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Barra ME, Forman R, Long-Fazio B, Merkler AE, Gurol ME, Izzy S, Sharma R. Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves. J Am Heart Assoc 2024; 13:e032094. [PMID: 38761076 PMCID: PMC11179836 DOI: 10.1161/jaha.123.032094] [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: 11/23/2023] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. METHODS AND RESULTS We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). CONCLUSIONS In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy Massachusetts General Hospital Boston MA
| | | | | | | | - M E Gurol
- Department of Neurology Massachusetts General Hospital Boston MA
| | - Saef Izzy
- Department of Neurology Brigham Women Hospital Boston MA
| | - Richa Sharma
- Department of Neurology Yale Medicine New Haven CT
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Hajra A, Ujjawal A, Ghalib N, Chowdhury S, Biswas S, Balasubramanian P, Gupta R, Aronow WS. Expanding Indications of Nonvitamin K Oral Anticoagulants Beyond Nonvalvular Atrial Fibrillation and Venous Thromboembolism: A Review of Emerging Clinical Evidence. Curr Probl Cardiol 2024; 49:102017. [PMID: 37544618 DOI: 10.1016/j.cpcardiol.2023.102017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Direct oral anticoagulants (DOAC) have emerged as a new therapy for patients who need and can tolerate oral anticoagulation. DOACs were initially approved for nonvalvular atrial fibrillation (NVAF) and treatment for deep vein thrombosis (DVT) and pulmonary embolism (PE). Ease of administration, no requirement of bridging with other anticoagulants, and less frequent dosing have made DOACs preferable choice for anticoagulation. Studies are showing promising results regarding use of DOACs beyond the common indications. Studies have been done to show the potential benefit of DOACs in valvular atrial fibrillation, heart failure, acute coronary syndrome, stroke, and peripheral arterial disease. Data have shown safety as well as comparable bleeding incidences with DOACs compared to vitamin K antagonist anticoagulants. Naturally interest is growing to see the use of DOACs apart from the NVAF, DVT, or PE. Authors have highlighted various study results to show the potential beneficial role of DOACs in the above-mentioned situations.
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Affiliation(s)
- Adrija Hajra
- Brigham and Women's Hospital/Harvard Medical School, Boston, MA.
| | | | - Natasha Ghalib
- Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | | | - Suman Biswas
- Calcutta National Medical College, Kolkata, West Bengal, India
| | | | | | - Wilbert S Aronow
- New York Medical College at Westchester Medical Center, New York, NY
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Suppah M, Kamal A, Saadoun R, Baradeiya AMA, Abraham B, Alsidawi S, Sorajja D, Fortuin FD, Arsanjani R. An Evidence-Based Approach to Anticoagulation Therapy Comparing Direct Oral Anticoagulants and Vitamin K Antagonists in Patients With Atrial Fibrillation and Bioprosthetic Valves: A Systematic Review, Meta-Analysis, and Network Meta-Analysis. Am J Cardiol 2023; 206:132-150. [PMID: 37703679 DOI: 10.1016/j.amjcard.2023.07.141] [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: 05/03/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 09/15/2023]
Abstract
Direct oral anticoagulants (DOACs) are a newer class of anticoagulants that inhibit factor Xa or factor IIa and include drugs such as rivaroxaban, apixaban, edoxaban, betrixaban, and dabigatran. Although vitamin K antagonists (VKAs) have been traditionally used to prevent thromboembolic events, DOACs have gained popularity because of their faster onset and offset of action and reduced need for monitoring. This study aimed to provide more data for anticoagulants in patients with atrial fibrillation with bioprosthetic heart valves by incorporating all available trials to date. A search was performed across 5 electronic databases to identify relevant studies. We analyzed the data using a pooled risk ratio for categorical outcomes and used the I2 test to determine heterogeneity. The quality of randomized controlled trials was assessed using the Cochrane risk of bias assessment tool, and the National Institutes of Health tool was used for observational studies. Our study included a frequentist network meta-analysis (MA) of the aggregate data to obtain the network estimates for the outcomes of interest. We retrieved 28 studies with a total of 74,660 patients with bioprosthetic heart valves. Our MA significantly showed that DOACs decrease the risk of all-cause bleeding (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.75 to 0.85, p >0.00001), stroke and systemic embolization (RR 0.89, 95% CI 0.80 to 0.99, p = 0.03), and intracranial bleeding outcomes (RR 0.62, 95% CI 0.45 to 0.86, p = 0.004) compared with VKA. In contrast, there was no significant difference between the compared groups in major bleeding (RR = 0.92, 95% CI 0.84 to 1.02, p = 0.10) and all-cause mortality outcomes (RR = 0.96, 95% CI 0.85 to 1.07, p = 0.43), respectively. In addition, the network MA results did not favor any of the studied interventions over each other (p <0.05) regarding all-cause bleeding, mortality, stroke and systemic embolization, and major bleeding outcomes. In conclusion, our study found that DOACs are more effective in reducing the risk of bleeding, stroke, systemic embolism, and intracranial bleeding than VKAs. However, no significant difference was observed in the incidence of gastrointestinal bleeding, major bleeding, thromboembolic events, and all-cause mortality. In addition, our network MA did not identify any specific DOAC treatment as more favorable than others.
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Affiliation(s)
- Mustafa Suppah
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Abdallah Kamal
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Rakan Saadoun
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Bishoy Abraham
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Said Alsidawi
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dan Sorajja
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - F David Fortuin
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Reza Arsanjani
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
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4
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Khatib R, Glowacki N, Colavecchia C, Mills JR, Glosner S, Cato M, Brady P. Associations between clinical and social factors and anticoagulant prescription among patients with atrial fibrillation: A retrospective cohort study from a large healthcare system. PLoS One 2023; 18:e0289708. [PMID: 37561772 PMCID: PMC10414629 DOI: 10.1371/journal.pone.0289708] [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] [Received: 02/22/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Patient clinical factors and social determinants of health (SDOH) are associated with an increased risk of stroke for patients with atrial fibrillation (AF); however, the association between these factors and the management of AF is not well characterized, particularly among those factors commonly collected in electronic health records (EHRs). This study used EHR data to evaluate the associations between patient clinical factors and SDOH and prescribing of an oral anticoagulant (OAC) for stroke prevention in AF. METHODS This analysis included adult patients with newly diagnosed AF who had ≥2 encounters in the Advocate Aurora Health system in Wisconsin between May 2016 and May 2021. Patient-level demographics, comorbidities, medications, and SDOH were retrospectively extracted from EHRs. Area deprivation index (ADI) was linked to patient records as a measure of socioeconomic status. RESULTS Of 16,656 patients with AF, 10,898 (65.4%) were prescribed an OAC within the first year of diagnosis. Patients were less likely to be prescribed an OAC (relative risk [95% CI]) if they were widowed (0.98 [0.96-0.99] vs single) or had a history of alcoholism (0.86 [0.79-0.95] vs no history). Most patients (53.3%) received prescriptions from a primary care provider. A linear relationship was found between worsening ADI and increased prescriptions for warfarin vs those for direct-acting OACs. CONCLUSIONS Although guideline-concordant anticoagulant use remained suboptimal, clinical characteristics were strongly associated for whether a patient with AF would be prescribed an OAC. Disparities in patient care regarding the prescribing of OACs due to SDOH and associated behaviors were small but present, particularly for national ADI.
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Affiliation(s)
- Rasha Khatib
- Advocate Aurora Research Institute, Downers Grove, IL, United States of America
| | - Nicole Glowacki
- Advocate Aurora Research Institute, Downers Grove, IL, United States of America
| | | | - J. Rebecca Mills
- Pfizer Inc, US Medical Affairs, New York, NY, United States of America
| | - Scott Glosner
- Pfizer Inc, US Medical Affairs, New York, NY, United States of America
| | - Matthew Cato
- Pfizer Inc, US Medical Affairs, New York, NY, United States of America
| | - Peter Brady
- Advocate Illinois Masonic Medical Center, Chicago, IL, United States of America
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5
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Galliazzo S, Pelitti V, Campiotti L, Poli D, Squizzato A. Direct oral anticoagulants in patients with a left-sided bioprosthetic heart valve: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:535-547. [PMID: 36746889 DOI: 10.1007/s11739-023-03208-9] [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: 10/14/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023]
Abstract
To compare the efficacy/effectiveness and safety of DOACs versus VKAs in patients with a previously and newly surgically implanted BHV with or without AF. A systematic search on MEDLINE and EMBASE was performed till November 2022. Treatment effects were estimated with relative risk (RR) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed with the I2 statistic. Four randomized controlled trials (RCTs), 2 subgroup analysis from ARISTOTLE and ENGAGE-AF-TIMI 48 and 4 observational studies were included for a total of 5808 patients, 1893 on DOACs and 3915 on VKAs. AF prevalence was 98.28%. In the overall analysis, DOACs vs VKAs were associated with a RR for stroke/transient ischemic attack (TIA)/systemic embolism (SE) of 0.63 (95% CI 0.51-0.79; I2 = 0%) and a RR of major bleeding of 0.50 (95% CI 0.39-0.63; I2 = 0%) in a median follow-up of 19 months (IQR 4.5-33.4). In the 3 RCTs (DAWA, RIVER, ENAVLE), DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.38 (95% CI 0.13-1.58, I2 = 0%) and of 0.68 (95% CI 0.32-1.44; I2 = 5%) respectively. In patients randomized during the first three months from valve surgery, DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.54 (95% CI 0.14-2.08; I2 = 0%) and of 0.76 (95% CI 0.05-10.72; I2 = 66%). In previously implanted BHV patients with AF, DOACs showed a risk-benefit profile at least comparable to VKAs. DOACs showed a similar, even if underpowered, risk-benefit profile during the first three months after BHV implantation prevalently in patients with AF.
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Affiliation(s)
- Silvia Galliazzo
- Internal Medicine, Ospedale San Valentino-AULSS 2 Marca Trevigiana, Via Palmiro Togliatti, 1, 31044, Montebelluna, Treviso, Italy.
| | - Valentina Pelitti
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | - Leonardo Campiotti
- Department of Medicine and Surgery, ASST Settelaghi, University of Insubria, Varese, Italy
| | - Daniela Poli
- Thrombosis Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandro Squizzato
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
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Lan B, Cheng G, Bai Y, Du Y, Xie X, Ma Y, Zeng H, He L, Xie H, He X, Song Q, Zhang Y. Efficacy and Safety of Left Atrial Appendage Occlusion in Mild Mitral Stenosis Patients with High Bleeding Risk. Int Heart J 2022; 63:492-497. [DOI: 10.1536/ihj.21-644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Beidi Lan
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Gesheng Cheng
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Yuan Bai
- Department of Cardiology, Changhai Hospital of the Navy Military Medical University
| | - Yajuan Du
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Xuegang Xie
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Yuying Ma
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Haowei Zeng
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Lu He
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Hang Xie
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Xumei He
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Qiang Song
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
| | - Yushun Zhang
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University
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7
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Gong X, He Q, Yan J, Chen J, Chen X, Huang M, Li J, Chen P. A drug utilization study of oral anticoagulants in five representative cities of China between 2015 and 2019. J Clin Pharm Ther 2021; 47:38-45. [PMID: 34592785 DOI: 10.1111/jcpt.13538] [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: 07/28/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Oral anticoagulants (OACs), including warfarin and newer direct-acting OACs (DOACs), have been used for decades to prevent thromboembolic diseases. A drug utilization study was performed to determine the prescribing patterns of OACs. METHODS Data were extracted from the Cooperation Project of Hospital Prescription Analysis in China. A total of 455,490 prescription records from 43 tertiary hospitals in five cities of China (Beijing, Shanghai, Guangzhou, Hangzhou and Chengdu) were selected for inclusion. Quarterly trends of defined daily doses (DDDs) and defined daily dose cost (DDDC) from 1 January 2015 to 31 December 2019 were calculated. RESULTS AND DISCUSSION Warfarin was the most widely used OAC with DDDs between 189,982 and 176,323 from the first quarter (Q1) of 2015 to the fourth quarter (Q4) of 2019, whereas the use of DOACs increased rapidly during this period. DDDs of rivaroxaban increased from 5409 in Q1 of 2015 to 125,800 in Q4 of 2019, whereas the DDDC declined from 160.5 to 45.7. From Q1 of 2018, rivaroxaban became the most prescribed OAC, surpassing warfarin, in patients diagnosed with deep vein thrombosis. In addition, the DDDs of rivaroxaban exceeded those of warfarin in patients diagnosed with non-valvular atrial fibrillation since the second quarter (Q2) of 2019. DDDs in outpatients and inpatients increased by 80.6% and 71.4%, respectively, and the DDDC for outpatients in Q4 of 2019 was 6.7-fold higher than that in Q1 of 2015. Among patients of all ages, the DDDs in elderly patients increased from 36.8% in Q1 of 2015 to 59.4% in Q4 of 2019. Moreover, the departments of cardiology and cardiothoracic surgery prescribed the majority of the OACs. WHAT IS NEW AND CONCLUSION In this study, we describe OAC prescription patterns in China. DOACs, especially rivaroxaban, contribute to the continuous increase in the use of OACs. In the investigated population of China, outpatients and elderly patients were observed to be administered the highest proportion of DOACs.
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Affiliation(s)
- Xiaojiao Gong
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Institute of clinical pharmacology, School of Pharmaceutical sciences, Sun Yat-sen University, Guangzhou, China
| | - Qiuyi He
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiajia Yan
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Institute of clinical pharmacology, School of Pharmaceutical sciences, Sun Yat-sen University, Guangzhou, China
| | - Jingjie Li
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pan Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Dawwas GK, Dietrich E, Cuker A, Barnes GD, Leonard CE, Lewis JD. Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation : A Population-Based Cohort Study. Ann Intern Med 2021; 174:910-919. [PMID: 33780291 DOI: 10.7326/m20-6194] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used in place of warfarin, but evidence about their effectiveness and safety in patients with valvular atrial fibrillation (AF) remains limited. OBJECTIVE To assess the effectiveness and safety of DOACs compared with warfarin in patients with valvular AF. DESIGN New-user retrospective propensity score-matched cohort study. SETTING U.S.-based commercial health care database from 1 January 2010 to 30 June 2019. PARTICIPANTS Adults with valvular AF who were newly prescribed DOACs or warfarin. MEASUREMENTS The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding. RESULTS Among a total of 56 336 patients with valvular AF matched on propensity score, use of DOACs (vs. warfarin) was associated with lower risk for ischemic stroke or systemic embolism (hazard ratio [HR], 0.64 [95% CI, 0.59 to 0.70]) and major bleeding events (HR, 0.67 [CI, 0.63 to 0.72]). The results for the effectiveness and safety outcomes remained consistent for apixaban (HRs, 0.54 [CI, 0.47 to 0.61] and 0.52 [CI, 0.47 to 0.57], respectively) and rivaroxaban (HRs, 0.74 [CI, 0.64 to 0.86] and 0.87 [CI, 0.79 to 0.96], respectively); with dabigatran, results were consistent for the major bleeding outcome (HR, 0.81 [CI, 0.68 to 0.97]) but not for effectiveness (HR, 1.03 [CI, 0.81 to 1.31]). LIMITATION Relatively short follow-up; inability to ascertain disease severity. CONCLUSION In this comparative effectiveness study using practice-based claims data, patients with valvular AF who were new users of DOACs had lower risks for ischemic stroke or systemic embolism and major bleeding than new users of warfarin. These data may be used to guide risk-benefit discussions regarding anticoagulant choices for patients with valvular AF. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ghadeer K Dawwas
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
| | - Eric Dietrich
- College of Pharmacy, University of Florida, Gainesville, Florida (E.D.)
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.C.)
| | | | - Charles E Leonard
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
| | - James D Lewis
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.)
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Chong DT, Andreotti F, Verhamme P, Dalal J, Uaprasert N, Wang CC, On YK, Li YH, Jiang J, Hasegawa K, Almuti K, Bai R, Lo ST, Krittayaphong R, Lee LH, Quek DK, Johar S, Seow SC, Hammett CJ, Tan JW. Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management. Eur Cardiol 2021; 16:e23. [PMID: 34135993 PMCID: PMC8201470 DOI: 10.15420/ecr.2020.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022] Open
Abstract
The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.
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Affiliation(s)
| | | | | | | | - Noppacharn Uaprasert
- Chulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok, Thailand
| | - Chun-Chieh Wang
- Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine Taoyuan City, Taiwan
| | - Young Keun On
- Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul, South Korea
| | - Yi-Heng Li
- National Cheng King University Hospital Taiwan
| | - Jun Jiang
- Second Affiliated Hospital Zhejiang University School of Medicine Zhejiang, China
| | - Koji Hasegawa
- Translational Research, National Hospital Organization Kyoto Medical Center Kyoto, Japan
| | | | - Rong Bai
- Beijing Anzhen Hospital, Capital Medical University Beijing, China
| | | | | | | | | | | | | | | | - Jack Wc Tan
- National Heart Centre Singapore.,Singapore General Hospital Singapore.,Sengkang General Hospital Singapore
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10
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Adhikari G, Baral N, Rauniyar R, Karki S, Abdelazeem B, Savarapu P, Isa S, Khan HMW, Khan MR, Changezi HU. Systematic Review and Meta-Analysis: Can We Compare Direct Oral Anticoagulants to Warfarin in Patients With Atrial Fibrillation and Bio-Prosthetic Valves? Cureus 2021; 13:e14651. [PMID: 34046282 PMCID: PMC8141356 DOI: 10.7759/cureus.14651] [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] [Indexed: 11/30/2022] Open
Abstract
Background There are no clear consensus guidelines on the indications and types of anticoagulation therapies in patients with bio-prosthetic valves either with concomitant atrial fibrillation (AF) or sinus rhythm. In our meta-analysis, we assessed the safety and efficacy of DOACs as compared to the standard treatment with warfarin in patients with AF and bioprosthetic valves. Methods We included randomized controlled trials (RCTs), cohort studies in the English language, and studies reporting patients with valvular heart disease that included bioprosthetic valvular disease. A systematic literature review using Embase, PubMed, and Web of Science was performed using the terms “Direct Acting Oral Anticoagulant,” “Oral Anticoagulants,” “Non-Vitamin K Antagonist Oral Anticoagulant,” “Atrial Fibrillation,” “Bioprosthetic Valve” for literature published prior to January 2021. Extraction of data from included studies was carried out independently by three reviewers from Covidence. We assessed the methodical rigor of the included studies using the modified Downs and Black checklist. Results Four RCTs and one observational study (n=1776) were included in our study. A random-effect model using RevMan (version 5.4; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for data analysis. The pooled data showed that there was a non-significant reduction in the incidence of stroke and systemic embolism in the patients taking DOACs as compared to warfarin (HR 0.69; 95% CI, 0.29, 1.67; I2 = 50%). The incidence of major bleeding was lower in the DOACs group; the difference was statistically significant (HR 0.42; 95% CI, 0.26, 0.67; I2 = 7%). The difference was not statistically significant for all-cause mortality in both groups (HR 1.24; 95% CI, 0.91, 1.67; I2 = 0%). Conclusion Our results showed that there was no difference in the outcomes of stroke and systemic embolism between DOACs and warfarin but there were statistically significantly lower major bleeding events. We conclude that larger clinical trials are needed to assess the true safety and efficacy of DOACs in patients with AF and bioprosthetic valves.
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Affiliation(s)
| | | | | | | | | | | | - Sakiru Isa
- Internal Medicine, McLaren Flint, Flint, USA
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11
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Nathan AS, Yang L, Geng Z, Dayoub EJ, Khatana SAM, Fiorilli PN, Herrmann HC, Szeto WY, Atluri P, Acker MA, Desai ND, Frankel DS, Marchlinski FE, Fanaroff AC, Giri J, Groeneveld PW. Oral anticoagulant use in patients with atrial fibrillation and mitral valve repair. Am Heart J 2021; 232:1-9. [PMID: 33214129 DOI: 10.1016/j.ahj.2020.10.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/15/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) who have undergone mitral valve repair are at risk for thromboembolic strokes. Prior to 2019, only vitamin K antagonists were recommended for patients with AF who had undergone mitral valve repair despite the introduction of direct oral anticoagulants (DOAC) in 2010. OBJECTIVE To characterize the use of anticoagulants in patients with AF who underwent surgical mitral valve repair (sMVR) or transcatheter mitral valve repair (tMVR). METHODS We performed a retrospective cohort analysis of patients with AF undergoing sMVR or tMVR between 04/2014 and 12/2018 using Optum's de-identified Clinformatics® Data Mart Database. We identified anticoagulants prescribed within 90 days of discharge from hospitalization. RESULTS Overall, 1997 patients with AF underwent valve repair: 1560 underwent sMVR, and 437 underwent tMVR. The mean CHA2DS2-VASc score among all patients was 4.1 (SD 1.9). The overall use of anticoagulation was unchanged between 2014 (72.2%) and 2018 (70.0%) (P = .49). Among patients who underwent sMVR or tMVR between April 2014 and December 2018, the use of VKA therapy decreased from 62.9% to 32.1% (P < .01 for trend) and the use of DOACs increased from 12.4% to 37.3% (P < .01 for trend). CONCLUSIONS Among patients with AF who underwent sMVR or tMVR between 2014 and 2018, roughly 30% of patients were not treated with any anticoagulant within 90 days of discharge, despite an elevated stroke risk in the cohort. The rate of DOAC use increased steadily over the study period but did not significantly increase the rate of overall anticoagulant use in this high-risk cohort.
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Affiliation(s)
- Ashwin S Nathan
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA.
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
| | - Zhi Geng
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
| | - Elias J Dayoub
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Sameed Ahmed M Khatana
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
| | - Paul N Fiorilli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Howard C Herrmann
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wilson Y Szeto
- Division of Cardiac Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Pavan Atluri
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nimesh D Desai
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA; Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David S Frankel
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alexander C Fanaroff
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
| | - Peter W Groeneveld
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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12
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Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, Tarasoutchi F, Paixão M, Hoffmann-Filho CR, Patriota R, Leiria TLL, Lamprea D, Precoma DB, Atik FA, Silveira FS, Farias FR, Barreto DO, Almeida AP, Zilli AC, de Souza Neto JD, Cavalcante MA, Figueira FAMS, Junior RA, Moisés VA, Mesas CE, Ardito RV, Kalil PSA, Paiva MSMO, Maldonado JGA, de Lima CEB, D'Oliveira Vieira R, Laranjeira L, Kojima F, Damiani L, Nakagawa RH, Dos Santos JRY, Sampaio BS, Campos VB, Saraiva JFK, Fonseca FH, Pinto IM, Magalhães CC, Ferreira JFM, Lopes RD, Pavanello R, Cavalcanti AB, Berwanger O. A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial. Am Heart J 2021; 231:128-136. [PMID: 33045224 DOI: 10.1016/j.ahj.2020.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Abstract
The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain. DESIGN: RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20 mg once daily (15 mg in those with creatinine clearance <50 mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12 months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism. SUMMARY: RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.
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Affiliation(s)
- Helio P Guimarães
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo-SP, Brazil.
| | | | | | | | | | - Milena Paixão
- Incor - Instituto do Coração do HCFMUSP, São Paulo, Brazil
| | | | - Rodrigo Patriota
- Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho, Brazil
| | - Tiago L L Leiria
- Instituto de Cardiologia do Rio Grande do Sul (FUC), Porto Alegre, Brazil
| | | | - Dalton B Precoma
- Sociedade Hospitalar Angelina Caron, Campina Grande do Sul, Brazil
| | - Fernando A Atik
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | | | | | | | - Adail P Almeida
- Unidade Médico Cirúrgica - Unimec, Vitória da Conquista, Brazil
| | | | | | | | | | - Roque A Junior
- HUPES-Hospital Universitário Prof Edgard Santos, Salvador, Brazil
| | | | - Cezar E Mesas
- Hospital de Universidade Estadual de Londrina, Londrina, Brazil
| | - Roberto V Ardito
- IMC - Instituto de Moléstias Cardiovasculares, São José do Rio Preto, Brazil
| | | | | | - Jaime G A Maldonado
- Serviço de Eletrofisiologia e Marca-Passo do Hospital Universitário Francisca Mendes (HUFM)-Manaus, Brazil
| | | | | | | | - Flávia Kojima
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | - Lucas Damiani
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Bruna S Sampaio
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | | | - Jose F K Saraiva
- Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Francisco H Fonseca
- UNIFESP, São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Ibraim M Pinto
- Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Carlos C Magalhães
- Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Joao F M Ferreira
- Incor - Instituto do Coração do HCFMUSP, São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | | | - Ricardo Pavanello
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | | | - Otavio Berwanger
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo-SP, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
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13
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Saxena A, Relan J. Authors' reply. Ann Pediatr Cardiol 2020; 13:376-377. [PMID: 33311936 PMCID: PMC7727901 DOI: 10.4103/apc.apc_174_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India. E-mail:
| | - Jay Relan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India. E-mail:
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14
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Dietz N, Ruff C, Giugliano RP, Mercuri MF, Antman EM. Pharmacogenetic-guided and clinical warfarin dosing algorithm assessments with bleeding outcomes risk-stratified by genetic and covariate subgroups. Int J Cardiol 2020; 317:159-166. [DOI: 10.1016/j.ijcard.2020.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
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15
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Moores M, Yogendrakumar V, Bereznyakova O, Alesefir W, Thavorn K, Pettem H, Stotts G, Dowlatshahi D, Shamy M. Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke. Neurohospitalist 2020; 11:12-17. [PMID: 33868551 DOI: 10.1177/1941874420946513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose It is unclear whether it is clinically necessary or cost-effective to routinely obtain a transthoracic echocardiogram (TTE) during inpatient admission for ischemic stroke. Methods We assessed consecutive patients presenting with acute ischemic stroke at a comprehensive stroke center from 2015 to 2017 who underwent TTE. We assessed for findings on TTE that would warrant urgent intervention including cardiac thrombus, atrial myxoma, mitral stenosis, valve vegetation, valve dysfunction requiring surgery, and low ejection fraction. Subsequent changes in management included changes in anticoagulation, antibiotics, or valve surgery. We calculated in-hospital resource utilization and associated costs for inpatient TTE using individual direct cost details within a case-costing system. Results Of 695 patients admitted with acute ischemic stroke, 516 (74%) had a TTE and were included in our analysis. TTE findings were potentially clinically significant in 30 patients (5.8%) and changed management in 17 patients (3.3%). Inpatient admission was prolonged to expedite TTE in 24 patients, while TTE occurred after discharge in 76 patients. After correcting for the cost of TTE, the mean difference in cost to prolong an admission for TTE was $555.52 (USD), or $16 832 per change in management. Conclusions Given the low clinical utility of inpatient TTE after acute ischemic stroke and the costs associated with prolonging admission, discharge from hospital should not be delayed solely to obtain TTE.
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Affiliation(s)
- Margaret Moores
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Vignan Yogendrakumar
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Olena Bereznyakova
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Walid Alesefir
- Department of Neurology, CHUM (Centre hospitalier de l'Université de Montréal), Montreal, Quebec, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Hailey Pettem
- Champlain Regional Stroke Network, Ottawa, Ontario, Canada
| | - Grant Stotts
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Shamy
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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16
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Dangas GD, De Backer O, Windecker S. A Controlled Trial of Rivaroxaban after Transcatheter Aortic-Valve Replacement. Reply. N Engl J Med 2020; 383:e8. [PMID: 32640145 DOI: 10.1056/nejmc2017351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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17
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Del Brutto VJ, Chaturvedi S, Diener HC, Romano JG, Sacco RL. Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel. J Am Coll Cardiol 2020; 74:786-803. [PMID: 31395130 DOI: 10.1016/j.jacc.2019.06.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023]
Abstract
Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jose G Romano
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
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18
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Nguyen MT, Gallagher C, Pitman BM, Emami M, Kadhim K, Hendriks JM, Middeldorp ME, Roberts-Thomson KC, Mahajan R, Lau DH, Sanders P, Wong CX. Quality of Warfarin Anticoagulation in Indigenous and Non-Indigenous Australians With Atrial Fibrillation. Heart Lung Circ 2020; 29:1122-1128. [PMID: 31980393 DOI: 10.1016/j.hlc.2019.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/20/2019] [Accepted: 11/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies have shown that suboptimal anticoagulation quality, as measured by time in therapeutic range (TTR), affects a significant percentage of patients with atrial fibrillation (AF). However, TTR has not been previously characterised in Indigenous Australians who experience a greater burden of AF and stroke. METHOD Indigenous and non-Indigenous Australians with AF on warfarin anticoagulation therapy were identified from a large tertiary referral centre between 1999 and 2012. Time in therapeutic range was calculated as a proportion of daily international normalised ratio (INR) values between 2 and 3 for non-valvular AF and 2.5 to 3.5 for valvular AF. INR values between tests were imputed using the Rosendaal technique. Linear regression models were employed to characterise predictors of TTR. RESULTS Five hundred and twelve (512) patients with AF on warfarin were included (88 Indigenous and 424 non-Indigenous). Despite younger age (51±13 vs 71±12 years, p<0.001), Indigenous Australians had greater valvular heart disease, diabetes, and alcohol excess compared to non-Indigenous Australians (p<0.05 for all). Time in therapeutic range was significantly lower in Indigenous compared to non-Indigenous Australians (40±29 vs 50±31%, p=0.006). Univariate predictors of poorer TTR included Indigenous ethnicity, younger age, diuretic use, and comorbidities, such as valvular heart disease, heart failure and chronic obstructive pulmonary disease (p<0.05 for all). Valvular heart disease remained a significant predictor of poorer TTR in multivariate analyses (p=0.004). CONCLUSION Indigenous Australians experience particularly poor warfarin anticoagulation quality. Our data also suggest that many non-Indigenous Australians spend suboptimal time in therapeutic range. These findings reinforce the importance of monitoring warfarin anticoagulation quality to minimise stroke risk.
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Affiliation(s)
- Mau T Nguyen
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bradley M Pitman
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kadhim Kadhim
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia.
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19
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Abstract
Direct oral anticoagulants (DOACs) have been developed as a viable and in some cases superior alternative to warfarin. These agents have overcome some of the limitations of warfarin, which has a narrow therapeutic window and many food and drug interactions. DOACs have been demonstrated to have a more predictable and reliable pharmacology and, unlike warfarin, do not require frequent monitoring of anticoagulant effect. For these reasons, the use of DOACs is increasing. Despite the many positive attributes of these agents, limitations and contraindications do exist. An understanding of the pharmacology, indications, and contraindications is therefore crucial for effective patient management. We review the available agents to aid in effective drug utilization.
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20
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Wang K, Liu Y, Huang S, Li H, Hou J, Huang J, Chen J, Feng K, Liang M, Chen G, Wu Z. Does an imbalance in circulating vascular endothelial growth factors (VEGFs) cause atrial fibrillation in patients with valvular heart disease? J Thorac Dis 2019; 11:5509-5516. [PMID: 32030270 DOI: 10.21037/jtd.2019.11.32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background The pathogenesis of atrial fibrillation (AF) remains unclear. Vascular endothelial growth factors (VEGFs) can stimulate fibrosis within the atrium and ventricle. We hypothesized that there is a relationship between the serum VEGFs/soluble vascular endothelial growth factor receptor (sVEGFRs) levels and AF in patients with valvular heart disease (VHD). This provides a new paradigm for studying AF. Methods The plasma levels of VEGF-A, VEGF-C, sVEGFR-1 and sVEGFR-2 were detected by enzyme-linked immunosorbent assay (ELISA). A total of 100 people, consisting of AF patients (long-standing, persistent AF; n=49), sinus rhythm (SR) patients (n=31) and healthy controls (n=20), were included in this study. Results The plasma levels of VEGF-A were significantly higher in AF patients compared to healthy control (P<0.05). The plasma levels of sVEGFR-1 were significantly higher in AF compared to SR (P<0.05). The plasma levels of sVEGFR-2 were significantly lower in AF patients compared to SR patients and healthy controls (both P<0.05). There was a significant and negative correlation between AF and the sVEGFR-2 levels in the groups (r=-0.432, P=0.000). Conclusions An imbalance in VEGFs and sVEGFRs may contribute to AF by breaking the balance of angiogenesis and lymphangiogenesis. Additionally, sVEGFR-2 may be an important biomarker of AF.
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Affiliation(s)
- Keke Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.,Department of Emergency, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yanyan Liu
- Department of Pathology, The First Affiliated Hospital of Traditional Medicine University, Guangzhou 510405, China
| | - Suiqing Huang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.,Key Laboratory of Assisted Circulation, Ministry of Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Huayang Li
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jian Hou
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.,Key Laboratory of Assisted Circulation, Ministry of Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Jiaxing Huang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jiantao Chen
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Kangni Feng
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Mengya Liang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Guangxian Chen
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.,Key Laboratory of Assisted Circulation, Ministry of Health, Sun Yat-sen University, Guangzhou 510080, China
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January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Heart Rhythm 2019; 16:e66-e93. [DOI: 10.1016/j.hrthm.2019.01.024] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Indexed: 02/08/2023]
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22
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January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125-e151. [DOI: 10.1161/cir.0000000000000665] [Citation(s) in RCA: 1256] [Impact Index Per Article: 251.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | - Hugh Calkins
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Lin Y. Chen
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Joaquin E. Cigarroa
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Joseph C. Cleveland
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Patrick T. Ellinor
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Michael D. Ezekowitz
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Michael E. Field
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Karen L. Furie
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Paul A. Heidenreich
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Katherine T. Murray
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Julie B. Shea
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Cynthia M. Tracy
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
| | - Clyde W. Yancy
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †HRS Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §STS Representative. ‖ACC/AHA Representative. ¶ACC/AHA Task Force on Performance Measures Representative
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Chang WT, Ho CH, Chang CL, Cheng BC, Wu NC, Chen ZC. Influence of warfarin on cardiac and cerebrovascular events following bioprosthetic aortic valve replacement: A nationwide cohort study. J Thorac Cardiovasc Surg 2019; 159:1730-1739.e1. [PMID: 31208804 DOI: 10.1016/j.jtcvs.2019.04.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/13/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The need for anticoagulation treatment following bioprosthetic aortic valve replacement remains controversial. We investigated the associations of warfarin treatment with the risks of major adverse cardiac and cerebrovascular events, including mortality, bleeding incidents, and reoperation requirement after bioprosthetic aortic valve replacement surgery. METHODS We identified 1086 patients who received first bioprosthetic aortic valve replacement between 2001 and 2010 using Taiwan's National Health Insurance Database. Patients were excluded for prior use of warfarin, warfarin use for >3 months, dual valve procedures, prior valve surgeries, or concomitant surgeries. Enrolled patients were divided into 2 groups according to whether they were warfarin-naïve or received warfarin for <3 months postsurgery. After propensity score matching, 282 patients not receiving warfarin were matched to 282 patients receiving warfarin for <3 months. Patients were followed-up for minimum 36 months. RESULTS Patients receiving warfarin were younger and showed less frequent kidney disease than those who did not use warfarin. The warfarin group demonstrated a gross decrease in major adverse cardiac and cerebrovascular events. Patients receiving warfarin for <30 days were at an even lower risk for major adverse cardiac and cerebrovascular events than those treated for ≥30 days. No significant difference in bleeding or reoperation risk was observed between warfarin users and warfarin nonusers. Similar findings remained after propensity-score matching but the benefit of short-term warfarin use diminished in a younger population. CONCLUSIONS Short-term use of postoperative warfarin (especially <30 days) following bioprosthetic aortic valve replacement may be associated with a reduction in MACCE compared with nonuse.
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Affiliation(s)
- Wei-Ting Chang
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Chia-Li Chang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Bor-Chih Cheng
- Department of Cardiovascular Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Nan-Chun Wu
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan; Department of Cardiovascular Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan; Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan.
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2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74:104-132. [PMID: 30703431 DOI: 10.1016/j.jacc.2019.01.011] [Citation(s) in RCA: 1269] [Impact Index Per Article: 253.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Antiplatelet Drugs in the Management of Venous Thromboembolism, Cardioembolism, Ventricular Assist Devices, and Pregnancy Complications. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
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Effects of a reminder to initiate oral anticoagulation in patients with atrial fibrillation/atrial flutter discharged from the emergency department: REMINDER study. CAN J EMERG MED 2018; 20:841-849. [DOI: 10.1017/cem.2018.415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CLINICIAN’S CAPSULEWhat is known about the topic?Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation or flutter; however, initiation rates in patients discharged from the ED are low.What did this study ask?Can a simple quality improvement intervention increase the initiation of appropriate OAC in the ED?What did this study find?The rate of OAC initiation was increased by 8.5%.Why does this study matter to clinicians?This simple intervention is transferrable and therefore can improve patient care.
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Tavares LC, Duarte NE, Marcatto LR, Soares RAG, Krieger JE, Pereira AC, Santos PCJL. Impact of incorporating ABCB1 and CYP4F2 polymorphisms in a pharmacogenetics-guided warfarin dosing algorithm for the Brazilian population. Eur J Clin Pharmacol 2018; 74:1555-1566. [PMID: 30051215 DOI: 10.1007/s00228-018-2528-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Interpatient variation of warfarin dose requirements may be explained by genetic variations and general and clinical factors. In this scenario, diverse population-calibrated dosing algorithms, which incorporate the main warfarin dosing influencers, have been widely proposed for predicting supposed warfarin maintenance dose, in order to prevent and reduce adverse events. The aim of the present study was to evaluate the impact of the inclusion of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms as additional covariates in a previously developed pharmacogenetic-based warfarin dosing algorithm calibrated for the Brazilian population. METHODS Two independent cohorts of patients treated with warfarin (n = 832 and n = 133) were included for derivation and replication of the algorithm, respectively. Genotyping of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms was performed by polymerase chain reaction followed by melting curve analysis and TaqMan® assay, respectively. A multiple linear regression was performed for the warfarin stable doses as a dependent variable, considering clinical, general, and genetic data as covariates. RESULTS The inclusion of ABCB1 and CYP4F2 polymorphisms was able to improve the algorithm's coefficient of determination (R2) by 2.6%. In addition, the partial determination coefficients of these variants revealed that they explained 3.6% of the warfarin dose variability. We also observed a marginal improvement of the linear correlation between observed and predicted doses (from 59.7 to 61.4%). CONCLUSION Although our study indicates that the contribution of the combined ABCB1 and CYP4F2 genotypes in explaining the overall variability in warfarin dose is not very large, we demonstrated that these pharmacogenomic data are statistically significant. However, the clinical relevance and cost-effective impact of incorporating additional variants in warfarin dosing algorithms should be carefully evaluated.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nubia E Duarte
- Department of Mathematic and Statistics, Universidad Nacional de Colombia, Manizales, Caldas, Colombia
| | - Leiliane R Marcatto
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Renata A G Soares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Jose E Krieger
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Paulo Caleb Junior Lima Santos
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil.
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo UNIFESP, São Paulo, SP, Brazil.
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Alperi A, Hernandez-Vaquero D, Pascual I, Diaz R, Silva I, Alvarez-Cabo R, Avanzas P, Moris C. Aortic valve replacement in young patients: should the biological prosthesis be recommended over the mechanical? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:183. [PMID: 29951505 DOI: 10.21037/atm.2018.02.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alberto Alperi
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Isaac Pascual
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rocio Diaz
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Iria Silva
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Pablo Avanzas
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Cesar Moris
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
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Wang NC, Sather MD, Hussain A, Althouse AD, Adelstein EC, Jain SK, Katz WE, Shalaby AA, Voigt AH, Saba S. Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta‐analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:767-774. [DOI: 10.1111/pace.13368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/20/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Norman C. Wang
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Matthew D. Sather
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Aliza Hussain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew D. Althouse
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Evan C. Adelstein
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sandeep K. Jain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - William E. Katz
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alaa A. Shalaby
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew H. Voigt
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Samir Saba
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
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Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular. Med Clin (Barc) 2018; 150 Suppl 1:8-24. [DOI: 10.1016/s0025-7753(18)30666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Tavares LC, Marcatto LR, Santos PCJL. Genotype-guided warfarin therapy: current status. Pharmacogenomics 2018; 19:667-685. [PMID: 29701078 DOI: 10.2217/pgs-2017-0207] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Warfarin pharmacogenomics has been an extensively studied field in the last decades as it is focused on personalized therapy to overcome the wide interpatient warfarin response variability and decrease the risk of side effects. In this expert review, besides briefly summarizing the current knowledge about warfarin pharmacogenetics, we also present an overview of recent studies that aimed to assess the efficacy, safety and economic issues related to genotype-based dosing algorithms used to guide warfarin therapy, including randomized and controlled clinical trials, meta-analyses and cost-effectiveness studies. To date, the findings still present disparities, mostly because of standard limitations. Thus, further studies should be encouraged to try to demonstrate the benefits of the application of warfarin pharmacogenomic dosing algorithms in clinical practice.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics & Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP 05403-900, Brazil
| | - Leiliane R Marcatto
- Laboratory of Genetics & Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP 05403-900, Brazil
| | - Paulo C J L Santos
- Department of Pharmacology, Universidade Federal de Sao Paulo UNIFESP, SP 04044-020, Brazil
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Obamiro KO, Chalmers L, Lee K, Bereznicki BJ, Bereznicki LR. Adherence to Oral Anticoagulants in Atrial Fibrillation: An Australian Survey. J Cardiovasc Pharmacol Ther 2018; 23:337-343. [DOI: 10.1177/1074248418770201] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The aim of this study was to investigate the proportion of patients who have suboptimal adherence to oral anticoagulant (OAC), identify the predictors of adherence, and determine whether patient-related factors vary across adherence levels in Australia. Methods: Respondents were recruited for an online survey using Facebook. Survey instruments included the Morisky Medication Adherence Scale, the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires, and a modified Cancer Information Overload scale. Predictors of medication adherence were identified using ordinal regression analysis. Results: Of the 386 responses eligible for analysis, only 54.9% reported a high level of adherence. Participants aged 65 years or younger were less likely to have high adherence compared to older participants (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.33-0.88; P = .013), while females were more likely to be highly adherent compared to males (OR, 1.69; 95% CI, 1.08-2.64; P = .023). The analyses showed that age, gender, treatment satisfaction, information overload, concerns about making mistake when taking OACs, and cost of medication were significant predictors of adherence. Conclusion: Self-reported suboptimal adherence to OAC is common among patients with atrial fibrillation. A focus on supporting people who are at higher risk of suboptimal adherence is needed to maximize the benefit of OAC therapy in this population.
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Affiliation(s)
- Kehinde O. Obamiro
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Leanne Chalmers
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Bonnie J. Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R. Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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O'Callaghan M, Chester R, Scheckel C, Lee JZ, Fernandes R, Shamoun F. Bioprosthetic Valve Thrombosis while on a Novel Oral Anticoagulant for Atrial Fibrillation. CASE (PHILADELPHIA, PA.) 2018; 2:54-58. [PMID: 30062310 PMCID: PMC6058412 DOI: 10.1016/j.case.2017.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BPVT occurred while on a DOAC for treatment of AF. Echocardiographic and pathologic images of BPVT are shown. The definition of NVAF is not uniform in clinical trials or guidelines. The optimal anticoagulation strategy for BPV and AF is unclear. Caution is advised in using DOACs for AF in patients with BPVs.
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Management of the Trauma Patient on Direct Oral
Anticoagulants. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goriacko P, Yaghdjian V, Koleilat I, Sinnett M, Shukla H. The Use of Idarucizumab for Dabigatran Reversal in Clinical Practice: A Case Series. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:699-703. [PMID: 29089726 PMCID: PMC5642159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To describe the use of idarucizumab (Praxbind, Boehringer Ingelheim) in routine clinical practice at a large urban academic medical center. SUMMARY Seven total doses of idarucizumab were administered to six unique patients from October 31, 2015, to October 31, 2016. The reversal agent was used in conjunction with local bleeding control measures, blood product transfusions, and acid-suppressive therapy. In 86% of cases, idarucizumab administration resulted in a successful cessation of bleeding by clinical assessment. Two patients expired due to coexisting conditions. Idarucizumab was administered to patients with normal baseline coagulation tests in 43% of cases. No adverse reactions related to idarucizumab were reported. CONCLUSIONS Idarucizumab administration resulted in successful resolution of bleeding by clinical assessment. The therapy for acute bleeding with use of dabigatran (Pradaxa, Boehringer Ingelheim) remains supportive care, in addition to idarucizumab in cases of severe or uncontrolled bleeding. Development of institution-specific protocols and better guidance for using baseline coagulation tests are needed.
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Williams BA, Evans MA, Honushefsky AM, Berger PB. Clinical Prediction Model for Time in Therapeutic Range While on Warfarin in Newly Diagnosed Atrial Fibrillation. J Am Heart Assoc 2017; 6:JAHA.117.006669. [PMID: 29025746 PMCID: PMC5721868 DOI: 10.1161/jaha.117.006669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Though warfarin has historically been the primary oral anticoagulant for stroke prevention in newly diagnosed atrial fibrillation (AF), several new direct oral anticoagulants may be preferred when anticoagulation control with warfarin is expected to be poor. This study developed a prediction model for time in therapeutic range (TTR) among newly diagnosed AF patients on newly initiated warfarin as a tool to assist decision making between warfarin and direct oral anticoagulants. Methods and Results This electronic medical record–based, retrospective study included newly diagnosed, nonvalvular AF patients with no recent warfarin exposure receiving primary care services through a large healthcare system in rural Pennsylvania. TTR was estimated as the percentage of time international normalized ratio measurements were between 2.0 and 3.0 during the first year following warfarin initiation. Candidate predictors of TTR were chosen from data elements collected during usual clinical care. A TTR prediction model was developed and temporally validated and its predictive performance was compared with the SAMe‐TT2R2 score (sex, age, medical history, treatment, tobacco, race) using R2 and c‐statistics. A total of 7877 newly diagnosed AF patients met study inclusion criteria. Median (interquartile range) TTR within the first year of starting warfarin was 51% (32, 67). Of 85 candidate predictors evaluated, 15 were included in the final validated model with an R2 of 15.4%. The proposed model showed better predictive performance than the SAMe‐TT2R2 score (R2=3.0%). Conclusions The proposed prediction model may assist decision making on the proper mode of oral anticoagulant among newly diagnosed AF patients. However, predicting TTR on warfarin remains challenging.
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Antunes MJ. Is new-onset postoperative atrial fibrillation a benign complication? J Thorac Cardiovasc Surg 2017; 154:490-491. [DOI: 10.1016/j.jtcvs.2017.03.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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Pan KL, Singer DE, Ovbiagele B, Wu YL, Ahmed MA, Lee M. Effects of Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.117.005835. [PMID: 28720644 PMCID: PMC5586302 DOI: 10.1161/jaha.117.005835] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The original non-vitamin K antagonist oral anticoagulant (NOAC) trials in nonvalvular atrial fibrillation (AF) enrolled patients with native valve pathologies. The object of this study was to quantify the benefit-risk profiles of NOACs versus warfarin in AF patients with native valvular heart disease (VHD). METHODS AND RESULTS Trials were identified by exhaustive literature search. Trial data were combined using inverse variance weighting to produce a meta-analytic summary hazard ratio (HR) and 95% confidence interval (CI) of efficacy and safety of NOACs versus warfarin. Our final analysis included 4 randomized controlled trials that enrolled 71 526 participants, including 13 574 with VHD. Pooling results from included trials showed that NOACs versus warfarin reduced stroke or systemic embolism (HR: 0.70; 95% CI, 0.60-0.82) and intracranial hemorrhage (HR: 0.47; 95% CI, 0.24-0.92) in AF patients with VHD. However, risk reduction of major bleeding and intracranial hemorrhage was driven by apixaban, edoxaban, and dabigatran (HR for major bleeding: 0.79 [95% CI, 0.69-0.91]; HR for intracranial hemorrhage: 0.33 [95% CI, 0.25-0.45]) but not rivaroxaban (HR for major bleeding: 1.56 [95% CI, 1.20-2.04]; HR for intracranial hemorrhage: 1.27 [95% CI, 0.77-2.10]). CONCLUSIONS Among patients with AF and native VHD, NOACs reduce stroke and systemic embolism compared with warfarin. Evidence shows that apixaban, dabigatran, and edoxaban also reduce bleeding in this patient subgroup, whereas major bleeding (but not intracranial hemorrhage or mortality rate) is significantly increased in VHD patients treated with rivaroxaban. NOACs are a reasonable alternative to warfarin in AF patients with VHD.
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Affiliation(s)
- Kuo-Li Pan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Chiayi, Puzi, Taiwan
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Yi-Ling Wu
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Mohamed A Ahmed
- Epidemiology and Biostatistics Department, American University of Beirut, Lebanon
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine Chang Gung Memorial Hospital at Chiayi, Puzi, Taiwan
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Direct oral anticoagulants in patients with cervical artery dissection and cerebral venous thrombosis. A case series and review of the literature. Int J Cardiol 2017. [PMID: 28629627 DOI: 10.1016/j.ijcard.2017.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND To date, very little is known about the effects of direct oral anticoagulants (DOA) use in patients with cervical artery dissection (CAD) and cerebral venous thrombosis (CVT). We present our initial experience with the use of DOA for CAD and CVT and an overview of the published literature. METHODS From our database, we identified 4 patients who received DOA after CAD and 4 patients after CVT. Also, we analyzed the data reported for 45 patients who received DOA after CAD and 23 after CVT from review of the literature. RESULTS Among patients with CAD, resolved or improved arterial stenosis was noted in 27 (55%), and symptomatic recurrent ischemic stroke in 2 (4%). Among patients with CVT, complete or partial recanalization was noted in 25 (90%), and no significant functional disability in 26 (93%). No patient developed intracranial hemorrhage. CONCLUSIONS Although no statistical conclusions can be drawn from these data, DOA could be an alternative in patients with CAD-related embolic infarct and CVT-related hemorrhagic venous infarct. A large-scale clinical trial will be needed to validate these results.
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Czuprynska J, Patel JP, Arya R. Current challenges and future prospects in oral anticoagulant therapy. Br J Haematol 2017; 178:838-851. [DOI: 10.1111/bjh.14714] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Julia Czuprynska
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
| | - Jignesh P. Patel
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
- Institute of Pharmaceutical Sciences; King's College London; London UK
| | - Roopen Arya
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
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Murthy SB, Gupta A, Merkler AE, Navi BB, Mandava P, Iadecola C, Sheth KN, Hanley DF, Ziai WC, Kamel H. Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis. Stroke 2017; 48:1594-1600. [PMID: 28416626 DOI: 10.1161/strokeaha.116.016327] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of restarting anticoagulation therapy after intracranial hemorrhage (ICH) remain unclear. We performed a systematic review and meta-analysis to summarize the associations of anticoagulation resumption with the subsequent risk of ICH recurrence and thromboembolism. METHODS We searched published medical literature to identify cohort studies involving adults with anticoagulation-associated ICH. Our predictor variable was resumption of anticoagulation. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between anticoagulation resumption and our outcomes. RESULTS Eight studies were eligible for inclusion in the meta-analysis, with 5306 ICH patients. Almost all studies evaluated anticoagulation with vitamin K antagonists. Reinitiation of anticoagulation was associated with a significantly lower risk of thromboembolic complications (pooled relative risk, 0.34; 95% confidence interval, 0.25-0.45; Q=5.12, P for heterogeneity=0.28). There was no evidence of increased risk of recurrent ICH after reinstatement of anticoagulation therapy, although there was significant heterogeneity among included studies (pooled relative risk, 1.01; 95% confidence interval, 0.58-1.77; Q=24.68, P for heterogeneity <0.001). No significant publication bias was detected in our analyses. CONCLUSIONS In observational studies, reinstitution of anticoagulation after ICH was associated with a lower risk of thromboembolic complications and a similar risk of ICH recurrence. Randomized clinical trials are needed to determine the true risk-benefit profile of anticoagulation resumption after ICH.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.).
| | - Ajay Gupta
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Alexander E Merkler
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Babak B Navi
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Pitchaiah Mandava
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Costantino Iadecola
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Kevin N Sheth
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Daniel F Hanley
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Wendy C Ziai
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Hooman Kamel
- From the Department of Neurology (S.B.M., A.E.M., B.B.N., C.I., H.K.), Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., A.G., A.E.M., B.B.N., C.I., H.K.), and Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY; Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX (P.M.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.); Division of Brain Injury Outcomes (D.F.H.), and Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
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Başaran Ö, Dogan V, Beton O, Tekinalp M, Aykan AÇ, Kalaycıoğlu E, Bolat I, Taşar O, Şafak Ö, Kalçık M, Yaman M, İnci S, Altıntaş B, Kalkan S, Kırma C, Biteker M. Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study. J Thromb Thrombolysis 2017; 43:157-165. [PMID: 27848065 DOI: 10.1007/s11239-016-1445-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA2DS2VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA2DS2VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.
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Affiliation(s)
- Özcan Başaran
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
| | - Volkan Dogan
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
| | - Osman Beton
- Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Mehmet Tekinalp
- Department of Cardiology, Kahramanmaraş Necip Fazıl State Hospital, Kahramanmaraş, Turkey
| | - Ahmet Çağrı Aykan
- Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ezgi Kalaycıoğlu
- Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ismail Bolat
- Department of Cardiology, Fethiye State Hospital, Muğla, Turkey
| | - Onur Taşar
- Department of Cardiology, Elazığ Education and Research Hospital, Elazig, Turkey
| | - Özgen Şafak
- Department of Cardiology, Burdur State Hospital, Burdur, Turkey
| | - Macit Kalçık
- Department of Cardiology, İskilip Atıf Hoca State Hospital, Iskilip, Turkey
| | - Mehmet Yaman
- Department of Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Sinan İnci
- Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey
| | - Bernas Altıntaş
- Department of Cardiology, Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Sedat Kalkan
- Department of Cardiology, Gönen State Hospital, Gönen, Turkey
| | - Cevat Kırma
- Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey
| | - Murat Biteker
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey
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Misasi S, Martini G, Paoletti O, Calza S, Scovoli G, Marengoni A, Testa S, Caimi L, Marchina E. VKORC1 and CYP2C9 polymorphisms related to adverse events in case-control cohort of anticoagulated patients. Medicine (Baltimore) 2016; 95:e5451. [PMID: 28033245 PMCID: PMC5207541 DOI: 10.1097/md.0000000000005451] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/31/2016] [Accepted: 10/28/2016] [Indexed: 01/27/2023] Open
Abstract
Vitamin K antagonists (VKAs) are highly effective but have a narrow therapeutic index and require routine monitoring of the INR. The primary aim of pharmacogenetics (PGx) is to optimize patient care, achieving drug treatments that are personalized according to the genetic profile of each patient. The best-characterized genes involved in VKA PGx involve pharmacokinetics (VKORC1) and pharmacodynamics (CYP2C9) of VKA metabolism. The role of these genes in clinical outcomes (bleeding and thrombosis) during oral anticoagulant (OAC) therapy is controversial. The aim of the present study was to evaluate any potential association between genotype VKORC1 and CYP2C9 and adverse events (hemorrhagic and/or thrombotic), during initiation and long-term VKA treatment, in Caucasian patients. Furthermore, we aimed to determine if the concomitant prescription of other selected drugs affected the association between genotype and adverse events.We performed a retrospective, matched case-control study to determine associations between multiple gene variants, drug intake, and any major adverse effects in anticoagulated patients, monitored in 2 Italian anticoagulation clinics.Our results show that anticoagulated patients have a high risk of adverse events if they are carriers of 1 or more genetic polymorphisms in the VKORC1 (rs9923231) and CYP2C9 (rs1799853 and rs1057910) genes.Information on CYP2C9 and VKORC1 variants may be useful to identify individualized oral anticoagulant treatment for each patient, improve management and quality of VKA anticoagulation control, and monitor drug surveillance in pharmacovigilance programs.
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Affiliation(s)
- Silvia Misasi
- Biology and Genetic Division, Department of Molecular and Translational Medicine, University of Brescia
| | - Giuliana Martini
- Hemostasis and Thrombosis Center, Civic Hospital of Brescia, Piazzale Spedali Civili, Brescia
| | - Oriana Paoletti
- Hemostasis and Thrombosis Center, Cremona Hospital, Via Concordia, Cremona
| | | | - Giovanni Scovoli
- Hemostasis and Thrombosis Center, Civic Hospital of Brescia, Piazzale Spedali Civili, Brescia
| | - Alessandra Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Viale Europa
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Cremona Hospital, Via Concordia, Cremona
| | - Luigi Caimi
- Department of Molecular and Translational Medicine
- Clinical Chemistry Laboratory, Civic Hospital of Brescia, Piazzale Spedali Civili, Brescia, Lombardia, Italy
| | - Eleonora Marchina
- Biology and Genetic Division, Department of Molecular and Translational Medicine, University of Brescia
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Santangelo G, Ielasi A, Antonio Scopelliti P, Pattarino F, Tespili M. Apixaban-Induced Resolution of A Massive Left Atrial and Appendage Thrombosis in a Very Elderly Patient. J Atr Fibrillation 2016; 9:1509. [PMID: 29250263 PMCID: PMC5673322 DOI: 10.4022/jafib.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/19/2016] [Accepted: 12/24/2016] [Indexed: 11/10/2022]
Abstract
A 86-year-old woman with first diagnosed atrial fibrillation (AF) underwent mitral valve annuloplasty 10 years before was admitted to our Unit due to congestive heart failure. Trans-thoracic echocardiogram (TTE) revealed a large fluctuant echogenic mass in the posterior wall of the left atrium. Trans-esophageal echo (TEE) showed the origin of the mass within the left atrial appendage. An adjusted dose of the novel oral anticoagulant (NOAC) apixaban, was prescribed. A complete disappearance was appreciated by examination at 12 weeks after the first drug administration. Although apixaban, resulted superior to warfarin in preventing stroke and thrombo-embolic events in patients with non valvular AF, while causing less bleeding, few data are actually available regarding the efficacy and safety of this drug in left atrium and appendage thrombosis management. Our report shows that this NOAC could be a simple and useful option to manage huge atrial thrombosis in very elderly patients.
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Affiliation(s)
- Gloria Santangelo
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Alfonso Ielasi
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Pasquale Antonio Scopelliti
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Francesco Pattarino
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
| | - Maurizio Tespili
- Cardiology Division, Azienda Socio Sanitaria Territoriale Bergamo Est , Bolognini Hospital, Seriate (BG), Italy
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