Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry

AIMS

We aimed to analyze prevalence and predictors of NOAC off-label under-dosing in AF patients before and after the index stroke.

METHODS

The post hoc analysis included 1080 patients of the investigator-initiated, multicenter prospective Berlin Atrial Fibrillation Registry, designed to analyze medical stroke prevention in AF patients after acute ischemic stroke.

RESULTS

At stroke onset, an off-label daily dose was prescribed in 61 (25.5%) of 239 NOAC patients with known AF and CHA₂DS₂-VASc score ≥ 1, of which 52 (21.8%) patients were under-dosed. Under-dosing was associated with age ≥ 80 years in patients on rivaroxaban [OR 2.90, 95% CI 1.05-7.9, P = 0.04; n = 29] or apixaban [OR 3.24, 95% CI 1.04-10.1, P = 0.04; n = 22]. At hospital discharge after the index stroke, NOAC off-label dose on admission was continued in 30 (49.2%) of 61 patients. Overall, 79 (13.7%) of 708 patients prescribed a NOAC at hospital discharge received an off-label dose, of whom 75 (10.6%) patients were under-dosed. Rivaroxaban under-dosing at discharge was associated with age ≥ 80 years [OR 3.49, 95% CI 1.24-9.84, P = 0.02; n = 19]; apixaban under-dosing with body weight ≤ 60 kg [OR 0.06, 95% CI 0.01-0.47, P < 0.01; n = 56], CHA₂DS₂-VASc score [OR per point 1.47, 95% CI 1.08-2.00, P = 0.01], and HAS-BLED score [OR per point 1.91, 95% CI 1.28-2.84, P < 0.01].

CONCLUSION

At stroke onset, off-label dosing was present in one out of four, and under-dosing in one out of five NOAC patients. Under-dosing of rivaroxaban or apixaban was related to old age. In-hospital treatment after stroke reduced off-label NOAC dosing, but one out of ten NOAC patients was under-dosed at discharge.

CLINICAL TRIAL REGISTRATION

NCT02306824.

Morphology and molecular data in phylogenetic fraternity: the tribe Wrightieae (Apocynaceae) revisited

The monophyly and classification of the tribe Wrightieae of the subfarnily Apocynoideae (Apocynaceae) are cladistically investigated. Nine taxa from the Wrightieae sensu Leeuwenberg, nine from other Apocynoideae sensu lato (s.I., including two from the traditional Asclepiadaceae), and two outgroup taxa from the Plumerioideae (Apocynaceae) were scored for rcbL sequence data and morphological data, mainly floral characters, and analyzed using successive weighting parsimony analysis. The Wrightieae sensu Leeuwenberg are shown to be largely paraphyletic, the constituent taxa being dispersed among four monophyletic clades. Previously not suggested relationships indicated by the study are the association of Pachypodium with Funtumia, Holarrhena, and Mascarenhasia and the position of Beaumontia close to Trachelospermum. A reclassification of the Wrightieae is discussed, in which three of the identified clades are recognized as tribes, the Wrightieae sensu stricto (s.s.), the Nerieae, and the Malouetieae. The support for the Wrightieae s.s. is very strong, as evaluated with Bremer support and bootstrap analysis. The Malouetieae are also strongly supported, but the Nerieae less so. Using Potential morphological synapomorphies identified in the study, circumscription of the tribes is discussed. A potential pseudogene of rcbL is reported tot Beaumontia.

Early aqueous activity on primitive meteorite parent bodies

The interstellar material from which the solar system formed has been modified by many processes: evaporation and condensation in the solar nebula, accretion into protoplanetary bodies and post-accretion processes within these bodies. Meteorites provide a record of these events and their chronology. Carbonaceous CI chondrites are among the most primitive, undifferentiated meteorites, but nevertheless show evidence of post-accretion alteration; they contain carbonates that are believed to have formed by reactions between anhydrous CI precursor materials and circulating fluids in the meteorite parent body (or bodies), yet little is known about the nature of these reactions or the timescale on which they occurred. Here we report measurements of excess 53Cr--formed by the decay of short-lived 53Mn--in five carbonate fragments from the CI chondrites Orgueil and Ivuna. Our results show that aqueous alteration on small protoplanetary bodies must have begun less than 20 Myr after the time of formation of the oldest known solar-nebula condensates (Allende refractory inclusions). This upper limit is much shorter than that of 50 Myr inferred from previous studies, and clearly establishes aqueous alteration as one of the earliest processes in the chemical evolution of the solar system.

Carbonates in CI chondrites: clues to parent body evolution

All CI chondrites are regolith breccias consisting of various types of chemically and mineralogically distinct mineral and lithic fragments (or units). In the CI chondrite Ivuna, for example, four different lithological units were identified and are referred to as lithology I, II, III, and IV. So far, lithologies III and IV have been identified in Orgueil as well. It appears that at least Ivuna and Orgueil consist of the same basic lithologies in different proportions. Carbonates in CIs occur as individual grains within such lithic units or exist as large fragments between them. Carbonate fragments are remnants of former carbonate veins and, in contrast to individual carbonate grains, are not genetically linked to lithological units. Four different types of carbonates (dolomite, breunnerite, calcite, siderite) occur in CIs and they constitute, on average, 5 vol% of each studied section. In this study, carbonates in the CI chondrites Orgueil, Ivuna, Alais, and Tonk were studied petrographically, mineralologically, and chemically. The results clearly indicate that, in contrast to most previous studies, compositional differences exist between dolomites within and among CI chondrites. From these differences it can be derived that (1) several episodes of alteration occurred on the CI parent body, (2) physicochemical conditions during carbonate formation must have been different among CIs, and (3) CI carbonates obviously were formed at low temperatures in equilibrium with surrounding fluid(s). While local compositional changes in fluid(s) on a micrometer to millimeter scale (as reflected by dolomite compositions within CI chondrites) were most likely controlled by the availability of Ca2+ Mg2+, Fe2+, and especially Mn2+ ions in the aqueous solutions, more widespread compositional changes on a meter (or even larger) scale were controlled by variable pH, Eh, CO2 partial pressure, and, especially, temperature conditions (as reflected by the compositional variability of dolomites among CIs).