Recent pharmacological advances for treating venous thromboembolism: are we witnessing the demise of warfarin?

Use of non-vitamin K antagonists oral anticoagulants in atrial fibrillation patients on dialysis

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) showed a benefit-risk profile superior to that of warfarin in atrial fibrillation (AF) patients with mild to moderate chronic kidney disease. However, the effectiveness and safety of NOACs in AF patients with end-stage renal disease (ESRD) on dialysis remain unclear. Therefore, we performed a meta-analysis regarding the effect of NOACs vs. warfarin in AF patients undergoing dialysis.

Methods

A search of the Pubmed and EMBASE databases until November 2021 was performed. Adjusted risk ratios (RRs) and 95%confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.

Results

Six studies involving 3,744 NOAC- and 26,973 warfarin- users were deemed to meet the criteria. In the pooled analysis, the use of mixed NOACs had similar incidences of effectiveness and safety outcomes compared with warfarin use. And factor Xa inhibitors (rivaroxaban or apixaban) did not have significantly better effectiveness than warfarin. For the safety outcomes, the use of factor Xa inhibitors was associated with a reduced risk of gastrointestinal bleeding (RR = 0.81, 95% CI 0.70–0.95), but not major bleeding and intracranial bleeding.

Conclusion

Compared with warfarin, the use of NOACs, especially factor Xa inhibitors (rivaroxaban or apixaban), showed at least similar effectiveness and safety outcomes in AF patients on dialysis.

Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation: JACC Review Topic of the Week

Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist as they share multiple risk factors, including hypertension, diabetes mellitus, and coronary artery disease. Although there is irrefutable evidence supporting anticoagulation in AF in the general population, these data may not be transferable to the setting of advanced CKD, where the decision to commence anticoagulation poses a conundrum. In this cohort, there is a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, complicating the decision to initiate anticoagulation. No definitive clinical guidelines derived from randomized controlled trials exist to aid clinical decision-making, and the findings from observational studies are conflicting. In this review, the authors outline the pathophysiological mechanisms at play and summarize the limited existing data related to anticoagulation in those with concomitant CKD and AF. Finally, the authors suggest how to approach the decision of whether and how to use oral anticoagulation in these patients.

Risk assessment and prophylaxis of venous thromboembolism in surgical inpatients: improving adherence to national guidelines

In Europe, venous thromboembolism (VTE) is the third most common cause of vascular death after myocardial infarction and stroke. It is especially common during and after hospitalisation for surgery and acute medical illness though many other risk factors have now been identified. VTE is often preventable with judicious use of preventative measures in the form of thromboprophylaxis and mechanical antiembolism stockings. In 2014, a study was undertaken across all surgical wards at a teaching hospital in London to assess compliance to national guidelines for VTE risk assessment and subsequent institution of protective measures.

The initial results demonstrated that performance could be improved in terms of meeting the national target of assessing 95% of surgical inpatients for risk of VTE at admission, prescribing anti-embolism stockings, ensuring that they are correctly worn, and reassessing patients 24 hours later. Utilising a multidisciplinary team approach, simple interventions were put in place such as e-mail reminders, posters, and senior input during ward rounds. Three subsequent measurements demonstrated that sustained improvement was achieved with the national guideline of 95% VTE risk assessment met. Improved performance was noted across all parameters considered, highlighting that simple intervention with all team members involved can improve patient safety and care.