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Ashburner JM, Chang Y, Borowsky LH, Khurshid S, McManus DD, Ellinor PT, Lubitz SA, Singer DE, Atlas SJ. Effect of clinic-based single-lead electrocardiogram rhythm assessment on oral anticoagulation prescriptions in patients with previously diagnosed atrial fibrillation. Heart Rhythm O2 2023; 4:469-477. [PMID: 37645259 PMCID: PMC10461197 DOI: 10.1016/j.hroo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. Objective The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. Methods VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. Results The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Conclusions Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.
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Affiliation(s)
- Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Leila H. Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Jones AE, McCarty MM, Cameron KA, Cavanaugh KL, Steinberg BA, Passman R, Kansal P, Guzman A, Chen E, Zhong L, Fagerlin A, Hargraves I, Montori VM, Brito JP, Noseworthy PA, Ozanne EM. Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation. MDM Policy Pract 2023; 8:23814683231178033. [PMID: 38178866 PMCID: PMC10765759 DOI: 10.1177/23814683231178033] [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: 02/14/2022] [Accepted: 04/06/2023] [Indexed: 01/06/2024] Open
Abstract
Introduction Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.
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Affiliation(s)
- Aubrey E. Jones
- College of Pharmacy, Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Madeleine M. McCarty
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Kenzie A. Cameron
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Kerri L. Cavanaugh
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A. Steinberg
- School of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rod Passman
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Preeti Kansal
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Adriana Guzman
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Emily Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lingzi Zhong
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Ian Hargraves
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Juan P. Brito
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Elissa M. Ozanne
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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Wang H, Xi S, Chen J, Zhao L, Gan T, He B. Severe Left Atrial Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation: Clinical Characteristics and Impact on Ischemic Risk Postablation. Thromb Haemost 2022; 123:522-534. [PMID: 36402133 DOI: 10.1055/a-1983-0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is an important precursor for intracardiac thrombus and stroke. There are very limited data on characteristics of severe SEC and its impact on ischemic risk of nonvalvular atrial fibrillation (NVAF) patients after radiofrequency catheter ablation. METHODS Transesophageal echocardiography files were reviewed between March 2009 and March 2021 in this monocentric retrospective study. SEC was classified into four levels. The primary endpoint was thromboembolic event (stroke, myocardial infarction, systemic embolism, and ensuing death), and the secondary endpoint included nonischemic mortality and recurrent atrial arrhythmia. RESULTS Six hundred SEC cases were enrolled and classified into mild SEC group (Grade 1-2, n = 515) and severe SEC group (Grade 3-4, n = 85). Independent risk factors for severe SEC included higher brain natriuretic peptide (BNP), erythrocyte sedimentation rate (ESR), and LAd/∆LVED (LAd = left atrial diameter; ∆LVED = left ventricular end-diastolic diameter - left ventricular end-systolic diameter). The severe SEC group had a higher peri-procedural ischemic event occurrence (7.1 vs. 1.9%, p = 0.007). At a median follow-up of 55 months, the severe SEC group had a lower freedom rate from ischemic events (90.1 vs. 75.3%, p < 0.001); older age and severe SEC were independent risk factors for ischemic events. In patients undergoing redo-procedure (n = 100), a remarkably reduced ESR (17.8 ± 12.0 vs. 28.2 ± 19.0 mm/h, p < 0.001) was observed in patients whose SEC disappeared. CONCLUSIONS Higher BNP, ESR, and LAd/∆LVED were the independent predictors for severe SEC. Severe SEC was associated with higher peri-procedural and long-term ischemic risks. ESR and LAd/∆LVED, as indicators of hematological and hemodynamic change, seemed helpful in identifying NVAF patients prone to developing severe SEC.
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Affiliation(s)
- Hao Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Siqi Xi
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jindong Chen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Liang Zhao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tian Gan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Yao C, Jones AE, Slager S, Fagerlin A, Witt DM. Exploring clinician perspectives on patients with atrial fibrillation who are not prescribed anticoagulation therapy. PEC INNOVATION 2022; 1:100062. [PMID: 37213758 PMCID: PMC10194321 DOI: 10.1016/j.pecinn.2022.100062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 05/23/2023]
Abstract
Objective To explore themes underlying why anticoagulants are under-prescribed for stroke prevention in atrial fibrillation (AF) patients from the clinician's perspective and characteristics of those patients. Methods Clinicians at the University of Utah Health system were recruited for semi-structured 15-minute interviews. An interview guide focused on anticoagulant prescribing practices for patients with AF. Interviews were transcribed verbatim. Two reviewers independently coded passages corresponding with key themes. Results Eleven practitioners were interviewed from cardiology, internal medicine, and family practice. Five themes were found: the role of compliance in anticoagulation decision making, the role of pharmacists in supporting clinicians, the use of shared decision making and risk communication, risk of bleeding as the main barrier to taking anticoagulants, and the variety of reasons patients have for not starting or discontinuing anticoagulants. Conclusion Fear of bleeding was the foremost reason underlying anticoagulant underutilization in patients with AF followed by compliance, and patient worries. Communication between patients and clinicians as well as interdisciplinary teamwork are key to understanding and improving anticoagulant prescribing in AF. Innovation Our study was the first to assess the role pharmacists play in prescribing clinician's decisions surrounding anticoagulant use in AF. Pharmacists could play an important collaborative role in SDM.
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Affiliation(s)
- Catherine Yao
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Aubrey E. Jones
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
- Corresponding author at: 30 South 2000 East Rm 4931, Salt Lake City, UT 84112, USA.
| | - Stacey Slager
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, USA
| | - Daniel M. Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
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Deitelzweig S, Terasawa E, Kang A, Atreja N, Hines DM, Noman A, Luo X. Payer formulary exclusions of apixaban: how patients respond and potential implications. Curr Med Res Opin 2022; 38:1885-1890. [PMID: 36164763 DOI: 10.1080/03007995.2022.2128189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In recent years, US payers have increased usage of formulary exclusions as a means to help manage costs. Earlier this year, one of the largest pharmacy benefit managers in the country added Eliquis (apixaban), the most widely used anticoagulant, to its list of excluded medicines from its formulary, raising concerns by physicians and patients. In this commentary, we examine the potential impacts of formulary exclusion of a drug like apixaban-a treatment for patients with atrial fibrillation and venous thromboembolism to help prevent stroke and clotting events and which has been demonstrated to have a strong efficacy and safety profile. We discuss the effect of formulary exclusions on patients' ability to access the most clinically appropriate treatment for their health needs, along with possible effects on their health and well-being. We also report descriptive results on apixaban-treated patients with traditional Medicare coverage who faced a formulary exclusion of apixaban in 2017, and these patients' observed behaviors. We found that the majority of these patients remained on apixaban either through pre-emptively switching to a different Part D drug plan with apixaban coverage or applying for formulary exception. Our findings suggest that formulary exclusion did not help to achieve the goal of switching patients to less costly medications but created additional hurdles for patients to access their preferred treatment and increased patient burden. Alternative ways to manage payer costs may be needed to help avoid poor outcomes and reduce the burden placed on patients in their efforts to access life-saving medications.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | | | - Amiee Kang
- Bristol Myers Squibb, Inc., Lawrence, NJ, USA
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García Rodríguez LA, Gaist D, Balabanova Y, Brobert G, Sharma M, Cea Soriano L. Pre- and post-stroke oral antithrombotics and mortality in patients with ischaemic stroke. Pharmacoepidemiol Drug Saf 2022; 31:1182-1189. [PMID: 35989512 PMCID: PMC9825966 DOI: 10.1002/pds.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/17/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Reducing stroke occurrence requires the effective management of cardiovascular and other stroke risk factors. PURPOSE To describe pre- and post-stroke medication use, focusing on antithrombotic therapy and mortality risk, in individuals hospitalised for ischaemic stroke (IS) in the United Kingdom. METHOD Using primary care electronic health records from the United Kingdom, we identified patients hospitalised for IS (July 2016-September 2019) and classed them into three groups: atrial fibrillation (AF) diagnosed pre-stroke, AF diagnosed post-stroke, and non-AF stroke (no AF diagnosed pre-/post-stroke). We determined use of cardiovascular medications in the 90 days pre- and post-stroke and calculated mortality rates. RESULTS There were 3201 hospitalised IS cases: 76.2% non-AF stroke, 15.7% AF pre-stroke, and 8.1% AF post-stroke. Oral anticoagulant (OAC) use increased between the pre- and post-stroke periods as follows: 54.3%-78.7% (AF pre-stroke group), 2.3%-84.8% (AF post-stroke group), and 3.4%-7.3% (non-AF stroke group). Corresponding increases in antiplatelet use were 30.8%-35.4% (AF pre-stroke group) 38.5%-47.5% (AF post-stroke group), and 37.5%-87.3% (non-AF stroke group). Among all IS cases, antihypertensive use increased from 66.8% pre-stroke to 78.8% post-stroke; statin use increased from 49.6%-85.2%. Mortality rates per 100 person-years (95% CI) were 17.30 (14.70-20.35) in the AF pre-stroke group and 9.65 (8.81-10.56) among all other stroke cases. CONCLUSION Our findings identify areas for improvement in clinical practice, including optimising the level of OAC prescribing to patients with known AF, which could potentially help reduce the future burden of stroke.
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Affiliation(s)
| | - David Gaist
- Research Unit for NeurologyOdense University Hospital, Denmark & University of Southern DenmarkOdenseDenmark
| | | | | | - Mike Sharma
- Division of Neurology, Department of MedicinePopulation Health Research Institute McMaster UniversityHamiltonCanada
| | - Lucía Cea Soriano
- Department of Public Health and Maternal and Child Health, Faculty of MedicineComplutense University of MadridMadridSpain
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Halvorsen S, Smith JA, Söderdahl F, Thuresson M, Solli O, Ulvestad M, Jonasson C. Changes in primary care management of atrial fibrillation patients following the shift from warfarin to non-vitamin K antagonist oral anticoagulants: a Norwegian population based study. BMC PRIMARY CARE 2022; 23:214. [PMID: 36008778 PMCID: PMC9404608 DOI: 10.1186/s12875-022-01824-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022]
Abstract
Background To assess baseline characteristics, drug utilisation and healthcare use for oral anticoagulants (OACs) following the introduction of non-vitamin K antagonist oral anticoagulants among patients with atrial fibrillation in primary care in Norway. Methods In this retrospective longitudinal cohort study, 92,936 patients with atrial fibrillation were identified from the Norwegian Primary Care Registry between 2010 and 2018. Linking to the Norwegian Prescription Database, we identified 64,112 patients (69.0%) treated with OACs and 28,824 (31%) who were untreated. Participants were followed until 15 May 2019, death, or loss to follow-up, whichever came first. For each OAC, predictors of initiation were assessed by modelling the probability of initiating the OAC using logistic regression, and predictors of the first switch after index date were assessed using multivariable Cox proportional hazards models. The numbers of primary care visits per quarter by index OAC were plotted and analysed with negative binomial regression analyses offset for the log of days at risk. Results Patients treated with OACs were older, had more comorbidities, and higher CHA2DS2-VASc scores than untreated patients. However, the mean CHA2DS2-VASc in the non-OAC group was 1.58 for men and 3.13 for women, suggesting an indication for OAC therapy. The percentage of patients with atrial fibrillation initiating OACs increased from 59% in 2010 to 79% in 2018. Non-vitamin K antagonist oral anticoagulant use increased throughout the study period to 95% of new OAC-treated patients in 2018, and switches from warfarin to non-vitamin K antagonist oral anticoagulants were common. The persistence of OAC treatment was > 60% after four years, with greatest persistence for apixaban. Patients treated with non-vitamin K antagonist oral anticoagulants had fewer primary care visits compared with those treated with warfarin (incidence rate ratio: 0.73, 95% confidence interval 0.71 to 0.75). Conclusion In this Norwegian primary care study, we found that the shift from warfarin to non-vitamin K antagonist oral anticoagulants was successful with 95% use in patients initiating OACs in 2018, and associated with fewer general practitioner visits. Persistence with OACs was high, particularly for apixaban. However, many patients eligible for treatment with OACs remained untreated. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01824-6.
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Chen W, Khurshid S, Singer DE, Atlas SJ, Ashburner JM, Ellinor PT, McManus DD, Lubitz SA, Chhatwal J. Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices. JAMA HEALTH FORUM 2022; 3:e222419. [PMID: 36003419 PMCID: PMC9356321 DOI: 10.1001/jamahealthforum.2022.2419] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Question Is population-based atrial fibrillation (AF) screening using wearable devices cost-effective? Findings In this economic evaluation of 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older, AF screening using wearable devices was cost-effective, with the overall preferred strategy identified as wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation (incremental cost-effectiveness ratio, $57 894 per quality-adjusted life-year). The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages, and with variation in the association of anticoagulation with risk of stroke associated with screening-detected AF. Meaning This study suggests that contemporary AF screening using wearable devices may be cost-effective. Importance Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown. Objective To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices. Design, Setting, and Participants This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older. Interventions Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening. Main Outcomes and Measures The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding. Results In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, −116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF. Conclusions and Relevance This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.
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Affiliation(s)
- Wanyi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
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Decision of Anticoagulation in Nonvalvular Atrial Fibrillation in the Real World in the Non-Antivitamin K Anticoagulants Era. Healthcare (Basel) 2022; 10:healthcare10071333. [PMID: 35885863 PMCID: PMC9317193 DOI: 10.3390/healthcare10071333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Patients with nonvalvular atrial fibrillation (NVAF) have five times higher risk of stroke than the general population. Anticoagulation (ACO) in NVAF is a class I indication after assessing the CHA2DS2-VASc and HAS-BLED scores. However, in the real world, NVAF patients receive less ACO than needed due to patients’ comorbidities that can be assessed by the Charlson comorbidity index (CCI). The use of non-antivitamin K anticoagulants (NOAC) has improved the decision to anticoagulate. Objective. We analyzed the factors influencing the ACO prescribing decision in NVAF patients in the real world and the changes induced by the introduction of NOAC. Method. We carried out an observational retrospective cross-sectional study that included consecutive patients with permanent NVAF and CHA2DS2-VASc ≥ 2, admitted to a community hospital between 2010–2011 (group 1, 286 patients), when only vitamin K antagonists (VKA) were used, and 2018–2019 (group 2, 433 patients), respectively. We calculated CHA2DS2-VASc, HAS-BLED, and CCI and recorded the ACO decision and the use of VKA or NOAC in group 2. We compared the calculated scores between ACO and non-anticoagulated (nonACO) patients in both groups and between groups. Results. A 31.5% share of patients in group 1 and 12.9% in group 2 did not receive ACO despite a CHA2DS2-VASc score ≥ 2. In group 1, nonACO patients had higher HAS-BLED and CCI scores than the ACO patients, but their CHA2DS2-VASc scores were not significantly different. Old age, dementia, severe chronic kidney disease, neoplasia, and anemia were the most frequent reasons not to prescribe anticoagulants. In group 2, more nonACO patients had dementia, diabetes mellitus, and higher HAS-BLED than ACO patients. Moderate-severe CKD, neoplasia with metastasis, liver disease, anemia, and diabetes mellitus were statistically significantly more frequent in nonACO patients from group 1 than those from group 2. In group 2, 55.7% of ACO patients received NOAC. Conclusions. In real-world clinical practice, the decision for anticoagulation in NVAF is influenced by patient age, comorbidities, and risk of bleeding, and many patients do not receive anticoagulants despite a high CHA2DS2-VASc score. The use of NOAC in the past few years has improved treatment decisions. At the same time, the correct diagnosis, treatment, and surveillance of comorbidities have cut down the risk of bleeding and allowed anticoagulant use according to guidelines.
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Lee MY, Han S, Bang OY, On YK, Jang SW, Han S, Ryu J, Park YJ, Kang S, Suh HS, Kim YH. Drug Utilization Pattern of Oral Anticoagulants in Patients with Atrial Fibrillation: A Nationwide Population-Based Study in Korea. Adv Ther 2022; 39:3112-3130. [PMID: 35524839 DOI: 10.1007/s12325-022-02151-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/28/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Treatment persistence for anticoagulant therapy is important in preventing thromboembolism in nonvalvular atrial fibrillation (NVAF) patients. Understanding drug utilization pattern and treatment changes in oral anticoagulant (OAC) users may facilite better NVAF management. Thus, our study aimed to examine OAC treatment patterns preceding events leading to switch or discontinuation and medication adherence in Korean NVAF patients. METHODS We conducted a drug utilization study on all Korean patients with atrial fibrillation (AF) newly prescribed OACs between July 2015 and November 2016 using the national claims data. We assessed treatment changes such as switching and discontinuation from index OAC and relevant events preceding the change and examined patient characteristics as predictors of changes that occurred among OAC users. Medication adherence was compared among OAC users by calculating the medication possession ratio (MPR). RESULTS A total of 48,389 NVAF patients were identified who initiated OACs within the study period. Most initiated nonvitamin K antagonist oral anticoagulants (NOACs) (22% apixaban, 24% dabigatran, 37% rivaroxaban), and 18% initiated warfarin. The frequency of switch to another OAC was 8.8% for apixaban, 16.1% for dabigatran, 6.6% for rivaroxaban, and 19.1% for warfarin. The frequency of discontinuation was lower for apixaban (22.9%), dabigatran (26.3%), and rivaroxaban (25.7%) than warfarin (31.6%). Compared to warfarin, NOAC users were less likely to switch treatment. Thromboembolic event was the most common clinical event preceding switch from warfarin to NOAC and from NOAC to warfarin. Discontinuation of OAC was often preceded by a bleeding event. Patients who initiated apixaban showed significantly higher mean MPR compared to those on dabigatran and warfarin. CONCLUSION In real-world practice in Korea, we have observed treatment change to be common in OAC users. Our results indicate better medication adherence with NOACs than with warfarin. (ClinicalTrials.gov registration number NCT03572972).
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Dhamane AD, Hernandez I, Di Fusco M, Gutierrez C, Ferri M, Russ C, Tsai WL, Emir B, Yuce H, Keshishian A. Non-persistence to Oral Anticoagulation Treatment in Patients with Non-valvular Atrial Fibrillation in the USA. Am J Cardiovasc Drugs 2022; 22:333-343. [PMID: 34671944 PMCID: PMC9061668 DOI: 10.1007/s40256-021-00501-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies have shown that patients with non-valvular atrial fibrillation (NVAF) who discontinue oral anticoagulants (OACs) are at higher risk of complications such as stroke. OBJECTIVE This analysis compared the risk of non-persistence with OACs among patients with NVAF. METHODS Adult patients with NVAF who initiated apixaban, dabigatran, rivaroxaban, or warfarin were identified using 01JAN2013-30JUN2019 data from Centers for Medicare and Medicaid Services and four US commercial claims databases. Non-persistence was defined as discontinuation (no evidence of index OAC use for ≥ 60 days from the last days' supply) or switch to another OAC. Kaplan-Meier curves were generated to illustrate time to non-persistence along with cumulative incidences of non-persistence. Baseline and time-varying covariates were evaluated, and adjusted Cox proportional hazards models were used to evaluate non-persistence risk. RESULTS In total, 363,823 patients receiving apixaban, 57,121 receiving dabigatran, 282,831 receiving rivaroxaban, and 317,337 receiving warfarin were included. Of these, 47-72% discontinued/switched OAC therapy within an average 9-month follow-up. Apixaban was associated with a lower risk of non-persistence than were dabigatran (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.61-0.62), rivaroxaban (HR 0.76; 95% CI 0.75-0.76), and warfarin (HR 0.74; 95% CI 0.74-0.75). Dabigatran was associated with a higher risk of non-persistence than were warfarin (HR 1.21; 95% CI 1.19-1.22) and rivaroxaban (HR 1.23; 95% CI 1.22-1.25), and rivaroxaban was associated with a lower risk of non-persistence than was warfarin (HR 0.98; 95% CI 0.97-0.98). Clinical events (stroke/systemic embolism and major bleeding [MB]) during follow-up were predictors of non-persistence (stroke HR 1.57; 95% CI 1.53-1.61; MB HR 2.96; 95% CI 2.92-3.00). CONCLUSION In over one million patients with NVAF, our results suggest differences in anticoagulation treatment persistence across OAC agents, even after accounting for clinical events after OAC initiation. It is important for clinicians and patients to take these differences into consideration, especially as non-persistence to OAC therapy is associated with thromboembolic complications.
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Affiliation(s)
| | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | - Wan-Lun Tsai
- STATinMED Research, 4110 Varsity Dr, Ann Arbor, MI, 48108, USA
| | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
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Konieczyńska M, Bijak P, Malinowski KP, Undas A. Knowledge about atrial fibrillation and anticoagulation affects the risk of clinical outcomes. Thromb Res 2022; 213:105-112. [DOI: 10.1016/j.thromres.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/25/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
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Vora P, Morgan Stewart H, Russell B, Asiimwe A, Brobert G. Time Trends and Treatment Pathways in Prescribing Individual Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: An Observational Study of More than Three Million Patients from Europe and the United States. Int J Clin Pract 2022; 2022:6707985. [PMID: 35685531 PMCID: PMC9159118 DOI: 10.1155/2022/6707985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Data directly comparing trends in the use of different oral anticoagulants (OACs) among patients with atrial fibrillation (AF) from different countries are limited. We addressed this using a large-scale network cohort study in the United States (US), Belgium, France, Germany, and the United Kingdom (UK). METHODS We used nine databases (claims or electronic health records) that had been converted into the Observational Medical Outcomes Partnership Common Data Model with analysis performed using open-source analytical tools. We identified adults with AF and a first OAC prescription, either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC), from 2010 to 2017. We described time trends in use, continuation, and switching. RESULTS In 2010, 87.5%-99.8% of patients started on a VKA. By 2017, the majority started on a DOAC: 87.0% (US), 88.3% (Belgium), 93.1% (France), 88.4% (Germany), and 86.1%-86.7% (UK). In the UK, DOACs became the most common starting OAC in 2015, 2-3 years later than elsewhere. Apixaban was the most common starting OAC by 2017, 50.2%-57.8% (US), 31.4% (Belgium), 45.9% (France), 39.5% (Germany), and 49.8%-50.5% (UK), followed by rivaroxaban, 24.8%-32.5% (US), 25.7% (Belgium), 38.4% (France), 24.9% (Germany), and 30.2%-31.2% (UK). Long-term treatment was less common in the US than in Europe, especially the UK. A minority of patients switched from their index OAC in the short and long term. CONCLUSIONS From 2010 to 2017, VKA use had significantly declined and DOAC use had significantly increased in the US and Europe. Apixaban was the most prescribed OAC in 2017, followed by rivaroxaban.
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14
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D'Ancona G, Arslan F, Safak E, Weber D, Al Ammareen R, Ince H. Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation. Int J Cardiol 2021; 351:61-64. [PMID: 34929249 DOI: 10.1016/j.ijcard.2021.12.027] [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: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
AIMS Comparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only. METHODS AND RESULTS Patients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records. Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1. Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281-8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607-2735) in OAC patients and € 1013 (IQR: € 0-4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = -0.8; CI: -1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7). CONCLUSION Percutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.
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Affiliation(s)
- Giuseppe D'Ancona
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany.
| | - Fatih Arslan
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany; Department of Cardiology, Leiden University Medical Center, Leiden, NL, the Netherlands
| | - Erdal Safak
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Denise Weber
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Raid Al Ammareen
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Hüseyin Ince
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
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15
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Khurshid S, Chen W, Singer DE, Atlas SJ, Ashburner JM, Choi JG, Hur C, Ellinor PT, McManus DD, Chhatwal J, Lubitz SA. Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model. J Am Heart Assoc 2021; 10:e020330. [PMID: 34476979 PMCID: PMC8649502 DOI: 10.1161/jaha.120.020330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022]
Abstract
Background Atrial fibrillation (AF) screening is endorsed by certain guidelines for individuals aged ≥65 years. Yet many AF screening strategies exist, including the use of wrist-worn wearable devices, and their comparative effectiveness is not well-understood. Methods and Results We developed a decision-analytic model simulating 50 million individuals with an age, sex, and comorbidity profile matching the United States population aged ≥65 years (ie, with a guideline-based AF screening indication). We modeled no screening, in addition to 45 distinct AF screening strategies (comprising different modalities and screening intervals), each initiated at a clinical encounter. The primary effectiveness measure was quality-adjusted life-years, with incident stroke and major bleeding as secondary measures. We defined continuous or nearly continuous modalities as those capable of monitoring beyond a single time-point (eg, patch monitor), and discrete modalities as those capable of only instantaneous AF detection (eg, 12-lead ECG). In total, 10 AF screening strategies were effective compared with no screening (300-1500 quality-adjusted life-years gained/100 000 individuals screened). Nine (90%) effective strategies involved use of a continuous or nearly continuous modality such as patch monitor or wrist-worn wearable device, whereas 1 (10%) relied on discrete modalities alone. Effective strategies reduced stroke incidence (number needed to screen to prevent a stroke: 3087-4445) but increased major bleeding (number needed to screen to cause a major bleed: 1815-4049) and intracranial hemorrhage (number needed to screen to cause intracranial hemorrhage: 7693-16 950). The test specificity was a highly influential model parameter on screening effectiveness. Conclusions When modeled from a clinician-directed perspective, the comparative effectiveness of population-based AF screening varies substantially upon the specific strategy used. Future screening interventions and guidelines should consider the relative effectiveness of specific AF screening strategies.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - Wanyi Chen
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Daniel E. Singer
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Steven J. Atlas
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jeffrey M. Ashburner
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jin G. Choi
- University of Chicago Pritzker School of MedicineChicagoIL
| | - Chin Hur
- Department of MedicineColumbia UniversityNew YorkNY
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNY
| | - Patrick T. Ellinor
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - David D. McManus
- Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jagpreet Chhatwal
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Steven A. Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
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16
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Byambajav T, Waki T, Miura K, Tanaka-Mizuno S. Association between adherence to warfarin and thrombotic events in patients with antiphospholipid syndrome in Japan: A claims-based retrospective cohort study. Pharmacoepidemiol Drug Saf 2021; 31:149-157. [PMID: 34382707 DOI: 10.1002/pds.5343] [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: 01/19/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE We aimed to evaluate adherence and persistence to warfarin therapy among patients with antiphospholipid syndrome (APS) and investigate the association between adherence and thrombotic events in those patients. METHODS We conducted a retrospective cohort study using the Japan Medical Data Center claims database from 2005 to 2018. Patients with APS receiving warfarin treatment were included in this study. Adherence and persistence were evaluated using the proportion of days covered (PDS) and refill gap methods, respectively. Demographic characteristics of patients were obtained. Kaplan-Meier curves with log-rank tests and Cox regression models were used to examine the association between adherence or persistence and time to thrombotic events. RESULTS A total of 186 patients (mean age: 46.5 ± 12.4 years, females 68.8%) were included in this study. No significant differences were observed in risk factors for thrombosis and cardiovascular diseases among groups. Most patients were adherent (91.4%) and persistent (88.2%) to warfarin treatment. Adherent and persistent patients had a significantly higher rate of thrombotic event-free survival than nonadherent and nonpersistent patients (p < 0.05). Multivariable Cox regression showed that the risk of thrombotic events was higher in nonadherent patients (with a hazard ratio of 3.23 [95% confidence interval CI: 1.15-9.11]) and in nonpersistent patients (with a hazard ratio of 3.45 [95% CI: 1.35-8.82]). CONCLUSIONS In patients with APS, nonadherence and nonpersistence to warfarin treatment was associated with a higher risk of thrombotic events, suggesting the careful monitoring of those patients.
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Affiliation(s)
- Tserenlkham Byambajav
- Department of Public Health, Shiga University of Medical Science, Otsu, Shiga, Japan.,Department of Clinical Pharmacy and Pharmaceutical Management, School of Pharmacy, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Takashi Waki
- Department of Public Health, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Katsuyuki Miura
- Department of Public Health, Shiga University of Medical Science, Otsu, Shiga, Japan.,NCD Epidemiology Research Center (NERC), Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Sachiko Tanaka-Mizuno
- Department of Public Health, Shiga University of Medical Science, Otsu, Shiga, Japan.,Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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17
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Deitelzweig S, Di Fusco M, Kang A, Savone M, Mokgokong R, Keshishian A, Gutierrez C, Cappelleri JC. Real-world persistence to direct oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis. Curr Med Res Opin 2021; 37:891-902. [PMID: 33686900 DOI: 10.1080/03007995.2021.1897555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To conduct a systematic review and network meta-analysis of real-world evidence comparing adherence, persistence, cost, and utilization between oral anticoagulant (OAC) in non-valvular atrial fibrillation (NVAF) patients. METHODS A systematic search of MEDLINE and Embase (inception-July 2019) was conducted for published observational cohort studies comparing outcomes between ≥2 OACs. A network meta-analysis was performed to estimate odds ratios for non-persistence using a random-effects model. RESULTS There were 80 studies evaluating the outcomes of interest. However, due to a paucity in adherence studies and heterogeneity in adherence, cost, and utilization definitions, persistence was the focus of this network meta-analysis. There were 36 studies evaluating non-persistence in 395,593 participants, 24 of which used 3 gap definitions (30-, 60-, and 90-days); 18 unique studies evaluating non-persistence at 12 months were included in the network meta-analysis. Using 30- and 90-day gaps, all NOACs, when compared with VKAs, had lower odds of non-persistence (30-day OR (95%CI): apixaban: 0.63 (0.58, 0.69); rivaroxaban: 0.69 (0.62, 0.76); dabigatran: 0.89 (0.82, 0.97); 90-day OR (95%CI): apixaban: 0.33 (0.22, 0.47); rivaroxaban: 0.47 (0.36, 0.61); dabigatran 0.61 (0.44, 0.85)). When using a 60-day gap, dabigatran had higher odds of non-persistence vs VKAs (OR: 1.35; 95%CI: 1.12, 1.61), but there were no significant differences for apixaban and rivaroxaban. Apixaban had the lowest probability of non-persistence across the 3-gap definitions (95.7% with 30-day gap, 76.9% with 60-day gap, 98.4% with 90-day gap). CONCLUSIONS The current findings, despite multiple limitations, can raise awareness and understanding of real-world persistence associated with OAC therapy in NVAF patients.
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Affiliation(s)
- Steven Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
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18
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Jackson LR, Jackson KP, Thomas KL. Percutaneous left atrial appendage occlusion: A review of current devices, clinical evidence, patient selection, and post procedural antithrombotic management. Prog Cardiovasc Dis 2021; 66:92-100. [PMID: 34332665 PMCID: PMC9899495 DOI: 10.1016/j.pcad.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.
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Affiliation(s)
- Larry R Jackson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America; Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America.
| | - Kevin P Jackson
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America
| | - Kevin L Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America; Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Medical Center, Durham, NC, United States of America
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Lindley RI. Balancing the benefits and harms of oral anticoagulation in non-valvular atrial fibrillation. Aust Prescr 2021; 44:49-52. [PMID: 33911332 PMCID: PMC8075749 DOI: 10.18773/austprescr.2021.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Non-valvular atrial fibrillation is becoming more common in Australia and globally The direct oral anticoagulants apixaban, dabigatran and rivaroxaban offer an improved safety profile over warfarin Patient preferences are important and shared decision-making supports better adherence to treatment
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Affiliation(s)
- Richard I Lindley
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney.,George Institute for Global Health, Sydney
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20
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Yagi N, Suzuki S, Nagai K, Tanaka T, Nagahama T, Arita T, Otsuka T, Yamashita T. Current status of oral anticoagulant adherence in Japanese patients with atrial fibrillation: A claims database analysis. J Cardiol 2021; 78:150-156. [PMID: 33663881 DOI: 10.1016/j.jjcc.2021.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). We investigated the adherence of DOACs for years known to be associated with the effectiveness in Japanese NVAF patients, using a claim database. METHOD We performed a retrospective evaluation of NVAF patients in a claims database in Japan, who initiated dabigatran, rivaroxaban, and apixaban between April 2011 and June 2016. Drug persistence was assessed by Kaplan-Meier method for the initially-prescribed DOAC and all DOACs including switched ones. Proportion of days covered (PDC) was also evaluated in patients with persistent prescription and compared among DOACs. RESULTS In the total of 671 patients, rivaroxaban (47%) was more prescribed than dabigatran (28%) and apixaban (25%). Drug persistence at 3 years was higher in rivaroxaban (69%) than dabigatran (57%) and apixaban (67%). Including switching to other DOACs, persistence of DOACs was 72% at 3 years without significant differences between index-DOACs. In multivariate Cox regression analysis, absence of hypertension, and prior history of cancer were significantly associated with the drug discontinuation of all DOACs. The mean PDC was ~ 95% and the frequency of high-adherent patients (PDC ≥0.80) was more than 90%, which similarly persisted at 3 years and showed no significant differences between index DOACs. CONCLUSION In a real-world Japanese claim data analysis, about 70% of patients under DOAC showed persistence with anticoagulation therapy at 3 years. High adherence to DOACs assessed by PDC (over 90%) persisted to 3 years regardless of the types of DOACs.
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Affiliation(s)
- Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan.
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | | | | | | | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
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21
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Rome BN, Gagne JJ, Avorn J, Kesselheim AS. Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study. Am Heart J 2021; 233:109-121. [PMID: 33358690 DOI: 10.1016/j.ahj.2020.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.
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Affiliation(s)
- Benjamin N Rome
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA.
| | - Joshua J Gagne
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
| | - Jerry Avorn
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
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22
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Kawakami H, Nolan MT, Phillips K, Scuffham PA, Marwick TH. Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk. Am Heart J 2021; 231:110-120. [PMID: 32822655 DOI: 10.1016/j.ahj.2020.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF. METHODS A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk. RESULTS In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk. CONCLUSIONS In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Mark T Nolan
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia
| | | | - Paul A Scuffham
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Thomas H Marwick
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
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23
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García Rodríguez LA, Cea Soriano L, Munk Hald S, Hallas J, Balabanova Y, Brobert G, Vora P, Sharma M, Gaist D. Discontinuation of oral anticoagulation in atrial fibrillation and risk of ischaemic stroke. Heart 2020; 107:heartjnl-2020-317887. [PMID: 33310887 PMCID: PMC7958105 DOI: 10.1136/heartjnl-2020-317887] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate associations between oral anticoagulant (OAC) discontinuation and risk of ischaemic stroke (IS) among patients with atrial fibrillation (AF). METHODS We undertook a population-based cohort study with nested case-control analysis using UK primary care electronic health records (IQVIA Medical Research Data-UK) and linked registries from the Region of Southern Denmark (RSD). Patients with AF (76 882 UK, 41 526 RSD) were followed to identify incident IS cases during 2016-2018. Incident IS cases were matched by age and sex to controls. Adjusted ORs for OAC discontinuation (vs current OAC use) were calculated using logistic regression. RESULTS We identified 616 incident IS cases in the UK and 643 in the RSD. ORs for IS with any OAC discontinuation were 2.99 (95% CI 2.31 to 3.86, UK) and 2.30 (95% CI 1.79 to 2.95, RSD), for vitamin K antagonist discontinuation they were 2.38 (95% CI 1.72 to 3.30, UK) and 1.83 (95% CI 1.34 to 2.49, RSD), and for non-vitamin K antagonist oral anticoagulant discontinuation they were 4.59 (95% CI 2.97 to 7.08, UK) and 3.37 (95% CI 2.35 to 4.85, RSD). ORs were unaffected by time since discontinuation and duration of use. Annually, up to 987 IS cases in the UK and 132 in Denmark could be preventable if OAC therapy is not discontinued. CONCLUSIONS Our results suggest that patients with AF who discontinue OAC therapy have a significant twofold to threefold higher risk of IS compared with those who continue therapy. Addressing OAC discontinuation could potentially result in a significant reduction in AF-attributed IS.
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Affiliation(s)
| | | | | | | | | | | | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada
| | - David Gaist
- University of Southern Denmark, Odense, Denmark
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24
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 312] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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25
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Machado-Alba JE, Gaviria-Mendoza A, Machado-Duque ME, Tovar-Yepes C, Ruigómez A, García Rodríguez LA. Use of non-vitamin K antagonist oral anticoagulants in Colombia: A descriptive study using a national administrative healthcare database. Pharmacoepidemiol Drug Saf 2020; 30:426-434. [PMID: 33063370 PMCID: PMC7983923 DOI: 10.1002/pds.5124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/26/2020] [Accepted: 08/25/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE We aimed to describe time-trends in the use of NOACs among a group of ambulatory patients with nonvalvular atrial fibrillation (NVAF) in Colombia and to describe treatment patterns and user characteristics. METHODS Using the Audifarma S.A administrative healthcare database in Colombia, we identified 10 528 patients with NVAF aged at least 18 years between July 2009 and June 2017 with a first prescription (index date) for apixaban, dabigatran or rivaroxaban (index NOAC) and followed them for at least year (max, 8.0 years, mean 2.2 years). We described patient characteristics, NOAC use over time, and the dose of the first NOAC prescription. RESULTS A total of 2153 (20.5%) patients started on apixaban, 3089 (29.3%) on dabigatran and 5286 (50.2%) on rivaroxaban. The incidence of new users of apixaban and rivaroxaban increased over study years while for dabigatran it decreased. Mean age at the index date was: 78.5 years (apixaban), 76.5 years (dabigatran), 76.0 years (rivaroxaban). The percentage of patients started NOAC therapy on the standard dose was: apixaban 38.0%, dabigatran 30.9%, rivaroxaban 56.9%. The percentage still prescribed their index NOAC at 6 months was apixaban 44.6%, dabigatran 51.4%, rivaroxaban 52.7%. Hypertension was the most common comorbidity (>80% in each NOAC cohort). CONCLUSION During the last decade, the incidence of NOAC use in patients with NVAF affiliated with a private healthcare regime in Colombia has markedly increased. Future studies should evaluate whether the large number of patients with NVAF starting NOAC treatment on a reduced dose are done so appropriately.
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Affiliation(s)
- Jorge E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Manuel E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia.,Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Carlos Tovar-Yepes
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Ana Ruigómez
- Centro Español de Investigación Farmacoepidemiológica (CEIFE), Madrid, Spain
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Midterm outcomes of LAA occlusion with the AMPLATZER Cardiac Plug and AMPLATZER Amulet devices in a high-risk cohort. Sci Rep 2020; 10:16323. [PMID: 33004939 PMCID: PMC7530649 DOI: 10.1038/s41598-020-73381-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/14/2020] [Indexed: 11/08/2022] Open
Abstract
LAA occlusion has become a favourable option in patients with atrial fibrillation not eligible for oral anticoagulation therapy. Proof of effectiveness of LAA closure devices in a midterm follow-up period. This retrospective single-center cohort study analysed outcome in patients treated with AMPLATZER Cardiac Plug or AMPLATZER Amulet device. A standardized follow-up by phone call focusing on data of death, stroke and bleeding events was performed. Routine antiplatelet strategy was DAPT for 3 months post procedural. 212 patients (mean age 77 ± 6 years) were included. Follow up was performed in 197 (93%) patients. Patients were at high risk for thromboembolic or bleeding events (prior stroke/TIA 29%; prior bleeding 54%. Overall, there was a mean follow-up period of 1244.2 days (± 756.7) and a total of 674 patient years. We observed 25 events later than day 8 post procedure. We were able to demonstrate a high effectiveness of the AMPLATZER Cardiac Plug/AMPLATZER Amulet devices regarding the prevention of stroke and bleedings in a high-risk real-world cohort during a midterm follow-up period. Overall, we observed remarkably lower rates of stroke and bleedings as predicted with CHA2DS2-VASc and HASBLED scores.
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27
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Carnicelli AP, Al-Khatib SM, Xavier D, Dalgaard F, Merrill PD, Wojdyla DM, Lewis BS, Hanna M, Alexander JH, Lopes RD, Wallentin L, Granger CB. Premature permanent discontinuation of apixaban or warfarin in patients with atrial fibrillation. Heart 2020; 107:713-720. [PMID: 32938772 DOI: 10.1136/heartjnl-2020-317229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS The ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial randomised patients with atrial fibrillation at risk of stroke to apixaban or warfarin. We sought to describe patients from ARISTOTLE who prematurely permanently discontinued study drug. METHODS/RESULTS We performed a posthoc analysis of patients from ARISTOTLE who prematurely permanently discontinued study drug during the study or follow-up period. Discontinuation rates and reasons for discontinuation were described. Death, thromboembolism (stroke, transient ischaemic attack, systemic embolism), myocardial infarction and major bleeding rates were stratified by ≤30 days or >30 days after discontinuation. A total of 4063/18 140 (22.4%) patients discontinued study drug at a median of 7.3 (2.2, 15.2) months after randomisation. Patients with discontinuation were more likely to be female and had a higher prevalence of cardiovascular disease, diabetes, renal impairment and anaemia. Premature permanent discontinuation was more common in those randomised to warfarin than apixaban (23.4% vs 21.4%; p=0.002). The most common reasons for discontinuation were patient request (46.1%) and adverse event (34.9%), with no significant difference between treatment groups. The cumulative incidence of clinical events ≤30 days after premature permanent discontinuation for all-cause death, thromboembolism, myocardial infarction, and major bleeding was 5.8%, 2.6%, 0.9%, and 3.0%, respectively. No significant difference was seen between treatment groups with respect to clinical outcomes after discontinuation. CONCLUSION Premature permanent discontinuation of study drug in ARISTOTLE was common, less frequent in patients receiving apixaban than warfarin and was followed by high 30-day rates of death, thromboembolism and major bleeding. Initiatives are needed to reduce discontinuation of oral anticoagulation.
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Affiliation(s)
| | | | - Denis Xavier
- St John's Medical College, Bangalore, Karnataka, India
| | | | - Peter D Merrill
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Michael Hanna
- Bristol-Myers Squibb Pharmaceutical Research and Development, Princeton, New Jersey, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Lars Wallentin
- Uppsala Clinical Research Center, University of Uppsala, Uppsala, Sweden
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Chu G, Seelig J, Trinks-Roerdink EM, van Alem AP, Alings M, van den Bemt B, Boersma LV, Brouwer MA, Cannegieter SC, Ten Cate H, Kirchhof CJ, Crijns HJ, van Dijk EJ, Elvan A, van Gelder IC, de Groot JR, den Hartog FR, de Jong JS, de Jong S, Klok FA, Lenderink T, Luermans JG, Meeder JG, Pisters R, Polak P, Rienstra M, Smeets F, Tahapary GJ, Theunissen L, Tieleman RG, Trines SA, van der Voort P, Geersing GJ, Rutten FH, Hemels ME, Huisman MV. Design and rationale of DUTCH-AF: a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation. BMJ Open 2020; 10:e036220. [PMID: 32843516 PMCID: PMC7449286 DOI: 10.1136/bmjopen-2019-036220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Anticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and AF-related adverse events in practice-based patient cohorts, in particular for non-vitamin K oral anticoagulants (NOAC). With the creation of DUTCH-AF, a nationwide longitudinal AF registry, we aim to provide clinical data and answer questions on the (anticoagulant) management over time and of the clinical course of patients with newly diagnosed AF in routine clinical care. Within DUTCH-AF, our current aim is to assess the effect of non-adherence and non-persistence of anticoagulation therapy on clinical adverse events (eg, bleeding and stroke), to determine predictors for such inadequate anticoagulant treatment, and to validate and refine bleeding prediction models. With DUTCH-AF, we provide the basis for a continuing nationwide AF registry, which will facilitate subsequent research, including future registry-based clinical trials. METHODS AND ANALYSIS The DUTCH-AF registry is a nationwide, prospective registry of patients with newly diagnosed 'non-valvular' AF. Patients will be enrolled from primary, secondary and tertiary care practices across the Netherlands. A target of 6000 patients for this initial cohort will be followed for at least 2 years. Data on thromboembolic and bleeding events, changes in antithrombotic therapy and hospital admissions will be registered. Pharmacy-dispensing data will be obtained to calculate parameters of adherence and persistence to anticoagulant treatment, which will be linked to AF-related outcomes such as ischaemic stroke and major bleeding. In a subset of patients, anticoagulation adherence and beliefs about drugs will be assessed by questionnaire. ETHICS AND DISSEMINATION This study protocol was approved as exempt for formal review according to Dutch law by the Medical Ethics Committee of the Leiden University Medical Centre, Leiden, the Netherlands. Results will be disseminated by publications in peer-reviewed journals and presentations at scientific congresses. TRIAL REGISTRATION NUMBER Trial NL7467, NTR7706 (https://www.trialregister.nl/trial/7464).
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Affiliation(s)
- Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap Seelig
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Emmy M Trinks-Roerdink
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk P van Alem
- Department of Cardiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - Bart van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lucas Va Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Harry Jgm Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Ewoud J van Dijk
- Deparment of Neurology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Arif Elvan
- Department of Cardiology, Isala Heart Centre, Isala Hospitals, Zwolle, Netherlands
| | - Isabelle C van Gelder
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Centre, Amsterdam University Medical Centre/University of Amsterdam, Amsterdam, Netherlands
| | | | - Jonas Ssg de Jong
- Department of Cardiology, Heart Centre, OLVG, Amsterdam, Netherlands
| | - Sylvie de Jong
- Department of Cardiology, Elkerliek Hospital, Helmond, Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Timo Lenderink
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Justin G Luermans
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Joan G Meeder
- Department of Cardiology, VieCuri Medical Centre Noord-Limburg, Venlo, Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
| | - Peter Polak
- Department of Cardiology, St. Anna Hospital, Geldrop, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Frans Smeets
- Department of Cardiology, Hospital Bernhoven, Uden, Netherlands
| | | | - Luc Theunissen
- Department of Cardiology, Maxima Medical Centre, Eindhoven, Netherlands
| | | | - Serge A Trines
- Department of Cardiology, Heart-Lung Centre, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Geert-Jan Geersing
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin Ew Hemels
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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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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Oguz M, Lanitis T, Li X, Wygant G, Singer DE, Friend K, Hlavacek P, Nikolaou A, Mattke S. Cost-Effectiveness of Extended and One-Time Screening Versus No Screening for Non-Valvular Atrial Fibrillation in the USA. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:533-545. [PMID: 31849021 PMCID: PMC7347708 DOI: 10.1007/s40258-019-00542-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND There is limited evidence on the clinical and cost benefits of screening for atrial fibrillation (AF) with electrocardiogram (ECG) in asymptomatic adults. METHODS We adapted a previously published Markov model to evaluate the clinical and economic impact of one-time screening for non-valvular AF (NVAF) with a single 12-lead ECG and a 14-day extended screening with a hand-held ECG device (Zenicor single-lead ECG, Z14) compared with no screening. Clinical events considered included ischemic stroke, systemic embolism, major bleeds, myocardial infarction, and death. Epidemiology and effectiveness data for extended screening were from the STROKESTOP study. Risks of clinical events in NVAF patients were derived from ARISTOTLE. Analyses were conducted from the perspective of a third-party payer, considering a population with undiagnosed NVAF, aged 75 years in the USA. Costs and utilities were discounted at a 3% annual rate. Parameter uncertainty was formally considered via deterministic and probabilistic sensitivity analyses (DSA and PSA). Structural uncertainty was assessed via scenario analyses. RESULTS In a hypothetical cohort of 10,000 patients followed over their lifetimes, the number of additional AF diagnoses was 54 with 12-lead ECG and 255 with Z14 compared with no screening. Both screening strategies led to better health outcomes (ischemic strokes avoided: ECG 12-lead, 9.8 and Z14, 42.2; quality-adjusted life-years gained: ECG 12-lead, 31 and Z14, 131). Extended screening and one-time screening were cost effective compared with no screening at a willingness-to-pay (WTP) threshold of $100,000 per QALY gained ($58,728/QALY with ECG 12-lead and $47,949/QALY with Z14 in 2016 US dollars). ICERs remained below $100,000 per QALY in all DSA, most PSA runs, and in all scenario analyses except for a scenario assuming low anticoagulation persistence. CONCLUSIONS Our analysis suggests that, screening the general population at age 75 years for NVAF is cost effective at a WTP threshold of $100,000. Both extended screening and one-time screening for NVAF are expected to provide health benefits at an acceptable cost.
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Affiliation(s)
- Mustafa Oguz
- Evidera, The Ark, 2nd Floor, 201 Talgarth Road, London, W6 8BJ UK
| | - Tereza Lanitis
- Evidera, The Ark, 2nd Floor, 201 Talgarth Road, London, W6 8BJ UK
| | - Xiaoyan Li
- Bristol-Myers Squibb, Lawrenceville, NJ USA
| | | | - Daniel E. Singer
- Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | | | | | - Andreas Nikolaou
- Evidera, The Ark, 2nd Floor, 201 Talgarth Road, London, W6 8BJ UK
| | - Soeren Mattke
- University of Southern California, Los Angeles, CA USA
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31
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Jackson LR, Kim S, Blanco R, Thomas L, Ansell J, Fonarow GC, Gersh BJ, Go AS, Kowey PR, Mahaffey KW, Hylek EM, Peterson ED, Piccini JP. Discontinuation rates of warfarin versus direct acting oral anticoagulants in US clinical practice: Results from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II). Am Heart J 2020; 226:85-93. [PMID: 32526533 DOI: 10.1016/j.ahj.2020.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/23/2020] [Indexed: 11/24/2022]
Abstract
While oral anticoagulation is a cornerstone of stroke prevention therapy in atrial fibrillation (AF), few studies have evaluated comparative discontinuation rates in clinical practice. The objective of this study is to evaluate discontinuation rates among patients on warfarin and direct oral anticoagulants (DOACs) in clinical practice. METHODS The ORBIT-AF II Registry enrolled 10,005 total AF patients with a CHA2DS2VASc score of ≥2 on warfarin or DOACs from 235 clinical practices across the US from February 13, 2013 and July 12, 2017. Descriptive statistics and multivariable Cox regression modeling were used to describe baseline characteristics and predictors of discontinuation. Unadjusted and adjusted discontinuation rates and 95% confidence intervals (CI) were calculated using Cox proportional hazards models and propensity score adjustment, respectively. RESULTS At baseline, 16.4% (N = 1642/10,005) were treated with warfarin, 83.6% (N = 8363/10,005) with DOACs and 1498/10,005 patients (15.0%) discontinued therapy [warfarin = 236/1642 (14.4%) vs DOACs = 1262/8363 (15.1%)]. At 6 and 12 months respectively, among 7049 patients with a new diagnosis of AF within 6 months, adjusted discontinuation rates for warfarin versus DOACs were as follows: [6 months: 7.9%, 95%CI (6.8%-9.0%) vs 9.6% (8.4%-10.7%), P = .16]; [12 months: 12.7% (11.0%-14.3%) vs 15.3% (13.6%-16.9%), P = .02)]. Patients who discontinued therapy with warfarin or DOACs had higher risk of adverse clinical outcomes including: all-cause mortality and cardiovascular death (CV) than those who continued treatment. CONCLUSION In a community based AF cohort, adjusted rates of discontinuation at 12-months were higher in DOAC-treated versus VKA-treated patients. Discontinuation of oral anticoagulation was associated with increased absolute risk of all-cause mortality and CV death. CLINICAL TRIAL REGISTRATION URL:https://clinicaltrials.gov. Unique Identifier: NCT01701817.
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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Mitrovic D, Folkeringa R, Veeger N, van Roon E. Reasons for discontinuation of novel oral anticoagulant therapy in patients with atrial fibrillation. Curr Med Res Opin 2020; 36:547-553. [PMID: 32011180 DOI: 10.1080/03007995.2020.1725743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aims: We sought to investigate the reasons for, and rates of, novel oral anticoagulant (DOAC) therapy discontinuation.Methods: This was an observational cohort study of patients with atrial fibrillation (AF) referred to a regional DOAC outpatient clinic between February 2013 and October 2017. The study population consisted of 875 consecutive patients with AF who visited the DOAC outpatient unit to initiate treatment with apixaban (N = 303), dabigatran (N = 267) or rivaroxaban (N = 305) for long-term ischemic stroke prophylaxis. All the patients came from the Leeuwarden Medical Center cardiology outpatient clinic, which offers a well structured and nurse-run DOAC unit in cooperation with the hospital's thrombosis service. This clinic operates according to the Dutch nationwide guidelines on integration of anticoagulation services.Results: Overall rate of discontinuation was 11.9 per 100 patient-years of follow-up. Discontinuation rates for apixaban, dabigatran and rivaroxaban were 8.1, 16.6 and 11.5 per 100 patient-years of follow-up.Apixaban had the lowest rate of discontinuation during the 36 month follow-up period. Dabigatran and rivaroxaban had high discontinuation rates during the 3-6 month period following DOAC therapy initiation. The main reasons for discontinuation of DOAC therapy were adverse side effects, patient-initiated discontinuation and any bleed.Limitation: This was a retrospective and non-randomized study, and our results should be interpreted in light of these observations.Conclusion: DOAC discontinuation rates varied significantly and appeared related to drug-specific side effects, patient-initiated discontinuation and bleeding. We observed longer-term administration of apixaban, suggesting that this drug is better tolerated than dabigatran or rivaroxaban.
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Affiliation(s)
- Darko Mitrovic
- Department of Hospital Pharmacy, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Richard Folkeringa
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Nic Veeger
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Eric van Roon
- Department of Pharmacotherapy, Epidemiology and Economy, Faculty Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Seelig J, Verheugt FWA, Hemels MEW, Illingworth L, Lucassen A, Adriaansen H, Bongaerts MCM, Pieterse M, Herrman JPR, Hoogslag P, Hermans W, Groenemeijer BE, Boersma LVA, Pieper K, Ten Cate H. Changes in anticoagulant prescription in Dutch patients with recent-onset atrial fibrillation: observations from the GARFIELD-AF registry. Thromb J 2020; 18:5. [PMID: 32256216 PMCID: PMC7104512 DOI: 10.1186/s12959-020-00218-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background For the improvement of AF care, it is important to gain insight into current anticoagulation prescription practices and guideline adherence. This report focuses on the largest Dutch subset of AF-patients, derived from the GARFIELD-AF registry. Methods Across 35 countries worldwide, patients with newly diagnosed ‘non-valvular’ atrial fibrillation (AF) with at least one additional risk factor for stroke were included. Dutch patients were enrolled in five, independent, consecutive cohorts from 2010 until 2016. Results In the Netherlands, 1189 AF-patients were enrolled. The prescription of non-vitamin K antagonist oral anticoagulants (NOAC) has increased sharply, and as per 2016, more patients were initiated on NOACs instead of vitamin K antagonists (VKA). In patients with a class I recommendation for anticoagulation, only 7.5% compared to 30.0% globally received no anticoagulation. Reasons for withholding anticoagulation in these patients were unfortunately often unclear. Conclusions The data from the GARFIELD-AF registry shows the rapidly changing anticoagulation preference of Dutch physicians in newly diagnosed AF. Adherence to European AF guidelines in terms of anticoagulant regimen would appear to be appropriate. In absence of structured follow up of AF patients on NOAC, the impact of these rapid practice changes in anticoagulation prescription in the Netherlands remains to be established.
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Affiliation(s)
- J Seelig
- 1Department of Cardiology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands.,16Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - F W A Verheugt
- 2Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - M E W Hemels
- 1Department of Cardiology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands.,3Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - A Lucassen
- Department of Cardiology, St. Jans Gasthuis, Weert, the Netherlands
| | - H Adriaansen
- 6Anticoagulation Clinic, Gelre Ziekenhuizen, Apeldoorn-Zutphen, the Netherlands
| | - M C M Bongaerts
- 7Anticoagulation Clinic, Ziekenhuis Rivierenland, Tiel, the Netherlands
| | - M Pieterse
- Stichting Cardiologie Amsterdam, Amsterdam, the Netherlands
| | - J P R Herrman
- 9Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - P Hoogslag
- Department of Cardiology, Isala Diaconessenhuis, Meppel, the Netherlands
| | - W Hermans
- 11Department of Cardiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - B E Groenemeijer
- 12Department of Cardiology, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - L V A Boersma
- 13Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands.,Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - K Pieper
- 4Thrombosis Research Institute, London, UK.,15Duke Clinical Research Institute, Durham, USA
| | - H Ten Cate
- 16Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Anticoagulation Clinic Maastricht, Maastricht, the Netherlands
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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: 132] [Impact Index Per Article: 33.0] [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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Salmasi S, Kapanen AI, Kwan L, Andrade JG, De Vera MA, Loewen P. Atrial fibrillation patients' experiences and perspectives of anticoagulation therapy changes. Res Social Adm Pharm 2020; 16:1409-1415. [PMID: 31983624 DOI: 10.1016/j.sapharm.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/02/2020] [Accepted: 01/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) patients' experiences with changes in their oral anticoagulant (OAC) therapy are understudied. OBJECTIVE The objective of this study was to qualitatively describe AF patients' experiences and perspectives of changes made to their OAC therapy (switches or discontinuations). METHODS A thematic analysis was performed on systematically-collected qualitative data from AF patients who experienced a therapy change (switching or discontinuing an OAC) as part of their participation in a large 2-year prospective observational study. RESULTS A total of 56 participants met the inclusion criteria. Six themes emerged from the data: 1. reasons for switch or discontinuation of therapy, 2. attitudes towards changes in therapy attributes, 3. challenges with taking medications after therapy change, 4. relief from perceived burden of medication after discontinuation, 5. patients' limited involvement in decision-making, and 6. inadequate education and follow up. Patients were found to request changes in therapy based on their subjective experience with it (rather than clinically justified reasons). They were found to have limited knowledge about their medications, differing reactions to changes in their therapy attributes after a switch, an overall negative attitude towards taking medications, adherence challenges after switching from once daily to twice daily medication, feelings of being excluded from the decision-making process about their therapy changes and feelings of being unsupported after these changes. CONCLUSIONS There are clear opportunities to improve patients' experiences with OAC therapy changes through improved shared decision-making and patient education/counselling.
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Affiliation(s)
- Shahrzad Salmasi
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Anita I Kapanen
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Leanne Kwan
- Atrial Fibrillation Clinic, Royal Columbian Hospital, New Westminster, Canada
| | - Jason G Andrade
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Mary A De Vera
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Peter Loewen
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.
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Rush KL, Burton L, Ollivier R, Wilson R, Loewen P, Janke R, Schaab K, Lukey A, Galloway C. Transitions in Atrial Fibrillation Care: A Systematic Review. Heart Lung Circ 2019; 29:1000-1014. [PMID: 32094081 DOI: 10.1016/j.hlc.2019.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.
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Affiliation(s)
- Kathy L Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada.
| | - Lindsay Burton
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Rachel Ollivier
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Ryan Wilson
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Robert Janke
- Library, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Kira Schaab
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Alexandra Lukey
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Camille Galloway
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
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Kanorskii SG. [How to maintain an adherence to oral anticoagulant in a patient with atrial fibrillation?]. KARDIOLOGIIA 2019; 59:76-83. [PMID: 31849302 DOI: 10.18087/cardio.2019.11.n724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Less onerous, compared with warfarin, treatment with direct oral anticoagulants (DOA) can lead to better adherence to treatment of patients with atrial fibrillation (AF). However, in a certain number of patients with AF, who were recommended by DOA, cardioembolic stroke recurs, which is largely due to the patients' failure to comply with medical recommendations. The appointment of DOA as first-line drugs does not guarantee a high adherence of patients with non-valvular AF. For elderly and old patients with AF and numerous comorbidities, the proposal of a simpler pharmacotherapy regimen is especially important. In a number of large modern studies performed in clinical practice, high adherence to rivaroxaban therapy has been established, which may be a result of taking this DOA 1 time per day, its safety and effectiveness.
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Ruigómez A, Vora P, Balabanova Y, Brobert G, Roberts L, Fatoba S, Fernandez O, García Rodríguez LA. Discontinuation of non-Vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: a population-based cohort study using primary care data from The Health Improvement Network in the UK. BMJ Open 2019; 9:e031342. [PMID: 31630107 PMCID: PMC6803078 DOI: 10.1136/bmjopen-2019-031342] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine discontinuation rates, patterns of use and predictors of discontinuation of non-vitamin K antagonist oral anticoagulants (NOACs) among patients with non-valvular atrial fibrillation (NVAF) in the first year of therapy. DESIGN Population-based cohort study. SETTING UK primary care. POPULATION 11 481 patients with NVAF and a first prescription (index date) for apixaban, dabigatran or rivaroxaban (January 2012 to December 2016) with at least 1 year of follow-up and at least one further NOAC prescription in the year following the index date were identified. 1 year rates and patterns of discontinuation were described. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures were the percentage of patients who, in the first year from starting NOAC therapy, discontinued with their oral anticoagulant (OAC) therapy (discontinuation was defined as a gap in OAC therapy of >30 days); switched OAC within 30 days; discontinued and reinitiated OAC therapy. Predictors of discontinuation were also evaluated. RESULTS 1 year discontinuation rates according to the index NOAC were 26.1% for apixaban, 40.0% for dabigatran and 29.6% for rivaroxaban. Reinitiation rates were 18.1% for apixaban, 21.7% for dabigatran and 17.3% for rivaroxaban, and switching rates were 2.8% for apixaban, 8.8% for dabigatran and 4.9% for rivaroxaban. More than 93% of reinitiations were with the index NOAC. Patients starting on dabigatran were more likely to switch OAC therapy than those starting on apixaban; ORs 4.28 (95% CI 3.24 to 5.65) for dabigatran and 1.89 (95% CI 1.49 to 2.39) for rivaroxaban. Severely reduced renal function was a predictor of any discontinuation, OR 1.77 (95% CI 1.28 to 2.44). CONCLUSION While the majority of patients with NVAF in the UK initiating NOAC treatment received continuous therapy in the first year of treatment, a substantial proportion of patients experienced gaps in treatment leaving them less protected against thromboembolism during these periods.
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Affiliation(s)
- Ana Ruigómez
- Pharmacoepidemiology, Spanish Centre for Pharmacoepidemiological Research, Madrid, Spain
| | | | | | | | | | | | - Oscar Fernandez
- Pharmacoepidemiology, Spanish Centre for Pharmacoepidemiological Research, Madrid, Spain
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Baker CL, Dhamane AD, Rajpura J, Mardekian J, Dina O, Russ C, Rosenblatt L, Lingohr-Smith M, Lin J. Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2019; 25:1076029619870249. [PMID: 31418293 PMCID: PMC6829636 DOI: 10.1177/1076029619870249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We compared the risks of switching to another oral anticoagulant (OAC) and discontinuation of direct oral anticoagulants (DOACs) among elderly patients with nonvalvular atrial fibrillation (NVAF) who were prescribed rivaroxaban or dabigatran versus apixaban. Patients (≥65 years of age) with NVAF prescribed DOACs (January 1, 2013 to September 30, 2017) were identified from the Humana research database and grouped into DOAC cohorts. Cox regression analyses were used to evaluate whether the risk for switching to another OAC or discontinuing index DOACs differed among cohorts. Of the study population (N = 38 250), 55.9% were prescribed apixaban (mean age: 78.6 years; 49.8% female), 37.3% rivaroxaban (mean age: 77.4 years; 46.7% female), and 6.8% dabigatran (mean age: 77.0 years; 44.0% female). Compared to patients prescribed apixaban, patients prescribed rivaroxaban (hazard ratio [HR]: 2.08; 95% confidence interval [CI], 1.92-2.25; P < .001) or dabigatran (HR: 3.74; 95% CI, 3.35-4.18, P < .001) had a significantly higher risk of switching to another OAC during the follow-up; compared to patients prescribed apixaban, the risks of discontinuation were also higher for patients treated with rivaroxaban (HR: 1.10; 95% CI, 1.07-1.13, P < .001) or dabigatran (HR: 1.29; 95% CI, 1.23-1.35, P < .001).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jay Lin
- 3 Novosys Health, Green Brook, NJ, USA
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Beyer-Westendorf J, Camm AJ, Fox KAA, Le Heuzey JY, Haas S, Turpie AGG, Virdone S, Kakkar AK. International longitudinal registry of patients with atrial fibrillation and treated with rivaroxaban: RIVaroxaban Evaluation in Real life setting (RIVER). Thromb J 2019; 17:7. [PMID: 31169831 PMCID: PMC6482585 DOI: 10.1186/s12959-019-0195-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background Real-world data on non-vitamin K oral anticoagulants (NOACs) are essential in determining whether evidence from randomised controlled clinical trials translate into meaningful clinical benefits for patients in everyday practice. RIVER (RIVaroxaban Evaluation in Real life setting) is an ongoing international, prospective registry of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) and at least one investigator-determined risk factor for stroke who received rivaroxaban as an initial treatment for the prevention of thromboembolic stroke. The aim of this paper is to describe the design of the RIVER registry and baseline characteristics of patients with newly diagnosed NVAF who received rivaroxaban as an initial treatment. Methods and results Between January 2014 and June 2017, RIVER investigators recruited 5072 patients at 309 centres in 17 countries. The aim was to enroll consecutive patients at sites where rivaroxaban was already routinely prescribed for stroke prevention. Each patient is being followed up prospectively for a minimum of 2-years. The registry will capture data on the rate and nature of all thromboembolic events (stroke / systemic embolism), bleeding complications, all-cause mortality and other major cardiovascular events as they occur. Data quality is assured through a combination of remote electronic monitoring and onsite monitoring (including source data verification in 10% of cases). Patients were mostly enrolled by cardiologists (n = 3776, 74.6%), by internal medicine specialists 14.2% (n = 718) and by primary care/general practice physicians 8.2% (n = 417). The mean (SD) age of the population was 69.5 (11.0) years, 44.3% were women. Mean (SD) CHADS2 score was 1.9 (1.2) and CHA2DS2-VASc scores was 3.2 (1.6). Almost all patients (98.5%) were prescribed with once daily dose of rivaroxaban, most commonly 20 mg (76.5%) and 15 mg (20.0%) as their initial treatment; 17.9% of patients received concomitant antiplatelet therapy. Most patients enrolled in RIVER met the recommended threshold for AC therapy (86.6% for 2012 ESC Guidelines, and 79.8% of patients according to 2016 ESC Guidelines). Conclusions The RIVER prospective registry will expand our knowledge of how rivaroxaban is prescribed in everyday practice and whether evidence from clinical trials can be translated to the broader cross-section of patients in the real world. Trial registration Unique identifier: NCT02444221. Registerd 14 May 2015; Retrospectively Registered.
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Affiliation(s)
- Jan Beyer-Westendorf
- 1Thrombosis Research Unit, Department of Medicine I, Division Haematology, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany.,2Kings Thrombosis Service, Department of Haematology, Kings College London, London, UK
| | - A John Camm
- 3Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- 4Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Sylvia Haas
- 6Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Ajay K Kakkar
- 8Thrombosis Research Institute, London, UK.,9University College of London, London, UK
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Ruff C, Koukalova L, Haefeli WE, Meid AD. The Role of Adherence Thresholds for Development and Performance Aspects of a Prediction Model for Direct Oral Anticoagulation Adherence. Front Pharmacol 2019; 10:113. [PMID: 30837879 PMCID: PMC6389873 DOI: 10.3389/fphar.2019.00113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/29/2019] [Indexed: 11/23/2022] Open
Abstract
Patients who do not sufficiently adhere to their dosing regimens will, ultimately, do not get the full benefit of their medication. For example, if direct oral anticoagulants (DOAC) are not taken continuously, an intervention to improve adherence or maintain persistence will show direct effects on clinical outcomes. Usually, adherent patients are defined by taking ≥80% of their medication. The resulting binary adherence status from this threshold can as well be used for predictive classification. Thus, the threshold can determine the prediction model’s performance to identify patients at risk for poor adherence by this binary adherence status. In this perspective, we propose a plan for model development and performance considering the threshold’s role. Concerning development demands, we extracted predictors from a systematic literature search on DOAC adherence to be used as a core set of candidate predictors. Independently, we investigated how well a future model would technically have to perform by modeling drug intake and thromboembolic events based on a rivaroxaban pharmacokinetic-pharmacodynamic model. Using this simulation framework for different thresholds, we projected the impact of an imperfectly predicted adherence status on the event risk, and how imperfect sensitivity and specificity affect the cost balance if a supporting intervention was offered to patients classified as non-adherent. Our simulation results suggest applying a rather high threshold (90%) for discrimination between patients at low or high risk for non-adherence by a prediction model in order to assure cost-efficient implementation.
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Affiliation(s)
- Carmen Ruff
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Ludmila Koukalova
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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Comparison of Drug Switching and Discontinuation Rates in Patients with Nonvalvular Atrial Fibrillation Treated with Direct Oral Anticoagulants in the United States. Adv Ther 2019; 36:162-174. [PMID: 30499067 PMCID: PMC6318235 DOI: 10.1007/s12325-018-0840-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Indexed: 02/07/2023]
Abstract
Introduction Continuous usage of direct oral anticoagulants (DOACs) among nonvalvular atrial fibrillation (NVAF) patients is essential to maintain stroke prevention. We examined switching and discontinuation rates for the three most frequently initiated DOACs in NVAF patients in the USA. Methods Patients who initiated apixaban, rivaroxaban, or dabigatran (index event/date) were identified from the Pharmetrics Plus claims database (Jan 1, 2013–Sep 30, 2016, includes patients with commercial and Medicare coverage) and grouped into cohorts by index DOAC. Patients were required to have a diagnosis of NVAF and continuous health plan enrollment for 12 months prior to the index date (baseline period) and at least 3 months during the follow-up period. Drug switching rates to any other DOAC or warfarin and index DOAC discontinuation rate were evaluated separately with descriptive statistics, Kaplan–Meier analysis, and multivariable Cox regression analysis. Results Of the NVAF study population (n = 41,864), 37% initiated apixaban (n = 15,352; mean age 62 years), 51% initiated rivaroxaban (n = 21,250; mean age 61 years), and 13% initiated dabigatran (n = 5262; mean age 61 years). During the follow-up period, the unadjusted drug switching rates of patients treated with apixaban, rivaroxaban, and dabigatran were 3.6%, 6.3%, and 11.1%, respectively (p < 0.001 across the three cohorts); while the index DOAC discontinuation rates were 52.8%, 60.3%, and 62.9%, respectively (p < 0.001). After we controlled for differences in patient characteristics, patients treated with rivaroxaban (HR 1.8; 95% CI 1.6–2.0; p < 0.001) and dabigatran (HR 3.4; 95% CI 3.0–3.8, p < 0.001) had a significantly greater likelihood for drug switching than patients treated with apixaban. Also, both rivaroxaban (HR 1.1; 95% CI 1.1–1.2, p < 0.001) and dabigatran (HR 1.3; 95% CI 1.2–1.3, p < 0.001) treated patients were more likely to discontinue treatment. Conclusion In the real-world setting, patients with NVAF newly treated with apixaban were less likely to switch or discontinue treatment compared to patients treated with rivaroxaban or dabigatran. Funding Pfizer and Bristol-Myers Squibb.
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Comparative Effectiveness and Safety of Rivaroxaban in Adults With Nonvalvular Atrial Fibrillation. Am J Ther 2018; 26:e679-e703. [PMID: 30461433 DOI: 10.1097/mjt.0000000000000890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND All evidence regarding benefits and harms of rivaroxaban for stroke prevention has not been appraised yet. STUDY QUESTION What are the comparative effectiveness and safety of rivaroxaban in adults with nonvalvular atrial fibrillation? DATA SOURCES Randomized controlled trials (RCTs), meta-analyses, and observational studies were identified in several databases in October 2018. STUDY DESIGN Rapid review with evidence appraisal using the Grading of Recommendations Assessment, Development and Evaluation working group approach. RESULTS Two direct RCTs (23,021 patients) suggest that rivaroxaban is noninferior to warfarin in the prevention of stroke and systemic embolism (pooled relative risk [RR] 0.73, 95% confidence interval [CI], 0.43-1.24), reduces risk of hemorrhagic stroke (RR 0.59, 95% CI, 0.38-0.92), fatal bleeding (RR 0.49, 95% CI, 0.31-0.76), and cardiac arrest (RR 0.45, 95% CI, 0.25-0.82, 2 RCTs), but increases risk of major gastrointestinal bleeding (RR 1.46, 95% CI, 1.19-1.78). In observational studies, rivaroxaban is associated with lower risk of ischemic stroke (RR 0.87, 95% CI, 0.77-0.99, 222,750 patients), acute myocardial infarction (RR 0.61, 95% CI, 0.48-0.78, 73,739 patients), and intracranial hemorrhage (RR 0.64, 95% CI, 0.45-0.92, 197,506 patients) but higher risk of gastrointestinal bleeding (RR 1.30, 95% CI, 1.19-1.42, 188,968 patients) and higher risk of mortality when compared with warfarin in European studies (RR 1.19, 103,270 patients in the UK; RR 2.02, 22,358 patients in Denmark) but lower risk of mortality in Taiwan (RR 0.58, 40,000 patients). Network meta-analyses and observational studies suggest that rivaroxaban is associated with higher risk of bleeding when compared with apixaban (RR 2.14, 72,586 patients), dabigatran (RR 1.24, 67,102 patients), and edoxaban (RR 1.32, 71,683 patients). CONCLUSIONS Research on the long-term comparative effectiveness, safety, and effects on quality of life between rivaroxaban and other novel oral anticoagulants is urgently needed.
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