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Spruit JR, de Vries TAC, Hemels MEW, Pisters R, de Groot JR, Jansen RWMM. Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Decade of Experience. Drugs Aging 2024:10.1007/s40266-024-01138-5. [PMID: 39141209 DOI: 10.1007/s40266-024-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Both the prevalence of atrial fibrillation (AF) and its subsequent use of direct oral anticoagulants (DOACs) are rapidly increasing in patients of older age. In the absence of contra-indications, guidelines advocate anticoagulation based on the CHA2DS2-VASc score for all AF patients aged 75 and above. However, some practitioners are hesitant to prescribe anticoagulants to older and frail patients due to perceived elevated bleeding risks. This review delves into the comparative treatment outcomes of DOACs versus vitamin K antagonists (VKAs) in older patients with AF, particularly focusing on those of advanced age, frailty, increased risk of falling, chronic kidney disease (CKD), or with a history of major bleeding. Additionally, considerations on the use of off-label DOAC doses, the role of left atrial appendage (LAA) closure and future developments in factor XIa-inhibitors will be discussed. RESULTS While strong evidence supports the use of DOACs in the vital older patients with nonvalvular AF, it remains scant in frail patient groups. There is some evidence from non-randomized studies suggesting that the effect of DOACs compared with VKAs is consistent between frail and nonfrail patients. However, recent findings from a single randomized trial showed increased bleeding risks but comparable thromboembolic outcomes in frail individuals switching from VKAs to DOACs. In patients with an increased risk of falling, data suggest no relevant interaction of increased risk of falling on the effectiveness and safety of DOACs compared with warfarin. Resuming oral anticoagulants in patients with Af after major bleeding seems to be beneficial. Off-label low-dose DOAC is often prescribed to patients who were underrepresented in larger randomized trails because of an elevated risk of bleeding or overexposure to DOACs, but its effect on clinical outcomes remains uncertain. CONCLUSIONS DOACs are the recommended oral anticoagulant for vital older patients with AF. The scarcity of data backing DOAC use in frail individuals, those with renal impairments, or significant bleeding history underscores the necessity for further investigation. However, existing evidence suggests at least similar effectiveness and safety and potential benefits for DOACs in these patient subsets. Therefore, there is no reason to suggest these patients should be treated differently than the established guidelines regarding anticoagulation.
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Affiliation(s)
- Jocelyn R Spruit
- Department of Geriatric Medicine, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands.
| | - Tim A C de Vries
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - René W M M Jansen
- Department of Geriatric Medicine, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
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Saeed D, Fuenmayor D, Niño Medina JA, Saleh I, Castiblanco Torres JD, Horn WL, Sosa Quintanilla MH, Leiva KE, Dannuncio V, Viteri M, Rivas M, Kumari N. Unraveling the Paradox: Can Anticoagulation Improve Outcomes in Patients With Heart Failure and Increased Bleeding Risk? Cureus 2024; 16:e57544. [PMID: 38707016 PMCID: PMC11068119 DOI: 10.7759/cureus.57544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Heart failure (HF) patients frequently present with comorbidities such as atrial fibrillation (AF) or other cardiovascular conditions, elevating their risk of thromboembolic events. Consequently, anticoagulation therapy is often considered for thromboprophylaxis, although its initiation in HF patients is complicated by concomitant bleeding risk factors. This review explores the paradoxical relationship between HF, increased bleeding risk, and the potential benefits of anticoagulation. Through an examination of existing evidence from clinical trials, observational studies, and meta-analyses, we aim to elucidate the role of anticoagulation in HF patients with increased bleeding risk. Despite guidelines recommending anticoagulation for certain HF patients with AF or other thromboembolic risk factors, uncertainty persists regarding the optimal management strategy for those at heightened risk of bleeding. The review discusses the pathophysiological mechanisms linking HF and thrombosis, challenges in bleeding risk assessment, and strategies to minimize bleeding risk while optimizing thromboprophylaxis. Shared decision-making between clinicians and patients is emphasized as essential for individualized treatment plans that balance the potential benefits of anticoagulation against the risk of bleeding complications. Furthermore, it examines emerging anticoagulant agents and their potential role in HF management, highlighting the need for further research to delineate optimal management strategies and inform evidence-based practice. In conclusion, while anticoagulation holds promise for improving outcomes in HF patients, careful consideration of patient-specific factors and ongoing research efforts are essential to optimize therapeutic strategies in this population.
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Affiliation(s)
- Danish Saeed
- Internal Medicine, Shaikh Zayed Medical Complex, Lahore, PAK
| | | | - Jose A Niño Medina
- Faculty of Legal and Political Sciences, Universidad de Carabobo, Valencia, VEN
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Inam Saleh
- Pediatrics, University of Kentucky College of Medicine, Lexington, USA
| | | | - Wendys L Horn
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | | | - Karen E Leiva
- General Medicine and Surgery, National Autonomous University of Honduras, Tegucigalpa, HND
| | | | - Maria Viteri
- Metabolic Syndrome Department, Hospital General Ambato, Ambato, ECU
| | - Miguel Rivas
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Neelam Kumari
- Internal Medicine, Jinnah Medical & Dental College, Karachi, PAK
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Abdul Rashid AM, Md Noh MSF, Yusof Khan AHK, Loh WC, Baharin J, Ibrahim A, Inche Mat LN, Wan Sulaiman WA, Hoo FK, Hanapiah FA, Basri H. NeuroAid II (MLC901) and polypharmacy in stroke and the risk of hepatotoxicity: a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00397-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
NeuroAid II (MLC901) is a promising therapy for stroke patients who present outside of therapeutic window for reperfusion therapy. Studies have proven its efficacy in ischemic stroke; however, data of drug safety and combination with other medications especially anticoagulants are heterogenous. We report a possible case of hepatotoxicity induced by NeuroAid II in combination with anticoagulants.
Case presentation
We report an elderly patient who developed symptoms of cardioembolic stroke presented outside of time window for reperfusion therapy. He was started on a regiment of statins, anticoagulation, beta blockers and NeuroAid II. One month later he presented with deranged liver enzymes. Cessation of NeuroAid II resulted in rapid improvement of transaminitis within days.
Conclusions
We wish to highlight the potential harmful effect of administering NeuroAid II with an anticoagulant and the importance of routine follow-up and blood monitoring in the elderly patients with stroke.
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Abstract
Rivaroxaban is one of the new anti-coagulants that inhibit Factor Xa and rarely cause rectus sheath hematoma and retroperitoneal haemorrhage which are uncommon, life-threatening complications. Here is a case of an elderly patient on rivaroxaban therapy for the stroke prevention in non-valvular atrial fibrillation who developed rectus sheath hematoma and retroperitoneal bleeding.
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Affiliation(s)
- Elif Börekci
- Department of Internal Medicine, Bozok University, School of Medicine, Yozgat, Turkey
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Lip GYH. The safety of NOACs in atrial fibrillation patient subgroups: A narrative review. Int J Clin Pract 2019; 73:e13285. [PMID: 30334313 DOI: 10.1111/ijcp.13285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/01/2018] [Accepted: 10/14/2018] [Indexed: 12/17/2022] Open
Abstract
AIM Four non-vitamin K oral anticoagulants (NOACs) have been evaluated in clinical trials for the prevention of stroke in patients with atrial fibrillation (AF). Although each of the NOACs have been shown to be at least non-inferior to warfarin for efficacy and safety outcomes, controversy remains over the relative safety of each NOAC inpatient subgroups. This narrative review provides an overview of phase III data on NOAC trials for the prevention of stroke in AF, with a focus on reporting the safety of each agent in key patient subgroups based on age, gender, accumulated risk factors, and primary or secondary prevention of stroke. METHODS A comprehensive literature search was completed and, where data permit, analyses of phase III trials of the NOACs are presented for each patient subgroup. RESULTS Analyses of key safety outcomes from NOAC trials were completed using primary trial data, including major bleeding and all-cause mortality. The safety of NOACs was generally consistent and favourable compared with warfarin according to patient age, gender, previous history of stroke, and the presence of risk factors for stroke. CONCLUSIONS The safety of the NOACs compared with warfarin was generally favourable across different patient subgroups, including those perceived to be at "high risk" for adverse outcomes. However, certain NOACs may be preferable to warfarin in some subgroups, based on indirect analyses.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Mo Y, Karakas-Torgut A, Pham AQ. Evaluation of Potential Drug-Drug Interactions With Direct Oral Anticoagulants in a Large Urban Hospital. J Pharm Pract 2018; 33:136-141. [PMID: 30004271 DOI: 10.1177/0897190018788264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study is to assess patterns of potential drug-drug interactions (DDIs) with direct oral anticoagulants (DOACs) in an inpatient hospital setting. METHODS A retrospective chart review was conducted at the Brookdale University Hospital and Medical Center (BUHMC) from January 2014 to November 2016. All adult patients admitted to the BUHMC who were treated with a DOAC for at least 3 days were screened. Among them, those who received selected interacting drugs at any time during the course of DOAC therapy were included in this study. RESULTS This study included 165 patients with an average of 73 years (standard deviation [SD] = 12.3) and 233 cases. The most commonly used concomitant drug with a DOAC was aspirin (58%), followed by amiodarone (16%) and P2Y12 inhibitors (11%). The combined use of dual antiplatelet therapy and a DOAC was identified in 18 (6%) cases. Approximately one-third of the cases encountered were classified as the "avoidance" category. CONCLUSIONS Despite computerized DDI alerts, potentially significant DDIs with DOACs still occur. While the present study provides insight into the current patterns of DDIs, further studies are needed to evaluate clinical outcomes of the potential DDIs with DOACs in practice.
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Affiliation(s)
- Yoonsun Mo
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University Pharmacy, Brooklyn, NY, USA
| | | | - Antony Q Pham
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University Pharmacy, Brooklyn, NY, USA
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State of play and future direction with NOACs: An expert consensus. Vascul Pharmacol 2018; 106:9-21. [DOI: 10.1016/j.vph.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/20/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
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