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Chan YH, Chao TF, Chen SW, Lee HF, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. SGLT2 inhibitors vs. GLP-1 receptor agonists and clinical outcomes in patients with diabetes with/without atrial fibrillation. J Clin Endocrinol Metab 2024:dgae157. [PMID: 38466894 DOI: 10.1210/clinem/dgae157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/24/2023] [Accepted: 03/10/2024] [Indexed: 03/13/2024]
Abstract
CONTEXT The coexistence of diabetes mellitus and atrial fibrillation (AF) is associated with substantial risks of adverse cardiovascular events. OBJECTIVE The relevant outcomes associated with the use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) versus glucagon-like peptide-1 receptor agonists (GLP-1RA) among patients with type 2 diabetes (T2D) with/without concomitant AF remained unknown. METHODS In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, there were 344,392 and 31,351 patients with T2D without AF, and 11,462 and 816 T2D patients with AF treated with SGLT2i and GLP-1RA from May 1, 2016, to December 31, 2019. Patients were followed from the drug-index date until the occurrence of study events, discontinuation of the index drug, or the end of the study period (December 31, 2020), whichever occurred first. We used propensity score stabilized weight to balance covariates across two medication groups. RESULTS The incidence rate of all study outcomes in patients with concomitant AF was much higher than in those without concomitant AF. For the AF cohort, SGLT2i vs. GLP-1RA was associated with a lower risk of hospitalization for heart failure (2.32 vs. 4.74 events per 100 person-years; hazard ratio (HR):0.48 [95% confidential interval (CI):0.36-0.66]), with no benefit seen for the non-AF cohort (P for homogeneity < 0.01). SGLT2i vs. GLP-1RA was associated with a lower risk of composite kidney outcomes both in the AF (0.38 vs. 0.79 events per 100 person-years; HR:0.47; [95%CI:0.23-0.96]) and non-AF cohorts (0.09 vs. 0.18 events per 100 person-years; HR:0.53; [95%CI:0.43-0.64]). There were no significant differences in the risk of major adverse cardiovascular events and all-cause mortality in those who received SGLT2i compared to GLP-1RA for the AF or non-AF cohorts. CONCLUSION Considering the high risk of developing HF and/or high prevalence of concomitant HF in patients with diabetes, whether SGLT2i should be the preferred treatment to GLP-1RA for such a high-risk population requires further investigation.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Cardiology, Department of Medicine, New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng branch, Taiwan)
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Wang CL, Wu LS, Wu CT, Yeh YH, Cheng YW, Yen KC, Chan YH, Chuang C, Kuo CT, Chu PH. Clinical significance of regional constructive and wasted work in patients receiving cardiac resynchronization therapy. Front Cardiovasc Med 2024; 11:1301140. [PMID: 38510200 PMCID: PMC10950977 DOI: 10.3389/fcvm.2024.1301140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 02/22/2024] [Indexed: 03/22/2024] Open
Abstract
Background Previous studies have shown that global constructive work (CW) and wasted work (WW) predict response to cardiac resynchronization therapy (CRT). This study evaluated the predictive value of regional CW and WW for reverse remodeling and clinical outcomes after CRT. Methods We performed a prospective study involving 134 CRT candidates with left bundle branch block and left ventricular ejection fraction ≤35%. Global and regional CW and WW were calculated using pressure-strain loop analysis. CRT response was defined by reverse remodeling as a reduction of ≥15% in left ventricular end-systolic volume after six months. Results At six-month follow-up, 92 (69%) patients responded to CRT. Of the regional CW and WW measures, lateral wall (LW) CW and septal WW were most strongly and significantly correlated with reverse remodeling. At multivariate analysis, LW CW and septal WW were both independent determinants of reverse remodeling. When LW CW and septal WW were included in the model, global CW and WW were not independently associated with reverse remodeling. LW CW and septal WW predicted reverse remodeling with an area under the curve (AUC) of 0.783 (95% CI: 0.700-0.866) and 0.737 (95% CI: 0.644-0.831), respectively. Using both variables increased the AUC to 0.832 (95% CI: 0.755-0.908). Both LW CW ≤878 mmHg% (HR 2.01; 95% CI: 1.07-3.79) and septal WW ≤181 mmHg% (HR 2.60; 95% CI: 1.38-4.90) were significant predictors of combined death and HF hospitalization at two-year follow-up. Conclusion LW CW and septal WW before CRT are important determinants of reverse remodeling and clinical outcomes.
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Affiliation(s)
- Chun-Li Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Tung Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Cheng
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kun-Chi Yen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi Chuang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Chi-Tai Kuo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Lin Y, Lin G, Peng MT, Kuo CT, Wan YL, Cherng WJ. The Role of Artificial Intelligence in Coronary Calcium Scoring in Standard Cardiac Computed Tomography and Chest Computed Tomography With Different Reconstruction Kernels. J Thorac Imaging 2024; 39:111-118. [PMID: 37982516 DOI: 10.1097/rti.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
PURPOSE To assess the correlation of coronary calcium score (CS) obtained by artificial intelligence (AI) with those obtained by electrocardiography gated standard cardiac computed tomography (CCT) and nongated chest computed tomography (ChCT) with different reconstruction kernels. PATIENTS AND METHODS Seventy-six patients received standard CCT and ChCT simultaneously. We compared CS obtained in 4 groups: CS CCT , by the traditional method from standard CCT, 25 cm field of view, 3 mm slice thickness, and kernel filter convolution 12 (FC12); CS AICCT , by AI from the standard CCT; CS ChCTsoft , by AI from the non-gated CCT, 40 cm field of view, 3 mm slice thickness, and a soft kernel FC02; and CS ChCTsharp , by AI from CCT image with same parameters for CS ChCTsoft except for using a sharp kernel FC56. Statistical analyses included Spearman rank correlation coefficient (ρ), intraclass correlation (ICC), Bland-Altman plots, and weighted kappa analysis (κ). RESULTS The CS AICCT was consistent with CS CCT (ρ = 0.994 and ICC of 1.00, P < 0.001) with excellent agreement with respect to cardiovascular (CV) risk categories of the Agatston score (κ = 1.000). The correlation between CS ChCTsoft and CS ChCTsharp was good (ρ = 0.912, 0.963 and ICC = 0.929, 0.948, respectively, P < 0.001) with a tendency of underestimation (Bland-Altman mean difference and 95% upper and lower limits of agreements were 329.1 [-798.9 to 1457] and 335.3 [-651.9 to 1322], respectively). The CV risk category agreement between CS ChCTsoft and CS ChCTsharp was moderate (κ = 0.556 and 0.537, respectively). CONCLUSIONS There was an excellent correlation between CS CCT and CS AICCT , with excellent agreement between CV risk categories. There was also a good correlation between CS CCT and CS obtained by ChCT albeit with a tendency for underestimation and moderate accuracy in terms of CV risk assessment.
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Affiliation(s)
- Yenpo Lin
- Department of Medical Imaging and Intervention
| | - Gigin Lin
- Department of Medical Imaging and Intervention
| | | | - Chi-Tai Kuo
- Division of Cardiology, Department of Internal Medicine; Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | | | - Wen-Jin Cherng
- Division of Cardiology, Department of Internal Medicine; Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
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Chan YH, Chao TF, Chen SW, Lee HF, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. Clinical outcomes in elderly atrial fibrillation patients at increased bleeding risk treated with very low dose vs. regular-dose non-vitamin K antagonist oral anticoagulants: a nationwide cohort study. Eur Heart J Cardiovasc Pharmacother 2023; 9:681-691. [PMID: 37580139 DOI: 10.1093/ehjcvp/pvad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/11/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023]
Abstract
AIMS The Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial showed that edoxaban at a very low dosage (VLD) of 15 mg/day was more effective than a placebo at preventing stroke/systemic embolism without significantly increasing the risk of serious bleeding. We aimed to compare the effectiveness and safety for VLD non-vitamin K antagonist oral anticoagulants (NOACs) [edoxaban 15 mg o.d., dabigatran 110 or 150 o.d., apixaban 2.5 mg o.d., or rivaroxaban 10 mg (without the diagnosis of chronic kidney disease) or <10 mg o.d.] vs. regular-dosage (RD) NOACs (edoxaban 60/30 mg o.d. or other labeling-dosage NOACs) among a real-world cohort of elderly atrial fibrillation (AF) population similar to the ELDERCARE-AF cohort. METHODS AND RESULTS In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database (NHIRD), we identified a total of 7294 and 4151 consecutive AF patients aged 80 years or older with a CHADS2 (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack (2 points) score ≥2 who met the enrollment criteria (generally similar to ELDERCARE-AF) taking VLD and RD NOACs from 1 June 2012 to 31 December 2019, respectively. Propensity-score stabilized weighting (PSSW) was used to balance covariates across study groups. Patients were followed up from the first date of prescription for NOACs until the first occurrence of any study outcome, death, or until the end date of the study period (31 December 2020). After PSSW, VLD NOAC was associated with a comparable risk of ischemic stroke/systemic embolism and major bleeding but a higher risk of major adverse limb events (MALEs) requiring lower limb revascularization or amputation [hazard ratio (HR): 1.54, 95% confidential interval (CI): 1.09-2.18; P = 0.014), venous thrombosis (HR: 3.75, 95% CI: 1.56-8.97; P = 0.003), and all-cause mortality (HR: 1.21, 95% CI: 1.15-1.29; P <0.001) compared with RD NOACs. VLD NOACs showed worse outcomes in most net clinical outcome (NCO) benefits. The main result was consistent based on on-treatment analysis or accounting for death as a competing risk. In general, the advantage of NCOs for the RD NOACs over VLD NOACs persisted in most high-risk subgroups, consistent with the main analysis (P for interaction > 0.05). CONCLUSION Use of VLD NOACs was associated with a greater risk of arterial and venous thrombosis, death as well as the composite outcomes, when compared with that of RD NOAC in high-risk elderly AF patients at increased bleeding risk. Thromboprophylaxis with RD NOAC is still preferable over VLD NOAC for the majority of elderly AF patients at increased bleeding risk.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 112304, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng Branch), New Taipei City 236017, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City 33302, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan City 33305, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
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Hsu YJ, Chang GJ, Lai YJ, Chan YH, Chen WJ, Kuo CT, Yeh YH. High-phosphate diet causes atrial remodeling and increases atrial fibrillation vulnerability via STAT3/NF-κB signaling and oxidative stress. Acta Physiol (Oxf) 2023; 238:e13964. [PMID: 36929808 DOI: 10.1111/apha.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
AIM Hyperphosphatemia is associated with adverse cardiovascular outcomes in both the general population and patients with end-stage renal disease. We evaluated whether high inorganic phosphate (Pi) intake causes atrial remodeling and increased atrial fibrillation (AF) risk. METHODS The 5/6 nephrectomized chronic kidney disease (CKD) mice were fed a high-Pi (2%) diet for 10 weeks. AF vulnerability was evaluated through transesophageal burst atrial pacing. Phosphoproteomic, Western blotting, and immunohistochemistry were used to evaluate the effects of high Pi in atrial fibroblasts, atrial myocytes and HL-1 myocytes. RESULTS CKD and sham mice fed a high-Pi diet exhibited increased AF vulnerability, atrial fibrosis, and oxidative stress compared with mice fed a normal diet. Compared with normal (1 mM) Pi, high (2 mM) Pi significantly increased the activity of atrial fibroblasts and mitochondrial oxidative stress. Phosphoproteomic analysis revealed that compared with normal Pi, high Pi considerably increased the phosphorylation of intracellular proteins in atrial fibroblasts, including proteins related to NF-κB signaling and STAT3. Inhibition of NF-κB, STAT3, and Nox4 by small interfering RNA reduced the high-Pi-induced expression of collagen. In HL-1 myocytes, the high Pi induced the degradation of myofibril proteins and hyperphosphorylation of RyR2, which was abolished by Nox4 and CaMKII inhibition. Switching back to a normal-Pi diet improved the atrial abnormalities induced by high-Pi diet. CONCLUSIONS High-Pi intake causes atrial structural and electrical remodeling and increases AF vulnerability, which is mediated through STAT3/NF-κB signaling and oxidative stress. High dietary Pi intake can exert detrimental effects on atria and may increase AF risk.
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Affiliation(s)
- Yu-Juei Hsu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan.,Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Ying-Ju Lai
- Department of Respiratory Therapy, Chang-Gung University, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Cardiovascular Division, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Jan Chen
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Cardiovascular Division, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Cardiovascular Division, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Cardiovascular Division, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
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Chao TF, Chan YH, Tsai PC, Lee HF, Chang SH, Kuo CT, Lip GYH, Chen SA, Yeh YH. Prothrombin Time-International Normalized Ratio Predicts the Outcome of Atrial Fibrillation Patients Taking Rivaroxaban. Biomedicines 2022; 10:biomedicines10123210. [PMID: 36551966 PMCID: PMC9775588 DOI: 10.3390/biomedicines10123210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Although direct oral anticoagulants (DOACs) for patients with atrial fibrillation (AF) are considered to be safe, over or under anticoagulation and increased bleeding or thromboembolic risk are still considered individually. We aimed to investigate whether there is an association between prothrombin time and international normalized ratio (PT-INR) or activated partial thromboplastin time (aPTT) ratio, and the risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding among AF patients taking rivaroxaban or dabigatran. Methods: This multi-center cohort study in Taiwan included 3192 AF patients taking rivaroxaban and 958 patients taking dabigatran for stroke prevention where data about PT-INR and aPTT were available. Results: For patients treated with rivaroxaban, a higher INR level was not associated with a higher risk of major bleeding compared to an INR level < 1.1. The risk of IS/SE was lower for patients having an INR ≥ 1.5 compared to those with an INR < 1.1 (aHR:0.57; [95%CI: 0.37−0.87]; p = 0.01). On-label dosing of rivaroxaban and use of digoxin were independent factors associated with an INR ≥ 1.5 after taking rivaroxaban. For patients taking dabigatran, a higher aPTT ratio was not associated with a higher risk of major bleeding. The risk of IS/SE was lower for patients having an aPTT ratio of 1.1−1.2 and 1.3−1.4 than those with an aPTT ratio < 1.1. Conclusions: In AF patients, rivaroxaban with an INR ≥ 1.5 was associated with a lower risk of IS/SE. PT-INR or aPTT ratios were not associated with bleeding events for rivaroxaban or dabigatran. INR may help predict the outcome of AF patients who take rivaroxaban.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Pei-Chien Tsai
- Department and Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9100 Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-(3)-3281200 (ext. 8162); Fax: +886-(3)-3271192
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Chan YH, Chao TF, Chen SW, Lee HF, Chen WM, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. Development of Interstitial Lung Disease Among Patients With Atrial Fibrillation Receiving Oral Anticoagulants in Taiwan. JAMA Netw Open 2022; 5:e2243307. [PMID: 36413365 PMCID: PMC9682427 DOI: 10.1001/jamanetworkopen.2022.43307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE There are emerging concerns from case reports and pharmacovigilance analyses of a possible risk of interstitial lung disease (ILD) associated with the use of factor Xa (FXa) inhibitors. OBJECTIVE To evaluate the risk of incident ILD associated with the use of oral anticoagulants (OACs) in patients with nonvalvular atrial fibrillation (NVAF). DESIGN, SETTING, AND PARTICIPANTS This nationwide retrospective cohort study used data from the Taiwan National Health Insurance Research Database. Patients with NVAF without preexisting lung disease who received OACs from June 1, 2012, to December 31, 2017, were included. Propensity score stabilized weighting (PSSW) was used to balance covariates across the medication groups (FXa inhibitors, dabigatran, and warfarin, with warfarin as the reference). Patients were followed up from the drug index date until the onset of ILD, death, or end of the study (December 31, 2019), whichever occurred first. Data were analyzed from September 11, 2021, to August 3, 2022. EXPOSURES Patients with NVAF were treated with FXa inhibitors, dabigatran, or warfarin. MAIN OUTCOMES AND MEASURES New-onset idiopathic ILD. RESULTS Among the 106 044 patients (mean [SD] age, 73.4 [11.9] years; 59 995 men [56.6%]) included in the study, 64 555 (60.9%) received FXa inhibitors (apixban [n = 15 386], edoxaban [n = 12 413], and rivaroxaban [n = 36 756]), 22 501 (21.2%) received dabigatran, and 18 988 (17.9%) received warfarin at baseline. The FXa inhibitors were associated with a higher risk of incident ILD (0.29 vs 0.17 per 100 patient-years; hazard ratio, 1.54 [95% CI, 1.22-1.94]; P < .001), whereas dabigatran was associated with a nonsignificant difference in risk of incident ILD compared with warfarin (reference) after PSSW. The higher risk of incident ILD for FXa inhibitors vs warfarin was consistent with several high-risk subgroups. CONCLUSIONS AND RELEVANCE Results of this study suggest that FXa inhibitors were associated with lung injury among patients with NVAF who were treated with OACs. Physicians should be vigilant in monitoring for any potential adverse lung outcomes associated with the use of these drugs.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- New Taipei City Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Tucheng Branch, New Taipei City, Taiwan
| | - Wei-Min Chen
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Yeh YH, Chan YH, Chen SW, Chang SH, Wang CL, Kuo CT, Lip GYH, Chen SA, Chao TF. Oral Anticoagulant Use for Patients with Atrial Fibrillation with Concomitant Anemia and/or Thrombocytopenia. Am J Med 2022; 135:e248-e256. [PMID: 35381212 DOI: 10.1016/j.amjmed.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hemoglobin levels and platelet counts have been associated with adverse clinical outcomes in patients with cardiovascular conditions. We aimed to assess the impact of oral anticoagulant use for patients with atrial fibrillation and concomitant anemia or thrombocytopenia. METHODS We used medical data from a multicenter health care system in Taiwan including 37,074 patients with atrial fibrillation. Patients were categorized into 3 groups based on hemoglobin and platelet levels: Group 1 (hemoglobin >10g/dL and platelet>100 K/µL; n = 29,147), Group 2 (hemoglobin<10 g/dL or platelet<100 K/µL; n = 7078), and Group 3 (hemoglobin <10 g/dL and platelet <100 K/µL; n = 849). Patients in each category were further stratified as 3 groups according to their stroke prevention strategies: no oral anticoagulant use (non-OAC), warfarin, or nonvitamin K antagonist oral anticoagulants (NOACs). RESULTS A higher hemoglobin or platelet level was associated with a higher risk of ischemic stroke/systemic embolism but lower risks of intracranial hemorrhage and major bleeding. The composite risks of ischemic stroke/systemic embolism, intracranial hemorrhage and major bleeding were higher in Group 3 or Group 2, compared with Group 1 (6.79% a year vs 6.41% year vs 4.13% year). Compared to non-OACs, warfarin was not associated with a lower composite risk in the 3 groups. NOACs were associated with a lower composite risk in Group 1 (adjusted hazard ratio:0.68, [95% confidence interval:0.60-0.76]) and Group 2 (adjusted hazard ratio:0.73, [95% confidence interval:0.53-0.99]) but was nonsignificant in Group 3. CONCLUSIONS Patients with atrial fibrillation with anemia or thrombocytopenia were a high-risk population. Compared with no OAC use, NOACs were associated with better clinical outcomes for patients with atrial fibrillation and advanced anemia (hemoglobin <10g/dL) or thrombocytopenia (platelet <100 K/µL) but not for those with both conditions.
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Affiliation(s)
- Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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9
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Chan YH, Chao TF, Chen SW, Lee HF, Li PR, Chen WM, Yeh YH, Kuo CT, See LC, Lip GYH. The risk of incident atrial fibrillation in patients with type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors: a nationwide cohort study. Cardiovasc Diabetol 2022; 21:118. [PMID: 35765074 PMCID: PMC9241240 DOI: 10.1186/s12933-022-01549-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/11/2022] [Indexed: 02/07/2023] Open
Abstract
Background Although a few meta-analyses were conducted to compare the risk of incident atrial fibrillation (AF) between sodium-glucose cotransporter-2 inhibitor (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and other anti-hyperglycemic agents using indirect or direct comparison, the above analyses showed conflicting results with each other. We aimed to evaluate the risk of new-onset AF associated with the use of SGLT2i, GLP-1RA, and dipeptidyl peptidase-4 inhibitor (DPP4i) among a large longitudinal cohort of diabetic patients. Methods In this nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database, a total of 344,893, 44,370, and 393,100 consecutive patients with type 2 diabetes without preexisting AF receiving GLP-1RA, SGLT2i, and DPP4i, respectively, were enrolled from May 1, 2016, to December 31, 2019. We used 1:1 propensity score matching (PSM) to balance covariates across paired study groups. Patients were followed from the drug index date until the occurrence of AF, death, discontinuation of the index drug, or the end of the study period (December 31, 2020), whichever occurred first. Results After PSM, there were 245,442, 43,682, and 39,190 paired cohorts of SGLT2i-DPP4i, SGLT2i-GLP-1RA, and GLP-1RA-DPP4i, respectively. SGLT2i treatment was associated with lower risk of new-onset AF in participants with type 2 diabetes compared with either DPP4i [hazard ratio (HR):0.90; 95% confidential interval (CI) 0.84–0.96; P = 0.0028] or GLP-1RA [HR 0.74; 95% CI 0.63–0.88; P = 0.0007] treatment after PSM. There was no difference in the risk of incident AF between GLP-1RA and DPP4i users [HR 1.01; 95% CI 0.86–1.19; P = 0.8980]. The above findings persisted among several important subgroups. Dapagliflozin was specifically associated with a lower risk of new-onset AF compared with DPP4i (P interaction = 0.02). Conclusions Compared with DPP4i, SGLT2i but not GLP-1RA was associated with a lower risk of incident AF in patients with type 2 diabetes. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01549-x.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City, 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng branch, New Taipei City, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Wei-Min Chen
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan. .,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, 33302, Taiwan. .,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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10
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Chan YH, Chao TF, Lee HF, Yeh YH, Chang SH, Kuo CT, Lip GY, Chen SA. Different Renal Function Equations and Dosing of Direct Oral Anticoagulants in Atrial Fibrillation. JACC: Asia 2022; 2:46-58. [PMID: 36340259 PMCID: PMC9627870 DOI: 10.1016/j.jacasi.2021.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/12/2021] [Accepted: 11/02/2021] [Indexed: 11/29/2022]
Abstract
Background Randomized trials of direct oral anticoagulants (DOACs) adopted the Cockcroft-Gault (CG) formula to calculate estimated glomerular filtration rate (eGFR) to determine the dosages of DOACs. Objectives The authors aimed to investigate the agreements/disagreements of eGFRs calculated using different equations (CG, Modified Diet in Renal Disease [MDRD], and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] formulas), and their impacts on the dosages of DOACs and clinical outcomes. Methods Medical data from a multicenter health care provider in Taiwan including 39,239 patients with atrial fibrillation were used. Among these patients, there were 11,185 and 2,323 patients treated with DOACs and warfarin, respectively. Results At the cutoff values of eGFR of <15, 15-50, and >50 mL/min, the agreements were 78% between MDRD and CG and 81% between CKD-EPI and CG. The disagreements among the different equations were largely due to overestimations, especially for patients aged >75 years and with a body weight of <50 kg (58.8% for MDRD and 50.9% for CKD-EPI). Among patients receiving DOACs whose dosages were defined as “on label” based on MDRD or CKD-EPI, only those whose dosages were “truly on label” based on CG were associated with a lower risk of major bleeding (adjusted HR: 0.34; 95% CI: 0.26-0.45) compared to warfarin. Conclusions The adoptions of MDRD or CKD-EPI rather than CG would result in inappropriate dosing of DOACs (mainly overdosing), which would attenuate the advantages of DOACs compared to warfarin. The CG equation should be used as the gold standard to calculate eGFRs and guide the DOAC dosages.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Address for correspondence: Dr Tze-Fan Chao, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan. @SPAF_tfchao
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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11
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Chan YH, Chao TF, Lee HF, Chen SW, Li PR, Liu JR, Wu LS, Chang SH, Yeh YH, Kuo CT, See LC, Lip GYH. Clinical Outcomes in Atrial Fibrillation Patients With a History of Cancer Treated With Non-Vitamin K Antagonist Oral Anticoagulants: A Nationwide Cohort Study. Stroke 2021; 52:3132-3141. [PMID: 34233467 DOI: 10.1161/strokeaha.120.033470] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation and cancer are limited, and patients with active cancer were excluded from randomized trials. We investigated the effectiveness and safety for NOACs versus warfarin among patients with atrial fibrillation with cancer. METHODS In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 6274 and 1681 consecutive patients with atrial fibrillation with cancer taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. Propensity score stabilized weighting was used to balance covariates across study groups. RESULTS There were 1031, 1758, 411, and 3074 patients treated with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. After propensity score stabilized weighting, NOAC was associated with a lower risk of major adverse cardiovascular events (hazard ratio, 0.63 [95% CI, 0.50-0.80]; P=0.0001), major adverse limb events (hazard ratio, 0.41 [95% CI, 0.24-0.70]; P=0.0010), venous thrombosis (hazard ratio, 0.37 [95% CI, 0.23-0.61]; P<0.0001), and major bleeding (hazard ratio, 0.73 [95% CI, 0.56-0.94]; P=0.0171) compared with warfarin. The outcomes were consistent with either direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, edoxaban, and rivaroxaban) use, among patients with stroke history, and among patients with different type of cancer and local, regional, or metastatic stage of cancer (P interaction >0.05). When compared with warfarin, NOAC was associated with lower risk of major adverse cardiovascular event, and venous thrombosis in patients aged <75 but not in those aged ≥75 years (P interaction <0.05). CONCLUSIONS Thromboprophylaxis with NOACs rather than warfarin should be considered for the majority of the atrial fibrillation population with cancer.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.)
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan (T.-F.C.).,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan (T.-F.C.)
| | - Hsin-Fu Lee
- New Taipei City Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Linkou, Taiwan. (H.-F.L.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan. (H.-F.L.)
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. (S.-W.C.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,Linkou Medical Center, Chang Gung University, Taiwan. (S.-W.C.)
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taiwan. (P.-R.L., J.-R.L., L.-C.S.)
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taiwan. (P.-R.L., J.-R.L., L.-C.S.)
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.)
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan. (S.-H.C.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.)
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.)
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.).,College of Medicine, Chang Gung University, Taiwan. (Y.-H.C., H.-F.L., S.-W.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.)
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taiwan. (P.-R.L., J.-R.L., L.-C.S.).,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taiwan. (L.-C.S.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.)
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Tung YC, See LC, Chang SH, Liu JR, Kuo CT, Chang CJ. Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease. Sci Rep 2020; 10:21345. [PMID: 33288822 PMCID: PMC7721794 DOI: 10.1038/s41598-020-78400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022] Open
Abstract
This nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.
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Affiliation(s)
- Ying-Chang Tung
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan, ROC.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Tai Kuo
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Jen Chang
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.
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13
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Chan YH, Chao TF, Chen SW, Lee HF, Yeh YH, Huang YC, Chang SH, Kuo CT, Lip GY, Chen SA. Off-label dosing of non–vitamin K antagonist oral anticoagulants and clinical outcomes in Asian patients with atrial fibrillation. Heart Rhythm 2020; 17:2102-2110. [DOI: 10.1016/j.hrthm.2020.07.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 12/31/2022]
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14
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See LC, Lee HF, Chao TF, Li PR, Liu JR, Wu LS, Chang SH, Yeh YH, Kuo CT, Chan YH, Lip GYH. Effectiveness and Safety of Direct Oral Anticoagulants in an Asian Population with Atrial Fibrillation Undergoing Dialysis: A Population-Based Cohort Study and Meta-Analysis. Cardiovasc Drugs Ther 2020; 35:975-986. [DOI: 10.1007/s10557-020-07108-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/11/2022]
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15
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Lee HF, Chen SW, Liu JR, Li PR, Wu LS, Chang SH, Yeh YH, Kuo CT, Chan YH, See LC. Major adverse cardiovascular and limb events in patients with diabetes and concomitant peripheral artery disease treated with sodium glucose cotransporter 2 inhibitor versus dipeptidyl peptidase-4 inhibitor. Cardiovasc Diabetol 2020; 19:160. [PMID: 32998736 PMCID: PMC7528264 DOI: 10.1186/s12933-020-01118-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/12/2020] [Indexed: 02/06/2023] Open
Abstract
Background Whether sodium glucose co-transporter 2 inhibitors (SGLT2i) are associated with a lower risk of cardiovascular as well as adverse lower limb events in patients with type-2 diabetes mellitus (T2DM) and concomitant peripheral artery disease (PAD) is unclear. We aimed to evaluate the risk of cardiovascular and limb events, and death associated with the use of SGLT2i compared with dipeptidyl peptidase-4 inhibitors (DPP4i) among a longitudinal and national cohort of patients with T2DM. Methods In this nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database, we identified a total of 11,431 and 93,972 consecutive T2DM patients with PAD taking SGLT2i and DPP4i, respectively, from May 1, 2016, to December 31, 2017. We used 1:1 propensity score matching (PSM) to balance covariates across study groups. Patients were followed from the drug index date until the occurrence of clinical outcomes, death, discontinuation of the index drug, or the end of the study period, whichever occurred first. Results Overall, 56% and 44% of the patients were treated with dapagliflozin and empagliflozin, respectively. The use of SGLT2i had comparable risks of ischemic stroke and acute myocardial infarction, and was associated with lower risks of congestive heart failure (CHF) [hazard ratio (HR): 0.66; 95% confidence interval (CI) 0.49–0.89; p = 0.0062], lower limb ischemia requiring revascularization (HR: 0.73; 95% CI 0.54–0.98; p = 0.0367) or amputation (HR: 0.43; 95% CI 0.30–0.62; p < 0.0001), and cardiovascular death (HR: 0.67; 95% CI 0.49–0.90; p = 0.0089) when compared with the DDP4i group after PSM. The subgroup analysis revealed consistent results for CHF and major adverse limb outcomes for SGLT2i versus DPP4i among patients aged ≥ 75 years, the presence of chronic kidney disease and established cardiovascular disease was consistent with the main analysis. Conclusions SGLT2i were associated with lower risks of CHF and adverse lower limb events compared with DPP4i among patients with T2DM and PAD in real-world practice.
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Affiliation(s)
- Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng branch, Taiwan), Taoyuan, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist, Taoyuan, 33302, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist, Taoyuan, 33302, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan. .,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist, Taoyuan, 33302, Taiwan. .,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan. .,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.
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16
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Chan YH, Wu LS, See LC, Liu JR, Chang SH, Chao TF, Yeh YH, Kuo CT, Lee HF, Lip GYH. Direct Oral Anticoagulants in Atrial Fibrillation Patients With Concomitant Hyperthyroidism. J Clin Endocrinol Metab 2020; 105:5721195. [PMID: 32009154 DOI: 10.1210/clinem/dgaa050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/30/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Patients with hyperthyroidism were excluded from the randomized clinical trials of direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). METHODS We performed a nationwide retrospective cohort study using data from the Taiwan National Health Insurance Research Database. We enrolled 3213 and 1181 NVAF patients with hyperthyroidism who were taking DOACs and warfarin, respectively, from June 1, 2012 to December 31, 2017. We also enrolled 53 591 and 16 564 NVAF patients without hyperthyroidism, taking DOACs and warfarin, respectively. We used propensity score stabilized weights (PSSWs) to balance covariates across the study groups. We also used 1:4 matching on both taking DOACs, with (n = 3213) and without hyperthyroidism (n = 12 852); and both taking warfarin, with (n = 1181) and without hyperthyroidism (n = 4724). RESULTS After PSSW, DOAC had a comparable risk of ischemic stroke/systemic embolism (IS/SE) and a lower risk of major bleeding (hazard ratio [HR] 0.65; 95% confidential interval [CI], 0.44-0.96; P = 0.0295) than warfarin among patients with hyperthyroidism. There were comparable risks of IS/SE and major bleeding between those patients with and without hyperthyroidism. However, among patients taking warfarin, those with hyperthyroidism had a lower risk of IS/SE than those without hyperthyroidism (HR 0.61; 95% CI, 0.43-0.86; P = 0.0050). CONCLUSION Among NVAF Asian patients with concomitant hyperthyroidism, DOACs may be an effective and safer alternative to warfarin. Thromboprophylaxis with DOACs may be considered for such patients, and it is important to validate this finding in further prospective study.
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Affiliation(s)
- Yi-Hsin Chan
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Lung-Sheng Wu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Hsin Yeh
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Chang CJ, Tung YC, Liu JR, Chang SH, Kuo CT, See LC. Efficacy and Safety of Ticagrelor vs. Clopidogrel in East Asian Patients with Acute Myocardial Infarction: A Nationwide Cohort Study. Clin Pharmacol Ther 2020; 109:443-451. [PMID: 32767756 DOI: 10.1002/cpt.2011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/26/2020] [Indexed: 01/24/2023]
Abstract
Ticagrelor improves clinical outcomes in patients with acute myocardial infarction (AMI). This study aimed to compare the efficacy and safety of ticagrelor vs. clopidogrel in East Asian patients with AMI. Between July 2013 and December 2015, patients with AMI prescribed dual antiplatelet therapy were identified from the National Health Insurance Research Database of Taiwan. Using propensity score weighting, ticagrelor was compared with clopidogrel for the primary efficacy end point (a composite of all-cause death, myocardial infarction (MI), and stroke) and bleeding. A total of 32,442 patients with AMI (ticagrelor: 10,057; clopidogrel: 22,385) were eligible for analysis. After propensity score weighting, ticagrelor was comparable to clopidogrel in the incidence rate of the primary efficacy end point (23.6 vs. 22.76/100 patient-years; hazard ratio (HR) 0.97; 95% confidence interval (CI) 0.89-1.06; P = 0.513). Ticagrelor was associated with a lower risk of stroke (1.78 vs. 2.66/100 patient-years; HR 0.64; 95% CI 0.49-0.85; P = 0.002) and higher risks of overall (21.59 vs. 18.35/100 patient-years; HR 1.16; 95% CI 1.06-1.27; P = 0.002) and Bleeding Academic Research Consortium (BARC) type 2 bleeding (18.67 vs. 15.08/100 patient-years; HR 1.22; 95% CI 1.11-1.36; P < 0.001). The risks of death, MI, and BARC 3 or 5 bleeding were comparable between ticagrelor and clopidogrel. In the present study, ticagrelor was comparable to clopidogrel in the composite of death, MI, and stroke, but had an increased risk of BARC type 2 bleeding. Ticagrelor may be beneficial in preventing post-MI stroke in East Asian patients.
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Affiliation(s)
- Chi-Jen Chang
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Chang Tung
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
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18
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Lee HF, Chan YH, Chang SH, Tu HT, Chen SW, Yeh YH, Wu LS, Kuo CF, Kuo CT, See LC. Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulant and Warfarin in Cirrhotic Patients With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2020; 8:e011112. [PMID: 30834802 PMCID: PMC6474939 DOI: 10.1161/jaha.118.011112] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Liver cirrhotic patients with nonvalvular atrial fibrillation have been excluded from randomized clinical studies regarding oral anticoagulants for stroke prevention. Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin for these patients remains unclear. Methods and Results This nationwide retrospective cohort study, with data collected from the Taiwan National Health Insurance Research Database, enrolled 2428 liver cirrhotic patients with nonvalvular atrial fibrillation taking apixaban (n=171), dabigatran (n=535), rivaroxaban (n=732), or warfarin (n=990) from June 1, 2012, to December 31, 2016. We used propensity score–based stabilized weights to balance covariates across study groups. Patients were followed until the occurrence of an event or the end date of study. The NOAC group (n=1438) showed risk of ischemic stroke/systemic embolism and intracranial hemorrhage comparable to that of the warfarin group (n=990) after adjustment. The NOAC group showed significantly lower risk of gastrointestinal bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.79]; P=0.0030) and all major bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.74]; P=0.0003) compared with warfarin group. Overall, 90% (n=1290) of patients were taking a low‐dose NOAC (apixaban 2.5 mg twice daily, rivaroxaban 10–15 mg daily, or dabigatran 110 mg twice daily). The subgroup analysis indicated that both dabigatran and rivaroxaban showed lower risk of all major bleeding than warfarin. The advantage of lower gastrointestinal and all major bleeding with NOACs over warfarin is contributed by those subgroups with either nonalcoholic or nonadvanced liver cirrhosis. Conclusions NOACs have a risk of thromboembolism comparable to that of warfarin and a lower risk of major bleeding among liver cirrhotic Asian patients with nonvalvular atrial fibrillation. Consequently, thromboprophylaxis with low‐dose NOACs may be considered for such patients. See Editorial by Gallagher et al
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Affiliation(s)
- Hsin-Fu Lee
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan.,7 Graduate Institute of Clinical Medical Sciences College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yi-Hsin Chan
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,2 Microscopy Core Laboratory Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Shang-Hung Chang
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Hui-Tzu Tu
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,8 Department of Public Health College of Medicine Chang Gung University Taoyuan Taiwan
| | - Shao-Wei Chen
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,4 Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yung-Hsin Yeh
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Lung-Sheng Wu
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chang-Fu Kuo
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,5 Division of Rheumatology, Allergy and Immunology Department of Internal Medicine Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chi-Tai Kuo
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Lai-Chu See
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,5 Division of Rheumatology, Allergy and Immunology Department of Internal Medicine Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,8 Department of Public Health College of Medicine Chang Gung University Taoyuan Taiwan.,9 Biostatistics Core Laboratory Molecular Medicine Research Center Chang Gung University Taoyuan Taiwan
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Lee HF, Chan YH, Li PR, Liu JR, Chao TF, Wu LS, Chang SH, Yeh YH, Kuo CT, See LC, Lip GYH. Oral Anticoagulants and Antiplatelet Agents in Patients With Atrial Fibrillation and Concomitant Critical Limb Ischemia: A Nationwide Cohort Study. Can J Cardiol 2020; 37:113-121. [PMID: 32492401 DOI: 10.1016/j.cjca.2020.02.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/13/2020] [Accepted: 02/07/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Evidence of clinical outcomes for oral anticoagulants and antiplatelet treatment (APT) in patients with atrial fibrillation (AF) and critical limb ischemia (CLI) is very limited. METHODS In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, 1223 patients with AF and CLI taking direct-acting oral coagulants (DOACs), warfarin, or APT were identified from June 1, 2012, to December 31, 2017. We used propensity score stabilized weighting (PSSW) to balance covariates across study groups. RESULTS After PSSW, DOAC (n = 446) was associated with lower risks of ischemic stroke/systemic embolism (IS/SE), all major adverse limb events, and all major bleeding events compared with warfarin (n = 237). DOAC was associated with lower risks of IS/SE, acute myocardial infarction (AMI), and all major adverse limb events and a comparable risk of major bleeding events compared with APT (n = 540). DOAC has a lower risk of composite net-clinical-benefit outcome (IS/SE, AMI, all major adverse limb events, plus all major bleeding events) compared with warfarin (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.35-0.65; P < 0.0001) or APT (HR: 0.44; 95% CI: 0.34-0.56; P < 0.0001). The composite net-clinical-benefit outcome was comparable for warfarin vs APT. The reduced risk of net-clinical-benefit outcome for DOAC vs warfarin or APT persisted in high subgroups including age > 75 years, presence of diabetes mellitus, or chronic kidney disease. CONCLUSIONS DOAC was associated with a significantly lower risk of composite net-clinical-benefit outcome than either warfarin or APT in patients with AF and concomitant CLI. Further prospective study is necessary to validate the findings in the future.
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Affiliation(s)
- Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Cardiology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Chan YH, Lee HF, Chao TF, Wu CT, Chang SH, Yeh YH, See LC, Kuo CT, Chu PH, Wang CL, Lip GYH. Real-world Comparisons of Direct Oral Anticoagulants for Stroke Prevention in Asian Patients with Non-valvular Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2020; 33:701-710. [PMID: 31745687 DOI: 10.1007/s10557-019-06910-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether four direct oral anticoagulants (DOACs) are superior to warfarin among Asians with non-valvular atrial fibrillation (NVAF) remains unclear in the real-world setting. METHODS We searched PubMed and Medline + Journals@Ovid + EMBASE from September 17, 2009 to May 4, 2019 to perform a systematic review and meta-analysis of all observational real-world studies comparing four DOACs with warfarin specifically focused on Asian patients with NVAF. RESULTS From the original 212 results retrieved, 18 studies were included in the meta-analysis. Overall, DOACs were associated with lower risks of thromboembolism (hazard ratio; [95% confidence interval], 0.70; [0.63-0.78]), acute myocardial infarction (0.67; [0.57-0.79]), all-cause mortality (0.62; [0.56-0.69]), major bleeding (0.59; [0.50-0.69]), intracranial hemorrhage (0.50; [0.40-0.62]), gastrointestinal bleeding (0.66; [0.46-0.95]), and any bleeding (0.82; [0.73-0.92]) than warfarin. There was statistic heterogeneity between DOACs for the risks of thromboembolism (P interaction = 0.03) and acute myocardial infarction (P interaction = 0.007) when compared to warfarin. However, all DOACs showed lower risks of thromboembolism and acute myocardial infarction than warfarin when pooling studies that compared individual DOAC with warfarin. With regard to the other outcomes when compared to warfarin, there was no statistical heterogeneity between DOACs. In addition, the effectiveness and safety of four DOACs versus warfarin persisted in the subgroups of either standard-dose or low-dose DOACs. CONCLUSIONS The meta-analysis shows that the DOACs had greater effectiveness and safety compared to warfarin in real-world practice for stroke prevention, among Asian patients with NVAF.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Tung Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Pao-Hsien Chu
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Chun-Li Wang
- The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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Chan YH, Lee HF, Li PR, Liu JR, Chao TF, Wu LS, Chang SH, Yeh YH, Kuo CT, See LC, Lip GYH. Effectiveness, safety, and major adverse limb events in atrial fibrillation patients with concomitant diabetes mellitus treated with non-vitamin K antagonist oral anticoagulants. Cardiovasc Diabetol 2020; 19:63. [PMID: 32404168 PMCID: PMC7222472 DOI: 10.1186/s12933-020-01043-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/09/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Evidence of adverse clinical outcomes for non-vitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation (AF) and diabetes mellitus are limited. We investigated the effectiveness, safety, and major adverse limb events for NOACs versus warfarin among diabetic AF patients. METHODS In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, we identified a total of 20,967 and 5812 consecutive AF patients with diabetes taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. We used propensity-score stabilized weighting to balance covariates across study groups. RESULTS NOAC was associated with a lower risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio (aHR):0.88; [95% confidential interval (CI) 0.78-0.99]; P = 0.0283), major adverse limb events (MALE) (aHR:0.72;[95% CI 0.57-0.92]; P = 0.0083), and major bleeding (aHR:0.67;[95% CI 0.59-0.76]; P < 0.0001) compared to warfarin. NOACs decreased MACE in patients of ≥ 75 but not in those aged < 75 years (P interaction = 0.01), and in patients with ischemic heart disease (IHD) compared to those without IHD (P interaction < 0.01). For major adverse limb events, the advantage of risk reduction for NOAC over warfarin persisted in high risk subgroups including age ≥ 75 years, chronic kidney disease, IHD, peripheral artery disease, or use of concomitant antiplatelet drugs. CONCLUSION Among diabetic AF patients, NOACs were associated with a lower risk of thromboembolism, major bleeding, and major adverse limb events than warfarin. Thromboprophylaxis with NOACs should be considered in the diabetic AF population with a high atherosclerotic burden.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng branch, Taiwan), Taipei, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan. .,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan. .,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, 33305, Taoyuan, Taiwan.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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Lee HF, See LC, Li PR, Liu JR, Chao TF, Chang SH, Wu LS, Yeh YH, Kuo CT, Chan YH, Lip GYH. Non-vitamin K antagonist oral anticoagulants and warfarin in atrial fibrillation patients with concomitant peripheral artery disease. Eur Heart J Cardiovasc Pharmacother 2019; 7:50-58. [PMID: 31778146 DOI: 10.1093/ehjcvp/pvz072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/13/2019] [Accepted: 11/26/2019] [Indexed: 01/21/2023]
Abstract
AIMS To investigate the effectiveness, safety, and outcomes of lower limb events for non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin among atrial fibrillation (AF) patients with concomitant peripheral artery disease (PAD). METHODS AND RESULTS In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, a total of 5768 and 2034 consecutive AF patients with PAD patients taking NOACs or warfarin were identified from 1 June 2012 to 31 December 2017, respectively. We used propensity score stabilized weighting to balance covariates across study groups. In the cohort, there were 89% patients were taking low-dose NOAC (dabigatran 110 mg twice daily, rivaroxaban 10-15 mg daily, apixaban 2.5 mg twice daily, or edoxaban 30 mg daily). Non-vitamin K antagonist oral anticoagulant was associated with a comparable risk of ischaemic stroke, and a lower risk of acute myocardial infarction [hazard ratio (HR): 0.61, 95% confidence interval (CI): 0.42-0.87; P = 0.007], lower extremity thromboembolism (HR: 0.56, 95% CI: 0.44-0.72; P < 0.0001), revascularization procedure (HR: 0.58, 95% CI: 0.47-0.72; P < 0.0001), lower limb amputation (HR: 0.32, 95% CI: 0.23-0.46; P < 0.0001), and all major bleeding (HR: 0.64, 95% CI: 0.50-0.80; P = 0.0001) than warfarin after weighting. The advantage of NOACs over warfarin persisted in high-risk subgroups including patients of ≥75 years of age, diabetes, renal impairment, or use of concomitant antiplatelet agent. CONCLUSION This population-based study indicated that NOACs were associated with a comparable risk of ischaemic stroke, and a significantly lower risk of major adverse limb events and major bleeding than warfarin among AF patients with concomitant PAD. Therefore, thromboprophylaxis with NOACs may be considered for such patients.
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Affiliation(s)
- Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,New Taipei City Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Tucheng Branch, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Chan YH, Chang GJ, Lai YJ, Chen WJ, Chang SH, Hung LM, Kuo CT, Yeh YH. Atrial fibrillation and its arrhythmogenesis associated with insulin resistance. Cardiovasc Diabetol 2019; 18:125. [PMID: 31558158 PMCID: PMC6761716 DOI: 10.1186/s12933-019-0928-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/14/2019] [Indexed: 02/07/2023] Open
Abstract
Background Insulin resistance (IR) is considered as a risk factor for atrial fibrillation (AF) even before diabetes develops. The pathophysiology and underlying mechanism are largely unclear. Methods We investigated the corresponding mechanism in two IR models of rats fed 15-week high-fat (HFa) and high-fructose/cholesterol (HFr) diets. AF was evaluated and induced by burst atrial pacing. Isolated atrial myocytes were used for whole-cell patch clamp and calcium assessment. Ex vivo whole heart was used for optical mapping. Western blot and immunofluorescence were used for quantitative protein evaluation. Results Both HFa and HFr rat atria were vulnerable to AF evaluated by burst atrial pacing. Isolated atrial myocytes from HFa and HFr rats revealed significantly increased sarcoplasmic reticulum calcium content and diastolic calcium sparks. Whole-heart mapping showed prolonged calcium transient duration, conduction velocity reduction, and repetitive ectopic focal discharge in HFa and HFr atria. Protein analysis revealed increased TGF-β1 and collagen expression; increased superoxide production; abnormal upregulation of calcium-homeostasis-related proteins, including oxidized CaMKIIδ, phosphorylated-phospholamban, phosphorylated-RyR-2, and sodium-calcium exchanger; and increased Rac1 activity in both HFa and HFr atria. We observed that inhibition of CaMKII suppressed AF in both HF and HFr diet-fed rats. In vitro palmitate-induced IR neonatal cardiomyocytes and atrial fibroblasts expressed significantly more TGF-β1 than did controls, suggesting paracrine and autocrine effects on both myocytes and fibroblasts. Conclusions IR engenders both atrial structural remodeling and abnormal intracellular calcium homeostasis, contributing to increased AF susceptibility. The inhibition of CaMKII may be a potential therapeutic target for AF in insulin resistance.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, Taiwan
| | - Ying-Ju Lai
- Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Jan Chen
- Cardiovascular Department, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Center for Big Data Analytics and Statistics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Li-Man Hung
- Department of Biomedical Sciences, College of Medicine, Healthy and Aging Research Center, Chang-Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan. .,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan. .,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.
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Chang SH, Kuo CF, Chou IJ, See LC, Yu KH, Luo SF, Huang LH, Zhang W, Doherty M, Wen MS, Kuo CT, Yeh YH. Association of a Family History of Atrial Fibrillation With Incidence and Outcomes of Atrial Fibrillation: A Population-Based Family Cohort Study. JAMA Cardiol 2019; 2:863-870. [PMID: 28678986 DOI: 10.1001/jamacardio.2017.1855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance The heritability of atrial fibrillation (AF), the contribution of genetic and environmental factors, and the association of a family history of AF with prognosis are unclear. Objectives To measure genetic and environmental factors in the familial aggregation of AF and to estimate the association of a family history of AF with major adverse cardiovascular events (MACE). Design, Setting, and Participants In this Taiwanese nationwide population-based study among more than 23 million people, a custom data set was obtained using the data of all patients having a diagnosis of AF recorded between January 1996 and December 2013 in the Taiwan National Health Insurance Research Database. The study population comprised all 23 422 955 individuals registered with the database in 2013, of whom 177 770 had a diagnosis of AF and were included in the heritability estimation. From the latter, a subgroup of patients having newly diagnosed AF with a first-degree relative affected by AF between 2000 and 2010 were selected and matched 1:4 to controls without a family history for estimating MACE-free survival. The dates of analysis were January 2010 to December 2013. Main Outcomes and Measures The prevalence and relative risk of AF in relatives of patients with AF, as well as the relative contributions of heritability and shared and nonshared environmental factors to AF susceptibility. Also measured was MACE-free survival after AF was diagnosed. Results In total, 1510 patients (204 [13.5%] female; mean [SD] age, 57.9 [9.2] years) had newly diagnosed AF with a first-degree relative affected by AF. Individuals with a first-degree relative affected by AF had a relative risk of 1.92 (95% CI, 1.84-1.99) for AF. The accountability for the phenotypic variance of AF was 19.9% for genetic factors (heritability), 3.5% for shared environmental factors, and 76.6% for nonshared environmental factors. After matching for age, sex, hypertension, type 2 diabetes, previous stroke, and anticoagulation, incident AF patients with vs without an affected first-degree relative had similar MACE-free survival. Conclusions and Relevance Genetic and environmental factors were associated with AF, with nonshared environmental factors accounting for three-fourths of the phenotypic variance in Taiwan. Patients having AF with a first-degree relative affected by AF did not have more MACE. Therefore, family history may not be particularly informative in the diagnosis or management of AF.
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Affiliation(s)
- Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Orthopedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, England.,Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Centre, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Hui Yu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shue-Fen Luo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lu-Hsiang Huang
- Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Weiya Zhang
- Division of Rheumatology, Orthopedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, England
| | - Michael Doherty
- Division of Rheumatology, Orthopedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, England
| | - Ming-Shien Wen
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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25
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Chan YH, Lee HF, See LC, Tu HT, Chao TF, Yeh YH, Wu LS, Kuo CT, Chang SH, Lip GYH. Effectiveness and Safety of Four Direct Oral Anticoagulants in Asian Patients With Nonvalvular Atrial Fibrillation. Chest 2019; 156:529-543. [PMID: 31103697 DOI: 10.1016/j.chest.2019.04.108] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/01/2019] [Accepted: 04/19/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Whether four direct oral anticoagulants (DOACs) are superior to warfarin in Asian patients with nonvalvular atrial fibrillation (NVAF) remains unclear. METHODS This nationwide retrospective cohort study was based on data from Taiwan's National Health Insurance Research Database from June 1, 2012, to December 31, 2017, covering patients with NVAF taking edoxaban (n = 4,577), apixaban (n = 9,952), rivaroxaban (n = 33,022), dabigatran (n = 22,371), and warfarin (n = 19,761). Propensity score weighting was used to balance covariates across study groups. Patients were followed up until occurrence of study outcomes or end date of study. RESULTS Edoxaban, apixaban, and rivaroxaban were associated with a lower risk of ischemic stroke/systemic embolism than warfarin. All DOACs had a lower risk of major bleeding than warfarin. Apixaban was associated with a lower risk of major bleeding than rivaroxaban and dabigatran, whereas the risk of major bleeding was comparable between edoxaban and apixaban. The reduced risks of thromboembolism/major bleeding for the four DOACs persisted in high-risk subgroups, including those with chronic kidney disease, elderly patients (age ≥ 75 years), secondary stroke prevention, or CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, age 65-74 years, and female sex) ≥ 4. A total of 2,924 (64%), 6,359 (64%), 31,108 (94%), and 19,821 (89%) patients received low-dose edoxaban (15-30 mg/d), apixaban (2.5 mg bid), rivaroxaban (10-15 mg/d), and dabigatran (110 mg bid), respectively. The effectiveness/safety outcomes with the four low-dose DOACs compared with warfarin were consistent with the main analysis. CONCLUSIONS In the largest real-world practice study among Asian patients with NVAF, four DOACs were associated with a comparable or lower risk of thromboembolism, and a lower risk of bleeding than warfarin. There was consistency even among high-risk subgroups and whether standard-or low-dose regimens were compared.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Public Health, Chang Gung University, Taoyuan, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Public Health, Chang Gung University, Taoyuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, England
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Abstract
UNLABELLED Osteoporosis is a well-known bone disorder affecting people worldwide. Patients with osteoporosis have an increased risk of bone fracture. This study provides new information on the risk of developing osteoporosis post burn injury and the risk of fracture among those with osteoporosis developed. INTRODUCTION The relationship between burn injury and hip fracture risk is unclear. Population-based evaluation on relationships between burn injury and osteoporosis development and subsequent fractures is limited. We conducted a retrospective cohort study as the investigation. METHODS From the insurance data of Taiwan, we established a cohort of 43,532 patients with a burn injury in 2000-2012 and a comparison cohort of 174,124 individuals without such an injury, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2013 to evaluate the occurrence of osteoporosis and hip fracture. RESULTS The incidence of osteoporosis was greater in the burn cohort than in the comparison cohort (6.40 vs. 4.75 per 1,000 person-years) with an adjusted IRR of 1.35 (95% confidence interval = 1.32-1.39). The incidence rates in both cohorts were greater in women than in men, increased with age, income, and Charlson comorbidity index. Patients with burns involving 20%-49% of total body surface area and with burns confined to the lower/upper limbs had the greatest incidence rates, 8.32 and 8.58 per 1,000 person-years, respectively. Osteoporosis incidence increased further to 22.7 per 1,000 person-years for burn victims with comorbid diabetes. The risk of fracture was over five-fold greater for burn victims with osteoporosis developed than for comparisons without osteoporosis. CONCLUSION Patients who have a burn injury deserve prevention intervention to reduce the risk of osteoporosis and fracture.
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Affiliation(s)
- O Kaewboonchoo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand
| | - F C Sung
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H C Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - C T Kuo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand.
- Department of Public Health, China Medical University College of Public Health, 91 Hseuh Shis Road, Taichung, 404, Taiwan.
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Wang CL, Kuo CF, Yeh YH, Hsieh MY, Kuo CT, Chang SH. Familial aggregation of myocardial infarction and coaggregation of myocardial infarction and autoimmune disease: a nationwide population-based cross-sectional study in Taiwan. BMJ Open 2019; 9:e023614. [PMID: 30898803 PMCID: PMC6475449 DOI: 10.1136/bmjopen-2018-023614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This study examined how a history of myocardial infarction (MI) in a person's first-degree relatives affects that person's risk of developing MI and autoimmune diseases. DESIGN Nationwide population-based cross-sectional study SETTING: All healthcare facilities in Taiwan. PARTICIPANTS A total of 24 361 345 individuals were enrolled. METHODS Using data from the National Health Insurance Research Database in Taiwan, we conducted a nationwide cross-sectional study of data collected from all beneficiaries in the Taiwan National Health Insurance system in 2015, of whom 259 360 subjects had at least one first-degree relative affected by MI in 2015. We estimated the absolute risks and relative risks (RRs) of MI and autoimmune disease in those subjects, and the relative contribution of genetic and environmental factors to their MI susceptibility. RESULTS The absolute risks of MI for subjects with at least one affected first-degree relative and the general population were 0.87% and 0.56%, respectively, in 2015. Patients with affected first-degree relatives were significantly associated with a higher RR of MI (1.76, 95% CI: 1.68 to 1.85) compared with the general population. There was no association with a higher RR of autoimmune disease. The sibling, offspring and parental MI history conferred RRs (95% CI) for MI of 2.35 (1.96 to 2.83), 2.21 (2.05 to 2.39) and 1.60 (1.52 to 1.68), respectively. The contributions of heritability, shared environmental factors and non-shared environmental factors to MI susceptibility were 19.6%, 3.4% and 77.0%, respectively. CONCLUSIONS Individuals who have first-degree relatives with a history of MI have a higher risk of developing MI than the general population. Non-shared environmental factors contributed more significantly to MI susceptibility than did heritability and shared environmental factors. A family history of MI was not associated with an increased risk of autoimmune disease.
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Affiliation(s)
- Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yun Hsieh
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
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28
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Chan YH, Yeh YH, Hsieh MY, Chang CY, Tu HT, Chang SH, See LC, Kuo CF, Kuo CT. The risk of acute kidney injury in Asians treated with apixaban, rivaroxaban, dabigatran, or warfarin for non-valvular atrial fibrillation: A nationwide cohort study in Taiwan. Int J Cardiol 2019; 265:83-89. [PMID: 29885705 DOI: 10.1016/j.ijcard.2018.02.075] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/02/2018] [Accepted: 02/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Whether or not non-vitamin K antagonist oral anticoagulants (NOACs) are associated with a lower risk of acute kidney injury (AKI) in patients with non-valvular atrial fibrillation (NVAF) remains unknown in real world practice. METHODS In this nationwide retrospective cohort study, 1507, 3200, 5765 and 4227 NVAF patients with chronic kidney disease (CKD) and 4368, 16,945, 22,301, and 16,908 NVAF patients without CKD taking apixaban, dabigatran, rivaroxaban, and warfarin, respectively, from June 1, 2012 to December 31, 2016 were enrolled from the Taiwan National Health Insurance Program. Propensity-score weighted method was used to balance covariates across study groups. Patients were followed until occurrence of AKI or end date of study. RESULTS Three NOACs were all associated with a significantly lower risk of AKI compared with warfarin for both CKD-free (hazard ratio, [95% confidential interval]; 0.65, [0.60-0.72] for apixaban; 0.68, [0.64-0.74] for dabigatran; 0.73, [0.68-0.79] for rivaroxaban) and CKD cohorts (0.50, [0.45-0.56] for apixaban; 0.54, [0.49-0.59] for dabigatran; 0.53, [0.49-0.58] for rivaroxaban). The annual incidence of AKI for all NOACs and warfarin increased gradually as the increment of CHA2DS2-VASc for both CKD-free and CKD cohorts after propensity score weighting. The reduced risk of AKI for three NOACs persisted in most subgroups in either CKD-free or CKD cohort. Multivariate analysis indicated that all three NOACs were all associated with lower risk of AKI than warfarin in either CKD-free or CKD cohort. CONCLUSIONS All three NOACs are associated with a lower risk of AKI than warfarin among Asians with NVAF in real-world practice.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Mei-Yun Hsieh
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Chia-Yu Chang
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Lai-Chu See
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan.
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.
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Lee KT, Chang SH, Yeh YH, Tu HT, Chan YH, Kuo CT, See LC. The CHA₂DS₂-VASc Score Predicts Major Bleeding in Non-Valvular Atrial Fibrillation Patients Who Take Oral Anticoagulants. J Clin Med 2018; 7:jcm7100338. [PMID: 30304802 PMCID: PMC6210214 DOI: 10.3390/jcm7100338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/03/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Patients with atrial fibrillation (AF) are at a substantial risk of ischemic stroke. The CHA2DS2-VASc score predicts the risk of thromboembolism, but its role in predicting major bleeding in patients taking oral anticoagulants is unclear. Methods: We used the National Health Insurance Research Database (NHIRD) of Taiwan to identify patients with AF from 2010 to 2016. They were divided into four groups according to the oral anticoagulants. The outcomes were ischemic stroke/systemic thromboembolism, and major bleeding. Results: A total of 279,776 patients were identified. Ischemic stroke or systemic embolism events were observed in 1.73%, 3.62%, 4.36%, and 5.02% of the patients in the apixaban, rivaroxaban, dabigatran, and warfarin groups, respectively. Major bleeding was recorded in 1.18%, 2.66%, 3.23%, and 4.70% of the patients in the apixaban, rivaroxaban, dabigatran, and warfarin groups, respectively. The highest rates for both ischemic stroke and bleeding events occurred in the patients with a CHA2DS2-VASc score of five or more. Conclusion: Non-valvular AF patients with high CHA2DS2-VASc scores are susceptible to both systemic thromboembolism and major bleeding. The trend was consistently observed in patients who took non-vitamin K oral anticoagulants (NOACs) or warfarin. NOACs might be potentially more effective in reducing overall events.
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Affiliation(s)
- Kuang-Tso Lee
- Cardiovascular Department of Chang-Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
| | - Shang-Hung Chang
- Cardiovascular Department of Chang-Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
- Medical School, Chang Gung University, Taoyuan City 33302, Taiwan.
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33303, Taiwan.
| | - Yung-Hsin Yeh
- Cardiovascular Department of Chang-Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
| | - Hui-Tzu Tu
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33305, Taiwan.
| | - Yi-Hsin Chan
- Cardiovascular Department of Chang-Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
| | - Chi-Tai Kuo
- Cardiovascular Department of Chang-Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 33305, Taiwan.
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City 33305, Taiwan.
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City 33305, Taiwan.
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30
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Lee HF, See LC, Chan YH, Yeh YH, Wu LS, Liu JR, Tu HT, Wang CL, Kuo CT, Chang SH. End-stage renal disease patients using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may reduce the risk of mortality: a Taiwanese Nationwide cohort study. Intern Med J 2018; 48:1123-1132. [DOI: 10.1111/imj.13971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 05/06/2018] [Accepted: 05/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Hsin-Fu Lee
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center; Chang Gung University; Taoyuan Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine; Chang Gung Memorial Hospital; Linkou Taiwan
| | - Yi-Hsin Chan
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Yung-Hsin Yeh
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Lung-Sheng Wu
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Chun-Li Wang
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Chi-Tai Kuo
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Shang-Hung Chang
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
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Chen YJ, Wang JS, Hsu CC, Lin PJ, Tsai FC, Wen MS, Kuo CT, Huang SC. Cerebral desaturation in heart failure: Potential prognostic value and physiologic basis. PLoS One 2018; 13:e0196299. [PMID: 29689105 PMCID: PMC5916527 DOI: 10.1371/journal.pone.0196299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 04/10/2018] [Indexed: 01/01/2023] Open
Abstract
Cerebral tissue oxygen saturation (SctO2) reflects cerebral perfusion and tissue oxygen consumption, which decline in some patients with heart failure with reduced ejection fraction (HFrEF) or stroke, especially during exercise. Its physiologic basis and clinical significance remain unclear. We aimed to investigate the association of SctO2 with oxygen transport physiology and known prognostic factors during both rest and exercise in patients with HFrEF or stroke. Thirty-four HFrEF patients, 26 stroke patients, and 17 healthy controls performed an incremental cardiopulmonary exercise test using a bicycle ergometer. Integrated near-infrared spectroscopy and automatic gas analysis were used to measure cerebral tissue oxygenation and cardiac and ventilatory parameters. We found that SctO2 (rest; peak) were significantly lower in the HFrEF (66.3±13.3%; 63.4±13.8%,) than in the stroke (72.1±4.2%; 72.7±4.5%) and control (73.1±2.8%; 72±3.2%) groups. In the HFrEF group, SctO2 at rest (SctO2rest) and peak SctO2 (SctO2peak) were linearly correlated with brain natriuretic peptide (BNP), peak oxygen consumption ( V˙O2peak), and oxygen uptake efficiency slope (r between -0.561 and 0.677, p < 0.001). Stepwise linear regression showed that SctO2rest was determined by partial pressure of end-tidal carbon dioxide at rest (PETCO2rest), hemoglobin, and mean arterial pressure at rest (MAPrest) (adjusted R = 0.681, p < 0.05), while SctO2peak was mainly affected by peak carbon dioxide production ( V˙CO2peak) (adjusted R = 0.653, p < 0.05) in patients with HFrEF. In conclusion, the study delineates the relationship of cerebral saturation and parameters associated with oxygen delivery. Moreover, SctO2peak and SctO2rest are correlated with some well-recognized prognostic factors in HFrEF, suggesting its potential prognostic value.
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Affiliation(s)
- Yu-Jen Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jong-Shyan Wang
- Healthy Aging Research Center, Graduate Institute of Rehabilitation Science, Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Chin Hsu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Pyng-Jing Lin
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Feng-Chun Tsai
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Shien Wen
- Cardiovascular Division, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Division, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shu-Chun Huang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
- * E-mail:
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32
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Chan YH, See LC, Tu HT, Yeh YH, Chang SH, Wu LS, Lee HF, Wang CL, Kuo CF, Kuo CT. Efficacy and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Asians With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2018; 7:JAHA.117.008150. [PMID: 29622587 PMCID: PMC6015442 DOI: 10.1161/jaha.117.008150] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin among Asians with nonvalvular atrial fibrillation remains unclear. Methods and Results In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, there were 5843, 20 079, 27 777, and 19 375 nonvalvular atrial fibrillation patients taking apixaban, dabigatran, rivaroxaban and warfarin, respectively, from June 1, 2012 to December 31, 2016. Propensity‐score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any efficacy or safety outcome or the end date of study. Hazard ratios (95% confidence intervals) comparing apixaban, dabigatran, and rivaroxaban with warfarin were: ischemic stroke/systemic embolism (IS/SE), 0.55 (0.43–0.69), 0.82 (0.68–0.98), and 0.81 (0.67–0.97); major bleeding, 0.41 (0.31–0.53), 0.65 (0.53–0.80), and 0.58 (0.46–0.72); and all‐cause mortality, 0.58 (0.51–0.66), 0.61 (0.54–0.68), and 0.57 (0.51–0.65). A total of 3623 (62%), 17 760 (88%), and 26 000 (94%) patients were taking low‐dose apixaban (2.5 mg twice daily), dabigatran (110 mg twice daily), and rivaroxaban (10–15 mg once daily), respectively. Similar to all‐dose NOACs, all low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. In contrast to other standard‐dose NOACs, apixaban was associated with lower risks of IS/SE (0.45 [0.31–0.65]), major bleeding (0.29 [0.18–0.46]), and mortality (0.23 [0.17–0.31]) than warfarin. Conclusions All NOACs were associated with lower risk of IS/SE, major bleeding, and mortality compared with warfarin in the largest real‐world practice among Asians with nonvalvular atrial fibrillation. All low‐dose NOACs had lower risk of IS/SE, major bleeding, and mortality when compared with warfarin. Standard‐dose apixaban caused a lower risk of IS/SE, major bleeding, and mortality compared with warfarin.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan .,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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33
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Chang CY, Yeh YH, Chan YH, Liu JR, Chang SH, Lee HF, Wu LS, Yen KC, Kuo CT, See LC. Dipeptidyl peptidase-4 inhibitor decreases the risk of atrial fibrillation in patients with type 2 diabetes: a nationwide cohort study in Taiwan. Cardiovasc Diabetol 2017; 16:159. [PMID: 29258504 PMCID: PMC5735601 DOI: 10.1186/s12933-017-0640-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/06/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Whether dipeptidyl peptidase-4 inhibitor (DPP4i) is associated with a lower risk of new-onset atrial fibrillation (AF) in patients with diabetes remains unclear. This study aimed to evaluate the risk of AF associated with use of DPP4i among a longitudinal cohort of patients with diabetes. METHODS Over a 3-year period, 480,000 patients with diabetes were analyzed utilizing Taiwan's National Health Insurance Research Database and 90,880 patients taking metformin as first-line therapy were enrolled. Patients were further divided into two groups: (1) DPP4i users: those taking DPP4i and (2) non-DPP4i users: those prescribed other hypoglycemic agents (HAs) as second-line drug. Study end point was defined by diagnosis of AF, addition of any third-line HA, or the end of the study period (December 31, 2013), whichever came first. RESULTS A total of 16,017 DPP4i users and 74,863 non-DPP4i users were eligible for the study. For the DPP4i group, most patients were prescribed sitagliptin (n = 12,180; 76%). Among the non-DPP4i group, most patients took sulfonylurea (n = 60,606; 81%) as their second-line medication. DPP4i users were associated with a lower risk of new-onset AF compared with non-DPP4i users after propensity-score weighting (hazard ratio 0.65; P < 0.0001). Subgroup analysis showed that DPP4i user were associated with a lower risk of new-onset AF compared with non-DPP4i users in most subgroups. Multivariate analysis indicated that use of DPP4i was associated with lower risk of new-onset AF and age > 65 years, presence of hypertension, and ischemic heart disease were independent risk factors for new-onset AF. CONCLUSIONS Among patients with diabetes prescribed with metformin, the patients with DPP4i as second HA were associated with a lower risk of AF compared with the patients with other drugs as second HAs in real-world practice.
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Affiliation(s)
- Chia-Yu Chang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Yung-Hsin Yeh
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Yi-Hsin Chan
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.,Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan, Taoyuan, 33302, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Lung-Sheng Wu
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Kun-Chi Yen
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Chi-Tai Kuo
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan, Taoyuan, 33302, Taiwan. .,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan. .,Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan.
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Kaewboonchoo O, Sung FC, Lin CL, Hsu HC, Kuo CT. Hip fracture risk in patients with burn injury: a retrospective cohort study in Taiwan. Osteoporos Int 2017; 28:3415-3420. [PMID: 28875313 DOI: 10.1007/s00198-017-4209-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED This work aimed to evaluate the hip fracture risk for patients with burn injury. A total of 16,430 patients with burn injury had an adjusted hazard ratio of 1.54 to encounter a hip fracture, compared with controls without the injury. These results encourage future studies focusing on mechanisms leading to fracture associated with burn injury. INTRODUCTION The relationship between burn injury and hip fracture risk is unclear. We conducted a retrospective cohort study to investigate this relationship. METHODS From insurance data of Taiwan, we identified a cohort with 16,430 burn patients in 2000-2010 and a comparison cohort of 65,716 persons without the history of burn, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2011 to evaluate the risk of hip fracture. RESULTS Patients with burn injury were 1.62-fold more likely than comparisons to encounter a hip fracture (6.95 vs. 4.28 per 1000 person-years), with an adjusted hazard ratio (aHR) of 1.54 (95% confidence interval (CI) = 1.40-1.68). The fracture incidence increased with age and is slightly greater for women than for men in both cohorts. The fracture risk was greater for patients with burn in the eyes, face, and head with an incidence of 7.14 per 1000 person-years, or an aHR of 2.09 (95% CI = 1.53, 2.86). Diabetes and osteoporosis were also associated with an increased hip fracture risk. CONCLUSION Burn injury is associated with an increased risk of hip fracture. Diabetes and osteoporosis are associated with an enhanced risk.
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Affiliation(s)
- O Kaewboonchoo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
| | - F C Sung
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H C Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - C T Kuo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand.
- Department of Public Health, China Medical University College of Public Health, 91 Hseuh Shih Road, Taichung, 404, Taiwan.
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Chan YH, Yeh YH, Tu HT, Kuo CT, Chang SH, Wu LS, Lee HF, See LC. Bleeding risk with dabigatran, rivaroxaban, warfarin, and antiplatelet agent in Asians with non-valvular atrial fibrillation. Oncotarget 2017; 8:98898-98917. [PMID: 29228736 PMCID: PMC5716776 DOI: 10.18632/oncotarget.22026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
It is not understood if dabigatran or rivaroxaban are superior to antiplatelet agents (AA) for safety outcomes in Asians with non-valvular atrial fibrillation (NVAF). In this study we evaluated the bleeding risk of dabigatran, rivaroxaban, warfarin and AA in Asians with NVAF. This national retrospective cohort study analyzed 6,600, 3,167, 5,338 and 8,238 consecutive NVAF patients taking dabigatran, rivaroxaban, warfarin or AAs (including aspirin, clopidogrel or ticlopidine), respectively, from June 1, 2012 to December 31, 2013. Propensity-score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any bleeding outcome or the end of the study. The CHA2DS2-VASc scores were 4.1±1.6, 4.1±1.6, 3.3±1.8 and 2.4±1.6 for the dabigatran, rivaroxaban, warfarin, and AA groups, respectively. There were 5,822 (88.2%) and 164 (5.2%) patients taking low dose dabigatran and rivaroxaban, respectively. Hazard ratios (95% confidence intervals) for dabigatran, rivaroxaban, or warfarin versus AA were: intracranial hemorrhage, 0.36 (0.23-0.57;PP=0.0037) and 1.34 (0.89-2.02;P=0.1664); gastrointestinal bleeding, 0.44 (0.32-0.59;PP=0.0189); and all hospitalized major bleeding, 0.41 (0.32-0.53;PP=0.0644) and 0.90 (0.70-1.16;P=0.4130) after adjustment. The risk reduction of all major bleeding for dabigatran versus AA persisted on subgroup analysis. In conclusion, we observed that dabiagtran was associated with a lower risk of all major bleeding in Asians with NVAF, whereas rivaroxaban had a similar risk of all major bleeding compared with antiplatelet agents after adjustment of comorbidities.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Center for Big Data Analytics and Statistics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang-Gung University, Taoyuan, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
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Chang SH, Chou IJ, Yeh YH, Chiou MJ, Wen MS, Kuo CT, See LC, Kuo CF. Association Between Use of Non-Vitamin K Oral Anticoagulants With and Without Concurrent Medications and Risk of Major Bleeding in Nonvalvular Atrial Fibrillation. JAMA 2017; 318:1250-1259. [PMID: 28973247 PMCID: PMC5818856 DOI: 10.1001/jama.2017.13883] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Non-vitamin K oral anticoagulants (NOACs) are commonly prescribed with other medications that share metabolic pathways that may increase major bleeding risk. OBJECTIVE To assess the association between use of NOACs with and without concurrent medications and risk of major bleeding in patients with nonvalvular atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using data from the Taiwan National Health Insurance database and including 91 330 patients with nonvalvular atrial fibrillation who received at least 1 NOAC prescription of dabigatran, rivaroxaban, or apixaban from January 1, 2012, through December 31, 2016, with final follow-up on December 31, 2016. EXPOSURES NOAC with or without concurrent use of atorvastatin; digoxin; verapamil; diltiazem; amiodarone; fluconazole; ketoconazole, itraconazole, voriconazole, or posaconazole; cyclosporine; erythromycin or clarithromycin; dronedarone; rifampin; or phenytoin. MAIN OUTCOMES AND MEASURES Major bleeding, defined as hospitalization or emergency department visit with a primary diagnosis of intracranial hemorrhage or gastrointestinal, urogenital, or other bleeding. Adjusted incidence rate differences between person-quarters (exposure time for each person during each quarter of the calendar year) of NOAC with or without concurrent medications were estimated using Poisson regression and inverse probability of treatment weighting using the propensity score. RESULTS Among 91 330 patients with nonvalvular atrial fibrillation (mean age, 74.7 years [SD, 10.8]; men, 55.8%; NOAC exposure: dabigatran, 45 347 patients; rivaroxaban, 54 006 patients; and apixaban, 12 886 patients), 4770 major bleeding events occurred during 447 037 person-quarters with NOAC prescriptions. The most common medications co-prescribed with NOACs over all person-quarters were atorvastatin (27.6%), diltiazem (22.7%), digoxin (22.5%), and amiodarone (21.1%). Concurrent use of amiodarone, fluconazole, rifampin, and phenytoin with NOACs had a significant increase in adjusted incidence rates per 1000 person-years of major bleeding than NOACs alone: 38.09 for NOAC use alone vs 52.04 for amiodarone (difference, 13.94 [99% CI, 9.76-18.13]); 102.77 for NOAC use alone vs 241.92 for fluconazole (difference, 138.46 [99% CI, 80.96-195.97]); 65.66 for NOAC use alone vs 103.14 for rifampin (difference, 36.90 [99% CI, 1.59-72.22); and 56.07 for NOAC use alone vs 108.52 for phenytoin (difference, 52.31 [99% CI, 32.18-72.44]; P < .01 for all comparisons). Compared with NOAC use alone, the adjusted incidence rate for major bleeding was significantly lower for concurrent use of atorvastatin, digoxin, and erythromycin or clarithromycin and was not significantly different for concurrent use of verapamil; diltiazem; cyclosporine; ketoconazole, itraconazole, voriconazole, or posaconazole; and dronedarone. CONCLUSIONS AND RELEVANCE Among patients taking NOACs for nonvalvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampin, and phenytoin compared with the use of NOACs alone, was associated with increased risk of major bleeding. Physicians prescribing NOAC medications should consider the potential risks associated with concomitant use of other drugs.
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Affiliation(s)
- Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Jun Chou
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Neurology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Meng-Jiun Chiou
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine and Biostatistics Core Laboratory, Molecular Medicine Research Centre, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Chang SH, Yeh YH, Lee JL, Hsu YJ, Kuo CT, Chen WJ. Transforming growth factor-β-mediated CD44/STAT3 signaling contributes to the development of atrial fibrosis and fibrillation. Basic Res Cardiol 2017; 112:58. [PMID: 28871329 DOI: 10.1007/s00395-017-0647-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/29/2017] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is associated with atrial fibrosis. Inhibition of atrial fibrosis might be a plausible approach for AF prevention and therapy. This study is designed to evaluate the potential role of CD44, a membrane receptor known to regulate fibrosis, and its related signaling in the pathogenesis of atrial fibrosis and AF. Treatment of cultured rat atrial fibroblasts with transforming growth factor-β (TGF-β, a key mediator of atrial fibrosis) led to a higher expression of hyaluronan (HA), CD44, STAT3, and collagen (a principal marker of fibrosis) than that of ventricular fibroblasts. In vivo, TGF-β transgenic mice and AF patients exhibited a greater expression of HA, CD44, STAT3, and collagen in their atria than wild-type mice and sinus rhythm subjects, respectively. Treating TGF-β transgenic mice with an anti-CD44 blocking antibody resulted in a lower expression of STAT3 and collagen in their atria than those with control IgG antibody. Programmed stimulation triggered less AF episodes in TGF-β transgenic mice treated with anti-CD44 blocking antibody than in those with control IgG. Blocking CD44 signaling with anti-CD44 antibody and mutated CD44 plasmids attenuated TGF-β-induced STAT3 activation and collagen expression in cultured atrial fibroblasts. Deletion and mutational analysis of the collagen promoter along with chromatin immunoprecipitation demonstrated that STAT3 served as a vital transcription factor in collagen expression. TGF-β-mediated HA/CD44/STAT3 pathway plays a crucial role in the development of atrial fibrosis and AF. Blocking CD44-dependent signaling may be a feasible way for AF management.
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Affiliation(s)
- Shang-Hung Chang
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Fu-Shin Road No. 5, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Fu-Shin Road No. 5, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Jia-Lin Lee
- Department of Medical Science, Institute of Molecular and Cellular Biology, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Fu-Shin Road No. 5, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Wei-Jan Chen
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Fu-Shin Road No. 5, Kwei-Shan, Taoyuan, 333, Taiwan.
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Lee KT, Yeh YH, Chang SH, See LC, Lee CH, Wu LS, Liu JR, Kuo CT, Wen MS. Metformin is associated with fewer major adverse cardiac events among patients with a new diagnosis of type 2 diabetes mellitus: A propensity score-matched nationwide study. Medicine (Baltimore) 2017; 96:e7507. [PMID: 28700501 PMCID: PMC5515773 DOI: 10.1097/md.0000000000007507] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/15/2017] [Accepted: 06/23/2017] [Indexed: 01/05/2023] Open
Abstract
Early type 2 diabetes mellitus (DM) may only require lifestyle modifications for glycemic control without the need for oral hypoglycemic agents (OHAs). Metformin is believed to improve cardiovascular outcomes in patients with DM, and it is considered to be a first-line therapy. However, it is unclear whether metformin is beneficial for patients with a new diagnosis of DM compared to those who do not need OHAs for glycemic control.Data were obtained from a population-based health care database in Taiwan. Patients with a new diagnosis of DM were enrolled if they received metformin monotherapy only between 1999 and 2010. A 4:1 propensity score-matched cohort of patients with a new diagnosis of DM who did not take OHAs or insulin during follow-up was also enrolled. The primary study endpoint was the occurrence of major adverse cardiovascular events (MACEs). The time to the endpoints was compared between groups using Cox proportional hazards models.A total of 474,410 patients with DM were enrolled. During a mean 5.8 years of follow-up, the incidence of MACEs was 1.072% (1072 per 100,000 person-years) in the metformin monotherapy group versus 1.165% in the lifestyle modification group (those who did not take OHAs) (P < .001). After adjusting for confounders, metformin independently protected the DM patients from MACEs (hazard ratio: 0.83, P < .001). The metformin group also had an improved MACE-free survival profile from year 1 to year 12 (P < .001).In addition to lifestyle modifications, the patients with a new diagnosis of DM treated with metformin monotherapy had a lower MACE rate than those who did not take OHAs. Our findings suggest that metformin may be given early to patients with a new diagnosis of DM, even when they do not need OHAs for glycemic control.
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Affiliation(s)
- Kuang-Tso Lee
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Yung-Hsin Yeh
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Shang-Hung Chang
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taiwan
| | - Cheng-Hung Lee
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Lung-Sheng Wu
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University
| | - Chi-Tai Kuo
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
| | - Ming-Shien Wen
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei
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Chan YH, Kuo CT, Yeh YH, Chang SH, Wu LS, Lee HF, Tu HT, See LC. Thromboembolic, Bleeding, and Mortality Risks of Rivaroxaban and Dabigatran in Asians With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2017; 68:1389-1401. [PMID: 27659460 DOI: 10.1016/j.jacc.2016.06.062] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND It is unclear whether the non-vitamin K antagonist oral anticoagulant agents rivaroxaban and dabigatran are superior to warfarin for efficacy and safety outcomes in Asians with nonvalvular atrial fibrillation (NVAF). OBJECTIVES The aim of this study was to compare the risk for thromboembolic events, bleeding, and mortality associated with rivaroxaban and dabigatran versus warfarin in Asians with NVAF. METHODS A nationwide retrospective cohort study was conducted of consecutive patients with NVAF taking rivaroxaban (n = 3,916), dabigatran (n = 5,921), or warfarin (n = 5,251) using data collected from the Taiwan National Health Insurance Research Database between February 1, 2013 and December 31, 2013. The propensity score weighting method was used to balance covariates across study groups. Patients were followed until the first occurrence of any study outcome or the study end date (December 31, 2013). RESULTS A total of 3,425 (87%) and 5,301 (90%) patients were taking low-dose rivaroxaban (10 to 15 mg once daily) and dabigatran (110 mg twice daily), respectively. Compared with warfarin, both rivaroxaban and dabigatran significantly decreased the risk for ischemic stroke or systemic embolism (p = 0.0004 and p = 0.0006, respectively), intracranial hemorrhage (p = 0.0007 and p = 0.0005, respectively), and all-cause mortality (p < 0.0001 and p < 0.0001, respectively) during the short follow-up period. In comparing the 2 non-vitamin K antagonist oral anticoagulant agents with each other, no differences were found regarding risk for ischemic stroke or systemic embolism, intracranial hemorrhage, myocardial infarction, or mortality. Rivaroxaban carried a significantly higher risk for hospitalization for gastrointestinal bleeding than dabigatran (p = 0.0416), but on-treatment analysis showed that the risk for hospitalized gastrointestinal bleeding was similar between the 2 drugs (p = 0.5783). CONCLUSIONS In real-world practice among Asians with NVAF, both rivaroxaban and dabigatran were associated with reduced risk for ischemic stroke or systemic embolism, intracranial hemorrhage, and all-cause mortality without significantly increased risk for acute myocardial infarction or hospitalization for gastrointestinal bleeding compared with warfarin.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.
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Chan YH, Yeh YH, See LC, Wang CL, Chang SH, Lee HF, Wu LS, Tu HT, Kuo CT. Acute Kidney Injury in Asians With Atrial Fibrillation Treated With Dabigatran or Warfarin. J Am Coll Cardiol 2017; 68:2272-2283. [PMID: 27884245 DOI: 10.1016/j.jacc.2016.08.063] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/23/2016] [Accepted: 08/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Whether dabigatran is associated with a lower risk of acute kidney injury (AKI) in patients with nonvalvular atrial fibrillation (NVAF) remains unknown. OBJECTIVES The authors compared the risk of AKI in Asians with NVAF who were prescribed dabigatran versus warfarin. METHODS The authors analyzed patients enrolled in the Taiwan nationwide retrospective cohort study from June 1, 2012, to December 31, 2013. Dabigatran and warfarin were taken by 7,702 and 7,885 NVAF patients without a history of chronic kidney disease (CKD) and 2,256 and 2,089 NVAF patients with a history of CKD, respectively. A propensity-score weighted method was used to balance covariates across study groups. RESULTS A total of 6,762 (88%) and 940 (12%) CKD-free patients and 2,025 (90%) and 231 (10%) CKD patients took dabigatran 110 mg and 150 mg twice daily, respectively. Dabigatran was associated with a lower risk of AKI than warfarin for either the CKD-free (hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.49 to 0.77; p < 0.001) or CKD (HR: 0.56; 95% CI: 0.46 to 0.69; p < 0.001) cohort. As the increment in CHA2DS2-VASc score (a risk score based on congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, aged 65 to 74 years, and female sex) increased from 0/1 to 6+ points, the incidence of AKI for the dabigatran group was relatively stable (1.87% to 2.91% per year for the CKD-free cohort; 7.31% to 13.15% per year for the CKD cohort) but increased obviously for patients taking warfarin for either CKD-free (2.00% to 6.16% per year) or CKD cohorts (6.82 to 26.03% per year). The warfarin group had a significantly higher annual risk of AKI than the dabigatran group for those with a high CHA2DS2-VASc score (≥4 for the CKD-free cohort and ≥3 for the CKD cohort). Subgroup analysis revealed that among dabigatran users, those taking either low-dose or standard-dose dabigatran, those with a warfarin-naïve or warfarin-experienced history, those with or without diabetes, and those with CHA2DS2-VASc ≥4 or HAS-BLED ≥3 (risk score based on hypertension, abnormal renal and liver function, stroke, prior major bleeding, labile international normalized ratios, age 65 years or older, drugs or alcohol usage history) all had a lower risk of AKI than those taking warfarin. CONCLUSIONS Among Asians with NVAF, dabigatran is associated with a lower risk of AKI than warfarin.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan; Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Li Wang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Hsiao FC, Yeh YH, Chen WJ, Chan YH, Kuo CT, Wang CL, Chang CJ, Tsai HY, Tsai FC, Hsu LA. MMP9 Rs3918242 Polymorphism Affects Tachycardia-Induced MMP9 Expression in Cultured Atrial-Derived Myocytes but Is Not a Risk Factor for Atrial Fibrillation among the Taiwanese. Int J Mol Sci 2016; 17:521. [PMID: 27070579 PMCID: PMC4848977 DOI: 10.3390/ijms17040521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 03/23/2016] [Accepted: 03/29/2016] [Indexed: 12/19/2022] Open
Abstract
Matrix metalloproteinase (MMP) plays an important role in the pathogenesis of atrial fibrillation (AF). The MMP9 promoter has a functional polymorphism rs3918242 that can regulate the level of gene transcription. This study recruited 200 AF patients and 240 controls. The MMP9 rs3918242 was examined by polymerase chain reactions. HL-1 atrial myocytes were cultured and electrically stimulated. Right atrial appendages were obtained from six patients with AF and three controls with sinus rhythm undergoing open heart surgery. The MMP9 expression and activity were determined using immunohistochemical analysis and gelatin zymography, respectively. Rapid pacing induces MMP9 secretion from HL-1 myocytes in a time- and dose-dependent manner. The responsiveness of MMP9 transcriptional activity to tachypacing was significantly enhanced by rs3918242. The expression of MMP9 was increased in fibrillating atrial tissue than in sinus rhythm. However, the distribution of rs3918242 genotypes and allele frequencies did not significantly differ between the control and AF groups. HL-1 myocyte may secrete MMP9 in response to rapid pacing, and the secretion could be modulated by rs3918242. Although the MMP9 expression of human atrial myocyte is associated with AF, our study did not support the association of susceptibility to AF among Taiwanese subjects with the MMP9 rs3918242 polymorphism.
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Affiliation(s)
- Fu-Chih Hsiao
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Yung-Hsin Yeh
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Wei-Jan Chen
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Yi-Hsin Chan
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Chi-Tai Kuo
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Chun-Li Wang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Chi-Jen Chang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Hsin-Yi Tsai
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
| | - Feng-Chun Tsai
- Division of Cardiac Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan.
| | - Lung-An Hsu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Shin Road, Kwei-Shan, Taoyuan 33305, Taiwan.
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Wu LS, Chang SH, Chang GJ, Liu JR, Chan YH, Lee HF, Wen MS, Chen WJ, Yeh YH, Kuo CT, See LC. A comparison between angiotensin converting enzyme inhibitors and angiotensin receptor blockers on end stage renal disease and major adverse cardiovascular events in diabetic patients: a population-based dynamic cohort study in Taiwan. Cardiovasc Diabetol 2016; 15:56. [PMID: 27039185 PMCID: PMC4818874 DOI: 10.1186/s12933-016-0365-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/10/2016] [Indexed: 01/13/2023] Open
Abstract
Background Contemporary guidelines recommend angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB) for hypertensive patients with diabetes. However, there is limited data to evaluate the comparison between ACEi and ARB on end stage renal disease (ESRD) and major adverse cardiovascular events (MACE), in Asian diabetic patients. Methods We used the Taiwan Longitudinal Cohort of Diabetes Patients Database to perform a population-based dynamic cohort study. The comparison between ACEi and ARB on ESRD and MACE in diabetic patients was examined using the propensity score weighting method. We followed these patients until the occurrence of first study outcomes or end date of the study, whichever came first. Results There were 6898 and 12,758 patients in ACEi and ARB groups, respectively. The mean follow-up period was about 3.5 years in ESRD and 2.5 years in MACE. The incidence of ESRD was 0.44 % and 0.63 % per person-years in the ACEi and ARB group, respectively. The risk of ESRD was lower in the ACEi group than the ARB group [hazard ratio (HR) 0.69; 95 % confidence interval (CI) 0.54–0.88, P = 0.0025]. Among those without chronic kidney disease (CKD), the incidence of ESRD was 0.30 % and 0.37 % per person-years in the ACEi and ARB group, respectively. ACEi was similar to ARB in preventing ESRD for those without CKD (P = 0.11). Among those with CKD, the incidence of ESRD was 1.39 % and 2.34 % per person-years in the ACEi and ARB group, respectively. The ACEi group had a lower risk of ESRD than the ARB group (HR 0.61; 95 % CI 0.42–0.88, P = 0.008). The incidence of MACE was 9.33 % and 9.62 % per person-years in the ACEi and ARB group, respectively. There was no significant difference in the composite MACE outcome between the two groups (P = 0.42), but the ACEi group was associated with a higher risk of stroke than the ARB group (HR 1.12; 95 % CI 1.02–1.24, P = 0.02). Conclusions ACEi compared with ARB was associated with a lower incidence of ESRD, especially in those with CKD. Though ACEi and ARB had a similar risk of composite MACE outcome, ACEi had a slightly higher incidence of stroke than ARB, among the Asian diabetic patients. Electronic supplementary material The online version of this article (doi:10.1186/s12933-016-0365-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lung-Sheng Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medicinal Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - Yi-Hsin Chan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Hsin-Fu Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Wei-Jan Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Yung-Hsin Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Chi-Tai Kuo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Linkou, Tao-Yuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan. .,Division of Rheumationalogy and Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.
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Chan YH, Wu LS, Chang SH, Lee HF, Liu JR, See LC, Yeh YH, Kuo CT. Young Male Patients with Atrial Fibrillation and CHA2DS2-VASc Score of 1 May Not Need Anticoagulants: A Nationwide Population-Based Study. PLoS One 2016; 11:e0151485. [PMID: 26986069 PMCID: PMC4795759 DOI: 10.1371/journal.pone.0151485] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/29/2016] [Indexed: 02/05/2023] Open
Abstract
Background It is unclear whether oral anticoagulants are beneficial for atrial fibrillation (AF) patients with low CHA2DS2-VASc score. Age could be important in determining the risk of thromboembolism in low risk AF patients (CHA2DS2-VASc score of 1 for male or 2 for female). Methods The Taiwan National Health Insurance Research Database (NHIRD) was used and 27,521 AF patients with CHA2DS2-VASc score of 1 (male) or 2 (female) not receiving anticoagulants were acquired as the study cohort, which were classified into three age groups: 20–49, 50–64, and 65–74 years. The clinical endpoint was the occurrence of ischemic thromboembolism within one year of follow up. Results During the follow-up of 0.94 ± 0.19 years, 385 (2.19%) male patients experienced ischemic thromboembolism, with annual rate of 2.32%. The annual risk ranged from 1.29%, 2.43% to 2.77% for male patients aged 20–49, 50–64 and 65–74 years respectively. Of the female patients, 218 (2.20%) experienced clinical event with annual rate of 2.32%. The annual risk increased from 1.87%, 2.28% to 2.64% for female patients aged 20–49, 50–64 and 65–74 years respectively. There was no difference in risk between the male patients aged 20–49 years with CHA2DS2-VASc score of 1 and overall male patients with CHA2DS2-VASc score of 0. (P = 0.631) The female patients aged 20–49 years with CHA2DS2-VASc score of 2 was associated with a higher risk of thromboembolic events than overall female patients with CHA2DS2-VASc score of 1 (HR = 1.93; P = 0.008). Conclusions Age is important in determining the risk of thromboembolism in AF patients with single risk factor. In male patients <50 years old with CHA2DS2-VASc score of 1, the risk of ischemic thromboembolism was low. Considering the benefits and the risk of bleeding, oral anticoagulation therapy may not be favorable in these patients.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
- Division of of Rheumationalogy and Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (Y-HY); (C-TK)
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (Y-HY); (C-TK)
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Chan YH, Lee HF, Wu LS, Wang CL, Wu CT, Yeh YH, Ho YWJ, Hsu LA, Chu PH, Kuo CT. Ratio of transmitral early filling velocity to early diastolic strain rate predicts outcomes in patients with systolic heart failure. Eur Heart J Cardiovasc Imaging 2016; 18:79-85. [DOI: 10.1093/ehjci/jew015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/15/2016] [Indexed: 11/12/2022] Open
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Lee HF, Wu LS, Chan YH, Lee CH, Liu JR, Tu HT, Wen MS, Kuo CT, Chen WJ, Yeh YH, See LC, Chang SH. Dialysis Patients with Implanted Drug-Eluting Stents Have Lower Major Cardiac Events and Mortality than Those with Implanted Bare-Metal Stents: A Taiwanese Nationwide Cohort Study. PLoS One 2016; 11:e0146343. [PMID: 26731408 PMCID: PMC4711720 DOI: 10.1371/journal.pone.0146343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/15/2015] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To investigate the efficacy and long-term clinical benefits of DES for dialysis patients. BACKGROUND It is unclear whether percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is associated with lower rates of major adverse cardiovascular events (MACE) or mortality compared to bare-metal stents (BMS). METHODS From a nationwide cohort selected from Taiwan's National Health Insurance Research Database, we enrolled 2,835 dialysis patients who were hospitalized for PCI treatment with stent implantation from Dec 1, 2006. Follow-up was from the date of index hospitalization for PCI until the first MACE, date of death, or December 31, 2011, whichever came first. RESULTS A total of 738 patients (26.0%) had DES implanted, and 2,097 (74%) had BMS implanted. The medium time to the first MACE was 0.53 years (interquartile range: 0.89 years; range: 0-4.62 years). At 1-year follow-up, patients treated with BMS had significantly, non-fatal myocardial infarction (MI), all-cause mortality, and composite MACE compared to those treated with DES. The overall repeat revascularization with coronary artery bypass graft (CABG), non-fatal MI, all-cause mortality, and composite MACE were significantly lower in patients treated with DES than those treated with BMS. Multivariate cox regression analysis showed that older age, history of diabetes, history of heart failure, history of stroke, and DES vs. BMS were independent significant predictors of MACE. CONCLUSIONS DES implantation conferred survival benefits in dialysis patients compared with BMS implantation.
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Affiliation(s)
- Hsin-Fu Lee
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Lung-Sheng Wu
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yi-Hsin Chan
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Cheng-Hung Lee
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chi-Tai Kuo
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Wei-Jan Chen
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yung-Hsin Yeh
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (LCS); (SHC)
| | - Shang-Hung Chang
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
- * E-mail: (LCS); (SHC)
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Chan YH, Yen KC, See LC, Chang SH, Wu LS, Lee HF, Tu HT, Yeh YH, Kuo CT. Cardiovascular, Bleeding, and Mortality Risks of Dabigatran in Asians With Nonvalvular Atrial Fibrillation. Stroke 2016; 47:441-9. [PMID: 26732563 DOI: 10.1161/strokeaha.115.011476] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/19/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Whether dabigatran is associated with different risks of cardiovascular, bleeding events, and mortality from warfarin in Asian patients with nonvalvular atrial fibrillation remains unclear. METHODS We used the Taiwan National Health Insurance Research Database to obtain 9940 and 9913 nonvalvular atrial fibrillation patients taking dabigatran and warfarin, respectively, from June 1, 2012, to December 31, 2013, as the dynamic cohort. Inverse probability of treatment weighting using propensity scores was used to balance covariates across 2 study groups. Patients were followed up until the first occurrence of any study outcome or end date of study. RESULTS During a median follow-up period of 0.67 years, there were 526 outcomes for dabigatran group. The hazard ratios (95% confidence intervals) comparing dabigatran with warfarin (reference) were as follows: ischemic stroke, 0.62 (0.52-0.73; P<0.0001); myocardial infarction, 0.67 (0.43-1.05; P=0.0803); intracranial hemorrhage, 0.44 (0.32-0.60; P<0.0001); major gastrointestinal bleeding, 0.99 (0.66-1.49; P=0.9658); all hospitalized major bleeding, 0.58 (0.46-0.74; P<0.0001); and all-cause mortality, 0.45 (0.38-0.53; P<0.0001). Dabigatran did not increase the risk of myocardial infarction or major gastrointestinal bleeding in all age groups when compared with warfarin. Total 8772 patients (88%) took a 110-mg dose in dabigatran group. The magnitude of effect for each outcome of 110-mg was comparable with that of 150-mg dose in the subgroup analysis. CONCLUSIONS In real-world practice, dabigatran was associated with a reduced risk of ischemic stroke, intracranial hemorrhage, all hospitalized major bleeding, and all-cause mortality compared with warfarin in Asian patients with nonvalvular atrial fibrillation. Dabigatran did not increase the risk of major gastrointestinal bleeding or myocardial infarction compared with warfarin.
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Affiliation(s)
- Yi-Hsin Chan
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Kun-Chi Yen
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Lai-Chu See
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Shang-Hung Chang
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Lung-Sheng Wu
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Hsin-Fu Lee
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Hui-Tzu Tu
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Yung-Hsin Yeh
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.)
| | - Chi-Tai Kuo
- From the Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); College of Medicine, Chang Gung University, Taoyuan, Taiwan (Y.-H.C., K.-C.Y., S.-H.C., L.-S.W., H.-F.L., Y.-H.Y., C.-T.K.); Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan (L.-C.S., H.-T.T.); and Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan (L.-C.S.).
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Chan YH, Kuo CT, Wu LS, Wang CL, Yeh YH, Hsu LA, Ho WJ. Combined Global Longitudinal Strain and Intraventricular Mechanical Dyssynchrony Predicts Long-Term Outcome in Patients With Systolic Heart Failure. Circ J 2016; 80:177-85. [DOI: 10.1253/circj.cj-15-0953] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yi-Hsin Chan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Chi-Tai Kuo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Lung-Sheng Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Chun-Li Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Yung-Hsin Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Lung-An Hsu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Wan-Jing Ho
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
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Tsai FC, Chang GJ, Hsu YJ, Lin YM, Lee YS, Chen WJ, Kuo CT, Yeh YH. Proinflammatory gene expression in patients undergoing mitral valve surgery and maze ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 151:1673-1682.e5. [PMID: 26774166 DOI: 10.1016/j.jtcvs.2015.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 11/27/2015] [Accepted: 12/05/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE It is difficult to achieve rhythm control in patients with long-standing persistent atrial fibrillation (AF). The radiofrequency maze procedure is an effective means in curing AF with a variable recurrence rate depending on patient characteristics and AF duration. In these patients, the characteristics of the atrial substrate have not been well investigated. Because the inflammatory process has been shown to be important in the pathogenesis of AF, we sought to characterize the proinflammatory gene expression in left atria obtained from patients with AF undergoing mitral valve surgery combined with the maze procedure to distinguish the changes associated with AF and its recurrence after the surgical ablation. METHODS Left atrial appendages from 35 patients receiving mitral valve surgery were used for study. Ten patients had sinus rhythm (SR) and 25 patients had persistent AF for more than 1 year and underwent the maze procedure. Among the AF patients, 13 patients remained in SR (AF-SR) and 12 patients had recurrent AF during the 1-year clinical follow-up (AF-AF). The nCounter Human Inflammation Array (NanoString Technologies, Seattle, Wash) was used for evaluating proinflammatory gene expression. Quantitative polymerase chain reaction, Western blot, and immunohistochemistry were applied for studying messenger RNA and protein expression. RESULTS Of 144 expressed proinflammatory genes, the inflammation array analysis revealed that 32 genes were differentially expressed between AF (including AF-SR and AF-AF) and SR. Thirteen genes were differentially expressed between AF-SR and AF-AF. The array and quantitative polymerase chain reaction produced parallel results in analyzing the expression of particular genes. Concordant with the gene expression difference between AF and SR patients, rapid pacing increased the expressions of SHC1, RHOA, PDGFA, and TRAF2 in HL-1 myocytes, implicating a causative effect of tachyarrhythmia on these genes. Compared with AF-SR, AF-AF expressed more intense oxidative stress, upregulations of collagen, transforming growth factor beta 1, and intranuclear nuclear factor of activated T-cells. Regression analysis showed that increased left atrial diameter was associated with the expression of RHOA and STAT1. CONCLUSIONS Differential expression profiles of proflammatory genes were presented between SR and AF and between maintained SR and recurrent AF after the maze procedure. The identified inflammatory molecules associated with AF and failed surgical ablation may provide clues for developing new potential therapeutic targets to improve AF rhythm control.
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Affiliation(s)
- Feng-Chun Tsai
- Division of Cardiac Surgery, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medical Sciences, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Min Lin
- School of Dentistry, National Yang-Ming University, Taipei, Taiwan
| | - Yun-Shien Lee
- Department of Biotechnology, Ming-Chuan University, Taoyuan, Taiwan
| | - Wei-Jan Chen
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
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Huang SC, Wong MK, Lin PJ, Tsai FC, Wen MS, Kuo CT, Hsu CC, Wang JS. Passive Leg Raising Correlates with Future Exercise Capacity after Coronary Revascularization. PLoS One 2015; 10:e0137846. [PMID: 26360736 PMCID: PMC4567136 DOI: 10.1371/journal.pone.0137846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 08/24/2015] [Indexed: 01/11/2023] Open
Abstract
Hemodynamic properties affected by the passive leg raise test (PLRT) reflect cardiac pumping efficiency. In the present study, we aimed to further explore whether PLRT predicts exercise intolerance/capacity following coronary revascularization. Following coronary bypass/percutaneous coronary intervention, 120 inpatients underwent a PLRT and a cardiopulmonary exercise test (CPET) 2–12 days during post-surgery hospitalization and 3–5 weeks after hospital discharge. The PLRT included head-up, leg raise, and supine rest postures. The end point of the first CPET during admission was the supra-ventilatory anaerobic threshold, whereas that during the second CPET in the outpatient stage was maximal performance. Bio-reactance-based non-invasive cardiac output monitoring was employed during PLRT to measure real-time stroke volume and cardiac output. A correlation matrix showed that stroke volume during leg raise (SVLR) during the first PLRT was positively correlated (R = 0.653) with the anaerobic threshold during the first CPET. When exercise intolerance was defined as an anaerobic threshold < 3 metabolic equivalents, SVLR / body weight had an area under curve value of 0.822, with sensitivity of 0.954, specificity of 0.593, and cut-off value of 1504·10-3mL/kg (positive predictive value 0.72; negative predictive value 0.92). Additionally, cardiac output during leg raise (COLR) during the first PLRT was related to peak oxygen consumption during the second CPET (R = 0.678). When poor aerobic fitness was defined as peak oxygen consumption < 5 metabolic equivalents, COLR / body weight had an area under curve value of 0.814, with sensitivity of 0.781, specificity of 0.773, and a cut-off value of 68.3 mL/min/kg (positive predictive value 0.83; negative predictive value 0.71). Therefore, we conclude that PLRT during hospitalization has a good screening and predictive power for exercise intolerance/capacity in inpatients and early outpatients following coronary revascularization, which has clinical significance.
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Affiliation(s)
- Shu-Chun Huang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - May-Kuen Wong
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - Pyng-Jing Lin
- Division of Thoracic and Cardiovascular Surgery, Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - Feng-Chun Tsai
- Division of Thoracic and Cardiovascular Surgery, Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Second Section of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- First Cardiovascular Division, Department of Cardiology, Chang Gung Memorial Hospital, Linkuo, Taoyuan, Taiwan
| | - Chih-Chin Hsu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Jong-Shyan Wang
- Healthy Aging Research Center, Graduate Institute of Rehabilitation Science, Medical College, Chang Gung University, Taoyuan, Taiwan
- * E-mail:
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Chang SH, Wu LS, Lee CH, Kuo CT, Liu JR, Wen MS, Chen WJ, See LC, Yeh YH. Simvastatin-ezetimibe combination therapy is associated with a lower rate of major adverse cardiac events in type 2 diabetics than high potency statins alone: A population-based dynamic cohort study. Int J Cardiol 2015; 190:20-5. [PMID: 25912112 DOI: 10.1016/j.ijcard.2015.04.121] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 03/04/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent trials have shown a reduction in the risk of major adverse cardiac events (MACE) with simvastatin-ezetimibe therapy in patients with acute coronary syndrome. The potential benefits of simvastatin-ezetimibe for patients at a lower risk of MACE are unclear. This study aimed to investigate the differences of MACE risk between patients with type 2 diabetes mellitus (DM) using simvastatin-ezetimibe or high potency statins. METHODS This population-based dynamic cohort study used data from the Taiwan National Health Insurance Database. The study subjects were patients with type 2 DM, aged between 40 and 75 years. The simvastatin-ezetimibe group took simvastatin-ezetimibe only, and the statin group took atorvastatin or rosuvastatin but not simvastatin or ezetimibe. The two groups were matched for age, gender, medication date, DM diagnosis date, hypertension, and cardiovascular complications. The outcome variable was new-onset MACE. Univariate and multivariate survival analyses were performed. RESULTS A total of 20,485 patients (53% male; 4099 in the simvastatin-ezetimibe group and 16,396 in the statin group) were included, with a mean age of 59.1 years. In a total of 37,388 person-years, 1100 patients developed new-onset MACE. The annual incidence rate of new-onset MACE was lower in the simvastatin-ezetimibe group (2.61%) than that in the statin group (3.02%) (p=0.0476). After Cox regression analysis, simvastatin-ezetimibe use was independently associated with a lower risk of MACE (HR, 0.77; 95% confidence interval 0.66-0.90). CONCLUSIONS Compared to high potency statins alone, simvastatin-ezetimibe therapy was associated with a lower incidence of MACE in patients with type 2 DM.
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Affiliation(s)
- Shang-Hung Chang
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Lung-Sheng Wu
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Cheng-Hung Lee
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chi-Tai Kuo
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taiwan
| | - Ming-Shien Wen
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Wei-Jan Chen
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taiwan; Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taiwan.
| | - Yung-Hsin Yeh
- Chang Gung University and Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan.
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