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Lehto M, Luojus A, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Kinnunen J, Lehtonen O, Teppo K, Tiili P, Kouki E, Itäinen-Strömberg S, Niemi M, Aro AL, Hartikainen J, Airaksinen KEJ. Time-in-therapeutic-range defined warfarin and direct oral anticoagulants in atrial fibrillation: a Nationwide Cohort Study. Ann Med 2024; 56:2364825. [PMID: 38873855 PMCID: PMC11182072 DOI: 10.1080/07853890.2024.2364825] [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: 03/30/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Little is known how individual time-in-therapeutic-range (TTR) impacts the effectiveness and safety of warfarin therapy compared to direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). OBJECTIVE To compare the effectiveness and safety of standard dose DOACs to warfarin in patients with AF, while categorizing warfarin treated patients into quartiles based on their individual TTR. MATERIALS AND METHODS We conducted a nationwide study including all patients with new-onset AF between 2011 and 2018 in Finland. Hazard ratios (HR) were calculated using Cox regression analysis with the inverse probability of treatment weighted method to assess the risks of ischaemic stroke (IS), intracranial haemorrhage (ICH) and mortality for users of apixaban (n = 12,426), dabigatran (n = 4545), rivaroxaban (n = 12,950) and warfarin (n = 43,548). RESULTS The median TTR for warfarin users was 72%. Compared to the second best TTR quartile (reference), the risk of IS was higher in the two poorest TTR quartiles, and lower in the best TTR quartile and on rivaroxaban [2.35 (95% confidence interval, 1.85-2.85), 1.44 (1.18-1.75), 0.60 (0.47-0.77) and 0.72 (0.56-0.92)]. These differences were non-significant for apixaban and dabigatran. HR of ICH was 6.38 (4.88-8.35) and 1.87 (1.41-2.49) in the two poorest TTR groups, 1.44 (1.02-1.93) on rivaroxaban, and 0.58 (0.40-0.85) in the best TTR group compared to the reference group. Mortality was higher in the two poorest TTR groups and lowest in the best TTR group. CONCLUSIONS The outcome was unsatisfactory in the two lowest TTR quartiles - in half of the patients treated with warfarin. The differences between the high TTR groups and standard dose DOACs were absent or modest.
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Affiliation(s)
- Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | | | | | | | - Jukka Putaala
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Janne Kinnunen
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Konsta Teppo
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Paula Tiili
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Saga Itäinen-Strömberg
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Aapo L. Aro
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - On behalf of the FinACAF Study Group
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
- Aalto University, Espoo, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
- University of Eastern Finland, Kuopio, Finland
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Krittayaphong R, Pumprueg S, Kaewkumdee P, Yindeengam A, Lip GYH. Three-year outcomes of patients with non-valvular atrial fibrillation: the COOL-AF registry. J Geriatr Cardiol 2023; 20:163-173. [PMID: 37091259 PMCID: PMC10114190 DOI: 10.26599/1671-5411.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Clinical outcomes of patients with non-valvular atrial fibrillation (AF) in Asian populations may be different from non-Asians. In this study, we aimed to determine the incidence of ischemic stroke/systemic embolism (SSE), major bleeding, and death, and the predictors for clinical outcomes in a contemporary Asian cohort of newly diagnosed AF patients. METHODS This is a prospective multicenter nationwide registry of patients with AF from 27 hospitals in Thailand. Baseline data and follow-up data were collected every 6 months until 3 years. Data collections included demographic, medical history, laboratory, and medication details. Clinical outcomes were SSE, major bleeding, and all-cause mortality. Incidence rates for each clinical outcome were calculated and presented as rate per 100 person-years. Univariate and multivariate analysis was performed to determine the independent predictors for clinical outcomes. RESULTS There was a total of 3405 patients: mean age was 67.8 ± 11.3 years, 1981 (58.2%) were male. During 30.8 ± 9.7 months follow-up, there was a total of 132 SSE (3.9%), 191 major bleeding (5.6%), and 357 all-cause deaths (10.5%). The incidence rates of SSE, major bleeding, and death were 1.56 (1.30-1.84), 2.26 (1.96-2.61), and 4.17 (3.33-4.25), per 100 person-years respectively. Independent predictors for clinical outcomes were age, type of AF, and the presence of comorbid conditions. CONCLUSION The incidence rate of SSE, major bleeding, and death remains high reflecting the unmet needs in AF management.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satchana Pumprueg
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pontawee Kaewkumdee
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Krittayaphong R, Winijkul A, Sairat P, Lip GYH. Predicting the Absolute Risk of Ischemic Stroke in Asian Patients with Atrial Fibrillation: Comparing the COOL-AF Risk Score with CARS/mCARS Models for Absolute Risk and the CHA2DS2-VASc Score. J Clin Med 2023; 12:jcm12072449. [PMID: 37048533 PMCID: PMC10095200 DOI: 10.3390/jcm12072449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The aims of this study were (1) to validate the CARS and mCARS methods in an Asian population with atrial fibrillation (AF) and (2) to compare the CARS and mCARS models for absolute risk using the COOL-AF method and CHA2DS2VASc scores for the prediction of ischemic stroke or systemic embolism (SSE). METHODS We analyzed the results from a prospective nationwide multicenter AF registry. Follow-up data were collected for 3 years. The main outcomes were SSE. Predictive models of the 3-year SSE of the COOL-AF model, the CHA2DS2VASc score, the CARS for the no-OAC group, and the mCARS for the OAC group were developed and evaluated by C-statistics, and calibration plots were created for the whole group, as well as for oral anticoagulant (OAC) users and no-OAC patients. RESULTS We studied 3405 patients (mean age: 67.8 years; 58.2% male, 75.4% OAC). The incidence rates of SSE were 1.51 (1.26-1.78), 1.93 (1.39-2.60), and 1.37 (1.10-1.68) for all patients, no-OAC patients, and OAC patients, respectively. For the whole population, the COOL-AF score had a C-statistic of 0.697 (0.682-0.713), which was superior to the CHA2DS2-VASc [0.655 (0.639-0.671)]. For the no-OAC group, the CARS predicted SSE with a C-statistic of 0.685 (0.652-0.716), which was similar to the CHA2DS2-VASc [0.684 (0.651-0.7150] and COOL-AF models [0.692 (0.659-0.723)]. For the OAC group, the mCARS had a C-statistic of 0.687 (0.669-0.705) that was similar to the COOL-AF [0.704 (0.686-0.721)] and better than the CHA2DS2-VASc score [0.655 (0.637-0.674)]. CONCLUSIONS The calculation of the individual absolute risks using the CARS and mCARS models can predict SSE in an Asian population. Small differences were evident between the COOL-AF and CHA2DS2-VASc scores.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
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Social App to Improve Warfarin Therapy in Post-MHVR Chinese Patients: A Randomized Controlled Trial. Cardiovasc Ther 2023; 2023:2342111. [PMID: 36714197 PMCID: PMC9867580 DOI: 10.1155/2023/2342111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 01/15/2023] Open
Abstract
Background Poor anticoagulation quality was a major problem among warfarin-treated patients, which called for innovative and effective methods to improve it. Objective To investigate whether social app could be used to reduce warfarin-associated adverse events among post-MHVR Chinese patients. Method 735 warfarin-treated patients (aged 50.8 ± 9.6 years, 59.9% female) were enrolled and randomized to a social app care group (warfarin therapy was guided by experienced clinicians via a social app) or a routine care group (warfarin therapy was managed through traditional in-office visits) at a 1 : 1 ratio. Ending points (bleeding and thrombotic events) were recorded during an 18-month follow-up period. Results A total of 718 patients were included in analysis. 57 of them suffered warfarin-associated adverse events, including 30 major bleedings and 27 thrombotic events. The time in the therapeutic range (TTR, Rosendaal method) in the social app group was 71.5%, which was significantly better than 52.6% in the routine care group (difference: 18.8%, 95% CI: 16.8-20.8). Compared with the patients from the social app group, patients under routine care experienced more bleeding (hazard ratio (HR): 2.31, 95% CI: 1.13-4.72). The social app care group had lower variation (0.55 vs. 0.70) in the international normalized ratio (INR) values and fewer incidents of extremely high INR (e.g., INR > 5.0, 0.87% vs. 3.42%) than the routine care group. Conclusions Social app management could significantly improve warfarin control and was associated with a reduction in bleeding risk. This trial was registered with NCT03264937.
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Safety and Tolerability of Tecarfarin (ATI-5923) in Healthy Chinese Volunteers: Multiple Oral Dose-Escalation Phase I Trial. Am J Cardiovasc Drugs 2023; 23:101-112. [PMID: 36622539 DOI: 10.1007/s40256-022-00562-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tecarfarin (ATI-5923), a structural analog of warfarin, was designed to provide more uniform and stable anticoagulation. OBJECTIVE We aimed to evaluate the safety, tolerability, pharmacokinetic and pharmacodynamic profile of tecarfarin when administered in multiple ascending doses (MADs) to healthy Chinese volunteers. METHODS Forty healthy Chinese volunteers were enrolled into four sequential cohorts (10, 20, 30, and 40 mg), with 10 subjects in each cohort. Participants in the MAD study for each sequential cohort were dose-titrated to achieve the target international normalized ratio (INR 1.7-2.0) for 14 days. Safety and tolerability were assessed throughout the study. RESULTS The pharmacokinetic and pharmacodynamic profile of tecarfarin was investigated in a healthy Chinese population. Dose titration of tecarfarin was necessary to keep the INR in the target range in all subjects in the 20, 30 and 40 mg cohorts and a few subjects (n = 3) in the 10 mg cohort. Tecarfarin was well tolerated without serious adverse events. Only one treatment-related adverse event (hematochezia) resulted in early withdrawal from the MAD 40 mg cohort. CONCLUSION Tecarfarin was well-tolerated by Chinese volunteers. Dose titration was needed for tecarfarin doses larger than 20 mg to keep the INR in the target range. REGISTRATION ClinicalTrials.gov identifier: NCT04627116.
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Du Z, Lin M, Tian Y, Jing L, Liu S, Li G, Jia T, Sun Q, Shi L, Sun J, Tian W, Xing L. Epidemiology of atrial fibrillation and risk of CVD mortality among hypertensive population: A prospective cohort study in Northeast China. Front Cardiovasc Med 2022; 9:955685. [PMID: 35966526 PMCID: PMC9366344 DOI: 10.3389/fcvm.2022.955685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDetermining risk factors of cardiovascular disease (CVD)-related mortality and evaluating their influence are important for effectively reducing corresponding mortality. However, few research findings have estimated the relationship between atrial fibrillation (AF) and CVD-related mortality among hypertension individuals.ObjectiveThe objective of this study was to investigate the epidemiology of AF in a hypertension population and determine the relationship between AF and CVD-related mortality.MethodsUsing a multistage, stratified, and cluster random sampling method, the prospective cohort study with a median follow-up of 3.51 years enrolled 10,678 hypertensive participants at baseline. The prevalence, awareness, and anticoagulation data of AF in this focal population were carefully assessed. Stepwise logistic regression and Cox regression analysis were respectively performed to evaluate the determinants of AF and the association between AF and CVD-related mortality.ResultsThe overall prevalence of AF was 1.3% (95% CI, 1.1%−1.6%) in the hypertensive population, and it was higher in men than in women (1.8% vs. 1.0%, respectively; p=0.001). The awareness of AF was 53.1%, and the rate of oral anticoagulant (OAC) therapy was only 4.2%, although all AF participants should have required according to the European Society of Cardiology guidelines. The determinants of AF included elder, male, and history of coronary heart disease in the hypertensive population. Besides, compared with individuals without AF, the risk of CVD-related mortality significantly increased in the hypertensive population with AF (HR 3.37, 95% CI 2.10–5.40).ConclusionOur results indicated a huge burden of AF and underuse of OAC therapy for them in a community-based hypertensive population. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals, as well as its high risk of mortality, long-term interventions including AF education, timely screening, and widespread use of OACs should be emphasized in the focal populations.
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Affiliation(s)
- Zhi Du
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Lin
- Department of Cardiovascular Medicine, Benxi Central Hospital, Benxi, China
| | - Yuanmeng Tian
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Department of Chronic Disease Preventive and Control, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Li Jing
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Department of Chronic Disease Preventive and Control, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Shuang Liu
- Department of Ultrasound, The Fourth Hospital of China Medical University, Shenyang, China
| | - Guangxiao Li
- Department of Medical Record Management Center, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Tong Jia
- College of Information Science and Engineering, Northeastern University, Shenyang, China
| | - Qun Sun
- Department of Chronic Disease, Disease Control and Prevention of Chaoyang City, Chaoyang, China
| | - Lei Shi
- Department of Chronic Disease, Disease Control and Prevention of Liaoyang City, Liaoyang, China
| | - Jixu Sun
- Department of Chronic Disease, Disease Control and Prevention of Dandong City, Dandong, China
| | - Wen Tian
- Department of Geriatric Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China
- Wen Tian
| | - Liying Xing
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Department of Chronic Disease Preventive and Control, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
- *Correspondence: Liying Xing
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Wong CK, Hai JJ, Lau YM, Zhou M, Lui HW, Lau KK, Chan KH, Mok TM, Liu Y, Feng Y, Tan N, Tam WC, Tam KC, Feng X, Zuo ML, Yin LX, Tan J, Zhang WJ, Jiang X, Huang X, Ye J, Liang Y, Jiang W, Lei Z, Huang D, Yue WS, Tan G, Yan BP, Evora MA, Chen JY, Siu CW. Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial. BMJ Open 2022; 12:e053466. [PMID: 35840293 PMCID: PMC9295642 DOI: 10.1136/bmjopen-2021-053466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Current international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream management to prevent stroke recurrence remain to be established. The objective of the study was to explore the use of long-term home-based ECG monitoring for AF detection and stroke prevention in patients with a history of stroke. METHODS AND ANALYSIS This prospective, randomised, open-label trial with blinded endpoint adjudication aimed to evaluate the efficacy of long-term home-based ECG monitoring for AF detection and stroke prevention in a 24-month period. Patients aged >18 years with a history of ischaemic stroke will be stratified according to the time from the index ischaemic stroke: <1, 1-3 and >3 years and then randomised in 1:1 to (1) home-based AF screening and (2) control. The home-based AF screening system comprises (1) a handheld single-lead ECG recorder (Comfit Healthcare Devices, Hong Kong SAR, China) and (2) a patient-facing smartphone application specially designed for the study. Patients randomised to the home-based AF group will record a 30 s single-lead ECG using a specially designed handheld ECG device every morning or when symptomatic. All remotely obtained data will be automatically transmitted in real-time through the study smartphone application to a secured cloud hosting and analysed using an artificial intelligence-based diagnostic system. When a diagnosis of AF is made with the system, the patients will be called back for a formal cardiology consultation within 1 week. The primary endpoint is the time to first detection of AF at 24 months of follow-up. Secondary endpoints include recurrent stroke or transient ischaemic attack, initiation of long-term anticoagulation therapy, hospitalisation for heart failure, cardiovascular death and all-cause death. ETHICS AND DISSEMINATION The study protocol has been approved by the institutional review board of The University of Hong Kong, and Hong Kong West Cluster, Hospital Authority, Hong Kong SAR, China. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04523649.
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Affiliation(s)
- Chun Ka Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Yuk-Ming Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Mi Zhou
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Hin-Wai Lui
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Kui Kai Lau
- Neurology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Koon-Ho Chan
- Neurology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Toi Meng Mok
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Yong Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Yingqing Feng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Weng-Chio Tam
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Kun-Chong Tam
- Department of Cardiology, Kiang Wu Hospital, Macau, Macau, China
| | - Xiuhua Feng
- Department of Cardiology, Kiang Wu Hospital, Macau, Macau, China
| | - Ming-Liang Zuo
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
| | - Li-Xue Yin
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
| | - Jing Tan
- Department of Ultrasound in Medicine, Sichuan Provincial People's Hospital Affiliated Wenjiang Hospital, Chengdu, China
| | - Wen-Jun Zhang
- Department of Ultrasound in Medicine, Sichuan Provincial People's Hospital Affiliated Wenjiang Hospital, Chengdu, China
| | - Xiaofei Jiang
- Department of Cardiology, Zhuhai People's Hospital, Zhuhai, China
| | - Xiaoyu Huang
- Department of Cardiology, People's Hospital of Yangjiang, Yangjiang, Guangdong, China
| | - Jianfeng Ye
- Department of Cardiology, Dongguan TCM Hospital, Dongguan, China
| | - Yan Liang
- Department of Cardiology, Maoming People's Hospital, Guangdong, China
| | - Wei Jiang
- Department of Cardiology, Union Shenzhen Hospital, Huazhong University of Science and Technology, Shenzhen, China
| | - Zhen Lei
- Department of Cardiology, Union Shenzhen Hospital, Huazhong University of Science and Technology, Shenzhen, China
| | - Duo Huang
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Wen-Sheng Yue
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Guanming Tan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Bryan P Yan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mario Alberto Evora
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
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Left Atrial Diameter in the Prediction of Thromboembolic Event and Death in Atrial Fibrillation. J Clin Med 2022; 11:jcm11071838. [PMID: 35407446 PMCID: PMC8999165 DOI: 10.3390/jcm11071838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study aimed to determine the predictive value of left atrial diameter (LAD), and the incremental prognostic value of LAD in combination with CHA2DS2-VASc score for predicting thromboembolic event and all-cause death in patients with non-valvular atrial fibrillation (AF). Methods: This is a prospective study from 27 hospitals during 2014−2017. LADi is LAD data indexed by body surface area, and LADi in the 4th quartile (LADi Q4) was considered high. Results: A total of 2251 patients (mean age 67.4 years, 58.6% male) were enrolled. Mean follow-up duration was 32.3 months. Rates of thromboembolic events and all-cause death were significantly higher in LADi Q4 patients than in LADi Q1−3 patients (2.89 vs. 1.11 per 100 person-years, p < 0.001, and 7.52 vs. 3.13 per 100 person-years, p < 0.001, respectively). LADi Q4 is an independent predictor of thromboembolic events and all-cause death with an adjusted hazard ratio and 95% confidence interval of 1.94 (1.24−3.05) and 1.81 (1.38−2.37), respectively. LADi has incremental prognostic value on top of the CHA2DS2-VASc score with the increase in global chi-square for thromboembolism (p = 0.005) and all-cause death (p < 0.001). Conclusions: LADi is an independent predictor of thromboembolic event and has incremental prognostic value in combination with CHA2DS2-VASc score in AF patients.
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Zhang S, Shu Y, Chen Y, Liu X, Liu Y, Cheng Y, Wu B, Lei P, Liu M. Low hemoglobin is associated with worse outcomes via larger hematoma volume in intracerebral hemorrhage due to systemic disease. MedComm (Beijing) 2022; 3:e96. [PMID: 35281786 PMCID: PMC8906467 DOI: 10.1002/mco2.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 02/05/2023] Open
Abstract
Whether hemoglobin is associated with outcomes of a specific subtype of intracerebral hemorrhage (ICH) is unknown. A total of 4643 patients with ICH from a multicenter cohort were included in the analysis (64.0% male; mean age [SD], 58.3 [15.2] year), of whom 1319 (28.4%) had anemia on admission. The unsupervised consensus cluster method was employed to classify the patients into three clusters. The patients of cluster 3 were characterized by a high frequency of anemia (85.3%) and mainly composed of patients of systemic disease ICH subtype (SD-ICH; 90.0%) according to the SMASH-U etiologies. In SD-ICH, a strong interaction effect was observed between anemia and 3-month death (adjusted odds ratio [aOR] 4.33, 95% confidence interval [CI] 1.60-11.9, p = 0.004), and the hemoglobin levels were linearly associated with 3-month death (aOR 0.75, 95% CI 0.60-0.92; p = 0.009), which was partially mediated by larger baseline hematoma volume (p = 0.008). This study demonstrated a strong linear association between low hemoglobin levels and worse outcomes in SD-ICH, suggesting that hemoglobin-elevating therapy might be extensively needed in a specific subtype of ICH.
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Affiliation(s)
- Shuting Zhang
- Department of Neurology, West China HospitalSichuan UniversityChengduP. R. China
| | - Yang Shu
- State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduP. R. China
| | - Yunlong Chen
- West China School of MedicineSichuan UniversityChengduP. R. China
| | - Xiaoyang Liu
- West China School of MedicineSichuan UniversityChengduP. R. China
| | - Yu Liu
- State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduP. R. China
| | - Yajun Cheng
- Department of Neurology, West China HospitalSichuan UniversityChengduP. R. China
| | - Bo Wu
- Department of Neurology, West China HospitalSichuan UniversityChengduP. R. China
| | - Peng Lei
- Department of Neurology, West China HospitalSichuan UniversityChengduP. R. China
- State Key Laboratory of Biotherapy, West China HospitalSichuan UniversityChengduP. R. China
| | - Ming Liu
- Department of Neurology, West China HospitalSichuan UniversityChengduP. R. China
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10
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Lin KJ, Schneeweiss S, Pawar A, Singer DE, Liu J, Gagne JJ. Using a Simple Prescription Gap to Determine Warfarin Discontinuation Can Lead to Substantial Misclassification. Thromb Haemost 2022; 122:386-393. [PMID: 33984866 DOI: 10.1055/a-1508-8187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Warfarin remains widely used and a key comparator in studies of other direct oral anticoagulants. As longer-than-needed warfarin prescriptions are often provided to allow for dosing adjustments according to international normalized ratios (INRs), the common practice of using a short allowable gap between dispensings to define warfarin discontinuation may lead to substantial misclassification of warfarin exposure. We aimed to quantify such misclassification and determine the optimal algorithm to define warfarin discontinuation. METHODS We linked Medicare claims data from 2007 to 2014 with a multicenter electronic health records system. The study cohort comprised patients ≥65 years with atrial fibrillation and venous thromboembolism initiating warfarin. We compared results when defining warfarin discontinuation by (1) different gaps (3, 7, 14, 30, and 60 days) between dispensings and (2) having a gap ≤60 days or bridging larger gaps if there was INR ordering at least every 42 days (60_INR). Discontinuation was considered misclassified if there was an INR ≥2 within 7 days after the discontinuation date. RESULTS Among 3,229 patients, a shorter gap resulted in a shorter mean follow-up time (82, 95, 117, 159, 196, and 259 days for gaps of 3, 7, 14, 30, 60, and 60_INR, respectively; p < 0.001). Incorporating INR (60_INR) can reduce misclassification of warfarin discontinuation from 68 to 4% (p < 0.001). The on-treatment risk estimation of clinical endpoints varied significantly by discontinuation definitions. CONCLUSION Using a short gap between warfarin dispensings to define discontinuation may lead to substantial misclassification, which can be improved by incorporating intervening INR codes.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Daniel E Singer
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
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11
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Chan N, Orchard J, Agbayani M, Boddington D, Chao T, Johar S, John B, Joung B, Krishinan S, Krittayaphong R, Kurokawa S, Lau C, Lim TW, Linh PT, Long VH, Naik A, Okumura Y, Sasano T, Yan B, Raharjo SB, Hanafy DA, Yuniadi Y, Nwe N, Awan ZA, Huang H, Freedman B. 2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening. J Arrhythm 2021; 38:31-49. [PMID: 35222749 PMCID: PMC8851593 DOI: 10.1002/joa3.12669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/11/2021] [Accepted: 12/15/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- Ngai‐Yin Chan
- Princess Margaret Hospital Hong Kong Special Administrative Region China
| | - Jessica Orchard
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute Sydney Australia
- Charles Perkins Centre The University of Sydney Sydney Australia
| | - Michael‐Joseph Agbayani
- Division of Electrophysiology Philippine Heart Center Manila Philippines
- Division of Cardiovascular Medicine Philippine General Hospital Manila Philippines
| | - Dean Boddington
- Cardiology Department Tauranga Hospital Tauranga New Zealand
| | - Tze‐Fan Chao
- Division of Cardiology Department of Medicine Taipei Veterans General Hospital Taipei Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center National Yang Ming Chiao Tung University Taipei Taiwan
| | - Sofian Johar
- Consultant Cardiologist Head of Cardiology RIPAS Hospital Bandar Seri Begawan Brunei Darussalam
- Consultant Cardiac Electrophysiologist Head of Cardiac Electrophysiology Gleneagles JPMC Jerudong Brunei Darussalam
- Institute of Health SciencesUniversiti Brunei Darussalam Jalan Tungku Link Gadong Brunei Darussalam
| | - Bobby John
- Cardiology UnitTownsville University Hospital Townsville Australia
- James Cook University Townsville Australia
| | - Boyoung Joung
- Internal Medicine Yonsei University College of Medicine Seoul Republic of Korea
| | | | - Rungroj Krittayaphong
- Division of Cardiology Department of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| | - Sayaka Kurokawa
- Division of Cardiology Department of Medicine Nihon University School of Medicine Tokyo Japan
| | - Chu‐Pak Lau
- Department of Medicine Queen Mary HospitalThe University of Hong Kong Hong Kong Special Administrative Region China
| | - Toon Wei Lim
- National University HospitalNational University Heart Centre Singapore
| | | | | | - Ajay Naik
- Division of Cardiology Care Institute of Medical Sciences Hospital Ahmedabad India
| | - Yasuo Okumura
- Division of Cardiology Department of Medicine Nihon University School of Medicine Tokyo Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine Tokyo Medical and Dental University Tokyo Japan
| | - Bernard Yan
- Melbourne Brain Centre University of Melbourne Melbourne Australia
| | - Sunu Budhi Raharjo
- Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Indonesia, and National Cardiovascular Center Harapan Kita Jakarta Indonesia
| | - Dicky Armein Hanafy
- Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Indonesia, and National Cardiovascular Center Harapan Kita Jakarta Indonesia
| | - Yoga Yuniadi
- Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas Indonesia, and National Cardiovascular Center Harapan Kita Jakarta Indonesia
| | - Nwe Nwe
- Department of Cardiology Yangon General HospitalUniversity of Medicine Yangon Myanmar
| | | | - He Huang
- Wuhan University Renmin Hospital Wuhan China
| | - Ben Freedman
- Charles Perkins Centre The University of Sydney Sydney Australia
- Heart Research Institute Charles Perkins Centre University of Sydney Sydney Australia
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12
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Jia Y, Li G, Song G, Ye X, Yang Y, Lu K, Huang S, Zhu S. SMASH-U aetiological classification: A predictor of long-term functional outcome after intracerebral haemorrhage. Eur J Neurol 2021; 29:178-187. [PMID: 34534389 DOI: 10.1111/ene.15111] [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: 08/25/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND SMASH-U is a systematic aetiological classification system for intracerebral haemorrhage (ICH) proven to be a predictor of post-ICH haematoma expansion and mortality. However, its role in predicting functional outcome remains elusive. Therefore, we aimed to investigate whether SMASH-U is associated with long-term functional outcome after ICH and improves the accuracy of prediction when added to max-ICH score. METHODS Consecutive acute ICH patients from 2012 to 2018 from the neurology department of Tongji Hospital were enrolled. ICH aetiology was classified according to the SMASH-U system. The association of SMASH-U with 12-month functional outcome after ICH and the predictive value were evaluated. RESULTS Of 1938 ICH patients, the aetiology of 1295 (66.8%) patients were classified as hypertension, followed by amyloid angiopathy (n = 250, 12.9%), undetermined (n = 159, 8.2%), structural lesions (n = 149, 7.7%), systemic disease (n = 74, 3.8%) and medication (n = 11, 0.6%). The baseline characteristics were different among the six aetiologies. In multivariate analysis, SMASH-U was proven to be a predictor of 12-month unfavourable functional outcome. When adding the SMASH-U system, the predictive performance of max-ICH score was improved (area under the receiver operating characteristic curve from 0.802 to 0.812, p = 0.010) and the predictive accuracy was enhanced (integrated discrimination improvement [IDI]: 1.60%, p < 0.001; continuous net reclassification improvement [NRI]: 28.16%, p < 0.001; categorical NRI: 3.34%, p = 0.004). CONCLUSIONS SMASH-U predicted long-term unfavourable functional outcomes after acute ICH and improved the accuracy of prediction when added to max-ICH score. Integrating the aetiology to a score model to predict the post-ICH outcome may be meaningful and worthy of further exploration.
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Affiliation(s)
- Yuchao Jia
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guini Song
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaodong Ye
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuyan Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kai Lu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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13
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Wong CK, Huang D, Zhou M, Hai J, Yue WS, Li WH, Yin LX, Zuo ML, Feng YQ, Tan N, Chen JY, Kwan J, Siu CW. Antithrombotic therapy and the risk of new-onset dementia in elderly patients with atrial fibrillation. Postgrad Med J 2020; 98:98-103. [PMID: 33184131 DOI: 10.1136/postgradmedj-2020-137916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/27/2020] [Accepted: 10/11/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with an increased risk of dementia. Little is known about the relationship of antithrombotic therapy and the risk of dementia in patients with AF without clinical stroke. METHOD This was an observational study based on a hospital AF registry. Patients aged 65-85 years at the time of AF diagnosis were identified via the computerised database of the clinical management system. Patients with prior stroke or known cognitive dysfunction were excluded. The primary outcome was newly diagnosed dementia during the follow-up period. RESULTS 3284 patients (mean age 76.4±5.3 years, 51.6% male) were included for analysis. The mean CHA2DS2-VASc score was 3.94±1.44. 18.5% patients were prescribed warfarin, 39.8% were prescribed aspirin and 41.7% were prescribed no antithrombotic therapy. After a mean follow-up of 3.6 years, 71 patients (2.2%) developed dementia, giving rise to an incidence of 0.61%/year. The incidence of dementia were 1.04%/year, 0.69%/year and 0.14%/year for patients on no therapy, aspirin and warfarin, respectively. Both univariate and multivariate analyses showed that age ≥75 years, female gender and high CHA2DS2-VASc score were associated with significantly higher risk of dementia; warfarin use was associated with significantly lower risk of dementia (HR: 0.14%, 95% CI 0.05 to 0.36, p<0.001). Patients on warfarin with time in therapeutic range (TTR) ≥65% had a non-significant trend towards a lower risk of dementia compared with those with TTR <65%. CONCLUSION In elderly AF patients, warfarin therapy was associated with a significantly lower risk of new-onset dementia compared those with no therapy or aspirin.
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Affiliation(s)
- Chun Ka Wong
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Duo Huang
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China.,Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Mi Zhou
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - JoJo Hai
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wen Sheng Yue
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wen-Hua Li
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Li-Xue Yin
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Ming-Liang Zuo
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Ying Qing Feng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academic of Medical Sciences, Guangzhou, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academic of Medical Sciences, Guangzhou, China
| | - Ji Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academic of Medical Sciences, Guangzhou, China
| | - Joseph Kwan
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chung Wah Siu
- Division of Geriatrics, Department of Medicine, The University of Hong Kong, Hong Kong, China
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14
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Zhou M, Chan EW, Hai JJ, Wong CK, Lau YM, Huang D, Lam CC, Tam CCF, Wong YTA, Yung SYA, Chan KWK, Feng Y, Tan N, Chen JY, Yung CY, Lee KL, Choi CW, Lam H, Ng A, Fan K, Jim MH, Yiu KH, Yan BP, Siu CW. Protocol, rationale and design of DAbigatran for Stroke PreVention In Atrial Fibrillation in MoDerate or Severe Mitral Stenosis (DAVID-MS): a randomised, open-label study. BMJ Open 2020; 10:e038194. [PMID: 32978200 PMCID: PMC7520829 DOI: 10.1136/bmjopen-2020-038194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Current international guidelines recommend non-vitamin K oral anticoagulants (NOACs) for stroke prevention among patients with non-valvular atrial fibrillation (AF) at significant ischaemic stroke risk given the superior safety and comparable efficacy of NOACs over warfarin. Nonetheless, the safety and effectiveness of NOACs have not been evaluated in patients with AF with underlying moderate or severe mitral stenosis (MS), hence the recommended stroke prevention strategy remains warfarin therapy. METHOD AND ANALYSIS MS remains disproportionately prevalent in Asian countries compared with the developed countries. This prospective, randomised, open-label trial with blinded endpoint adjudication aims to evaluate the safety and efficacy of dabigatran for stroke prevention in AF patients with moderate or severe MS. Patients with AF aged ≥18 years with moderate or severe MS not planned for valvular intervention in the coming 12 months will be randomised in a 1:1 ratio to receive dabigatran 110 mg or 150 mg two times per day or warfarin with international normalised ratio 2-3 in an open-label design. Patients with estimated creatinine clearance <30 mL/min, or with a concomitant indication for antiplatelet therapy will be excluded. The primary outcome is a composite of stroke and systemic embolism. Secondary outcomes are ischaemic stroke, systemic embolism, haemorrhagic stroke, intracranial haemorrhage, major bleeding and death. The estimated required sample size is approximately 686 participants. ETHICS AND DISSEMINATION The study protocol has been approved by the Institutional Review Board of the University of Hong Kong and Hong Kong West Cluster, Hospital Authority, Hong Kong for Fung Yiu King Hospital, Grantham Hospital, Queen Mary Hospital and Tung Wah Hospital in Hong Kong. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04045093); pre-results.
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Affiliation(s)
- Mi Zhou
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun Ka Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuk Ming Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Duo Huang
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Cheung Chi Lam
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chor Cheung Frankie Tam
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yiu Tung Anthony Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - See Yue Arthur Yung
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ki Wan Kelvin Chan
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yingqing Feng
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ning Tan
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ji-Yan Chen
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
- Cardiology Division, South China University of Technology, Guangzhou, Guangdong, China
| | - Chi Yui Yung
- Cardiology Division, Department of Medicine and Geriatrics, Ruttonjee and Tang Siu Kin Hospital, Hong Kong, Hong Kong SAR, China
| | - Kwok Lun Lee
- Cardiology Division, Department of Medicine and Geriatrics, Ruttonjee and Tang Siu Kin Hospital, Hong Kong, Hong Kong SAR, China
| | - Chun Wai Choi
- Cardiology Division, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Ho Lam
- Cardiology Division, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Andrew Ng
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Katherine Fan
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Man Hong Jim
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Kai Hang Yiu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bryan P Yan
- Cardiology Division, Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
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15
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Poor Time in Therapeutic Range Control is Associated with Adverse Clinical Outcomes in Patients with Non-Valvular Atrial Fibrillation: A Report from the Nationwide COOL-AF Registry. J Clin Med 2020; 9:jcm9061698. [PMID: 32498302 PMCID: PMC7355466 DOI: 10.3390/jcm9061698] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Warfarin remains the most commonly used oral anticoagulant (OAC) in Thailand for stroke prevention among patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the relationship between time in therapeutic range (TTR) after warfarin initiation and clinical outcomes of NVAF. METHODS TTR was calculated by the Rosendaal method from international normalized ratio (INR) data acquired from a nationwide NVAF registry in Thailand. Patients were followed-up every six months. The association between TTR and clinical outcomes was analyzed. RESULTS There was a total of 2233 patients from 27 hospitals. The average age was 68.4 ± 10.6 years. The average TTR was 53.56 ± 26.37%. Rates of ischemic stroke/TIA, major bleeding, ICH, and death were 1.33, 2.48, 0.76, and 3.3 per 100 person-years, respectively. When patients with a TTR < 65% were compared with those with TTR ≥ 65%, the adjusted hazard ratios (aHR) for the increased risks of ischemic stroke/TIA, major bleeding, ICH, and death were 3.07, 1.90, 2.34, and 2.11, respectively. CONCLUSION Poor TTR control is associated with adverse clinical outcomes in patients with NVAF who were on warfarin. Efforts to ensure good TTR (≥65%) after initiation of warfarin are mandatory to minimize the risk of adverse clinical outcomes.
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16
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Comparative effectiveness and safety of oral anticoagulants for atrial fibrillation: A retrospective cohort study. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2020; 27:e28-e44. [PMID: 32320170 DOI: 10.15586/jptcp.v27i2.662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/19/2020] [Indexed: 11/18/2022]
Abstract
Oral anticoagulants (OACs) are high-priority medications, frequently used with clinically important benefit and serious harm. Our objective was to compare the safety and effectiveness of direct-acting oral anticoagulants (DOACs) versus warfarin in a population where anticoagulation management and DOACs were readily available. A retrospective cohort study of all adults living in British Columbia with a diagnosis of atrial fibrillation and a first prescription for an OAC was conducted. Co-primary outcomes were ischemic stroke and systemic embolism, and major bleeding. Secondary outcomes included a net clinical outcome composite and analysis of discontinuation, switching, and key subgroups. We estimated the effects of treatment using time-to-event models with high-dimensional propensity score adjustment to control confounding. After adjustment for prescribing bias, a cohort (n = 20,113, 43.8% female, mean age 72.4 years) with a mean follow-up of 18.1 months showed that patients taking warfarin tended to be poorer, sicker, and less likely to have a cardiologist prescriber. Outcome event rates were not significantly different for DOACs compared to warfarin [adjusted rate ratio of 1.15 (0.91, 1.46) for systemic embolism, 0.94 (0.82, 1.08) for major bleeding, and 0.98 (0.90, 1.06) for net clinical outcome]. Only the effect of age on net clinical outcome met our strict criteria for predicting which group might be superior. Switch of drug class was associated with increased risk of events (p < 0.003). In this population, we found no difference in important clinical outcomes between warfarin and DOACs. Switching compared to not switching was associated with harm.
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17
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Xiong Q, Wang C, Liu H, Tan Z, Chen C, Li J, Lip GYH, Hong K. Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Asians With Nonvalvular Atrial Fibrillation: A Network Meta-Analysis. Clin Appl Thromb Hemost 2020; 25:1076029619885188. [PMID: 31718263 PMCID: PMC7019404 DOI: 10.1177/1076029619885188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
There are few head-to-head trials directly comparing non-vitamin K antagonist oral anticoagulants (NOACs) against one other. A network meta-analysis (NMA) was performed to examine the indirect comparisons among NOACs in Asians with nonvalvular atrial fibrillation (NVAF). STATA 15.0 and ADDIS 1.16.8 softwares were used to perform the statistical analysis. Odds ratios with 95% credible intervals were applied to evaluate the end points. The probabilities of treatment rank were used to understand which interventions are more effective and safe, and the total rank probability was 1. In our NMA, the rank probabilities of apixaban in the case of stroke or systemic embolism, death from any cause, major bleeding, and intracranial hemorrhage (ICH) were 0.47, 0.49, 0.42, and 0.51, respectively. For cases of myocardial infarction, the rank probabilities of rivaroxaban were 0.40. This NMA indirectly compares the main efficacy and safety end points among NOACs in Asians with NVAF, and the rank probability analysis showed that apixaban likely performs best in cases of stroke or systemic embolism, death from any cause, and ICH; rivaroxaban may have the best performance for myocardial infarction.
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Affiliation(s)
- Qinmei Xiong
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Cen Wang
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Hualong Liu
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhaochong Tan
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Chen Chen
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Juxiang Li
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kui Hong
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Jiangxi, China.,Jiangxi Key Laboratory of Molecular Medicine, Jiangxi, China
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18
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Risk of Major Gastrointestinal Bleeding With New vs Conventional Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2020; 18:792-799.e61. [PMID: 31195162 DOI: 10.1016/j.cgh.2019.05.056] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over whether use of non-vitamin K antagonist oral anticoagulants (NOACs) associates with increased risk of major gastrointestinal bleeding (GIB) compared with conventional therapies (such as vitamin K antagonists or anti-platelet agents). We performed a systematic review and meta-analysis of data from randomized controlled trials and high-quality real-world studies. METHODS We performed a systematic search of the MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov Website databases (through Oct 12, 2018) for randomized controlled trials and high-quality real-world studies that reported major GIB events in patients given NOACs or conventional therapy. Relative risks (RRs) for randomized controlled trials and adjusted hazard ratios (aHRs) for real-world studies were calculated separately using random-effects models. RESULTS We analyzed data from 43 randomized controlled trials (183,752 patients) and 41 real-world studies (1,879,428 patients). The pooled major rates of GIB for patients on NOACs (1.19%) vs conventional treatment (0.92%) did not differ significantly (RR from randomized controlled trials, 1.09; 95% CI, 0.91-1.31 and aHR from real-world studies, 1.02; 95% CI, 0.94-1.10; Pinteraction=.52). Rivaroxaban, but not other NOACs, was associated with an increased risk for major GIB (RR from randomized controlled trials, 1.39; 95% CI, 1.17-1.65 and aHR from real-world studies, 1.14; 95% CI, 1.04-1.23; Pinteraction = .06). Analyses of subgroups, such as patients with different indications, dosage, or follow-up time, did not significantly affect results. Meta-regression analysis failed to detect any potential confounding to impact the primacy outcome. CONCLUSIONS In a systematic review and meta-analysis of data from randomized controlled trials and real-world studies, we confirmed that there is no significant difference in risk of major GIB between patients receiving NOACs vs conventional treatment. Rivaroxaban users had a 39% increase in risk for major GIB.
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Fung KP, Chan KH, Ng V, Tsui PT, You JHS. Health Economic Analysis of Rivaroxaban and Warfarin for Venous Thromboembolism Management in Chinese Patients. Cardiovasc Drugs Ther 2020; 33:331-337. [PMID: 30888571 DOI: 10.1007/s10557-019-06872-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Rivaroxaban, a direct oral anticoagulant, has demonstrated non-inferiority to warfarin for venous thromboembolism (VTE) treatment in clinical trials. This study aimed to analyze the direct medical costs for VTE management with rivaroxaban versus warfarin in Hong Kong Chinese patients. METHODS In this retrospective observational study, VTE patients admitted to the Princess Margaret Hospital from March 2012 to February 2017 who were initiated and discharged with either rivaroxaban or warfarin were included. Patient demographic and clinical data, and healthcare resource utilization for VTE management were collected for the VTE index admission and 1-year post-discharge period. RESULTS A total of 181 patients (90 in the rivaroxaban group; 91 in the warfarin group) were included. The mean (± SD) length of stay (LOS) was 4.8 ± 2.7 days and 8.0 ± 3.0 days in the rivaroxaban and warfarin groups, respectively (p > 0.001). The total cost for VTE index admission in the rivaroxaban group was significantly lower than that of the warfarin group (USD 5473 ± 1914 versus USD 3457 ± 1796; p < 0.001) (USD 1 = HKD 7.8). Recurrent VTE and bleeding rates in 1-year post-discharge period were not significantly different between the two groups. The direct total cost of the rivaroxaban group (USD 1271 ± 767) was significantly lower than that of the warfarin group (USD 1739 ± 1045) in 1-year post-discharge period (p < 0.001). CONCLUSIONS Total direct cost and LOS for VTE admission and total cost in 1-year post-discharge period were significantly lower in patients initiated and discharged with rivaroxaban than those of warfarin.
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Affiliation(s)
- Ka-Po Fung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.,Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Kei-Hong Chan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.,Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Vivien Ng
- Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Ping-Tim Tsui
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.
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Persistence, effectiveness and safety of dabigatran in “real-world” Chinese patients with nonvalvular atrial fibrillation. Heart Vessels 2020; 35:977-984. [DOI: 10.1007/s00380-020-01565-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
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21
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Cost-effectiveness of Dabigatran Compared With Rivaroxaban for Prevention of Stroke and Systemic Embolism in Patients With Atrial Fibrillation in China. Clin Ther 2020; 42:144-156.e1. [PMID: 31932080 DOI: 10.1016/j.clinthera.2019.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 09/24/2019] [Accepted: 11/17/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE In China, dabigatran and rivaroxaban are the only approved non-vitamin K antagonist oral anticoagulants for the treatment of atrial fibrillation (AF). The goal of this article was to assess the cost-effectiveness of dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in Chinese patients with AF from the perspective of the Chinese health care system. METHODS A Markov model was constructed to estimate the cost-effectiveness of dabigatran versus rivaroxaban. Clinical events were modeled for a lifetime horizon, based on clinical efficacy data from indirect treatment comparisons. The weighted average of the most recent prices of these 2 drugs was used as the drug acquisition cost. Other costs, including follow-up costs and event costs, were collected by using a survey from a panel of local experts. Utility inputs (health state utilities, clinical event disutilities, and event history utility) were obtained from published literature. Sensitivity analyses that included scenario analyses and a probabilistic sensitivity analysis were conducted to examine the robustness of the economic model. FINDINGS Over a lifetime, patients treated with dabigatran experienced fewer ischemic strokes (2.14 dabigatran vs 2.61 rivaroxaban) and fewer intracranial hemorrhage (0.48 vs 0.94) per 100 patient-years. In the base case analysis, dabigatran had an incremental cost of ¥28,128 but with higher life years (10.38 vs 10.14) and quality-adjusted life years (QALYs) (7.95 vs 7.70). The resulting incremental cost-effectiveness ratio of ¥112,910 per QALY gained and net monetary benefit of ¥12,214 versus rivaroxaban showed that dabigatran was a cost-effective alternative to rivaroxaban. Extensive sensitivity analyses indicated that the results were robust over a wide range of inputs. The probabilistic sensitivity analysis indicated that dabigatran was cost-effective in 84.2% of the 10,000 Monte Carlo simulations compared with rivaroxaban. IMPLICATIONS Dabigatran reduced the occurrence of clinical events and increased QALYs compared with rivaroxaban. The use of dabigatran for the prevention of stroke and systemic embolism is a cost-effective option compared with rivaroxaban among patients with AF in China.
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22
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Wiggins WF, Potter CA, Sodickson AD. Dual-Energy CT to Differentiate Small Foci of Intracranial Hemorrhage from Calcium. Radiology 2019; 294:129-138. [PMID: 31687919 DOI: 10.1148/radiol.2019190792] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Diagnostic uncertainty in CT of possible intracranial hemorrhage requires short-interval follow-up imaging, resulting in reduced efficiency of care and higher costs. Purpose To quantify the diagnostic performance of dual-energy CT versus simulated single-energy CT in the differentiation of small foci of intracranial hemorrhage from calcium. Materials and Methods Images from consecutive unenhanced dual-energy CT of the head in patients from a single emergency department obtained from December 2014 to April 2016 were reviewed retrospectively for hyperattenuating intracranial foci. Ground truth was established from reference standard comparison CT or MRI. Foci were divided into development and test sets. Development set foci regions of interest were used to derive candidate CT attenuation thresholds for virtual noncalcium (VNCa) and calcium images. Test set foci were used for threshold validation, and diagnostic performance and confidence were evaluated for two readers blinded to final diagnosis. Statistical comparisons were made with exact binomial tests or repeated-measures analysis of variance. Results The study included 137 patients (65 years ± 17; 70 men) with 146 foci. Foci were divided into a development set (n = 105) and a test set (n = 41). Quantitative analysis of the development set produced candidate thresholds of 44 HU for VNCa images and 7 HU for calcium-only images, yielding diagnostic accuracies for the test set of 88% (36 of 41 foci; 95% confidence interval [CI]: 78%, 98%) and 95% (39 of 41 foci; 95% CI: 88%, 100%), respectively. Dual-energy CT improved reader accuracy from 90% (reader 1, 37 of 41 foci; 95% CI: 81%, 99%) and 93% (reader 2, 38 of 41 foci; 95% CI: 85%, 100%) to 100% (both readers, 41 of 41 foci; 95% CI: 100%, 100%). Diagnostic confidence (classifications rated as "certain") increased from 71% (29 of 41 foci; 95% CI: 57%, 85%) to 90% (37 of 41 foci; 95% CI: 81%, 99%) for reader 1 (P = .019) and from 46% (19 of 41 foci; 95% CI: 31%, 62%) to 85% (35 of 41 foci; 95% CI: 75%, 96%) for reader 2 (P = .0001). Conclusion Dual-energy CT showed high diagnostic performance in the differentiation of small foci of intracranial hemorrhage from calcium and improved diagnostic accuracy and confidence in the initial evaluation of suspected hemorrhage. © RSNA, 2019 See also the editorial by Kotsenas in this issue.
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Affiliation(s)
- Walter F Wiggins
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher A Potter
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Aaron D Sodickson
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Lamperti M, Khozenko A, Kumar A. Perioperative Management of Patients Receiving New Anticoagulants. Curr Pharm Des 2019; 25:2149-2157. [PMID: 31560280 DOI: 10.2174/1381612825666190709220449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/25/2019] [Indexed: 01/01/2023]
Abstract
There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.
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Affiliation(s)
- Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Andrey Khozenko
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Arun Kumar
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Qiu R, Hu J, Huang Y, Han S, Zhong C, Li M, He T, Lin Y, Guan M, Chen J, Shang H. Outcome reporting from clinical trials of non-valvular atrial fibrillation treated with traditional Chinese medicine or Western medicine: a systematic review. BMJ Open 2019; 9:e028803. [PMID: 31471437 PMCID: PMC6720335 DOI: 10.1136/bmjopen-2018-028803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To examine variation in outcomes, outcome measurement instruments (OMIs) and measurement times in clinical trials of non-valvular atrial fibrillation (NVAF) and to identify outcomes for prioritisation in developing a core outcome set (COS) in this field. DESIGN This study was a systematic review. DATA SOURCES Clinical trials published between January 2015 and March 2019 were obtained from PubMed, the Cochrane Library, Web of Science, Wanfang Database, the China National Knowledge Infrastructure and SinoMed. ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) and observational studies were considered. Interventions included traditional Chinese medicine and Western medicine. The required treatment duration or follow-up time was ≥4 weeks. The required sample size was ≥30 and≥50 in each group in RCTs and observational studies, respectively. We excluded trials that aimed to investigate the outcome of complications of NVAF, to assess the mechanisms or pharmacokinetics, or for which full text could not be acquired. DATA EXTRACTION AND SYNTHESIS The general information and outcomes, OMIs and measurement times were extracted. The methodological and outcome reporting quality were assessed. The results were analysed by descriptive analysis. RESULTS A total of 218 articles were included from 25 255 articles. For clinical trials of antiarrhythmic therapy, 69 outcomes from 16 outcome domains were reported, and 28 (31.82%, 28/88) outcomes were reported only once; the most frequently reported outcome was ultrasonic cardiogram. Thirty-one outcomes (44.93%, 31/69) were provided definitions or OMIs; the outcome measurement times ranged from 1 to 20 with a median of 3. For clinical trials of anticoagulation therapy, 82 outcomes from 18 outcome domains were reported; 38 (29.23%, 38/130) outcomes were reported only once. The most frequently reported outcome was ischaemic stroke. Forty (48.78%, 40/82) outcomes were provided OMIs or definitions; and the outcome measurement times ranged from 1 to 27 with a median of 8. CONCLUSION Outcome reporting in NVAF is inconsistent. Thus, developing a COS that can be used in clinical trials is necessary.
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Affiliation(s)
- Ruijin Qiu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiayuan Hu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ya Huang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Songjie Han
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Changming Zhong
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Min Li
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Tianmai He
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yiyi Lin
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Manke Guan
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Chen
- Baokang Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Evidence-based Medicine Center, Jiangxi University of Chinese Medicine, Nanchang, China
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Marietta M, Banchelli F, Pavesi P, Manotti C, Quintavalla R, Sinigaglia T, Guazzaloca G, Pattacini C, Urbinati S, Malavasi VL, Boriani G, Voci C, D'Amico R, Magrini N. Direct oral anticoagulants vs non-vitamin K antagonist in atrial fibrillation: A prospective, propensity score adjusted cohort study. Eur J Intern Med 2019; 62:9-16. [PMID: 30635146 DOI: 10.1016/j.ejim.2018.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/11/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy.
| | | | | | - Cesare Manotti
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - Roberto Quintavalla
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - Tiziana Sinigaglia
- Cardiovascular Medicine Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Giuliana Guazzaloca
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Stefano Urbinati
- Cardiology Department, Bellaria Hospital, AUSL of Bologna, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Claudio Voci
- Servizio Strutture, Tecnologie e Sistemi Informativi, Regione Emilia-Romagna, Bologna, Italy
| | - Roberto D'Amico
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Italy
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The comparison of non-vitamin K antagonist oral anticoagulants versus well-managed warfarin with a lower INR target of 1.5 to 2.5 in Asians patients with non-valvular atrial fibrillation. PLoS One 2019; 14:e0213517. [PMID: 30883567 PMCID: PMC6422299 DOI: 10.1371/journal.pone.0213517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background Previous studies indicated low-intensity warfarin (INR target of 1.5–2.5) achieved reduced hemorrhage without increasing thromboembolism for Asians with non-valvular atrial fibrillation (NVAF). Whether non-vitamin K antagonist oral anticoagulant (NOAC) is superior to warfarin with good time in the therapeutic range (TTR) based on lower INR target among Asians with NVAF remains unknown. Methods In this retrospective study collected from Taiwan Chang Gung Memorial Hospital Database, there were 5,197, 3,396, and 9,898 consecutive patients taking warfarin, NOAC, and no-treatment, respectively, from January 1, 2000 to December 31, 2015. Propensity-score weighting was used across the study groups. Patients were followed until the first occurrence of study outcome or end date of study. Results Among those patients taking warfarin, the mean”artificial” TTR (aTTR) based on a lower INR target of 1.5–2.5 was 44.4±33.3%. Total 79.2% (n = 2,690) patients took low-dose NOACs. Patients with aTTR in the range from <30%(34.0%), 30–50%(17.6%), 50–70%(23.5%) to >70%(24.9%) showed decremental risks of efficacy and composite outcome compared with no-treatment. The risk of major bleeding didn’t increase among patients with top aTTR>70% compared to no-treatment. The NOAC group showed a comparable risk of composite outcome to the warfarin subgroup with aTTR of >70% (P = 0.485). The NOAC group had a lower risk of composite outcome than warfarin subgroup with TTR of>70% based on the INR target of 2.0–3.0 (P = 0.004). Conclusions NOACs showed a comparable risk of efficacy, safety, and composite outcome to well-managed warfarin based on a lower INR target of 1.5–2.5 in Asians with NVAF taking oral anticoagulants.
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Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events. J Neurol Sci 2019; 398:69-74. [PMID: 30684767 DOI: 10.1016/j.jns.2019.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/29/2018] [Accepted: 01/17/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The quality of anticoagulation is closely associated with efficacy and safety in warfarin users. Although genetic polymorphisms have been related to warfarin dosages and vascular events(VE), genetic evaluations have not been recommended for all warfarin users. The aim is to evaluate the significance of the maintenance dose of warfarin (MDW) on VE, considering the time in therapeutic range (TTR). METHODS This retrospective study analyzed the data of patients who received warfarin for any reasons. A total of 11,835 patients with warfarin were divided into quartiles by MDW. We assessed TTR using the Rosendaal method and VE. RESULTS VE occurred in 9.1% of the warfarin users. The mean TTR level was 34.0 ± 25.7%, and the MDW was 3.38 ± 1.06 mg per day. Patients with VE were more likely to have a lower MDW and lower TTR levels. In moderate- or well-controlled TTR status, a lower MDW was significantly related to under-controlled anticoagulation and associated with higher risks of VE. Lower MDW had a higher risk of stroke or arterial/venous thromboembolism (Q1: OR, 1.57; 95% CI 1.25 to 1.96; Q2: OR, 1.40; 95% CI 1.12 to 1.75; Q3: OR, 1.35; 95% CI 1.08 to 1.68). CONCLUSIONS We suggest that patients with very low MDW might be at risk when using warfarin. Therefore, we propose that patients with a very low MDW might be alternatively considered for novel oral anticoagulants rather than warfarin.
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28
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Kim HM, Choi EK, Park CS, Cha MJ, Lee SY, Kwon JM, Oh S. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in octogenarian patients with non-valvular atrial fibrillation. PLoS One 2019; 14:e0211766. [PMID: 30845196 PMCID: PMC6405244 DOI: 10.1371/journal.pone.0211766] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 01/21/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Elderly patients with atrial fibrillation (AF) are known to have a high risk of stroke and bleeding. We investigated the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in octogenarian patients with non-valvular AF compared with warfarin. METHODS A total of 687 octogenarian patients with AF who were administered NOACs (n = 403) or warfarin (n = 284) for stroke prevention between 2012 and 2016 were included. Thromboembolic (TE) events (stroke or systemic embolism), major bleeding events, and all-cause death were analyzed. RESULTS The NOACs group (age 83.4±3.2 years, women 52.4%, CHA2DS2-VASc score 5.0±1.8) comprised 141 dabigatran, 158 rivaroxaban, and 104 apixaban users. Most patients from the NOACs group had been prescribed a reduced dose of medication (85.6%). During 14±18 months of follow-up periods, there were 19 TE events and 18 major bleeding events. Patients with NOAC showed a lower risk of TE (1.84 vs. 2.71 per 100 person-years, hazard ration [HR] 0.134, 95% confidence interval [CI] 0.038-0.479, P = 0.002), major bleeding (1.48 vs. 2.72 per 100 person-years, HR 0.110, 95% CI 0.024-0.493, P = 0.001), and all-cause death (2.57 vs. 3.50 per 100 person-years, HR 0.298, 95% CI 0.108-0.824, P = 0.020). CONCLUSION In octogenarian Asian patients with AF, NOACs might be associated with lower risks of thromboembolic events, major bleeding, and all-cause death than warfarin. Although most patients had received reduced doses, on-label use of NOACs was effective and safe.
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Affiliation(s)
- Hyue Mee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Cardiology, Heart Stroke Vascular Center, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
| | - Chan Soon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Myung-Jin Cha
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seo-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joon-Myung Kwon
- Department of Emergency medicine, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Tiili P, Putaala J, Mehtälä J, Khanfir H, Niiranen J, Korhonen P, Raatikainen P, Lehto M. Poor Quality of Warfarin Treatment Increases the Risk of All Types of Intracranial Hemorrhage in Atrial Fibrillation. Circ J 2019; 83:540-547. [DOI: 10.1253/circj.cj-18-0975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Paula Tiili
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki
| | | | | | - Jussi Niiranen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | | | - Pekka Raatikainen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | - Mika Lehto
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
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Briere JB, Bowrin K, Coleman C, Fauchier L, Levy P, Folkerts K, Toumi M, Taieb V, Millier A, Wu O. Real-world clinical evidence on rivaroxaban, dabigatran, and apixaban compared with vitamin K antagonists in patients with nonvalvular atrial fibrillation: a systematic literature review. Expert Rev Pharmacoecon Outcomes Res 2018; 19:27-36. [DOI: 10.1080/14737167.2018.1518134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | | | - Craig Coleman
- School of Pharmacy, Storrs Hartford Hospital, University of Connecticut, Hartford, Connecticut, USA
| | - Laurent Fauchier
- Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Pierre Levy
- Université Paris-Dauphine, PSL Research University, Paris, France
| | | | - Mondher Toumi
- Faculty of Medicine, University of Aix-Marseille, Marseille, France
| | - Vanessa Taieb
- Consultant, HEOR department, Evidence Synthesis team, Creativ-Ceutical, London, UK
| | | | - Olivia Wu
- University of Glasgow, Hehta, Institute of Health & Wellbeing, Glasgow, UK
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Fanning L, Ryan-Atwood TE, Bell JS, Meretoja A, McNamara KP, Dārziņš P, Wong IC, Ilomäki J. Prevalence, Safety, and Effectiveness of Oral Anticoagulant Use in People with and without Dementia or Cognitive Impairment: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2018; 65:489-517. [DOI: 10.3233/jad-180219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Laura Fanning
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Pharmacy, Eastern Health, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Taliesin E. Ryan-Atwood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, Australia
| | - Atte Meretoja
- Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Kevin P. McNamara
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Deakin Rural Health, School of Medicine and Centre for Population Health, Deakin University, Melbourne, Australia
| | - Pēteris Dārziņš
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Ian C.K. Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Korpallová B, Samoš M, Bolek T, Škorňová I, Kovář F, Kubisz P, Staško J, Mokáň M. Role of Thromboelastography and Rotational Thromboelastometry in the Management of Cardiovascular Diseases. Clin Appl Thromb Hemost 2018; 24:1199-1207. [PMID: 30041546 PMCID: PMC6714776 DOI: 10.1177/1076029618790092] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The monitoring of coagulation by viscoelastometric methods—thromboelastography and rotational thromboelastometry—may detect the contributions of cellular and plasma components of hemostasis. These methods might overcome some of the serious limitations of conventional laboratory tests. Viscoelastic testing can be repeatedly performed during and after surgery and thus provides a dynamic picture of the coagulation process during these periods. Several experiences with the use of these methods in cardiovascular surgery have been reported, but there is perspective for more frequent use of these assays in the assessment of platelet response to antiplatelet therapy and in the assessment of coagulation in patients on long-term dabigatran therapy. This article reviews the current role and future perspectives of thromboelastography and thromboelastometry in the management of cardiovascular diseases.
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Affiliation(s)
- Barbora Korpallová
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Tomáš Bolek
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ingrid Škorňová
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - František Kovář
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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Li X, Tse VC, Au-Doung LW, Wong ICK, Chan EW. The impact of ischaemic stroke on atrial fibrillation-related healthcare cost: a systematic review. Europace 2018; 19:937-947. [PMID: 27209573 DOI: 10.1093/europace/euw093] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/12/2016] [Indexed: 01/13/2023] Open
Abstract
The aim of this study was to summarize healthcare costs incurred by patients with atrial fibrillation (AF) who developed ischaemic stroke, explore factors associated with increased cost, and highlight the importance of anticoagulation therapy for stroke prophylaxis. A systematic literature search of PubMed, EMBASE, Web of Science, and the health economic evaluation database was conducted up to December 2015. Studies focused on the cost and/or resource utilization of ischaemic stroke in patients with AF were included. Reported costs were converted to international dollars (I$) and adjusted to 2015 values. Alongside the narrative review of included studies, Spearman's correlation, independent-samples t-test, and one-way ANOVA were used to explore factors associated with cost differences between studies. Sixteen studies published from nine countries were identified. Based on currency conversion rates in 2015, ischaemic stroke-related healthcare costs were estimated to be I$41 420, I$12 895, and I$8184 for high-income, upper middle-income, and lower middle-income economies, respectively. Local GDP per capita accounted for ∼50% of the healthcare cost variation among countries. Major component of overall cost was from hospitalization. Ischaemic stroke incurring in patients with AF ≥75 years was 2.3 times that of their younger peers (P = 0.049). The economic burden from ischaemic stroke in patients with AF is considerable with positive association to country income. Clinicians and stakeholders should be aware of the importance of anticoagulation therapies in stroke prophylaxis, the occurrence of stroke, and the downstream economic burden on an increasingly ageing population.
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Affiliation(s)
- Xue Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Hong Kong SAR, China
| | - Vicki C Tse
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Hong Kong SAR, China
| | - Lung Wai Au-Doung
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Hong Kong SAR, China
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Hong Kong SAR, China.,Research Department of Practice and Policy, School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Hong Kong SAR, China
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Liu L, Huang J, Zhang X, Tang X. Efficacy and safety of triple therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing coronary stenting: A meta-analysis. PLoS One 2018; 13:e0199232. [PMID: 29920547 PMCID: PMC6007837 DOI: 10.1371/journal.pone.0199232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The optimal antithrombotic therapy for atrial fibrillation (AF) patients undergoing coronary stenting is unknown. The present meta-analysis sought to investigate the efficacy and safety of triple therapy (TT; warfarin, clopidogrel and aspirin) vs dual antiplatelet therapy (DAPT; clopidogrel plus aspirin) in those patients. METHODS PubMed and Cochrane Library were searched for studies enrolling AF patients undergoing coronary stenting on TT and DAPT up to September 2016, and fourteen studies were included. Efficacy outcomes included ischemic stroke, stent thrombosis, major adverse cardiovascular event (MACE), all-cause mortality and myocardial infarction (MI); safety outcome was major bleeding. We conducted meta-analysis and used odds ratio (OR) with 95% confidence intervals (CI) to compare TT and DAPT. Meta-regression, sensitivity and subgroup analysis were taken to investigate the source of heterogeneity in the outcome of major bleeding. RESULTS 14 eligible observational studies with 11,697 subjects were identified. Compared with DAPT, TT had decreased the risk of ischemic stroke [OR = 0.74, 95% CI (0.59, 0.93), P = 0.009] and stent thrombosis [OR = 0.40, 95% CI (0.18, 0.93), P = 0.033]. While, there was an increased risk of major bleeding [OR = 1.55, 95% CI (1.16, 2.09), P = 0.004] associated with TT. The risk of MACE, all-cause mortality and MI had no significant statistical difference between TT and DAPT. Furthermore, the results of univariate and multivariate meta-regression analysis implicated that there were no obvious correlations between certain baseline characteristics (age, gender, race, hypertension, study design) and risk of major bleeding. Also of major bleeding, the findings of sensitivity analysis were generally robust, and a prespecified subgroup analysis of race demonstrated that the source of heterogeneity might attribute to Asian studies mostly. CONCLUSIONS TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable major bleeding risk compared with DAPT, and TT was considered as a valid alternative in AF patients undergoing coronary stenting. Further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.
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Affiliation(s)
- Liyao Liu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Jietao Huang
- Department of Cardiology, Chongqing Emergency Medical Center, Chongqing, P. R. China
| | - Xiaogang Zhang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Xiaoman Tang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
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Chan YH, See LC, Tu HT, Yeh YH, Chang SH, Wu LS, Lee HF, Wang CL, Kuo CF, Kuo CT. Efficacy and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Asians With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2018; 7:JAHA.117.008150. [PMID: 29622587 PMCID: PMC6015442 DOI: 10.1161/jaha.117.008150] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin among Asians with nonvalvular atrial fibrillation remains unclear. Methods and Results In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, there were 5843, 20 079, 27 777, and 19 375 nonvalvular atrial fibrillation patients taking apixaban, dabigatran, rivaroxaban and warfarin, respectively, from June 1, 2012 to December 31, 2016. Propensity‐score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any efficacy or safety outcome or the end date of study. Hazard ratios (95% confidence intervals) comparing apixaban, dabigatran, and rivaroxaban with warfarin were: ischemic stroke/systemic embolism (IS/SE), 0.55 (0.43–0.69), 0.82 (0.68–0.98), and 0.81 (0.67–0.97); major bleeding, 0.41 (0.31–0.53), 0.65 (0.53–0.80), and 0.58 (0.46–0.72); and all‐cause mortality, 0.58 (0.51–0.66), 0.61 (0.54–0.68), and 0.57 (0.51–0.65). A total of 3623 (62%), 17 760 (88%), and 26 000 (94%) patients were taking low‐dose apixaban (2.5 mg twice daily), dabigatran (110 mg twice daily), and rivaroxaban (10–15 mg once daily), respectively. Similar to all‐dose NOACs, all low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. In contrast to other standard‐dose NOACs, apixaban was associated with lower risks of IS/SE (0.45 [0.31–0.65]), major bleeding (0.29 [0.18–0.46]), and mortality (0.23 [0.17–0.31]) than warfarin. Conclusions All NOACs were associated with lower risk of IS/SE, major bleeding, and mortality compared with warfarin in the largest real‐world practice among Asians with nonvalvular atrial fibrillation. All low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. Standard‐dose apixaban caused a lower risk of IS/SE, major bleeding, and mortality compared with warfarin.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan .,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Huang D, Wong CL, Cheng KW, Chan PH, Yue WS, Wong CK, Ho CW, Wong ICK, Chan EW, Siu CW. Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin. Postgrad Med J 2018; 94:207-211. [PMID: 29459408 DOI: 10.1136/postgradmedj-2017-135457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/08/2018] [Accepted: 01/20/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised. AIM To evaluate the impact of provision of TTR results during clinic visits on anticoagulation management. DESIGN Single-centred, randomised controlled study. SETTING Fifteen arrhythmia clinics in Hong Kong. PATIENTS AF patients prescribed warfarin. INTERVENTIONS Provision of TTR or no provision of TTR. MAIN OUTCOME MEASURES A documented discussion between doctors and patients about switching warfarin to a non-vitamin K oral anticoagulant (NOAC). RESULTS Four hundred and eighty one patients with AF prescribed warfarin were randomly assigned to (1) a TTR provision group or (2) control. Their mean age was 73.6±12.0 years and 60.7% were men. The mean CHA2DS2-VASc score was 3.2±1.6 and the mean HASBLED score was 1.7±1.2. The mean TTR was 63.9%±29.9%. At the index clinic visit, 71 of 481 patients (14.8%) had a documented discussion about switching warfarin to a NOAC. Patients with provision of TTR results were more likely to discuss switching warfarin to a NOAC than controls (19.1% vs 10.6%, P=0.03), especially those with a TTR <65% (35.2% vs 10.6%, P<0.001). A higher proportion of patients with provision of TTR results switched to a NOAC (5.9% vs 4.1%, P=0.49). CONCLUSIONS The provision of TTR among patients on warfarin was associated with a discussion about switching from warfarin to a NOAC in those with TTR <65%, but did not result in actual switching to a NOAC, suggesting additional barriers.
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Affiliation(s)
- Duo Huang
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi-Lap Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kwan-Wa Cheng
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Pak-Hei Chan
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wen-Sheng Yue
- Affiliated Hospital of North Sichuan Medical College and Medical Imaging Key Laboratory, Nanchong, China
| | - Chun-Ka Wong
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi-Wai Ho
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Murphy A, Banerjee A, Breithardt G, Camm AJ, Commerford P, Freedman B, Gonzalez-Hermosillo JA, Halperin JL, Lau CP, Perel P, Xavier D, Wood D, Jouven X, Morillo CA. The World Heart Federation Roadmap for Nonvalvular Atrial
Fibrillation. Glob Heart 2017; 12:273-284. [DOI: 10.1016/j.gheart.2017.01.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Marín F, Vanessa R. The importance of excellence in the quality of anticoagulation control whilst taking vitamin K antagonists. Thromb Haemost 2017; 113:671-3. [DOI: 10.1160/th14-12-1087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 01/18/2015] [Indexed: 12/11/2022]
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39
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Costa FM, Ferreira J, Mendes M, Carmo J. Dabigatran in real-world atrial fibrillation. Thromb Haemost 2017; 116:754-63. [DOI: 10.1160/th16-03-0203] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
SummaryIn the RE-LY clinical trial, dabigatran presented a better effectiveness/ safety profile when compared to warfarin. However, clinical trials are not very representative of the real-world setting. We aimed to assess the performance of dabigatran in real-world patients with atrial fibrillation (AF) by means of a systematic review and meta-analysis of observational comparison studies with vitamin K antagonists (VKA). We searched PubMed, Embase and Scopus databases until November 2015 and selected studies according to the following criteria: observational study performed with nonvalvular AF patients; reporting adjusted hazard ratios (HR) of clinical events in a follow-up period; for dabigatran 75 mg, 110 mg or 150 mg versus VKA. Twenty studies were selected which included 711,298 patients, 210,279 of which were treated with dabigatran and the remaining 501,019 with VKA. Ischaemic stroke incidence was of 1.65 /100 patient-years for dabigatran and 2.85/100 patient-years for VKA (HR 0.86, 95 % confidence interval of 0.74–0.99). Major bleeding rate was 3.93/100 patient-years for dabigatran and 5.61/100 patient-years for VKA (0.79, 0.69–0.89). Risk of mortality (0.73, 0.61–0.87) and intracranial bleeding (0.45, 0.38–0.52) were significantly lower in patients treated with dabigatran when compared to patients on VKA. Risk of gastrointestinal (GI) bleeding was significantly higher in patients treated with dabigatran (1.13, 1.00–1.28). No significant difference was observed in risk of myocardial infarction (0.99, 0.89–1.11). In this combined analysis of real-world observational comparison studies with VKA, dabigatran was associated with a lower risk of ischaemic stroke, major bleeding, intracranial bleeding and mortality, higher risk of GI bleeding and a similar risk of myocardial infarction.Supplementary Material to this article is available online at www.thrombosis-online.com.
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40
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Chan YH, Yeh YH, Tu HT, Kuo CT, Chang SH, Wu LS, Lee HF, See LC. Bleeding risk with dabigatran, rivaroxaban, warfarin, and antiplatelet agent in Asians with non-valvular atrial fibrillation. Oncotarget 2017; 8:98898-98917. [PMID: 29228736 PMCID: PMC5716776 DOI: 10.18632/oncotarget.22026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
It is not understood if dabigatran or rivaroxaban are superior to antiplatelet agents (AA) for safety outcomes in Asians with non-valvular atrial fibrillation (NVAF). In this study we evaluated the bleeding risk of dabigatran, rivaroxaban, warfarin and AA in Asians with NVAF. This national retrospective cohort study analyzed 6,600, 3,167, 5,338 and 8,238 consecutive NVAF patients taking dabigatran, rivaroxaban, warfarin or AAs (including aspirin, clopidogrel or ticlopidine), respectively, from June 1, 2012 to December 31, 2013. Propensity-score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any bleeding outcome or the end of the study. The CHA2DS2-VASc scores were 4.1±1.6, 4.1±1.6, 3.3±1.8 and 2.4±1.6 for the dabigatran, rivaroxaban, warfarin, and AA groups, respectively. There were 5,822 (88.2%) and 164 (5.2%) patients taking low dose dabigatran and rivaroxaban, respectively. Hazard ratios (95% confidence intervals) for dabigatran, rivaroxaban, or warfarin versus AA were: intracranial hemorrhage, 0.36 (0.23-0.57;PP=0.0037) and 1.34 (0.89-2.02;P=0.1664); gastrointestinal bleeding, 0.44 (0.32-0.59;PP=0.0189); and all hospitalized major bleeding, 0.41 (0.32-0.53;PP=0.0644) and 0.90 (0.70-1.16;P=0.4130) after adjustment. The risk reduction of all major bleeding for dabigatran versus AA persisted on subgroup analysis. In conclusion, we observed that dabiagtran was associated with a lower risk of all major bleeding in Asians with NVAF, whereas rivaroxaban had a similar risk of all major bleeding compared with antiplatelet agents after adjustment of comorbidities.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Center for Big Data Analytics and Statistics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang-Gung University, Taoyuan, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
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Lin KJ, Singer DE, Glynn RJ, Blackley S, Zhou L, Liu J, Dube G, Oertel LB, Schneeweiss S. Prediction Score for Anticoagulation Control Quality Among Older Adults. J Am Heart Assoc 2017; 6:JAHA.117.006814. [PMID: 28982676 PMCID: PMC5721874 DOI: 10.1161/jaha.117.006814] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to develop and validate a prediction model for TTR in older adults taking VKA for nonvalvular atrial fibrillation and venous thromboembolism. Methods and Results The study cohort comprised patients aged ≥65 years who were taking VKA for atrial fibrillation or venous thromboembolism and who were identified in the 2 US electronic health record databases linked with Medicare claims data from 2007 through 2014. With the predictors identified from a systematic review and clinical knowledge, we built a prediction model for TTR, using one electronic health record system as the training set and the other as the validation set. We compared the performance of the new models to that of a published prediction score for TTR, SAMe‐TT2R2. Based on 1663 patients in the training set and 1181 in the validation set, our optimized score included 42 variables and the simplified model included 7 variables, abbreviated as PROSPER (Pneumonia, Renal dysfunction, Oozing blood [prior bleeding], Staying in hospital ≥7 days, Pain medication use, no Enhanced [structured] anticoagulation services, Rx for antibiotics). The PROSPER score outperformed SAMe‐TT2R2 when predicting both TTR ≥70% (area under the receiver operating characteristic curve 0.67 versus 0.55) and the thromboembolic and bleeding outcomes (area under the receiver operating characteristic curve 0.62 versus 0.52). Conclusions Our geriatric TTR score can be used as a clinical decision aid to select appropriate candidates to receive VKA therapy and as a research tool to address confounding and treatment effect heterogeneity by anticoagulation quality.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA .,Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Daniel E Singer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Suzanne Blackley
- Clinical and Quality Analysis, Information Systems, Partners HealthCare System, Boston, MA
| | - Li Zhou
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners HealthCare System, Boston, MA
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gina Dube
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lynn B Oertel
- Anticoagulation Management Service, Department of Nursing, Massachusetts General Hospital, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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Cha MJ, Choi EK, Han KD, Lee SR, Lim WH, Oh S, Lip GYH. Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Asian Patients With Atrial Fibrillation. Stroke 2017; 48:3040-3048. [PMID: 28974629 DOI: 10.1161/strokeaha.117.018773] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/16/2017] [Accepted: 09/01/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE There are limited real-world data comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in Asians with nonvalvular atrial fibrillation. We aimed to compare the effectiveness and safety between NOACs and warfarin users in the Korean atrial fibrillation population, with particular focus on high-risk patients. METHODS Using the Korean National Health Insurance Service database, we analyzed the risk of ischemic stroke, intracranial hemorrhage (ICH) events, and all-cause death in NOAC users (n=11 611 total, n=5681 taking rivaroxaban, n=3741 taking dabigatran, and n=2189 taking apixaban) compared with propensity score-matched warfarin users (n=23 222) among patients with high-risk atrial fibrillation (CHA2DS2-VASc score ≥2) between 2014 and 2015. RESULTS NOAC treatment was associated with similar risk of ischemic stroke and lower risk of ICH and all-cause mortality compared with warfarin. All 3 NOACs were associated with a similar risk of ischemic stroke and a lower risk of ICH compared with warfarin. Dabigatran and apixaban were associated with a lower risk of total mortality and the composite net clinical outcome (ischemic stroke, ICH, and all-cause death) compared with warfarin, whereas this was nonsignificant for rivaroxaban. Among previously oral anticoagulant-naive patients (n=23 262), dabigatran and apixaban were superior to warfarin for ICH prevention, whereas rivaroxaban and warfarin were associated with similar risk of ICH. CONCLUSIONS In real-world practice among a high-risk Asian atrial fibrillation population, all 3 NOACs demonstrated similar risk of ischemic stroke and lower risk of ICH compared with warfarin. All-cause mortality was significantly lower only with dabigatran and apixaban.
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Affiliation(s)
- Myung-Jin Cha
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
| | - Eue-Keun Choi
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.).
| | - Kyung-Do Han
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
| | - So-Ryoung Lee
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
| | - Woo-Hyun Lim
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
| | - Seil Oh
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
| | - Gregory Y H Lip
- From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (M.-J.C., E.-K.C., S.O.); Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (K.-D.H.); Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Republic of Korea (S.-R.L.); Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Republic of Korea (W.-H.L.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.)
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Yoon CY, Noh J, Jhee JH, Chang TI, Kang EW, Kee YK, Kim H, Park S, Yun HR, Jung SY, Oh HJ, Park JT, Han SH, Kang SW, Kim C, Yoo TH. Warfarin Use in Patients With Atrial Fibrillation Undergoing Hemodialysis. Stroke 2017; 48:2472-2479. [DOI: 10.1161/strokeaha.117.017114] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Chang-Yun Yoon
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Juhwan Noh
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Jong Hyun Jhee
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Tae Ik Chang
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Ea Wha Kang
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Youn Kyung Kee
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Hyoungnae Kim
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Seohyun Park
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Hae-Ryong Yun
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Su-Young Jung
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Hyung Jung Oh
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Jung Tak Park
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Seung Hyeok Han
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Shin-Wook Kang
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Changsoo Kim
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
| | - Tae-Hyun Yoo
- From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C
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Zoppellaro G, Granziera S, Bertozzo G, Denas G, Marigo L, Petruzzellis F, Padayattil Jose S, Rossi K, Nante G, Pengo V. Consequences of warfarin suspension after major bleeding in very elderly patients with non valvular atrial fibrillation. Thromb Haemost 2017; 117:1828-1830. [PMID: 28726972 DOI: 10.1160/th16-11-0846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/17/2017] [Indexed: 12/16/2022]
Abstract
Supplementary Material to this article is available online at www.thrombosis-online.com.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Vittorio Pengo
- Vittorio Pengo, Clinica Cardiologica - Centro Gallucci, Via Giustiniani 2, 35128 Padova, Italy, Tel.: +39 049 821 5658, Fax: +39 049 821 5658, E-mail:
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Rivera-Caravaca JM, Esteve-Pastor MA, Roldán V, Marín F, Lip GY. Non-vitamin K antagonist oral anticoagulants: impact of non-adherence and discontinuation. Expert Opin Drug Saf 2017; 16:1051-1062. [DOI: 10.1080/14740338.2017.1351542] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- José Miguel Rivera-Caravaca
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Gregory Y.H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Almutairi AR, Zhou L, Gellad WF, Lee JK, Slack MK, Martin JR, Lo-Ciganic WH. Effectiveness and Safety of Non-vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses. Clin Ther 2017; 39:1456-1478.e36. [PMID: 28668628 DOI: 10.1016/j.clinthera.2017.05.358] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/16/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE The findings from the observational studies comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) for atrial fibrillation (AF) and venous thromboembolism (VTE) are inconsistent. We conducted separate meta-analyses examining the efficacy/effectiveness and safety of NOACs versus VKAs by disease (AF vs VTE), study design (randomized controlled trials [RCTs] vs observational studies), and NOAC (dabigatran, rivaroxaban, apixaban, and edoxaban). METHODS The main data sources included PubMed/MEDLINE, EMBASE, Web of Science, CINAHL, and Scopus from January 1, 2005, to February 15, 2016. We searched for Phase III RCTs and observational studies comparing NOACs versus VKAs. The primary outcomes were stroke/systemic embolism (SE) for AF; recurrent VTE/fatal pulmonary embolism (PE) for VTE; and major bleeding for both conditions. Secondary outcomes included stroke and myocardial infarction (MI) for AF, recurrent deep vein thrombosis (DVT)/PE for VTE, and mortality, intracranial hemorrhage (ICH), and gastrointestinal bleeding for both conditions. Pooled hazard ratios (HRs) were reported by using inverse variance-weighted random effects models. FINDINGS A total of 13 RCTs and 27 observational studies (AF, n = 32; VTE, n = 8) were included. For AF, dabigatran and VKAs were comparable for stroke/SE risk in 1 RCT (HR, 0.77 [95% CI, 0.57-1.03]) and 6 observational studies (HR, 1.03 [95% CI, 0.83-1.27]). Rivaroxaban had a 20% decreased risk of stroke/SE in 3 RCTs (HR, 0.80 [95% CI, 0.67-0.95]) compared with VKA, but the effect was nonsignificant in 3 observational studies (HR, 0.78 [95% CI, 0.59-1.04]). Apixaban decreased stroke/systemic embolism risk (HR, 0.79 [95% CI, 0.66-0.95]) compared with VKA in 1 RCT, but edoxaban was comparable to VKA (HR, 0.99 [95% CI, 0.77-1.28]) in 1 RCT (no observational studies available for apixaban/edoxaban). Dabigatran, apixaban, and edoxaban decreased the risk of hemorrhagic stroke, mortality, major bleeding, and ICH by 10% to 71% compared with VKAs but not rivaroxaban. For VTE, NOACs and VKAs were comparable for recurrent VTE/fatal PE/DVT/PE risk in 7 RCTs and 1 observational study. The 7 RCTs demonstrated a 32% to 69% decreased risk of major bleeding for dabigatran, rivaroxaban, and apixaban compared with VKAs. No difference was shown in 1 rivaroxaban observational study (HR, 0.77 [95% CI, 0.40-1.49]) and 1 edoxaban RCT (HR, 0.84 [95% CI, 0.59-1.20]). Except for dabigatran, the NOACs had a 61% to 86% decreased risk of ICH and gastrointestinal bleeding. IMPLICATIONS Overall, NOACs were comparable or superior to VKAs. Although no observational studies are currently available for apixaban/edoxaban, a few notable inconsistencies exist for dabigatran (ischemic stroke, MI) and rivaroxaban (stroke/SE, major bleeding in VTE) between RCTs and observational studies. Individualizing NOAC/VKA therapy based on benefit/safety profiles and patient characteristics is suggested.
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Affiliation(s)
- Abdulaali R Almutairi
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Lili Zhou
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Walid F Gellad
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Health Equity Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Jeannie K Lee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Marion K Slack
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Jennifer R Martin
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona; Arizona Health Sciences Library, University Libraries, University of Arizona, Tucson, Arizona
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona.
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Chiang CE, Okumura K, Zhang S, Chao TF, Siu CW, Wei Lim T, Saxena A, Takahashi Y, Siong Teo W. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm 2017; 33:345-367. [PMID: 28765771 PMCID: PMC5529598 DOI: 10.1016/j.joa.2017.05.004] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/29/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2-fold increase in mortality and a 5-fold increase in stroke. The Asian population is rapidly aging, and in 2050, the estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF-associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF-associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non-vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub-committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub-committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People׳s Republic of China
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore
| | - Anil Saxena
- Cardiac Pacing & Electrophysiology Center, Fortis Escorts Heart Institute, New Delhi, India
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Sun Q, Chang S, Lu S, Zhang Y, Chang Y. The Efficacy and Safety of 3 Types of Interventions for Stroke Prevention in Patients With Cardiovascular and Cerebrovascular Diseases: A Network Meta-analysis. Clin Ther 2017; 39:1291-1312.e8. [PMID: 28606562 DOI: 10.1016/j.clinthera.2017.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 04/05/2017] [Accepted: 04/09/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE The goal of this study was to compare the relative efficacy and safety of different types of interventions for stroke prevention in patients with cardiovascular and cerebrovascular diseases. METHODS This network meta-analysis (NMA) was conducted with a random effects model of Bayesian framework using Stata version 12.0. Odds ratios (ORs) and their credible intervals (CrIs) were applied for the efficacy and safety evaluation of various medical interventions, including aspirin, dipyridamole, ticlopidine, warfarin, and apixaban. In addition, the ranking of probability of every clinical outcome was estimated by comparing the surface under the cumulative ranking curve. FINDINGS Compared with dabigatran, both edoxaban and aspirin + warfarin exhibited a higher rate of all-cause stroke (OR, 2.84 [95% CrI, 1.17-6.97]; OR, 3.42 [95% CrI, 1.20-9.84]). With respect to intracranial hemorrhage, aspirin + clopidogrel yielded worse outcomes than 7 treatments, including placebo, apixaban, aspirin, aspirin + dipyridamole, cilostazol, clopidogrel, and dabigatran (OR, 2.21 [95% CrI, 1.45-3.40]; OR, 2.11 [95% CrI, 1.05-4.17]; OR, 1.53 [95% CrI, 1.11-2.15]; OR, 1.78 [95% CrI, 1.01-3.03]; OR, 4.17 [95% CrI, 1.37-14.28]; OR, 1.85 [95% CrI, 1.22-2.86]; and OR, 2.56 [95% CrI, 1.37-4.76]). In terms of ischemic stroke, dabigatran provided better efficacy than placebo, aspirin, and aspirin + dipyridamole (OR, 0.36 [95% CrI, 0.18-0.72]; OR, 0.43 [95% CrI, 0.21-0.84]; and OR, 0.41 [95% CrI, 0.17-0.94]). As for mortality, dabigatran resulted in a lower mortality compared with aspirin, aspirin + clopidogrel, edoxaban, and warfarin (OR, 0.48 [95% CrI, 0.23-0.97]; OR, 0.40 [95% CrI, 0.17-0.92]; OR, 0.27 [95% CrI, 0.10-0.72]; and OR, 0.52 [95% CrI, 0.28-0.92]). IMPLICATIONS There are still some limitations to our NMA research. For instance, the lack of direct evidence for some therapies resulted in inconsistencies, particularly for warfarin compared with placebo and clopidogrel under different end points. Moreover, the included randomized controlled trials for patients with cardiovascular and cerebrovascular diseases are relatively broad, involving atrial fibrillation, myocardial infarction, and large-artery atherosclerosis stroke. Although further research is needed, dabigatran is highly recommended based on the present NAM for the treatment of cardiovascular and cerebrovascular diseases due to the drug's efficacy and safety.
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Affiliation(s)
- Qian Sun
- Department of Ward Retired Officers Three, Tangshan Gongren Hospital of Ward Retire, Hebei, People's Republic of China
| | - Shumei Chang
- Department of Ward Retired Officers Three, Tangshan Gongren Hospital of Ward Retire, Hebei, People's Republic of China
| | - Songtao Lu
- Department of Ward Retired Officers Three, Tangshan Gongren Hospital of Ward Retire, Hebei, People's Republic of China
| | - Yajing Zhang
- Department of Medical Rehabilitation, Tangshan Gongren Hospital, Hebei, People's Republic of China
| | - Yajun Chang
- Department of Chinese Medicine, Tangshan Gongren Hospital, Hebei, People's Republic of China.
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49
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Cea Soriano L, Gaist D, Soriano-Gabarró M, García Rodríguez LA. Incidence of intracranial bleeds in new users of low-dose aspirin: a cohort study using The Health Improvement Network. J Thromb Haemost 2017; 15:1055-1064. [PMID: 28371181 DOI: 10.1111/jth.13686] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 01/01/2023]
Abstract
Essentials Intracranial bleeds (ICB) are serious clinical events that have been associated with aspirin use. Incidence rates of ICB were calculated among new-users of low-dose aspirin in the UK (2000-2012). Over a median follow-up of 5.58 years, the incidence of ICB was 0.08 per 100 person-years. Our estimates are valuable for inclusion in risk-benefit assessments of low-dose aspirin use. SUMMARY Background Low-dose aspirin protects against both ischemic cardiovascular (CV) events and colorectal cancer (CRC). However, low-dose aspirin may be associated with a slightly increased risk of intracranial bleeds (ICBs). Objectives To obtain the incidence rates of ICBs overall and by patient subgroups among new users of low-dose aspirin. Patients/Methods Using The Health Improvement Network (THIN) UK primary-care database (2000-2012), we identified a cohort of new users of low-dose aspirin aged 40-84 years (N = 199 079; mean age at start of follow-up, 63.9 years) and followed them for up to 14 years (median 5.58 years). Incident ICB cases were identified and validated through linkage to hospitalization data and/or review of THIN records with free-text comments. Incidence rates with 95% confidence intervals (CIs) were calculated. Results Eight hundred and eighty-one incident ICBs cases were identified: 407 cases of intracerebral hemorrhage (ICH), 283 cases of subdural hematoma (SDH), and 191 cases of subarachnoid hemorrhage (SAH). Incidence rates per 100 person-years were 0.08 (95% CI 0.07-0.08) for all ICBs, 0.04 (95% CI 0.03-0.04) for ICH, 0.03 (95% CI 0.02-0.03) for SDH, and 0.02 (95% CI 0.01-0.02) for SAH. The ICB incidence rates per 100 person-years for individuals with an indication of primary CV disease prevention were 0.07 (95% CI 0.06-0.07) and 0.09 (95% CI 0.08-0.10) for secondary CV disease prevention. Incidence rates were higher in men for SDH, and higher in women for ICH and SAH. Conclusions Our results provide valuable estimates of the absolute ICB risk for incorporation into risk-benefit assessments of low-dose aspirin use.
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Affiliation(s)
- L Cea Soriano
- Spanish Center for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - D Gaist
- Department of Neurology, Odense University Hospital, Odense University, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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50
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Healey JS, Oldgren J. Risk of mortality and stroke after atrial fibrillation - Authors' reply. Lancet 2017; 389:907. [PMID: 28271840 DOI: 10.1016/s0140-6736(17)30594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Jeff S Healey
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada.
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