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Johnson LS, Benz AP, Shoamanesh A, Eikelboom JW, Ezekowitz M, Giugliano RP, Wallentin L, Ruff CT, Lopes RD, Jolly S, Whitlock R, Granger CB, Connolly S, Healey JS. Residual Stroke Risk Among Patients With Atrial Fibrillation Prescribed Oral Anticoagulants: A Patient-Level Meta-Analysis From COMBINE AF. J Am Heart Assoc 2024:e034758. [PMID: 39190578 DOI: 10.1161/jaha.123.034758] [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: 02/21/2024] [Accepted: 06/10/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Despite oral anticoagulation, patients with atrial fibrillation (AF) remain at risk of ischemic stroke and systemic embolism (SE) events. For patients whose residual risk is sufficiently high, additional therapies might be useful to mitigate stroke risk. METHODS AND RESULTS Individual patient data from 5 landmark trials testing oral anticoagulation in AF were pooled in A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in AF (COMBINE AF). We calculated the rate of ischemic stroke/SE among oral anticoagulation-treated patients with a CHA2DS2-VASc score≥2, across strata of CHA2DS2-VASc score, stroke history, and AF type, as either paroxysmal or nonparoxysmal. We included 71 794 patients with AF (median age 72 years, interquartile range, 13 years, 61.3% male) randomized to a direct oral anticoagulant or vitamin K antagonist, and followed for a mean of 2.1 (±0.8) years. The median CHA2DS2-VASc score was 4 (interquartile range, 3-5), 18.8% had a prior stroke, and 76.4% had nonparoxysmal AF. The overall rate of stroke/SE was 1.33%/y (95% CI, 1.27-1.39); 1.38%/y (95% CI, 1.31-1.45) for nonparoxysmal AF, and 1.15%/y (95% CI, 1.05-1.27) for paroxysmal AF. The rate of ischemic stroke/SE increased by a rate ratio of 1.36 (95% CI, 1.32-1.41) per 1-point increase in CHA2DS2-VASc, reaching 1.67%/y (95% CI, 1.59-1.75) ≥4 CHA2DS2-VASc points. Patients with both nonparoxysmal AF and CHA2DS2-VASc ≥4 had a stroke/SE rate of 1.75%/y (95% CI, 1.66-1.85). In patients with a prior stroke, the risk was 2.51%/y (95% CI, 2.33-2.71). CONCLUSIONS AF type, CHA2DS2-VASc score, and stroke history can identify patients with AF, who despite oral anticoagulation have a residual stroke/SE risk of 1.5% to 2.5% per year. Evaluation of additional stroke/SE prevention strategies in high-risk patients is warranted.
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Affiliation(s)
- Linda S Johnson
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Clinical Sciences Lund University Malmö Sweden
| | - Alexander P Benz
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Cardiology University Medical Center Mainz, Johannes Gutenberg-University Mainz Germany
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University Hamilton Canada
- Division of Neurology McMaster University Hamilton ON Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University Hamilton Canada
| | - Michael Ezekowitz
- Sydney Kimmel Medical School Thomas Jefferson University Philadelphia PA USA
- Cardiology Department, Lankenau Medical Center Bryn Mawr Hospital/Mainline Health Wynnewood PA USA
| | - Robert P Giugliano
- Division of Cardiovascular Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA USA
- Thrombolysis in Myocardial Infarction Study Group Boston MA USA
| | - Lars Wallentin
- Uppsala Clinical Research Centre Uppsala University Uppsala Sweden
- Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Christian T Ruff
- Division of Cardiovascular Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA USA
- Thrombolysis in Myocardial Infarction Study Group Boston MA USA
| | - Renato D Lopes
- Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
- Duke Clinical Research Institute, Duke University Durham NC USA
| | - Sanjit Jolly
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
| | - Christopher B Granger
- Division of Cardiology Duke University Durham NC USA
- Duke Clinical Research Institute, Duke University Durham NC USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University Hamilton Canada
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University Hamilton Canada
- Department of Medicine McMaster University Hamilton ON Canada
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Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024; 45:2914-2932. [PMID: 39027946 PMCID: PMC11335376 DOI: 10.1093/eurheartj/ehae398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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Thomas VV, Lenin A, George TK, Thenmozhi M, Iyadurai R, Sudarsanam TD. Trends in oral anticoagulant use - A 10-year retrospective analysis from a general medicine department of a tertiary care hospital in south India. J Postgrad Med 2024; 70:77-83. [PMID: 37470633 PMCID: PMC11160985 DOI: 10.4103/jpgm.jpgm_10_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The prescribing practice of newer oral anticoagulants (NOACs) has not been adequately studied in the Indian scenario. AIMS We aimed to describe the prescribing practices of oral anticoagulants, the patient profile and medical comorbidities among patients admitted in a general medicine unit. METHODS In this retrospective study of the 2742 patients prescribed vitamin- K antagonists (VKAs), during the study period, 150 cases were randomly taken for analysis to match the 105 NOACs cases. Their demographic details, clinical characteristics and treatment details were analyzed. RESULTS More than 95% of anticoagulants prescribed were VKAs. The prescription of anticoagulants was more common in men (median age 63 years) for prescription of NOACs and 52 years for VKAs. Dabigatran (60.9%) and warfarin (81.3%) were the most prescribed drugs in their respective classes. The most common indication was for cardiovascular diseases with atrial fibrillation (32%). Diabetes and hypertension were the most common comorbidities in patients prescribed oral anticoagulants with a larger proportion of patients with heart failure being prescribed VKAs ( P < 0.01). Patients in the NOACs group had a higher HAS-BLED high-risk score (33.3% vs. 17.3%; P = 0.002). Logistic regression analysis revealed that patients with co-morbidities of congestive heart failure were more likely to be prescribed VKAs while diabetics were more likely to receive NOACs. CONCLUSIONS VKAs were the most prescribed anticoagulants; congestive heart failure, diabetes, and hypertension were the commonest comorbidities; and atrial fibrillation was the commonest indication. Patients with a high HAS-BLED score were prescribed NOACs more often.
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Affiliation(s)
- VV Thomas
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A Lenin
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - TK George
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - M Thenmozhi
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - R Iyadurai
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - TD Sudarsanam
- Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Bergler-Klein J, Gotcheva N, Kalējs O, Kalarus Z, Kovačić D, Peršić V, Shlyakhto E, Uuetoa T, Huisman MV, Lip GYH, Vinereanu D. Antithrombotic Usage, Including Three-Year Outcomes With Dabigatran and Vitamin K Antagonists for Atrial Fibrillation, in Eastern Europe: A Descriptive Analysis From Phase 3 of the GLORIA-AF Registry. Am J Ther 2024; 31:e1-e12. [PMID: 38231576 DOI: 10.1097/mjt.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) is a prospective registry of outcomes from patients with newly diagnosed AF at risk of stroke. In the propensity score (PS)-matched global population of phase 3 GLORIA-AF, at 3 years, dabigatran-treated patients experienced reduced risk for major bleeding, and similar risk for stroke and myocardial infarction, compared with vitamin K antagonist (VKA)-treated patients. STUDY QUESTION Do patients in Eastern Europe benefit from treatment with dabigatran versus VKA? STUDY DESIGN Descriptive analysis, without PS matching. To contextualize the Eastern Europe results of GLORIA-AF phase 3, we also descriptively analyzed the global population without PS matching. Consecutive patients with newly diagnosed AF and CHA2DS2-VASc-score ≥1 were enrolled until December 2016 in 38 countries (9 in Eastern Europe). MEASURES AND OUTCOMES Three-year outcomes with dabigatran and VKA. RESULTS In Eastern Europe, 1341 patients were eligible (6% of patients globally), and incidence rates (per 100 patient-years) for the following outcomes were numerically lower with dabigatran (N = 498) versus VKA (N = 466): major bleeding (0.26 vs. 0.90), all-cause death (2.04 vs. 3.50), and a composite of stroke, systemic embolism, myocardial infarction, life-threatening bleeding, and vascular death (1.37 vs. 1.92); stroke was comparable (0.51 vs. 0.50). All incidence rates were numerically lower in Eastern Europe versus the global population for both treatments. Chronic concomitant use of high bleeding risk medications (eg, nonsteroidal anti-inflammatories) was lower in Eastern Europe (dabigatran 3.8%, VKA 9.3%) than globally (dabigatran 14.8%, VKA 20.6%) and persistence with dabigatran was higher in Eastern Europe (76%) than globally (64%). CONCLUSIONS Dabigatran was associated with numerically reduced major bleeding, all-cause death, and cardiovascular (CV) composite, with comparable risk of stroke versus VKA, in Eastern Europe. Limitations of this descriptive analysis include few CV events (n = 11 for stroke, in the dabigatran and VKA groups combined) and a lack of statistical analysis and PS matching, which precludes definitive conclusions; however, the CV outcomes in Eastern Europe were consistent with the beneficial impact of dabigatran versus VKA in the statistically analyzed global population with PS matching.
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Affiliation(s)
- Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nina Gotcheva
- Department of Cardiology, National Heart Hospital, Sofia, Bulgaria
| | - Oskars Kalējs
- Department of Arrhythmology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Dragan Kovačić
- Department of Cardiology, General Hospital Celje, Celje, Slovenia
| | - Viktor Peršić
- Department of Medical Rehabilitation, Medical Faculty, University of Rijeka, Rijeka, Croatia
- Division of Cardiology, Hospital for Medical Rehabilitation of the Heart and Lung Diseases and Rheumatism "Thalassotherapia Opatija," Opatija, Croatia
| | - Evgeny Shlyakhto
- Clinical Endocrinology Laboratory, Department of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - 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
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; and
- Department of Cardiology and Cardiovascular Surgery, University and Emergency Hospital, Bucharest, Romania
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Álvaro Thomsen T, Mesa Guadalupe J, Huerta C, de Burgos A, Cea Soriano L. Risk of ischemic stroke associated with direct oral anticoagulants discontinuation on patients with non-valvular atrial fibrillation. Pharmacoepidemiol Drug Saf 2024; 33:e5733. [PMID: 38011912 DOI: 10.1002/pds.5733] [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: 01/27/2023] [Revised: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Although direct oral anticoagulants' (DOACs) prescriptions have experienced immense growth in the last decade, the proportion of discontinuers is still common yielding an increased risk of ischemic stroke (IS) onset. AIMS We aimed to estimate the association between DOACs discontinuation and risk of IS among patients with non-valvular atrial fibrillation (NVAF). METHODS We used data from a cohort of new DOACs users, followed patients from the first DOAC prescription date up to IS (index date) and conducted a nested case-control analysis using conditional logistic regression. Adjusted odds ratios, 95% confidence intervals were calculated for discontinuation of DOACs (current use compared with past use). The latter, subdivided among those stopping treatment 3 to 2 months and 6 and 3 months prior to index date. The effect of naïve current users against IS onset compared with non-naïve current users was also evaluated. RESULTS DOACs discontinuation showed an OR of IS of 1.47 (95% CI: 1.02-2.12); estimates were 2.51 (95% CI: 1.84-3.42) for whom discontinued treatment within months 3 and 2 and 1.43 (95% CI: 0.96-2.13) for those between months 6 and 3 prior to index date. Analyzing DOACs individually, risk of IS associated with past users compared with current users: 1.98 (95% CI: 1.25-3.12) for apixaban, 1.38 (95% CI: 0.40-4.72) for edoxaban, 1.98 (95% CI: 1.24-2.65) for dabigatran and 1.87 (95% CI: 1.26-2.76) for rivaroxaban. Similar results were found when stratified by naïve and non-naïve users. CONCLUSIONS DOACs' discontinuation is associated with higher risk of IS, especially in the second and third months following interruption.
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Affiliation(s)
- T Álvaro Thomsen
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - J Mesa Guadalupe
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - C Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - A de Burgos
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - L Cea Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS Expert Consensus Statement on Transcatheter Left Atrial Appendage Closure. JACC Cardiovasc Interv 2023; 16:1384-1400. [PMID: 36990858 DOI: 10.1016/j.jcin.2023.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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Patti G, Wang R, Marston XL, Yeh YC, Zimmermann L, Ye X, Gao X, Brüggenjürgen B. Anticoagulant Treatment Adherence and Persistence in German Patients with Atrial Fibrillation. Cardiol Ther 2023; 12:371-391. [PMID: 37138193 DOI: 10.1007/s40119-023-00315-8] [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: 01/08/2023] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION Treatment adherence and persistence impact the effectiveness of edoxaban for the prevention of thromboembolism in patients with atrial fibrillation (AF). The objective of this analysis was to assess adherence and persistence of edoxaban vs. other non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs). METHODS Utilizing a German claims database, adults with AF with the first pharmacy claim identified for edoxaban, apixaban, dabigatran, rivaroxaban, or VKAs from January 2013 to December 2017 were included in a propensity score-matched analysis. The first pharmacy claim was the index claim. Adherence (i.e., proportion of days covered [PDC]) and persistence (proportion of patients who continued therapy) were compared between edoxaban and other therapies. Patients receiving once-daily (QD) vs. twice-daily (BID) NOAC were also analyzed. RESULTS Overall, 21,038 patients were included (1236 edoxaban, 6053 apixaban, 1306 dabigatran, 7013 rivaroxaban, and 5430 VKA). After matching, baseline characteristics were well balanced across cohorts. Adherence was significantly higher for edoxaban vs. apixaban, dabigatran, and VKAs (all P < 0.0001). Significantly more edoxaban patients continued therapy vs. rivaroxaban (P = 0.0153), dabigatran (P < 0.0001), and VKAs (P < 0.0001). Time to discontinuation was significantly longer for edoxaban vs. dabigatran, rivaroxaban, and VKAs (all P < 0.0001). More patients receiving NOACs QD had a PDC ≥ 0.8 compared with those receiving NOACs BID (65.3 vs. 49.6%, respectively; P < 0.05); persistence rates were comparable between QD and BID groups. CONCLUSIONS Patients with AF receiving edoxaban had significantly higher adherence and persistence compared with those receiving VKAs. This trend was also seen in NOAC QD regimens vs. NOAC BID regimens for adherence. These results provide insight into how adherence and persistence may contribute to the effectiveness of edoxaban for stroke prevention in patients with AF in Germany.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
| | - Rosa Wang
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | | | | | | | - Xin Ye
- Daiichi Sankyo Inc., Basking Ridge, NJ, USA
| | - Xin Gao
- OPEN Health, Bethesda, MD, USA
| | - Bernd Brüggenjürgen
- Orthopedic Department, Medical School Hannover at DIAKOVERE Annastift Hospital, Hannover, Germany
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS Expert Consensus Statement on Transcatheter Left Atrial Appendage Closure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100577. [PMID: 39130704 PMCID: PMC11307869 DOI: 10.1016/j.jscai.2022.100577] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L. Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V. Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M. Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D. Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M. Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G. Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure. Heart Rhythm 2023; 20:e1-e16. [PMID: 36990925 DOI: 10.1016/j.hrthm.2023.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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10
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Adelakun AR, Turgeon RD, De Vera MA, McGrail K, Loewen PS. Oral anticoagulant switching in patients with atrial fibrillation: a scoping review. BMJ Open 2023; 13:e071907. [PMID: 37185198 PMCID: PMC10151984 DOI: 10.1136/bmjopen-2023-071907] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Oral anticoagulants (OACs) prevent stroke in patients with atrial fibrillation (AF). Several factors may cause OAC switching. OBJECTIVES To examine the phenomenon of OAC switching in patients with AF, including all available evidence; frequency and patterns of switch, clinical outcomes, adherence, patient-reported outcomes, reasons for switch, factors associated with switch and evidence gaps. DESIGN Scoping review. DATA SOURCES MEDLINE, Embase and Web of Science, up to January 2022. RESULTS Of the 116 included studies, 2/3 examined vitamin K antagonist (VKA) to direct-acting OAC (DOAC) switching. Overall, OAC switching was common and the definition of an OAC switch varied across. Switching from VKA to dabigatran was the most prevalent switch type, but VKA to apixaban has increased in recent years. Patients on DOAC switched more to warfarin than to other DOACs. OAC doses involved in the switches were hardly reported and patients were often censored after the first switch. Switching back to a previously taken OAC (frequently warfarin) occurred in 5%-21% of switchers.The risk of ischaemic stroke and gastrointestinal bleeding in VKA to DOAC switchers compared with non-switchers was conflicting, while there was no difference in the risk of other types of bleeding. The risk of ischaemic stroke in switchers from DOAC versus non-switchers was conflicting. Studies evaluating adherence found no significant changes in adherence after switching from VKA to DOAC, however, an increase in satisfaction with therapy were reported. Reasons for OAC switch, and factors associated with OAC switch were mostly risk factors for stroke and bleeding. Clinical outcomes, adherence and patient-reported outcomes were sparse for switches from DOACs. CONCLUSIONS OAC switching is common in patients with AF and patients often switch back to an OAC they have previously been on. There are aspects of OAC switching that have received little study, especially in switches from DOACs.
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Affiliation(s)
- Adenike R Adelakun
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter S Loewen
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
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11
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De Luca L, Dovizio M, Sangiorgi D, Perrone V, Degli Esposti L. Incidence and Predictors of Switching and Dose Change of Direct Oral Anticoagulants among Elderly Patients with Nonvalvular Atrial Fibrillation: A 5-Year Analysis of a Large Administrative Database. J Clin Med 2023; 12:jcm12062379. [PMID: 36983380 PMCID: PMC10056372 DOI: 10.3390/jcm12062379] [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: 02/23/2023] [Revised: 03/09/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
In the last decade, novel oral anticoagulants (NOACs) have emerged as prominent therapeutic options in non-valvular atrial fibrillation (NVAF). We analysed the clinical burden and the switching rate between all available NOACs, and their dosage change over a period of 5 years in a representative population of patients with NVAF aged between 70 and 75 years. Methods and Results: This is a retrospective observational study on administrative databases, covering approximately 6.2 million health-assisted individuals by the Italian National Health System (around 11% of the entire Italian residents). Out of 4640 NVAF patients treated with NOACs and aged 70-75 years in 2017, 3772 (81.3%) patients were still in treatment with NOAC up to 2021 and among them, 3389 (73.0%) patients remained in treatment with the same NOAC during 2017-2021. In fact, 10.2% of patients switched NOAC type and 10.3% changed the dose of the same NOAC. Overall, after switching, the dabigatran and rivaroxaban groups lost, respectively, 13.5% and 2.8% of patients, while apixaban and edoxaban resulted in a relative percentage increase of 6.8% and 44.6% of patients, respectively. By a logistic regression analysis, the treatment with rivaroxaban, apixaban, and edoxaban (respect to dabigatran) was associated with a significant risk reduction of switch of 57%, 68%, and 44%, respectively. On the other hand, several features of high risk were associated with dose reduction. Conclusions. In our 5-year analysis of a large administrative database, a switching among NOACs or a change in NOAC dosages occurred in around 20% of elderly patients with NVAF. The type of NOAC was associated with a high switching rate, while several characteristics of high risk resulted as predictors of dose reduction of NOACs. Moreover, a worsening trend of clinical conditions occurred in patients maintaining the same NOAC treatment across 2017-2021.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic-Vascular Sciences, A.O. San Camillo-Forlanini, 00151 Rome, Italy
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo-Forlanini Circonvallazione Gianicolense, 87, 00152 Roma, Italy
- UniCamillus-Saint Camillus International, University of Health Sciences, 00131 Rome, Italy
| | - Melania Dovizio
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Diego Sangiorgi
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Valentina Perrone
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Luca Degli Esposti
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
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12
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Choi SH, Kim M, Kim H, Kim DH, Baek YS. Cardiovascular and renal protective effects of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation. PLoS One 2022; 17:e0275103. [PMID: 36227869 PMCID: PMC9560050 DOI: 10.1371/journal.pone.0275103] [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: 03/30/2022] [Accepted: 09/11/2022] [Indexed: 11/18/2022] Open
Abstract
Aim Data on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in relation to the risk of cardiovascular (CV) disease and renal protection among patients with atrial fibrillation (AF), are relatively sparse. We aimed to compare the effectiveness and safety of NOACs with those of warfarin for vascular protection in a large-scale, nationwide Asian population with AF. Methods and results Patients with AF who were prescribed oral anticoagulants according to the Korean Health Insurance Review and Assessment database between 2014 and 2017 were analyzed. The warfarin and NOAC groups were balanced using propensity score weighting. Clinical outcomes included ischemic stroke, myocardial infarction, angina pectoris, peripheral artery disease, chronic kidney disease (CKD), end-stage renal disease (ESRD), CV death, and all-cause death. NOAC use was associated with a lower risk of angina pectoris (HR, 0.79 [95% CI, 0.69–0.89] p<0.001), CKD stage 4 (HR, 0.5 [95% CI, 0.28–0.89], p = 0.02), and ESRD (HR, 0.15[95% CI, 0.08–0.32], p<0.001) than warfarin use. NOACs and warfarin did not significantly differ with respect to stroke reduction (HR, 1.05 [95% CI, 0.88–1.25], p = 0.19). NOAC use was associated with a lower risk of intracranial hemorrhage (HR, 0.6 [95% CI, 0.44–0.83], p = 0.0019), CV death (HR, 0.55 [95% CI, 0.43–0.70], p<0.001), and all-cause death (HR, 0.6 [95% CI, 0.52–0.69], p<0.001) than warfarin use. Conclusion NOACs were associated with a significantly lower risk of adverse CV and renovascular outcomes than warfarin in patients with AF.
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Affiliation(s)
- Seong Huan Choi
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
| | - Mina Kim
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Hoseob Kim
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Dae-Hyeok Kim
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
| | - Yong-Soo Baek
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
- * E-mail:
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13
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Grymonprez M, Capiau A, Steurbaut S, Mehuys E, Boussery K, De Backer TL, Lahousse L. Adherence and persistence to oral anticoagulants in patients with atrial fibrillation: A Belgian nationwide cohort study. Front Cardiovasc Med 2022; 9:994085. [PMID: 36247477 PMCID: PMC9558210 DOI: 10.3389/fcvm.2022.994085] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSince non-vitamin K antagonist oral anticoagulants (NOACs) do not require coagulation monitoring, concerns of lower adherence and persistence to NOACs than vitamin K antagonists (VKAs) have been raised. Moreover, little is known on the frequency of permanent cessation and switching between anticoagulants in patients with atrial fibrillation (AF). Therefore, persistence, reinitiation, switching and adherence to oral anticoagulants (OACs) were investigated.Materials and methodsAF patients with a first OAC prescription claim between 2013 and 2019 were identified in Belgian nationwide data. Persistence, reinitiation and switching were estimated using Kaplan-Meier analyses. Adherence was investigated using the proportion of days covered (PDC). Predictors for non-adherence and non-persistence were identified by multivariable logistic regression.ResultsAmong 277,782 AF patients, 69.6% NOAC and 37.2% VKA users were persistent after 1 year, whereas 44.3% and 18.9% after 5 years, respectively. After one year, 67.1% rivaroxaban, 68.1% dabigatran, 69.8% apixaban, and 76.9% edoxaban users were persistent. Among subjects having discontinued NOAC or VKA treatment, 75.4% and 46.1% reinitiated any OAC within 5 years, respectively. VKAs were more frequently switched to NOACs than vice versa (17.6% versus 2.5% after 1 year). After 1 year, a high PDC (≥ 90%) was observed in 87.8% apixaban, 88.6% dabigatran, 91.3% rivaroxaban, and 94.7% edoxaban users (90.2% NOAC users). Adherence and persistence were higher in older, female subjects, while lower in subjects with dementia or hyperpolypharmacy.ConclusionAdherence and persistence to NOACs were high. However, 10% of subjects were non-adherent after 1 year and one-fourth did not reinitiate anticoagulation within 5 years after NOAC discontinuation.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Center for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
- Department of Hospital Pharmacy, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- *Correspondence: Lies Lahousse,
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14
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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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15
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Vora P, Morgan Stewart H, Russell B, Asiimwe A, Brobert G. Time Trends and Treatment Pathways in Prescribing Individual Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: An Observational Study of More than Three Million Patients from Europe and the United States. Int J Clin Pract 2022; 2022:6707985. [PMID: 35685531 PMCID: PMC9159118 DOI: 10.1155/2022/6707985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Data directly comparing trends in the use of different oral anticoagulants (OACs) among patients with atrial fibrillation (AF) from different countries are limited. We addressed this using a large-scale network cohort study in the United States (US), Belgium, France, Germany, and the United Kingdom (UK). METHODS We used nine databases (claims or electronic health records) that had been converted into the Observational Medical Outcomes Partnership Common Data Model with analysis performed using open-source analytical tools. We identified adults with AF and a first OAC prescription, either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC), from 2010 to 2017. We described time trends in use, continuation, and switching. RESULTS In 2010, 87.5%-99.8% of patients started on a VKA. By 2017, the majority started on a DOAC: 87.0% (US), 88.3% (Belgium), 93.1% (France), 88.4% (Germany), and 86.1%-86.7% (UK). In the UK, DOACs became the most common starting OAC in 2015, 2-3 years later than elsewhere. Apixaban was the most common starting OAC by 2017, 50.2%-57.8% (US), 31.4% (Belgium), 45.9% (France), 39.5% (Germany), and 49.8%-50.5% (UK), followed by rivaroxaban, 24.8%-32.5% (US), 25.7% (Belgium), 38.4% (France), 24.9% (Germany), and 30.2%-31.2% (UK). Long-term treatment was less common in the US than in Europe, especially the UK. A minority of patients switched from their index OAC in the short and long term. CONCLUSIONS From 2010 to 2017, VKA use had significantly declined and DOAC use had significantly increased in the US and Europe. Apixaban was the most prescribed OAC in 2017, followed by rivaroxaban.
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16
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Zhao M, Hou CR, Xiong X, Post F, Herold N, Yu J. Safety and effectiveness of left atrial appendage closure in patients with non-valvular atrial fibrillation and prior major bleeding. Expert Rev Med Devices 2021; 18:1209-1217. [PMID: 34886730 DOI: 10.1080/17434440.2021.2011718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To investigate safety and effectiveness of left atrial appendage closure (LAAC) in atrial fibrillation patients with prior major bleeding. METHODS A total of 377 consecutive patients scheduled for LAAC with Watchman device were divided into bleeding group (n = 137) and non-bleeding group (n = 240). Data were compared between groups. RESULTS The bleeding group had more patients ≥75 years old (P = 0.044), higher CHA2DS2-VASc (P = 0.029) and HAS-BLED scores (P = 0.001) than the non-bleeding group. During the long-term follow-up, except for thromboembolism event (P = 0.031), the incidences of major bleeding , all-cause death , co-primary efficacy events , and the cumulative survival ratio after adjustment of confounding factors were comparable. The observed thromboembolism rate was reduced by 86.3% (P = 0.0002) and 55.1% (P = 0.0293) and the observed major bleeding rate was decreased by 61.9% (P = 0.0393) and 35.7% (P = 0.2426) compared with expected risks in bleeding and non-bleeding groups, respectively. The risk reduction in thromboembolism and major bleeding were significantly greater in bleeding group versus non-bleeding group (all P < 0.0001). CONCLUSIONS Among patients with prior bleeding, LAAC is a safe and effective alternative to anticoagulation therapy and seems to emerge as a higher efficacy in risk reduction of thromboembolism and major bleeding compared to those without prior bleeding.
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Affiliation(s)
- Mingzhong Zhao
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,Heart Center, Zhengzhou Ninth People's Hospital, Zhengzhou, China
| | - Cody R Hou
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - Xiaolin Xiong
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,The Faculty of Medicine, The Faculty of MedicineUniversity of Cologne, Cologne, Germany
| | - Felix Post
- Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Nora Herold
- Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Jiangtao Yu
- Department of Cardiology, Helmu t-G.-Walther-Klinikum, Lichtenfels, Germany.,Clinic for General Internal Medicine and Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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17
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Chimenti C, Lavalle C, Magnocavallo M, Alfarano M, Mariani MV, Bernardini F, Della Rocca DG, Galardo G, Severino P, Di Lullo L, Miraldi F, Fedele F, Frustaci A. A proposed strategy for anticoagulation therapy in noncompaction cardiomyopathy. ESC Heart Fail 2021; 9:241-250. [PMID: 34918480 PMCID: PMC8788052 DOI: 10.1002/ehf2.13694] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/19/2021] [Accepted: 10/25/2021] [Indexed: 12/23/2022] Open
Abstract
Noncompaction cardiomyopathy (NCCM) is a rare condition characterized by prominent trabeculae, deep intertrabecular recesses, and a left ventricular myocardium with a two‐layered structure, characterized by a spongy endocardial layer and a thinner and compacted epicardial one. NCCM can be isolated or associated with other congenital heart diseases and complex syndromes involving neuromuscular disorders and facial dysmorphisms. To date, more than 40 genes coding for sarcomeric, cytoskeletal, ion channels, and desmosomal proteins have been identified. Clinical presentation is also highly variable, ranging from no symptoms to end‐stage heart failure (HF), lethal arrhythmias, sudden cardiac death, or thromboembolic events. In particular, the prevalence of thromboembolism in NCCM patients appears to be higher than that of a similar, age‐matched population without NCCM. Thromboembolism has a multifactorial aetiology, which is linked to genetic, as well as traditional cardiovascular risk factors. In previous studies, atrial fibrillation (AF) was observed in approximately 25–30% of adult NCCM patients and embolism had a cardiac source in ~63–69% of cases; therefore, AF represents a strong predictor of adverse events, especially if associated to HF and neuromuscular disorders. Left ventricular dysfunction is another risk factor for thromboembolism, as a result of blood stagnation and local myocardial injury. Moreover, it is not completely clarified if the presence of deep intertrabecular recesses causing stagnant blood flow can constitute per se a thrombogenic substrate even in absence of ventricular dysfunction. For the clinical management of NCCM patients, an appropriate stratification of the thromboembolic risk is of utmost importance for a timely initiation of anticoagulant therapy. The aim of the present study is to review the available literature on NCCM with particular attention on thromboembolic risk stratification and prevention and the current evidence for oral anticoagulation therapy. The use of direct oral anticoagulants vs. vitamin K antagonists is also discussed with important implications for patient treatment and prognosis.
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Affiliation(s)
- Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.,Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Federico Bernardini
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | | | - Gioacchino Galardo
- Medical Emergency Unit, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Italy
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.,Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
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18
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Speed V, Auyeung V, Patel JP, Cooper D, Miller S, Roberts LN, Patel RK, Arya R. Adherence to rivaroxaban for the treatment of venous thromboembolism-Results from the FIRST registry. Res Pract Thromb Haemost 2021; 5:e12614. [PMID: 34849447 PMCID: PMC8606029 DOI: 10.1002/rth2.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Medication nonadherence can result in poor clinical outcomes and significant costs to health care providers. When treating venous thromboembolism (VTE), subtherapeutic anticoagulation may contribute to complications such as recurrent VTE or postthrombotic syndrome. OBJECTIVES To describe the extent, reasons for, and predictors of nonadherence to rivaroxaban for the treatment of VTE in clinical practice in the United Kingdom reported by participants of the FIRST registry. PATIENTS/METHODS The FIRST registry was an observational, multicenter registry reporting on the use of rivaroxaban in routine clinical practice. FIRST registry participants completed an adherence screening questionnaire during their treatment and follow-up. RESULTS In total, 1028 participants completed 1660 questionnaires over 2 years. One hundred thirteen of 1028 (11%) reported nonadherence at 28 days (interquartile range, 21-45). Reasons given for nonadherence at 1 month were forgetfulness (8.6% vs 74.7%; P < .001), carelessness (2.7% vs 27.3%; P < .001) or a change in routine (7.4% vs 25.5%; P < .001) reported by adherent and nonadherent participants, respectively. Older age (10-year increments) was the strongest predictor of good adherence (adjusted odds ratio, 1.21; 95% confidence interval, 1.06-1.39; 1 = adherent). CONCLUSIONS Overall adherence to rivaroxaban was high, and most nonadherence was unintentional. Identification of those at risk of nonadherence may reduce the risk of VTE recurrence and long-term complications.
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Affiliation(s)
- Victoria Speed
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | - Vivian Auyeung
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | - Jignesh P. Patel
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | | | | | - Lara N. Roberts
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Raj K. Patel
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Roopen Arya
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
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19
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Bah A, Nuotio I, Palomäki A, Mustonen P, Kiviniemi T, Ylitalo A, Hartikainen P, Airaksinen KEJ, Hartikainen JEK. Inadequate oral anticoagulation with warfarin in women with cerebrovascular event and history of atrial fibrillation: the FibStroke study. Ann Med 2021; 53:287-294. [PMID: 33475002 PMCID: PMC7877996 DOI: 10.1080/07853890.2021.1875499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/08/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Women with atrial fibrillation (AF) may be treated less actively with oral anticoagulation (OAC) than men. PATIENTS AND METHODS We assessed sex differences in the implementation of stroke risk stratification with CHADS2 and CHA2DS2-VASc scores and reasons not to use OAC in 1747 AF patients suffering their first cerebrovascular event after the AF diagnosis. RESULTS Women were older and had more often a high stroke risk (CHADS2/CHA2DS2-VASc ≥2) than men (p < .001). On admission, 46.4% of women and 48.2% of men were on OAC with no sex difference (p = .437). However, of patients without OAC, 74.4% of women and 49.5% of men should have been on OAC based on CHADS2/CHA2DS2-VASc ≥2 (p < .001). Conversely, 34.8% of men and 17.5% of women on OAC had a low or moderate risk (CHADS2/CHA2DS2-VASc 0-1, p < .001). A valid reason to omit OAC was reported in 38.6% of patients and less often in women (p < .001). CONCLUSIONS OAC was underused in high-risk AF patients, particularly women, but prescribed often in men with low or moderate stroke risk. Reasons for omitting OAC treatment were poorly reported, particularly for women. KEY MESSAGE Women were at higher stroke risk, but were less often treated with oral anticoagulation (OAC). Men were more often on OAC at low or moderate stroke risk. Reasons for omitting guideline based OAC were poorly reported, particularly for women.
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Affiliation(s)
- Aissa Bah
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ilpo Nuotio
- Department of Acute Internal Medicine, Turku University Hospital, Turku, Finland
| | - Antti Palomäki
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital, Jyväskylä, Finland
- Faculty of Information Technology, Jyväskylä University, Jyväskylä, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Antti Ylitalo
- Heart Center, Satakunta Central Hospital, Pori, Finland
| | | | | | - Juha E. K. Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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20
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Yang L, Guo J, Liang Q, Newman TV, Gellad WF, Hernandez I. Primary care provider payment models and adherence to anticoagulation in patients with atrial fibrillation. J Manag Care Spec Pharm 2021; 27:1672-1679. [PMID: 34818086 DOI: 10.18553/jmcp.2021.27.12.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Oral anticoagulation (OAC) is recommended for the prevention of stroke in atrial fibrillation (AF). However, only 50%-60% of AF patients in the United States are treated with OAC, and 60% of them adhere to OAC therapy over time. OBJECTIVES: To (1) compare adherent use of OAC between AF patients who received primary care from practices involved in shared-savings models and patients who received care from practices not involved in shared savings and (2) examine the trend of adherence to OAC over time. Because OAC can save downstream medical costs associated with averted stroke events, we hypothesized that OAC adherence would be higher among patients receiving care from practices involved in shared savings. METHODS: Using 2014-2019 claims data from a health insurer in western Pennsylvania, we identified 20,637 AF patients from 2015-2018. Patients were followed from the first AF diagnosis (index date) for 12 months or until disenrollment. We categorized patients according to the payment model of the practice from which they received primary care: shared savings (n = 8,844) and no shared savings (n = 11,793). The primary outcome was adherent use of OAC therapy, which was defined as having at least 80% of the followup period covered with OAC. Secondary outcomes included adherent use of direct oral anticoagulants (DOACs) and adherent use of warfarin. We constructed logistic regression models to assess the association between involvement in shared savings and adherent use of OAC, while controlling for demographics, clinical characteristics, and index year. RESULTS: 34% of patients in the shared-savings group adhered to OAC, compared with 32.7% in the no shared-savings group (P = 0.04). After adjustment, adherence was higher for the shared-savings group for OAC (adjusted odds ratio [aOR] = 1.07, 95% CI = 1.01-1.14) and warfarin (aOR = 1.11, 95% CI = 1.02-1.20) compared with the no shared-savings group. However, the odds of adherent use of DOACs did not statistically differ between shared savings and no shared savings (aOR = 0.99, 95% CI = 0.91-1.08). The odds of adherent OAC use increased over time: the aOR of adherent use of OAC was 1.21 (95% CI = 1.09-1.34) for index year 2016; 1.50 (95% CI = 1.36-1.67) for 2017; and 1.78 (95% CI 1.60-1.98) for 2018, all compared with 2015. CONCLUSIONS: Receipt of primary care from a practice involved in shared savings was associated with a higher adherent use of OAC and warfarin for patients with atrial fibrillation. Furthermore, adherent use of OAC improved over time for both treatment groups. Our research demonstrates that the alignment of financial incentives between providers and insurers may improve the use of therapies with downstream cost-saving potential. DISCLOSURES: This project was funded by the National Heart, Lung and Blood Institute (grant number K01HL142847). Hernandez has received consulting fees from Pfizer and BMS, outside of the submitted work. The other authors have nothing to disclose.
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Affiliation(s)
- Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville
| | | | - Terri V Newman
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA
| | - Walid F Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Inmaculada Hernandez
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego
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21
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Sabaté M, Vidal X, Ballarin E, Rottenkolber M, Schmiedl S, Grave B, Huerta C, Martin-Merino E, Montero D, Leon-Muñoz LM, Gasse C, Moore N, Droz C, Lassalle R, Aakjær M, Andersen M, De Bruin ML, Souverein P, Klungel OH, Gardarsdottir H, Ibáñez L. Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008-2015). Front Pharmacol 2021; 12:682890. [PMID: 34803665 PMCID: PMC8596153 DOI: 10.3389/fphar.2021.682890] [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: 03/19/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: To describe and compare the adherence to different direct oral anticoagulants (DOACs) in eight European databases representing six countries. Methods: Longitudinal drug utilization study of new users (≥18 years) of DOACs (dabigatran, rivaroxaban, apixaban) with a diagnosis of non-valvular atrial fibrillation (2008-2015). Adherence was examined by estimating persistence, switching, and discontinuation rates at 12 months. Primary non-adherence was estimated in BIFAP and SIDIAP databases. Results: The highest persistence rate was seen for apixaban in the CPRD database (81%) and the lowest for dabigatran in the Mondriaan database (22%). The switching rate for all DOACs ranged from 2.4 to 13.1% (Mondriaan and EGB databases, respectively). Dabigatran had the highest switching rate from 5.0 to 20.0% (Mondriaan and EGB databases, respectively). The discontinuation rate for all DOACs ranged from 16.0 to 63.9% (CPRD and Bavarian CD databases, respectively). Dabigatran had the highest rate of discontinuers, except in the Bavarian CD and AOK NORDWEST databases, ranging from 23.2 to 64.6% (CPRD and Mondriaan databases, respectively). Combined primary non-adherence for examined DOACs was 11.1% in BIFAP and 14.0% in SIDIAP. There were differences in population coverage and in the type of drug data source among the databases. Conclusion: Despite the differences in the characteristics of the databases and in demographic and baseline characteristics of the included population that could explain some of the observed discrepancies, we can observe a similar pattern throughout the databases. Apixaban was the DOAC with the highest persistence. Dabigatran had the highest proportion of discontinuers and switchers at 12 months in most databases (EMA/2015/27/PH).
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Affiliation(s)
- M Sabaté
- Fundació Institut Català de Farmacologia (FICF), Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - X Vidal
- Fundació Institut Català de Farmacologia (FICF), Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - E Ballarin
- Fundació Institut Català de Farmacologia (FICF), Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M Rottenkolber
- Diabetes Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - S Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - B Grave
- AOK NORDWEST, Dortmund, Germany
| | - C Huerta
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - E Martin-Merino
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - D Montero
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - L M Leon-Muñoz
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - C Gasse
- Aarhus University, Aarhus, Denmark
| | - N Moore
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - C Droz
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - R Lassalle
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - M Aakjær
- Pharmacovigilance Research Centre, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M Andersen
- Pharmacovigilance Research Centre, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M L De Bruin
- Copenhagen Centre for Regulatory Science (CORS), Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - P Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, Netherlands
| | - O H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, Netherlands.,Julius Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - H Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
| | - L Ibáñez
- Fundació Institut Català de Farmacologia (FICF), Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Barcelona, Spain
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22
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Cao B, Yao X, Zhang L, Hu X, Chen M, Shen M, Xu L. Efficacy and Safety of Direct Oral Anticoagulants in Patients with Diabetes and Nonvalvular Atrial Fibrillation: Meta-Analysis of Observational Studies. Cardiovasc Ther 2021; 2021:5520027. [PMID: 34729079 PMCID: PMC8523231 DOI: 10.1155/2021/5520027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND This meta-analysis was performed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for stroke prevention in real-world patients with diabetes and nonvalvular atrial fibrillation (NVAF) through observational studies. METHODS PubMed, Embase, and Web of Science databases were searched up to August 2020 for eligible studies. Outputs were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs) by using a random-effect model. RESULTS Seven observational studies involving 249,794 diabetic NVAF patients were selected. Compared with VKAs, the use of DOACs was associated with significantly reduced risks of stroke (RR = 0.56, 95% CI 0.45-0.70; p < 0.00001), ischemic stroke (RR = 0.61, 95% CI 0.48-0.78; p < 0.0001), stroke or systemic embolism (SSE) (RR = 0.81, 95% CI 0.68-0.95; p = 0.01), myocardial infarction (RR = 0.69, 95% CI 0.55-0.88; p = 0.002), major bleeding (RR = 0.75, 95% CI 0.63-0.90; p = 0.002), intracranial hemorrhage (RR = 0.50, 95% CI 0.44-0.56; p < 0.00001), and major gastrointestinal bleeding (RR = 0.77, 95% CI 0.62-0.95; p = 0.02), and a borderline significant decrease in major adverse cardiac events (RR = 0.87, 95% CI 0.75-1.00; p = 0.05) in NVAF patients with diabetes. CONCLUSION For patients with NVAF and diabetes in real-world clinical settings, DOACs showed superior efficacy and safety profile over VKAs and significantly reduced risks of stroke, ischemic stroke, SSE, myocardial infarction, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding.
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Affiliation(s)
- Bo Cao
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Xingcan Yao
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Lifang Zhang
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Xiaobo Hu
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Min Chen
- Department of Cardiovascular Medicine, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Mingfeng Shen
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
| | - Lan Xu
- Department of Clinical Pharmacy, Affiliated Ninth Hospital of Suzhou University, Suzhou, China
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23
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Pastori D, Menichelli D, Cammisotto V, Pignatelli P. Use of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Comparison of the International Guidelines. Front Cardiovasc Med 2021; 8:715878. [PMID: 34414220 PMCID: PMC8368436 DOI: 10.3389/fcvm.2021.715878] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022] Open
Abstract
Antiphospholipid antibody syndrome (APS) requires long-term anticoagulation to prevent recurrent thrombosis. Direct oral anticoagulants (DOACs) have been increasingly used in APS patients, but contradictory guidelines recommendations on their use do exist. We performed a systematic review of literature including studies investigating the role of DOACs in APS patients. At this aim, PubMed and Cochrane databases were searched according to PRISMA guidelines. We identified 14 studies which investigated the use of DOACs in patients with APS, of which 3 randomized clinical trials (RCTs), 1 post-hoc analysis of 3 RCTs, 7 case series and 3 cohort studies (2 prospective and 1 retrospective). Among DOACs, rivaroxaban was the most used (n = 531), followed by dabigatran (n = 90) and apixaban (n = 46). Regarding guidelines indications, the 2019 European Society of Cardiology (ESC) and American Society of Hematology (ASH) guidelines recommend against the use of DOACs in all APS patients. The European League Against Rheumatism (EULAR), British Society for Haematology (BSH), and International Society on Thrombosis and Haemostasis (ISTH) guidance provided more detailed indications stating that warfarin should be the first-choice treatment but DOACs may be considered in patients (1) already on a stable anticoagulation with a DOAC, (2) with low-quality anticoagulation by warfarin, (3) unwilling/unable to undergo INR monitoring, (4) with contraindications or serious adverse events under warfarin. Patients with arterial APS or triple positivity should be treated with warfarin while venous APS with single or double positivity may be candidate to DOACs, but high-quality studies are needed.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittoria Cammisotto
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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24
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Kefale AT, Peterson GM, Bezabhe WM, Bereznicki LR. Switching of oral anticoagulants in patients with non-valvular atrial fibrillation: A narrative review. Br J Clin Pharmacol 2021; 88:514-534. [PMID: 34350609 DOI: 10.1111/bcp.15021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022] Open
Abstract
Approval of direct-acting oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation (AF) was an important milestone, providing a wider range of treatment options and creating the possibility for drug switching after initiation. In addition to improved utilisation of oral anticoagulants (OACs) for stroke prevention, reports of switching among OACs are growing in the literature; switching may influence clinical outcomes, healthcare costs and patient satisfaction. This review aimed to summarise the current literature on the pattern of OAC switching in patients with AF, including reasons for switching and clinical consequences following switching. A literature search was conducted in PubMed, Scopus, and Embase on Jun 27, 2020. We included 39 articles published after 2013, following the introduction of apixaban. The review found that switching among OACs was common in clinical practice, significantly varying with the type of OAC. Studies reporting the reason for switching and clinical outcomes were comparatively limited. The decision to switch was often related to safety issues (usually bleeding), poor anticoagulation control and ease-of-use. Patient characteristics, clinical conditions and drug interactions were found to be associated with switching from OACs. Findings regarding bleeding outcomes following switching were inconsistent, possibly confounded by the rationale for switching and the switching protocol. Noting the limited number of studies included and their relatively short follow-up periods, switching did not have a significant impact on the risk of stroke and other thrombotic outcomes. Further prospective studies are needed to understand better potential rationales for switching and the clinical outcomes.
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Affiliation(s)
| | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Australia
| | | | - Luke R Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Australia
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25
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Rasmussen PV, Hylek E. Persistence with treatment in atrial fibrillation: still a pressing issue in the era of direct oral anticoagulants. Eur Heart J 2021; 42:4138-4140. [PMID: 34347053 DOI: 10.1093/eurheartj/ehab524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Peter Vibe Rasmussen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Elaine Hylek
- Department of Medicine, Boston University Medical Centre, Boston, MA, USA
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26
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021; 40:595-605. [PMID: 34392904 DOI: 10.1016/j.repce.2020.07.022] [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: 04/21/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.
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27
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Optimizing prognosis in atrial fibrillation: A call to action in Portugal. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Wu J, Alsaeed ES, Barrett J, Hall M, Cowan C, Gale CP. Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis. Europace 2021; 22:1311-1319. [PMID: 32778878 DOI: 10.1093/europace/euaa126] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF). METHODS AND RESULTS Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009-2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5-1.7%] to 2.4% (2.3-2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55-1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009-2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51-0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This 'OAC prescription gap' reduced over the study period (OR 0.93, 0.90-0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0-0.2%) in 2011 to 58.8% (58.4-59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke. CONCLUSION Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.
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Affiliation(s)
- Jianhua Wu
- School of Dentistry, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Eman S Alsaeed
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK
| | - James Barrett
- PRIMIS, Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Marlous Hall
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK
| | - Campbell Cowan
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK.,Department of Cardiology, Leeds General Infirmary, Leeds, UK
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29
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Kotalczyk A, Potpara TS, Lip GYH. How effective is pharmacotherapy for stroke and what more is needed? A focus on atrial fibrillation. Expert Opin Pharmacother 2021; 22:1807-1810. [PMID: 34148469 DOI: 10.1080/14656566.2021.1921738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland.,School of Medicine, University of Belgrade, Belgrade, Serbia.,Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Paquette M, Mbuagbaw L, Iorio A, Nieuwlaat R. Methodological considerations for investigating oral anticoagulation persistence in atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:251-260. [PMID: 32428195 PMCID: PMC8141301 DOI: 10.1093/ehjcvp/pvaa052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/20/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
AIMS Reports of long-term oral anticoagulant (OAC) therapy for atrial fibrillation (AF) reveal highly variable, and generally suboptimal estimates of medication persistence. The objective of this review is to summarize current literature and highlight important methodological considerations for interpreting persistence research and designing studies of persistence on OAC treatment. METHODS AND RESULTS We summarize differences in study methodology, setting, timing, treatment, and other factors associated with reports of better or worse persistence. For example, prospective compared with retrospective study designs are associated with higher reported persistence. Similarly, patient factors such as permanent AF or high stroke risk, and treatment with non-vitamin K oral antagonists relative to vitamin K antagonists are associated with higher persistence. Persistence has also been reported to be higher in Europe compared with North America and higher when the treating physician is a general practitioner compared with a specialist. We propose a framework for assessing and designing persistence studies. This framework includes aspects of patient selection, reliability and validity of measures, persistence definitions, clinical utility of measurements, follow-up periods, and analytic approaches. CONCLUSIONS Differences in study design, patient selection, treatments, and factors such as the countries/regions where studies are conducted or the type of treating physician may help explain the variability in OAC persistence estimates. A framework is proposed to assess persistence studies. This may have utility to compare and interpret published studies as well as for planning of future studies.
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Affiliation(s)
- Miney Paquette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Medicine, Boehringer Ingelheim Ltd, Burlington, ON L7L 5H4, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
- Centre for the Development of Best Practices in Health, Yaoundé, Cameroon
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
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Rahme E, Godin R, Nedjar H, Dasgupta K, Tagalakis V. Dose specific effectiveness and safety of DOACs in patients with non-valvular atrial fibrillation: A Canadian retrospective cohort study. Thromb Res 2021; 203:121-130. [PMID: 34000493 DOI: 10.1016/j.thromres.2021.05.005] [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: 01/27/2021] [Revised: 04/14/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been proven to be effective and safe for prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). However, suboptimal adherence, variable dosing and use in patient populations that otherwise would have been excluded from clinical trials may impact the efficacy and safety profile of DOACs in a routine care setting. We compared stroke, bleeding, and mortality rates on and off therapy for standard and low-dose DOACs (apixaban, rivaroxaban, dabigatran) versus warfarin in a Canadian cohort. We also assessed persistence of DOACs compared to warfarin. METHODS We conducted six 1-1 propensity-score matched retrospective cohort analyses using Quebec health administrative databases (2011-2017). NVAF patients (≥18 years) covered by the public medication insurance plan entered the cohort on the first OAC dispensation date. We excluded those with OAC use in the previous year or stroke or bleeding diagnoses in the previous two years. Follow-up ended at death, March 2017 or end of medication coverage by the public plan. Time-dependent Cox regression was applied. RESULTS We evaluated 10,893 patients initiated on apixaban (7206 standard, 3687 low-dose), 10,190 on rivaroxaban (7396 standard, 2794 low-dose), 5884 on dabigatran (2756 standard, 3128 low-dose), and propensity score-matched warfarin users. Across standard-dose DOACs, compared to warfarin, stroke risks were similar; bleeding risks were lower with apixaban (hazard ratio 0.63; 95% confidence interval 0.52-0.77) and dabigatran (0.47; 0.35-0.64) but not rivaroxaban (0.93; 0.79-1.10); death risks were lower with all DOACs. For low-dose DOACs, rivaroxaban demonstrated higher stroke (1.79; 1.21-2.64) and bleeding risks (1.37; 1.09-1.73); other agents had stroke risks similar to warfarin and bleeding risks lower than warfarin; only low-dose dabigatran had lower death risk (0.59; 0.52-0.68). Treatment discontinuation was lower with DOACs versus warfarin with the exception of low-dose rivaroxaban. The risks of stroke were 2-4 folds higher during time off any OAC versus time on warfarin. The risks of death were higher, while the risks of bleeding were generally lower during times off any OAC. CONCLUSIONS Standard-dose DOACs had similar stroke, better persistence and mortality profiles than warfarin. Only standard dose apixaban and dabigatran had better bleeding profiles than warfarin. Low-dose rivaroxaban had worse persistence, stroke and bleeding profiles than warfarin, while low-dose apixaban and dabigatran had similar stroke and better bleeding profiles. Real-world use of DOACs may explain some of the differences observed in Canadian routine care versus the phase III clinical trials.
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Affiliation(s)
- Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | | | - Hacene Nedjar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kaberi Dasgupta
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Vicky Tagalakis
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
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Freixa-Pamias R, Blanch Gràcia P, Rodríguez Latre ML, Basile L, Sanchez Chamero P, Gomez-Choco M, Armario P, Martínez-Rubio A, Lupón J. Impact of prescription patterns of antithrombotic treatment on atrial fibrillation-related ischemic stroke. Curr Med Res Opin 2021; 37:357-365. [PMID: 33326304 DOI: 10.1080/03007995.2020.1865892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze the temporal trends of atrial fibrillation (AF)-related ischemic stroke (IS) and their relationship with the prescription patterns of antithrombotic treatment from 2013 to 2019 in the Health Assistance Area of a regional hospital. METHODS First, a retrospective ecological study of aggregate data to analyze the annual incidence of IS between 2013 and 2019 was performed. Second, we selected those patients diagnosed with AF between 2013 and 2019 and performed a retrospective longitudinal study to assess the role of antithrombotic therapy in the development of AF-related IS. RESULTS During this period, whereas the annual incidence of IS remained stable (from 1.3 in 2013 to 1.2 cases per 1000 inhabitants in 2019; adjusted P for trend .829), the annual incidence of AF-related IS decreased over time (from 23.8 to 18.8 cases per 1000 inhabitants, respectively; adjusted P for trend .001). Among AF patients, the use of direct oral anticoagulants increased from 5.5% to 46.8%, while the prescription of antiplatelets and vitamin K antagonists decreased from 21.9% to 6.0% and from 63.8% to 36.1%, respectively. Overall, the use of oral anticoagulants increased from 69.3% to 82.9%; p < .001. Patients under antiplatelet agents had a higher probability of presenting IS than those patients taking oral anticoagulants, either vitamin K antagonists or direct oral anticoagulants (adjusted OR 1.89; 95% CI 1.52-2.37; p < .001). CONCLUSIONS The prescription of oral anticoagulants, particularly direct oral anticoagulants, has increased from 2013 to 2019 in our Health Assistance Area. This increase might partially explain the reduction in AF-related IS.
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Affiliation(s)
- Román Freixa-Pamias
- Department of Cardiology, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
- Coordinator of the Catalan Society of Cardiology & the Catalan Society of Family & Community Medicine (CAMFiC) Working Group for coordination between Cardiology & Primary Care, Barcelona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Pedro Blanch Gràcia
- Cardiology Service, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Maria Lluïsa Rodríguez Latre
- Methodology, Evaluation and Quality Care, Primary Care Service Baix Llobregat Centre, Institut Català de la Salut, Barcelona, Spain
| | - Luca Basile
- Cardiology Service, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
- Public Health Agency of Catalonia, Generalitat de Catalunya, Barcelona, Spain
| | - Pilar Sanchez Chamero
- Cardiology Service, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Manuel Gomez-Choco
- Neurology Service, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Pedro Armario
- Internal Medicine Service, Consorci Sanitari Integral, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Antoni Martínez-Rubio
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- Director of Cardiology of the University Hospital of Sabadell (Universitat Autònoma de Barcelona), Sabadell, Spain
| | - Josep Lupón
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- Heart Failure Clinic and Cardiology Service, Health Sciences Research Institute & University Hospital Germans Trias i Pujol, Badalona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
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Kotalczyk A, Gue YX, Potpara TS, Lip GYH. Current trends in the use of anticoagulant pharmacotherapy in the United Kingdom are changes on the horizon? Expert Opin Pharmacother 2021; 22:1061-1070. [PMID: 33491506 DOI: 10.1080/14656566.2021.1879050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Effective stroke prevention with oral anticoagulation (OAC) reduces the risk of stroke and death among patients with atrial fibrillation (AF). For most patients with AF, treatment options include vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOACs). NOACs have been introduced as an alternative to VKAs, and their use has been steadily increasing in the United Kingdom and Europe over a decade. In randomized clinical trials, NOACs had a favorable risk-benefit profile as compared to warfarin. However, there is a concern about their long-term safety in clinical practice, especially in high-risk patients. There have been a number of registries and surveys based on the real-world patients with AF which has been conducted and published, providing data on contemporary AF management. AREAS COVERED In this narrative review, the authors discuss current trends in the use of OAC in the United Kingdom and Europe, considering the potential directions for future anticoagulant therapy in patients with AF. EXPERT OPINION The increasing prevalence of AF and AF-related comorbidities proves the need for comprehensive prevention and management strategies. The challenge is the optimization of therapy for each patient. However, there are still gaps in optimal stroke prevention, and the mortality rates remain high in patients with AF.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland.,School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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Different Risk Profiles of European Patients Using Direct Oral Anticoagulants or Vitamin K Antagonists: a Rapid Review. CURR EPIDEMIOL REP 2020. [DOI: 10.1007/s40471-020-00257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Purpose of Review
We investigated the risk profiles of patients using direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) in European cohort studies to estimate the importance of potential (measured or unmeasured) confounding factors in analyses comparing these drugs. We searched MEDLINE and EMBASE (2008–2018) for relevant studies and extracted information on age, sex, comorbidity, Charlson comorbidity index, HAS-BLED score (assessing risk of bleeding) and CHA2DS2-VASc score (assessing risk of stroke).
Recent Findings
Overall, 66 studies with 2,808,757 patients were included. Most patients were from France (37%), Denmark (24%) and Germany (23%). In 56 studies (85%), the focus was on patients with atrial fibrillation. Of the 43 studies comparing DOAC with VKA users, 33% reported a higher and 16% a lower age of DOAC compared with VKA users. The mean age varied by about 1 year in most of these studies. Rivaroxaban was used in the widest age range. Patients with DOAC more often had a history of stroke or bleedings, and patients with VKA more often had a history of diabetes, renal failure, cancer, heart failure or other heart diseases. Most studies did not observe differences regarding the HAS-BLED score or the CHA2DS2-VASc score between groups.
Summary
Our review suggests that there are relevant differences in the risk profiles of DOAC versus VKA users and between users of individual DOACs. Reported HAS-BLED or CHA2DS2-VASc scores did not reflect these differences. These patterns require careful consideration in the interpretation of observational studies comparing the effectiveness and the risks of these drugs, also when comparing the results of studies conducted in different countries.
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Streb W, Mitręga K, Morawski S, Kowalska W, Kalarus Z. The Extended Utility of CHA 2DS 2VASc and HAS-BLED Scores in the Selection for Transcutaneous Left Atrial Appendage Closure. J Clin Med 2020; 9:E3438. [PMID: 33114743 PMCID: PMC7692802 DOI: 10.3390/jcm9113438] [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: 09/27/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Left atrial appendage closure (LAAC) is an option for stroke prevention in atrial fibrillation patients. Randomized studies have demonstrated the effectiveness and safety of LAAC but included patients with an average risk of stroke and bleeding complications. The current study aimed to assess the extended utility of CHA2DS2VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 75 years; and sex category) and HAS-BLED (hypertension; abnormal renal/liver function; stroke; bleeding history or predisposition; labile INR, elderly, drugs/alcohol concomitantly) scores for qualification and prognosis after LAAC. METHODS The study population comprised 270 patients aged 72.8 ± 8.78 years. The occluders used were the Amplatzer Amulet (N = 205), Amplatzer Cardiac Plug (N = 53), and Watchman device (N = 12). The prognosis after LAAC was analyzed for different cohorts of patients distinguished based on different CHA2DS2VASc and HAS-BLED scores. The mean duration of follow-up was 21.6 ± 10.3 months. RESULTS The observed rates of ischemic stroke and bleeding were much lower than that expected (2.2% vs. 5.6%, and 0.76% vs. 6.05%, respectively). The mortality rate did not differ concerning the CHA2DS2CVASc score. It was significantly lower (8.3%) for HAS-BLED < 3, and it raised to 17.9% for HAS-BLED = 3 and to 25.9% for HAS-BLED > 3. Significant differences (p = 0.003) occurred for Kaplan-Meier curves for extreme HAS-BLED subgroups. A composite endpoint was most often found in high/very high risk of bleeding patients. CONCLUSIONS HAS-BLED, but not CHA2DS2CVASc score, may be a useful tool to predict the prognosis of patients after LAAC. Qualification for LAAC based on the risk of stroke should not differ from qualification for anticoagulation. Despite the worse prognosis of patients with the highest bleeding risk, this group is likely to experience the greatest benefit from reducing the bleeding risk from LAAC.
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Affiliation(s)
- Witold Streb
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy SUM, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland; (K.M.); (S.M.); (W.K.); (Z.K.)
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Giner-Soriano M, Cortes J, Gomez-Lumbreras A, Prat-Vallverdú O, Quijada-Manuitt MA, Morros R. The use and adherence of oral anticoagulants in Primary Health Care in Catalunya, Spain: A real-world data cohort study. Aten Primaria 2020; 52:529-538. [PMID: 32788057 PMCID: PMC7505898 DOI: 10.1016/j.aprim.2020.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We aimed to describe sociodemographic, comorbidities, co-medication and risk of thromboembolic events and bleeding in patients with NVAF initiating oral anticoagulants (OAC) for stroke prevention, and to estimate adherence and persistence to OAC. SETTING Primary Health Care (PHC) in the Catalan Health Institute (ICS), Catalunya, Spain. PARTICIPANTS All NVAF adult patients initiating OAC for stroke prevention in August 2013-December 2015. METHODS Population-based cohort study. Persistence was measured in patients initiating OAC in August 2013-December 2014. DATA SOURCE SIDIAP, which captures electronic health records from PHC in the (ICS), covering approximately 5.8 million people. RESULTS 51,690 NVAF patients initiated OAC; 47,197 (91.3%) were naive to OAC and 32,404 (62.7%) initiated acenocoumarol. Mean age was 72.8 years (SD 12.3) and 49.4% were women. Platelet-aggregation inhibitors were taken by 9105 (17.6%) of the patients. Persistence and adherence were estimated up to the end of follow-up. For 22,075 patients, persistence was higher among the non-naive patients [n=258 (61.7%)] than among the naive [n=11,502 (53.1%)]. Adherence was estimated for patients initiating DOAC and it was similar in naive and non-naive patients. Among the naive to DOAC treatment, those starting rivaroxaban showed a highest proportion [(n=360 (80.1%)] of good adherence at implementation (MPR>80%) while patients starting dabigatran were less adherent [n=203 (47.8%)]. CONCLUSIONS Acenocoumarol was the most frequently prescribed OAC as first therapy in NVAF patients. Non-naive to DOAC showed better persistence than naive. Rivaroxaban showed higher proportion of adherent patients during the implementation phase than apixaban and dabigatran the lowest.
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Affiliation(s)
- Maria Giner-Soriano
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Institut Català de la Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Jordi Cortes
- Department d'Estadística i Investigació Operativa, Universitat Politècnica de Catalunya, Spain
| | - Ainhoa Gomez-Lumbreras
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Departament de Ciències Mèdiques, Facultat de Medicina, Universitat de Girona, Girona, Spain.
| | - Oriol Prat-Vallverdú
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Mª Angeles Quijada-Manuitt
- Department of Clinical Pharmacology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Pathology and Experimental Therapeutics, Unitat Docent Campus de Bellvitge, Universitat de Barcelona, L'Hospitalet (Barcelona), Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Institut Català de la Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, Spain; UICEC IDIAP Jordi Gol, Plataforma SCReN, Barcelona, Spain
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Persistence with Anticoagulation for Atrial Fibrillation: Report from the GLORIA-AF Phase III 1-Year Follow-up. J Clin Med 2020; 9:jcm9061969. [PMID: 32586056 PMCID: PMC7356563 DOI: 10.3390/jcm9061969] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 01/25/2023] Open
Abstract
Background: We aimed to assess the extent to which drug persistence is better with non-vitamin K antagonist oral anticoagulants (NOACs) than vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients and to estimate the difference in therapy persistence depending on NOAC dosing regimen (once daily (QD) vs. twice daily (BID)). Methods: Consecutive patients were followed for 1 year in phase III of the GLORIA-AF registry. Drug persistence was defined as the use of OAC without any discontinuation in >30 days or switching to alternative therapy. Results: Among 21,109 eligible patients in phase III, 17,266 patients who were prescribed OAC at baseline and those who took ≥1 OAC dose were included. The 1-year proportion of patients receiving NOAC and VKA who persisted on treatment was 80% and 75%, respectively. The 1-year persistence with NOACs BID and NOACs QD was 81% and 80%, respectively. Female gender, hypertension, older age, alcohol use, permanent, asymptomatic, and minimally symptomatic AF were associated with better OAC persistence. Region, medication usage predisposing to bleeding, being a current smoker, treatment reimbursement, and proton pump inhibitors were associated with lower OAC persistence. Conclusions: Drug persistence was higher with NOACs (1-year persistence was 80%) than with VKAs (75%). There was little difference in 1-year persistence between NOAC dosing regimens.
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Vitolo M, Lane DA, Boriani G, Lip GYH. The importance of adherence and persistence with oral anticoagulation treatment in patients with atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f81-f83. [PMID: 32324229 DOI: 10.1093/ehjcvp/pvaa020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - 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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40
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Birkinshaw A, Fry CH, Fluck D, Sharma P, Han TS. Changing trends in the use of novel oral anticoagulants and warfarin for treating non-valvular atrial fibrillation. JRSM Cardiovasc Dis 2020; 9:2048004020915406. [PMID: 32284860 PMCID: PMC7119231 DOI: 10.1177/2048004020915406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/06/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023] Open
Abstract
Background Prevention of thromboembolism by novel oral anticoagulants is increasing, whilst use of vitamin K antagonists is on the decline. We assessed changes in the use of these anticoagulants in treating non-valvular atrial fibrillation between 2014 and 2018. Methods One-hundred and sixty-two consecutive patients (95 men, 67 women) with non-valvular atrial fibrillation, mean age 72.3 years (standard deviation = 11.0), underwent cardiac assessment in a single cardiac unit. Use of anticoagulants at the time of investigation was documented: overall 83 (51.2%) patients were prescribed novel oral anticoagulants and 79 (48.8%) warfarin treatment. Trends in treatment rates with either anticoagulant class over time were characterised by calculating the average annual percentage change using a Joinpoint Regression Program 4.7.0.0. Results There were diverging trends in anticoagulant treatment from 2014 to 2018 without join points: yearly increase in novel oral anticoagulant treatment (41.9, 45.5, 53.7, 53.1 and 72.7%, average annual percentage change = 16.2%, 95% confidence interval = 5.8% to 27.5%, p < 0.001), and decrease in warfarin treatment (57.1, 54.5, 46.3, 46.9 and 27.3%, average annual percentage change = −14.4%, 95% confidence interval = −25.2% to −2.1%, p < 0.001). Conclusions Changing trends in treatment with anticoagulants for patients with non-valvular atrial fibrillation observed within less than two years provide important information to healthcare services to estimate future pharmaco-economic costs for such treatments.
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Affiliation(s)
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - David Fluck
- Department of Cardiology, Ashford & St Peter's Foundation Trust, Chertsey, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
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41
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Ozaki AF, Choi AS, Le QT, Ko DT, Han JK, Park SS, Jackevicius CA. Real-World Adherence and Persistence to Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes 2020; 13:e005969. [PMID: 32148102 DOI: 10.1161/circoutcomes.119.005969] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Stroke reduction with direct oral anticoagulants (DOACs) in atrial fibrillation (AF) is dependent on adherence and persistence in the real-world setting. Individual study estimates of DOAC adherence/persistence rates have been discordant. Our aims were to characterize real-world observational evidence for DOAC adherence/persistence and evaluate associated clinical outcomes in patients with AF. METHODS AND RESULTS PubMed, EMBASE, and CINAHL were searched from inception to June 2018. Observational studies that reported real-world DOAC adherence/persistence in patients with AF were included. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Outcomes included DOAC mean proportion of days covered or medication possession ratio, proportion of good adherence (proportion of days covered/medication possession ratio ≥80%), persistence, DOAC versus vitamin K antagonists persistence, and clinical outcomes associated with nonadherence/nonpersistence. Forty-eight observational studies with 594 784 unique patients with AF (59% male; mean age 71 years) were included. The overall pooled mean proportion of days covered/medication possession ratio was 77% (95% CI, 75%-80%), proportion of patients with good adherence was 66% (95% CI, 63%-70%), and proportion persistent was 69% (95% CI, 65%-72%). The pooled proportion of patients with good adherence was 71% (95% CI, 64%-78%) for apixaban, 60% (95% CI, 52%-68%) for dabigatran, and 70% (95% CI, 64%-75%) for rivaroxaban. Similar patterns were found for pooled persistence by agent. The pooled persistence was higher with DOACs than vitamin K antagonists (odds ratio, 1.44 [95% CI, 1.12-.86]). DOAC nonadherence was associated with an increased risk of stroke (hazard ratio, 1.39 [95% CI, 1.06-1.81]). CONCLUSIONS Suboptimal adherence and persistence to DOACs was common in patients with AF, with 1 in 3 patients adhering to their DOAC <80% of the time, which was associated with poor clinical outcomes in nonadherent patients. Although it is convenient that DOACs do not require laboratory monitoring, greater effort in monitoring for and interventions to prevent nonadherence may be necessary to optimize stroke prevention. Increased clinician awareness of DOAC nonadherence may help identify at-risk patients.
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Affiliation(s)
- Aya F Ozaki
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.).,Pharmacy Department (A.F.O., C.A.J.), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Austin S Choi
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.)
| | - Quan T Le
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.)
| | - Dennis T Ko
- ICES, Toronto, Canada (D.T.K., C.A.J.).,University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada (D.T.K., C.A.J.)
| | - Janet K Han
- Division of Cardiology (J.K.H., S.S.P.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,Division of Cardiology, University of California, Los Angeles, Los Angeles, CA (J.K.H., S.S.P.)
| | - Sandy S Park
- Division of Cardiology (J.K.H., S.S.P.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,Division of Cardiology, University of California, Los Angeles, Los Angeles, CA (J.K.H., S.S.P.)
| | - Cynthia A Jackevicius
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.).,Pharmacy Department (A.F.O., C.A.J.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,ICES, Toronto, Canada (D.T.K., C.A.J.).,University Health Network, Pharmacy Department, Toronto, Canada (C.A.J.).,University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada (D.T.K., C.A.J.)
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42
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Choosing antithrombotics for atrial fibrillation in primary care. Br J Gen Pract 2020; 70:102-103. [PMID: 32107215 DOI: 10.3399/bjgp20x708317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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43
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Paquette M, França LR, Teutsch C, Diener HC, Lu S, Dubner SJ, Ma CS, Rothman KJ, Zint K, Halperin JL, Olshansky B, Huisman MV, Lip GY, Nieuwlaat R. Dabigatran Persistence and Outcomes Following Discontinuation in Atrial Fibrillation Patients from the GLORIA-AF Registry. Am J Cardiol 2020; 125:383-391. [PMID: 31785775 DOI: 10.1016/j.amjcard.2019.10.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/27/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
Prospective studies evaluating persistence to nonvitamin K antagonist oral anticoagulants in patients with atrial fibrillation are needed to improve our understanding of drug discontinuation. The study objective was to evaluate if and when patients with newly diagnosed atrial fibrillation stop dabigatran treatment and to report outcomes following discontinuation. Patients prescribed dabigatran in diverse clinical practice settings were consecutively enrolled and followed for 2 years. Dabigatran persistence over time, reasons for discontinuation, and outcomes post discontinuation were assessed. Of 4,859 patients, aged 70.2 ± 10.4 years, 55.7% were male. Overall 2-year dabigatran persistence was 70.9% (95% confidence interval [CI] 69.6 to 72.2). Persistence probability was lower in the first 6-month period (83.7% [82.7 to 84.8]) than in subsequent periods for patients on dabigatran at the start of each period (6 to 12 months, 92.5% [91.6 to 93.3]; 12 to 18 months, 95.1% [94.3 to 95.8]; 18 to 24 months, 96.3% [95.6 to 96.9]). Of 1,305 patients (26.9%) who discontinued dabigatran, adverse events were reported as the reason for discontinuation in 457 (35.0%). Standardized stroke incidence rate post discontinuation (per 100 patient-years) in patients discontinuing without switching to another oral anticoagulant was 1.76 (95% CI 0.89 to 2.76) and 1.02 (95% CI 0.43 to 1.76) in those who switched, consistent with the expected benefit of remaining on treatment. Patients persistent with treatment at 1 year had >90% probability of remaining persistent at 2 years suggesting clinical interventions to improve persistence should be focused on the early period following treatment initiation.
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Olimpieri P, Di Lenarda A, Mammarella F, Gozzo L, Cirilli A, Cuomo M, Gulizia M, Colivicchi F, Murri G, Gabrielli D, Trotta F. Non-vitamin K antagonist oral anticoagulation agents in patients with atrial fibrillation: Insights from Italian monitoring registries. IJC HEART & VASCULATURE 2020; 26:100465. [PMID: 32021902 PMCID: PMC6994529 DOI: 10.1016/j.ijcha.2019.100465] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/12/2019] [Accepted: 12/25/2019] [Indexed: 12/20/2022]
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with an increased risk of stroke and thromboembolism. Anticoagulation with Vitamin K antagonists (VKAs) or with novel oral anti-coagulants (NOACs) represents the cornerstone of the pharmacological treatment to reduce the risk of thromboembolism. This study aims to provide real-world data from a whole large European country about NOAC use in "non-valvular atrial fibrillation" (NVAF). Methods We analysed the Italian Medicines Agency (AIFA) monitoring registries collecting data of a nationwide cohort of patients with "NVAF" treated with NOACs. Using logistic regression analysis, baseline characteristics and treatment discontinuation information were compared among initiators of the 4 NOACs. Results In the reference period, the NOAC database collected data for 683,172 patients. The median age was 78 years with 19.5% aged 85 or older. Overall, the treatments were in accordance with guidelines. About 1/3 of patients switched from a prior VKA treatment; in the 72.3% of cases, these patients had a labile International Normalized Ratio (INR) at first prescription. The most prescribed NOAC was rivaroxaban, followed by apixaban, dabigatran and edoxaban. Conclusions This study is the largest European real-world study ever published on NOACs. It includes all Italian patients treated with NOACs since 2013 accounting for about 1/3 of subjects with AF. The enrolled population consisted of very elderly patients, at high risk of ischemic adverse events. The AIFA registries are consolidated tools that guarantee the appropriateness of prescription and provide important information for the governance of National Health System by collecting real-world data.
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Affiliation(s)
| | - A. Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
- Corresponding authors.
| | - F. Mammarella
- Agenzia Italiana del Farmaco, Rome, Italy
- Corresponding authors.
| | - L. Gozzo
- Agenzia Italiana del Farmaco, Rome, Italy
| | - A. Cirilli
- Agenzia Italiana del Farmaco, Rome, Italy
| | - M. Cuomo
- Agenzia Italiana del Farmaco, Rome, Italy
| | - M.M. Gulizia
- Cardiology Division, High Specialization Hospital “Garibaldi” of Catania, Italy
| | - F. Colivicchi
- Cardiology Division San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - G. Murri
- Cardiology Division San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - D. Gabrielli
- Cardiology Division, Hospital “Murri”, Fermo, Italy
| | - F. Trotta
- Agenzia Italiana del Farmaco, Rome, Italy
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45
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Martinez C, Wallenhorst C, Rietbrock S, Freedman B. Ischemic Stroke and Transient Ischemic Attack Risk Following Vitamin K Antagonist Cessation in Newly Diagnosed Atrial Fibrillation: A Cohort Study. J Am Heart Assoc 2020; 9:e014376. [PMID: 31937194 PMCID: PMC7033838 DOI: 10.1161/jaha.119.014376] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background In nonvalvular atrial fibrillation (AF), oral anticoagulants prevent ischemic strokes and transient ischemic attacks (TIAs), but nonpersistence with vitamin K antagonist (VKA) oral anticoagulant therapy (20-50% at 1 year) is problematic. The precise risk of stroke/TIA after VKA cessation and its time course during extended follow-up is unknown. Methods and Results The study cohort of incident AF in patients receiving initial VKA between 2001 and 2013 was identified from the UK Clinical Practice Research Datalink (linked hospitalizations and causes of death). Using a nested case-control analysis, patients with incident stroke/TIA were matched to patients without stroke/TIA (controls). Relative risk with time since VKA cessation compared with current VKA use was approximated from conditional logistic regression. We studied 16 696 patients with incident AF and initial VKA treatment. There were 489 stroke/TIA cases matched to 2137 controls (mean CHA2DS2-VASc score 4.3). Compared with current VKA use, the excess incidence rate of stroke/TIA following VKA cessation in the first year after AF diagnosis was 2.29 (95% CI, 0.98-3.90) per 100 person-years of VKA cessation or 1 additional stroke/TIA per 43 patients per year discontinuing VKA, compared with 1.43 (95% CI, 0.97-1.88) per 100 person-years corresponding to 1 additional stroke/TIA per 70 patients per year, when VKA was discontinued more than 1 year after AF diagnosis. Conclusions VKA cessation is associated with a continuous excess thromboembolic stroke/TIA risk. Increasing oral anticoagulant persistence, especially in the year after AF diagnosis, should be a therapeutic target to reduce stroke/TIA in AF.
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Affiliation(s)
- Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | | | - Stephan Rietbrock
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | - Ben Freedman
- Heart Research InstituteCharles Perkins CentreUniversity of SydneyAustralia
- Department of Cardiology and Anzac Research InstituteConcord HospitalSydneyAustralia
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46
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Zielinski GD, van Rein N, Teichert M, Klok FA, Rosendaal FR, van der Meer FJM, Huisman MV, Cannegieter SC, Lijfering WM. Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study. Res Pract Thromb Haemost 2020; 4:141-153. [PMID: 31989096 PMCID: PMC6971315 DOI: 10.1002/rth2.12261] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In contrast to vitamin K antagonists (VKA), direct oral anticoagulants (DOAC's) are not strictly monitored and dose titrated by anticoagulation clinics in the Netherlands. This may affect drug persistence of atrial fibrillation (AF) patients, whom often require lifelong treatment. OBJECTIVES To assess persistence of DOACs and of VKAs in patients with AF. METHODS Dispensing data from the Dutch Foundation of Pharmaceutical Statistics were used to monitor persistence of AF patients to DOAC from 1 January 2012-1 April 2016. In addition, we estimated the persistence of AF patients to VKA between 1 January 2004 and 1 January 2012 in data from the Anticoagulation Clinic Leiden. Non-persistence was defined as the cumulative incidence of patients who completely stopped DOAC, switched to another oral anticoagulant or stopped their VKA. RESULTS DOAC users (n = 77 333) were younger than VKA users (n = 10 079; 70 vs 73 years). Non-Persistence to DOAC (ie stopping with any oral anticoagulant) was 34% at 1 and 64% at 4 years, compared to 22% at one and 36% at 4 years for VKA. Approximately a Twenty-five percent of those who had stopped their initial DOAC switched to another anticoagulant (VKA or another DOAC). Multivariable analyses revealed that young age, female sex, no concomitant drug use and non-adherence were predictors for non-persistence of DOAC. CONCLUSIONS Persistence to DOAC was low and in line with other observational studies, and higher for VKA. Our results show a clear correlation between age <60 years and worse persistence, as well as with female and non-adherence to DOAC.
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Affiliation(s)
- Gilda Denise Zielinski
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | | | - Menno V. Huisman
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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47
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Perreault S, Denus S, White‐Guay B, Côté R, Schnitzer ME, Dubé M, Dorais M, Tardif J. Oral Anticoagulant Prescription Trends, Profile Use, and Determinants of Adherence in Patients with Atrial Fibrillation. Pharmacotherapy 2019; 40:40-54. [DOI: 10.1002/phar.2350] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
| | - Simon Denus
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
- Montreal Heart Institute Montreal Quebec Canada
| | - Brian White‐Guay
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | | | - Marie‐Pierre Dubé
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | - Marc Dorais
- StatSciences Inc. Notre‐Dame‐de‐l’Île‐Perrot Quebec Canada
| | - Jean‐Claude Tardif
- Montreal Heart Institute Montreal Quebec Canada
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
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48
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1283] [Impact Index Per Article: 256.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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49
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Ruigómez A, Vora P, Balabanova Y, Brobert G, Roberts L, Fatoba S, Fernandez O, García Rodríguez LA. Discontinuation of non-Vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: a population-based cohort study using primary care data from The Health Improvement Network in the UK. BMJ Open 2019; 9:e031342. [PMID: 31630107 PMCID: PMC6803078 DOI: 10.1136/bmjopen-2019-031342] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine discontinuation rates, patterns of use and predictors of discontinuation of non-vitamin K antagonist oral anticoagulants (NOACs) among patients with non-valvular atrial fibrillation (NVAF) in the first year of therapy. DESIGN Population-based cohort study. SETTING UK primary care. POPULATION 11 481 patients with NVAF and a first prescription (index date) for apixaban, dabigatran or rivaroxaban (January 2012 to December 2016) with at least 1 year of follow-up and at least one further NOAC prescription in the year following the index date were identified. 1 year rates and patterns of discontinuation were described. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures were the percentage of patients who, in the first year from starting NOAC therapy, discontinued with their oral anticoagulant (OAC) therapy (discontinuation was defined as a gap in OAC therapy of >30 days); switched OAC within 30 days; discontinued and reinitiated OAC therapy. Predictors of discontinuation were also evaluated. RESULTS 1 year discontinuation rates according to the index NOAC were 26.1% for apixaban, 40.0% for dabigatran and 29.6% for rivaroxaban. Reinitiation rates were 18.1% for apixaban, 21.7% for dabigatran and 17.3% for rivaroxaban, and switching rates were 2.8% for apixaban, 8.8% for dabigatran and 4.9% for rivaroxaban. More than 93% of reinitiations were with the index NOAC. Patients starting on dabigatran were more likely to switch OAC therapy than those starting on apixaban; ORs 4.28 (95% CI 3.24 to 5.65) for dabigatran and 1.89 (95% CI 1.49 to 2.39) for rivaroxaban. Severely reduced renal function was a predictor of any discontinuation, OR 1.77 (95% CI 1.28 to 2.44). CONCLUSION While the majority of patients with NVAF in the UK initiating NOAC treatment received continuous therapy in the first year of treatment, a substantial proportion of patients experienced gaps in treatment leaving them less protected against thromboembolism during these periods.
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Affiliation(s)
- Ana Ruigómez
- Pharmacoepidemiology, Spanish Centre for Pharmacoepidemiological Research, Madrid, Spain
| | | | | | | | | | | | - Oscar Fernandez
- Pharmacoepidemiology, Spanish Centre for Pharmacoepidemiological Research, Madrid, Spain
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50
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Orchard J, Lowres N, Neubeck L, Freedman B. Atrial fibrillation: is there enough evidence to recommend opportunistic or systematic screening? Int J Epidemiol 2019; 47:1372-1378. [PMID: 29931278 DOI: 10.1093/ije/dyy111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/25/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jessica Orchard
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Nicole Lowres
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Heart Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Ben Freedman
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Heart Research Institute, University of Sydney, Sydney, NSW, Australia
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