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Engelbertz C, Marschall U, Feld J, Makowski L, Lange SA, Freisinger E, Gerß J, Breithardt G, Faldum A, Reinecke H, Köppe J. Apixaban, edoxaban and rivaroxaban but not dabigatran are associated with higher mortality compared to vitamin-K antagonists: A retrospective German claims data analysis. J Intern Med 2024. [PMID: 39221828 DOI: 10.1111/joim.20006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Vitamin-K antagonists (VKAs) have widely been replaced by non-VKA oral anticoagulants (NOACs). This includes Austria, Germany and Switzerland, where as VKA, instead of warfarin, the much longer-acting phenprocoumon is used, which was not compared to NOACs in clinical trials. METHODS Using administrative data from a large German health insurance, we included all anticoagulation-naïve patients with a first prescription of a NOAC or VKA between 2012 and 2020. We analysed overall survival, major adverse cardiac and cerebrovascular events, major thromboembolic events and major bleeding. RESULTS Overall, 570,137 patients were included (apixaban: 26.9%, dabigatran: 4.6%, edoxaban: 8.8%, rivaroxaban: 39.1% and VKA: 20.7% of these 99.4% phenprocoumon). In the primary analysis using a 1:1 propensity score matching-cohort (PSM-cohort), a significantly higher overall mortality was found for apixaban, edoxaban and rivaroxaban (all p < 0.001) but not for dabigatran (p = 0.13) compared to VKA. In this PSM-cohort, 5-year mortality was 22.7% for apixaban versus 12.7% for VKA, 19.5% for edoxaban versus 11.4% for VKA, 16.0% for rivaroxaban versus 12.3% for VKA (all p < 0.001) and 13.0% for dabigatran versus 12.8% for VKA (p = 0.06). The observed effect was confirmed in sensitivity analyses using un-weighted and three different weighted Fine-Gray regression models on the basis of the entire cohort. CONCLUSIONS In this large real-world analysis, apixaban, edoxaban and rivaroxaban, but not dabigatran, were associated with worse survival compared to VKA. These findings, consistent with a few other studies including phenprocoumon, cast profound doubts on the unreflected, general use of NOACs. Randomized trials should assess whether phenprocoumon might actually be superior to NOACs.
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Affiliation(s)
- Christiane Engelbertz
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | | | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Lena Makowski
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Stefan A Lange
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Eva Freisinger
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Günter Breithardt
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Andreas Faldum
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
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Santamaria A, Antón Maldonado C, Sánchez-Quiñones B, Ibarra Vega N, Ayo González M, Gonzalez Cabezas P, Carrasco Moreno R. Implementing Telemedicine in Clinical Practice in the First Digital Hematology Unit: Feasibility Study. JMIR Form Res 2023; 7:e48987. [PMID: 38048143 PMCID: PMC10728787 DOI: 10.2196/48987] [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: 05/14/2023] [Revised: 09/17/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Currently, there are no telemedicine models that fully integrate all areas of hematology into daily practice. OBJECTIVE The objectives of this feasibility study were to assess the practicality of implementing telemedicine into our clinical practice in the first Digital Hematology Unit and propose an innovative integrative design for clinical practice. METHODS We designed the Digital Hematology Unit, which is a specific physical space dedicated to carrying out telemedicine and monitoring patients in a holistic way. Also, a satisfaction questionnaire was performed and health care indicators were measured. RESULTS In 2021, there were 1331 first visits and 7534 follow-up visits. Of the first visits, 12.2% (n=163) were face-to-face and 87.8% (n=1168) were telematic. For follow-up visits, 29.9% (n=2251) were face-to-face and 70.1% (n=5283) were telematic. The health care management indicators showed that we had a waiting time of less than 4 days and took less than 4 hours to answer interconsultations among specialists. Moreover, patients reported a high level of satisfaction with the services provided. CONCLUSIONS Our Digital Hematology Unit, as a case of success, serves as an example of how innovative digital solutions can contribute to the quality of care and excellence in health care achieved through a digital transformation process led by hematologists.
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Affiliation(s)
- Amparo Santamaria
- Hematology Department, University Hospital Vinalopó, Alicante, Spain
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Hohmann C, Pfister R, Frerker C, Beckmann A, Walther T, Bleiziffer S, Ensminger S, Bekeredjian R, Seiffert M, Sinning JM, Möllmann H, Beyersdorf F, Baldus S, Böning A, Herrmann E, Balaban Ü, Kuhn E. Direct oral anticoagulants versus vitamin K antagonist after transcatheter aortic valve implantation. Heart 2023; 109:1706-1713. [PMID: 37407220 DOI: 10.1136/heartjnl-2023-322548] [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: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE After transcatheter aortic valve implantation (TAVI), the optimal regimen of anticoagulant therapy in patients with an additional indication for oral anticoagulation remains a matter of debate. This study investigates the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients after TAVI in a real-world population. METHODS The German Aortic Valve RegistrY (GARY) is a prospective, multicentre registry enrolling patients undergoing invasive treatment for aortic valve disease. From January 2011 to December 2019, 1 41 790 patients from 92 hospitals in Germany were enrolled. Anticoagulatory treatment regimens were assessed at hospital discharge for patients after TAVI procedures. All-cause mortality and the combined endpoint 'cardiac and cerebrovascular events' containing myocardial infarction, stroke, transient ischaemic attack, aortic prosthesis reintervention and all-cause mortality in the first year after TAVI were examined by treatment regimen. RESULTS Of 45 598 patients (mean age 80.7±5.7 years, 49.3% males) undergoing TAVI, 16 974 patients (37.2%) received an anticoagulant regimen that included VKA or DOAC. Hereof, the majority of patients were prescribed VKA (n=11 333, 66.8%) compared with DOAC (n=5641, 33.2%) with an increase of DOAC use from 9.4% in 2011 to 69.9% in 2019. During the 1-year follow-up, the absolute event rates per 100 person-years for all-cause mortality and the combined endpoint cardiac and cerebrovascular events were 1.9 and 1.3 for VKA-treated and 1.7 and 1.2 for DOAC-treated patients, respectively. After adjustment for baseline confounders, all-cause mortality (HR 0.95, 95% CI 0.88 to 1.01, p=0.114) and cardiac and cerebrovascular event-free survival (HR 0.93, 95% CI 0.86 to 1.01, p=0.071) did not differ significantly between VKA and DOAC groups. CONCLUSIONS This study supports evidence of the efficacy of DOAC use after TAVI in patients with an indication for oral anticoagulation.
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Affiliation(s)
- Christopher Hohmann
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Christian Frerker
- Department of Cardiology, Vascular Medicine and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andreas Beckmann
- Department of Cardiac Surgery, Heart Centre Duisburg, Evangelisches Krankenhaus Niederrhein, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Germany
| | - Thomas Walther
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Department of Cardiothoracic Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Sabine Bleiziffer
- Department of Cardiothoracic Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital SchleswigHolstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Moritz Seiffert
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jan-Malte Sinning
- Department of Cardiology, St. Vinzenz-Hospital Cologne, Cologne, Germany
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Andreas Böning
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Eva Herrmann
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Ümniye Balaban
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
- Department of Cardiothoracic Surgery, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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Lindhoff-Last E, Birschmann I, Bidenharn AJ, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Phenprocoumon in Emergency Situations-Results of the Prospective Observational RADOA-Registry (Reversal Agent Use in Patients Treated with Direct Oral Anticoagulants or Vitamin K Antagonists Registry). Pharmaceuticals (Basel) 2022; 15:ph15111437. [PMID: 36422567 PMCID: PMC9692621 DOI: 10.3390/ph15111437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Phenprocoumon has been used as an oral anticoagulant in patients with thromboembolic disease for more than 40 years. So far its pharmacokinetics have not been analyzed in emergency situations. Methods: Phenprocoumon-treated patients with major bleeding or urgent surgery were included in a prospective, observational registry. Phenprocoumon drug concentrations were analyzed in samples, collected as part of routine care using ultraperformance liquid chromatography tandem mass spectrometry. Moreover, anticoagulant intensity and drug half-life (t1/2) were calculated. Results: 115 patients were included. Phenprocoumon levels declined over time with a half-life of 5.27 and 5.29 days in patients with major bleedings (n = 82) and with urgent surgery (n = 33). Baseline phenprocoumon levels were 2.2 times higher in the bleeding group compared to the surgery group (1.92 vs. 0.87 ng/mL, p < 0.0001). International normalized ratio (INR) values decreased rapidly during the first 24 h. In 27.6% of patients a rebound of INR (recurrent increase > 1.5) was observed which was associated with significantly increased bleeding rates (22% vs. 4.2% in patients with or without INR rebound, p = 0.012). Conclusions: In emergency situations, the long half-life of phenprocoumon may cause INR rebound and associated recurrent bleedings. Optimal management may need to include repeated vitamin K supplementation over days.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Correspondence: (E.L.-L.); (I.B.); Tel.: +49-69-9450280 (E.L.-L.); +49-5731-973819 (I.B.); Fax: +49-69-461613 (E.L.-L.); +49-5731-972307 (I.B.)
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, 44789 Bochum, Germany
- Correspondence: (E.L.-L.); (I.B.); Tel.: +49-69-9450280 (E.L.-L.); +49-5731-973819 (I.B.); Fax: +49-69-461613 (E.L.-L.); +49-5731-972307 (I.B.)
| | - Antonia J. Bidenharn
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, 44789 Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWITH Aachen University Hospital, 52074 Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, 24105 Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, 17475 Greifswald, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine 1, Division of Thrombosis & Hemostasis, Dresden University Clinic, 01307 Dresden, Germany
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60590 Frankfurt, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, 17475 Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
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Alanazi Z, Almutairi N, AlDukkan L, Arafat AA, Albabtain MA. Time in therapeutic range for virtual anticoagulation clinic versus in-person clinic during the COVID-19 pandemic: a crossover study. Ann Saudi Med 2022; 42:305-308. [PMID: 36252144 PMCID: PMC9557787 DOI: 10.5144/0256-4947.2022.305] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND COVID-19 infection affects the quality of the medical services globally. The pandemic required changes to medical services in several institutions. We established a virtual clinic for anticoagulation management during the pandemic using the Whatsapp application. OBJECTIVES Compare anticoagulation management quality in virtual versus in-person clinics. DESIGN A retrospective crossover study SETTINGS: Specialized cardiac care center PATIENTS AND METHODS: The study included patients who presented to Prince Sultan Cardiac Center in Riyadh for anticoagulation management during the pandemic from March 2020 to January 2021. We compared time in therapeutic range (TTR) in the same patients during virtual and in-person clinics. All international normalized ratio (INR) measures during the virtual clinic visits and prior ten INR measures from the in-person clinic were recorded. Patients who had no prior follow-up in the in-person clinic were excluded. MAIN OUTCOME MEASURE TTR calculated using the Rosendaal method. SAMPLE SIZE 192 patients RESULTS: The mean age was 58.6 (16.6) years and 116 (60.4%) were males. Patients were diagnosed with atrial fibrillation (n=101, 52.6%), mechanical mitral valve (n=88, 45.8%), mechanical aortic valve (n=79, 41%), left ventricular thrombus (n=5, 2.6%) and venous thromboembolism (n=8, 4.2%). Riyadh residents represented 56.7% of the study population (n=93). The median (IQR) percent TTR was 54.6 (27.3) in the in-person clinic versus 50.0 (33.3) (P=.07). CONCLUSION Virtual clinic results were comparable to in-person clinics for anticoagulation management during the COVID-19 pandemic. LIMITATIONS Number of INR measures during the virtual clinic visits, retrospective nature and single-center experience. CONFLICT OF INTEREST None.
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Affiliation(s)
- Zaid Alanazi
- From the Department of Pharmacy, Clinical Pharmacy Division, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Nawaf Almutairi
- From the Department of Pharmacy, Clinical Pharmacy Division, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Latifah AlDukkan
- From the Department of Pharmacy, Clinical Pharmacy Division, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Amr A Arafat
- From the Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbiya, Egypt.,From the Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Monirah A Albabtain
- From the Department of Pharmacy, Clinical Pharmacy Division, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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Barrios V, Cinza-Sanjurjo S, García-Alegría J, Freixa-Pamias R, Llordachs-Marques F, Molina CA, Santamaría A, Vivas D, Suárez Fernandez C. Role of telemedicine in the management of oral anticoagulation in atrial fibrillation: a practical clinical approach. Future Cardiol 2022; 18:743-754. [PMID: 35822847 DOI: 10.2217/fca-2022-0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Compared with face-to-face consultations, telemedicine has many advantages, including more efficient use of healthcare resources, partial relief of the burden of care, reduced exposure to COVID-19, treatment adjustment, organization of more efficient healthcare circuits and patient empowerment. Ensuring optimal anticoagulation in atrial fibrillation patients is mandatory if we want to reduce the thromboembolic risk. Of note, telemedicine is an excellent option for the long-term management of atrial fibrillation patients. Moreover, direct oral anticoagulants may provide an added value in telemedicine (versus vitamin K antagonists), as it is not necessary to monitor anticoagulant effect or make continuous dosage adjustments. In this multidisciplinary consensus document, the role of telemedicine in anticoagulation of this population is discussed and practical recommendations are provided.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, Ramón y Cajal University Hospital, Alcalá University, Madrid, Spain
| | - Sergio Cinza-Sanjurjo
- Family Medicine, Porto do Son Health Center, Santiago de Compostela Health Area, A Coruña, Spain
| | | | - Román Freixa-Pamias
- Department of Cardiology, Moisés Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Frederic Llordachs-Marques
- Expert consultant in E-Health/Telemedicine, Founder at Doctoralia and CEO at Doctomatic, Barcelona, Spain
| | - Carlos A Molina
- Department of Neurology, Stroke Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Amparo Santamaría
- Department of Hematology, Vinalopó University Hospital, Alicante, Spain
| | - David Vivas
- Department of Cardiology, San Carlos Hospital, Madrid, Spain
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Hohmann C, Lutz M, Vignali S, Borchert K, Seidel K, Braun S, Baldus S, Näbauer M. Clinical outcomes in patients receiving edoxaban or phenprocoumon for prevention of stroke in atrial fibrillation: a German real-world cohort study. Thromb J 2022; 20:37. [PMID: 35787710 PMCID: PMC9251920 DOI: 10.1186/s12959-022-00395-x] [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: 03/28/2022] [Accepted: 06/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Appropriate and timely anticoagulant therapy with vitamin K antagonists (VKAs) or non-vitamin K oral antagonists (NOACs) is essential for stroke prevention in non-valvular atrial fibrillation (NVAF). Comparative data regarding effectiveness and safety for edoxaban vs phenprocoumon, the predominant VKA in Germany, are scarce. Objectives The study evaluates effectiveness and safety of edoxaban vs phenprocoumon in NVAF patients in a German real-world setting. Methods German statutory health insurance claims data of the Institute for Applied Health Research Berlin (InGef) Research Database from 2014 until 2019 were analyzed. In NVAF patients, new users of edoxaban and phenprocoumon were compared to assess effectiveness (stroke/systemic embolism (SE)) and safety (bleeding) during therapy. Hazard ratios (HR) were estimated through multiple outcome-specific cox proportional hazard models adjusting for baseline characteristics. Outcomes of geriatric patients were analyzed in subgroup analyses. Results Between 2015 and 2018, 7,975 and 13,319 NVAF patients newly initiated treatment with edoxaban or phenprocoumon. After adjusting for baseline confounders, the risk of stroke/SE (HR: 0.85, 95% CI: 0.70–1.02) was numerically but not significantly lower, while the risk of major bleeding (HR: 0.69, 95% CI: 0.58–0.81) was significantly lower for edoxaban. In the geriatric subgroups, homogenous results compared to the main analysis were obtained. Conclusion The results of this real-world analysis indicated better effectiveness and safety outcomes in patients with NVAF initiating edoxaban treatment compared to phenprocoumon. The findings confirm that the beneficial effects observed in the pivotal ENGAGE AF-TMI 48 trial can also be achieved in real-world use of edoxaban. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00395-x.
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Affiliation(s)
- Christopher Hohmann
- Department III for Internal Medicine, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Magnus Lutz
- Daiichi Sankyo Deutschland GmbH, Zielstattstr. 48, 81379, Munich, Germany
| | - Sheila Vignali
- Daiichi Sankyo Deutschland GmbH, Zielstattstr. 48, 81379, Munich, Germany
| | | | | | | | - Stephan Baldus
- Department III for Internal Medicine, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Michael Näbauer
- Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
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Warkentin L, Hueber S, Deiters B, Klohn F, Kühlein T. Vitamin-K-antagonist phenprocoumon versus low-dose direct oral anticoagulants (DOACs) in patients with atrial fibrillation: a real-world analysis of German claims data. Thromb J 2022; 20:31. [PMID: 35619140 PMCID: PMC9137171 DOI: 10.1186/s12959-022-00389-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background For stroke prevention in patients with atrial fibrillation (AF), direct oral anticoagulants (DOACs) have been increasingly prescribed instead of vitamin-K-antagonists (VKA). For some patients a lower dosage of DOACs (ld-DOACs) is recommended. Ld-DOAC prescribing seems to be common, although previous studies did not show clear superiority of ld-DOACs over warfarin. In Germany, phenprocoumon is used almost exclusively as VKA. Randomized controlled trials comparing DOACs and phenprocoumon in the general population of patients with AF do not exist. Therefore, we aimed to compare ld-DOACs and phenprocoumon in a real-world setting in Germany. Methods In a retrospective observational cohort study, claims data from a group of small to medium-sized health insurance companies were analysed. Risks for the outcomes thromboembolism, death and major bleeding were estimated by Cox regression. Out of 93,685 patients with atrial fibrillation and a first prescription of an oral anticoagulant, 20,179 receiving VKA and 21,724 ld-DOACs (29.6% of all DOAC patients) were included. For the sensitivity analysis phenprocoumon was compared to the five ld-DOAC groups (ld-apixaban, ld-dabigatran, ld-edoxaban, ld-rivaroxaban, and the composite of all ld-DOACs) after propensity-score matching. Results Phenprocoumon was associated with statistically significant fewer thromboembolic events (HR = 1.29, 95% CI [1.13, 1.48], p < .001) and deaths (HR = 1.52, 95% CI [1.41, 1.63], p < .001) and a non-significant higher bleeding risk (HR = 0.89, 95% CI [0.79, 1.00], p = .051) than composite ld-DOAC. Regarding the subgroups, only patients with ld-apixaban had a statistically significant higher risk for thromboembolic events (HR = 1.42, 95% CI [1.21, 1.65], p < .001) and a lower bleeding risk (HR = 0.75, 95% CI [0.65, 0.86], p < .001). Ld-apixaban, ld-edoxaban, and ld-rivaroxaban were associated with a higher risk of death. The sensitivity analysis confirmed these associations. Conclusion Phenprocoumon seems to be superior to ld-DOACs for patients with AF. As a hypothesis phenprocoumon might turn out to be the wiser choice for high-risk patients with AF as compared to ld-DOACs, especially regarding thromboembolic events and death. Therefore, RCTs comparing ld-DOACs with phenprocoumon are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00389-9.
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Affiliation(s)
- Lisette Warkentin
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Universitätsklinikum Erlangen, Universitätsstraße, Erlangen, Germany.
| | - Susann Hueber
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Universitätsklinikum Erlangen, Universitätsstraße, Erlangen, Germany
| | - Barthold Deiters
- GWQ ServicePlus AG, Gesellschaft für Wirtschaftlichkeit und Qualität bei Krankenkassen, Tersteegenstraße, Düsseldorf, Germany
| | - Florian Klohn
- GWQ ServicePlus AG, Gesellschaft für Wirtschaftlichkeit und Qualität bei Krankenkassen, Tersteegenstraße, Düsseldorf, Germany
| | - Thomas Kühlein
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Universitätsklinikum Erlangen, Universitätsstraße, Erlangen, Germany
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Keller K, Prochaska JH, Coldewey M, Göbel S, Schmitt VH, Hahad O, Ullmann A, Nagler M, Lamparter H, Espinola-Klein C, Münzel T, Wild PS. Atherosclerosis and Its Impact on the Outcomes of Patients with Deep Venous Thrombosis. Life (Basel) 2022; 12:734. [PMID: 35629401 PMCID: PMC9143312 DOI: 10.3390/life12050734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction: Atherosclerosis and pulmonary embolism (PE) affect cardiovascular mortality substantially. We aimed to investigate the impact of atherosclerosis on the outcomes of patients with deep venous thrombosis (DVT) and to identify the differences in DVT patients with and without PE. Methods: Patients with DVT with and without symptomatic atherosclerosis (defined as coronary artery disease, myocardial infarction and/or peripheral artery disease) as well as with and without PE under oral anticoagulation were enrolled during January 2011−April 2013 and compared. The impact of symptomatic atherosclerosis on several outcomes was analyzed. Results: Overall, 509 DVT patients (70.0 [56.0−77.0] years, 51.9% females) were included in this study. Among them, 179 (36.3%) had symptomatic atherosclerosis and 204 (40.1%) a concomitant PE. DVT patients with symptomatic atherosclerosis were older (74.0 [IQR 65.0−80.0] vs. 63.0 [48.0−75.0] years, p < 0.0001), more often male (56.4% vs. 43.9%, p = 0.0087) and had a higher prevalence of classical CVRF and a higher Charlson comorbidity index (7.00 [5.00−8.00] vs. 4.00 [2.00−6.00], p < 0.001). Symptomatic atherosclerosis was associated with increased mortality (HR 1.98 [95%CI 1.12−3.49], p = 0.018) and hospitalizations (HR 1.64 [95%CI 1.21−2.21], p = 0.0012) and primary long-term outcome (HR 1.99 [95%CI 1.31−3.04], p = 0.0013) during the 2 years follow-up-period in DVT patients. DVT patients without PE had diabetes mellitus (28.2% vs. 16.3%, p < 0.01) and symptomatic atherosclerosis (42.9% vs. 26.4%, p < 0.001) more often compared to DVT patients with PE, and symptomatic atherosclerosis was associated with isolated DVT (without PE) (OR 2.01 [95%CI 1.28−3.16], p < 0.01). Conclusions: Atherosclerosis was associated with isolated DVT (without PE) and increased mortality in DVT patients under oral anticoagulation. The profile of CVRF and comorbidities differed between DVT patients with and without a concomitant PE. In the case of DVT or PE, patients should be screened for concomitant atherosclerotic disease. Clinical Trial Registration: at clinicaltrials with Unique identifier NCT01809015.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
- Department of Sports Medicine, Medical Clinic VII, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Jürgen H. Prochaska
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
| | - Meike Coldewey
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
| | - Sebastian Göbel
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
- Leibniz Institute for Resilience Research (LIR), 55131 Mainz, Germany
| | - Alexander Ullmann
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
| | - Markus Nagler
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
| | - Heidrun Lamparter
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (M.C.); (S.G.); (V.H.S.); (O.H.); (C.E.-K.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
| | - Philipp S. Wild
- Center for Thrombosis and Hemostasis, University Medical Center Mainz of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.H.P.); (A.U.); (M.N.); (H.L.); (P.S.W.)
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein Main, 55131 Mainz, Germany
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10
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Keri RS, Budagumpi S, Balappa Somappa S. Synthetic and natural coumarins as potent anticonvulsant agents: A review with structure-activity relationship. J Clin Pharm Ther 2022; 47:915-931. [PMID: 35288962 DOI: 10.1111/jcpt.13644] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 12/25/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The main objective of this review is to highlight the most relevant studies since 1990 (to date) in the area of medicinal chemistry aspects to provide a panoramic view to the biologists/medicinal chemists working in this area and would assist them in their efforts to design, synthesize and extract (from natural source) coumarin-based anticonvulsant agents. Also, the structure-activity relationship (SAR) studies are also discussed for further rational design of this kind of derivatives. It is hoped that this review will be helpful for new thoughts in the quest for rational designs of more active and less toxic coumarin-based antiepileptic agents. METHODS A literature review emphasizing the application of coumarin core as antiepileptic agents identify articles related to the topic; we performed a standardized search from 1990 to November 2021, using search engines like Scifinder, web of Science, Pubmed and Scopus. RESULTS AND DISCUSSION This review gives an overview of attempts to shed light and compile published reports on coumarin derivatives along with some opinions on different approaches to help the medicinal chemists in designing future generation potent yet safer anticonvulsant agents. The possible structure-activity relationships (SARs) will also be discussed to indicate the direction for the rational design of more effective candidates. WHAT IS NEW AND CONCLUSION The findings from this review provide new indications or directions for the discovery of new and better drugs from synthetic and naturally occurring coumarins as antiepileptic agents. In our review, we have tried to depict the recent researches which made in the design and development of novel anticonvulsant compounds with coumarin nucleus. Also, SAR of expressed derivatives indicated that the choice of a fitting substitution containing electron-withdrawing/donating groups to coumarin or with some heterocyclic moieties joined to parent coumarin skeleton assumes an essential role in changing the anticonvulsant activity of synthesized derivatives. These findings encourage the scientific community towards the optimization of the pharmacological profile of this structural moiety as an important scaffold for the treatment of epilepsy.
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Affiliation(s)
- Rangappa S Keri
- Centre for Nano and Material Sciences, Jain University, Bangalore, India
| | | | - Sasidhar Balappa Somappa
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India.,Organic Chemistry Section, Chemical Sciences and Technology Division, Council of Scientific and Industrial Research (CSIR)-National Institute for Interdisciplinary Science and Technology (NIIST), Thiruvananthapuram, India
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11
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Efficacy and safety of app-based remote warfarin management during COVID-19-related lockdown: a retrospective cohort study. J Thromb Thrombolysis 2022; 54:20-28. [PMID: 35092566 PMCID: PMC8799972 DOI: 10.1007/s11239-021-02630-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 12/14/2022]
Abstract
This study aimed to explore the effectiveness, and safety of internet-based warfarin management during the pandemic. In this single-center retrospective cohort study, we compared the safety and efficacy of online warfarin management using a smartphone app (the Alfalfa app) versus conventional outpatient clinic management from January 1, 2020 to March 31, 2020. Patients in the online management group used the Alfalfa app to communicate coagulation test results and other relevant information to a doctor or clinical pharmacist, who then responded with the dose adjustment plan and the date of the next blood test. The outcomes examined were the time in therapeutic range (TTR), incidence of clinical events (i.e., bleeding events, thrombotic events, warfarin-related emergency department visits, and warfarin-related hospital admissions), and the distribution of international normalized ratio (INR) values. Data from 117 patients were analyzed in this study. TTR was significantly higher in the online group than in the offline group (61.0% vs. 39.6%, P < 0.01). Incidence of major bleeding events, thrombotic events, and warfarin-related hospital admissions were comparable between the online and offline groups. However, minor bleeds (5.3% vs. 28.3%, P < 0.01) and warfarin-related emergency department visits (1.8% vs. 23.3%, P = 0.02) were significantly fewer in the online group than in the offline group. The proportion of INR values in the therapeutic range (53.8% vs. 40.1%, P < 0.01) was significantly higher in the online group. Warfarin management using the Alfalfa app appears to be a safe and effective method for warfarin management when patients cannot physically visit hospitals for follow-up.
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12
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Douros A, Basedow F, Cui Y, Walker J, Enders D, Tagalakis V. Effectiveness and safety of direct oral anticoagulants with antiplatelet agents in patients with venous thromboembolism: A multi-database cohort study. Res Pract Thromb Haemost 2022; 6:e12643. [PMID: 35036824 PMCID: PMC8749078 DOI: 10.1002/rth2.12643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 11/29/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) often have comorbidities that require use of antiplatelets. However, evidence on the effects of concomitant use of direct oral anticoagulants (DOACs) and antiplatelets in this high-risk population is scarce. Our international, multi-database cohort study assessed the real-world effectiveness and safety of concomitant use of DOACs and antiplatelets among patients with VTE. METHODS We assembled two population-based cohorts using administrative health care databases from Québec and Germany. We included patients with incident VTE who initiated treatment with a DOAC or a vitamin K antagonist (VKA), while being exposed to antiplatelets (acetylsalicylic acid, clopidogrel, ticagrelor, prasugrel, dipyridamole). The study period spanned from 2012 to 2016 (Québec) or 2019 (Germany). Concomitant use of DOACs and antiplatelets was compared with concomitant use of VKAs and antiplatelets, using inverse probability of treatment weighting to balance exposure groups. Cox proportional hazards models estimated site-specific hazard ratios (HRs) and 95% confidence intervals (CIs) of major bleeding, all-cause mortality (primary outcomes), and recurrent VTE (secondary outcome). Site-specific estimates were meta-analyzed using random-effects models. RESULTS Overall, 4971 patients with VTE initiated concomitant use of a DOAC (n = 2289) or a VKA (n = 2682) and antiplatelets. Compared with concomitant use of VKAs and antiplatelets, concomitant use of DOACs and antiplatelets was associated with similar risks of major bleeding (HR, 0.81; 95% CI, 0.46-1.45), all-cause mortality (HR, 1.25; 95% CI, 0.87-1.79), and recurrent VTE (HR, 0.96; 95% CI, 0.40-2.27). CONCLUSIONS Among patients with VTE using antiplatelets, there were no major differences in effectiveness and safety between DOACs and VKAs.
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Affiliation(s)
- Antonios Douros
- Centre for Clinical EpidemiologyLady Davis InstituteMontrealQuebecCanada
- Department of MedicineMcGill UniversityMontrealQuebecCanada
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealQuebecCanada
- Institute of Clinical Pharmacology and ToxicologyCharité‐Universitätsmedizin BerlinBerlinGermany
| | | | - Ying Cui
- Centre for Clinical EpidemiologyLady Davis InstituteMontrealQuebecCanada
| | - Jochen Walker
- InGef ‐ Institute for Applied Health Research BerlinBerlinGermany
| | - Dirk Enders
- InGef ‐ Institute for Applied Health Research BerlinBerlinGermany
| | - Vicky Tagalakis
- Centre for Clinical EpidemiologyLady Davis InstituteMontrealQuebecCanada
- Department of MedicineMcGill UniversityMontrealQuebecCanada
- Division of General Internal MedicineJewish General HospitalMontrealQuebecCanada
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13
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Jang I. A Systematic Review on Mobile Health Applications' Education Program for Patients Taking Oral Anticoagulants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18178902. [PMID: 34501492 PMCID: PMC8430962 DOI: 10.3390/ijerph18178902] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022]
Abstract
Warfarin is widely used as an oral anticoagulant. However, it is difficult to manage patients due to its narrow therapeutic range and individualized differences. Using controlled trials and real-world observational studies, this systematic review aimed to analyze health education’s impact among patients on warfarin therapy by mobile application. Smartphone and tablet applications have the potential to actively educate patients by providing them with timely information through push notifications. MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane electronic databases were searched using the keywords “anticoagulants,” “warfarin”, “mobile application”, and “smartphone” up to May 2020. Of the 414 articles obtained, 12 articles met the inclusion criteria for this review. The education and self-management programs using the mobile health application had diverse contents. A meta-analysis was not deemed appropriate because of the heterogeneity of populations, interventions, and outcomes. Thus, a narrative synthesis is presented instead. This review demonstrates that educating patients for anticoagulation management through their smartphones or tablets improves their knowledge levels, medication or treatment adherence, satisfaction, and clinical outcomes. Moreover, it has a positive effect on continuing health care. Future research concerning patients taking warfarin should include key self-management outcomes in larger, more rigorously designed studies, allowing for comparisons across studies. This study proposes a continuous application of timely education through smartphone applications to the current medical and nursing practice.
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Affiliation(s)
- Insil Jang
- Department of Nursing, Chung-Ang University, Seoul 06974, Korea
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14
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Zhu Z, Li C, Shen J, Wu K, Li Y, Liu K, Zhang F, Zhang Z, Li Y, Han J, Qin Y, Yang Y, Fan G, Zhang H, Ding Z, Xu D, Chen Y, Zheng Y, Zheng Z, Meng X, Zhang H. New Internet-Based Warfarin Anticoagulation Management Approach After Mechanical Heart Valve Replacement: Prospective, Multicenter, Randomized Controlled Trial. J Med Internet Res 2021; 23:e29529. [PMID: 34397393 PMCID: PMC8398748 DOI: 10.2196/29529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Mechanical heart valve replacement (MHVR) is an effective method for the treatment of severe heart valve disease; however, it subjects patient to lifelong warfarin therapy after MHVR with the attendant risk of bleeding and thrombosis. Whether internet-based warfarin management reduces complications and improves patient quality of life remains unknown. OBJECTIVE This study aimed to compare the effects of internet-based warfarin management and the conventional approach in patients who received MHVR in order to provide evidence regarding alternative strategies for long-term anticoagulation. METHODS This was a prospective, multicenter, randomized, open-label, controlled clinical trial with a 1-year follow-up. Patients who needed long-term warfarin anticoagulation after MHVR were enrolled and then randomly divided into conventional and internet-based management groups. The percentage of time in the therapeutic range (TTR) was used as the primary outcome, while bleeding, thrombosis, and other events were the secondary outcomes. RESULTS A total of 721 patients were enrolled. The baseline characteristics did not reach statistical differences between the 2 groups, suggesting the random assignment was successful. As a result, the internet-based group showed a significantly higher TTR (mean 0.53, SD 0.24 vs mean 0.46, SD 0.21; P<.001) and fraction of time in the therapeutic range (mean 0.48, SD 0.22 vs mean 0.42, SD 0.19; P<.001) than did those in the conventional group. Furthermore, as expected, the anticoagulation complications, including the bleeding and embolic events had a lower frequency in the internet-based group than in the conventional group (6.94% vs 12.74%; P=.01). Logistic regression showed that internet-based management increased the TTR by 7% (odds ratio [OR] 1.07, 95% CI 1.05-1.09; P<.001) and reduced the bleeding and embolic risk by 6% (OR 0.94, 95% CI 0.92-0.96; P=.01). Moreover, low TTR was found to be a risk factor for bleeding and embolic events (OR 0.87, 95% CI 0.83-0.91; P=.005). CONCLUSIONS The internet-based warfarin management is superior to the conventional method, as it can reduce the anticoagulation complications in patients who receive long-term warfarin anticoagulation after MHVR. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1800016204; http://www.chictr.org.cn/showproj.aspx?proj=27518. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2019-032949.
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Affiliation(s)
- Zhihui Zhu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Ludwig Maximilian University of Munich, Munich, Germany
| | - Chenyu Li
- Renal Division, Department of Medicine IV, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jinglun Shen
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kaisheng Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuehuan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fan Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Cardiovascular Surgery, Beijing Luhe Hospital,, Capital Medical University, Beijing, China
| | - Yan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Qin
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu Yang
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Guangpu Fan
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Huajun Zhang
- Department of Cardiovascular Surgery, PLA General Hospital, Beijing, China
| | - Zheng Ding
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Xu
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Yu Chen
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Yingli Zheng
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Meng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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15
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Cao H, Jiang S, Lv M, Wu T, Chen W, Zhang J. Effectiveness of the Alfalfa App in Warfarin Therapy Management for Patients Undergoing Venous Thrombosis Prevention and Treatment: Cohort Study. JMIR Mhealth Uhealth 2021; 9:e23332. [PMID: 33650976 PMCID: PMC7967226 DOI: 10.2196/23332] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/13/2020] [Accepted: 01/08/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Over the years, the internet has enabled considerable progress in the management of chronic diseases, especially hypertension and diabetes. It also provides novel opportunities in online anticoagulation management. Nevertheless, there is insufficient evidence regarding the effectiveness of online anticoagulation management. OBJECTIVE This study explored the effectiveness and safety of warfarin management via the Alfalfa app, so as to provide evidence in support of anticoagulant management through online services. METHODS In this retrospective, observational cohort study, 824 patients were included. In the offline group, patients went to the hospital clinic for warfarin management. In the Alfalfa app group, patients reported the dose of warfarin, current international normalized ratio (INR) value, and other related information through the Alfalfa app. Physicians or pharmacists used the app to adjust the dose of warfarin and determined the time for the next blood INR testing. Patients completed INR testing by point-of-care at home or hospital. The primary outcome of the study was the percentage of time in therapeutic range (TTR). Secondary outcomes included minor and major bleeding events, thrombotic events, warfarin-related emergency department visits, hospital admissions, and high INR values. RESULTS The TTR and percentage of INR values in the range were significantly higher in the Alfalfa app group than in the offline group (79.35% vs 52.38%, P<.001; 3314/4282, 77.39% vs 2005/4202, 47.72%, P<.001, respectively). Patients managed via the Alfalfa app had lower rates of subtherapeutic (172/4282, 4.02% vs 388/4202, 9.23%; P<.001), supratherapeutic (487/4282, 11.37% vs 882/4202, 20.99%; P<.001), and extreme subtherapeutic INR values (290/4282, 6.77% vs 910/4202, 21.66%; P<.001). Additionally, the Alfalfa app group had lower incidences of major bleeding (2/425, 0.5% vs 12/399, 3.0%; P=.005), warfarin-related emergency department visits (13/425, 3.1% vs 37/399, 9.3%; P<.001), and hospital admissions (1/425, 0.2% vs 12/399, 3.0%; P=.001) compared with the offline group. However, the Alfalfa app group had a higher incidence of minor bleeding than the offline group (45/425, 10.6% vs 20/399, 5.0%; P=.003). There were similar incidences in extreme supratherapeutic INR values (19/4282, 0.44% vs 17/4202, 0.40%; P=.78) and thromboembolic events (1/425, 0.2% vs 1/399, 0.3%; P=.53) between the two groups. CONCLUSIONS Warfarin management is superior via the Alfalfa app than via offline services in terms of major bleeding events, warfarin-related emergency department visits, and hospital admissions.
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Affiliation(s)
- Hua Cao
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Cardiac Surgery, Fujian Maternity and Children Health Hospital, Fuzhou, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
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16
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Eggebrecht L, Ludolph P, Göbel S, Panova-Noeva M, Arnold N, Nagler M, Bickel C, Lauterbach M, Hardt R, Cate HT, Lackner KJ, Espinola-Klein C, Münzel T, Prochaska JH, Wild PS. Cost saving analysis of specialized, eHealth-based management of patients receiving oral anticoagulation therapy: Results from the thrombEVAL study. Sci Rep 2021; 11:2577. [PMID: 33510343 PMCID: PMC7844022 DOI: 10.1038/s41598-021-82076-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/30/2020] [Indexed: 11/25/2022] Open
Abstract
To evaluate the cost-saving of a specialized, eHealth-based management service (CS) in comparison to regular medical care (RMC) for the management of patients receiving oral anticoagulation (OAC) therapy. Costs of hospitalization were derived via diagnosis-related groups which comprise diagnoses (ICD-10) and operation and procedure classification system (OPS), which resulted in OAC-related (i.e. bleeding/ thromboembolic events) and non-OAC-related costs for both cohorts. Cost for anticoagulation management comprised INR-testing, personnel, and technical support. In total, 705 patients were managed by CS and 1490 patients received RMC. The number of hospital stays was significantly lower in the CS cohort compared to RMC (CS: 23.4/100 py; RMC: 68.7/100 py); with the most pronounced difference in OAC-related admissions (CS: 2.8/100 py; RMC: 13.3/100 py). Total costs for anticoagulation management amounted to 101 EUR/py in RMC and 311 EUR/py in CS, whereas hospitalization costs were 3261 [IQR 2857-3689] EUR/py in RMC and 683 [504-874] EUR/py in CS. This resulted in an overall cost saving 2368 EUR/py favoring the CS. The lower frequency of adverse events in anticoagulated patients managed by the telemedicine-based CS compared to RMC translated into a substantial cost-saving, despite higher costs for the specialized management of patients.Trial registration: ClinicalTrials.gov, unique identifier NCT01809015, March 8, 2013.
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Affiliation(s)
- Lisa Eggebrecht
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Paul Ludolph
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sebastian Göbel
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Marina Panova-Noeva
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Natalie Arnold
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | | | - Roland Hardt
- Center for General Medicine and Geriatric Medicine, University Medical Center Mainz, Johannes Gutenberg University-Mainz, Mainz, Germany
| | - Hugo Ten Cate
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- CARIM/ Department of Vascular Medicine, Heart and Vascular Center, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Karl J Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christine Espinola-Klein
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Jürgen H Prochaska
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp S Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany.
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany.
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17
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Keller K, Göbel S, ten Cate V, Panova-Noeva M, Eggebrecht L, Nagler M, Coldewey M, Foebel M, Bickel C, Lauterbach M, Espinola-Klein C, Lackner KJ, ten Cate H, Münzel T, S. Wild P, H. Prochaska J. Telemedicine-Based Specialized Care Improves the Outcome of Anticoagulated Individuals with Venous Thromboembolism-Results from the thrombEVAL Study. J Clin Med 2020; 9:E3281. [PMID: 33066188 PMCID: PMC7602093 DOI: 10.3390/jcm9103281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022] Open
Abstract
Venous thromboembolism (VTE) is a life-threatening disease with risk of recurrence. Oral anticoagulation (OAC) with vitamin K antagonists (VKA) is effective to prevent thromboembolic recurrence. We aimed to investigate the quality of OAC of VTE patients in regular medical care (RMC) compared to a telemedicine-based coagulation service (CS). The thrombEVAL study (NCT01809015) is a prospective, multi-center study to investigate OAC treatment (recruitment: January 2011-March 2013). Patients were evaluated using clinical visits, computer-assisted personal interviews, self-reported data and laboratory measurements according to standard operating procedures. Overall, 360 patients with VTE from RMC and 254 from CS were included. Time in therapeutic range (TTR) was higher in CS compared to RMC (76.9% (interquartile range [IQR] 63.2-87.1%) vs. 69.5% (52.3-85.6%), p < 0.001). Crude rate of thromboembolic events (rate ratio [RR] 11.33 (95% confidence interval [CI] 1.85-465.26), p = 0.0015), clinically relevant bleeding (RR 6.80 (2.52-25.76), p < 0.001), hospitalizations (RR 2.54 (1.94-3.39), p < 0.001) and mortality under OAC (RR 5.89 (2.40-18.75), p < 0.001) were consistently higher in RMC compared with CS. Patients in RMC had higher risk for primary outcome (clinically relevant bleedings, thromboembolic events and mortality, hazard ratio [HR] 5.39 (95%CI 2.81-10.33), p < 0.0001), mortality (HR 5.54 (2.22-13.84), p = 0.00025), thromboembolic events (HR 6.41 (1.51-27.24), p = 0.012), clinically relevant bleeding (HR 5.31 (1.89-14.89), p = 0.0015) and hospitalization (HR 1.84 (1.34-2.55), p = 0.0002). Benefits of CS care were still observed after adjusting for comorbidities and TTR. In conclusion, anticoagulation quality and outcome of VTE patients undergoing VKA treatment was significantly better in CS than in RMC. Patients treated in CS had lower rates of adverse events, hospitalizations and lower mortality. CS was prognostically relevant, beyond providing advantages of improved international ratio (INR) monitoring.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.)
| | - Sebastian Göbel
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
| | - Vincent ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Preventive Cardiology and Preventive Medicine—Center of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Marina Panova-Noeva
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
| | - Lisa Eggebrecht
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Preventive Cardiology and Preventive Medicine—Center of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Markus Nagler
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Preventive Cardiology and Preventive Medicine—Center of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Meike Coldewey
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.)
| | - Maike Foebel
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany;
| | - Michael Lauterbach
- Department of Medicine 3, Barmherzige Brüder Hospital, 54292 Trier, Germany;
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.)
| | - Karl J. Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Hugo ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Thrombosis Center Maastricht, Cardiovascular Research Institute Maastricht and Maastricht University Medical Center, 6229HX Maastricht, The Netherlands
| | - Thomas Münzel
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
| | - Philipp S. Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
- Preventive Cardiology and Preventive Medicine—Center of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Jürgen H. Prochaska
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (K.K.); (V.t.C.); (M.P.-N.); (L.E.); (M.N.); (M.C.); (M.F.); (H.t.C.); (T.M.); (P.S.W.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany;
- Preventive Cardiology and Preventive Medicine—Center of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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18
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Paschke LM, Klimke K, Altiner A, von Stillfried D, Schulz M. Comparing stroke prevention therapy of direct oral anticoagulants and vitamin K antagonists in patients with atrial fibrillation: a nationwide retrospective observational study. BMC Med 2020; 18:254. [PMID: 32847578 PMCID: PMC7450597 DOI: 10.1186/s12916-020-01695-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/02/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are not only increasingly being used for the initial stroke prevention therapy but progressively also substitute vitamin K antagonist (VKA) treatment in patients with non-valvular atrial fibrillation (AF). DOACs have been compared regarding therapeutic efficacy and adverse outcomes to warfarin in several pivotal studies and showed non-inferiority in terms of stroke prevention and superiority in terms of bleeding complications. However, comprehensive comparative studies are lacking for phenprocoumon, a VKA prescribed frequently outside the USA and the UK and accounting for 99% of all VKA prescriptions in Germany. Patients treated with phenprocoumon seem to meet more often international normalized ratio values in the therapeutic range, which may have implications concerning their efficacy and safety. This study aims at comparing the risk of stroke and bleeding in phenprocoumon- and DOAC-treated patients with AF in an adequately powered observational study population. METHODS Retrospective analysis of stroke and bleeding incidence of 837,430 patients (1.27 million patient years) treated with DOAC or phenprocoumon for stroke prevention in German ambulatory care between 2010 and 2017. Relative risks of stroke and bleeding were estimated by calculating cox regression-derived hazard ratios (HR) and 95% confidence intervals (CI) of propensity score-matched cohorts. RESULTS Patients treated with DOAC had an overall higher risk for stroke (HR 1.32; CI 1.29-1.35) and a lower risk for bleeding (0.89; 0.88-0.90) compared to phenprocoumon. When analyzed separately, the risk for stroke was higher for dabigatran (1.93; 1.82-2.03), apixaban (1.52; 1.46-1.58), and rivaroxaban (1.13; 1.10-1.17) but not for edoxaban (0.88; 0.74-1.05). The risk for bleeding was lower for dabigatran (0.85; 0.83-0.88), apixaban (0.71; 0.70-0.73), and edoxaban (0.29; 0.17-0.51) but not for rivaroxaban (1.03; 1.01-1.04). CONCLUSIONS This study provides a comprehensive view of the stroke and bleeding risks associated with phenprocoumon and DOAC use in Germany. Phenprocoumon may be preferable to DOAC treatment for the prevention of strokes in AF in a real-world population cared for in ambulatory care.
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Affiliation(s)
- Lena M Paschke
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care in Germany, Salzufer 8, 10587, Berlin, Germany.
| | - Kerstin Klimke
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care in Germany, Salzufer 8, 10587, Berlin, Germany
| | - Attila Altiner
- Department of General Practice, Medical Faculty, University of Rostock, 18055, Rostock, Germany
| | - Dominik von Stillfried
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care in Germany, Salzufer 8, 10587, Berlin, Germany
| | - Maike Schulz
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care in Germany, Salzufer 8, 10587, Berlin, Germany
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Dhippayom T, Devine B. Letter to the editor for a published article titled "The effect of online versus hospital warfarin management on patient outcomes: a systematic review and meta-analysis". Int J Clin Pharm 2020; 42:1-2. [PMID: 32240483 DOI: 10.1007/s11096-019-00947-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/26/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Teerapon Dhippayom
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, 65000, Thailand.
| | - Beth Devine
- School of Pharmacy, The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington, Seattle, USA
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20
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Lauterbach M, Uhrich E, Eggebrecht L, Göbel S, Panova-Noeva M, Nagler M, ten Cate V, Bickel C, Espinola-Klein C, Münzel T, S. Wild P, H. Prochaska J. Specialized Management of Oral Anticoagulation Therapy Improves Outcome in Patients with Chronic Renal Insufficiency. J Clin Med 2020; 9:jcm9030645. [PMID: 32121153 PMCID: PMC7141283 DOI: 10.3390/jcm9030645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Oral anticoagulation (OAC) is effective at preventing and treating thromboses and thromboembolism in patients with normal renal function. We aimed to research the impact of severe renal failure (RF) on patient outcome and to determine the potential benefit of caring for these patients in a specialized coagulation service (CS). A total of 1516 usual medical care patients and 756 CS-managed patients of the thrombEVAL multicenter (21 centers), prospective, cohort study (NCT01809015) were analyzed in a 3-year follow-up. Patients with RF (serum creatinine >3 mg/dL, no renal replacement therapy) were compared to patients without RF in usual care and a CS. The fluctuations in the international normalized ratios were significantly lower in CS-managed patients, and regardless of treatment in usual care or a CS, the time in therapeutic range was significantly lower in RF patients. Cox regression-adjusted hazard ratios for long-term outcome (1.5, 95% CI: 1.22–1.83, p < 0.001), death (1.62, CI: 1.27–2.08, p < 0.001), and hospitalization (1.21, CI: 1.02–1.44, p = 0.032) were significantly higher in RF patients in usual care. Furthermore, there was a trend of more bleeding events in RF patients. CS-treated patients had significantly lower adjusted hazard ratios for death (0.24, CI: 0.14–0.39, p < 0.001), hospitalizations (0.41, CI: 0.34–0.5, p < 0.001), clinically relevant bleeding (0.29, CI: 0.18–0.47, p < 0.001), and major bleeding (0.33, CI: 0.18–0.59, p < 0.001). Thus, patients who required oral anticoagulation therapy benefitted significantly from being managed in a specialized coagulation service, regardless of their renal function.
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Affiliation(s)
- Michael Lauterbach
- 3rd Medical Clinic-Cardiology, Barmherzige Brüder Hospital, 54292 Trier, Germany;
- Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.); (T.M.)
- Correspondence: ; Tel.: +49-651-208-2784; Fax: +49-651-208-2876
| | - Eduard Uhrich
- 3rd Medical Clinic-Cardiology, Barmherzige Brüder Hospital, 54292 Trier, Germany;
| | - Lisa Eggebrecht
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (L.E.); (M.N.); (V.t.C.); (P.S.W.); (J.H.P.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Sebastian Göbel
- Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Marina Panova-Noeva
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (L.E.); (M.N.); (V.t.C.); (P.S.W.); (J.H.P.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Vincent ten Cate
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (L.E.); (M.N.); (V.t.C.); (P.S.W.); (J.H.P.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany;
| | - Christine Espinola-Klein
- Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.); (T.M.)
| | - Thomas Münzel
- Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (S.G.); (C.E.-K.); (T.M.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Philipp S. Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (L.E.); (M.N.); (V.t.C.); (P.S.W.); (J.H.P.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Jürgen H. Prochaska
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (L.E.); (M.N.); (V.t.C.); (P.S.W.); (J.H.P.)
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
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21
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Michal M, Eggebrecht L, Göbel S, Panova-Noeva M, Nagler M, Arnold N, Lauterbach M, Bickel C, Wiltink J, Beutel ME, Münzel T, Wild PS, Prochaska JH. The relevance of depressive symptoms for the outcome of patients receiving vitamin K antagonists: results from the thrombEVAL cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:271-279. [PMID: 31922545 DOI: 10.1093/ehjcvp/pvz085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/14/2019] [Accepted: 01/06/2020] [Indexed: 02/02/2023]
Abstract
AIMS Although depressive symptoms are highly prevalent in patients receiving oral anticoagulation (OAC), the relevance of depression for the outcome of anticoagulated individuals is unknown. METHODS AND RESULTS We analysed data from the multicentre cohort study thrombEVAL (NCT01809015) investigating the efficacy of OAC with vitamin K antagonists. There was an independent study monitoring, and an independent review panel assessed the endpoints. Out of n = 1558 participants, information about depressive symptoms, as measured by the two-item screener of the patient health questionnaire (PHQ-2), was available in n = 1405 individuals. The mean follow-up period was 28.04 months, with a standard deviation of 11.52 months. In multivariable Cox regression analysis, baseline PHQ-2 sum score was a strong and robust predictor of clinically relevant bleeding [hazard ratio (HR) 1.13, 95% confidence interval 1.03-1.24; P = 0.011] and all-cause mortality (HR 1.18, 1.08-1.28; P = 0.001) independent of age, sex, high school graduation, partnership, clinical profile, intake of serotonin reuptake inhibitors, and quality of OAC therapy. Individuals with clinically significant depressive symptoms (PHQ-2 ≥ 3) had a 57% increased risk for clinically relevant bleeding (fully adjusted HR 1.57, 1.08-2.28) and 54% greater risk for death (fully adjusted HR 1.54, 1.09-2.17). There was no association of depressive symptoms with thromboembolic events. For hospitalization, individuals with depressive symptoms (PHQ-2 ≥ 3) did not experience an elevated risk in the fully adjusted model (HR 1.08, 0.86-1.35; P = 0.52). CONCLUSION Assessment of depression by the PHQ-2 provided independent long-term prognostic information beyond common biomedical risk factors. These findings highlight the need for targeting depressive symptoms in the management of patients receiving OAC therapy.
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Affiliation(s)
- Matthias Michal
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Lisa Eggebrecht
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Sebastian Göbel
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Marina Panova-Noeva
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Natalie Arnold
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Michael Lauterbach
- Department of Medicine 3, Barmherzige Brüder Hospital Trier, Nordallee 1, 54292 Trier, Germany
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital, Rübenacher Str. 170, 56072 Koblenz, Germany
| | - Jörg Wiltink
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
| | - Manfred E Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
| | - Thomas Münzel
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Philipp S Wild
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany.,Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Jürgen H Prochaska
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Langenbeckstr. 1, 55131 Mainz, Germany.,Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
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Zhu Z, Li Y, Meng X, Han J, Li Y, Liu K, Shen J, Qin Y, Zhang H. New warfarin anticoagulation management model after heart valve surgery: rationale and design of a prospective, multicentre, randomised trial to compare an internet-based warfarin anticoagulation management model with the traditional warfarin management model. BMJ Open 2019; 9:e032949. [PMID: 31811010 PMCID: PMC6924837 DOI: 10.1136/bmjopen-2019-032949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Warfarin is an effective anticoagulant and the only oral anticoagulant available for patients with mechanical heart valves. The prothrombin time and the associated international normalised ratio (INR) are routinely tested to monitor the response to anticoagulation therapy in patients. Patients who undergo mechanical heart valve replacement need lifelong anticoagulation therapy, and their INR is regularly measured to adjust the anticoagulation strength and the dose of anticoagulation drugs. Appropriate warfarin anticoagulation management can reduce patient complications, such as bleeding and thrombosis, and improve the long-term survival rate. We propose modern internet technology as a platform to build a warfarin anticoagulation follow-up system after valve replacement surgery. This system will provide doctors and patients with more standardised and safer follow-up methods as well as a method to further reduce the risk of warfarin anticoagulation-related complications and improve its therapeutic effects. METHODS AND ANALYSIS A prospective, multicentre, randomised, controlled trial will be conducted. A total of 700 patients who require long-term warfarin anticoagulation monitoring after heart valve replacement will be enrolled and randomly divided at a 1:1 ratio into a traditional outpatient anticoagulation management group and a group undergoing a new method of management based on the internet technology with follow-up for 1 year. Differences in the percentage of time in the therapeutic range (TTR), drug dose adjustments, bleeding/thrombosis and other related complications will be observed. The primary endpoint is the difference in the TTR between the two groups. The purpose of this study is to explore a safer and more effective mode of doctor-patient interaction and communication in the internet era. As of 13 July 2019, 534 patients had been enrolled. ETHICS AND DISSEMINATION This study protocol was approved by the Ethics Committee of Beijing Anzhen Hospital, Capital Medical University. The results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER ChiCTR1800016204.
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Affiliation(s)
- Zhihui Zhu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuehuan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Meng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinglun Shen
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Qin
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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23
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Mertens C, Siebenhofer A, Berghold A, Pregartner G, Ulrich LR, Mergenthal K, Kemperdick B, Schulz-Rothe S, Rauck S, Harder S, Gerlach FM, Petersen JJ. Differences in the quality of oral anticoagulation therapy with vitamin K antagonists in German GP practices - results of the cluster-randomized PICANT trial (Primary Care Management for Optimized Antithrombotic Treatment). BMC Health Serv Res 2019; 19:539. [PMID: 31370840 PMCID: PMC6676561 DOI: 10.1186/s12913-019-4372-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily. Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors. Methods The PICANT trial (2012–2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice−/ patient-level factors and TTR. Results Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized. Conclusions The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes. Trial registration ISRCTN registry, ISRCTN41847489, registered 27 February 2012. Electronic supplementary material The online version of this article (10.1186/s12913-019-4372-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelia Mertens
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Andrea Siebenhofer
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany. .,Institute of General Practice and Evidence-based Health Services Research, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria.
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria
| | - Lisa-Rebekka Ulrich
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Birgit Kemperdick
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sylvia Schulz-Rothe
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sandra Rauck
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sebastian Harder
- Institute of Clinical Pharmacology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Ferdinand Michael Gerlach
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Juliana Johanna Petersen
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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Luani B, Genz C, Herold J, Mitrasch A, Mitusch J, Wiemer M, Schmeißer A, Braun-Dullaeus RC, Rauwolf T. Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device. BMC Cardiovasc Disord 2019; 19:112. [PMID: 31092201 PMCID: PMC6518765 DOI: 10.1186/s12872-019-1097-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/03/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Impaired renal function increases the bleeding risk, leading to a conservative prescription and frequent discontinuation of oral anticoagulation in atrial fibrillation patients with chronic kidney disease (CKD). Interventional left atrial appendage closure (LAAC) might be an alternative therapeutic strategy for these patients. METHODS We aimed to prospectively assess cerebrovascular (CE) and bleeding events, as well as peri-procedural and long-term complications in a cohort of consecutive patients undergoing interventional LAAC using the WATCHMAN™ device, with focus on CKD patients. RESULTS One hundred and eighty-nine consecutive patients undergoing interventional LAAC were included in this analysis; 171 (90.5%) patients had a reduced estimated glomerular filtration rate (eGFR; patients for each CKD stage: II = 66; IIIa = 32; IIIb = 43; IV = 18; V = 12). During a follow-up of 310 patient years three (1.0%) patients suffered a CE (two strokes, one transitory ischemic attack) and five (1.6%) other ones a bleeding complication. The observed stroke rate was more than two-thirds and the bleeding risk more than half lower than expected. Device related thrombi (DRT) were detected in twelve (6.5%) patients; women had significantly more DRT than men (12.5% vs. 2.6%; p = 0.009). Patients with an eGFR< 30 ml/min/1.73m2 showed a trend to a higher DRT rate as compared to the opposite group (13.3% vs. 5.1%; p = 0.10). Thrombus resolved with temporary oral anticoagulation therapy in ten patients without sequelae; thrombus consolidation was confirmed by serial TEE controls in the remaining two patients. CONCLUSIONS Atrial fibrillation patients with CKD have low CE and bleeding rates after LAAC with the WATCHMAN™ device. DRT risk is higher in female and patients with severe CKD. More frequent post-interventional TEE controls might be justified for early DRT detection and safe management of patients at high DRT risk. TRIAL REGISTRATION (German Clinical Trials Register ID: DRKS00 010768 ; Registration Date 07.07.2016).
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Affiliation(s)
- Blerim Luani
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Hans-Nolte-Str. 1, 32429 Minden, Germany
| | - Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Joerg Herold
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Andreas Mitrasch
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Julius Mitusch
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Marcus Wiemer
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Hans-Nolte-Str. 1, 32429 Minden, Germany
| | - Alexander Schmeißer
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Rüdiger C. Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Thomas Rauwolf
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
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Kaurav MS, Sahu PK, Sahu PK, Messali M, Almutairi SM, Sahu PL, Agarwal DD. An efficient, mild and metal free l-proline catalyzed construction of fused pyrimidines under microwave conditions in water. RSC Adv 2019; 9:3755-3763. [PMID: 35518091 PMCID: PMC9060310 DOI: 10.1039/c8ra07517d] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 01/10/2019] [Indexed: 02/03/2023] Open
Abstract
One-pot condensation of 4-hydroxy coumarins, aldehydes and urea/thiourea to build C-C and C-N bonds is described. Fused pyrimidines have been synthesized under mild reaction conditions using l-proline. The protocol has been performed rapidly and efficiently in water under metal free conditions. Heterocyclic derivatives have been synthesized using the present methodology and avoid the use of hazardous solvents over conventional organic solvents. A proposed mechanism could be established for three component reactions. The present study reveals the first case in which l-proline has been explored as a homogeneous catalyst in the synthesis of fused pyrimidines in water under microwave irradiation. This synthesis involves simple workup and acceptable efficiency. The most notable feature of this protocol is the ability of the catalyst to influence asymmetric induction in the reaction.
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Affiliation(s)
- Manvendra S Kaurav
- School of Studies in Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
| | - Pramod K Sahu
- School of Studies in Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
- Department of Industrial Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
| | - Praveen K Sahu
- Department of Industrial Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
| | - Mouslim Messali
- Department of Chemistry, Taibah University 30002 Al-Madina Al-Mounawara Saudi Arabia
| | - Saud M Almutairi
- King Abdulaziz City for Science and Technology P. O. Box 6086 Riyadh 11442 Saudi Arabia
| | - Puran L Sahu
- Indian Pharmacopoeia Commission, Ministry of Health and Family Welfare Sector-23, Raj Nagar Ghaziabad 201002 India
- National Dope Testing Laboratory (NDTL), Ministry of Youth Affair & Sports, Government of India J. L. N. Stadium Complex East Gate No. 10, Lodi Road New Delhi-3 India
| | - Dau D Agarwal
- School of Studies in Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
- Department of Industrial Chemistry, Jiwaji University Gwalior-474011 Madhya Pradesh India
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Diel R, Lampenius N. Cost-benefit analysis of VKA versus NOAC treatment in German patients with atrial fibrillation utilizing patient self-testing. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:142-159. [PMID: 32685587 PMCID: PMC7299443 DOI: 10.36469/9774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 05/07/2023]
Abstract
BACKGROUND Clinical complications of long-term anticoagulation in patients with atrial fibrillation cause significant morbidity and have a substantial economic impact on the healthcare system. OBJECTIVE To assess the cost-benefit by implementing patient self-testing (PST) in German patients anticoagulated with vitamin K antagonists (VKA) compared to treatment with the new oral anticoagulant drugs (NOAC) apixaban, dabigatran, edoxaban, and rivaroxaban. METHODS A deterministic decision-analytic model was developed simulating the number of major bleedings, ischemic strokes, and hemorrhagic strokes and their associated costs by utilizing PST compared to those of treatment with NOAC. Data on the rates of these adverse events in both groups during the 1st year of treatment was taken from the NOAC approval studies. Direct costs were evaluated from the perspective of the Statutory Health Insurance (SHI) considering the use of resources directly related to PST testing and costs incurred by hospital treatment of the adverse events. Univariate sensitivity analysis was performed to examine the extent to which our calculations were affected by varying the parameters considered in our model within plausible extremes. To capture the interactions between multiple inputs, we also provided a probabilistic sensitivity analysis (PSA). RESULTS When achieving an average time in therapeutic range (TTR) of 78%, implementing PST in VKA patients reduces cost per patient compared to NOAC treatment between €603.38 [USD 681.52] (edoxaban) and €762.64 [USD 861.40] (rivaroxaban) during the 1-year observation period. In line with the TTR increase, the initially higher number of adverse events per VKA patient compared to NOACtreated patients in the approval studies becomes largely aligned; the difference in associated hospital costs per patient in the NOAC groups is then only €1.03 [USD 1.16] (in favor of dabigatran), €23.41 [USD 26.44] (in favor of apixaban), €0.53 [USD 0.60] (in favor of edoxaban) and €52.62 [USD 59.43] (in favor of VKA anticoagulation in the rivaroxaban group).In PSA, implementation of self-management results on average in a cost saving between €619.20 [USD 699.39] and €785.24 [USD 886.93] per VKA patient in favor of the SHI. Under all reasonable assumptions, PST remains constantly less expensive irrespective of which NOAC is administered. CONCLUSION Implementing PST in German VKA patients may significantly reduce SHI expenditures compared to utilizing NOAC.
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Affiliation(s)
- Roland Diel
- Institute for Epidemiology, University Medical Hospital Schleswig-Holstein, Kiel
- Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, Germany
| | - Niklas Lampenius
- Department of Accounting and Finance, University of Hohenheim, Stuttgart, Germany
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Xia X, Wu J, Zhang J. The effect of online versus hospital warfarin management on patient outcomes: a systematic review and meta-analysis. Int J Clin Pharm 2018; 40:1420-1429. [PMID: 30367374 DOI: 10.1007/s11096-018-0731-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/04/2018] [Indexed: 01/11/2023]
Abstract
Background Patients using oral anticoagulants are prone both to thrombus from insufficient anticoagulant therapy and to bleeding by overmedication, so there is a need for further exploring. Aim of the review To assess the effect of online management (using electronic communication such as smartphone), and hospital management on the outcome of patients on long-term anticoagulant therapy, and to explore an appropriate anticoagulation management model. Method Studies published in English prior to July 2017 were retrieved from PubMed, EMBASE, Web of Science, and the Cochrane Library. Two researchers screened the literature independently, extracted the data and evaluated the methodological quality of the included studies. Meta-analysis was conducted using RevMan 5.3 software. The publication bias analysis was evaluated. Results A total of ten studies met the inclusion criteria, covering 16,915 patients. Of these, 8260 cases formed the online anticoagulation management group, and the other 8655 cases the hospital anticoagulant management group. There were no significant differences between the management models for time in therapeutic range, incidence of major or minor bleeding events, thromboembolic events, or warfarin-related emergency department visits. However, online management was associated with fewer warfarin-related hospital admissions than hospital management (odds ratio: 0.47, 95% confidence interval [0.30, 0.73]; P = 0.0009). Conclusion The online management of anticoagulant therapy was not inferior to hospital management, and may provide more convenient, higher quality anticoagulant therapy services for patients.
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Affiliation(s)
- Xiaotong Xia
- Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Jianmei Wu
- Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Jinhua Zhang
- Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
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Himmler S, Müller M, Ostwald D, Seddik A, Basic E, Hradetzky E. Long-term health benefits of stroke prevention with apixaban versus vitamin K antagonist warfarin in patients with non-valvular atrial fibrillation in Germany: a population-based modelling study. Expert Rev Pharmacoecon Outcomes Res 2018; 19:223-230. [DOI: 10.1080/14737167.2019.1522501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | | | | | - Edin Basic
- Health Technology Assessment & Outcomes Research, Pfizer Deutschland GmbH, Berlin, Germany
| | - Eva Hradetzky
- Medical Affairs Internal Medicine, Pfizer Pharma GmbH, Berlin, Germany
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Outcomes of warfarin therapy managed by pharmacists via hospital anticoagulation clinic versus online anticoagulation clinic. Int J Clin Pharm 2018; 40:1072-1077. [PMID: 29956134 DOI: 10.1007/s11096-018-0674-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 06/14/2018] [Indexed: 12/25/2022]
Abstract
Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P = 0.393) and adverse events [major bleeding events (0 vs. 1.2%, P = 1.000), minor bleeding events (10.0 vs. 9.8%, P = 0.960), thromboembolic events (0 vs. 0%, P = 1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P = 1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P = 1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P = 0.148), and extreme total (8.4 vs. 5.8%, P = 0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P = 0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P = 0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.
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Comparative risks of bleeding, ischemic stroke and mortality with direct oral anticoagulants versus phenprocoumon in patients with atrial fibrillation. Eur J Clin Pharmacol 2018; 74:1317-1325. [DOI: 10.1007/s00228-018-2504-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/07/2018] [Indexed: 12/29/2022]
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Sustained atrial fibrillation increases the risk of anticoagulation-related bleeding in heart failure. Clin Res Cardiol 2018; 107:1170-1179. [PMID: 29948286 DOI: 10.1007/s00392-018-1293-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Oral anticoagulation therapy in individuals with atrial fibrillation (AF) reduces the risk of thromboembolic events at cost of an increased bleeding risk. Whether anticoagulation-related outcomes differ between patients with paroxysmal and sustained AF receiving anticoagulation is controversially discussed. METHODS In the present analysis of the prospective multi-center cohort study thrombEVAL, the incidence of anticoagulation-related adverse events was analyzed according to the AF phenotype. Information on outcome was centrally recorded over 3 years, validated via medical records and adjudicated by an independent review panel. Study monitoring was provided by an independent institution. RESULTS Overall, the sample comprised 1089 AF individuals, of whom n = 398 had paroxysmal AF and n = 691 experienced sustained AF. In Cox regression analysis with adjustment for potential confounders, sustained AF indicated an independently elevated risk of clinically relevant bleeding compared to paroxysmal AF [hazard ratio (HR) 1.40 (1.02; 1.93); P = 0.038]. For clinically relevant bleeding, a significant interaction of the pattern of AF type with concomitant heart failure (HF) was detected: HRHF 2.45 (1.51, 3.98) vs. HRno HF 0.85 (0.55, 1.34); Pinteraction = 0.003. In HF patients, sustained AF indicated also an elevated risk of major bleeding [HR 2.25 (1.26, 4.20); P = 0.006]. A simplified HAS-BLED score incorporating only information on age (> 65 years), bleeding history, and HF with sustained AF demonstrated better discriminative performance for clinically relevant bleeding than the original version: AUCHAS-BLED: 0.583 vs. AUCsimplifiedHAS-BLED: 0.642 (P = 0.004). CONCLUSIONS In HF patients receiving oral anticoagulation, sustained AF indicates a substantially elevated risk of bleeding. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov , identifier: NCT01809015.
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Prochaska JH, Göbel S, Keller K, Coldewey M, Ullmann A, Lamparter H, Schulz A, Schinzel H, Bickel C, Lauterbach M, Michal M, Hardt R, Binder H, Espinola-Klein C, Lackner KJ, Ten Cate H, Münzel T, Wild PS. e-Health-based management of patients receiving oral anticoagulation therapy: results from the observational thrombEVAL study. J Thromb Haemost 2017; 15:1375-1385. [PMID: 28457013 DOI: 10.1111/jth.13727] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Indexed: 12/13/2022]
Abstract
Essentials e-Health based health care by an expert centre may advance management of oral anticoagulation. Outcome of patients was compared between an e-health based coagulation service and regular care. Patients in the coagulation service cohort experienced a significantly better clinical outcome. Lower risk for adverse events was related to anticoagulation-specific and non-specific outcome. SUMMARY Background Management of oral anticoagulation (OAC) therapy is essential to minimize adverse events in patients receiving vitamin K-antagonists (VKAs). Data on the effect of e-health-based anticoagulation management systems on the clinical outcome of OAC patients are limited. Objectives To compare the clinical outcome of OAC patients managed by an e-health-based coagulation service (CS) with that of patients receiving regular medical care (RMC). Methods The prospective multicenter cohort study thrombEVAL (NCT01809015) comprised 1558 individuals receiving RMC and 760 individuals managed by a CS. Independent study monitoring and adjudication of endpoints by an independent review panel were implemented. Results The primary study endpoint (composite of thromboembolism, clinically relevant bleeding and death) occurred in 15.7 per 100 patient-years (py) with RMC and in 7.0 per 100 py with the CS (rate ratio [RR], 2.3; 95% confidence interval [CI], 1.7-3.1). Rates for major and clinically relevant bleeding were higher with RMC than with the CS: 6.8 vs. 2.6 and 10.1 vs. 3.6 per 100 py, respectively. Thromboembolic events showed an RR of 1.5 (95% CI, 0.8-2.6) comparing RMC with the CS. Hospitalization (RR, 2.6; 95% CI, 2.3-3.0) and all-cause mortality (RR, 4.6; 95% CI, 2.8-7.7) were markedly more frequent with RMC. In Cox regression analysis with adjustment for age, sex, cardiovascular risk factors, comorbidities, treatment characteristics and sociodemographic status, hazard ratios (HR) for the primary endpoint (HR, 2.2; 95% CI, 1.5-3.4), clinically relevant bleeding (HR, 3.1; 95% CI, 1.7-5.5), hospitalization (HR, 2.2; 95% CI, 1.8-2.8) and all-cause mortality (HR, 5.6; 95% CI, 2.9-11.0) favored CS treatment. Conclusions In this study, e-health-based management of OAC therapy was associated with a lower frequency of OAC-specific and non-specific adverse events.
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Affiliation(s)
- J H Prochaska
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein-Main, Mainz, Germany
| | - S Göbel
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein-Main, Mainz, Germany
| | - K Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - M Coldewey
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - A Ullmann
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Chrestos Concept GmbH, Ratingen, Germany
| | - H Lamparter
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - A Schulz
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - H Schinzel
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - C Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital, Koblenz, Germany
| | - M Lauterbach
- Department of Medicine 3, Barmherzige Brüder Hospital, Trier, Germany
| | - M Michal
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - R Hardt
- Center for General Medicine and Geriatrics, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - H Binder
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - C Espinola-Klein
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - K J Lackner
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein-Main, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - H Ten Cate
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Thrombosis Expertise Center Maastricht, Cardiovascular Research Institute Maastricht and Maastricht University Medical Center, Maastricht, the Netherlands
| | - T Münzel
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein-Main, Mainz, Germany
| | - P S Wild
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhein-Main, Mainz, Germany
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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Atas H, Sahin AA, Barutçu Atas D, Sunbul M, Kepez A, Agirbasli M. Potential Causes and Implications of Low Target Therapeutic Ratio in Warfarin-Treated Patients for Thrombosis Prophylaxis: A Single-Center Experience. Clin Appl Thromb Hemost 2017; 24:536-541. [PMID: 28301912 DOI: 10.1177/1076029617695484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Time in therapeutic range (TTR) of international normalized ratio is crucial for the safety and efficacy of anticoagulation with warfarin and it is influenced by many factors. There are limited data about the quality of warfarin therapy and its effects on clinical outcomes in Turkey. The aim of this study is to demonstrate the quality of anticoagulant therapy with warfarin and evaluate the parameters that affect the quality of warfarin therapy. A total of 170 patients with atrial fibrillation (AF; mean age: 62.2 ± 13.3; 69.2% female) treated with warfarin were included in this study. The mean follow-up period was 20 ± 8.4 months. The mean TTR levels of all patients were found to be 54.2% ± 21.4%. The TTR levels were similar in patients with valvular AF (VAF) and nonvalvular AF (NVAF). Logistic regression analysis revealed that elderly, heart failure (HF), and renal dysfunction were independent predictors of lower TTR. There were no significant differences between the VAF and NVAF subgroups regarding the incidence of mortality, stroke, and myocardial infarction. Cox regression analysis revealed that HF, coronary artery disease, and renal dysfunction were independent predictors of clinical outcomes in addition to lower TTR. Our results provide data regarding the quality of anticoagulation with warfarin from a single tertiary center in Istanbul, Turkey. The questions remain in seeking quality improvement in anticoagulation.
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Affiliation(s)
- Halil Atas
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Ahmet Anıl Sahin
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Dilek Barutçu Atas
- 2 Division of Nephrology, Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Murat Sunbul
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Alper Kepez
- 1 Department of Cardiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Agirbasli
- 3 Department of Cardiology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
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Laroche JP, Schved JF. [Vitamin K antagonist, direct oral anticoagulants: Where is the truth?]. ACTA ACUST UNITED AC 2016; 41:383-388. [PMID: 27817997 DOI: 10.1016/j.jmv.2016.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
Vitamin K antagonists (VKA) and direct oral anticoagulants (DOACs) are now in competition. The companies are trying to replace VKA by DOACs, totally or at least greatly VKA should VKA disappear in favor of DOACs? There are still many questions about DOACs. The purpose of this article is to make a well-considered decision in this area. The aim is not to denigrate one or the other but to share things between these two families of anticoagulants. Physicians using these drugs must have a full knowledge about compared efficacy and safety. We feel necessary to increase distance between effective results of the clinical trials and industrial communication around DOACs.
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Affiliation(s)
- J-P Laroche
- Service de médecine vasculaire, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
| | - J-F Schved
- Département d'hématologie biologique, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
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Kruse CS, Mileski M, Moreno J. Mobile health solutions for the aging population: A systematic narrative analysis. J Telemed Telecare 2016; 23:439-451. [PMID: 27255207 DOI: 10.1177/1357633x16649790] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction The ubiquitous nature of mobile technology coupled with the acceptance of mobile health (mHealth) among the elderly offers an opportunity to augment the existing medical workforce in long-term care. The objective of this review and narrative analysis is to identify and analyse facilitators and barriers to adoption of mHealth for the elderly. Methods Studies over the last year were identified in multiple database indices, and three reviewers examined abstracts ( k = 0.82) and analysed articles for themes which were tallied in affinity diagrams to identify frequency of occurrence in the literature (n = 36). Results The three facilitators mentioned most often were independence (18%), understanding (13%), and visibility (13%). The three barriers mentioned most often were complexity (21%), limited by users (12%) and ineffective (12%). Discussion and conclusions The reviewers concluded that the work done so far illustrates that mHealth enables a perception of independence. Future research should focus on the barriers of complexity of technology and improving existing medical literacy in order to facilitate further adoption.
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Affiliation(s)
| | - Michael Mileski
- School of Health Administration, Texas State University, USA
| | - Joshua Moreno
- School of Health Administration, Texas State University, USA
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Keller K, Prochaska JH, Coldewey M, Gobel S, Ullmann A, Jünger C, Lamparter H, Ariza L, Bickel C, Lauterbach M, Konstantinides S, Rostock T, Münzel T, Wild PS. History of deep vein thrombosis is a discriminator for concomitant atrial fibrillation in pulmonary embolism. Thromb Res 2015; 136:899-906. [PMID: 26376038 DOI: 10.1016/j.thromres.2015.08.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/22/2015] [Accepted: 08/29/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 70% of all cases. Although, PE and DVT are commonly related to risk factors of Virchow's triad, both entities are linked to cardiovascular risk factors, but risk factors seem differently important in both entities. OBJECTIVES We aimed to investigate clinical profile and outcome of patients with PE history stratified by concomitant DVT. PATIENTS/METHODS Data from the observational multi-center thrombEVAL-study were analyzed. RESULTS The sample (N=2,318) comprised 295 PE patients, of whom 69.2% (N=204) had DVT. Individuals without DVT were older and had higher prevalence of concomitant atrial fibrillation (AF), chronic lung diseases, coronary artery disease, heart failure and hypertension. Multivariable regression revealed an independent association of AF (Odds Ratio (OR) 3.17, 95% CI 1.63-6.18, P<0.001) and coronary artery disease (OR 2.31, 95% CI 1.15-4.66, P=0.019) with PE without DVT. There was higher frequency of permanent AF in individuals without DVT, whereas paroxysmal AF was more prevalent in individuals with DVT. All AF subtypes were independently associated with PE without DVT with increasing ORs from paroxysmal to permanent AF. PE patients with and without DVT did not differ in survival (P=0.32) and cost-relevant clinical outcome (P=0.26) during follow-up. AF in PE patients was associated with cost-relevant clinical outcome (Hazard Ratio (HR) 1.78, 95% CI 1.03-3.09, P=0.040), but no significant difference in survival (HR 0.93, 95% CI 0.35-2.50, P=0.88) was observed. CONCLUSIONS History of DVT is a significant discriminator for clinical profile of PE patients. Individuals without DVT had more often cardiac and pulmonary disease with strongest association with AF. Data advocate a potential link between AF and PE. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov, Unique identifier NCT01809015.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Meike Coldewey
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sebastian Gobel
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany
| | - Alexander Ullmann
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Claus Jünger
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Heidrun Lamparter
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Liana Ariza
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Michael Lauterbach
- Department of Internal Medicine III, Hospital of Barmherzige Brüder Trier, Trier, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Rostock
- Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany; Preventive Cardiology and Preventive Medicine, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany.
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