‘Real world’ use of non-vitamin K antagonist oral anticoagulants (NOACs): Lessons from the Dresden NOAC Registry

Anticoagulant Therapy in Patients with Non-valvular Atrial Fibrillation in Real Clinical Practice: in Appropriate Dose Reductions

Aim. To study the frequency of administration of direct oral anticoagulant (DOACs) in doses recommended and not recommended by the instructions of the drugs in non-valve atrial fibrillation (AF) patients.

Material and methods. 10663 case histories of patients hospitalized for 5 years (2014-2018) were studied, 1307/10663 (12,3%) case histories of patients with AF were selected. In patients with AF, the risk of stroke and systemic embolism, the risk of bleeding, the anticoagulant therapy (ACT) recommended at the prehospital stage and its adequacy was evaluated.

Results. 1 261/1 307 (96,5%) patients had a non-valve AF. The risk of stroke and systemic embolism was 4,7±1,5 (CHA2DS2-VASс), 97,5% of patients with non-valve AF (1229/1261) needed ACT. Only 665/1229 (54.1%) patients with AF received ACT at the time of hospitalization and 578/1229 (47,0%) of patients did not receive ACT. Before hospitalization 281/665 (42,3%) patients received vitamin K antagonist (warfarin). The international normalized ratio in the target range (2,0-3,0) was in 111/281 (39,5%) patients. 57,7% (384/665) outpatients with AF received NOAC: rivaroxaban - 180/384 (46,9%) patients, dabigatran etexilate - 110/384 (28,6%) patients, apixaban - 94/384 (24,5%) patients. Inappropriate reduced doses of DOAC were revealed in 68/384 (17,7%) patients: apixaban - 23,4%, dabigatran - 16,4% and rivaroxaban - 15,6% (p>0,05).

Conclusion. In real clinical practice 42,3% AF patients used warfarin, only 39,5% of them had INR in target values. DOAC in inappropriate reduced doses used 17,7% patients.

Rational and design of the China Pulmonary Thromboembolism Registry Study (CURES): A prospective multicenter registry

BACKGROUND

Epidemiological data on pulmonary embolism (PE) in China needs to be updated and reported. The China Pulmonary Thromboembolism Registry Study (CURES) is designed to provide the cross-sectional spectrum and chronological trends of PE in China, as well as to reveal the intrinsic etiology and pathogenesis of the disease.

METHODS AND DESIGN

The CURES is an ongoing large prospective multicenter registry, which was originally initiated in January 2009 via enrolling suspected or confirmed PE or PE with DVT (deep venous thrombosis) patients and assessed their in-hospital outcomes. As of July 2011, in order to determine the PE-relevant short-term outcomes, enrolled participants were followed-up for at least three months in a longitudinal manner. Since August 2016, with the launch and development of precision medicine research scheme in China, the main principle investigators of CURES decided to collect enrolled patients' blood samples with regular follow-ups every three or six months for at least two years (for long-term outcomes). Up to 31 December 2019, the CURES has enrolled 14,937 eligible patients and collected 1500 blood samples of patients from 100 medical centers in the China PE-DVT network. The study protocol has been approved by the China-Japan Friendship Hospital ethics committee, and all collaborating centers received approvals from their local ethics committee. All patients provided written or verbal informed consent to their participation.

CONCLUSIONS

Findings of the CURES will be valuable for revealing the natural history of PE, and facilitating better disease management in China. Registration Number inClinicalTrials.gov:NCT02943343.

Clinical profile and management of rivaroxaban in patients with atrial fibrillation in routine practice in Spain: data from six nationwide studies

AIMS

To analyze the clinical profile and management of patients with nonvalvular atrial fibrillation taking rivaroxaban in routine practice in Spain.

METHODS

Clinical data from the observational studies HEROIC (cardiology and hematology; n=1,727), EMIR (cardiology; n=1,493), BRONCE-AP (primary care; n=133), SILVER-AP (primary care; n=457), ALADIN (internal medicine and neurology; n=249), and ESPARTA (internal medicine; n=110) of patients taking rivaroxaban were analyzed. The clinical profile was compared with those of the XANTUS and ROCKET-AF studies.

RESULTS

Overall, mean age was 74.9±9.4 years, CHA₂DS₂-VASc score was 3.7±1.5, and 43.2% had a HAS-BLED score ≥3. Patients included in the HEROIC and EMIR studies were older and more frequently had a creatinine clearance <50 mL/min and a higher thromboembolic risk than those in the XANTUS study, and patients included in the ALADIN study were older and had more prior cerebrovascular disease, but a lower thromboembolic risk than those in the ROCKET-AF trial. In those studies with available data, medication adherence and satisfaction with rivaroxaban were high.

CONCLUSION

Bearing in mind differences according to the clinical setting of each study, atrial fibrillation patients taking rivaroxaban in Spain were elderly and had a high thromboembolic risk. Medication adherence and satisfaction with rivaroxaban were high.

Characteristics of patients initiated on edoxaban in Europe: baseline data from edoxaban treatment in routine clinical practice for patients with atrial fibrillation (AF) in Europe (ETNA-AF-Europe)

Background

Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have substantially improved anticoagulation therapy for prevention of stroke and systemic embolism in patients with atrial fibrillation (AF). The available routine care data have demonstrated the safety of different NOACs; however, such data for edoxaban are scarce. Here, we report baseline characteristics of 13,638 edoxaban-treated patients with AF enrolled between November 2016 and February 2018.

Methods

ETNA-AF-Europe is a multinational, multi-centre, post-authorisation, observational study conducted in 825 sites in 10 European countries. Patients will be followed up for four years.

Results

Overall, 13,980 patients were enrolled of which 342 patients were excluded from the analysis. Mean patient age was 73.6 years with an average creatinine clearance of 69.4 mL/min. 56.6% were male. The calculated CHA₂DS₂-VASc and HAS-BLED mean scores were 3.1 and 2.6, respectively. Overall, 3.3, 14.6 and 82.0% of patients had low (CHA₂DS₂-VASc = 0), intermediate (CHA₂DS₂-VASc = 1) and high (CHA₂DS₂-VASc≥2) risks of stroke, respectively. High-risk patients (those with prior stroke, prior major bleeding, prior intracranial bleed or CHA₂DS₂-VASc ≥4) comprised 38.4% of the overall population. For 75.1% of patients edoxaban was their first anticoagulant prescription, whilst 16.9% switched from a VKA and 8.0% from another NOAC. A total of 23.4% of patients in ETNA-AF-Europe received the reduced dose of edoxaban 30 mg. Overall, 83.8% of patients received an edoxaban dose in line with the criteria outlined in the label.

Conclusion

Edoxaban was predominantly initiated in older, often anticoagulation-naïve, unselected European patients with AF, with a good overall adherence to the approved label.

Trial registration

NCT02944019; Date of registration: October 24, 2016.

Anticoagulation with rivaroxaban in a hematology unit: clinical profile, events and discontinuation rates in real-life patients with nonvalvular atrial fibrillation

AIM

To assess the clinical profile and thromboembolic and bleeding events in patients with nonvalvular atrial fibrillation (AF) who were attended in a hematology unit.

METHODS

Retrospective study of AF patients that started treatment with rivaroxaban between February 2012 and June 2016 in a hematology unit from a tertiary hospital in Spain.

RESULTS

Overall, 243 patients (mean age 78.4 ± 10.1 years; 47.5% women, CHA₂DS₂-VASc 3.7 ± 1.5) were included. After a mean follow-up of 16.5 ± 12.7 months, rivaroxaban was discontinued in only 2.4% of patients. During the follow-up, seven (2.0 events/100 patient-years) patients had a thromboembolic event and six patients (1.7 events/100 patient-years) a major bleeding.

CONCLUSION

Rivaroxaban was effective and safe among AF patients treated in a hematology unit, with very low discontinuation rates.

Effectiveness and safety of rivaroxaban in a cohort of 142 patients with nonvalvular atrial fibrillation treated with rivaroxaban for the prevention of stroke

Aim: To evaluate the clinical profile and effectiveness/safety of patients taking rivaroxaban in clinical practice. Methods: Retrospective study that included patients with nonvalvular atrial fibrillation treated with rivaroxaban for the prevention of stroke between January 2012 and December 2016 in a tertiary hospital in Spain. Results: A total of 142 patients (median age 78 years, 40.1% men, 32.4% creatinine clearance <50 ml/min; 96.5% CHA2DS2-VASc ≥2; 44.3% HAS-BLED ≥3) were included. Only two patients had a thromboembolic event (in both cases ischemic stroke) and three patients had major bleeding (rates of 1.3 and 1.9 events/100 patient years, respectively). Conclusion: Data regarding effectiveness and safety in our cohort were consistent with previous studies, showing that rivaroxaban can be effective and safely used in our setting.

Novel oral anticoagulants in chronic kidney disease: ready for prime time?

PURPOSE OF REVIEW

Patients with chronic kidney disease (CKD) are at increased risk of atrial fibrillation, stroke, and bleeding posing unique clinical challenges. Novel oral anticoagulants (NOACs) including dabigatran, rivaroxaban, and apixaban have become recognized as alternative therapy to Vitamin K Antagonists (VKA) regarding the prevention of venous thromboembolism (VTE) and reduce the risk of stroke in atrial fibrillation. However, the understanding of NOACs in CKD is still underdeveloped. This review summarizes recent literature on the efficacy and safety of NOACs in patients with CKD.

RECENT FINDINGS

Studies focusing on patients with moderate kidney disease were drawn from post hoc analyses from three major NOAC trials, meta-analyses, and postmarketing surveillance studies. Cumulatively, these studies continue to demonstrate NOACs as equivalent if not superior therapies to VKAs in regards to both efficacy and safety. These studies are limited by small sample sizes as well as a lack of direct comparison between NOACs.

SUMMARY

The role of NOACs in managing VTE and atrial fibrillation is increasing. Current research suggests that NOACs are at least as efficacious and well tolerated as VKAs. More research is required to elucidate which NOAC is preferable in the clinical setting.

New Approaches to the Role of Thrombin in Acute Coronary Syndromes: Quo Vadis Bivalirudin, a Direct Thrombin Inhibitor?

The pathophysiology of acute coronary syndrome (ACS) involves platelet activation and thrombus formation after the rupture of atherosclerotic plaques. Thrombin is generated at the blood-plaque interface in association with cellular membranes on cells and platelets. Thrombin also amplifies the response to the tissue injury, coagulation and platelet response, so the treatment of ACS is based on the combined use of both antiplatelet (such as aspirin, clopidogrel, prasugrel and ticagrelor) and antithrombotic drugs (unfractionated heparin, enoxaparin, fondaparinux and bivalirudin). Bivalirudin competitively inhibits thrombin with high affinity, a predictable response from its linear pharmacokinetics and short action. However, a present remarkable controversy exists between the latest main Guidelines in Clinical Practice and the key trials evaluating the use of bivalirudin in ACS. The aim of this review is to update the development of bivalirudin, including pharmacological properties, obtained information from clinical trials evaluating efficacy and safety of bivalirudin in ACS; as well as the recommendations of clinical Guidelines.

Edoxaban for reducing the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation

INTRODUCTION

Oral anticoagulation is central to the management of patients with atrial fibrillation (AF) and at least one additional stroke risk factor. For decades, the vitamin K antagonists (e.g. warfarin) remained the only oral anticoagulant available for stroke prevention in AF. The non-vitamin K oral anticoagulants (NOACs) are now available, and these drugs include the direct thrombin inhibitors and factor Xa inhibitors. The latter class includes edoxaban, which has recently been approved for stroke prevention in AF by the United States Food and Drug Administration and the European Medicine Agency. In line with other NOACs, edoxaban avoids the many limitations of warfarin associated with variability of anticoagulation effect and multiple food and drug interactions.

AREAS COVERED

In this review, the currently available evidence on edoxaban in patients with non-valvular AF is discussed. The pharmacology, efficacy and safety, and current aspects of use of edoxaban in patients with non-valvular AF for stroke and thromboembolism prevention are reviewed.

EXPERT OPINION

Phase III trials on edoxaban for stroke prevention in non-valvular AF confirms non-inferiority of edoxaban compared to well-managed warfarin both in terms of efficacy and safety. Currently ongoing and future trials as well as real-world data are warranted to confirm its effectiveness and safety for chronic anticoagulation and improve evidence in other areas which are lacking evidence where NOAC use remains controversial.