://clinicaltrials.gov/ct2/show/NCT04813094.
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Affiliation(s)
- Hui-Ling Hsieh
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Wen Kao
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yue-Cune Chang
- Department of Mathematics, Tamkang University, Taipei, Taiwan
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Impact of Reduced-Dose Nonvitamin K Antagonist Oral Anticoagulants on Outcomes Compared to Warfarin in Korean Patients with Atrial Fibrillation: A Nationwide Population-Based Study. J Clin Med 2021; 10:jcm10173918. [PMID: 34501364 PMCID: PMC8432037 DOI: 10.3390/jcm10173918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
Reduced-dose nonvitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed to Asian patients with nonvalvular atrial fibrillation (NVAF). We aimed to compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between patients treated with reduced-dose NOACs and those treated with warfarin, using the claims database in Korea. Patients with NVAF newly initiated on oral anticoagulants (OACs; apixaban, dabigatran, rivaroxaban, and warfarin) between 1 July 2015 and 30 November 2016 were included. Among all patients with NVAF treated with OACs, 5249, 6033, 7602, and 8648 patients were treated with reduced-dose apixaban, dabigatran, rivaroxaban, and warfarin, respectively. Patients treated with reduced-dose NOACs were older and had higher CHA2DS2-VASc and HAS-BLED scores than those treated with warfarin. Compared to warfarin, all reduced-dose NOACs showed significantly lower risk of S/SE (hazard ratios (95% confidence interval), 0.63 (0.52–0.75) for apixaban; 0.51 (0.42–0.61) for dabigatran; and 0.67 (0.57–0.79) for rivaroxaban) and MB (0.54 (0.45–0.65) for apixaban; 0.58 (0.49–0.69) for dabigatran; 0.73 (0.63–0.85) for rivaroxaban). In the real-world practice among Asians with NVAF, all reduced-dose NOACs were associated with a significantly lower risk of S/SE and MB compared to those of warfarin.
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Chao WC, Wu CL, Huang JA, Chai JW, Teng CL, Lee WL, Fu YC, Chen SA. Association between Early Absolute Neutrophil Count and Level of D-Dimer among Patients with COVID-19 Infection in Central Taiwan. J Clin Med 2021; 10:jcm10173891. [PMID: 34501339 PMCID: PMC8432119 DOI: 10.3390/jcm10173891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 12/24/2022] Open
Abstract
Thromboembolism is a critical event in patients with coronavirus disease (COVID)-19 infection and highly associated with neutrophil extracellular traps. D-dimer has been found to be an essential thromboembolism-associated biomarker; however, the association between absolute neutrophil count (ANC) and level of D-dimer in patients with COVID-19 infection remains unclear. In this study, we enrolled consecutive patients with COVID-19 admitted to Taichung Veterans General Hospital (TCVGH), a referral center in central Taiwan with 20 airborne infection isolation rooms. Spearman correlation was used to determine the association between ANC and level of D-dimer in distinct time periods. A total of 28 consecutive patients with COVID-19 infection were enrolled, and 32.1% (9/28) of them required mechanical ventilation. Patients requiring mechanical ventilation had a higher ANC (8225 vs. 3427/µL, p < 0.01) and levels of D-dimer (6.0 vs. 0.6 mg/L, p < 0.01) compared with those without mechanical ventilation. Notably, we identified five patients with image-proven thromboembolic events during the hospital course, with the number of patients with pulmonary embolism, venous thrombosis and acute ischemic stroke were 2, 1, and 2, respectively. We found that ANC within 4 days correlated with the level of D-dimer to a moderate level (r = 0.71, p < 0.05), and the association between ANC and D-dimer no longer exist after day 5. In conclusion, we found highly prevalent thromboembolic events among patients with severe COVID-19 infection in central Taiwan and identified the association between early ANC and D-dimer. More studies are warranted to elucidate the underlying mechanism.
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Affiliation(s)
- Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.C.); (C.-L.W.)
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung 407802, Taiwan
- Big Data Center, National Chung Hsing University, Taichung 40227, Taiwan
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.C.); (C.-L.W.)
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung 407802, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 407224, Taiwan
| | - Jin-An Huang
- Department of Neurological Institute, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Jyh-Wen Chai
- Department of Radiology, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Chieh-Lin Teng
- Division of Hematology and Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Department of Life Science, Tunghai University, Taichung 407224, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Department of Medicine, National Yang-Ming Chiou Tung University, Taipei 112, Taiwan
- Correspondence: (W.-L.L.); (Y.-C.F.)
| | - Yun-Ching Fu
- Section of Pediatric Cardiology, Department of Pediatrics, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiou Tung University, Taipei 112, Taiwan
- Correspondence: (W.-L.L.); (Y.-C.F.)
| | - Shih-Ann Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Institute of Clinical Medicine, National Yang Ming Chiou Tung University, Taipei 112, Taiwan
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Kim SM, Jeon ET, Jung JM, Lee JS. Real-world oral anticoagulants for Asian patients with non-valvular atrial fibrillation: A PRISMA-compliant article. Medicine (Baltimore) 2021; 100:e26883. [PMID: 34397907 PMCID: PMC8360482 DOI: 10.1097/md.0000000000026883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate the comparative efficacy and safety of 4 non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in Asians with non-valvular atrial fibrillation in real-world practice through a network meta-analysis of observational studies. METHODS We searched multiple comprehensive databases (PubMed, Embase, and Cochrane library) for studies published until August 2020. Hazard ratios and 95% confidence intervals were used for the pooled estimates. Efficacy outcomes included ischemic stroke (IS), stroke/systemic embolism (SSE), myocardial infarction (MI), and all-cause mortality, and safety outcomes included major bleeding, gastrointestinal (GI) bleeding, and intracerebral hemorrhage (ICH). The P score was calculated for ranking probabilities. Subgroup analyses were separately performed in accordance with the dosage range of NOACs ("standard-" and "low-dose"). RESULTS A total of 11, 6, and 8 studies were allocated to the total population, standard-dose group, and low-dose group, respectively. In the total study population, edoxaban ranked the best in terms of IS and ICH prevention and apixaban ranked the best for SSE, major bleeding, and GI bleeding. In the standard-dose regimen, apixaban ranked the best in terms of IS and SSE prevention. For major bleeding, GI bleeding, and ICH, edoxaban ranked the best. In the low-dose regimen, edoxaban ranked the best for IS, SSE, GI bleeding, and ICH prevention. For major bleeding prevention, apixaban ranked best. CONCLUSIONS All 4 NOACs had different efficacy and safety outcomes according to their type and dosage. Apixaban and edoxaban might be relatively better and more well-balanced treatment for Asian patients with non-valvular atrial fibrillation.
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Affiliation(s)
- Seung Min Kim
- Department of Neurology, Veterans Health Service Medical Center, Seoul
| | - Eun-Tae Jeon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine
- Korea University Zebrafish Translational Medical Research Center, Ansan
| | - Ji-Sung Lee
- Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Risk of major bleeding and thromboembolism in Asian patients with nonvalvular atrial fibrillation using direct oral anticoagulants versus warfarin. Int J Clin Pharm 2021; 44:34-43. [PMID: 34324128 DOI: 10.1007/s11096-021-01309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
Background Bleeding and thromboembolism prevention is important in patients with nonvalvular atrial fibrillation receiving anticoagulants, including direct oral anticoagulants and warfarin. Asians have higher risks of bleeding complications when taking anticoagulants. However, evidence that considers laboratory parameters is lacking. Objective We aimed to compare the safety and effectiveness between direct oral anticoagulants and warfarin in Asian patients with nonvalvular atrial fibrillation. Setting Retrospective design using hospital-based data. Method This propensity score-matched cohort study included data extracted from the electronic medical records of the En Chu Kong Hospital Research Database. Main outcome measure Outcome measures were major bleeding and thromboembolism. Cox proportional hazard models were applied for evaluating hazard ratios with 95% confidence intervals. Results Among 1075 patients with nonvalvular atrial fibrillation, 687 and 388 were administered direct oral anticoagulants and warfarin, respectively. After propensity score matching, 264 patient pairs were selected. Compared with warfarin use, direct oral anticoagulant use was associated with similar risks for major bleeding and thromboembolism; however, the latter was associated with increased gastrointestinal bleeding risks (adjusted hazard ratio 3.59; 95% confidence interval, 1.31-11.39). Notably, an approximately 10 fold increased risk of gastrointestinal bleeding was observed in 0-6 month direct oral anticoagulant users (adjusted hazard ratio 10.13, 95% confidence interval 1.27-80.89). Conclusion Direct oral anticoagulant use was not associated with major bleeding and thromboembolism occurrence in Asian patients with nonvalvular atrial fibrillation. However, direct oral anticoagulant use was associated with increased gastrointestinal bleeding risks, especially when used within 0-6 months of direct oral anticoagulant use.
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