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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC. ASIA 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Diastolic blood pressure achieved at target systolic blood pressure (120-140 mm Hg) and dabigatran-related bleeding in patients with nonvalvular atrial fibrillation: A real-world study. Anatol J Cardiol 2021; 24:267-273. [PMID: 33001045 PMCID: PMC7585965 DOI: 10.14744/anatoljcardiol.2020.11823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: Elevated systolic blood pressure (SBP) can significantly increase the bleeding risk in patients with atrial fibrillation (AF). However, it is unclear whether elevated diastolic blood pressure (DBP), in the presence of well-controlled SBP is also associated with bleeding. Therefore, we aimed to examine the specific relationship between DBP and bleeding in patients with AF treated with anticoagulants and had well-controlled SBP. Methods: We analyzed data from 542 of 929 patients with nonvalvular AF (NVAF) treated with dabigatran from the Monitor System for the Safety of Dabigatran Treatment study (MISSION-AF) who had a SBP of 120–140 mm Hg at the time of enrollment. The association between DBP and bleeding was analyzed using multivariate logistic regression and smooth curve fitting (penalized spline method). Threshold saturation effect analysis was used to show the nonlinear relationship between DBP and bleeding. Results: After 3 months of follow-up, 49 bleeding events occurred. Compared with participants with DBP <80 mm Hg, those with DBP ≥80 mm Hg had a 118% higher bleeding risk [hazard ratio (HR): 2.18; 95% confidence interval (CI): 1.19, 3.98; p<0.05]. The smooth curve showed a nonlinear relationship between DBP and bleeding risk, and the inflection point of DBP was 80 mm Hg. When DBP was ≥80 mm Hg, the bleeding risk increased by 59% (HR: 1.59; 95% CI: 1.16, 2.19; p<0.05) for every 5 mm Hg increase in DBP. Conclusion: Upon achieving an optimal SBP (120–140 mm Hg), a higher DBP might be associated with a higher bleeding risk in patients with NVAF treated with dabigatran.
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Buck J, Fromings Hill J, Martin A, Springate C, Ghosh B, Ashton R, Lee G, Orlowski A. Reasons for discontinuing oral anticoagulation therapy for atrial fibrillation: a systematic review. Age Ageing 2021; 50:1108-1117. [PMID: 33693496 PMCID: PMC8839858 DOI: 10.1093/ageing/afab024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia and can lead to significant comorbidities and mortality. Persistence with oral anticoagulation (OAC) is crucial to prevent stroke but rates of discontinuation are high. This systematic review explored underlying reasons for OAC discontinuation. Methods A systematic review was undertaken to identify studies that reported factors influencing discontinuation of OAC in AF, in 11 databases, grey literature and backwards citations from eligible studies published between 2000 and 2019. Two reviewers independently screened titles, abstracts and papers against inclusion criteria and extracted data. Study quality was appraised using Gough’s weight of evidence framework. Data were synthesised narratively. Results Of 6,619 sources identified, 10 full studies and 2 abstracts met the inclusion criteria. Overall, these provided moderate appropriateness to answer the review question. Four reported clinical registry data, six were retrospective reviews of patients’ medical records and two studies reported interviews and surveys. Nine studies evaluated outcomes relating to dabigatran and/or warfarin and three included rivaroxaban (n = 3), apixaban (n = 3) and edoxaban (n = 1). Bleeding complications and gastrointestinal events were the most common factors associated with discontinuation, followed by frailty and risk of falling. Patients’ perspectives were seldom specifically assessed. Influence of family carers in decisions regarding OAC discontinuation was not examined. Conclusion The available evidence is derived from heterogeneous studies with few relevant data for the newer direct oral anticoagulants. Reasons underpinning decision-making to discontinue OAC from the perspective of patients, family carers and clinicians is poorly understood.
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Affiliation(s)
- Jackie Buck
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Julia Fromings Hill
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | | | | | | | - Rachel Ashton
- Imperial College Health Partners, London NW1 2FB, UK
| | - Gerry Lee
- Adult Nursing, James Clerk Maxwell Building, King’s College London, London SE1 8WA, UK
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Barbieri MA, Cutroneo PM, Baratelli C, Cicala G, Battaglia A, Santoro V, Andò G, Spina E. Adverse drug reactions with oral anticoagulants: data from sicilian spontaneous reporting system database. J Clin Pharm Ther 2021; 46:1027-1040. [PMID: 33646603 DOI: 10.1111/jcpt.13391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/07/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Direct oral anticoagulants (DOACs) were developed to avoid the limitations of vitamin K antagonists (VKAs). DOACs are associated with a greater incidence of gastrointestinal bleeding and a smaller number of intracranial haemorrhages than VKAs. Therefore, it is important to deepen our knowledge of their safety profiles. The aim of this study was thus to analyse adverse drug reaction (ADR) reports on DOACs and VKAs using the Sicilian Spontaneous Reporting System (SRS) database. METHODS All ADR reports with DOACs and VKAs as suspected drugs that were entered into the Sicilian SRS database during the period 2001-2019 were selected. In detail, all reports with the following single active substances were included: dabigatran etexilate, rivaroxaban, apixaban and edoxaban; acenocoumarol and warfarin were included as a comparator group. Descriptive statistical methodology was used to evaluate characteristics of the reported cases with a case-by-case assessment. RESULTS AND DISCUSSION Out of 521 reports related to anticoagulants, 444 (85.2%) and 77 (14.8%) involved DOACs and VKAs, respectively. DOAC-related reports were mainly of gastrointestinal disorders. In contrast, VKAs were mostly associated with blood and lymphatic system disorders, injury, investigations and vascular disorders. Many more cases of ADRs in the form of gastrointestinal disorders concerned dabigatran etexilate (n = 179, 73.7%) than the other DOACs, while ADRs in the form of blood disorders were mainly associated with acenocoumarol (n = 27, 57.4%). The most commonly reported Preferred Terms for DOACs were dyspepsia (n = 89, 17.1%), upper abdominal pain (n = 41, 9.2%) and pruritus (n = 26, 5.8%), whereas for VKAs, they were anaemia (n = 21, 27.3%) and hypocoagulable state (n = 18, 3.5%). Potentially interacting concomitant medications particularly included antithrombotic agents (n = 19, 4.3%) for DOACs and proton-pump inhibitors (PPIs) (n = 37, 48.1%) and antithrombotic agents (n = 13, 16.9%) for VKAs. CONCLUSION The ADRs most commonly associated with DOACs, especially dabigatran, were gastrointestinal disorders, particularly gastrointestinal bleeding. Our study also highlights the potential role of drug-drug interactions in the ADRs. The cases of gastrointestinal bleeding highlight the need for careful prescribing of DOACs and use of potentially interacting concomitant drugs.
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Affiliation(s)
| | - Paola Maria Cutroneo
- Sicilian Regional Pharmacovigilance Centre, University Hospital of Messina, Messina, Italy
| | - Chiara Baratelli
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Battaglia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenza Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Wang CY, Pham PN, Thai TN, Brown JD. Updating the Cost Effectiveness of Oral Anticoagulants for Patients with Atrial Fibrillation Based on Varying Stroke and Bleed Risk Profiles. PHARMACOECONOMICS 2020; 38:1333-1343. [PMID: 32924092 DOI: 10.1007/s40273-020-00960-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Previous investigations into the cost effectiveness of direct oral anticoagulants only considered individual stroke risk but not bleed risk even though bleeding is an important and potentially fatal side effect for anticoagulated patients. OBJECTIVE This study aimed to evaluate the cost effectiveness of dabigatran, rivaroxaban, apixaban, and edoxaban vs warfarin in patients with atrial fibrillation with varying stroke/bleed risk profiles over a lifetime horizon. METHODS A Markov micro-simulation was adapted to examine the lifetime costs and quality-adjusted survival of five anticoagulants from a US private payer's perspective. The study hypothetical cohort consisted of 10,000 patients with atrial fibrillation with age, CHA2DS2-VASc, and HAS-BLED scores similar to a commercially insured patient with atrial fibrillation cohort. Model input parameters including the efficacy and safety of each strategy, utilities, and cost were estimated from public sources, published literature, and analysis conducted in the IBM MarketScan database. Lifetime cost, quality-adjusted life-years, and incremental cost-effectiveness ratios were assessed for each treatment strategy. Subgroup analyses stratified by age, stroke risk score alone, bleed risk score alone and both were performed. Uncertainty was assessed by a deterministic sensitivity analysis and a probabilistic sensitivity analysis. RESULTS The base-case analysis suggested dabigatran was the optimal treatment with an incremental cost-effectiveness ratio of $35,055 per quality-adjusted life-year relative to warfarin. Subgroup analyses stratified by age, stroke risk score, and bleed risk score alone were largely consistent with the base-case analysis. Subgroup analyses stratified by both stroke and bleed risk score showed edoxaban was the preferred treatment in patients with a low stroke and a low or medium bleed risk, and patients with a high stroke and low bleed risk. Apixaban was the preferred treatment in patients with a medium stroke and high bleed risk. Results of the deterministic sensitivity analysis indicate the model results were most sensitive to the drug cost and hazard ratio for stroke and bleeding event. Results of the probability sensitivity analysis showed dabigatran is cost effective vs. other treatments in 32.8% and 42.4% of iterations at a willingness to pay of $50,000/quality-adjusted life-year and a willingness to pay of $100,000/quality-adjusted life year, respectively. CONCLUSIONS From a US private payer's perspective, dabigatran appears cost effective compared with other anticoagulants. This study indicated risk stratification especially considering both stroke and bleed risk simultaneously is important not only in clinical practice but also in health technology assessment exercises among patients with atrial fibrillation.
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Affiliation(s)
- Ching-Yu Wang
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32610, USA
| | - Phuong N Pham
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32610, USA
| | - Thuy N Thai
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32610, USA
| | - Joshua D Brown
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32610, USA.
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Romiti GF, Corica B, Proietti M. A comprehensive appraisal of dabigatran etexilate clinical evidence and applications: a 10-year-long story. Future Cardiol 2020; 17:215-226. [PMID: 32883107 DOI: 10.2217/fca-2020-0084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
During the last decade, non-vitamin K antagonist oral anticoagulants (NOACs) revolutionized the thromboprophylaxis management of several medical conditions, including atrial fibrillation and venous thromboembolism. Dabigatran etexilate was the first NOAC widely available worldwide, and it is currently the only one that directly inhibits thrombin. More recently, the availability of idarucizumab, a specific reversal agent, has increased the safety of dabigatran use in clinical practice, especially for those patients with severe and life-threatening bleeding. This review aims to summarize current evidence on dabigatran, starting from its pharmacological characteristics, and providing an updated overview of pivotal randomized controlled trials and real-world data on its efficacy and safety.
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Affiliation(s)
- Giulio Francesco Romiti
- Department of Translational & Precision Medicine, Sapienza - University of Rome, 00161 Rome, Italy
| | - Bernadette Corica
- Department of Translational & Precision Medicine, Sapienza - University of Rome, 00161 Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences & Community Health, University of Milan, 20122 Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L14 3PE, UK
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Hwang J, Lee SR, Park HS, Lee YS, Ahn JH, Choi JI, Shin DG, Kim DK, Park JS, Hwang KW, Cha TJ, Choi EK, Han S. Adherence to dabigatran and the influence of dabigatran-induced gastrointestinal discomfort in the real-world practice. Int J Cardiol 2020; 323:77-82. [PMID: 32805331 DOI: 10.1016/j.ijcard.2020.08.032] [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] [Received: 03/01/2020] [Revised: 07/04/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dabigatran-induced gastrointestinal discomfort (DGID) is an important factor influencing the adherence to dabigatran. We investigated the incidence and risk factors of DGID and its impact on the adherence and persistence to dabigatran. METHODS We prospectively enrolled the patients prescribed with dabigatran in 10 tertiary hospitals of the South Korea. The adherence was assessed using the percentage of the prescribed doses of the medication presumably taken by the patient (PDT by pill count). We evaluated the relationship between DGID and the baseline GI symptoms or the previous GI disease history using a questionnaire. RESULTS A total of 474 patients (mean age 67.8 ± 9.3 years, male 68.6%, and mean CHA2DS2-VASc score 2.2 ± 1.2) were enrolled. The adherence assessed by the PDT was 93.5 ± 5.5% at 1-month and 96.4 ± 8.4% at 6-months among the persistent patients. During the 6-month follow-up, 82 (18.1%) patients discontinued dabigatran, and the most common reason for dabigatran discontinuation was DGID (49, 59.8%). Sixty-eight (14.3%) patients experienced DGID, and there was no difference in the clinical factors between those with or without DGID. Among the patients who experienced DGID, 42 discontinued dabigatran (61.8%). In a multivariate analysis, DGID was the only predictor of dabigatran discontinuation and a low adherence. CONCLUSION Overall adherence of dabigatran was excellent, but those with DGID showed low adherence and persistence. Furthermore, it was challenging to predict DGID by clinical parameters. Therefore, it is recommended to follow the patients closely to check for DGID when prescribing dabigatran.
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Affiliation(s)
- Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - So-Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Jin Hee Ahn
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Pusan, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Dong Gu Shin
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Dae-Kyeong Kim
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Pusan, Republic of Korea
| | - Jong Sung Park
- Division of Cardiology, Department of Internal Medicine, Dong-A University Medical Center, Pusan, Republic of Korea
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Gyeongsangnam-do, Republic of Korea
| | - Tae-Joon Cha
- Division of Cardiology, Department of Internal Medicine, Kosin University Gospel Hospital, Pusan, Republic of Korea
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea.
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Peripheral leukocyte count and risk of bleeding in patients with non-valvular atrial fibrillation taking dabigatran: a real-world study. Chin Med J (Engl) 2020; 132:2150-2156. [PMID: 31490268 PMCID: PMC6797159 DOI: 10.1097/cm9.0000000000000423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The association between peripheral leukocyte count and bleeding events in nonvalvular atrial fibrillation (NVAF) patients treated with dabigatran remains unclear. This study aimed to explore the association between leukocyte count and bleeding events after excluding other confounders in NVAF patients taking dabigatran. METHODS A total of 851 NVAF patients treated with dabigatran (110 mg bid) were recruited from 12 centers in China from February 2015 to December 2017. Follow-up was completed by May 2018. The exposure and outcome variables were leukocyte count measured at baseline and the number of bleeding events within the subsequent 6 months. Multivariate Cox proportional hazards models were constructed to analyze independent associations, and a Cox proportional hazards regression with cubic spline functions and smooth curve fitting (penalized spline method) was used to address nonlinearity between leukocyte count and bleeding. The inflection point was calculated using a recursive algorithm, and then a two-piecewise Cox proportional hazards model for both sides of the inflection point was constructed. RESULTS During 6-month follow-up, 87 participants occurred bleeding events. For every 1 × 10/L increase in leukocyte count, the risk of bleeding increased by 11% (hazard ratio [HR]: 1.11, 95% confidence interval [CI]: 0.99-1.25). The smooth curve showed nonlinear relationship between leukocyte count and bleeding events. The inflection point of the leukocyte count was 6.75 × 10/L. For leukocyte counts < 6.75 × 10/L, the HR (95% CI) was 0.88 (0.69-1.13), and for leukocyte counts ≥ 6.75 × 10/L, the HR (95% CI) was 1.28 (1.09-1.51). CONCLUSION This study found a J-shaped association between baseline leukocyte count and risk of bleeding in NVAF patients treated with dabigatran. CLINICAL TRIAL REGISTRATION NCT02414035, https://clinicaltrials.gov.
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Ozaki AF, Choi AS, Le QT, Ko DT, Han JK, Park SS, Jackevicius CA. Real-World Adherence and Persistence to Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes 2020; 13:e005969. [PMID: 32148102 DOI: 10.1161/circoutcomes.119.005969] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Stroke reduction with direct oral anticoagulants (DOACs) in atrial fibrillation (AF) is dependent on adherence and persistence in the real-world setting. Individual study estimates of DOAC adherence/persistence rates have been discordant. Our aims were to characterize real-world observational evidence for DOAC adherence/persistence and evaluate associated clinical outcomes in patients with AF. METHODS AND RESULTS PubMed, EMBASE, and CINAHL were searched from inception to June 2018. Observational studies that reported real-world DOAC adherence/persistence in patients with AF were included. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses for pooled estimates were performed using DerSimonian and Laird random-effects models. Outcomes included DOAC mean proportion of days covered or medication possession ratio, proportion of good adherence (proportion of days covered/medication possession ratio ≥80%), persistence, DOAC versus vitamin K antagonists persistence, and clinical outcomes associated with nonadherence/nonpersistence. Forty-eight observational studies with 594 784 unique patients with AF (59% male; mean age 71 years) were included. The overall pooled mean proportion of days covered/medication possession ratio was 77% (95% CI, 75%-80%), proportion of patients with good adherence was 66% (95% CI, 63%-70%), and proportion persistent was 69% (95% CI, 65%-72%). The pooled proportion of patients with good adherence was 71% (95% CI, 64%-78%) for apixaban, 60% (95% CI, 52%-68%) for dabigatran, and 70% (95% CI, 64%-75%) for rivaroxaban. Similar patterns were found for pooled persistence by agent. The pooled persistence was higher with DOACs than vitamin K antagonists (odds ratio, 1.44 [95% CI, 1.12-.86]). DOAC nonadherence was associated with an increased risk of stroke (hazard ratio, 1.39 [95% CI, 1.06-1.81]). CONCLUSIONS Suboptimal adherence and persistence to DOACs was common in patients with AF, with 1 in 3 patients adhering to their DOAC <80% of the time, which was associated with poor clinical outcomes in nonadherent patients. Although it is convenient that DOACs do not require laboratory monitoring, greater effort in monitoring for and interventions to prevent nonadherence may be necessary to optimize stroke prevention. Increased clinician awareness of DOAC nonadherence may help identify at-risk patients.
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Affiliation(s)
- Aya F Ozaki
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.).,Pharmacy Department (A.F.O., C.A.J.), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Austin S Choi
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.)
| | - Quan T Le
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.)
| | - Dennis T Ko
- ICES, Toronto, Canada (D.T.K., C.A.J.).,University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada (D.T.K., C.A.J.)
| | - Janet K Han
- Division of Cardiology (J.K.H., S.S.P.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,Division of Cardiology, University of California, Los Angeles, Los Angeles, CA (J.K.H., S.S.P.)
| | - Sandy S Park
- Division of Cardiology (J.K.H., S.S.P.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,Division of Cardiology, University of California, Los Angeles, Los Angeles, CA (J.K.H., S.S.P.)
| | - Cynthia A Jackevicius
- Western University of Health Sciences, College of Pharmacy, Pomona, CA (A.F.O., A.S.C., Q.T.L., C.A.J.).,Pharmacy Department (A.F.O., C.A.J.), VA Greater Los Angeles Healthcare System, Los Angeles, CA.,ICES, Toronto, Canada (D.T.K., C.A.J.).,University Health Network, Pharmacy Department, Toronto, Canada (C.A.J.).,University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada (D.T.K., C.A.J.)
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Godino C, Melillo F, Rubino F, Arrigoni L, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Colombo A, Salerno A, Cera M, Margonato A. Real-world 2-year outcome of atrial fibrillation treatment with dabigatran, apixaban, and rivaroxaban in patients with and without chronic kidney disease. Intern Emerg Med 2019; 14:1259-1270. [PMID: 31073827 DOI: 10.1007/s11739-019-02100-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 01/05/2023]
Abstract
Patients with non-valvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) are at increased risk of stroke and bleeding. Although direct oral anticoagulant (DOAC) trials excluded patients with severe CKD, a growing portion of CKD patients have been starting DOACs and limited data from real-world outcome in this high-risk setting are available. The INSigHT registry included 632 consecutive NVAF patients that started apixaban (256 patients, 41%), dabigatran (245, 39%) and rivaroxaban (131, 20%) between 2012 and 2015. Based on creatinine clearance, two sub-cohorts were defined: (1) non-CKD group (CrCl 60-89 mL/min, 413 patients) and (2) CKD group (15-59 ml/min, 219). Compared to non-CKD patients, those with CKD, were at higher ischemic (CHA2DS2-VASc 4.5 vs 2.9, p < 0.001) and hemorrhagic risk (HAS-BLED 2.4 vs 1.8, p < 0.001). At 2-year follow-up, the overall ISTH-major bleeding and thromboembolic event rates were 5.2% and 2.3% and no significant difference between non-CKD and CKD patients for both efficacy and safety endpoints were observed. In non-CKD patients, the 2-year ISTH-major bleeding rates were higher in rivaroxaban group (HR 2.9, 95% CI 1.1-7.3; p = 0.047) while dabigatran showed non-significant excess in thromboembolic events (HR 4.3, 95% CI 0.9-20.8; p = 0.068). In CKD patients, a significantly higher rate of thromboembolic events was observed in rivaroxaban (HR 6.3, 95% CI 1.1-38.1; p = 0.044). This real-world, non-insurance database registry shows remarkable 2-year safety and efficacy profile of DOACs even in patients with moderate to severe CKD. Head to head differences between DOACs are exploratory, hypothesis generating and warrant further investigation in larger studies.
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Affiliation(s)
- Cosmo Godino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Francesco Melillo
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Rubino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Arrigoni
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Cappelletti
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Mattiello
- Information Systems Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiovascular Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Michela Cera
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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12
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Association between activated partial thromboplastin time, age and bleeding events in NVAF patients receiving dabigatran. Eur J Clin Pharmacol 2018; 75:321-328. [DOI: 10.1007/s00228-018-2583-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/22/2018] [Indexed: 01/19/2023]
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Verdecchia P, Vedovati MC, Conti S, Giustozzi M, Aita A, Molini G, Angeli F, Turturiello D, Becattini C, Cavallini C, Agnelli G. Long-term outcome in patients with non-valvular atrial fibrillation on dabigatran: a prospective cohort study. Expert Opin Drug Saf 2018; 17:1063-1069. [PMID: 30260252 DOI: 10.1080/14740338.2018.1529166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Most studies on thromboembolic and bleeding risk in patients with non-valvular atrial fibrillation (NVAF) exposed to non-vitamin K oral anticoagulants stem from interrogation of insurance databases. Areas covered: We studied 742 consecutive patients with NVAF who started treatment with dabigatran in three hospitals in Italy. Average follow-up was 1.80 years. Mean age was 76.2 years. CHA2DS2VASc score was 0-1 in 37 (5%), 2 in 97 (13%) and ≥ 3 in 604 (82%) patients. NVAF was permanent in 349 (48%). Overall, 76% of patients remained on treatment over the entire follow-up period. Among 180 patients who discontinued permanently, the most frequent reasons were dyspepsia (33.9%), bleeding (17.8%), and renal worsening (12.1%). About 48% and 74% of permanent discontinuations occurred during the first 6 and 12 months of treatment, respectively. Rates of major events (per 100 patient-years) were 0.75 for stroke, 0.31 for myocardial infarction, 1.50 for all-cause death, and 1.80 for major bleedings. The rate of intracranial bleedings was 0.45 and that of major gastrointestinal bleedings was 0.75. Expert opinion: This prospective cohort study confirms the low incidence of stroke, major bleeding and intracranial bleeding, and a 76% persistence with treatment, in patients with NVAF treated with dabigatran over about 2 years.
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Affiliation(s)
- Paolo Verdecchia
- a Division of Cardiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Maria Cristina Vedovati
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Serenella Conti
- c Division of Cardiology , S. Matteo degli Infermi Hospital , Spoleto , Italy
| | - Michela Giustozzi
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Adolfo Aita
- d Department of Medicine , Hospital of Assisi , Assisi , Italy
| | | | - Fabio Angeli
- e Division of Cardiology and Cardiovascular Pathophysiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Dario Turturiello
- e Division of Cardiology and Cardiovascular Pathophysiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Cecilia Becattini
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
| | - Claudio Cavallini
- a Division of Cardiology , Hospital S. Maria della Misericordia , Perugia , Italy
| | - Giancarlo Agnelli
- b Internal, Vascular and Emergency Medicine - Stroke Unit , University of Perugia , Perugia , Italy
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Huang D, Wong CL, Cheng KW, Chan PH, Yue WS, Wong CK, Ho CW, Wong ICK, Chan EW, Siu CW. Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin. Postgrad Med J 2018; 94:207-211. [PMID: 29459408 DOI: 10.1136/postgradmedj-2017-135457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/08/2018] [Accepted: 01/20/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised. AIM To evaluate the impact of provision of TTR results during clinic visits on anticoagulation management. DESIGN Single-centred, randomised controlled study. SETTING Fifteen arrhythmia clinics in Hong Kong. PATIENTS AF patients prescribed warfarin. INTERVENTIONS Provision of TTR or no provision of TTR. MAIN OUTCOME MEASURES A documented discussion between doctors and patients about switching warfarin to a non-vitamin K oral anticoagulant (NOAC). RESULTS Four hundred and eighty one patients with AF prescribed warfarin were randomly assigned to (1) a TTR provision group or (2) control. Their mean age was 73.6±12.0 years and 60.7% were men. The mean CHA2DS2-VASc score was 3.2±1.6 and the mean HASBLED score was 1.7±1.2. The mean TTR was 63.9%±29.9%. At the index clinic visit, 71 of 481 patients (14.8%) had a documented discussion about switching warfarin to a NOAC. Patients with provision of TTR results were more likely to discuss switching warfarin to a NOAC than controls (19.1% vs 10.6%, P=0.03), especially those with a TTR <65% (35.2% vs 10.6%, P<0.001). A higher proportion of patients with provision of TTR results switched to a NOAC (5.9% vs 4.1%, P=0.49). CONCLUSIONS The provision of TTR among patients on warfarin was associated with a discussion about switching from warfarin to a NOAC in those with TTR <65%, but did not result in actual switching to a NOAC, suggesting additional barriers.
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Affiliation(s)
- Duo Huang
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi-Lap Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kwan-Wa Cheng
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Pak-Hei Chan
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wen-Sheng Yue
- Affiliated Hospital of North Sichuan Medical College and Medical Imaging Key Laboratory, Nanchong, China
| | - Chun-Ka Wong
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi-Wai Ho
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Hammersley D, Signy M. Navigating the choice of oral anticoagulation therapy for atrial fibrillation in the NOAC era. Ther Adv Chronic Dis 2017; 8:165-176. [PMID: 29201334 PMCID: PMC5692140 DOI: 10.1177/2040622317720106] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/31/2017] [Indexed: 01/13/2023] Open
Abstract
Atrial fibrillation (AF) is a major cause of ischaemic stroke. The majority of these strokes can be prevented by treatment with oral anticoagulation therapy. The advent of non-vitamin K antagonist oral anticoagulants (NOACs) has resulted in a choice of therapeutic agents available to physicians for anticoagulation for stroke prevention in patients with AF beyond the long-established vitamin K antagonists (VKAs). Pivotal trials have demonstrated non-inferiority of NOACs compared with VKAs, and in some cases superiority, for the prevention of stroke and systemic embolism in non-valvular AF. Yet there are no direct head-to-head comparator trials for the efficacy of NOACs. Therefore, the question of which oral anticoagulant for each individual patient can present a challenge to physicians. In this review article, we assess which patients with AF require anticoagulation, review the available therapeutic options, assessing the evidence base for each and offering guidance as to patient-specific factors that can influence this choice.
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Affiliation(s)
- Daniel Hammersley
- Department of Cardiology, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley, GU16 7UJ
| | - Mark Signy
- Department of Cardiology, Worthing Hospital, Worthing, UK
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16
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Forero JE, Moreno JM, Agudelo CA, Rodríguez EA, Sánchez PA. Fibrilación auricular: enfoque para el médico no cardiólogo. IATREIA 2017. [DOI: 10.17533/udea.iatreia.v30n4a05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chan LX, Wong YM, Chia PL, Kek ZL. A single institution’s experience with using dabigatran, rivaroxaban and warfarin for prevention of thromboembolism in atrial fibrillation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817719913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Although non-vitamin K antagonist oral anticoagulants (NOACs) are approved for stroke prevention in atrial fibrillation (AF) patients, their use in the local clinical setting has not been well studied. This study aims to evaluate the clinical outcomes of dabigatran, rivaroxaban and warfarin in a tertiary hospital in Singapore. Methods: This is a retrospective cohort study with one-year follow-up. A total of 383 patients recruited between June 2011 and December 2014 were studied. Incidents of stroke, systemic embolism and clinically relevant bleeding events were compared between dabigatran, rivaroxaban and warfarin. Results: Stroke rates were 5.47% per year with warfarin, 7.27% per year with dabigatran (HR=1.32; 95% CI 0.48−3.64; p=0.591) and 2.76% per year with rivaroxaban (HR=0.49; 95% CI 0.14−1.69; p=0.261). The warfarin group had significantly higher incidence of minor bleeding (62.4% vs 3.64% for dabigatran vs 13.79% for rivaroxaban; p<0.001), major bleeding (3.91% for warfarin, 0.91% for dabigatran, 0% for rivaroxaban; p=0.028) and other adverse events (51.18% for warfarin, 3.64% for dabigatran, 8.28% for rivaroxaban; p<0.001). Incidence of dyspepsia was higher in both NOAC groups compared to warfarin (0% for warfarin, 7.27% for dabigatran, 5.52% for rivaroxaban; p=0.003). Conclusion: Stroke and venous thromboembolism rates after one year were comparable among dabigatran, rivaroxaban and warfarin. Warfarin was associated with more bleeding and adverse events while both NOACs were associated with higher rates of dyspepsia. Further study is needed to assess the clinical benefit of NOACs in the Singaporean population.
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Affiliation(s)
- Li Xin Chan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Yee May Wong
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Pow-Li Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Zhen Liang Kek
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
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18
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Vedovati MC, Verdecchia P, Giustozzi M, Molini G, Conti S, Pierpaoli L, Valecchi F, Aita A, Agnelli G, Becattini C. Permanent discontinuation of non vitamin K oral anticoagulants in real life patients with non-valvular atrial fibrillation. Int J Cardiol 2017; 236:363-369. [PMID: 28131705 DOI: 10.1016/j.ijcard.2017.01.098] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/02/2017] [Accepted: 01/16/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Persistence to treatment affects clinical outcomes in patients with chronic disease such as atrial fibrillation (AF). METHODS This prospective cohort study included consecutive non-valvular AF patients prescribed with non-vitamin K oral anticoagulants (NOACs) and investigated for any permanent discontinuation at 1-year of this therapy, as well as any reasons for discontinuation. RESULTS Overall, 1305 patients were prescribed with dabigatran (N=473), rivaroxaban (N=425) or apixaban (N=407). Of these, 201 patients (15.4%) discontinued NOACs during the first year of treatment. More than 60% of these discontinuations occurred during the first 6months. Reasons for discontinuation included: dyspepsia or abdominal pain in 38 patients (2.9%) and bleeding in 59 (4.5%). Discontinuation for the former occurred earlier (50% within 2months) compared to the latter (66% after the first 4months). The prescription of reduced NOAC doses resulted being an independent predictor of discontinuation (OR 1.74, 95% CI 1.23-2.45, p=0.002). Regarding the use of dabigatran, rivaroxaban and apixaban, the following were observed: discontinuers were 22.0% (95% CI 18.5-25.9), 14.4% (95% CI 11.3-18.0) and 8.8% (95% CI 6.5-12.0), the risk of discontinuation associated with bleeding was 20.2%, 44.3% and 30.6% and dyspepsia or abdominal pain was 35.6%, 1.6% and 0%, respectively. CONCLUSION Discontinuation of NOACs in AF patients was relatively common and more than often occurred in the first six months after prescription. Patients treated with reduced doses of NOACs had a higher probability to discontinue compared to those who were prescribed conventional doses.
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Affiliation(s)
- Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | | | - Michela Giustozzi
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Serenella Conti
- Division of Cardiology, S. Matteo degli Infermi Hospital, Spoleto, Italy
| | - Lucia Pierpaoli
- Emergency Medicine, S. Maria Delle Croci Hospital, Ravenna, Italy
| | | | - Adolfo Aita
- Department of Medicine, Hospital of Assisi, Assisi, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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Garkina SV, Vavilova TV, Lebedev DS, Mikhaylov EN. Compliance and adherence to oral anticoagulation therapy in elderly patients with atrial fibrillation in the era of direct oral anticoagulants. J Geriatr Cardiol 2016; 13:807-810. [PMID: 27899946 PMCID: PMC5122507 DOI: 10.11909/j.issn.1671-5411.2016.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Affiliation(s)
- Svetlana V Garkina
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
- Neuromodulation unit, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Tatiana V Vavilova
- Department of Clinical Laboratory Diagnostics and Genetics, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Dmitry S Lebedev
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Evgeny N Mikhaylov
- Arrhythmia Department, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
- Neuromodulation unit, Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russian Federation
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20
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Chan PH, Hai JJ, Huang D, Ho MH, Chan EW, Cheung BMY, Chan AOO, Wong ICK, Tse HF, Hung IFN, Siu CW. Burden of upper gastrointestinal symptoms in patients prescribed dabigatran for stroke prevention. SAGE Open Med 2016; 4:2050312116662414. [PMID: 27551422 PMCID: PMC4976790 DOI: 10.1177/2050312116662414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 07/07/2016] [Indexed: 11/18/2022] Open
Abstract
Background: Dabigatran, a non-vitamin K antagonist oral anticoagulant, has been shown to prevent stroke in patients with non-valvular atrial fibrillation. Nonetheless, studies show that 10%–30% of those prescribed dabigatran experience dyspepsia that may eventually lead to discontinuation of therapy and loss of clinical benefit. Aim: To evaluate the gastrointestinal tolerability of dabigatran utilizing a validated questionnaire, as well as determining subsequent non-compliance and drug discontinuation. Method: This is an observational study. All patients were assessed by a validated questionnaire, Hong Kong dyspepsia index, prior to drug prescription and again 4 weeks later. Results: In this study, 115 patients with non-valvular atrial fibrillation (mean age: 74.6 ± 11.4 years; mean CHA2DS2-VASc score was 3.39 ± 1.59) were prescribed dabigatran. At baseline, the mean Hong Kong dyspepsia index was 12.9 ± 1.6 and nine patients had significant dyspepsia (Hong Kong dyspepsia index ⩾ 16). After 4 weeks, the mean Hong Kong dyspepsia index was similar at 12.6 ± 1.9 (p = 0.23). There was no change in Hong Kong dyspepsia index after initiation of dabigatran in 59 (51.3%) patients, and improvement in 37 (32.2%). Only 19 (16.5%) patients had worsening of Hong Kong dyspepsia index, and among these 19 patients, only 1 patient (0.9%) discontinued dabigatran due to significant dyspepsia. Conclusion: Worsening of dyspepsia with dabigatran 110 mg twice daily was uncommon with correct drug administration and clear instructions provided. Systematic assessment of dyspeptic symptoms using a validated questionnaire (i.e. Hong Kong dyspepsia index) before and after treatment initiation allows a more objective comparison of dyspeptic symptoms.
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Affiliation(s)
- Pak-Hei Chan
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Jo-Jo Hai
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Duo Huang
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Mei-Han Ho
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Bernard Man-Yung Cheung
- Division of Clinical Pharmacology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Annie On-On Chan
- Division of Gastroenterology and Hepatology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Ian Chi-Kei Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Ivan Fan-Ngai Hung
- Division of Gastroenterology and Hepatology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chung-Wah Siu
- Division of Cardiology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Beshir SA, Chee KH, Lo YL. Factors associated with abrupt discontinuation of dabigatran therapy in patients with atrial fibrillation in Malaysia. Int J Clin Pharm 2016; 38:1182-90. [DOI: 10.1007/s11096-016-0350-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 07/06/2016] [Indexed: 12/15/2022]
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Cost-effectiveness modelling of novel oral anticoagulants incorporating real-world elderly patients with atrial fibrillation. Int J Cardiol 2016; 220:794-801. [PMID: 27400183 DOI: 10.1016/j.ijcard.2016.06.087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/20/2016] [Accepted: 06/21/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) expand the treatment options for patients with atrial fibrillation (AF). Their benefits need to be weighed against the risk-benefit ratio in real-world elderly patients, prompting this cost-effectiveness study of NOACs (apixaban, dabigatran, edoxaban and rivaroxaban), warfarin and aspirin for stroke prevention in AF. METHODS Applying effectiveness estimates from a network meta-analysis involving over 800,000 patients from randomised controlled trials and observation studies, our Markov model projected cost and health outcomes for a cohort of 65-year-old AF patients over a life-time. We performed subgroup analysis stratified by age (65-74 and ≥75years), with further analysis limited to observational studies involving dabigatran and rivaroxaban. RESULTS Compared to warfarin, NOACs (except dabigatran 110) were associated with incremental cost-effectiveness ratios ranging from USD 24,476 to USD 41,448 that were within cost-effectiveness threshold of USD 49,700 (one gross domestic product per capita in Singapore in 2015). Aspirin regimens were dominated. In elderly aged ≥75years, cost effectiveness of NOACs (except apixaban) decreased, owing to worsened performance in safety profile. Analysis limited to observational studies revealed that dabigatran 150 and rivaroxaban were not cost-effective, reflecting increased bleeding risks in non-controlled settings. Threshold analyses revealed that apixaban was no longer cost-effective at two to three times higher bleeding risk. CONCLUSIONS Whilst NOACs are cost-effective in the younger elderly compared to warfarin, their benefits appear to be offset by worsened risk profile in older elderly, especially in non-controlled settings. Decisions on appropriate AF treatment should balance treatment-related benefits, risks, and patient preference.
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Li X, Wen SN, Li SN, Bai R, Liu N, Feng L, Ruan YF, Du X, Dong JZ, Ma CS. Over 1-year efficacy and safety of left atrial appendage occlusion versus novel oral anticoagulants for stroke prevention in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials and observational studies. Heart Rhythm 2016; 13:1203-14. [DOI: 10.1016/j.hrthm.2015.12.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Indexed: 10/22/2022]
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Beyer-Westendorf J, Ehlken B, Evers T. Real-world persistence and adherence to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation. Europace 2016; 18:1150-7. [DOI: 10.1093/europace/euv421] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/15/2015] [Indexed: 11/12/2022] Open
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Does novel oral anticoagulant improve anticoagulation for non-valvular atrial fibrillation associated stroke: An inpatient registration study in Shanghai. Chronic Dis Transl Med 2016; 1:203-209. [PMID: 29063008 PMCID: PMC5643732 DOI: 10.1016/j.cdtm.2015.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To summarize the use rate, safety, efficacy of antithrombotics in stroke/transient ischemic attack (TIA) prevention, and reasons for not using dabigatran etexilate (DE) in Shanghai, China. METHODS Non-valvular atrial fibrillation (NVAF)-associated stroke patients were prospectively registered as an electronic database. Use rate of antithrombotics and reasons for not using DE were extracted during follow-up. Patients' baseline characteristics, recurrent ischemic stroke/TIA events and bleeding complications were analyzed. PATIENTS From April 2012 to August 2014, 110 inpatients with NVAF-associated stroke were studied in our hospital. NVAF was diagnosed by 12-lead electrocardiogram, 24 h Holter and echocardiography. RESULTS Before introduction of DE (April 2013), use rates of warfarin and antiplatelets were 28.9% (11/38) and 60.5% (23/38) respectively; after that, use rates of warfarin, DE, and antiplatelets were 20.8% (15/72), 12.5% (9/72), and 43.1% (31/72). The DE did not improve use of anticoagulants (P = 0.639). There were 19 (17.3%) recurrent ischemic stroke events up to October 2015; two (9.5%) in the non-user group, 10 (18.5%) in the antiplatelet group, and seven (20.0%) in the anticoagulants group (P = 0.570). Furthermore, recurrence rates were similar between the DE group (20.0%) and the Warfarin group (20.0%, P = 1.000). The most common reason for not using DE was financial concerns (61.0%), followed by inconvenience to purchase (14.0%) and hemorrhage concerns (11.0%). Two patients using warfarin found fecal occult blood so they stopped warfarin and began to use antiplatelet drugs. No bleeding event occurred in the other groups. Only one patient had side effects (dyspepsia and gastroesophageal reflux) from DE. CONCLUSION The use rate of either DE or warfarin in Shanghai was low; DE had not improved anticoagulation therapy for NVAF patients in Shanghai mainly because DE had not been covered by health insurance.
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Palareti G, Poli D. The challenges and limitations of widespread direct oral anticoagulant treatment: practical suggestions for their best use. Expert Rev Cardiovasc Ther 2015; 14:163-76. [DOI: 10.1586/14779072.2016.1115344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Chan PH, Li WH, Hai JJ, Chan EW, Wong ICK, Tse HF, Lip GYH, Siu CW. Time in Therapeutic Range and Percentage of International Normalized Ratio in the Therapeutic Range as a Measure of Quality of Anticoagulation Control in Patients With Atrial Fibrillation. Can J Cardiol 2015; 32:1247.e23-1247.e28. [PMID: 26927855 DOI: 10.1016/j.cjca.2015.10.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/26/2015] [Accepted: 10/11/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Time in therapeutic range (TTR), albeit the standard measure of quality of anticoagulation control for warfarin, is underused in everyday clinical practice because of its tedious calculation. In contrast, the percentage of international normalized ratio measurements in range (PINRR) is a convenient alternative. Our objective was to investigate the correlation between PINRR and TTR and whether PINRR has clinical utility for prediction of ischemic stroke and intracranial hemorrhage in a "real-world" atrial fibrillation (AF) cohort. METHODS This is an observational study based on a hospital-based AF registry. RESULTS Among 1428 Chinese patients with AF who were taking warfarin (76.2 ± 8.7 years; mean CHA2DS2-VASc, 4.2 ± 1.6 and HAS-BLED, 2.3 ± 0.9), mean and median TTR values were 38.2% ± 24.4% and 38.8% (interquartile range, 17.9% and 56.2%), respectively. Patients with TTR ≥ 65% (14.8%) had a lower annual risk of ischemic stroke (3.04% per year) than did those with TTR < 65% (5.35% per year). Mean and median PINRR were 34.3% ± 17.1% and 34.2% (interquartile range, 22.7% and 46.0%), respectively. TTR significantly correlated with PINRR in a linear fashion (r = 0.81; P < 0.0001). A cutoff of PINRR ≤ 56.1% was a good discriminator of TTR < 65%, with a high sensitivity (98.3%) and positive predictive value (91.9%). The annual ischemic stroke risk in patients with PINRR > 56.1% was 2.56% per year, lower than those with TTR ≥ 65% (3.04% per year). Patients with PINRR > 56.1% had an annual incidence of intracranial hemorrhage comparable to those with TTR ≥ 65% (0.49% per year vs 0.68% per year). CONCLUSIONS Among patients with AF who are taking warfarin, the PINRR is a user-friendly alternative to TTR, having a high sensitivity and positive predictive value in predicting TTR. As with TTR, PINRR is associated with clinical adverse events, ie, ischemic stroke and intracranial hemorrhage.
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Affiliation(s)
- Pak-Hei Chan
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wen-Hua Li
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China; Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Jo-Jo Hai
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chung-Wah Siu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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Lin L, Lim WS, Zhou HJ, Khoo AL, Tan KT, Chew AP, Foo D, Chin JJ, Lim BP. Clinical and Safety Outcomes of Oral Antithrombotics for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Network Meta-analysis. J Am Med Dir Assoc 2015; 16:1103.e1-19. [PMID: 26527225 DOI: 10.1016/j.jamda.2015.09.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/15/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Novel oral anticoagulants (NOACs) expanded the options for stroke prevention in atrial fibrillation (AF). Earlier studies comparing their relative effectiveness and safety typically do not incorporate age-related differences or postmarketing studies. This study aimed to summarize and compare clinical and safety outcomes of oral antithrombotics for stroke prevention in AF in younger (65-74 years) and older (≥75 years) elderly. METHODS We searched PubMed, Embase, and The Cochrane Library from inception through May 1, 2015, for randomized and nonrandomized studies comparing NOACs, warfarin, and aspirin in elderly with AF. Stroke and systemic embolism (SSE) and major bleeding (MB) are the main outcomes. We also studied secondary outcomes of ischemic stroke, all-cause mortality, intracranial bleeding, and gastrointestinal bleeding. RESULTS Of 5255 publications identified, 25 randomized controlled trials and 24 nonrandomized studies of 897,748 patients were included. NOACs reduced the risk of SSE compared with warfarin (rate ratios [RRs] range from 0.78-0.82). Relative to SSE, NOACs demonstrated a smaller benefit for ischemic stroke (dabigatran 110 mg, RR 1.08; edoxaban, 1.00; apixaban, 0.99). On the contrary, aspirin was associated with a significantly higher risk of SSE, ischemic stroke, and mortality than warfarin or NOACs (RR > 1), particularly in older elderly. Regarding safety, medium-dose aspirin (100-300 mg daily) and aspirin/clopidogrel combination showed an increased risk of MB compared with warfarin (RR 1.17 and 1.15, respectively), as per dabigatran 150 mg and rivaroxaban in older elderly (RR 1.17 and 1.12, respectively). Among the NOACs, dabigatran 150 mg conferred greater gastrointestinal bleeding risk compared with warfarin (RR 1.51), whereas rivaroxaban (RR 0.73) demonstrated less benefit of reduced intracranial bleeding than other NOACs (RRs range 0.39-0.46). CONCLUSIONS Lower rates of SSE and intracranial bleeding were observed with the NOACs compared with warfarin. Dabigatran 150 mg and rivaroxaban were associated with higher rates of MB in older elderly.
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Affiliation(s)
- Liang Lin
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Institute of Geriatrics and Active Aging, Tan Tock Seng Hospital, Singapore
| | - Hui Jun Zhou
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Keng Teng Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Aik Phon Chew
- Department of Geriatric Medicine, Institute of Geriatrics and Active Aging, Tan Tock Seng Hospital, Singapore
| | - David Foo
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Jing Jih Chin
- Department of Geriatric Medicine, Institute of Geriatrics and Active Aging, Tan Tock Seng Hospital, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
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Nishino M, Okamoto N, Tanaka A, Mori N, Hara M, Yano M, Makino N, Egami Y, Shutta R, Tanouchi J. Different risk factors for bleeding and discontinuation between dabigatran and rivaroxaban. J Cardiol 2015; 68:156-60. [PMID: 26443373 DOI: 10.1016/j.jjcc.2015.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unclear whether risk factors for bleeding and discontinuation are different between dabigatran and rivaroxaban. METHODS AND RESULTS We enrolled consecutive patients with atrial fibrillation who received dabigatran or rivaroxaban, had a CHADS2 score >1 and creatinine clearance >30ml/min. During this period, only dabigatran and rivaroxaban were available as non-vitamin K oral anticoagulants (NOACs) in our hospital. We compared the clinical and demographic data and the incidence of bleeding for one year between dabigatran group and rivaroxaban group. As a result, the dabigatran group consisted of 177 patients and the rivaroxaban group consisted of 179 patients. The incidence of discontinuation was significantly higher in the dabigatran group than in the rivaroxaban group (27.7% vs. 13.4%, p<0.001). Multivariate analysis, even after propensity score-matching analysis, revealed that there were no independent risk factors for bleeding in the dabigatran group, while in the rivaroxaban group, use of antiplatelet therapy was an independent factor correlating with bleeding. CONCLUSIONS The risk factors for bleeding may be different between dabigatran and rivaroxaban. To avoid bleeding, rivaroxaban should be prescribed with caution or avoided in patients using antiplatelet therapy. Upon discontinuation, rivaroxaban may be more favorable than dabigatran.
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Affiliation(s)
- Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Naotaka Okamoto
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Akihiro Tanaka
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Naoki Mori
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Masahiko Hara
- Department of Cardiovascular Medicine and Medical Innovation, Osaka University Hospital, Suita, Osaka, Japan
| | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Nobuhiko Makino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Ryu Shutta
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Jun Tanouchi
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
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Chan PH, Li WH, Hai JJ, Tse HF, Siu CW. Impact of Antithrombotic Therapy in Atrial Fibrillation on the Presentation of Coronary Artery Disease. PLoS One 2015; 10:e0131479. [PMID: 26098876 PMCID: PMC4476741 DOI: 10.1371/journal.pone.0131479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/01/2015] [Indexed: 01/20/2023] Open
Abstract
Background Little is known about whether atrial fibrillation is a presentation of coronary disease. There is a paucity of knowledge about their causal relationship and also the impact of different antithrombotic strategies on the subsequent presentation of symptomatic coronary disease. Methods and Results We studied 7,526 Chinese patients diagnosed with non-valvular atrial fibrillation and no documented history of coronary artery disease. The primary endpoint was the new occurrence of coronary artery disease—either stable coronary artery disease or acute coronary syndrome. After a mean follow-up of 3.2±3.5 years (24,071 patient-years), a primary endpoint occurred in 987 patients (13.1%). The overall annual incidence of coronary artery disease was 4.10%/year. No significant differences in age, sex, and mean CHA2DS2-VASc score were observed between patients with and without the primary endpoint. When stratified according to the antithrombotic strategies applied for stroke prevention, the annual incidence of coronary artery disease was 5.49%/year, 4.45%/year and 2.16%/year respectively in those prescribed no antithrombotic therapy, aspirin, and warfarin. Similar trends were observed in patients with acute coronary syndromes. Diabetes mellitus, smoking history and renal failure requiring dialysis were predictors for primary endpoint in all antithrombotic therapies. Conclusion In patients with non-valvular atrial fibrillation, there is a modest association with coronary artery disease. Patients prescribed warfarin had the lowest risk of new onset coronary artery disease.
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Affiliation(s)
- Pak Hei Chan
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Wen Hua Li
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
- * E-mail:
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Chang HY, Zhou M, Tang W, Alexander GC, Singh S. Risk of gastrointestinal bleeding associated with oral anticoagulants: population based retrospective cohort study. BMJ 2015; 350:h1585. [PMID: 25911526 PMCID: PMC4413867 DOI: 10.1136/bmj.h1585] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the real world safety of dabigatran or rivaroxaban compared with warfarin in terms of gastrointestinal bleeding. DESIGN Retrospective cohort study. SETTING Large administrative database of commercially insured people in United States from 1 October 2010 through 31 March 2012. PARTICIPANTS Enrollees with a prescription of warfarin, dabigatran, or rivaroxaban between 1 October 2010 and 31 March 2012, who were aged 18 years or older, had continuous enrollment and no oral anticoagulant use during the six months before the entry date, with known age and sex, and with no gastrointestinal bleeding for at least six months before the cohort entry date. The final study sample of 46,163 patients included 4907 using dabigatran, 1649 using rivaroxaban, and 39,607 using warfarin. MAIN OUTCOME MEASURE Time to gastrointestinal bleeding. Hazard ratios were derived from Cox proportional hazard models with propensity score weighting and robust estimates of errors. RESULTS Dabigatran users tended to be older (dabigatran v rivaroxaban v warfarin: 62.0 v 57.6 v 57.4 years) and more likely to be male (69% v 49% v 53%). The rate of gastrointestinal bleeding was highest among dabigatran users and lowest among rivaroxaban users (dabigatran v rivaroxaban v warfarin: 9.01 v 3.41 v 7.02 cases per 100 person years). After adjustment for potentially confounding covariates, there was no evidence of a statistically significant difference in the risk of gastrointestinal bleeding between dabigatran and warfarin users (adjusted hazard ratio 1.21, 95% confidence interval 0.96 to 1.53) or between rivaroxaban and warfarin users (0.98, 0.36 to 2.69). CONCLUSIONS Although rates of gastrointestinal bleeding seem to be similar in this commercially insured sample of adults in the United States, we cannot rule out as much as a 50% increase in the risk of gastrointestinal bleeding with dabigatran compared with warfarin or a more than twofold higher risk of bleeding with rivaroxaban compared with warfarin.
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Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Meijia Zhou
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Wenze Tang
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - G Caleb Alexander
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Sonal Singh
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21205, USA
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Ho CW, Ho MH, Chan PH, Hai JJ, Cheung E, Yeung CY, Lau KK, Chan KH, Lau CP, Lip GY, Leung GKK, Tse HF, Siu CW. Ischemic Stroke and Intracranial Hemorrhage With Aspirin, Dabigatran, and Warfarin. Stroke 2015; 46:23-30. [DOI: 10.1161/strokeaha.114.006476] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Chi-Wai Ho
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Mei-Han Ho
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Pak-Hei Chan
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Jo-Jo Hai
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Emmanuel Cheung
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Chun-Yip Yeung
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Kui-Kai Lau
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Koon-Ho Chan
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Chu-Pak Lau
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Gregory Y.H. Lip
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Gilberto Ka-Kit Leung
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Hung-Fat Tse
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
| | - Chung-Wah Siu
- From the Cardiology Division (C.-W.H., M.-H.H., P.-H.C., J.-J.H., E.C., C.-P.L., H.-F.T., C.-W.S.), Endocrinology Division (C.-Y.Y.), and Neurology Division (K.-K.L., K.-H.C.), Department of Medicine, Queen Mary Hospital and Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine (G.K.-K.L.), University of Hong Kong, Hong Kong SAR, China; and University of Birmingham Centre for Cardiovascular Sciences, City Hospital, University Department of Medicine, Birmingham, United
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