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Maille B, Defaye P, Bentounes SA, Herbert J, Clerc JM, Pierre B, Torras O, Deharo JC, Fauchier L. Outcomes Associated With Left Atrial Appendage Occlusion Via Implanted Device in Atrial Fibrillation. Mayo Clin Proc 2024; 99:754-765. [PMID: 38180394 DOI: 10.1016/j.mayocp.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To compare outcomes after left atrial appendage occlusion (LAAO) via implanted device vs no LAAO in a matched cohort of patients with atrial fibrillation (AF). METHODS This longitudinal retrospective cohort study was based on the national database covering hospital care for the entire French population. Adults (≥18 years of age) who had been hospitalized with AF (January 1, 2015, to January 1, 2020) who underwent LAAO were identified. Propensity score matching was used to control for potential confounders of the treatment-outcome relationship. The primary outcome was a composite of ischemic stroke, major bleeding, or all-cause death during follow-up. RESULTS After propensity score matching, 1216 patients with AF who were treated with LAAO were matched with 1216 controls (patients AF who were not treated with LAAO). Mean follow-up was 14.5 months (median, 13 months; IQR, 7-21 months). Patients with LAAO had a lower risk of the composite outcome (HR, 0.48; 95% CI, 0.42 to 0.55). Total events (309 for LAAO vs 640 for controls) and event rates (23.3% vs 44.0%/year, respectively) were lower for LAAO, driven primarily by a decreased risk of all-cause death (HR, 0.39; 95% CI, 0.33 to 0.46; P<.0001), whereas ischemic stroke risk was higher (HR, 1.75; 95% CI, 1.17 to 2.64). Significant interactions were observed in subgroups with a history of ischemic stroke (P<.001) and of bleeding (P=.002). CONCLUSION Among AF patients at high bleeding risk, our nationwide study highlights a high risk of clinical events during follow-up. LAAO appeared less effective than no LAAO in preventing stroke but more effective in preventing death. Left atrial appendage occlusion is particularly effective in patients with previous ischemic stroke or any episode of bleeding.
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Affiliation(s)
- Baptiste Maille
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Pascal Defaye
- Service de Cardiologie, Centre Hospitalier Universitaire Grenoble Alpes, Unite de Rythmologie, Grenoble, France
| | - Sid Ahmed Bentounes
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Jean Michel Clerc
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Bertrand Pierre
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Olivier Torras
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Jean Claude Deharo
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
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Tittl L, Marten S, Naue C, Beyer-Westendorf J. Patterns of atrial fibrillation anticoagulation with rivaroxaban - 7-year follow-up from the Dresden NOAC registry. Thromb Res 2024; 236:61-67. [PMID: 38394987 DOI: 10.1016/j.thromres.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Data on long-term effectiveness and safety of rivaroxaban for stroke prevention in atrial fibrillation (SPAF) are scarce and not available from randomized clinical trials. METHODS We used data from the prospective, non-interventional DRESDEN NOAC REGISTRY to evaluate rates of stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and ISTH major bleeding, in general and changes of event patterns over time. RESULTS Between 1st October 2011 and 31st December 2022, 1204 SPAF patients receiving rivaroxaban were followed for 6.7 ± 3.4 years with a mean rivaroxaban exposure of 4.9 ± 3.5 years. During follow up, intention-to treat rates of stroke/TIA/SE were 3.5/100 pt. years (95 % CI 2.5-4.7) in the first year and fell to 1.6/100 pt. years (95 % CI 1.2-2.0) in years 2-5 and 2.1/100 pt. years (95 % CI 1.6-2.7) after 5 years. Similarly, on-treatment event rates fell from 2.4/100 pt. years (95 % CI 1.5-3.5) to 1.1 (95 % CI 0.7-1.5) and 1.6 (95 % CI 1.0-2.3), respectively. Major bleeding rates on treatment were 3.5/100 pt. years in the first treatment year (95 % CI 2.5-4.8) and 2.7 (95 % CI 2.2-3.4) and 3.5 (95 % CI 2.7-4.6) in the periods 2-5 and > 5 years, respectively. Of note, rates of fatal bleeding were low throughout follow-up (0.2 vs. 0.2 vs. 0.1/100 pt. years). CONCLUSIONS Our results demonstrate the long-term effectiveness and safety of rivaroxaban therapy in unselected SPAF patients in daily care. Our data indicate that patterns of cardiovascular events remain constant over many years. In contrast, bleeding patterns change over time, possibly due to effects of co-morbidities in an ageing population.
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Affiliation(s)
- Luise Tittl
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Sandra Marten
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Christiane Naue
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hemostaseology, University Hospital "Carl Gustav Carus" Dresden, Technical University, Fetscherstrasse 74, D-01307 Dresden, Germany.
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Wu T, Wu S, Li L, Xiang J, Wang N, Chen W, Zhang J. The impact of ABCB1, CYP3A4/5 and ABCG2 gene polymorphisms on rivaroxaban trough concentrations and bleeding events in patients with non-valvular atrial fibrillation. Hum Genomics 2023; 17:59. [PMID: 37420302 DOI: 10.1186/s40246-023-00506-3] [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: 12/17/2022] [Accepted: 07/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The influence of genetic factors on the pharmacokinetics and clinical outcomes of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) is poorly understood. This study aimed to explore the effects of CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms on the trough concentrations and the bleeding risk of rivaroxaban in NVAF patients. PATIENTS AND METHODS This study is a prospective multicenter study. The patient's blood samples were collected to detect the steady-state trough concentrations of rivaroxaban and gene polymorphisms. We visited the patients regularly at month 1, 3, 6, and 12 to record bleeding events and medications. RESULTS A total of 95 patients were enrolled in this study, and 9 gene loci were detected. For the dose-adjusted trough concentration ratio (Ctrough/D) of rivaroxaban, the homozygous mutant type was significantly lower than wild type at ABCB1 rs4148738 locus (TT vs. CC, P = 0.033), and the mutant type was significantly lower than the wild type at ABCB1 rs4728709 locus (AA + GA vs. GG, P = 0.008). ABCB1 (rs1045642, rs1128503), CYP3A4 (rs2242480, rs4646437), CYP3A5 (rs776746), and ABCG2 (rs2231137, rs2231142) gene polymorphisms had no significant effect on the Ctrough/D of rivaroxaban. For the bleeding events, we found that there were no significant differences among genotypes of all gene loci. CONCLUSION This study found for the first time that ABCB1 rs4148738 and rs4728709 gene polymorphisms had a significant impact on the Ctrough/D of rivaroxaban in NVAF patients. CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms were not associated with the bleeding risk of rivaroxaban.
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Affiliation(s)
- Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Li Li
- Department of Pharmacy, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jing Xiang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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de Pouvourville G, Cunningham D, Fricke FU, Lindgren P, Mantovani L, Murphy LA, Solà-Morales O, Mestre-Ferrandiz J, Akehurst R. Across-Country Variations of Real-World Data and Evidence for Drugs: A 5-European-Country Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:3-10. [PMID: 36709042 DOI: 10.1016/j.jval.2023.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVES This study aimed to describe the role of real-world data (RWD) and real-world evidence (RWE) in health technology assessment (HTA) in 5 European countries and to identify the hurdles to the acceptance of RWE and suggest directions toward its more effective use. METHODS Authors from France, Germany, Italy, and Sweden used a common template to extract evidence. For England, the Cancer Drugs Fund was described and analyzed as a particular model for the use of RWD to provide evidence for coverage decisions and managed entry agreements. RESULTS In all countries except Germany, HTA bodies acknowledged the relevance of RWD/RWE to address postlaunch uncertainties. In Germany, evidence from randomized controlled trials remains the gold standard, and evidence based on RWD is generally rejected. Multiple sources of RWD exist, but the quality, the immediate relevance of existing sources, and their interoperability limit their adaptation to the specifics of a given drug. This leads to skepticism about the validity of the evidence. Timing is also a key issue: the production of evidence may not be synchronized with the HTA and pricing bodies' agendas. The Cancer Drugs Fund case emphasizes that a strong partnership among all stakeholders and a pragmatic use of existing data, alongside clinical evidence provided by companies, are key success factors. CONCLUSIONS A continuous investment in national health information systems is a key issue for providing valid RWE. Processes and aids to guide the acceptability and usage of RWE derived from pairing between sources and questions are essential.
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de Pouvourville G, Armoiry X, Lavorel A, Bilbault P, Maugendre P, Bensimon L, Beziz D, Blin P, Borget I, Bouée S, Collignon C, Dervaux B, Durand-Zaleski I, Julien M, de Léotoing L, Majed L, Martelli N, Séjourné T, Viprey M. Real-world data and evidence in health technology assessment: When are they complementary, substitutes, or the only sources of data compared to clinical trials? Therapie 2023; 78:81-94. [PMID: 36464522 DOI: 10.1016/j.therap.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Within the life-cycle assessment of health technologies, real-world data (RWD) have until now been of secondary importance to clinical trial data. The availability of massive, better quality RWD, particularly with the emergence of connected devices, the improvement of methods for characterizing populations, make it possible to have a better insight into the effects of treatment, sometimes on a national scale the importance of RWD is likely to progress in the eyes of health technology assessors, going from being traditionally complementary to possibly replacing clinical trial data. This is the fundamental question that the round table, involving experts from the academic and/or hospital, institutional, and industrial worlds, set out to answer. This work served first to establish the current role of RWD in health technology assessment, by distinguishing the main purposes of RWD, the timing of the evaluation in relation to the life cycle of the technology, and then according to the party commissioning or receiving the outcomes of RWD-based studies. Secondly, the round table proposed six general recommendations for more intensive and decisive use of RWD in the assessment and decision-making process.
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Affiliation(s)
| | - Xavier Armoiry
- Université Claude Bernard Lyon 1, Institut des sciences pharmaceutiques et biologiques (ISPB)/UMR CNRS 5510 MATEIS/Hôpital Edouard Herriot, service pharmaceutique, 690008 Lyon, France.
| | | | - Pascal Bilbault
- LYSARC, centre hospitalier Lyon sud, 69495 Pierre Bénite, France
| | | | | | - Dan Beziz
- Novartis, 92300 Levallois Perret, France
| | | | | | | | | | | | | | | | | | | | | | | | - Marie Viprey
- Hospices civils de Lyon, Health Data Department, Lyon, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, 69000 Lyon, France
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Données et preuves en vie réelle dans l’évaluation des technologies de santé : dans quels cas sont-elles complémentaires, substitutives, ou les seules sources de données par rapport aux essais cliniques ? Therapie 2023; 78:66-80. [PMID: 36446648 DOI: 10.1016/j.therap.2022.10.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/21/2022] [Indexed: 11/27/2022]
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Alosaimi HM, Alqahtani S, Balkhi B, Alqahtani M, Alzamil F, Alhossan A, Alqahtany FS, Alharbi AA, Alqahtani NA, Albackr H, Elgohary G, Algahtani FH. A retrospective study of real-world effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation and venous thromboembolism in Saudi Arabia. PeerJ 2022; 10:e13974. [PMID: 36105646 PMCID: PMC9466595 DOI: 10.7717/peerj.13974] [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: 02/28/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023] Open
Abstract
Background Real-world evidence on factor Xa inhibitor (rivaroxaban) prescribing patterns, safety, and efficacy in patients with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) is rare. Herein, we sought to examine the above outcomes in the largest academic center in the Kingdom of Saudi Arabia (KSA). Methods This is a retrospective observational study designed to examine the prescribing pattern, safety and real-world effectiveness of the factor Xa inhibitor rivaroxaban in patients with NVAF and VTE. Data on rivaroxaban prescriptions were collected and analyzed. Bleeding outcomes were defined as per the International Society on Thrombosis and Hemostasis (ISTH) definition. Results A total of 2,316 patients taking rivaroxaban recruited through several departments of King Saud University Medical City (KSUMC). The mean age was 61 years (±17.8) with 55% above the age of 60 and 58% were females. Deep vein thrombosis and pulmonary embolism (VTE) was the most prevalent reason for prescribing rivaroxaban, followed by NVAF. A total daily dosage of 15 mg was given to 23% of the patients. The incidence rate of recurrent thrombosis and recurrent stroke was 0.2%. Furthermore, rivaroxaban had a 0.04 percent incidence rate of myocardial infarction. Half of the patients with recurrent thrombosis and stroke were taking 15 mg per day. The incidence rate of major bleeding was 1.1%. More over half of the patients who experienced significant bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score (>2 score), 48 percent of patients who experienced significant bleeding had a high risk of bleeding. Non-major bleeding occurred in 0.6% of cases. Similarly, 40% of patients with non-major bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score, just 6.6% of these individuals had a high risk of bleeding. 93.4% of the patients, on the other hand, were at intermediate risk. Conclusion The prescription of rivaroxaban in this real-life cohort study differs from the prescribing label and the outcomes of a phase 3 randomised clinical trial. However, for individuals with VTE and NVAF, the 20 mg dose looked to be more efficacious than the pivotal trial outcomes. Furthermore, among patients with VTE and NVAF, rivaroxaban was linked to a decreased incidence of safety events such as recurrent thrombosis, recurrent stroke, MI, major bleeding, and non-major haemorrhage in a real-world environment.
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Affiliation(s)
- Hind M. Alosaimi
- Clinical Pharmacy Department, College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia,Pharmacy Services, King Fahad Medical City, Riyadh Second Health Cluster, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Bander Balkhi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mishari Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faisal Alzamil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Fatmah S. Alqahtany
- Hematopathology Unit, Department of Pathology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf Abdullah Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hanan Albackr
- Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ghada Elgohary
- Department of Adult Hematology/Oncology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,Clinical Hematology and Bone Marrow Transplantation Unit, Division of Internal Medicine, Ain Shams University, Cairo, Egypt
| | - Farjah H. Algahtani
- Division of Oncology/Hematology, Department of Medicine, College of Medicine, King Saud University, Kind Saud University Medical City, Riyadh, Saudi Arabia
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Utility of automated data-adaptive propensity score method for confounding by indication in comparative effectiveness study in real world Medicare and registry data. PLoS One 2022; 17:e0272975. [PMID: 35969535 PMCID: PMC9377588 DOI: 10.1371/journal.pone.0272975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/31/2022] [Indexed: 11/19/2022] Open
Abstract
Background Confounding by indication is a serious threat to comparative studies using real world data. We assessed the utility of automated data-adaptive analytic approach for confounding adjustment when both claims and clinical registry data are available. Methods We used a comparative study example of carotid artery stenting (CAS) vs. carotid endarterectomy (CEA) in 2005–2008 when CAS was only indicated for patients with high surgical risk. We included Medicare beneficiaries linked to the Society for Vascular Surgery’s Vascular Registry >65 years old undergoing CAS/CEA. We compared hazard ratios (HRs) for death while adjusting for confounding by combining various 1) Propensity score (PS) modeling strategies (investigator-specified [IS-PS] vs. automated data-adaptive [ada-PS]); 2) data sources (claims-only, registry-only and claims-plus-registry); and 3) PS adjustment approaches (matching vs. quintiles-adjustment with/without trimming). An HR of 1.0 was used as a benchmark effect estimate based on CREST trial. Results The cohort included 1,999 CAS and 3,255 CEA patients (mean age 76). CAS patients were more likely symptomatic and at high surgical risk, and experienced higher mortality (crude HR = 1.82 for CAS vs. CEA). HRs from PS-quintile adjustment without trimming were 1.48 and 1.52 for claims-only IS-PS and ada-PS, 1.51 and 1.42 for registry-only IS-PS and ada-PS, and 1.34 and 1.23 for claims-plus-registry IS-PS and ada-PS, respectively. Estimates from other PS adjustment approaches showed similar patterns. Conclusions In a comparative effectiveness study of CAS vs. CEA with strong confounding by indication, ada-PS performed better than IS-PS in general, but both claims and registry data were needed to adequately control for bias.
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Wu HH, Chang SH, Lee TH, Tu HT, Liu CH, Chang TY. Concurrent use of statins decreases major bleeding and intracerebral hemorrhage in non-valvular atrial fibrillation patients taking direct oral anticoagulants—A nationwide cohort study. Front Cardiovasc Med 2022; 9:969259. [PMID: 36003918 PMCID: PMC9393418 DOI: 10.3389/fcvm.2022.969259] [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: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Statins are frequently prescribed with direct oral anticoagulants (DOACs), and previous studies have raised concerns about the increased risk of intracerebral hemorrhage or other major bleeding in concurrent statins and DOACs use. The objective of this study is to evaluate the risk of major bleeding in non-valvular atrial fibrillation patients taking DOACs with or without statins. Methods This nationwide, retrospective cohort study used data from the Taiwan National Health Insurance Research Database, enrolled a total of 90,731 non-valvular atrial fibrillation patients receiving rivaroxaban, dabigatran, apixaban or edoxaban from January 1st, 2012 to December 31st, 2017. Major bleeding was defined as a hospitalization or emergency department visit with a primary diagnosis of intracerebral hemorrhage, gastrointestinal tract bleeding, urogenital tract bleeding, or other sites of bleeding. Adjusted incidence rate ratios (IRR) and differences of major bleeding between person-quarters of DOACs with or without statins were estimated using a Poisson regression and inverse probability of treatment weighting using the propensity score. Results 50,854 (56.0%) of them were male with a mean age of 74.9 (SD, 10.4) years. Using DOACs without statins as a reference, the adjusted IRR for all major bleedings in concurrent use of DOACs and statins was 0.8 (95% CI 0.72–0.81). Lower major bleeding risk was seen in both low-to-moderate-intensity statins (IRR: 0.8, 95% CI 0.74–0.84) and high-intensity statins (IRR: 0.8, 95% CI 0.74–0.88). Concurrent use of DOACs and statins decreased the risk for intracerebral hemorrhage with an IRR of 0.8 (95% CI 0.66–0.93), and gastrointestinal tract bleeding with an IRR of 0.7 (95% CI 0.69–0.79). The protective effect of statins on intracerebral hemorrhage was observed only in female patients (IRR 0.67, 95% CI 0.51–0.89), but not in male patients (IRR 0.87, 95% CI 0.70–1.08). Conclusions Among non-valvular atrial fibrillation patients who were taking DOACs, concurrent use of statins decreased major bleeding risk, including intracerebral hemorrhage and gastrointestinal tract bleeding. Considering this and other cardioprotective effects, statins should be considered in all eligible patients prescribed with DOACs.
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Affiliation(s)
- Hsin-Hsu Wu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hung Liu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ting-Yu Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Ting-Yu Chang
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Badescu MC, Badulescu OV, Butnariu LI, Floria M, Ciocoiu M, Costache II, Popescu D, Bratoiu I, Buliga-Finis ON, Rezus C. Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia. J Pers Med 2022; 12:519. [PMID: 35455634 PMCID: PMC9029474 DOI: 10.3390/jpm12040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Internal Medicine Clinic, “Dr. Iacob Czihac” Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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11
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Zhang F, Chen X, Wu T, Huang N, Li L, Yuan D, Xiang J, Wang N, Chen W, Zhang J. Population Pharmacokinetics of Rivaroxaban in Chinese Patients with Non-Valvular Atrial Fibrillation: A Prospective Multicenter Study. Clin Pharmacokinet 2022; 61:881-893. [PMID: 35316848 DOI: 10.1007/s40262-022-01108-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Rivaroxaban is a novel oral anticoagulant widely used for thromboprophylaxis in patients with non-valvular atrial fibrillation (NVAF). The present study aimed to develop a population pharmacokinetic (PPK) model for rivaroxaban in Chinese patients with NVAF. METHODS We performed a prospective multicenter study. The plasma concentration of rivaroxaban was directly detected by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) and indirectly by rivaroxaban-calibrated chromogenic anti-Xa assay (STA®). Gene polymorphisms were detected by MassARRAY single nucleotide polymorphism genotyping technology. Nonlinear mixed-effects modeling was used to develop the PPK model for rivaroxaban in patients with NVAF, and we simulated the steady-state rivaroxaban exposures under different dosing strategies in different covariate levels. RESULTS A total of 150 patients from five centers were recruited, including 263 plasma concentrations detected by HPLC-MS/MS, 2626 gene polymorphisms, and 131 plasma concentrations detected by anti-Xa assay. In our study, an oral one-compartment model was used to describe the pharmacokinetics of rivaroxaban in patients with NVAF. In the final model, the estimated apparent clearance (CL/F) and volume of distribution (V/F) were 5.79 L/h (relative standard error [RSE] 4.4%) and 51.5 L (RSE 5.0%), respectively. Covariates in the final model included creatinine clearance, total bilirubin, rs4728709, and body weight. The simulation results showed that in the 15 mg once-daily dosing regimen, in most instances the maximum plasma concentration at steady state (Cmax,ss) and trough plasma concentration at steady state (Cmin,ss) were in the target range for different covariate levels. When patients were administered rivaroxaban 15 or 20 mg once daily, the Cmax,ss and Cmin,ss in the different bodyweight levels were also in the target range. For patients with the ABCB1 rs4728709 mutation, the Cmin,ss in the 10, 15, and 20 mg once-daily dosing regimens were lower than the target range. The anti-Xa assay was highly linearly correlated with the HPLC-MS/MS method [y = 1.014x - 2.4648 (R2 = 0.97)]. CONCLUSIONS Our study was the first multicenter PPK model for rivaroxaban in Chinese patients with NVAF (Alfalfa-RIVAAF-PPK). The study found that 15 mg once daily may be suitable as the principal rivaroxaban dose for Chinese patients with NVAF. For patients with the rs4728709 mutation, it may be necessary to examine insufficient anticoagulation. We found that the rivaroxaban-calibrated chromogenic anti-Xa assay and HPLC-MS/MS method were highly linearly correlated. Prospective studies with larger sample sizes and real-world studies are needed for further verification.
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Affiliation(s)
- Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuehai Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Li Li
- Department of Pharmacy, Guizhou Provincial People's Hospital, Guiyang, China
| | - Dongdong Yuan
- Department of Pharmacy, The Seventh People's Hospital of Zhengzhou, Zhengzhou, China
| | - Jing Xiang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.
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12
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Liu PH, Liu ZH, Niu MH, Chen P, Shi YB, He F, Guo R. A Comparative Study of the Clinical Benefits of Rivaroxaban and Warfarin in Patients With Non-valvular Atrial Fibrillation With High Bleeding Risk. Front Cardiovasc Med 2022; 9:803233. [PMID: 35252386 PMCID: PMC8888829 DOI: 10.3389/fcvm.2022.803233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo compare the clinical benefits of rivaroxaban and warfarin in patients with non-valvular atrial fibrillation (NVAF) with high bleeding risk.MethodsA retrospective study was conducted on patients with high bleeding risk NVAF who were hospitalized at the First Affiliated Hospital of Zhengzhou University between May 31, 2016 and May 31, 2019 and took at least rivaroxaban and warfarin. The clinical benefits of both drugs were assessed by efficacy benefit and safety risk. The primary efficacy benefit was a composite end point for stroke (both ischemic and hemorrhagic) and systemic embolism. The secondary efficacy end points were death and myocardial infarction (MI). The principal safety end point was the composite end point of fatal bleeding and critical organ bleeding.ResultsA total of 1,246 patients with high bleeding risk were enrolled, including 787 patients in the rivaroxaban group and 459 patients in the warfarin group. Results of the primary efficacy benefit endpoint were obtained from 104 patients (13.2%) in the rivaroxaban group and 88 (19.2%) patients in the warfarin group (hazard ratio [HR]: 0.681; 95% confidence interval [CI]: 0.512–0.906; P < 0.001 for non-inferiority). The principal safety end points were observed in 49 (6.23%) patients in the rivaroxaban group and in 55 (11.98%) patients in the warfarin group (HR: 0.469 in the rivaroxaban group; 95% CI: 0.314–0.702; P < 0.001). With respect to secondary efficacy and benefit endpoints, 28 (3.56%) patients in the rivaroxaban group and 22 (4.79%) patients in the warfarin group died, with an HR of 0.760 (95% CI: 0.435–1.329; P = 0.336); 32 (4.07%) patients in the rivaroxaban group; and 26 (5.66%) patients in the warfarin group had MI, with an HR of 1.940 (95% CI: 0.495–1.069, P = 0.254) in the rivaroxaban group.ConclusionsRivaroxaban is non-inferior to warfarin in the prevention of stroke and systemic embolism in patients with high blood NVAF. Rivaroxaban is superior to warfarin in reducing fatal bleeding and bleeding in critical organs.Clinical Trial RegistrationChinese Clinical Trials Registry, identifier ChiCTR2100052454.
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Affiliation(s)
- Peng-Hui Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ze-Hua Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming-Hui Niu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ping Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan-Bin Shi
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei He
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Fei He
| | - Rong Guo
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Rong Guo
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13
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Blin P, Darmon P, Henry P, Guiard E, Bernard MA, Dureau-Pournin C, Maizi H, Thomas-Delecourt F, Lassalle R, Droz-Perroteau C, Moore N. Patients with stable coronary artery disease and type 2 diabetes but without prior myocardial infarction or stroke and THEMIS-like patients: real-world prevalence and risk of major outcomes from the SNDS French nationwide claims database. Cardiovasc Diabetol 2021; 20:229. [PMID: 34823531 PMCID: PMC8620638 DOI: 10.1186/s12933-021-01416-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/12/2021] [Indexed: 11/10/2022] Open
Abstract
AIM AND HYPOTHESES The THEMIS randomized trial compared ticagrelor plus aspirin versus placebo plus aspirin for patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), and without prior myocardial infarction (MI) or stroke. The aim of the study was to quantify the size of the CAD-T2DM population without prior MI or stroke population in a real-world setting, and more specifically populations with similar THEMIS selection criteria (THEMIS-like and THEMIS-PCI-like populations), as well as their risk of major outcomes in current practice. METHODS A 2-year follow-up cohort study included all CAD-T2DM without MI/stroke prevalent patients on January 1st, 2014 in the SNDS French nationwide claims database. The THEMIS-like population concerned those ≥ 50 years of age with similar THEMIS inclusion and exclusion criteria. Prevalence was standardized to the European population. The cumulative incidence function was used to estimate the incidence of clinical outcomes (MI, ischemic stroke, and major bleeding according to the TIMI classification) with death as competing risk, and the Kaplan-Meier estimate for all-cause death and a composite outcome of MI, stroke and all-cause death. RESULTS From a population of about 50 million adults, the prevalence of CAD-T2DM without MI/stroke, THEMIS-like and THEMIS-PCI-like populations was respectively at 6.04, 1.50 and 0.27 per 1000 adults, with a mean age of 72.7, 72.3 and 70.9 years and less comorbidities and diabetic complications for the THEMIS-like and THEMIS-PCI-like population. The 2-year cumulative incidence was respectively 1.7%, 1.3% and 1.6% for MI, 1.7%, 1.5% and 1.4% for stroke, 4.8%, 3.1% and 2.9% for major bleeding, 13.6%, 9.7% and 6.8% for all-cause death, and 16.2%, 12.0% and 9.5% for the composite outcome. CONCLUSION THEMIS-like prevalence was estimated at 1.50 per 1,000 adults, representing about a quarter of CAD-T2DM without MI/stroke patients, and 0.27 per 1000 adults for the THEMIS-PCI-like populations. In current French practice, the median age of both these populations was about 5-6 years older than in the THEMIS trial, with a 2-year incidence of major outcomes between two or four time above the ones of the placebo arm of the THEMIS trial using very close definitions. Registration No. EUPAS27402 ( http://www.ENCEPP.eu ).
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Affiliation(s)
- Patrick Blin
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France.
| | - Patrice Darmon
- Hospital La Conception, Marseille, France.,Aix-Marseille University, INSERM, INRA, C2VN, Marseille, France
| | | | - Estelle Guiard
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France
| | - Marie-Agnès Bernard
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France
| | | | - Hélène Maizi
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France
| | | | - Régis Lassalle
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France
| | | | - Nicholas Moore
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 33000, Bordeaux, France
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Bonanad C, García-Blas S, Torres Llergo J, Fernández-Olmo R, Díez-Villanueva P, Ariza-Solé A, Martínez-Sellés M, Raposeiras S, Ayesta A, Bertomeu-González V, Tarazona Santabalbina F, Facila L, Vivas D, Gabaldón-Pérez A, Bodi V, Nuñez J, Cordero A. Direct Oral Anticoagulants versus Warfarin in Octogenarians with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:5268. [PMID: 34830548 PMCID: PMC8618042 DOI: 10.3390/jcm10225268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63-0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70-0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69-1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76-1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36-0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF.
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Affiliation(s)
- Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
| | - Javier Torres Llergo
- Cardiology Department, Hospital Universitario de Jaén, 23007 Jaén, Spain; (J.T.L.); (R.F.-O.)
| | - Rosa Fernández-Olmo
- Cardiology Department, Hospital Universitario de Jaén, 23007 Jaén, Spain; (J.T.L.); (R.F.-O.)
| | | | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain;
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Sergio Raposeiras
- Cardiology Department, Hospital Álvaro Cunqueiro, 36213 Vigo, Spain;
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Vicente Bertomeu-González
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario de San Joan, 03550 Alicante, Spain
- Department of Clinical Medicine, Universidad Miguel Hernandez, 03550 Alicante, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General Universitario de Valencia, 46014 Valencia, Spain;
| | - David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Ana Gabaldón-Pérez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
| | - Vicente Bodi
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
| | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario de San Joan, 03550 Alicante, Spain
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15
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Mu G, Zhang H, Liu Z, Xie Q, Zhou S, Wang Z, Wang Z, Hu K, Hou J, Zhao N, Xiang Q, Cui Y. Standard- vs. low-dose rivaroxaban in patients with atrial fibrillation: a systematic review and meta-analysis. Eur J Clin Pharmacol 2021; 78:181-190. [PMID: 34651200 DOI: 10.1007/s00228-021-03226-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/23/2021] [Indexed: 01/27/2023]
Abstract
PURPOSE Low-dose rivaroxaban is often given to patients with atrial fibrillation (AF) around the world, but the rationale for its use remains unclear. We aimed to compare the efficacy and safety of standard- or low-dose rivaroxaban in patients with AF through systematic review of literature with meta-analysis. METHODS We searched PubMed, Web of Science, EMBASE, Clinical Trials.gov, the Cochrane Library, and Bayer trial website from inception of each database until June 2020. Randomized controlled trials (RCTs) and cohort studies were included in the meta-analysis. A random-effects model was employed to calculate the pooled effect estimates. RESULTS Two RCTs and 17 cohort studies were included in the qualitative analysis. Indirect comparison of RCTs showed no significant difference between the two rivaroxaban dosages in risk of efficacy or safety outcomes (p > 0.05). Indirect comparison of cohort studies showed a lower risk of MACE among Caucasians in standard-dose group (HR 0.779; 95% CI 0.687-0.884; p < 0.001). Bleeding outcomes did not differ significantly between the two dosage regimens in Asian or Caucasian populations, except that the standard dose was associated with higher risk of major bleeding among elderly Caucasian patients (HR 1.329; 95% CI 1.141-1.547; p < 0.001). The quality of evidence was rated ranging from very low to low for all the efficacy and safety outcomes. CONCLUSION In Caucasians with AF, standard-dose rivaroxaban may prevent MACE significantly better than low-dose treatment. Further studies in Asians are needed to verify the advantages of the standard dose.
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Affiliation(s)
- Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jingyi Hou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Nan Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.
- Institute of Clinical Pharmacology, Peking University, Beijing, China.
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16
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Alasnag M, Naccarelli GV. Leaps and Gaps in Transcatheter Aortic Valve Replacement Management. Circ Cardiovasc Interv 2021; 14:e010719. [PMID: 33877867 DOI: 10.1161/circinterventions.121.010719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia (M.A.)
| | - Gerald V Naccarelli
- Penn State University College of Medicine, Milton S. Hershey Medical Center, Heart and Vascular Institute, PA (G.V.N.)
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Gedikli Ö, Altay S, Ünlü S, Çakmak HA, Aşkın L, Yanık A, Beşli F, Sinan ÜY, Canpolat U, Şahin M, Pehlivanoğlu S. Real-life data of major and minor bleeding events with direct oral anticoagulants in the one-year follow-up period: The NOAC-TURK study. Anatol J Cardiol 2021; 25:196-204. [PMID: 33690135 DOI: 10.5152/anatoljcardiol.2021.57635] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the safety of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) during daily clinical practice. METHODS This was a prospective study conducted between January 01, 2016, and April 01, 2017, in patients aged ≥18 years with a diagnosis of NVAF. We performed the study in 9 clinical centers from different regions of Turkey, and the mean follow-up period was 12+2 months. We investigated major and minor bleeding events of DOAC. RESULTS A total of 1807 patients with NVAF were enrolled. The mean age of the patients was 73.6±10.2 years, CHA2DS2-VASc score was 3.6±1.4, and HAS-BLED score was 2±1.2. The most frequently prescribed DOAC was dabigatran 110 mg bid in 409 (22.6%) patients. The patients on apixaban 2.5 mg bid were older (p<0.001). Patients on rivaroxaban 15 mg od also had a higher prevalence of chronic renal failure, 46 (16.7%) patients. A total of 205 (11.4%) bleeding events were observed; among these, 34 (1.9%) patients had major bleeding and 171 (9.4%) patients had minor bleeding. The major and minor bleeding events were 2/273 (0.7%) and 30/273 (10.9%) in patients receiving dabigatran 150 mg bid, 13/409 (3%) and 44/409 (10.7%) in patients receiving dabigatran 110 mg bid, 4/385 (1%) and 42/385 (10.9%) in patients receiving rivaroxaban 20 mg od, 8/276 (2.9%) and 27/276 (9.7%) in patients receiving rivaroxaban 15 mg od, 3/308 (0.9%) and 14/308 (4.5%) in patients receiving apixaban 5 mg bid, 4/156 (2.5%) and 14/156 (9%) in patients receiving apixaban 2.5 mg bid, respectively. The total bleeding events were 17 (5.6%) in patients receiving apixaban 5 mg, less than those receiving other DOACs. On multivariate analyses, rivaroxaban 20 mg od (p=0.002), ATRIA and HAS-BLED scores, and peripheral artery disease were independent indicators of bleeding. The most frequent location of major bleeding was the gastrointestinal system (GIS) [17 (0.9%) patients], and the most frequent location of minor bleeding was the gingiva [45 (2.5%) patients]. CONCLUSION This study showed that similar results as the previous real-life study; however, we had some different results, such as the GIS tract bleeding was more frequent in patients receiving dabigatran 110 mg bid. The major and intracranial bleeding events were similar for different DOACs; and among DOACs, only rivaroxaban 20 mg od was associated with a high risk of bleeding.
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Affiliation(s)
- Ömer Gedikli
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayıs University; Samsun-Turkey
| | - Servet Altay
- Department of Cardiology, Faculty of Medicine, Trakya University; Edirne-Turkey
| | - Serkan Ünlü
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara-Turkey
| | | | - Lütfü Aşkın
- Department of Cardiology, Faculty of Medicine, Adıyaman University; Adıyaman-Turkey
| | - Ahmet Yanık
- Department of Cardiology, Samsun Education and Research Hospital; Samsun-Turkey
| | - Feyzullah Beşli
- Department of Cardiology, Faculty of Medicine, Harran University; Şanlıurfa-Turkey
| | - Ümit Yaşar Sinan
- Institute of Cardiology, Faculty of Medicine, İstanbul University; İstanbul-Turkey
| | - Uğur Canpolat
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara-Turkey
| | - Mahmut Şahin
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayıs University; Samsun-Turkey
| | - Seçkin Pehlivanoğlu
- Department of Cardiology, Faculty of Medicine, Başkent University, İstanbul-Turkey
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Belkouche A, Yao H, Putot A, Chagué F, Rochette L, Danchin N, Fauchier L, Zeller M, Cottin Y. The Multifaceted Interplay between Atrial Fibrillation and Myocardial Infarction: A Review. J Clin Med 2021; 10:E198. [PMID: 33430505 PMCID: PMC7826531 DOI: 10.3390/jcm10020198] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/26/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
This review was conducted to emphasize the complex interplay between atrial fibrillation (AF) and myocardial infraction (MI). In type 1 (T1) MI, AF is frequent and associated with excess mortality. Moreover, AF after hospital discharge for T1MI is not rare, suggesting the need to improve AF screening and to develop therapeutic strategies for AF recurrence. Additionally, AF is a common trigger for type 2 MI (T2MI), and recent data have shown that tachyarrhythmia or bradyarrhythmia could be a causal factor in, respectively, 13-47% or 2-7% of T2MI. In addition, AF is involved in T2MI pathogenesis as a result of severe anemia related to anticoagulants. AF is also an underestimated and frequent cause of coronary artery embolism (CE), as a situation at risk of myocardial infarction with non-obstructive coronary arteries. AF-causing CE is difficult to diagnose and requires specific management. Moreover, patients with both AF and chronic coronary syndromes represent a therapeutic challenge because the treatment of AF include anticoagulation, depending on the embolic risk, and ischemic heart disease management paradoxically includes antiplatelet therapy.
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Affiliation(s)
- Alban Belkouche
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, 21000 Dijon, France; (A.B.); (H.Y.); (F.C.)
| | - Hermann Yao
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, 21000 Dijon, France; (A.B.); (H.Y.); (F.C.)
| | - Alain Putot
- Department of Geriatry, University Teaching Hospital Dijon Bourgogne, 21000 Dijon, France;
| | - Frédéric Chagué
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, 21000 Dijon, France; (A.B.); (H.Y.); (F.C.)
| | - Luc Rochette
- Team PEC2, EA 7460, University of Burgundy, 21078 Dijon, France; (L.R.); (M.Z.)
| | - Nicolas Danchin
- Department of Cardiology, University Teaching Hospital of Georges Pompidou, 75015 Paris, France;
| | - Laurent Fauchier
- Department of Cardiology, University Teaching Hospital of Trousseau and University François Rabelais, 37000 Tours, France;
| | - Marianne Zeller
- Team PEC2, EA 7460, University of Burgundy, 21078 Dijon, France; (L.R.); (M.Z.)
| | - Yves Cottin
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, 21000 Dijon, France; (A.B.); (H.Y.); (F.C.)
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Tsai CT, Liao JN, Chiang CE, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chung FP, Chao TF, Lip GYH, Chen SA. Association of Ischemic Stroke, Major Bleeding, and Other Adverse Events With Warfarin Use vs Non-vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation With a History of Intracranial Hemorrhage. JAMA Netw Open 2020; 3:e206424. [PMID: 32478848 PMCID: PMC7265096 DOI: 10.1001/jamanetworkopen.2020.6424] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Current guidelines recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). Data regarding warfarin sodium use compared with NOAC use in patients with AF with a history of intracranial hemorrhage (ICH) are limited. OBJECTIVE To compare the clinical outcomes of warfarin use and NOAC use in patients with AF with a history of ICH using a nationwide cohort with AF. DESIGN, SETTING, AND PARTICIPANTS A nationwide cohort study from January 1, 2012, to December 31, 2016, was performed using data from the Taiwan National Health Insurance Research Database. The dates of analysis were July 1 to September 1, 2019. The study population comprised patients with AF with a history of ICH and a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, prior stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease], age 65-74 years, sex category [female]) of at least 1 for men or at least 2 for women who had received warfarin or NOACs. The clinical outcomes were examined using Cox proportional hazards regression analyses among the study population before and after propensity score matching. EXPOSURES Oral anticoagulation with warfarin or NOACs. MAIN OUTCOMES AND MEASURES The clinical outcomes measured were all-cause mortality, ischemic stroke, ICH, major bleeding, and adverse events. RESULTS The study cohort included 4540 patients (mean [SD] age, 76.0 [10.5] years; 2653 men [58.4%]), with 1047 patients receiving warfarin (mean [SD] age, 75.1 [11.4] years; 571 men [54.5%]) and 3493 patients receiving NOACs (mean [SD] age, 76.3 [10.2] years; 2082 men [59.6%]). Compared with warfarin use, NOAC use was associated with statistically significantly lower risk of all-cause mortality (adjusted hazard ratio [aHR], 0.517; 95% CI, 0.457-0.585), ICH (aHR, 0.556; 95% CI, 0.389-0.796), and major bleeding (aHR, 0.645; 95% CI, 0.525-0.793), whereas the rate of ischemic stroke was similar in the 2 groups (aHR, 0.879; 95% CI, 0.678-1.141). These results were generally consistent after propensity score matching among 973 patients in each group. CONCLUSIONS AND RELEVANCE Among patients with AF with prior ICH, NOAC use was associated with lower rates of ICH and major bleeding compared with warfarin use, whereas the rate of ischemic stroke was similar in the 2 groups. Among patients with AF with prior ICH, NOACs could be the preferred choice for stroke prevention.
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Affiliation(s)
- Chuan-Tsai Tsai
- 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
| | - Jo-Nan Liao
- 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
| | - Chern-En Chiang
- 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
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- 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
| | - Shih-Lin Chang
- 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
| | - Li-Wei Lo
- 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
| | - Yu-Feng Hu
- 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
| | - Ta-Chuan Tuan
- 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
| | - Fa-Po Chung
- 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
| | - 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
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- 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
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20
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Abstract
At the time of their marketing authorization, the effects of drugs and especially their efficacy have been mostly studied in randomized controlled clinical trials (RCT), comparing them to placebo or to existing drugs. However, RCT are by nature limited in their extent, and the often stringent inclusion and exclusion criteria destined to provide for homogeneous study populations reduce the generalizability of RCT results.The post-authorization evaluation of drugs (pharmacoepidemiology or real-world evidence (RWE)) covers the description of drug utilization and population risks or benefits of these drugs after they have been marketed and provided to their target populations. Though field studies have existed for a long time, modern pharmacoepidemiology has been made possible essentially by the emergence of large population databases compiled from claims data or electronic health records. The methods can be exposure or disease-based cohorts or event-driven case-based studies, tailored to the specific questions to be answered. They rely on scrupulous analysis and execution of impeccable methodology, to ensure the most reliable results possible.Pharmacoepidemiology requires knowledge of the pharmacology of drugs, of the clinical aspects of diseases and disease management, and of the epidemiological methods that can apply.
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Affiliation(s)
- Nicholas Moore
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, Bordeaux, France.
| | - Patrick Blin
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, Bordeaux, France
| | - Cécile Droz
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, Bordeaux, France
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