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Polo-García J, Pallares-Carratalá V, Turegano-Yedro M, Romero-Vigara JC, Prieto-Díaz MA, Cinza-Sanjurjo S. [Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. Semergen 2024; 50:102136. [PMID: 38052147 DOI: 10.1016/j.semerg.2023.102136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 12/07/2023]
Abstract
Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.
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Affiliation(s)
- J Polo-García
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - V Pallares-Carratalá
- Medicina Familiar y Comunitaria, Departamento de Medicina, Universidad JaimeI, Castellón, España.
| | - M Turegano-Yedro
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - J C Romero-Vigara
- Medicina Familiar y Comunitaria, Centro de Salud Alfajarín, Alfajarín, Zaragoza, España
| | - M A Prieto-Díaz
- Medicina Familiar y Comunitaria, Centro de Salud Vallobín-La Florida, Oviedo, España
| | - S Cinza-Sanjurjo
- Medicina Familiar y Comunitaria, Centro de Salud Milladoiro, Área de Salud de Santiago de Compostela. Instituto de Investigación en Salud de Santiago de Compostela (IDIS). Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, La Coruña, España
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Svaguša T, Šimić S, Grabant F, Kereš T, Čančarević O, Paić F, Grizelj D, Blivajs A, Bulum T, Prkačin I. Comparison of vitamin K and non-vitamin K oral anticoagulants and the bleeding frequency in the emergency department. High Blood Press Cardiovasc Prev 2024; 31:23-30. [PMID: 38190093 DOI: 10.1007/s40292-023-00616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Safety studies of anticoagulant therapy have so far been conducted on many subjects in controlled conditions (i.e., clinically monitored) and demonstrated the noninferiority of new ones over old anticoagulant drugs. Data on the propositions for the presence of symptoms and signs of bleeding among various anticoagulants in the emergency department indicate that these data do not match the data published so far. AIM The aim of the study was to investigate the differences in the frequency of bleeding and bleeding-related symptoms as a reason for emergency department attendance in patients on anticoagulant therapy. METHODS The study included patients from the emergency department of University Hospital for one year, who were on anticoagulant therapy and who met the inclusion criteria. Out of a total of 595 patients, 409 were on warfarin (68.74%), and the rest were taking direct oral anticoagulants (DOAC): dabigatran 71 (11.93%), rivaroxaban 66 (11.09%) and apixaban 49 (8.23%). RESULTS Out of 409 patients taking warfarin, 34.4% were adequately anticoagulated with the frequency of bleeding 13.7%, while in 57.2% of patients, PT INR was higher than the reference values with the frequency of bleeding 15.0%. A comparison between all DOAC groups and adequately anticoagulated warfarin patients in the frequency of bleeding and bleeding-related symptoms as a reason for emergency attendance yielded a difference that was marginally statistically significant (Pearson Chi-Square = 7.554, p = 0.052). CONCLUSION Monitoring the frequency of bleeding and bleeding-related symptoms in patients on oral anticoagulant therapy as a reason for emergency department attendance may be a new safety and efficacy factor in real-life patient scenarios.
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Affiliation(s)
- Tomo Svaguša
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Stjepan Šimić
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia
| | - Filip Grabant
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Tatjana Kereš
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Ognjen Čančarević
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Frane Paić
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Danijela Grizelj
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Aleksandar Blivajs
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Tomislav Bulum
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia.
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia.
| | - Ingrid Prkačin
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Internal Medicine, University Hospital Merkur, Zagreb, Croatia
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3
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Zhang B, Cheng W, Kaisaier W, Gu Z, Zhu W, Jiang Q. Effect of edoxaban compared with other oral anticoagulants for stroke prevention in patients with atrial fibrillation: A meta-analysis. Heliyon 2023; 9:e21740. [PMID: 38027839 PMCID: PMC10665752 DOI: 10.1016/j.heliyon.2023.e21740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background and aim Current observational studies have compared the effectiveness and safety of edoxaban with other oral anticoagulants in patients with AF, but the results are still disputed. This meta-analysis was conducted to compare the effect of edoxaban in patients with AF. Methods We performed systematic research from the PubMed, EMBASE, and Cochrane Library databases until November 2022 to obtain relevant observational studies. Adjusted risk ratios (RRs) and 95 % confidence intervals (CIs) of the outcomes were collected and pooled by a random-effects model. This study was prospectively registered in PROSPERO (CRD42022314222). Results A total of 17 observational studies were included in this meta-analysis. Compared with vitamin K antagonists, edoxaban was associated with lower risks of stroke or systemic embolism (RR = 0.67, 95 % CI:0.61-0.74), major bleeding (RR = 0.54, 95 % CI:0.44-0.67), and intracranial hemorrhage (RR = 0.51, 95 % CI:0.29-0.90). Compared with dabigatran or rivaroxaban, edoxaban was associated with reduced risks of stroke or systemic embolism (dabigatran [RR = 0.76, 95 % CI:0.66-0.87]; rivaroxaban [RR = 0.81, 95 % CI:0.70-0.94]) and major bleeding (dabigatran [RR = 0.82, 95 % CI:0.69-0.98]; rivaroxaban [RR = 0.81, 95 % CI:0.70-0.94]). Compared with apixaban, edoxaban was associated with a reduced risk of stroke or systemic embolism (RR = 0.87, 95 % CI:0.79-0.97), but had similar risks of bleeding events. Conclusions Our current evidence suggested that edoxaban might have superior effectiveness and/or safety outcomes than vitamin K antagonists, dabigatran, rivaroxaban, and apixaban for stroke prevention in patients with AF.
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Affiliation(s)
- Bailin Zhang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, Jiangxi 341000, China
| | - Winglam Cheng
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China
| | - Wulamiding Kaisaier
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China
| | - Zhenbang Gu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China
| | - Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China
| | - Qiuhua Jiang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, Jiangxi 341000, China
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Rodilla E, Orts-Martínez MI, Sanz-Caballer MA, Gimeno-Brosel MT, Arilla-Morel MJ, Navarro-Gonzalo I, Castillo-Valero I, Salvador-Mercader I, Carral-Tatay A. Patterns and outcomes of switching direct oral anticoagulants in non-valvular atrial fibrillation: a real-world experience from Spain. Rev Clin Esp 2023:S2254-8874(23)00055-3. [PMID: 37105383 DOI: 10.1016/j.rceng.2023.04.005] [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: 04/29/2023]
Abstract
AIMS The aim is to evaluate a management program for direct oral anticoagulants (DOACs) in non-valvular atrial fibrillation (NVAF) patients according to their profiles, appropriateness of dosing, patterns of crossover, effectiveness and safety. This is an observational and longitudinal prospective study in a cohort of patients attended in daily clinical practice in a regional hospital in Spain with 3-year a follow-up plan for patients initiating dabigatran, rivaroxaban or apixaban between JAN/2012-DEC/2016. METHODS We analyzed 490 episodes of treatment (apixaban 2.5 9.4%, apixaban 5 21.4%, dabigatran 75 0.6%, dabigatran 110 12,4%, dabigatran 150 19.8%, rivaroxaban 15 17.8% and rivaroxaban 20 18.6%) in 445 patients. 13.6% of patients on dabigatran, 9.7% on rivaroxaban, and 3.9% on apixabanswitched to other DOACs or changed dosing. RESULTS Apixaban was the most frequent DOAC switched to. The most frequent reasons for switching were toxicity (23.8%), bleeding (21.4%) and renal deterioration (16.7%). Inappropriateness of dose was found in 23.8% of episodes. Rates of stroke/transient ischemic attack (TIA) were 1.64/0.54 events/100 patients-years, while rates of major, clinically relevant non-major (CRNM) bleeding and intracranial bleeding were 2.4, 5, and 0.5 events/100 patients-years. Gastrointestinal and genitourinary bleeding were the most common type of bleeding events (BE). On multivariable analysis, prior stroke and age were independent predictors of stroke/TIA. Concurrent platelet inhibitors, male gender and age were independent predictors of BE. CONCLUSION This study complements the scant data available on the use of DOACs in NVAF patients in Spain, confirming a good safety and effectiveness profile.
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Affiliation(s)
- E Rodilla
- Internal Medicine Department, Hypertension and Vascular Risk Unit, Hospital Universitario de Sagunto, Department of Medicine, Valencia, Spain; Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain.
| | - M I Orts-Martínez
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M A Sanz-Caballer
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M T Gimeno-Brosel
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - M J Arilla-Morel
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Navarro-Gonzalo
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Castillo-Valero
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
| | - I Salvador-Mercader
- Internal Medicine Department, Cardiology, Hospital Universitario de Sagunto, Spain
| | - A Carral-Tatay
- Internal Medicine Department, Hematology, Hospital Universitario de Sagunto, Spain
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5
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Lau WCY, Torre CO, Man KKC, Stewart HM, Seager S, Van Zandt M, Reich C, Li J, Brewster J, Lip GYH, Hingorani AD, Wei L, Wong ICK. Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation : A Multinational Population-Based Cohort Study. Ann Intern Med 2022; 175:1515-1524. [PMID: 36315950 DOI: 10.7326/m22-0511] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Current guidelines recommend using direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), but head-to-head trial data do not exist to guide the choice of DOAC. OBJECTIVE To do a large-scale comparison between all DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) in routine clinical practice. DESIGN Multinational population-based cohort study. SETTING Five standardized electronic health care databases, which covered 221 million people in France, Germany, the United Kingdom, and the United States. PARTICIPANTS Patients who were newly diagnosed with AF from 2010 through 2019 and received a new DOAC prescription. MEASUREMENTS Database-specific hazard ratios (HRs) of ischemic stroke or systemic embolism, intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model. RESULTS A total of 527 226 new DOAC users met the inclusion criteria (apixaban, n = 281 320; dabigatran, n = 61 008; edoxaban, n = 12 722; and rivaroxaban, n = 172 176). Apixaban use was associated with lower risk for GIB than use of dabigatran (HR, 0.81 [95% CI, 0.70 to 0.94]), edoxaban (HR, 0.77 [CI, 0.66 to 0.91]), or rivaroxaban (HR, 0.72 [CI, 0.66 to 0.79]). No substantial differences were observed for other outcomes or DOAC-DOAC comparisons. The results were consistent for patients aged 80 years or older. Consistent associations between lower GIB risk and apixaban versus rivaroxaban were observed among patients receiving the standard dose (HR, 0.72 [CI, 0.64 to 0.82]), those receiving a reduced dose (HR, 0.68 [CI, 0.61 to 0.77]), and those with chronic kidney disease (HR, 0.68 [CI, 0.59 to 0.77]). LIMITATION Residual confounding is possible. CONCLUSION Among patients with AF, apixaban use was associated with lower risk for GIB and similar rates of ischemic stroke or systemic embolism, ICH, and all-cause mortality compared with dabigatran, edoxaban, and rivaroxaban. This finding was consistent for patients aged 80 years or older and those with chronic kidney disease, who are often underrepresented in clinical trials. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Wallis C Y Lau
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (W.C.Y.L., K.K.C.M.)
| | - Carmen Olga Torre
- IQVIA, Real-World Solutions, Brighton, United Kingdom (C.O.T., H.M.S., S.S.)
| | - Kenneth K C Man
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (W.C.Y.L., K.K.C.M.)
| | | | - Sarah Seager
- IQVIA, Real-World Solutions, Brighton, United Kingdom (C.O.T., H.M.S., S.S.)
| | - Mui Van Zandt
- IQVIA, Real-World Solutions, Plymouth Meeting, Pennsylvania (M.V., C.R.)
| | - Christian Reich
- IQVIA, Real-World Solutions, Plymouth Meeting, Pennsylvania (M.V., C.R.)
| | - Jing Li
- IQVIA, Real-World Solutions, Durham, North Carolina (J.L., J.B.)
| | - Jack Brewster
- IQVIA, Real-World Solutions, Durham, North Carolina (J.L., J.B.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (G.Y.H.L.)
| | - Aroon D Hingorani
- Institute of Cardiovascular Sciences, University College London, and University College London British Heart Foundation Research Accelerator, London, United Kingdom (A.D.H.)
| | - Li Wei
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (L.W.)
| | - Ian C K Wong
- Aston Pharmacy School, Aston University, Birmingham, United Kingdom, Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom, Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, and Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong (I.C.K.W.)
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6
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Marin F, Fernández MS, Lekuona I, Arribas F, Barón-Esquivias G, Barrios V, Cosin-Sales J, Freixa-Pamias R, Masjuan J, Pérez-Cabeza AI, Schilling VR, Vázquez Rodríguez JM, Priu CR, Sánchez MA. Rivaroxaban for the prevention of outcomes in patients with atrial fibrillation in clinical practice: an indirect comparison of national and international registries. J Comp Eff Res 2022; 11:1173-1184. [PMID: 36148923 DOI: 10.2217/cer-2022-0111] [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: 11/21/2022] Open
Abstract
Objective: To analyze the effectiveness and safety of rivaroxaban in patients with atrial fibrillation (AF). Methods: The clinical profile and outcomes of the EMIR study were indirectly compared with those of ROCKET-AF, eight other Spanish observational studies and XANTUS. Results: In EMIR, mean age was 74.2 years and CHA2DS2-VASc was 3.5. In the rivaroxaban arm of the ROCKET-AF trial, mean age was 73 years and CHADS2 was 3.5, whereas in the Spanish studies mean age ranged from 74.9 years to 78.4 years and CHA2DS2-VASc from 3.5 to 4.3. In EMIR, rates of stroke/systemic embolism, major adverse cardiovascular events, cardiovascular death and major bleeding were 0.57, 1.07, 0.63 and 1.04 events/100 patient-years, respectively. In ROCKET-AF, these numbers were 1.7, 3.91, 1.53 and 3.6 events/100 patient-years, respectively. In the Spanish studies, rates of stroke and major bleeding were 0-1.8 and 0.22-4.2 events/100 patient-years, respectively. In XANTUS, rates of stroke, major adverse cardiovascular events and major bleeding were 0.7, 1.8 and 2.1 events/100 patient-years, respectively. Conclusion: Despite the fact that rivaroxaban is prescribed for elderly patients with a high thromboembolic risk, rates of outcomes remain low.
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Affiliation(s)
- Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | | | - Iñaki Lekuona
- Department of Cardiology, Hospital Galdakao-Usansolo, Bizkaia, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigacion Sanitaria Hospital 12 de Octubre (imas12); CIBERCV, Madrid, Spain
| | - Gonzalo Barón-Esquivias
- Department of Cardiology, Hospital Universitario Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain; Unidad Cardiovascular, Instituto de Biotecnología de Sevilla; Centro de Investigación en Red Cardiovascular, Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid; Alcalá University, Madrid, Spain
| | - Juan Cosin-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Román Freixa-Pamias
- Department of Cardiology, Hospital Universitari Complex Moisès Broggi, Barcelona, Spain
| | - Jaime Masjuan
- Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, Departamento de Medicina, Universidad de Alcalá. Red INVICTUS, Madrid, Spain
| | | | - Vanessa Roldán Schilling
- Department of Haematology & Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Murcia, Spain
| | | | | | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Reina Sofía Córdoba, IMIBIC, University of Cordoba, Córdoba, Spain
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7
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Antithrombotic Therapy in Elderly Patients with Acute Coronary Syndromes. J Clin Med 2022; 11:jcm11113008. [PMID: 35683397 PMCID: PMC9181473 DOI: 10.3390/jcm11113008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.
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8
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Escobar C, Camm AJ. Changing paradigms: from prevention of thromboembolic events to improved survival in patients with atrial fibrillation. Europace 2021; 23:837-843. [PMID: 33221894 DOI: 10.1093/europace/euaa324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation is associated with a five-fold increase in the risk of stroke. Current guidelines recommend the use of the CHA2DS2-VASc score to stratify the risk of stroke. In addition, guidelines recommend the identification of the conditions that increase the risk of haemorrhage to be modified and thus decrease the risk of bleeding. Nevertheless, many patients with a high thromboembolic risk are prescribed antiplatelet treatment or do not receive any antithrombotic therapy. In addition, therapeutic inertia is common in anticoagulated patients taking vitamin K antagonists, and underdosing is an emerging problem with direct oral anticoagulants, probably because many physicians consider the risk of stroke and the risk of major bleeding to be equal. It is necessary to develop a new approach to risk stratification, an approach that moves from morbidity to mortality, i.e., from stratification of the risk of stroke and major bleeding to stratification of the risk of mortality associated with stroke and the risk of mortality associated with bleeding. In this article, we propose a novel risk stratification approach based on the mortality associated with stroke and bleeding, illustrated by data derived from the literature.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - A John Camm
- Cardiovascular Clinical Academic Group, St. George's University of London, London, UK
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9
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Fernández MS, Marín F, Rafols C, Arribas F, Barrios V, Cosín-Sales J, Sánchez MA. Thromboembolic and bleeding events with rivaroxaban in clinical practice in Spain: impact of inappropriate doses (the EMIR study). J Comp Eff Res 2021; 10:583-593. [PMID: 33787316 DOI: 10.2217/cer-2020-0286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aim: To analyze the frequency and variables related to inappropriate rivaroxaban dosage in clinical practice and its impact on outcomes after 2 years. Materials & methods: Postauthorization, observational, multicenter study, in which atrial fibrillation patients, treated with rivaroxaban ≥6 months were included. Results: A total of 1421 patients (74.2 ± 9.7 years, CHA2DS2-VASc 3.5 ± 1.6) were included. Overall, 22.9% received rivaroxaban 15 mg. The proper dose of rivaroxaban was taken by 83.3% (9.7% underdosed, 7.0% overdosed). Older age and renal insufficiency were associated with inadequate rivaroxaban dosage. There was a trend toward higher all-cause mortality among underdosed patients (adjusted hazard ratio 1.39; 95% CI 0.75-2.58), and more bleedings in overdosed patients (2.29 vs 0.80 events/100 patient-years; p = 0.14). Conclusion: In clinical practice, rivaroxaban is properly dosed in most patients.
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Affiliation(s)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Carles Rafols
- Department of Medical Affairs, Bayer Hispania, Barcelona, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12); CIBERCV, Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, Hospital Ramón y Cajal; Alcalá University, Madrid, Spain
| | - Juan Cosín-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Universitario Reina Sofia, IMIBIC, University of Córdoba, Córdoba, Spain
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10
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Hempenius M, Groenwold RHH, Souverein PC, de Boer A, Klungel OH, Gardarsdottir H. Impact of anticoagulant exposure misclassification on the bleeding risk of direct oral anticoagulants. Br J Clin Pharmacol 2021; 87:3508-3517. [PMID: 33543516 PMCID: PMC8451929 DOI: 10.1111/bcp.14764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 12/04/2022] Open
Abstract
Aims Drug exposure status based on routinely collected data might be misclassified when the database contains only prescriptions from 1 type of prescriber (e.g. general practitioner and not specialist). This study aims to quantify the impact of such exposure misclassification on the risk of major bleeding and stroke/transient ischaemic attack (TIA)associated with direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs). Methods Incident anticoagulant users (>12 mo free of anticoagulation use) in the Dutch PHARMO Database Network between 2008 and 2017 were included. Drug exposure was assessed using pharmacy dispensing information. The risks of hospital admission of major bleeding for DOAC vs. VKA users was assessed with Cox regression analysis, where exposure was based on all dispensings, on general practitioner (GP)‐prescribed dispensings only or on specialist‐prescribed dispensings only. Hazard ratios (HRs) were estimated also for hospitalization for gastrointestinal bleeding, intracranial bleeding and stroke/TIA. Results We included 99 182 VKA‐initiators and 21 795 DOAC‐initiators. Use of DOAC was associated with a lower risk of major bleeding compared to VKA use; HR 0.79 (95% confidence interval 0.70–0.90), 0.78 (0.68–0.91) and 0.62 (0.50–0.76), for exposure based on complete dispensing information, only GP‐ and only specialist‐prescribed dispensings, respectively. Similar results were found for the other bleeding outcomes. For stroke/TIA the HRs were 0.96 (0.84–1.09), 1.00 (0.84–1.18) and 0.72 (0.58–0.90), respectively. Conclusion Including only GP‐prescribed anticoagulant dispensings in this case did not materially impact the effect estimates compared to including all anticoagulant dispensings. Including only specialist‐prescribed dispensings, however, strengthened the effect estimates.
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Affiliation(s)
- Mirjam Hempenius
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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11
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Bunge EM, van Hout B, Haas S, Spentzouris G, Cohen A. Critical appraisal and issues regarding generalisability of comparative effectiveness studies of NOACs in atrial fibrillation and their relation to clinical trial data: a systematic review. BMJ Open 2021; 11:e042024. [PMID: 33526502 PMCID: PMC7852966 DOI: 10.1136/bmjopen-2020-042024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To critically appraise the published comparative effectiveness studies on non-vitamin K antagonist oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF). Results were compared with expectations formulated on the basis of trial results with specific attention to the patient years in each study. METHODS All studies that compared the effectiveness or safety between at least two NOACs in patients with NVAF were eligible. We performed a systematic literature review in Medline and EMbase to investigate the way comparisons between NOACs were made, search date 23 April 2019. Critical appraisal of the studies was done using among others ISPOR Good Research Practices for comparative effectiveness research. RESULTS We included 39 studies in which direct comparison between at least two NOACs were made. Almost all studies concerned patient registries, pharmacy or prescription databases and/or health insurance database studies using a cohort design. Corrections for differences in patient characteristics was applied in all but two studies. Eighteen studies matched using propensity scores (PS), 8 studies weighted patients based on the inverse probability of treatment, 1 study used PS stratification and 10 studies applied a proportional hazards model. These studies have some important limitations regarding unmeasured confounders and channelling bias, even though the larger part of the studies were well conducted technically. On the basis of trial results, expected differences are small and a naïve analysis suggests trials with between 7200 and 56 500 patients are needed to confirm the observed differences in bleedings and between 51 800 and 7 994 300 to confirm differences in efficacy. DISCUSSION Comparisons regarding effectiveness and safety between NOACs on the basis of observational data, even after correction for baseline characteristics, may not be reliable due to unmeasured confounders, channelling bias and insufficient sample size. These limitations should be kept in mind when results of these studies are used to decide on ranking NOAC treatment options.
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Affiliation(s)
- Eveline M Bunge
- Pallas health research and consultancy BV, Rotterdam, The Netherlands
| | - Ben van Hout
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Alexander Cohen
- Department of Haematology, Guys and St Thomas' NHS Foundation Trust, King's College London, London, UK
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12
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Prevención del ictus en pacientes con fibrilación auricular. Mejorar la protección enla era de la COVID-19. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2021. [PMCID: PMC8320275 DOI: 10.1016/s1131-3587(21)00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
La fibrilación auricular aumenta hasta en 5 veces el riesgo de ictus. Los ictus cardioembólicos habitualmente son más graves y tienen altas tasas de recurrencias y discapacidad permanente en comparación con los ictus de otras etiologías. En consecuencia, la reducción del riesgo de ictus mediante una adecuada anticoagulación es uno de los principales objetivos en el tratamiento de los pacientes con fibrilación auricular. Los antagonistas de la vitamina K han sido ampliamente superados por los anticoagulantes orales de acción directa, ya que tanto los resultados de los ensayos clínicos como los de los estudios de práctica clínica y, últimamente, estudios poblacionales han demostrado que los anticoagulantes orales de acción directa tienen mayores eficacia (menos ictus y muerte) y seguridad (menos hemorragias intracraneales) que los antagonistas de la vitamina K. Además, durante la pandemia de COVID-19, el empleo preferente de anticoagulantes orales de acción directa frente a los antagonistas de la vitamina K constituye una estrategia clave para garantizar una calidad óptima de la anticoagulación y una mejor protección del paciente contra el SARS-CoV-2, al no precisarse control de la razón internacional normalizada.
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13
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Fernández CS, Gullón A, Formiga F. The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. J Comp Eff Res 2020; 9:509-523. [PMID: 32329353 DOI: 10.2217/cer-2019-0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.
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Affiliation(s)
| | - Alejandra Gullón
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Riera-Mestre A, Camafort M, María Suriñach J, Muñoz Rodríguez FJ, Padilla F, Francisco-Pascual J, Mateo Arranz J, Martínez Rubio A, Villuendas Sabaté R, Freixa-Pamias R, Suárez Fernández C, Santamaría A. Anticoagulación del paciente anciano pluripatológico con fibrilación auricular no valvular: papel del rivaroxabán. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2020. [DOI: 10.1016/s1131-3587(20)30011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Dormer L. Introducing Volume 9 of the Journal of Comparative Effectiveness Research. J Comp Eff Res 2019; 9:1-5. [PMID: 31852215 DOI: 10.2217/cer-2019-0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Laura Dormer
- Commissioning Editor, Future Medicine Ltd, Unitec House, London, N3 1QB, UK
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Navarro-Almenzar B, Cerezo-Manchado JJ, Caro-Martinez C, García-Candel F, Flores Blanco PJ, Ruiz GE, Andreu Cayuelas JM, Montoya FA, Cascales A, Lova Navarro A, García Alberola A, Andrés Pascual Figal D, Bailen Lorenzo JL, Manzano-Fernández S. Real-life behaviour of direct oral anticoagulants in a Spanish cohort with non-valvular atrial fibrillation: Refase Registry. Curr Med Res Opin 2019; 35:2035-2041. [PMID: 31335222 DOI: 10.1080/03007995.2019.1647735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Aim: To analyse the effectiveness and safety of DOAC (direct oral anticoagulants) in non-valvular atrial fibrillation (NVAF) patients attending clinical practice.Methods: Retrospective study of AF patients who started treatment with DOAC from January 1, 2013 to December 31, 2016 in three Spanish hospitals. Mean follow-up was 1.6 years. The primary outcomes were rates of all-cause death, ischaemic stroke, and bleeding. These outcomes were also studied depending on correct dosage adjustment and standard/adjusted dose.Results: The study included 2494 patients (age = 76.0 ± 9.5 years, CHA2DS2-VASc = 4.0 ± 1.6). The most prescribed DOAC was rivaroxaban (41.1%). Patients taking dabigatran were the youngest (mean age = 73.1 ± 10.3 years), with better kidney function (mean CrCl = 80.6 ± 35.8 ml/min) and lower CHA2DS2-VASc (3.7 ± 1.4) and HAS-BLED (2.1 ± 0.9) scores. Patients taking apixaban were the oldest, and had the highest CHA2DS2-VASc and HAS-BLED scores (4.3 ± 1.6 and 2.6 ± 0.9, respectively). Rates of stroke/major bleeding/intracranial bleeding were 1.8/3.0/0.3 events per 100 patient-years, respectively, with no differences among DOAC. Based on dose adjustment according to technical data, it was observed that 517 patients (23.5%) received DOAC doses inconsistent with labelling (p < .001) and, within this group, under-dosed patients had a higher death rate although it did not reach a significant result after multivariate adjustment.Conclusions: The results of safety and efficacy are very similar to those of other previously published national registries. There were no differences among the different types of DOAC regarding outcomes. However, it was found that people taking the adjusted dose of the drug seemed to have a higher risk of death. A non-negligible proportion of patients received DOAC doses inconsistent with labelling (mostly underdose).
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Affiliation(s)
- Begoña Navarro-Almenzar
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Juan José Cerezo-Manchado
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - César Caro-Martinez
- Servicio de Cardiología, Hospital Vega Baja, Orihuela, Alicante, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | - Faustino García-Candel
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Pedro José Flores Blanco
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Ginés Elvira Ruiz
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - José Miguel Andreu Cayuelas
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Francisco Arregui Montoya
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Almudena Cascales
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Alejandro Lova Navarro
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Arcadio García Alberola
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Domingo Andrés Pascual Figal
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | | | - Sergio Manzano-Fernández
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
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