1
|
Adelkhanova A, Oli PR, Shrestha DB, Shtembari J, Jha V, Shantha G, Bodziock GM, Biswas M, Zaman MO, Patel NK. Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta-analysis. Health Sci Rep 2024; 7:e2044. [PMID: 38650729 PMCID: PMC11033493 DOI: 10.1002/hsr2.2044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Background and Aim Obesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well-established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta-analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF. Methods The PRISMA guidelines were followed for this meta-analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full-text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure. Results Two thousand two hundred fifty-nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66-0.75) and (OR 0.47, CI 0.35-0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54-0.83), major bleeding (OR 0.62, CI 0.54-0.72), and composite outcome (OR 0.72, CI 0.63-0.81). Conclusion Based on the findings from this meta-analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population.
Collapse
Affiliation(s)
- Alla Adelkhanova
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Prakash Raj Oli
- Department of Internal MedicineProvince HospitalBirendranagarNepal
| | | | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Vivek Jha
- Department of Internal MedicineJohn H. Stroger, Jr. Hospital of Cook CountyChicagoIllinoisUSA
| | - Ghanshyam Shantha
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyWake Forest University School of MedicineWinston SalemNorth CarolinaUSA
| | - George Michael Bodziock
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyWake Forest University School of MedicineWinston SalemNorth CarolinaUSA
| | - Monodeep Biswas
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyUniversity of Maryland Medical CenterBaltimoreMarylandUSA
| | - Muhammad Omer Zaman
- Department of Internal Medicine, Division of CardiologyRudd Heart HospitalLouisvilleKentuckyUSA
| | | |
Collapse
|
2
|
Rueda-Camino JA, Barba R, Otálora S, Bura-Riviere A, Visonà A, Mahé I, Alda-Lozano A, Alfonso Megido J, Pacheco-Gómez N, Rosovsky RP, Monreal M. Real life results of direct-acting oral anticoagulants recommended-dose in obese vs normal-weight patients with venous thromboembolism. Thromb Res 2024; 233:165-172. [PMID: 38070219 DOI: 10.1016/j.thromres.2023.12.001] [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: 08/30/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/01/2024]
Abstract
BACKGROUND There is scarce evidence on the effectiveness and safety of recommended-dose direct acting oral anticoagulants (DOACs) in obese patients with venous thromboembolism (VTE). MATERIAL AND METHODS We used the data in the RIETE registry to compare the rates of VTE recurrences and major bleeding during long-term therapy with DOACs at recommended doses in patients with body mass index ≥30 kg/m2 (obese) vs. those with BMI 18.5-24.9 kg/m2 (normal weight). We performed regression models with competing risks for death. RESULTS From January 2013 through October 2022, 2885 obese patients and 2676 with normal weight in RIETE received rivaroxaban (n = 3020), apixaban (n = 1754), edoxaban (n = 636) or dabigatran (n = 151). Median age was 63 years and 52 % were female. At baseline, obese patients were more likely to have diabetes (18.6 % vs. 8.4 %), hypertension (51.9 % vs. 31.4 %) or pulmonary embolism (67.7 % vs. 61 %), and less likely to have renal insufficiency (5.3 % vs. 16 %) or anaemia (21.8 % vs. 28 %%). During anticoagulation (median, 147 vs. 101 days), the obese had a similar rate of VTE recurrences (1.71 vs. 2.14 events per 100 patients-years; hazard ratio (HR): 0.81; 95 % CI: 0.49-1.34) or major bleeding (1.45 vs. 1.76 per 100 patients-years; HR: 0.91; 95 % CI: 0.52-1.59) than those with normal weight. These findings persisted after multivariable analysis (recurrent VTE, HR: 0.80; 95 % CI: 0.48-1.32; major bleeding, HR: 1.11; 95 % CI: 0.60-2.07). CONCLUSION The use of DOACs at recommended doses in obese patients with VTE was associated with similar rates of VTE recurrences or major bleeding than in patients with normal weight.
Collapse
Affiliation(s)
- José Antonio Rueda-Camino
- Department of Internal Medicine, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Health Research Institute Fundación Jiménez Díaz, Madrid, Spain.
| | - Raquel Barba
- Department of Internal Medicine, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Health Research Institute Fundación Jiménez Díaz, Madrid, Spain
| | - Sonia Otálora
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | | | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Isabelle Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), Colombes, France; Université Paris Cité, France, INSERM UMR-S-1140, Paris, France
| | - Alicia Alda-Lozano
- Department of Internal Medicine, Hospital Reina Sofía, Tudela, Navarra, Spain
| | | | | | - Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| |
Collapse
|
3
|
Tian T, Wang L, Xu J, Jia Y, Xue K, Huang S, Shen T, Luo Y, Li S, Min L. Prediction of early neurological deterioration in acute ischemic stroke patients treated with intravenous thrombolysis. J Cereb Blood Flow Metab 2023; 43:2049-2059. [PMID: 37668997 PMCID: PMC10925869 DOI: 10.1177/0271678x231200117] [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: 03/30/2023] [Revised: 07/06/2023] [Accepted: 08/13/2023] [Indexed: 09/06/2023]
Abstract
A proportion of acute ischemic stroke (AIS) patients suffer from early neurological deterioration (END) within 24 hours following intravenous thrombolysis (IVT), which greatly increases the risk of poor prognosis of these patients. Therefore, we aimed to explore the predictors of early neurological deterioration of ischemic origin (ENDi) in AIS patients after IVT and develop a nomogram prediction model. This study collected 244 AIS patients with post-thrombolysis ENDi as the derivation cohort and 155 patients as the validation cohort. To establish a nomogram prediction model, risk factors were identified by multivariate logistic regression analysis. The results showed that neutrophil to lymphocyte ratio (NLR) (OR 2.616, 95% CI 1.640-4.175, P < 0.001), mean platelet volume (MPV) (OR 3.334, 95% CI 1.351-8.299, P = 0.009), body mass index (BMI) (OR 1.979, 95% CI 1.285-3.048, P = 0.002) and atrial fibrillation (AF) (OR 8.012, 95% CI 1.341-47.873, P = 0.023) were significantly associated with ENDi. The area under the curve of the prediction model constructed from the above four factors was 0.981 (95% CI 0.961-1.000) and the calibration curve was close to the ideal diagonal line. Therefore, this nomogram prediction model exhibited good discrimination and calibration power and might be a reliable and easy-to-use tool to predict post-thrombolysis ENDi in AIS patients.
Collapse
Affiliation(s)
- Tian Tian
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Lanjing Wang
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiali Xu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yujie Jia
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Kun Xue
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Shuangfeng Huang
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tong Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yumin Luo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Lianqiu Min
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| |
Collapse
|
4
|
Chin-Hon J, Davenport L, Huang J, Akerman M, Hindenburg A. Safety and efficacy of oral anticoagulants in extreme weights. Thromb Res 2023; 231:1-6. [PMID: 37738772 DOI: 10.1016/j.thromres.2023.09.001] [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: 04/16/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND The 2021 International Society on Thrombosis and Haemostasis' (ISTH) recommends standard doses of apixaban and rivaroxaban regardless of high body mass index (BMI) and weight, but had not compare DOACs head-to-head in obesity or address underweight patients. METHODS Our aim is to evaluate the safety and efficacy of DOACs in underweight and obese patients compared to warfarin. The primary endpoints include incidence of thromboembolic and bleeding events. Descriptive statistics was used for continuous variables. The Kruskal-Wallis test was used to compare the four-groups for continuous measures and the chi-square test or Fisher's exact test was used to analyze categorical data. The chi-square test or Fisher's exact test, was used for categorical variables, and the Mann-Whitney test (the non-parametric counterpart to the two-sample t-test) for continuous data. RESULTS Of 2940 patients receiving anticoagulation for venous thromboembolism (VTE) treatment or atrial fibrillation (AF), 492 met eligibility criteria. Within each group, 248 patients received warfarin, 101 received apixaban, 100 received rivaroxaban and 43 received dabigatran. Patients were characterized in 4 body mass index (BMI) categories, in which 80 were underweight and 412 were obese. CONCLUSIONS When each DOAC was compared to warfarin in rates of VTE, apixaban showed statistically significant lower rate of VTE (p = 0.0149). However, no statistical significance was identified in the rate of VTE between DOACs combined vs. warfarin (p = 0.1529). When each DOAC was compared to warfarin, apixaban showed the lowest rate of overall bleeding (p = 0.0194). However, no statistical difference in the rate of bleeding was observed between DOACs combined vs. warfarin (p = 0.3284). Patients with extreme body weights requiring anticoagulation for VTE and AF may safety benefit from DOAC therapy. This evaluation showed apixaban with the lowest rate of VTE and bleeding compared to warfarin, rivaroxaban, and dabigatran. These results provide experience for the clinician to use DOACs, particularly apixaban, in underweight and obese populations.
Collapse
Affiliation(s)
- J Chin-Hon
- NYU Langone Hospital - Long Island, Department of Pharmacy, United States of America; NYU Long Island School of Medicine, United States of America.
| | - L Davenport
- NYU Langone Hospital - Long Island, Department of Pharmacy, United States of America
| | - J Huang
- Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates - Mineola, United States of America
| | - M Akerman
- NYU Long Island School of Medicine, United States of America
| | - A Hindenburg
- NYU Long Island School of Medicine, United States of America; Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates - Mineola, United States of America
| |
Collapse
|
5
|
Moore KT, Zannikos PN, Masters JC, Willmann S, Shen J, Frost C. The Importance of Assessing Drug Pharmacokinetics and Pharmacodynamics in the Obese Population During Drug Development. J Clin Pharmacol 2023; 63 Suppl 2:S78-S84. [PMID: 37942912 DOI: 10.1002/jcph.2361] [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: 07/14/2023] [Accepted: 09/21/2023] [Indexed: 11/10/2023]
Abstract
Obesity remains a US national health crisis and a growing concern worldwide. Concerningly, individuals who are obese are at an increased risk for comorbid diseases that include, but are not limited to, hypertension, diabetes, cardiovascular disease, and cancer. Beyond the risk for developing these conditions, obesity may also impact the pharmacological activity of the therapies being used to treat them and other disease states. The pharmacokinetics (PK), pharmacodynamics (PD), safety, and efficacy of therapies, both currently marketed and under clinical development, may be directly impacted by the physiological alterations that occur secondary to the occurrence of chronic excess body weight. The increased prevalence of this disease should not be ignored. Both private and federal institutions involved in drug research and development should consider, as appropriate, a greater inclusion of individuals who are obese in clinical trials throughout the entirety of drug development, and leverage the available PK, PD, safety, and efficacy data to make more informed dosing recommendations.
Collapse
Affiliation(s)
- Kenneth T Moore
- Johnson & Johnson Innovative Medicine, Scientific Affairs, Titusville, NJ, USA
| | - Peter N Zannikos
- Johnson & Johnson Innovative Medicine, Clinical Pharmacology and Pharmacometrics, Titusville, NJ, USA
| | - Joanna C Masters
- Pfizer Worldwide Research, Development and Medical, Clinical Pharmacology and Bioanalytics, San Diego, CA, USA
| | - Stefan Willmann
- Bayer AG, Pharmaceuticals, Research & Development, Pharmacometrics/Modeling & Simulation, Wuppertal, Germany
| | - Jinshan Shen
- Relay Therapeutics, Clinical Pharmacology, Cambridge, MA, USA
| | - Charles Frost
- Bristol-Myers Squibb, Global Scientific and Regulatory Documentation, Princeton, NJ, USA
| |
Collapse
|
6
|
Zakynthinos GE, Tsolaki V, Oikonomou E, Vavouranakis M, Siasos G, Zakynthinos E. Metabolic Syndrome and Atrial Fibrillation: Different Entities or Combined Disorders. J Pers Med 2023; 13:1323. [PMID: 37763092 PMCID: PMC10533132 DOI: 10.3390/jpm13091323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Obesity, hypertension, insulin resistance, and dyslipidemia are all clusters of an entity called "Metabolic Syndrome". The global trends of this syndrome's incidence/prevalence continue to increase reciprocally, converting it into a massive epidemic problem in the medical community. Observing the risk factors of atrial fibrillation, a medical condition that is also converted to a scourge, almost all parts of the metabolic syndrome are encountered. In addition, several studies demonstrated a robust correlation between metabolic syndrome and the occurrence of atrial fibrillation. For atrial fibrillation to develop, a combination of the appropriate substrate and a trigger point is necessary. The metabolic syndrome affects the left atrium in a multifactorial way, leading to atrial remodeling, thus providing both the substrate and provoking the trigger needed, which possibly plays a substantial role in the progression of atrial fibrillation. Due to the remodeling, treatment of atrial fibrillation may culminate in pernicious sequelae, such as repeated catheter ablation procedures. A holistic approach of the patient, with simultaneous treatment of both entities, is suggested in order to ensure better outcomes for the patients.
Collapse
Affiliation(s)
- George E. Zakynthinos
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (M.V.); (G.S.)
| | - Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Mezourlo, 41335 Larissa, Greece; (V.T.); (E.Z.)
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (M.V.); (G.S.)
| | - Manolis Vavouranakis
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (M.V.); (G.S.)
| | - Gerasimos Siasos
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (M.V.); (G.S.)
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Epaminondas Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Mezourlo, 41335 Larissa, Greece; (V.T.); (E.Z.)
| |
Collapse
|