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Prandoni P, Haas S, Fluharty M, Schellong S, Goto S, MacCallum P, Tse E, Pieper K, Kayani G, Kakkar A. Incidence and risk factors of post-thrombotic syndrome in patients with isolated calf vein thrombosis. Findings from the GARFIELD-VTE registry. Thromb Res 2024; 235:75-78. [PMID: 38308881 DOI: 10.1016/j.thromres.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Affiliation(s)
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Meg Fluharty
- Thrombosis Research Institute, London, United Kingdom
| | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | - Peter MacCallum
- Department of Hematology, Queen Mary University of London, London, United Kingdom
| | - Eric Tse
- Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Karen Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Ajay Kakkar
- Thrombosis Research Institute, London, United Kingdom
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Goldhaber SZ, Bassand JP, Camm AJ, Virdone S, Pieper K, Cools F, Corbalan R, Gersh BJ, Goto S, Haas S, Misselwitz F, Parkhomenko A, Steffel J, Stepinska J, Turpie AGG, Verheugt FWA, Kayani G, Kakkar AK. Clinical Outcomes in Older Patients with Atrial Fibrillation: Insights from the GARFIELD-AF Registry. Am J Med 2024; 137:128-136.e13. [PMID: 37918777 DOI: 10.1016/j.amjmed.2023.10.027] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underutilized in older patients with atrial fibrillation, despite proven clinical benefits. Our objective was to investigate baseline characteristics, treatment patterns, and impact of anticoagulation upon clinical outcomes with respect to age. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed up for 24 months. Adjusted hazard ratios (HR) were obtained via Cox proportional-hazards models with applied weights, to quantify the association of age with clinical outcomes. Comparative effectiveness of OAC vs No OAC and non-vitamin K oral anticoagulants (NOAC) vs vitamin K antagonists (VKA) were assessed using a propensity score with an overlap weighting scheme. RESULTS Of 52,018 patients, 32.6% were 65-74 years of age, 29.3% were 75-84 years, and 7.9% were ≥85 years. OAC treatment was associated with a numerical reduction in all-cause mortality among those aged 65-74 years (HR; 95% confidence interval) (0.86; 0.69-1.06) and aged 75-84 years (0.89; 0.75-1.05) and a significant reduction in patients ≥85 years (0.77; 0.63-0.95) vs no OAC. Similarly, OACs were associated with a decrease in stroke: 65-74 (0.51; 0.35-0.76) and ≥85 years (0.58; 0.34-0.99) and a numerical decrease in 75-84 years (0.84; 0.59-1.18). No increase in major bleeding was observed in patients aged ≥85 treated with OACs. Compared with VKA, NOACs were associated with a significant reduction in all-cause mortality in patients aged <65 and 65-74, with numerical reductions in those aged 75-84 and ≥85 years. CONCLUSIONS Older patients using OACs saw lower all-cause mortality and stroke risk; NOACs had less mortality and major bleeding compared with VKAs.
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Affiliation(s)
| | | | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's University of London, London, UK
| | | | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Ramon Corbalan
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Technical University of Munich, Germany
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Prandoni P, Haas S, Fluharty ME, Schellong S, Gibbs H, Tse E, Carrier M, Jacobson B, Ten Cate H, Panchenko E, Verhamme P, Pieper K, Kayani G, Kakkar LA. Incidence and predictors of post-thrombotic syndrome in patients with proximal DVT in a real-world setting: findings from the GARFIELD-VTE registry. J Thromb Thrombolysis 2024; 57:312-321. [PMID: 37932591 PMCID: PMC10869374 DOI: 10.1007/s11239-023-02895-7] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 11/08/2023]
Abstract
Although substantial progress has been made in the pathophysiology and management of the post-thrombotic syndrome (PTS), several aspects still need clarification. Among them, the incidence and severity of PTS in the real world, the risk factors for its development, the value of patient's self-evaluation, and the ability to identify patients at risk for severe PTS. Eligible participants (n = 1107) with proximal deep-vein thrombosis (DVT) from the global GARFIELD-VTE registry underwent conventional physician's evaluation for PTS 36 months after diagnosis of their DVT using the Villalta score. In addition, 856 patients completed a Villalta questionnaire at 24 months. Variable selection was performed using stepwise algorithm, and predictors of severe PTS were incorporated into a multivariable risk model. The optimistic adjusted c-index was calculated using bootstrapping techniques. Over 36-months, 27.8% of patients developed incident PTS (mild in 18.7%, moderate in 5.7%, severe in 3.4%). Patients with incident PTS were older, had a lower prevalence of transient risk factors of DVT and a higher prevalence of persistent risk factors of DVT. Self-assessment of overall PTS at 24 months showed an agreement of 63.4% with respect to physician's evaluations at 36 months. The severe PTS multivariable model provided an optimistic adjusted c-index of 0.68 (95% CI 0.59-0.77). Approximately a quarter of DVT patients experienced PTS over 36 months after VTE diagnosis. Patient's self-assessment after 24 months provided added value for estimating incident PTS over 36 months. Multivariable risk analysis allowed good discrimination for severe PTS.
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Affiliation(s)
| | - Sylvia Haas
- Technical University of Munich, Munich, Germany
| | | | | | - Harry Gibbs
- Department of General Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Eric Tse
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Barry Jacobson
- Department of Haematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Hugo Ten Cate
- Division of Vascular Medicine and Thrombosis Expertise Center, Department of Internal Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Elizaveta Panchenko
- National Medical Research Center of Cardiology Named After Academician E.I. Chazov, Moscow, Russia
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Verheugt FWA, Fox KAA, Virdone S, Ambrosio G, Gersh BJ, Haas S, Pieper KS, Kayani G, Camm AJ, Parkhomenko A, Misselwitz F, Ragy H, Ten Cate H, Keltai M, Kakkar AK. Outcomes of Oral Anticoagulation in Atrial Fibrillation Patients With or Without Comorbid Vascular Disease: Insights From the GARFIELD-AF Registry. Am J Med 2023; 136:1187-1195.e15. [PMID: 37704071 DOI: 10.1016/j.amjmed.2023.08.019] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation suffer from comorbid vascular disease. The comparative efficacy and safety of different types of oral anticoagulation (OAC) in this patient group have not been widely studied. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed for 24 months. Associations of vascular disease with clinical outcomes were analyzed using adjusted hazard ratios (HR) obtained via Cox proportional-hazard modeling. Outcomes of OAC vs no OAC, and of non-vitamin K antagonist OAC (NOAC) vs vitamin K antagonist (VKA) treatment, were compared by overlap propensity-weighted Cox proportional-hazard models. RESULTS Of 51,574 atrial fibrillation patients, 25.9% had vascular disease. Among eligible atrial fibrillation patients, those with vascular disease received OAC less frequently than those without (63% vs 73%). Over 2-year follow-up, patients with vascular disease showed a higher risk of all-cause mortality (HR 1.30; 95% confidence interval [CI], 1.16-1.47) and cardiovascular mortality (HR 1.59; 95% CI, 1.28-1.97). OAC was associated with a significant decrease in all-cause mortality and non-hemorrhagic stroke, and increased risk of major bleeding in non-vascular disease. In vascular disease, similar but non-significant trends existed for stroke and major bleeding. A significantly lower risk of all-cause mortality (HR 0.74; 95% CI, 0.61-0.90) and major bleeding (HR 0.45; 95% CI, 0.29-0.70) was observed in vascular disease patients treated with NOACs, compared with VKAs. CONCLUSIONS Atrial fibrillation patients with a history of vascular disease have worse long-term outcomes than those without. The association of NOACs vs VKA with clinical outcomes was more evident in atrial fibrillation patients with vascular disease.
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Affiliation(s)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine Cardiology, Italy
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn, USA
| | - Sylvia Haas
- [Formerly] Department of Medicine, Technical University of Munich, Germany
| | | | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, UK
| | - Alexandr Parkhomenko
- National Scientific Centre "MD Strazhesko Institute of Cardiology", Kyiv, Ukraine
| | | | - Hany Ragy
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Hugo Ten Cate
- Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute (CARIM), Maastricht University, Netherlands; Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany
| | - Matyas Keltai
- Semmelweis University, Hungarian Cardiovascular Institute, Budapest, Hungary
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Knudsen Pope M, Hall TS, Virdone S, Atar D, John Camm A, Pieper KS, Jansky P, Haas S, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation - Observations from the GARFIELD-AF registry. Int J Cardiol Heart Vasc 2023; 49:101302. [PMID: 38020059 PMCID: PMC10656718 DOI: 10.1016/j.ijcha.2023.101302] [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: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
Background Investigate real-world outcomes of early rhythm versus rate control in patients with recent onset atrial fibrillation. Methods The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is an international multi-centre, non-interventional prospective registry of newly diagnosed (≤6 weeks' duration) atrial fibrillation patients at risk for stroke. Patients were stratified according to treatment initiated at baseline (≤48 days post enrolment), and outcome risks evaluated by overlap propensity weighted Cox proportional-hazards models. Results Of 45,382 non-permanent atrial fibrillation patients, 23,858 (52.6 %) received rhythm control and 21,524 (47.4 %) rate control. Rhythm-controlled patients had lower median age (68.0 [Q1;Q3: 60.0;76.0] versus 73.0 [65.0;79.0]), fewer histories of stroke/transient ischemic attack/systemic embolism (9.4 % versus 13.0 %), and lower expected probabilities of death (median GARFIELD-AF death score 4.0 [2.3;7.5] versus 5.1 [2.8;9.2]). The two groups had the same median CHA2DS2-VASc scores (3.0 [2.0;4.0]) and similar proportions of anticoagulated patients (rhythm control: 66.0 %, rate control: 65.5 %). The propensity-score-weighted hazard ratios of rhythm vs rate control (reference) were 0.85 (95 % CI: 0.79-0.92, p-value < 0.0001) for all-cause mortality, 0.84 (0.72-0.97, p-value 0.020) for non-haemorrhagic stroke/systemic embolism and 0.90 (0.78-1.04, p-value 0.164) for major bleeding. Conclusion Rhythm control strategy was initiated in about half of the patients with newly diagnosed non-valvular non-permanent atrial fibrillation. After balancing confounders, significantly lower risks of all-cause mortality and non-haemorrhagic stroke were observed in patients who received early rhythm control.
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Affiliation(s)
| | - Trygve S. Hall
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Saverio Virdone
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, the United Kingdom of Great Britain and Northern Ireland
| | - Karen S Pieper
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Petr Jansky
- Department of Cardiovascular Surgery, Motol University Hospital, Prague, Czech Republic
| | - Sylvia Haas
- Sylvia Haas: Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gonzalo Baron-Esquivias
- Servicio de Cardiología y Cirugía Cardíaca, Hospital Universitario Virgen del Rocío., Universidad de Sevilla., Sevilla. Departamento Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Spain
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
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Haas S, Sun X, Conceição ALC, Horbach J, Pfeffer S. The new small-angle X-ray scattering beamline for materials research at PETRA III: SAXSMAT beamline P62. J Synchrotron Radiat 2023; 30:1156-1167. [PMID: 37860939 PMCID: PMC10624033 DOI: 10.1107/s1600577523008603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/28/2023] [Indexed: 10/21/2023]
Abstract
The SAXSMAT beamline P62 (Small-Angle X-ray Scattering beamline for Materials Research) is a new beamline at the high-energy storage ring PETRA III at DESY. This beamline is dedicated to combined small- and wide-angle X-ray scattering (SAXS/WAXS) techniques for both soft and hard condensed matter systems. It works mainly in transmission geometry. The beamline covers an energy range from 3.5 keV to 35.0 keV, which fulfills the requirements of the user community to perform anomalous scattering experiments. Mirrors are used to reduce the intensity of higher harmonics. Furthermore, the mirrors and 2D compound refracting lenses can focus the beam down to a few micrometres at the sample position. This option with the high photon flux enables also SAXS/WAXS tensor tomography experiments to be performed at this new beamline in a relatively short time. The first SAXS/WAXS pattern was collected in August 2021, while the first user experiment was carried out two months later. Since January 2022 the beamline has been in regular user operation mode. In this paper the beamline optics and the SAXS/WAXS instrument are described and two examples are briefly shown.
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Affiliation(s)
- S. Haas
- Deutsches Elektronen-Synchrotron (DESY), Notkestrasse 85, Hamburg 22607, Germany
| | - X. Sun
- Deutsches Elektronen-Synchrotron (DESY), Notkestrasse 85, Hamburg 22607, Germany
| | - A. L. C. Conceição
- Deutsches Elektronen-Synchrotron (DESY), Notkestrasse 85, Hamburg 22607, Germany
| | - J. Horbach
- Deutsches Elektronen-Synchrotron (DESY), Notkestrasse 85, Hamburg 22607, Germany
| | - S. Pfeffer
- Deutsches Elektronen-Synchrotron (DESY), Notkestrasse 85, Hamburg 22607, Germany
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Bassand JP, Virdone S, Camm AJ, Fox KAA, Goldhaber SZ, Goto S, Haas S, Hacke W, Kayani G, Keltai M, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Oral anticoagulation across diabetic subtypes in patients with newly diagnosed atrial fibrillation: A report from the GARFIELD-AF registry. Diabetes Obes Metab 2023; 25:3040-3053. [PMID: 37435777 DOI: 10.1111/dom.15202] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
AIMS This study aims to describe both management and prognosis of patients with diabetes mellitus (DM) and newly diagnosed atrial fibrillation (AF), overall as well as by antidiabetic treatment, and to assess the influence of oral anticoagulation (OAC) on outcomes by DM status. METHODS The study population comprised 52 010 newly diagnosed patients with AF, 11 542 DM and 40 468 non-DM, enrolled in the GARFIELD-AF registry. Follow-up was truncated at 2 years after enrolment. Comparative effectiveness of OAC versus no OAC was assessed by DM status using a propensity score overlap weighting scheme and weights were applied to Cox models. RESULTS Patients with DM [39.3% oral antidiabetic drug (OAD), 13.4% insulin ± OAD, 47.2% on no antidiabetic drug] had higher risk profile, OAC use, and rates of clinical outcomes compared with patients without DM. OAC use was associated in patients without DM and patients with DM with lower risk of all-cause mortality [hazard ratio 0.75 (0.69-0.83), 0.74 (0.64-0.86), respectively] and stroke/systemic embolism (SE) [0.69 (0.58-0.83), 0.70 (0.53-0.93), respectively]. The risk of major bleeding with OAC was similarly increased in patients without DM and those with DM [1.40 (1.14-1.71), 1.37 (0.99-1.89), respectively]. Patients with insulin-requiring DM had a higher risk of all-cause mortality and stroke/SE [1.91 (1.63-2.24)], [1.57 (1.06-2.35), respectively] compared with patients without DM, and experienced significant risk reductions of all-cause mortality and stroke/SE with OAC [0.73 (0.53-0.99); 0.50 (0.26-0.97), respectively]. CONCLUSIONS In both patients with DM and patients without DM with AF, OAC was associated with lower risk of all-cause mortality and stroke/SE. Patients with insulin-requiring DM derived significant benefit from OAC.
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Affiliation(s)
- Jean-Pierre Bassand
- University of Besançon Franche-Comté, Besançon, France
- Thrombosis Research Institute, London, UK
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
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Barco S, Virdone S, Götschi A, Ageno W, Arcelus JI, Bingisser R, Colucci G, Cools F, Duerschmied D, Gibbs H, Fumagalli RM, Gerber B, Haas S, Himmelreich JCL, Hobbs R, Hobohm L, Jacobson B, Kayani G, Lopes RD, MacCallum P, Micieli E, Righini M, Robert-Ebadi H, Rocha AT, Rosemann T, Sawhney J, Schellong S, Sebastian T, Spirk D, Stortecky S, Turpie AGG, Voci D, Kucher N, Pieper K, Held U, Kakkar AK. Enoxaparin for symptomatic COVID-19 managed in the ambulatory setting: An individual patient level analysis of the OVID and ETHIC trials. Thromb Res 2023; 230:27-32. [PMID: 37625200 DOI: 10.1016/j.thromres.2023.08.009] [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: 06/25/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Antithrombotic treatment may improve the disease course in non-critically ill, symptomatic COVID-19 outpatients. METHODS We performed an individual patient-level analysis of the OVID and ETHIC randomized controlled trials, which compared enoxaparin thromboprophylaxis for either 14 (OVID) or 21 days (ETHIC) vs. no thromboprophylaxis for outpatients with symptomatic COVID-19 and at least one additional risk factor. The primary efficacy outcome included all-cause hospitalization and all-cause death within 30 days from randomization. Both studies were prematurely stopped for futility. Secondary efficacy outcomes were major symptomatic venous thromboembolic events, arterial cardiovascular events, or their composite occurring within 30 days from randomization. The same outcomes were assessed over a 90-day follow-up. The primary safety outcome was major bleeding (ISTH criteria). RESULTS A total of 691 patients were randomized: 339 to receive enoxaparin and 352 to the control group. Over 30-day follow-up, the primary efficacy outcome occurred in 6.0 % of patients in the enoxaparin group vs. 5.8 % of controls for a risk ratio (RR) of 1.05 (95%CI 0.57-1.92). The incidence of major symptomatic venous thromboembolic events and arterial cardiovascular events was 0.9 % vs. 1.8 %, respectively (RR 0.52; 95%CI 0.13-2.06). Most cardiovascular thromboembolic events were represented by symptomatic venous thromboembolic events, occurring in 0.6 % vs. 1.5 % of patients, respectively. A similar distribution of outcomes between the treatment groups was observed over 90 days. No major bleeding occurred in the enoxaparin group vs. one (0.3 %) in the control group. CONCLUSIONS We found no evidence for the clinical benefit of early administration of enoxaparin thromboprophylaxis in outpatients with symptomatic COVID-19. These results should be interpreted taking into consideration the relatively low occurrence of events.
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Affiliation(s)
- Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Germany.
| | | | - Andrea Götschi
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Juan I Arcelus
- Department of Surgery, University of Granada, Granada, Spain
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Giuseppe Colucci
- Service of Hematology, Clinica Luganese Moncucco, Lugano, Switzerland; Department of Hematology, University of Basel, Basel, Switzerland; Clinica Sant'Anna, Sorengo, Switzerland
| | - Frank Cools
- Department of Cardiology, General Hospital Klina, Brasschaat, Belgium
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany; Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harry Gibbs
- Department of General Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; University of Zurich, Zurich, Switzerland
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Richard Hobbs
- Oxford Primary Care, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK; Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Barry Jacobson
- Department of Haematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Renato D Lopes
- Duke University Medical Center, Durham, USA; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Peter MacCallum
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Evy Micieli
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Ana Thereza Rocha
- Department of Family Health, Federal University of Bahia, Salvador, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Thomas Rosemann
- Institute of Primary Care, University Hospital Zurich, Zurich, Switzerland
| | - Jitendra Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Sebastian Schellong
- Department of Internal Medicine, Municipal Hospital Dresden, Dresden, Germany
| | - Tim Sebastian
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - David Spirk
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Davide Voci
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
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Heinrich K, Karthaus M, Fruehauf S, Graeven U, Mueller L, König AO, von Weikersthal LF, Caca K, Kretzschmar A, Goekkurt E, Haas S, Alig AHS, Kurreck A, Stahler A, Held S, Sommerhäuser G, Heinemann V, Stintzing S, Trarbach T, Modest DP. Impact of sex on the efficacy and safety of panitumumab plus fluorouracil and folinic acid versus fluorouracil and folinic acid alone as maintenance therapy in RAS WT metastatic colorectal cancer (mCRC). Subgroup analysis of the PanaMa-study (AIO-KRK-0212). ESMO Open 2023; 8:101568. [PMID: 37441876 PMCID: PMC10507735 DOI: 10.1016/j.esmoop.2023.101568] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/11/2023] [Accepted: 04/24/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Clinical trials in metastatic colorectal cancer (mCRC) are usually conducted irrespective of sex. Sex-associated differences relating to safety and efficacy in the treatment of mCRC, however, are gaining interest. METHODS PanaMa investigated the efficacy of panitumumab (Pmab) plus fluorouracil and folinic acid (FU/FA) versus FU/FA alone after induction therapy with six cycles of FU/FA and oxaliplatin plus Pmab in patients with RAS wild-type mCRC. In this post hoc analysis, the study population was stratified for sex. Evaluated efficacy endpoints during maintenance treatment were progression-free survival (PFS, primary endpoint of the trial), overall survival (OS) and objective response rate during maintenance therapy. Safety endpoints were rates of any grade and grade 3/4 adverse events during maintenance therapy. RESULTS In total, 165 male and 83 female patients were randomized and treated. Male and female patients showed numerically better objective response rates with Pmab, without reaching statistical significance. Male patients derived a significant benefit from the addition of Pmab to maintenance treatment with regard to PFS [hazard ratio (HR) 0.63; 95% confidence interval (CI) 0.45-0.88; P = 0.006] that was not observed in female patients (HR 0.85; 95% CI 0.53-1.35; P = 0.491). The better PFS for male patients treated with Pmab did not translate into improved OS (HR 0.85; 95% CI 0.55-1.30; P = 0.452). Female patients showed numerically improved OS when treated with Pmab. There was no difference in the total of grade ≥3 adverse events during maintenance regarding sex (P = 0.791). Female patients, however, had a higher rate of any grade nausea, diarrhea and stomatitis. CONCLUSIONS In the PanaMa trial, the addition of Pmab to maintenance treatment of RAS wild-type mCRC with FU/FA improved the outcome in terms of the primary endpoint (PFS) particularly in male patients. Female patients did not show the same benefit while experiencing higher rates of adverse events. Our results support the development of sex-specific protocols.
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Affiliation(s)
- K Heinrich
- Department of Medicine III, University Hospital, LMU Munich, Munich; German Cancer Consortium (DKTK), Partner Site Munich, Munich. https://twitter.com/heinrich_kat
| | - M Karthaus
- Department of Hematology and Oncology, Munich Hospital Neuperlach, Munich
| | | | - U Graeven
- Kliniken Maria Hilf GmbH, Moenchengladbach
| | | | - A O König
- Department of Gastroenterology, University Medicine Göttingen, Goettingen
| | | | - K Caca
- Department of Gastroenterology, Hematology and Oncology, Hospital Ludwigsburg, Ludwigsburg
| | | | - E Goekkurt
- Practice of Hematology and Oncology (HOPE), Hamburg; University Cancer Center Hamburg (UCCH), Hamburg
| | - S Haas
- Department of Hematology and Oncology, Friedrich-Ebert-Hospital, Neumünster
| | - A H S Alig
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - A Kurreck
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - A Stahler
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - S Held
- ClinAssess GmbH, Leverkusen
| | - G Sommerhäuser
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - V Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich; German Cancer Consortium (DKTK), Partner Site Munich, Munich; Comprehensive Cancer Center, University Hospital (LMU), Munich
| | - S Stintzing
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin; German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg
| | - T Trarbach
- Reha-Zentrum am Meer, Bad Zwischenahn; Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - D P Modest
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin; German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg.
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10
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Haas S, Camm JA, Harald D, Steffel J, Virdone S, Pieper K, Brodmann M, Schellong S, Misselwitz F, Kayani G, Kakkar AK. GARFIELD-AF: risk profiles, treatment patterns and 2-year outcomes in patients with atrial fibrillation in Germany, Austria and Switzerland (DACH) compared to 32 countries in other regions worldwide. Clin Res Cardiol 2023; 112:759-771. [PMID: 36094573 DOI: 10.1007/s00392-022-02079-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/29/2022] [Indexed: 06/06/2023]
Abstract
BACKGROUND The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is a worldwide non-interventional study of stroke prevention in patients with non-valvular AF. METHODS AND RESULTS 52,080 patients with newly diagnosed AF were prospectively enrolled from 2010 to 2016. 4121 (7.9%) of these patients were recruited in DACH [Germany (n = 3567), Austria (n = 465) and Switzerland (n = 89) combined], and 47,959 patients were from 32 countries in other regions worldwide (ORW). Hypertension was most prevalent in DACH and ORW (85.3% and 75.6%, respectively). Diabetes, hypercholesterolaemia, carotid occlusive disease and vascular disease were more prevalent in DACH patients vs ORW (27.6%, 49.4%, 5.8% and 29.0% vs 21.7%, 40.9%, 2.8% and 24.5%). The use of non-vitamin K antagonist oral anticoagulants (NOACs) increased more in DACH over time. Management of vitamin K antagonists was suboptimal in DACH and ORW (time in therapeutic range of INR ≥ 65% in 44.6% and 44.4% of patients or ≥ 70% in 36.9% and 36.0% of patients, respectively). Adjusted rates of cardiovascular mortality and MI/ACS were higher in DACH while non-haemorrhagic stroke/systemic embolism was lower after 2-year follow-up. CONCLUSIONS Similarities and dissimilarities in AF management and clinical outcomes are seen in DACH and ORW. The increased use of NOAC was associated with a mismatch of risk-adapted anticoagulation (over-and-undertreatment) in DACH. Suboptimal control of INR requires educational activities in both regional groups. Higher rates of cardiovascular death in DACH may reflect the higher risk profile of these patients and lower rates of non-haemorrhagic stroke could be associated with increased NOAC use.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany.
| | - John A Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Darius Harald
- Formerly Vivantes Netzwerk Für Gesundheit, Berlin, Germany
| | - Jan Steffel
- University Hospital, Zurich and University of Zurich, Zurich, Switzerland
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11
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Apenteng P, Virdone S, Camm J, Fox KAA, Bassand JP, Turpie AGG, Oh S, Brodmann M, Cools F, Barretto ACP, Nielsen J, Haas S, Kayani G, Pieper KS, Kakkar AK. Determinants and clinical outcomes of patients who refused anticoagulation: findings from the global GARFIELD-AF registry. Open Heart 2023; 10:e002275. [PMID: 37169491 PMCID: PMC10410826 DOI: 10.1136/openhrt-2023-002275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVE There is a substantial incidence of stroke in patients with atrial fibrillation (AF) not receiving anticoagulation. The reasons for not receiving anticoagulation are generally attributed to clinician's choice, however, a proportion of AF patients refuse anticoagulation. The aim of our study was to investigate factors associated with patient refusal of anticoagulation and the clinical outcomes in these patients. METHODS Our study population comprised patients in the Global Anticoagulant Registry in the FIELD (GARFIELD-AF) registry with CHA2DS2-VASc≥2. A logistic regression was developed with predictors of patient anticoagulation refusal identified by least absolute shrinkage and selection operator methodology. Patient demographics, medical and cardiovascular history, lifestyle factors, vital signs (body mass index, pulse, systolic and diastolic blood pressure), type of AF and care setting at diagnosis were considered as potential predictors. We also investigated 2-year outcomes of non-haemorrhagic stroke/systemic embolism (SE), major bleeding and all-cause mortality in patients who refused versus patients who received and patients who did not receive anticoagulation for other reasons. RESULTS Out of 43 154 AF patients, who were at high risk of stroke, 13 283 (30.8%) did not receive anticoagulation at baseline. The reason for not receiving anticoagulation was unavailable for 38.7% (5146/13 283); of the patients with a known reason for not receiving anticoagulation, 12.5% (1014/8137) refused anticoagulation. Diagnosis in primary care/general practitioner, Asian ethnicity and presence of vascular disease were strongly associated with a higher risk of patient refusal of anticoagulation. Patient refusal of anticoagulation was associated with a higher risk of non-haemorrhagic stroke/SE (adjusted HR (aHR) 1.16 (95% CI 0.77 to 1.76)) but lower all-cause mortality (aHR 0.59 (95% CI 0.43 to 0.80)) compared with patients who received anticoagulation. The GARFIELD-AF mortality score corroborated this result. CONCLUSION The data suggest patient refusal of anticoagulation is a missed opportunity to prevent AF-related stroke. Further research is required to understand the patient profile and mortality outcome of patients who refuse anticoagulation.
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Affiliation(s)
- Patricia Apenteng
- Institute of Applied Health Research, University of Birmingham Institute of Applied Health Research, Birmingham, UK
| | - Saverio Virdone
- Department of Statistics, Thrombosis Research Institute, London, UK
| | - John Camm
- Cardiology, St Georges Hospital, London, UK
| | - Keith A A Fox
- Cardiology, University of Edinburgh and Royal Infirmary, Edinburgh, UK
| | | | | | - Seil Oh
- Internal Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Antonio C P Barretto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Jørn Nielsen
- Department of Cardiology, University of Copenhagen, Kobenhavn, Denmark
| | - Sylvia Haas
- Haemostasis and Thrombosis Research Group, Institute for Experimental Oncology and Therapy Research, Formerly Technical University, Munich, Germany
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12
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Camm AJ, Steffel J, Virdone S, Bassand JP, Fox KAA, Goldhaber SZ, Goto S, Haas S, Turpie AGG, Verheugt FWA, Misselwitz F, Herreros RC, Kayani G, Pieper KS, Kakkar AK. Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF. Eur Heart J Open 2023; 3:oead051. [PMID: 37293139 PMCID: PMC10246824 DOI: 10.1093/ehjopen/oead051] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
Aims This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362). Methods and results Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHA2DS2-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease (n = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism. Conclusion In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHA2DS2-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use. Clinical Trial Registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Affiliation(s)
- Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- University of Besançon, Besançon, France
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Sylvia Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
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13
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Pope MK, Hall TS, Atar D, Virdone S, Pieper K, Jansky P, Steffel J, Haas S, Gersh BJ, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Camm AJ, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation: observations from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Background
Atrial fibrillation is associated with considerable morbidity and mortality. Real-world reports on the effect of early rhythm control on patient outcomes in patient with recent onset atrial fibrillation are limited.
Purpose
To assess the effect of early rhythm versus rate control on clinical outcomes in patients with newly diagnosed non-valvular atrial fibrillation.
Method
The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is a non-interventional registry of adult (≥18 years) patients with newly diagnosed atrial fibrillation (≤ six weeks' duration) and at least one investigator determined risk factor for stroke. Patients were enrolled in 1317 participating sites in 35 countries between March 2010 and August 2016. Patients with permanent atrial fibrillation were excluded. Stratification to rhythm or rate control was based on treatment strategy initiated at baseline (≤48 days post enrolment). Rhythm control was defined as investigator reported initiation of rhythm control (antiarrhythmic drug(s), cardioversion, or ablation – alone or in combination with rate modifiers). Rate control was defined as investigator reported initiation of rate control and absence of rhythm control therapy. Overlap propensity weighting and Cox proportional-hazards models were used to evaluate effect on outcomes.
Results
Of 45,382 included patients, 23,858 (52.6%) received rhythm control and 21,524 (47.4%) rate control. Rates of rhythm control were similar throughout the study time period (52.7% in 2010/2011, 54.2% in 2015/2016). Patients in the rhythm control group were younger (median age (Q1; Q3) 68.0 (60.0; 76.0) versus 73.0 (65.0; 79.0)), had lower rates of prior stroke/transitory ischemic attack/systemic embolism (9.4% vs 13.0%), and a lower median GARFIELD death score (4.0 (2.3; 7.5) versus 5.1 (2.8; 9.2)). Median CHA2DS2-VASc Scores were 3.0 (2.0; 4.0) in both groups. Rate of anticoagulation treatment was similar in the rhythm and rate control group (66.0% versus 65.5%). After propensity score overlap weighting, patients of the two groups were well balanced on all observed characteristics.
Event rates per 100 person-years (95% confidence interval [CI]) over two years follow-up in the rhythm and rate control group were 2.94 (2.78–3.10) versus 4.43 (4.22–4.64) for mortality, 0.84 (0.75–0.92) versus 1.16 (1.05–1.27) for non-haemorrhagic stroke/systemic embolism and 0.84 (0.76–0.93) versus 1.16 (1.06–1.27) for major bleeding. Adjusted hazard ratios (95% CI) for the same time period were 0.85 (0.79–0.92), 0.84 (0.72–0.97) and 0.9 (0.78–1.04).
Conclusion
In this large, internation registry, a rhythm control strategy was initiated at baseline in about half of the patients with newly diagnosed non-valvular atrial fibrillation. After adjustment for confounding factors, a significantly lower risk of all-cause mortality and non-haemorrhagic stroke/systemic embolism were observed for patients that received an early rhythm control strategy.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).
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Affiliation(s)
- M K Pope
- University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - T S Hall
- Oslo University Hospital Ulleval, Department of Cardiology , Oslo , Norway
| | - D Atar
- Oslo University Hospital Ulleval, Department of Cardiology , Oslo , Norway
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - P Jansky
- Motol University Hospital, Department of Cardiovascular Surgery , Prague , Czechia
| | - J Steffel
- University of Zurich , Zurich , Switzerland
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine , Munich , Germany
| | - B J Gersh
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine , Rochester , United States of America
| | - S Goto
- Tokai University School of Medicine , Kanagawa , Japan
| | - E Panchenko
- National Medical Research Center of Cardiology , Moscow , Russian Federation
| | | | - P Angchaisuksiri
- Ramathibodi Hospital, Department of Medicine , Mahidol University , Thailand
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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14
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Verheugt FWA, Fox KAA, Virdone S, Gersh BJ, Haas S, Pieper K, Kayani G, Camm AJ, Parkhomenko A, Kakkar AK. Differential efficacy and safety of oral anticoagulation in atrial fibrillation patients with or without comorbid vascular disease: insights from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/12/2022] Open
Abstract
Abstract
Background
Many patients with atrial fibrillation (AF) have comorbid vascular disease. The effects of oral anticoagulation (OAC) in AF patients with vascular disease, however, have not been widely studied.
Purpose
To investigate the impact of OAC in AF patients with (Vasc) or without (nVasc) concomitant vascular disease.
Methods
GARFIELD-AF is the largest multinational, prospective AF registry. The study comprised 51,574 GARFIELD-AF patients with newly diagnosed AF, 13,365 Vasc and 38,209 nVasc patients. All patients who reported coronary artery disease, aortic or peripheral artery disease, acute coronary syndromes, myocardial infarction, stenting, or coronary artery bypass graft were classified as having vascular disease. Adjusted hazard ratios were obtained via Cox proportional-hazards models to quantify the association of vascular disease with selected endpoints. Comparative effectiveness analyses were restricted to patients enrolled from April 2013-September 2016 (when NOACs became widely available) and who were eligible for anticoagulation (CHA2DS2-VASc ≥2 excl. gender). To evaluate the safety and efficacy of different anticoagulation strategies in Vasc and nVasc patients, propensity score using an overlap weighting scheme was applied. Weights were applied to Cox proportional-hazards models to estimate the effects of OAC vs No OAC and NOAC vs VKA.
Results
Vasc patients were older (median (Q1; Q3): 72.0 (65.0; 79.0) vs 70.0 (62.0; 78.0) and more often male (62.0 vs 53.6%). Vasc patients had a higher rate of comorbidities including heart failure, hypertension, and diabetes. Vasc patients received less OAC (62.8 vs 68.3%). NOACs were less common compared with nVasc patients (23.8% vs 28.7%) but a similar proportion of VKAs was observed in both (39.0% vs 39.6%). Antiplatelet monotherapy was more common in Vasc (31%) than nVasc (18%) patients.
At 2-years, Vasc was associated with a higher risk of all-cause (HR [95% CI]: 1.30 [1.16–1.47]) and cardiovascular mortality (1.59 [1.28–1.97]). OACs significantly lowered the risk of all-cause mortality and stroke in nVasc patients (0.72 [0.63–0.82] and 0.64 [0.49–0.84], respectively), but not in nVasc patients. OACs led to a numerical increase in major bleeding in Vasc patients (1.32 [0.90–1.93]) and a significant increase in major bleeding in nVasc patients (1.40 [1.03–1.90]) (Figure 1). Compared with VKAs, NOACs did not significantly improve the risk of outcomes in nVasc patients. In Vasc patients however, NOACs significantly lowered the risk of all-cause mortality (0.74 [0.61–0.90]) and major bleeding (0.45 [0.29–0.70]) compared with VKAs (Figure 2).
Conclusion
AF patients with vascular disease have worse long-term outcomes than those without. They receive less often OAC, specifically NOAC, and more antiplatelet agents. The beneficial effects of NOAC over VKA are much more pronounced in patients with than in those without vascular disease.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).
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Affiliation(s)
- F W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG) , Amsterdam , The Netherlands
| | - K A A Fox
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - B J Gersh
- Mayo Clinic College of Medicine and Science , Rochester , United States of America
| | - S Haas
- Vascular Centre Munich , Munich , Germany
| | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - G Kayani
- Thrombosis Research Institute , London , United Kingdom
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - A Parkhomenko
- National Scientific Center of Ukraine, MD Strazhesko Institute of Cardiology , Kiev , Ukraine
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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15
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Haas S, Farjat AE, Pieper K, Ageno W, Angchaisuksiri P, Bounameaux H, Goldhaber SZ, Goto S, Mantovani L, Prandoni P, Schellong S, Turpie AG, Weitz JI, MacCallum P, Cate HT, Panchenko E, Carrier M, Jerjes-Sanchez C, Gibbs H, Jansky P, Kayani G, Kakkar AK. On-treatment Comparative Effectiveness of Vitamin K Antagonists and Direct Oral Anticoagulants in GARFIELD-VTE, and Focus on Cancer and Renal Disease. TH Open 2022; 6:e354-e364. [DOI: 10.1055/s-0042-1757744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) provide a safe, effective alternative to vitamin K antagonists (VKAs) for venous thromboembolism (VTE) treatment, as shown via intention-to-treat comparative effectiveness analysis. However, on-treatment analysis is imperative in observational studies because anticoagulation choice and duration are at investigators' discretion.
Objectives The aim of the study is to compare the effectiveness of DOACs and VKAs on 12-month outcomes in VTE patients using on-treatment analysis.
Methods The Global Anticoagulant Registry in the FIELD - VTE (GARFIELD-VTE) is a world-wide, prospective, non-interventional study observing treatment of VTE in routine clinical practice.
Results In total, 8,034 patients received VKAs (n = 3,043, 37.9%) or DOACs (n = 4,991, 62.1%). After adjustment for baseline characteristics and follow-up bleeding events, and accounting for possible time-varying confounding, all-cause mortality was significantly lower with DOACs than VKAs (hazard ratio: 0.58 [95% confidence interval 0.42–0.79]). Furthermore, patients receiving VKAs were more likely to die of VTE complications (4.9 vs. 2.2%) or bleeding (4.9 vs. 0.0%). There was no significant difference in rates of recurrent VTE (hazard ratio: 0.74 [0.55–1.01]), major bleeding (hazard ratio: 0.76 [0.47–1.24]), or overall bleeding (hazard ratio: 0.87 [0.72–1.05]) with DOACs or VKAs. Unadjusted analyses suggested that VKA patients with active cancer or renal insufficiency were more likely to die than patients treated with DOAC (52.51 [37.33–73.86] vs. 26.52 [19.37–36.29] and 9.97 [7.51–13.23] vs. 4.70 [3.25–6.81] per 100 person-years, respectively).
Conclusion DOACs and VKAs had similar rates of recurrent VTE and major bleeding. However, DOACs were associated with reduced all-cause mortality and a lower likelihood of death from VTE or bleeding compared with VKAs.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Karen Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, United States
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | - Lorenzo Mantovani
- Center for Public Health Research, University of Milan-Bicocca, Monza, Italy
| | | | - Sebastian Schellong
- Department of Health Sciences, Medical Department 2, Municipal Hospital Dresden, Germany
| | | | - Jeffrey I. Weitz
- Department of Haematology, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Hugo ten Cate
- Department of Vascular Medicine and Internal Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht; Maastricht, The Netherlands
| | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Carlos Jerjes-Sanchez
- Tecnológico de Monterrey. Escuela de Medicina y Ciencias de la Salud., Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, Sa Pedro Garza Garcia, Mexico
| | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Australia
| | - Petr Jansky
- Motol University Hospital, Department of Cardiovascular Surgery, Prague, Czech Republic
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom
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16
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Cools F, Virdone S, Sawhney J, Lopes RD, Jacobson B, Arcelus JI, Hobbs FDR, Gibbs H, Himmelreich JCL, MacCallum P, Schellong S, Haas S, Turpie AGG, Ageno W, Rocha AT, Kayani G, Pieper K, Kakkar AK. Thromboprophylactic low-molecular-weight heparin versus standard of care in unvaccinated, at-risk outpatients with COVID-19 (ETHIC): an open-label, multicentre, randomised, controlled, phase 3b trial. Lancet Haematol 2022; 9:e594-e604. [PMID: 35779560 PMCID: PMC9243570 DOI: 10.1016/s2352-3026(22)00173-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [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: 04/12/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/22/2022]
Abstract
Background COVID-19 is associated with inflammation and an increased risk of thromboembolic complications. Prophylactic doses of low-molecular-weight heparin have been used in hospitalised and non-critically ill patients with COVID-19. We aimed to evaluate the efficacy and safety of prophylactic low-molecular-weight heparin (enoxaparin) versus standard of care (no enoxaparin) in at-risk outpatients with COVID-19. Methods This open-label, multicentre, randomised, controlled, phase 3b trial (ETHIC) was done at 15 centres in six countries (Belgium, Brazil, India, South Africa, Spain, and the UK). We consecutively enrolled participants aged at least 30 years who had not received a COVID-19 vaccine and had symptomatic, confirmed COVID-19 in the outpatient setting plus at least one risk factor for severe disease. Within 9 days of symptom onset and by use of a web-based random block design (block size either 2 or 4), eligible participants were randomly assigned (1:1) to receive either subcutaneous enoxaparin for 21 days (40 mg once daily if they weighed <100 kg and 40 mg twice daily if they weighed ≥100 kg) or standard of care (without enoxaparin). The primary efficacy endpoint was the composite of all-cause hospitalisation and all-cause mortality at 21 days after randomisation and, in our main analysis, was analysed in the intention-to-treat population, which comprised all patients who were randomly assigned. Safety was also analysed in the intention-to-treat population for our main analysis. This trial is registered with ClinicalTrials.gov, NCT04492254, and is complete. Findings Following the advice of the Data and Safety Monitoring Board, this study was terminated early due to slow enrolment and a lower-than-expected event rate. Between Oct 27, 2020, and Nov 8, 2021, 230 patients with COVID-19 were assessed for eligibility, of whom 219 were enrolled and randomly assigned to receive standard of care (n=114) or enoxaparin (n=105). 96 (44%) patients were women, 122 (56%) were men, and one patient had missing sex data. 141 (65%) of 218 participants with data on race and ethnicity were White, 60 (28%) were Asian, and 16 (7%) were Black, mixed race, or Arab or Middle Eastern. Median follow-up in both groups was 21 days (IQR 21–21). There was no difference in the composite of all-cause mortality and hospitalisation at 21 days between the enoxaparin group (12 [11%] of 105 patients) and the standard-of-care group (12 [11%] of 114 patients; unadjusted hazard ratio 1·09 [95% CI 0·49–2·43]; log-rank p=0·83). At 21 days, two (2%) of 105 patients in the enoxaparin group (one minor bleed and one bleed of unknown severity) and one (1%) of 114 patients in the standard-of-care group (major abnormal uterine bleeding) had a bleeding event. 22 (21%) patients in the enoxaparin group and 13 (11%) patients in the standard-of-care group had adverse events. The most common adverse event in both groups was COVID-19-related pneumonia (six [6%] patients in the enoxaparin group and five [4%] patients in the standard-of-care group). One patient in the enoxaparin group died and their cause of death was unknown. Interpretation The ETHIC trial results suggest that prophylaxis with low-molecular-weight heparin had no benefit for at-risk outpatients with COVID-19. Although the trial was terminated early, our data, combined with data from similar studies, provide further insights to inform international guidelines and influence clinical practice. Funding The Thrombosis Research Institute and Sanofi UK.
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Affiliation(s)
- Frank Cools
- Department of Cardiology, General Hospital Klina, Brasschaat, Belgium
| | | | - Jitendra Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Renato D Lopes
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Barry Jacobson
- Department of Haematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Juan I Arcelus
- Department of Surgery, University of Granada, Granada, Spain
| | - F D Richard Hobbs
- Oxford Primary Care, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Harry Gibbs
- Department of General Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Peter MacCallum
- Department of Haematology, Queen Mary University of London, London, UK
| | - Sebastian Schellong
- Department of Heart and Circulatory Diseases, Städtisches Klinikum Dresden, Dresden, Germany
| | - Sylvia Haas
- Institute for Experimental Oncology and Therapeutic Research, Technical University of Munich, Munich, Germany
| | | | - Walter Ageno
- Department of Medicine, University of Insubria, Varese, Italy
| | - Ana Thereza Rocha
- Department of Family Health, Federal University of Bahia, Salvador, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
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17
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Camm CF, Virdone S, Goto S, Bassand JP, van Eickels M, Haas S, Gersh BJ, Pieper K, Fox KAA, Misselwitz F, Turpie AGG, Goldhaber SZ, Verheugt F, Camm J, Kayani G, Panchenko E, Oh S, Luciardi HL, Sawhney JPS, Connolly SJ, Angchaisuksiri P, ten Cate H, Eikelboom JW, Kakkar AK. Association of body mass index with outcomes in patients with newly diagnosed atrial fibrillation: GARFIELD-AF. Open Heart 2022. [PMCID: PMC9362832 DOI: 10.1136/openhrt-2022-002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective While greater body mass index (BMI) is associated with increased risk of developing atrial fibrillation (AF), the impact of BMI on outcomes in newly diagnosed AF is unclear. We examine the influence of BMI on outcomes and whether this is modified by sex and evaluate the effect of non-vitamin K oral anticoagulants (NOACs) in patients with high BMI. Methods GARFIELD-AF is a prospective registry of 52 057 newly diagnosed AF patients. The study population comprised 40 482 participants: 703 underweight (BMI <18.5 kg/m2), 13 095 normal (BMI=18.5–24.9 kg/m2), 15 043 overweight (BMI=25.0–29.9 kg/m2), 7560 obese (BMI=30.0–34.9 kg/m2) and 4081 extremely obese (BMI ≥35.0 kg/m2). Restricted cubic splines quantified the association of BMI with outcomes. Comparative effectiveness of NOACs and vitamin K antagonists (VKAs) by BMI was performed using propensity score overlap-weighted Cox models. Results The median age of participants was 71.0 years (Q1; Q3 62.0; 78.0), and 55.6% were male. Those with high BMI were younger, more often had vascular disease, hypertension and diabetes. Within 2-year follow-up, a U-shaped relationship between BMI and all-cause mortality was observed, with BMI of ~30 kg/m2 associated with the lowest risk. The association with new/worsening heart failure was similar. Only low BMI was associated with major bleeding and no association emerged for non-haemorrhagic stroke. BMI was similarly associated with outcomes in men and women. BMI did not impact the lower rate of all-cause mortality of NOACs compared with VKAs. Conclusions In the GARFIELD-AF registry, underweight and extremely obese AF patients have increased risk of mortality and new/worsening heart failure compared with normal or obese patients.
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Cohen O, Ageno W, Farjat AE, Turpie AGG, Weitz JI, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Management strategies and clinical outcomes in patients with inferior vena cava thrombosis: Data from GARFIELD-VTE. J Thromb Haemost 2022; 20:366-374. [PMID: 34714962 PMCID: PMC9299483 DOI: 10.1111/jth.15574] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/08/2021] [Accepted: 10/25/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation. OBJECTIVE We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n = 100) with lower extremity deep vein thrombosis (LEDVT) patients (n = 7629). METHODS GARFIELD-VTE is a prospective, observational registry of 10 868 patients with objectively diagnosed VTE from 415 sites in 28 countries. RESULTS IVC thrombosis patients were younger (51.9 vs. 59.8 years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57-20.58] vs. 4.91 [4.55-5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85-9.15] vs. 4.18 [3.84-4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66-6.31] vs. 1.66 [1.45-1.89]). CONCLUSION In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.
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Affiliation(s)
- Omri Cohen
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
- National Hemophilia CenterInstitute of Thrombosis and HemostasisSheba Medical CenterTel‐HashomerIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | | | | | - Jeffrey I. Weitz
- McMaster UniversityHamiltonOntarioCanada
- Thrombosis and Atherosclerosis Research InstituteHamiltonOntarioCanada
| | - Sylvia Haas
- Formerly Technical University of MunichMunichGermany
| | - Shinya Goto
- Department of Medicine (Cardiology)Tokai University School of MedicineIseharaJapan
| | | | | | - Harry Gibbs
- Vascular LaboratoryThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter MacCallum
- Thrombosis Research InstituteLondonUK
- Queen Mary University of LondonLondonUK
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19
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Fox KAA, Virdone S, Bassand JP, Camm AJ, Goto S, Goldhaber SZ, Haas S, Kayani G, Koretsune Y, Misselwitz F, Oh S, Piccini JP, Parkhomenko A, Sawhney JPS, Stepinska J, Turpie AGG, Verheugt FWA, Kakkar AK. Do baseline characteristics and treatments account for geographical disparities in the outcomes of patients with newly diagnosed atrial fibrillation? The prospective GARFIELD-AF registry. BMJ Open 2022; 12:e049933. [PMID: 34996784 PMCID: PMC8744109 DOI: 10.1136/bmjopen-2021-049933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/04/2022] Open
Abstract
OBJECTIVE In patients with newly diagnosed atrial fibrillation (AF), do baseline risk factors and stroke prevention strategies account for the geographically diverse outcomes. DESIGN Global Anticoagulant Registry in the FIELD-Atrial Fibrillation is a prospective multinational non-interventional registry of patients with newly diagnosed AF (n=52 018 patients). SETTING Investigator sites (n=1317) were representative of the care settings/locations in each of the 35 participating countries. Treatment decisions were all determined by the local responsible clinicians. PARTICIPANTS The patients (18 years and over) with newly diagnosed AF had at least 1 investigator-determined stroke risk factor and patients were not required to meet specific thresholds of risk score for anticoagulant treatment. MAIN OUTCOMES AND MEASURES Observed 1-year event rates and risk-standardised rates were derived. RESULTS Rates of death, non-haemorrhagic stroke/systemic embolism and major bleeding varied more than three-to-four fold across countries even after adjustment for baseline factors and antithrombotic treatments. Rates of anticoagulation and antithrombotic treatment varied widely. Patients from countries with the highest rates of cardiovascular mortality and stroke were among the least likely to receive oral anticoagulants. Beyond anticoagulant treatment, variations in the treatment of comorbidities and lifestyle factors may have contributed to the variations in outcomes. Countries with the lowest healthcare Access and Quality indices (India, Ukraine, Argentina, Brazil) had the highest risk-standardised mortality. CONCLUSION The variability in outcomes across countries for patients with newly diagnosed AF is not accounted for by baseline characteristics and antithrombotic treatments. Residual mortality rates were correlated with Healthcare Access and Quality indices. The findings suggest the management of patients with AF needs to not only address guideline indicated and sustained anticoagulation, but also the treatment of comorbidities and lifestyle factors. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- Department of Cardiology, University of Besançon, Besancon, France
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine Graduate School of Medicine, Isehara, Japan
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munchen, Germany
| | | | | | | | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Jongno-gu, Korea (the Republic of)
| | | | - Alex Parkhomenko
- National Scientific Center M D Strazhesko Institute of Cardiology, The National Academy of Medical Sciences of Ukraine, Kiiv, Ukraine
| | | | - Janina Stepinska
- Institute of Cardiology, Intensive Cardiac therapy clinic, Warsaw, Poland
| | | | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
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20
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Bounameaux H, Haas S, Farjat AE, Ageno W, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Schellong S, Mantovani LG, Prandoni P, Kakkar AK. Corrigendum to "Comparative effectiveness of oral anticoagulants in venous thromboembolism: GARFIELD-VTE" [Thromb. Res. 2020 Jul; 191:103-112]. Thromb Res 2021; 216:129. [PMID: 34863582 DOI: 10.1016/j.thromres.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | | | - Lorenzo G Mantovani
- IRCCS Multimedica, Sesto San Giovanni, Italy; University of Milano-Bicocca, Milan, Italy
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom; University College London, London, United Kingdom
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21
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Weitz JI, Farjat AE, Ageno W, Turpie AGG, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Carrier M, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Influence of body mass index on clinical outcomes in venous thromboembolism: Insights from GARFIELD-VTE. J Thromb Haemost 2021; 19:3031-3043. [PMID: 34487616 DOI: 10.1111/jth.15520] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is limited information on the influence of body mass index (BMI) on clinical outcomes in patients with venous thromboembolism (VTE). OBJECTIVES Investigate the influence of BMI on baseline characteristics, treatment patterns, and 24-month outcomes in VTE patients. METHODS GARFIELD-VTE is a prospective, non-interventional study of 10 869 patients with objectively confirmed VTE. Patients were grouped according to BMI: <18.5 (underweight; n = 214); 18.5-24.9 (normal; n = 2866); 25.0-29.9 (overweight; n = 3326); ≥30 (obese; n = 3073). RESULTS Compared with patients with a normal BMI, obese patients were more frequently Caucasian (77.4% vs. 57.9%), treated in the outpatient setting (30.4% vs. 23.1%), and had previous VTE (17.5% vs. 11.7%). Active cancer was associated with lower BMI (underweight: 30.4%, normal: 13.5%, overweight: 9.4%, obese: 7.0%). At baseline, overweight and obese patients less often received parenteral therapy alone (16.7% and 14.4%) compared with those with an underweight or normal BMI (30.8% and 21.6%). Obese patients more commonly remained on anticoagulants for ≥2-years compared to those with a normal BMI (52.3% vs. 37.7%). After 24-months, the risk of all-cause mortality was lower in overweight and obese patients than in those with normal BMI (adjusted hazard ratio [95% CI]; 0.75 [0.63-0.89] and 0.59 [0.49-0.72], respectively). Underweight patients more often experienced major bleeding (2.45 [1.41-4.26]) and all-cause mortality (1.90 [1.43-2.53]) than patients with a normal BMI. Recurrent VTE was comparable among groups. CONCLUSION Underweight VTE patients have the highest risk of mortality and major bleeding. The risk of mortality in obese VTE patients is lower than that in VTE patients with a normal BMI.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter MacCallum
- Thrombosis Research Institute, London, UK
- Queen Mary University of London, UK
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Henri Bounameaux
- University Hospital of Geneva and Faculty of Medicine, Geneva, Switzerland
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22
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Virdone S, Himmelreich J, Pieper K, Camm A, Bassand JP, Fox K, Fitzmaurice D, Goldhaber S, Goto S, Haas S, Kayani G, Misselwitz F, Turpie A, Verheugt F, Kakkar A. Comparative effectiveness of NOAC vs VKA in patients representing common clinical challenges: results from the GARFIELD-AF registry. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/13/2022] Open
Abstract
Abstract
Introduction
Large phase III trials of non-valvular atrial fibrillation (AF) patients have shown a favourable risk-to-benefit ratio with Non-Vitamin K antagonist oral anticoagulants (NOAC) compared to Vitamin K antagonists (VKA). Although the results of these trials are directly applicable to many AF patients, important subsets of patients were under-represented. Thus, there remains uncertainty about the safety and effectiveness of NOAC therapy in common challenging scenarios.
Purpose
The main purpose of this study is to quantify and compare the impact of NOAC vs VKA in settings where clinical uncertainty still exists and represents a considerable proportion of AF patients in clinical practice.
Methods
The analysis was conducted in patients enrolled in the largest AF multinational prospective registry (the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation, GARFIELD-AF). We evaluated the effectiveness and safety of NOAC compared to VKA in three groups of patients representing common clinical challenges (CCC): 1) elderly patients (i.e. age ≥75), 2) increased bleeding risk (i.e. HAS-BLED ≥3 or prior bleeding), and 3) renal impairment (i.e. CKD stages II to IV).
We applied a propensity score using an overlap weighting scheme to obtain unbiased estimates of the treatment effect within each CCC group. Weights were applied to Cox proportional hazards models to estimate the effects of the NOAC vs VKA comparison on the occurrence of death, non-haemorrhagic stroke/SE and major bleeding within 2 years of enrolment.
Results
Comparative effectiveness of NOAC vs VKA was assessed in 8607 elderly patients, 1711 with increased bleeding risk, and 4460 with renal impairment.
The proportion of anticoagulated patients was low in patients with increased bleeding risk (59%), while in the other two CCC groups the corresponding proportion was close to the one in the overall population (72%).
Among anticoagulated patients, NOAC were prescribed to 50–55% of patients in the CCC groups. Patients with a high risk of bleeding and impaired kidney function were less likely to be prescribed NOAC instead of VKA compared with the overall anticoagulated population (−5.4% and −4.7%, respectively).
Propensity-weighted hazard ratios for all-cause mortality favored NOAC (vs VKA) in all three CCC groups: 0.86 (95% CI: 0.74–0.99) for elderly patients, 0.73 (0.53–1.00) for patients with increased bleeding risk, and 0.80 (0.65–0.98) for patients with renal impairment (Figure).
Conclusion
In the selected common challenging scenarios of AF patients, there were significant mortality reductions in favor of NOACs compared to VKAs. These observations suggest that NOACs are safe and effective in patients who are elderly, at increased bleeding risk, or renally impaired.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK, which sponsors the GARFIELD-AF registry. The work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.
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Affiliation(s)
- S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - J.C.L Himmelreich
- Thrombosis Research Institute, London, UK and Amsterdam UMC, Department of General Practice, Amsterdam, Netherlands (The)
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besancon, France
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | | | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Munich, Germany
| | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | | | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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23
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Camm A, Virdone S, Fox K, Pieper K, Beyer-Westendorf J, Le Heuzey JY, Haas S, Kayani G, Gersh B, Turpie A, Kakkar A. Rivaroxaban dosing in patients with atrial fibrillation: results from the RIVER registry – is dosing according to renal function appropriate? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
Rivaroxaban is recommended as an option for anticoagulation in patients with nonvalvular atrial fibrillation (AF) with one or more risk factors for stroke. The approved/recommended rivaroxaban dose for stroke prevention in patients with atrial fibrillation (AF) is solely based on renal function: 20 mg once daily (od) for patients with a creatinine clearance [CrCl] ≥50 ml/min and 15 mg od in patients with CrCl 15–49 mL/min).
Purpose
To assess the patterns of rivaroxaban prescription as per the creatinine clearances levels and to assess the impact of the rivaroxaban dosing on the rate of events at 2-year follow-up in patients with AF.
Methods
RIVaroxaban Evaluation in Real Life setting (RIVER) is a prospective international registry of patients with newly diagnosed non-valvular AF treated with rivaroxaban for the prevention of thromboembolic stroke and at least one investigator-determined risk factor for stroke. Adjusted hazard ratios (HRs) were obtained through Cox proportional-hazard model.
Results
Among 3402 patients with normal renal function (CrCl ≥50 mL/min), 82.1% were prescribed the recommended rivaroxaban dose of 20 mg (od) at baseline. Among 524 patients with moderate or severe renal impairment (CrCl 15–50 mL/min), 55.3% patients received rivaroxaban 15 mg (od), 39.9% received 20 mg (od) and 4.2% 10 mg (od). Non-recommended dosing was rare in patients younger than 70 (13.5%) but more frequent in older patients (28.8%). Non-recommended low dosing was more frequent in Asians (38.9%), compared to non-Asian patients (13.8%).
Regarding clinical outcomes, adjusted hazards ratios (HR, presented with 95% confidence intervals) showed that the non-recommended low dosing (<20 mg od) was associated with higher risk of non-cardiovascular mortality (HR 2.09 (1.16–3.77)) in patients with normal renal function. The non-recommended high dosing (>15 mg od) was associated with lower risk of all-cause mortality (HR 0.63 (0.42–0.93)) and cardiovascular mortality (HR 0.32 (0.13–0.77)) and higher risk of major bleeding (HR 2.86 (1.49–5.50)) in patients with moderate to severe renal impairment (figure 1 and 2).
Conclusion
In patients with normal renal function, non-recommended low dose rivaroxaban was associated with increased cardiovascular mortality without reducing the risk of major bleeding compared to recommended dosing. In patients with CrCl <50 ml/min, non-recommended high dose rivaroxaban was associated with reduced cardiovascular mortality but at the cost of increased major bleeding. These observational data largely support the reduction of rivaroxaban dosing according to renal function but educational strategies are needed to ensure that rivaroxaban is used appropriately.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK, which sponsors the RIVER registry. This work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.
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Affiliation(s)
- A.J Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's Uni, London, United Kingdom
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - J Beyer-Westendorf
- Thrombosis Research Unit, University Hospital “Carl Gustav Carus”, Department of Medicine I, Division Haematology, Dresden, Germany
| | - J.-Y Le Heuzey
- Georges Pompidou Hospital, René Descartes University, Paris, France
| | - S Haas
- Technical University of Munich, Munich, Germany
| | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - B.J Gersh
- Mayo Clinic College of Medicine, Rochester, United States of America
| | | | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Himmelreich J, Virdone S, Camm A, Harskamp R, Pieper K, Fox K, Bassand JP, Fitzmaurice D, Goldhaber S, Goto S, Haas S, Misselwitz F, Turpie A, Verheugt F, Kakkar A. Safety and efficacy of apixaban and rivaroxaban versus warfarin in real-world atrial fibrillation patients are similar to their randomized trials: insights from GARFIELD-AF registry. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
Generalisability of patient selection in the landmark trials for the approval of apixaban (ARISTOTLE) and rivaroxaban (ROCKET AF) for use in non-valvular atrial fibrillation (AF) is limited. Although observational data have confirmed the safety and efficacy of these non-vitamin K oral anticoagulants (NOACs) in unselected AF populations, robust replication of randomized trials in observational studies is warranted.
Purpose
To investigate the proportion of real-world AF patients who would have been eligible for the landmark trials for ARISTOTLE and ROCKET AF, and to assess reproducibility of these landmark trials in the largest, worldwide, prospective registry of newly diagnosed AF patients.
Methods
We analysed data from the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation (GARFIELD-AF) registry. We assessed the eligibility of AF patients treated with apixaban or vitamin K antagonist (VKA) for ARISTOTLE, and those treated with rivaroxaban or VKA for ROCKET AF, using the selection criteria of the original trials. We replicated the inclusion and exclusion criteria of ARISTOTLE and ROCKET AF by deriving the set of patients eligible for each trial and calculating the adjusted hazard ratios (HRs) for stroke or systemic embolism, major bleeding, and all-cause mortality within 2 years of enrolment, using a propensity score overlap weighted Cox model. We compared the results from observational data with those reported in the original ARISTOTLE and ROCKET AF publications.
Results
Among all patients enrolled in GARFIELD-AF, 67% were eligible for recruitment in ARISTOTLE and 37% in ROCKET AF. The corresponding proportions among anticoagulated patients were 70% and 39%, respectively. Among patients on apixaban and VKA, 2570/3615 (71%) and 8005/11718 (68%), respectively, were eligible for ARISTOTLE. Of patients using rivaroxaban and VKA, 2005/4914 (41%) and 4368/11721 (37%), respectively, were eligible for ROCKET AF. Annual eligibility rates among real-world NOAC users were stable over time (Figure 1). Registry participants on rivaroxaban or VKA eligible for ROCKET AF had a higher burden of cardiovascular co-morbidity than those on apixaban or VKA eligible for ARISTOTLE. The adjusted HRs in observational data were compatible with results of the original trials in all selected outcomes (Figure 2).
Conclusion
Representativeness of ARISTOTLE and ROCKET AF for real-world AF populations was limited, with ROCKET AF's criteria being more restrictive. Despite inclusion of only incident AF cases in GARFIELD-AF versus mostly prevalent AF cases in the original trials, the results were similar. Our work indicates that the results from ARISTOTLE and ROCKET AF appear robust and reproducible in real-world patients with newly diagnosed AF.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK, which sponsors the GARFIELD-AF registry. This work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.
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Affiliation(s)
- J.C.L Himmelreich
- Thrombosis Research Institute, London, UK and Amsterdam UMC, Department of General Practice, Amsterdam, Netherlands (The)
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - R.E Harskamp
- Amsterdam UMC Location AMC, Department of General Practice, Amsterdam Public Health, Amsterdam, Netherlands (The)
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | | | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Munich, Germany
| | | | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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25
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Beyer-Westendorf J, Camm A, Virdone S, Fox K, Pieper K, Le Heuzey JY, Haas S, Kayani G, Gersh B, Turpie A, Kakkar A. Two-year outcomes of patients with atrial fibrillation treated with rivaroxaban: results from RIVER registry. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
Non-vitamin-K oral anticoagulants (NOACs) were recommended in preference to oral vitamin K antagonists (VKAs) in the 2020 updated guidelines for stroke prevention in atrial fibrillation (AF), from the European Society of Cardiology (ESC). Rivaroxaban is a NOAC that is approved in many countries worldwide for reducing the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF).
Purpose
To explore the baseline characteristics, dosing and 2-year outcomes of patients with AF treated with rivaroxaban.
Methods
RIVaroxaban Evaluation in Real Life setting (RIVER) is a prospective international, multicenter registry of patients with newly diagnosed non-valvular AF treated with rivaroxaban for the prevention of thromboembolic stroke and at least one investigator-determined risk factor for stroke.
Results
A total of 5043 patients were enrolled into RIVER between January 2015 and June 2017. Mean (SD) age at diagnosis was 69.5 (11.0) years and 55.7% were males. Caucasian patients represented the largest proportion of patients in RIVER (80.3%), followed by Asians (5.5%) and hispanic/latino (3.7%). Almost all patients (98.5%) were prescribed a single daily dose of rivaroxaban, most commonly 20 mg (77.3%) and 15 mg (20.4%), while a 10 mg dose was prescribed in only 2.3% of patients. During the 2-year follow-up, the rates (95% CI) of all-cause mortality, stroke/SE, and major bleeding were 2.75 (2.43 to 3.12), 0.89 (0.72; 1.11), and 1.26 (1.05 to 1.52) per 100 person years, respectively (Figure 1). The most common cardiovascular cause of death was congestive heart failure (30.4%) and myocardial infarction (11.4%). Leading non-cardiovascular causes of death were malignancy (27.4%), respiratory failure (18.9%) and infections/sepsis (13.2%). Over 2 years, 710 (14.1%) of patients discontinued rivaroxaban. The corresponding proportions at 6 months and 1 year were 7.8% and 10.8%, respectively. Out of all the patients who discontinued, 62 (8.7%) restarted rivaroxaban during their follow-up (Table 1).
Conclusion
During 2 years of follow up in the international, prospective RIVER registry, rivaroxaban treatment for AF was associated with low rates of stroke or major bleeding.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK. This work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.
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Affiliation(s)
- J Beyer-Westendorf
- University Hospital “Carl Gustav Carus” Dresden, Center for Vascular Medicine, Dresden, Germany
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - J.-Y Le Heuzey
- Georges Pompidou Hospital, René Descartes University, Paris, France
| | - S Haas
- Technical University of Munich, Munich, Germany
| | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - B.J Gersh
- Mayo Clinic College of Medicine, Rochester, United States of America
| | | | - A.K Kakkar
- Thrombosis Research Institute and University College London, london, United Kingdom
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Himmelreich J, Virdone S, Camm A, Harskamp R, Pieper K, Fox K, Bassand JP, Fitzmaurice D, Goldhaber S, Goto S, Haas S, Misselwitz F, Turpie A, Verheugt F, Kakkar A. Comparing rivaroxaban and apixaban in GARFIELD-AF according to ROCKET AF and ARISTOTLE trial selection criteria. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
There is debate on the extent to which differences in selection criteria and outcome definitions used for ARISTOTLE and ROCKET AF – the trials for the approval of apixaban and rivaroxaban, respectively, for non-valvular atrial fibrillation – influenced their differences in outcomes relative to vitamin K antagonists (VKAs). In absence of randomized trials comparing the two non-vitamin K oral antagonists (NOACs) directly, this question can be addressed using data from the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation (GARFIELD-AF) registry, a large, high-quality prospective observational study of newly diagnosed AF patients.
Purpose
To assess the influence of the ARISTOTLE and ROCKET AF inclusion and exclusion criteria on results for safety and efficacy of apixaban and rivaroxaban versus VKA using uniform endpoints in GARFIELD-AF.
Methods
We selected patients treated with apixaban, rivaroxaban or VKA from GARFIELD-AF who were eligible for ARISTOTLE or ROCKET AF as per the original trial criteria. We replicated the inclusion criteria in the GARFIELD-AF population and derived those eligible for each trial. We calculated the adjusted hazard ratios (HRs) for stroke or systemic embolism, major bleeding and all-cause mortality within 2 years of enrolment for apixaban as well as rivaroxaban versus VKA (reference) in those eligible for each trial. We used a propensity score overlap weighted Cox model to emulate trial randomization between NOAC and VKA.
Results
Among patients on apixaban, rivaroxaban and VKA, 2570/3615 (71%), 3560/4914 (72%) and 8005/11734 (71%) were eligible for ARISTOTLE, respectively, and 1612/3615 (45%), 2005/4914 (41%) and 4368/11734 (37%), respectively, were eligible for ROCKET AF. Cardiovascular co-morbidity was greater in those eligible for ROCKET AF than in those eligible for ARISTOTLE. In patients selected using the more restrictive ROCKET AF criteria, apixaban and rivaroxaban users showed similar results when compared with VKA (see Figure). The two sets of comparisons remained non-significant in difference when applying the less restrictive ARISTOTLE criteria, but there were trends for less similarity.
Conclusion
Apixaban showed similar results to rivaroxaban when selecting for higher-risk patients using the ROCKET AF criteria. In patients selected using ARISTOTLE criteria the similarity was less pronounced. Our results underline the problems faced in comparing treatments across rather than within clinical trials. For instance, co-morbidities were substantially different for patients recruited into the original ARISTOTLE and ROCKET AF trials. The current work points to the need for high-quality observational data for assessment of relative drug performance in absence of direct drug comparisons through randomized trials.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK, which sponsors the GARFIELD-AF registry. This work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.
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Affiliation(s)
- J.C.L Himmelreich
- Thrombosis Research Institute, London, UK and Amsterdam UMC, Department of General Practice, Amsterdam, Netherlands (The)
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - R.E Harskamp
- Amsterdam UMC Location AMC, Department of General Practice, Amsterdam Public Health, Amsterdam, Netherlands (The)
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | | | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Munich, Germany
| | | | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, lONDON, United Kingdom
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27
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Cools F, Johnson D, Camm AJ, Bassand J, Verheugt FWA, Yang S, Tsiatis A, Fitzmaurice DA, Goldhaber SZ, Kayani G, Goto S, Haas S, Misselwitz F, Turpie AGG, Fox KAA, Pieper KS, Kakkar AK. Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: Results from the GARFIELD-AF Registry. J Thromb Haemost 2021; 19:2322-2334. [PMID: 34060704 PMCID: PMC8390436 DOI: 10.1111/jth.15415] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral anticoagulation (OAC) in atrial fibrillation (AF) reduces the risk of stroke/systemic embolism (SE). The impact of OAC discontinuation is less well documented. OBJECTIVE Investigate outcomes of patients prospectively enrolled in the Global Anticoagulant Registry in the Field-Atrial Fibrillation study who discontinued OAC. METHODS Oral anticoagulation discontinuation was defined as cessation of treatment for ≥7 consecutive days. Adjusted outcome risks were assessed in 23 882 patients with 511 days of median follow-up after discontinuation. RESULTS Patients who discontinued (n = 3114, 13.0%) had a higher risk (hazard ratio [95% CI]) of all-cause death (1.62 [1.25-2.09]), stroke/systemic embolism (SE) (2.21 [1.42-3.44]) and myocardial infarction (MI) (1.85 [1.09-3.13]) than patients who did not, whether OAC was restarted or not. This higher risk of outcomes after discontinuation was similar for patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) (p for interactions range = 0.145-0.778). Bleeding history (1.43 [1.14-1.80]), paroxysmal vs. persistent AF (1.15 [1.02-1.29]), emergency room care setting vs. office (1.37 [1.18-1.59]), major, clinically relevant nonmajor, and minor bleeding (10.02 [7.19-13.98], 2.70 [2.24-3.25] and 1.90 [1.61-2.23]), stroke/SE (4.09 [2.55-6.56]), MI (2.74 [1.69-4.43]), and left atrial appendage procedures (4.99 [1.82-13.70]) were predictors of discontinuation. Age (0.84 [0.81-0.88], per 10-year increase), history of stroke/transient ischemic attack (0.81 [0.71-0.93]), diabetes (0.88 [0.80-0.97]), weeks from AF onset to treatment (0.96 [0.93-0.99] per week), and permanent vs. persistent AF (0.73 [0.63-0.86]) were predictors of lower discontinuation rates. CONCLUSIONS In GARFIELD-AF, the rate of discontinuation was 13.0%. Discontinuation for ≥7 consecutive days was associated with significantly higher all-cause mortality, stroke/SE, and MI risk. Caution should be exerted when considering any OAC discontinuation beyond 7 days.
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Affiliation(s)
| | - Dana Johnson
- Department of StatisticsNorth Carolina State UniversityRaleighNCUSA
| | - Alan J. Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research InstituteSt. George’s University of LondonLondonUK
| | | | | | - Shu Yang
- North Carolina State UniversityRaleighNCUSA
| | | | | | | | | | - Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | - Sylvia Haas
- Formerly Department of MedicineTechnical University of MunichMunichGermany
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
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28
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Camm AJ, Fox KAA, Virdone S, Bassand JP, Fitzmaurice DA, Berchuck SI, Gersh BJ, Goldhaber SZ, Goto S, Haas S, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Cappato R, Kakkar AK. Comparative effectiveness of oral anticoagulants in everyday practice. Heart 2021; 107:962-970. [PMID: 33593994 PMCID: PMC8165153 DOI: 10.1136/heartjnl-2020-318420] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study evaluated the comparative effectiveness of vitamin K antagonists (VKAs), direct thrombin inhibitors (DTIs) and factor Xa inhibitors (FXaI) in patients with atrial fibrillation (AF) at risk of stroke in everyday practice. METHODS Data from patients with AF and Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular disease, Age 65-74 years, Sex category (CHA2DS2-VASc) score ≥2 (excluding gender) in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation registry were analysed using an improved method of propensity weighting, overlap weights and Cox proportional hazards models. RESULTS All-cause mortality, non-haemorrhagic stroke/systemic embolism (SE) and major bleeding over 2 years were compared in 25 551 patients, 7162 (28.0%) not treated with oral anticoagulant (OAC) and 18 389 (72.0%) treated with OAC (FXaI (41.8%), DTI (11.4%) and VKA (46.8%)). OAC treatment compared with no OAC treatment was associated with decreased risk of all-cause mortality (HR 0.82 (95% CI 0.74 to 0.91)) and non-haemorrhagic stroke/SE (HR 0.71 (95% CI 0.57 to 0.88)) but increased risk of major bleeding (HR 1.46 (95% CI 1.15 to 1.86)). Non-vitamin K antagonist oral anticoagulant (NOAC) use compared with no OAC treatment was associated with lower risks of all-cause mortality and non-haemorrhagic stroke/SE (HR 0.67 (95% CI 0.59 to 0.77)) and 0.65 (95% CI 0.50 to 0.86)) respectively, with no increase in major bleeding (HR 1.10 (95% CI 0.82 to 1.47)). NOAC use compared with VKA use was associated with lower risk of all-cause mortality and major bleeding (rates/100 patient-years 3.6 (95% CI 3.3 to 3.9) vs 4.8 (95% CI 4.5 to 5.2) and 1.0 (95% CI 0.9 to 1.1) vs 1.4 (95% CI 1.2 to 1.6); HR 0.79 (95% CI 0.70 to 0.89) and 0.77 (95% CI 0.61 to 0.98) respectively), with similar risk of non-haemorrhagic stroke/SE (rates/100 patient-years 0.8 (95% CI 0.7 to 0.9) versus 1.0 (95% CI 0.8 to 1.1); HR 0.96 (95% CI 0.73 to 1.25). CONCLUSION Important benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypes. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- Department of Cardiology, University of Besançon, Besançon, France
| | | | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich, Germany
| | | | | | | | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS - MultiMedica Group, Sesto San Giovanni (Milan), Italy
| | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK
- University College London, London, UK
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29
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Haas S. [Postoperative venous thromboembolism prevention]. MMW Fortschr Med 2021; 163:46-53. [PMID: 33950449 DOI: 10.1007/s15006-021-9813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sylvia Haas
- ehemals Klinikum rechts der Isar TUM, München, München, Germany
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30
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Affiliation(s)
- Harald Darius
- Klinik für Kardiologie, Angiologie, Nephrologie und kons. Intensivmedizin, Vivantes Klinikum Neukölln, Rudower Straße, 12351, Berlin, Deutschland.
| | | | - Sylvia Haas
- ehemals Klinikum rechts der Isar TUM, München, München, Deutschland
| | | | | | - Wolfgang Miesbach
- Universitätsklinikum Frankfurt am Main, Frankfurt am Main, Deutschland
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31
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Fox KAA, Virdone S, Pieper KS, Bassand JP, Camm AJ, Fitzmaurice DA, Goldhaber SZ, Goto S, Haas S, Kayani G, Oto A, Misselwitz F, Piccini JP, Dalgaard F, Turpie AGG, Verheugt FW, Kakkar AK. GARFIELD-AF risk score for mortality, stroke and bleeding within 2 years in patients with atrial fibrillation. Eur Heart J Qual Care Clin Outcomes 2021; 8:214-227. [PMID: 33892489 PMCID: PMC8888127 DOI: 10.1093/ehjqcco/qcab028] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/08/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
Aims To determine whether the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation (GARFIELD-AF) integrated risk tool predicts mortality, non-haemorrhagic stroke/systemic embolism, and major bleeding for up to 2 years after new-onset AF and to assess how this risk tool performs compared with CHA2DS2-VASc and HAS-BLED. Methods and results Potential predictors of events included demographic and clinical characteristics, choice of treatment, and lifestyle factors. A Cox proportional hazards model was identified for each outcome by least absolute shrinkage and selection operator methods. Indices were evaluated in comparison with CHA2DS2-VASc and HAS-BLED risk predictors. Models were validated internally and externally in ORBIT-AF and Danish nationwide registries. Among the 52 080 patients enrolled in GARFIELD-AF, 52 032 had follow-up data. The GARFIELD-AF risk tool outperformed CHA2DS2-VASc for all-cause mortality in all cohorts. The GARFIELD-AF risk score was superior to CHA2DS2-VASc for non-haemorrhagic stroke, and it outperformed HAS-BLED for major bleeding in internal validation and in the Danish AF cohort. In very low- to low-risk patients [CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)], the GARFIELD-AF risk score offered strong discriminatory value for all the endpoints when compared to CHA2DS2-VASc and HAS-BLED. The GARFIELD-AF tool also included the effect of oral anticoagulation (OAC) therapy, thus allowing clinicians to compare the expected outcome of different anticoagulant treatment decisions [i.e. no OAC, non-vitamin K antagonist (VKA) oral anticoagulants, or VKAs]. Conclusions The GARFIELD-AF risk tool outperformed CHA2DS2-VASc at predicting death and non-haemorrhagic stroke, and it outperformed HAS-BLED for major bleeding in overall as well as in very low- to low-risk group patients with AF. Clinical trial registration URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF: NCT01090362, ORBIT-AF I: NCT01165710; ORBIT-AF II: NCT01701817.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute (TRI), London, UK.,Department of Cardiology, University of Besançon, Besançon, France
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | | | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai School of medicine, Kanagawa, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich, Germany
| | | | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | | | | | - Frederik Dalgaard
- Department of Cardiology, Hertlev & Gentofte Hospital, Hellerup, Copenhagen, Denmark
| | | | - Freek Wa Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Ajay K Kakkar
- Thrombosis Research Institute (TRI), London, UK.,University College London, London, UK
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Jacobson BF, Schapkaitz E, Mer M, Louw S, Haas S, Buller HR, Brenner B, Abdool-Carrim ATO, De Jong P, Hsu P, Jankelow D, Lebos M, Levy B, Radford H, Rowji P, Redman L, Sussman M, Van der Jagt D, Wessels PF, Williams PG, Society Of Thrombosis And Haemostasis OBOTSA. Recommendations for the diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia. S Afr Med J 2021; 111:535-537. [PMID: 34382561] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 06/13/2023] Open
Abstract
There have recently been safety concerns regarding an increased risk of vaccine-induced immune thrombotic thrombocytopenia (VITT) following administration of SARS-CoV-2 adenoviral vector vaccines. The Southern African Society of Thrombosis and Haemostasis reviewed the emerging literature on this idiosyncratic complication. A draft document was produced and revised by consensus agreement by a panel of professionals from various specialties. The recommendations were adjudicated by independent international experts to avoid local bias. We present concise, practical guidelines for the clinical management of VITT.
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Affiliation(s)
- B F Jacobson
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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33
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Haas S, Mantovani LG, Kreutz R, Monje D, Schneider J, Zell ER, Tamm M, Gebel M, Bugge J, Ageno W, Turpie AGG. Anticoagulant treatment for venous thromboembolism: A pooled analysis and additional results of the XALIA and XALIA-LEA noninterventional studies. Res Pract Thromb Haemost 2021; 5:426-438. [PMID: 33870028 PMCID: PMC8035798 DOI: 10.1002/rth2.12489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/04/2020] [Accepted: 01/01/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The XALIA and XALIA-LEA prospective, noninterventional studies investigated the safety and effectiveness of rivaroxaban versus standard anticoagulation for venous thromboembolism (VTE) treatment in routine clinical practice across global regions. OBJECTIVES This pooled analysis combined their data to determine the incidence of thromboembolic and bleeding events in both treatment groups and addressed specific bleeding patterns in a broad range of patients. METHODS Patients with objectively confirmed VTE and an indication for ≥3 months' anticoagulation treatment received rivaroxaban or standard anticoagulation (eg, initial treatment with heparin/fondaparinux, followed by a vitamin K antagonist [VKA]). Treatment choice, dose, management, and duration were at the physician's discretion. Primary outcomes (major bleeding, recurrent VTE, and all-cause mortality) were compared between the two treatment groups. Propensity score stratification, and matching were used to reduce bias due to confounding variables. RESULTS Overall, 7129 patients were enrolled from 36 countries; 6445 and 2714 patients were included in the propensity score-stratified and -matched analyses, respectively. Major bleeding and incidences of recurrent VTE were similar between treatment groups; all-cause mortality was lower with rivaroxaban than with standard anticoagulation. The incidences of genitourinary bleeding were higher with rivaroxaban than with standard anticoagulation therapy (46 and 23 events in the matched analysis, respectively). VKA management in real-world practice was suboptimal. CONCLUSION XALIA and XALIA-LEA show similar safety and effectiveness profiles of rivaroxaban and standard anticoagulation for VTE treatment in routine practice in many parts of the world. The observations are consistent with results from the phase III EINSTEIN randomized controlled trials.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University MunichMunichGermany
| | - Lorenzo G. Mantovani
- IRCCS MultimedicaSesto San GiovanniItaly
- CESP‐Center for Public Health ResearchUniversity of Milan BicoccaMonzaItaly
| | - Reinhold Kreutz
- Institute of Clinical Pharmacology and ToxicologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universitä BerlinHumboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | | | | | | | | | | | | | - Walter Ageno
- Department of Clinical and Experimental MedicineUniversity of InsubriaVareseItaly
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Bunge EM, van Hout B, Haas S, Spentzouris G, Cohen A. Critical appraisal and issues regarding generalisability of comparative effectiveness studies of NOACs in atrial fibrillation and their relation to clinical trial data: a systematic review. BMJ Open 2021; 11:e042024. [PMID: 33526502 PMCID: PMC7852966 DOI: 10.1136/bmjopen-2020-042024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [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] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To critically appraise the published comparative effectiveness studies on non-vitamin K antagonist oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF). Results were compared with expectations formulated on the basis of trial results with specific attention to the patient years in each study. METHODS All studies that compared the effectiveness or safety between at least two NOACs in patients with NVAF were eligible. We performed a systematic literature review in Medline and EMbase to investigate the way comparisons between NOACs were made, search date 23 April 2019. Critical appraisal of the studies was done using among others ISPOR Good Research Practices for comparative effectiveness research. RESULTS We included 39 studies in which direct comparison between at least two NOACs were made. Almost all studies concerned patient registries, pharmacy or prescription databases and/or health insurance database studies using a cohort design. Corrections for differences in patient characteristics was applied in all but two studies. Eighteen studies matched using propensity scores (PS), 8 studies weighted patients based on the inverse probability of treatment, 1 study used PS stratification and 10 studies applied a proportional hazards model. These studies have some important limitations regarding unmeasured confounders and channelling bias, even though the larger part of the studies were well conducted technically. On the basis of trial results, expected differences are small and a naïve analysis suggests trials with between 7200 and 56 500 patients are needed to confirm the observed differences in bleedings and between 51 800 and 7 994 300 to confirm differences in efficacy. DISCUSSION Comparisons regarding effectiveness and safety between NOACs on the basis of observational data, even after correction for baseline characteristics, may not be reliable due to unmeasured confounders, channelling bias and insufficient sample size. These limitations should be kept in mind when results of these studies are used to decide on ranking NOAC treatment options.
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Affiliation(s)
- Eveline M Bunge
- Pallas health research and consultancy BV, Rotterdam, The Netherlands
| | - Ben van Hout
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Alexander Cohen
- Department of Haematology, Guys and St Thomas' NHS Foundation Trust, King's College London, London, UK
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35
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Ageno W, Farjat A, Haas S, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Dalsgaard Nielsen J, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Provoked versus unprovoked venous thromboembolism: Findings from GARFIELD-VTE. Res Pract Thromb Haemost 2021; 5:326-341. [PMID: 33733032 PMCID: PMC7938631 DOI: 10.1002/rth2.12482] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) has a long-term risk of recurrence, dependent on the presence or absence of provoking risk factors at the time of the event. OBJECTIVE To compare clinical characteristics, anticoagulant patterns, and 12-month outcomes in patients with transient provoking factors, active cancer, and unprovoked VTE. METHODS The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE is a prospective, observational study that enrolled 10 207 patients with objectively diagnosed VTE from 415 sites in 28 countries. RESULTS Patients with transient provoking factors were younger (53.0 years) and more frequently women (61.2%) than patients with unprovoked VTE (60.3 years; 43.0% women) or active cancer (63.6 years; 51.7% women). After 6 months, 59.1% of patients with transient provoking factors remained on anticoagulation, compared to 71.3% with unprovoked VTE and 47.3% with active cancer. At 12 months, this decreased to 36.7%, 51.5%, and 25.4%, respectively. The risk of mortality (hazard ratio [HR], 1.21; 95% confidence interval [CI], 0.90-1.62), recurrent VTE (HR, 0.84; 95% CI, 0.62-1.14), and major bleeding (HR, 1.26; 95% CI, 0.86-1.85) was comparable in patients with transient provoking factors and unprovoked VTE. Patients with minor and major transient provoking factors had a similar risk of recurrent VTE (HR, 0.99; 95% CI, 0.59-1.66), but those with major transient risk factors had a lower risk of death (HR, 0.61; 95% CI, 0.38-0.98). CONCLUSION At 1 year, nearly 40% of patients with transient provoking factors and slightly over half of patients with unprovoked VTE were on anticoagulant treatment. Event rates were comparable between the two groups. Risk of death was higher in patients with minor transient factors than in those with major transient factors.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | | | - Sylvia Haas
- Formerly Technical University of MunichMunichGermany
| | - Jeffrey I. Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research InstituteHamiltonONCanada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology)Tokai University School of MedicineShibuya CityJapan
| | | | | | | | | | | | | | | | - Ajay K. Kakkar
- Thrombosis Research InstituteLondonUK
- University College LondonLondonUK
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36
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Jerjes-Sánchez C, Rodriguez D, Farjat AE, Kayani G, MacCallum P, Lopes RD, Turpie AGG, Weitz JI, Haas S, Ageno W, Goto S, Goldhaber SZ, Angchaisuksiri P, Nielsen JD, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Pregnancy-Associated Venous Thromboembolism: Insights from GARFIELD-VTE. TH Open 2021; 5:e24-e34. [PMID: 33532693 PMCID: PMC7840428 DOI: 10.1055/s-0040-1722611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction
The risk of venous thromboembolism (VTE) increases during pregnancy and the puerperium such that VTE is a leading cause of maternal mortality.
Methods
We describe the clinical characteristics, diagnostic strategies, treatment patterns, and outcomes of women with pregnancy-associated VTE (PA-VTE) enrolled in the Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE. Women of childbearing age (<45 years) were stratified into those with PA-VTE (
n
= 183), which included pregnant patients and those within the puerperium, and those with nonpregnancy associated VTE (NPA-VTE;
n
= 1,187). Patients with PA-VTE were not stratified based upon the stage of pregnancy or puerperium.
Results
Women with PA-VTE were younger (30.5 vs. 34.8 years), less likely to have pulmonary embolism (PE) (19.7 vs. 32.3%) and more likely to have left-sided deep vein thrombosis (DVT) (73.9 vs. 54.8%) compared with those with NPA-VTE. The most common risk factors in PA-VTE patients were hospitalization (10.4%), previous surgery (10.4%), and family history of VTE (9.3%). DVT was typically diagnosed by compression ultrasonography (98.7%) and PE by chest computed tomography (75.0%). PA-VTE patients more often received parenteral (43.2 vs. 15.1%) or vitamin K antagonists (VKA) (9.3 vs. 7.6%) therapy alone. NPA-VTE patients more often received a DOAC alone (30.2 vs. 13.7%). The risk (hazard ratio [95% confidence interval]) of all-cause mortality (0.59 [0.18–1.98]), recurrent VTE (0.82 [0.34–1.94]), and major bleeding (1.13 [0.33–3.90]) were comparable between PA-VTE and NPA-VTE patients. Uterine bleeding was the most common complication in both groups.
Conclusion
VKAs or DOACs are widely used for treatment of PA-VTE despite limited evidence for their use in this population. Rates of clinical outcomes were comparable between groups.
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Affiliation(s)
- Carlos Jerjes-Sánchez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | - David Rodriguez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, United States
| | | | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Tokai, Japan
| | | | | | | | | | | | - Lorenzo G Mantovani
- IRCCS Multimedica Milan, Milan, Italy.,University of Milano, Bicocca, Milan, Italy
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Goto S, Goto S, Pieper KS, Bassand JP, Camm AJ, Fitzmaurice DA, Goldhaber SZ, Haas S, Parkhomenko A, Oto A, Misselwitz F, Turpie AGG, Verheugt FWA, Fox KAA, Gersh BJ, Kakkar AK. New artificial intelligence prediction model using serial prothrombin time international normalized ratio measurements in atrial fibrillation patients on vitamin K antagonists: GARFIELD-AF. Eur Heart J Cardiovasc Pharmacother 2020; 6:301-309. [PMID: 31821482 PMCID: PMC7556811 DOI: 10.1093/ehjcvp/pvz076] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/14/2019] [Accepted: 12/05/2019] [Indexed: 12/05/2022]
Abstract
Aims Most clinical risk stratification models are based on measurement at a single time-point rather than serial measurements. Artificial intelligence (AI) is able to predict one-dimensional outcomes from multi-dimensional datasets. Using data from Global Anticoagulant Registry in the Field (GARFIELD)-AF registry, a new AI model was developed for predicting clinical outcomes in atrial fibrillation (AF) patients up to 1 year based on sequential measures of prothrombin time international normalized ratio (PT-INR) within 30 days of enrolment. Methods and results Patients with newly diagnosed AF who were treated with vitamin K antagonists (VKAs) and had at least three measurements of PT-INR taken over the first 30 days after prescription were analysed. The AI model was constructed with multilayer neural network including long short-term memory and one-dimensional convolution layers. The neural network was trained using PT-INR measurements within days 0–30 after starting treatment and clinical outcomes over days 31–365 in a derivation cohort (cohorts 1–3; n = 3185). Accuracy of the AI model at predicting major bleed, stroke/systemic embolism (SE), and death was assessed in a validation cohort (cohorts 4–5; n = 1523). The model’s c-statistic for predicting major bleed, stroke/SE, and all-cause death was 0.75, 0.70, and 0.61, respectively. Conclusions Using serial PT-INR values collected within 1 month after starting VKA, the new AI model performed better than time in therapeutic range at predicting clinical outcomes occurring up to 12 months thereafter. Serial PT-INR values contain important information that can be analysed by computer to help predict adverse clinical outcomes.
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Affiliation(s)
- Shinichi Goto
- Department of Cardiology, Keio University School of Medicine, Shinanomachi 35, Shinjuku 160-8582, Tokyo, Japan
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
| | - Karen S Pieper
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK
| | - Jean-Pierre Bassand
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK.,Department of Cardiology, University of Besançon Boulevard Fleming, 25000 Besançon, France
| | - Alan John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George's University of London, Cranmer Terrace, Tooting, London, UK
| | - David A Fitzmaurice
- Department of Cardio-respiratory Primary Care, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Samuel Z Goldhaber
- Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Normannenstr. 34a, Munich 80333, Germany
| | - Alexander Parkhomenko
- National Scientific Center, Strazhesko Institute of Cardiology, 5 Narodnogo Opolcheniya Street, Kiev 03680, Ukraine
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Sihhiye, 06100, Ankara, Turkey
| | - Frank Misselwitz
- Therapeutic areas Thrombosis & Hematology, Bayer AG, Müllerstraße 178, 13353 Berlin, Germany
| | - Alexander G G Turpie
- Department of Medicine, McMaster University, 237 Barton St E Hamilton, Ontario L8L 2X2, Canada
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, NL-1091-AC Amsterdam, Netherlands
| | - Keith A A Fox
- Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK.,Department of Surgery, University College London, Gower St, Bloomsbury, London WC1E 6BT, UK
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Camm C, Camm A, Virdone S, Bassand JP, Fitzmaurice D, Fox K, Goldhaber S, Goto S, Haas S, Turpie A, Verheugt F, Misselwitz F, Kayani G, Pieper K, Kakkar A. The effect of body mass index on clinical outcomes in patients with newly diagnosed atrial fibrillation in the GARFIELD-AF registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/13/2022] Open
Abstract
Abstract
Introduction
Higher body mass index (BMI) is associated with a higher risk of atrial fibrillation (AF). However, previous evidence has suggested an inverse association between BMI and risk of AF outcomes.
Purpose
To explore the association between BMI and outcomes in those with newly diagnosed AF in the GARFIELD-AF registry.
Methods
GARFIELD-AF is an international registry of consecutively recruited patients aged ≥18 years with newly diagnosed AF and ≥1 stroke risk factor. Data were collected prospectively on 52,080 patients. Participants with missing or extreme BMI values and those without two-year follow-up were excluded. Cox proportional hazard models were used to estimate the effect of BMI on the risk of outcomes. Models were adjusted for age, sex, ethnicity, smoking, alcohol, and ≥moderate chronic kidney disease. Where appropriate participants were divided into groups based on BMI. Restricted cubic splines were used to assess non-linear relationships.
Results
BMI and outcome data were available for 40,495 patients. Those with higher BMI were generally younger, and more likely to have pre-existing hypertension, diabetes, or vascular disease (Table). Underweight patients received anticoagulation less often than those in other groups (60.3% vs 67.9%, respectively). During follow-up, 2,801 participants (6.9%) died and 603 (1.5%) had new/worsening heart failure. Following adjustment for potential confounders, a U-shaped relationship was seen between BMI and all-cause mortality and new/worsening heart failure (Figure). For all-cause mortality, the lowest risk was at 30kg/m2. Below this level, there was an 8% higher risk of mortality (95% confidence interval (CI) 6 to 9%) per 1kg/m2 lower BMI. Above 30kg/m2, there was a 5% higher risk of mortality per 1kg/m2 higher BMI (95% CI 4 to 7%). For new/worsening heart failure, the lowest risk was at 25kg/m2. Above this level, 1kg/m2 higher BMI was associated with an 5% higher risk (95% CI 13 to 6%).
Conclusions
BMI was an important risk factor for both all-cause mortality and new/worsening heart failure in AF. Those at both extremes of BMI are at higher risk.
BMI and selected outcomes
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.
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Affiliation(s)
- C.J.F Camm
- University of Oxford, Oxford, United Kingdom
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute,, London, United Kingdom
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | | | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine, Munich, Germany
| | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | | | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Cools F, Johnson D, Pieper K, Camm A, Bassand JP, Fitzmaurice D, Fox K, Goldhaber S, Goto S, Haas S, Turpie A, Verheugt F, Misselwitz F, Kayani G, Kakkar A. Permanent discontinuation of different anticoagulants in patients with atrial fibrillation and the impact on clinical outcome: data from the GARFIELD-AF registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/13/2022] Open
Abstract
Abstract
Background
Non-Vitamin K Antagonists (NOAC) are replacing vitamin K Antagonists (VKA) as first line oral anticoagulant therapy (OAC) in patients with non-valvular atrial fibrillation (NVAF). Discontinuation of OAC might put patients at increased risk. It was anticipated that patients who were on NOAC would discontinue OAC less.
Purpose
We compare the rates and impact on outcome of the discontinuation of NOAC and VKA using data from the GARFIELD-AF registry.
Methods
Patients included in GARFIELD-AF, had a new diagnosis of NVAF and at least 1 stroke risk factor. In this analysis 26,299 patients (VKA: 13,012; NOAC: 13,287) that received OAC were included. Permanent discontinuation was defined as stopping OAC for at least 7 consecutive days (whether or not restarted during follow-up). Marginal structural Cox proportional hazards models estimated the effect of discontinuation on death, cardiovascular (CV) death, non-haemorrhagic stroke + systemic embolism (NHS+SE), myocardial infarction (MI), or combined endpoints. Adjustments were made for both baseline factors and time dependent variables.
Results
Of all patients, 15.6% discontinued OAC (VKA: 15.4%; NOAC: 15.8%) over a median follow-up of 181 days (IQR: 359). Most discontinued early (67.0% of patients on VKA and 47.1% of patients on NOAC ≤4 months). Significantly higher discontinuation risk was seen with worsening kidney function, coronary artery disease, history of bleeding (baseline factors), as well as with all types of bleeding (time dependent factors). Lower discontinuation rates were seen with history of stroke/TIA, hypertension, increasing age, permanent AF (all p<0.01).
Mean CHA2DS2-VASc score was 3 in all groups. Patients in both treatment arms who discontinued were at increased risk for death, NHS+SE, MI as well as combined endpoints of death/NHS+SE/MI, death/NHS+SE and a trend towards higher CV death (Figure 1). All interaction tests for the interaction of treatment and discontinuation had a p value >0.4. The association between discontinuation and outcomes did not change when a 30 day discontinuation window was used.
Conclusion
The rate of discontinuation in this study was 15.8% and comparable for VKA and NOAC over a 2-year follow-up. Discontinuation rates were the highest soon after the initiation of treatment. When VKA or NOAC was stopped for ≥7 consecutive days, the risk of NHS+SE, death, MI or any combined endpoints were significantly worse in both treatment arms. These data suggest that discontinuation of anticoagulant treatment with VKA or NOAC should be discouraged.
HR of patients who discontinued OAC
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.
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Affiliation(s)
- F Cools
- General Hospital Klina, Brasschaat, Belgium
| | - D Johnson
- North Carolina State University, Department of Statistics, Raleigh, United States of America
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - A.J Camm
- St. George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | | | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine, Munich, Germany
| | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | | | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, UK, London, United Kingdom
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Apenteng P, Fitzmaurice D, Virdone S, Camm A, Fox K, Bassand JP, Goldhaber S, Goto S, Haas S, Turpie A, Verheugt F, Misselwitz F, Kayani G, Pieper K, Kakkar A. Clinical outcomes of patients with newly diagnosed atrial fibrillation who refused anticoagulation: findings from the global GARFIELD-AF registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) remains a common cause of stroke and anticoagulation (AC) treatment reduces the risk of stroke. Reasons for patients with AF not receiving anticoagulation are generally attributed to the clinician decision, however in reality a proportion of patients refuse anticoagulation. The aim of our study was to investigate the clinical outcomes of patients with AF who refused anticoagulation.
Methods
The Global Anticoagulant Registry in the FIELD (GARFIELD-AF) was an international prospective observational study of patients ≥18 years with newly diagnosed AF and ≥1 investigator determined risk factor for stroke. We analysed two-year outcomes (unadjusted) of non-haemorrhagic stroke/systemic embolism (stroke/SE), major bleeding and all-cause mortality in patients at high risk of stroke (men with CHA2DS2VASc≥2 and women with CHA2DS2VASc≥3) who did not received anticoagulation due to patient refusal, patients at high risk of stroke who received anticoagulation, and patients who were not on anticoagulation due to reasons other than patient refusal.
Results
Out of 43,154 patients, 13,283 (30.8%) are at the higher risk of stroke and did not received anticoagulation at baseline. The reason for not receiving anticoagulation was unavailable for 38.7% (5146/13283); of the patients with a known reason for not receiving anticoagulation, 12.5% (1014/8137) refused anticoagulation. Overall the study participants had a mean (SD) age of 72.2 (9.9) years and 50% were female. The median (Q1; Q3) CHA2DS2VASc score was 3.0 (3.0; 5.0) in patients who refused anticoagulation and 4.0 (3.0; 4.0) in patients who received anticoagulation. The median (Q1; Q3) HAS-BLED score was 1.0 (1.0; 2.0) in both groups. Of the patients who received anticoagulants, 59.7% received VKA and 40.3% received non-VKA oral anticoagulants. 79.4% of patients who refused anticoagulation were on antiplatelets. At two-year follow up the rate of events per 100 person-years (AC refused vs AC received) were: stroke/SE 1.42 vs 0.95 (p=0.04), major bleeding 0.62 vs 1.20 (p=0.02), and all-cause mortality 2.28 vs 3.90 (p=0.0004) (Figure). The event rates in patients who were not on anticoagulation for reasons other than patient refusal were stroke/SE 1.56, major bleeding 0.91, and all-cause mortality 5.49.
Conclusion
In this global real-world prospective study of patients with newly diagnosed AF, patients who refused anticoagulation had a higher rate of stroke/SE but lower rates of all-cause mortality and major bleeding than patients who received anticoagulation. While patient refusal of anticoagulation is an acceptable outcome of shared decision-making, clinically it is a missed opportunity to prevent AF related stroke. Patients' beliefs about AF related stroke and anticoagulation need to be explored. The difference in all-cause mortality warrants further investigation; further analysis will include adjusted results.
Event rates at two years of follow-up
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.
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Affiliation(s)
- P Apenteng
- University of Warwick, Coventry, United Kingdom
| | | | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine, Munich, Germany
| | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | | | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Camm A, Steffel J, Virdone S, Bassand JP, Fitzmaurice D, Fox K, Goldhaber S, Goto S, Haas S, Turpie A, Verheugt F, Misselwitz F, Kayani G, Pieper K, Kakkar A. Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
The GARFIELD-AF registry is a prospective, multicentre, observational study of adults with recently diagnosed non-valvular atrial fibrillation (AF) and at least one risk factor for stroke. In GARFIELD-AF the absolute risk reduction of mortality associated with anticoagulation is far greater than the apparent absolute risk reduction in (ischemic) stroke. One potential explanation is improved treatment, with the use of comprehensive guideline-directed medical therapies (GDMT), in patients with AF receiving oral anticoagulant (OAC) therapy. The objectives were to identify the potential relationships between anticoagulation status, GDMT use and clinical outcomes.
Methods
Use of GDMT was determined on the basis of published European Society for Cardiology guidelines operative between 2010 and 2016. We explored the use of GDMT in patients enrolled in GARFIELD-AF (March 2010-Aug 2016) with CHA2DS2-VASc ≥2 and with one or more of five comorbidities–coronary artery disease, diabetes mellitus, heart failure, hypertension and peripheral vascular disease. Association between GDMT use and clinical outcomes events was evaluated with Cox-proportional hazards models. The models included stratification by all possible combinations of the five comorbidities used to define GDMT eligibility.
Results
The study population comprised of 39,946 patients who had one or more comorbidities (3238 [8.1%] received none of the GDMT, 17,398 [43.6%] received some, and 19,310 [48.3%] received all of the GDMT for which they were eligible). Patients on OAC tended to receive all the GDMTs more frequently compared to patients on no OAC (50.2% vs 44.8%, respectively).
Comprehensive GDMT was associated with a lower risk of all-cause mortality (HR: 0.89 [0.80–0.99]) and non-cardiovascular mortality (0.80 [0.68–0.95]) compared to inadequate or no GDMT but was not associated with a lower risk of stroke (HR: 1.04 (0.88–1.24)] (Figure). The effect of OAC was beneficial for mortality and stroke risk whether receiving comprehensive GDMT or not.
Conclusion
OAC therapy is associated with a lower risk of all-cause mortality, non-cardiovascular mortality and stroke/SE in comparison with no OAC, irrespective of GDMT use in patients with CHA2DS2-VASc ≥2. Although the use of GDMT is associated with a significant reduction in mortality, there is little evidence that this explains the decrease in mortality with the use of OAC.
GDMT use at two years of follow-up
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.
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Affiliation(s)
- A.J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, London, United Kingdom
| | - J Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | | | - K.A.A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - S.Z Goldhaber
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine, Munich, Germany
| | | | - F.W.A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands (The)
| | | | - G Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - K.S Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - A.K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
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Goto S, Haas S, Ageno W, Goldhaber SZ, Turpie AGG, Weitz JI, Angchaisuksiri P, Nielsen JD, Kayani G, Farjat A, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Assessment of Outcomes Among Patients With Venous Thromboembolism With and Without Chronic Kidney Disease. JAMA Netw Open 2020; 3:e2022886. [PMID: 33112399 PMCID: PMC7593818 DOI: 10.1001/jamanetworkopen.2020.22886] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Patients with venous thromboembolism (VTE) and concomitant chronic kidney disease (CKD) have been reported to have a higher risk of thrombosis and major bleeding complications compared with patients without concomitant CKD. The use of anticoagulation therapy is challenging, as many anticoagulant medications are excreted by the kidney. Large-scale data are needed to clarify the impact of CKD for anticoagulant treatment strategies and clinical outcomes of patients with VTE. OBJECTIVE To compare clinical characteristics, treatment patterns, and 12-month outcomes among patients with VTE and concomitant moderate to severe CKD (stages 3-5) vs patients with VTE and mild to no CKD (stages 1-2) in a contemporary international registry. DESIGN, SETTING, AND PARTICIPANTS The Global Anticoagulant Registry in the Field-Venous Thromboembolism (GARFIELD-VTE) study is a prospective noninterventional investigation of real-world treatment practices. A total of 10 684 patients from 415 sites in 28 countries were enrolled in the GARFIELD-VTE between May 2014 and January 2017. This cohort study included 8979 patients (6924 patients with mild to no CKD and 2055 patients with moderate to severe CKD) who had objectively confirmed VTE within 30 days before entry in the registry. Chronic kidney disease stages were defined by estimated glomerular filtration rates. Data were extracted from the study database on December 8, 2018, and analyzed between May 1, 2019, and July 30, 2020. EXPOSURE Moderate to severe CKD vs mild to no CKD. MAIN OUTCOMES AND MEASURES The primary outcomes were all-cause mortality, recurrent VTE, and major bleeding. Event rates and 95% CIs were calculated and expressed per 100 person-years. Hazard ratios (HRs) were estimated with Cox proportional hazards regression models and adjusted for relevant confounding variables. All-cause mortality was considered a competing risk for other clinical outcomes in the estimation of cumulative incidences. RESULTS Of the 10 684 patients with objectively confirmed VTE, serum creatinine data were available for 8979 patients (84.0%). Of those, 4432 patients (49.4%) were female and 5912 patients (65.8%) were White; 6924 patients (77.1%; median age, 57 years; interquartile range [IQR], 44-69 years) were classified as having mild to no CKD, and 2055 patients (22.9%; median age, 70 years; IQR, 59-78 years) were classified as having moderate to severe CKD. Calculations using the equation from the Modification of Diet in Renal Disease study indicated that, among the 6924 patients with mild to no CKD, 2991 patients had stage 1 CKD, and 3933 patients had stage 2 CKD; among the 2055 patients with moderate to severe CKD, 1650 patients had stage 3 CKD, 190 patients had stage 4 CKD, and 215 patients had stage 5 CKD. The distribution of VTE presentation was comparable between groups. In total, 1171 patients (57.0%) with moderate to severe CKD and 4079 patients (58.9%) with mild to no CKD presented with deep vein thrombosis alone, 547 patients (26.6%) with moderate to severe CKD and 1723 patients (24.9%) with mild to no CKD presented with pulmonary embolism alone, and 337 patients (16.4%) with moderate to severe CKD and 1122 patients (16.2%) with mild to no CKD presented with both pulmonary embolism and deep vein thrombosis. Compared with patients with mild to no CKD, patients with moderate to severe CKD were more likely to be female (3259 women [47.1%] vs 1173 women [57.1%]) and older than 65 years (2313 patients [33.4%] vs 1278 patients [62.2%]). At baseline, the receipt of parenteral therapy alone was comparable between the 2 groups (355 patients [17.3%] with moderate to severe CKD vs 1253 patients [18.1%] with mild to no CKD). Patients with moderate to severe CKD compared with those with mild to no CKD were less likely to be receiving direct oral anticoagulant therapy, either alone (557 patients [27.1%] vs 2139 patients [30.9%]) or in combination with parenteral therapy (319 patients [15.5%] vs 1239 patients [17.9%]). Patients with moderate to severe CKD had a higher risk of all-cause mortality (adjusted hazard ratio [aHR], 1.44; 95% CI, 1.21-1.73), major bleeding (aHR, 1.40; 95% CI, 1.03-1.90), and recurrent VTE (aHR, 1.40; 95% CI, 1.10-1.77) than patients with mild to no CKD. CONCLUSIONS AND RELEVANCE In this study of patients with VTE, the presence of moderate to severe CKD was associated with increases in the risk of death, VTE recurrence, and major bleeding compared with the presence of mild to no CKD.
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Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Sylvia Haas
- Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Jeffrey I. Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
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Camm AJ, Amarenco P, Haas S, Hess S, Kirchhof P, Lambelet M, Bach M, Turpie AGG. Real-world vs. randomized trial outcomes in similar populations of rivaroxaban-treated patients with non-valvular atrial fibrillation in ROCKET AF and XANTUS. Europace 2020; 21:421-427. [PMID: 30052894 DOI: 10.1093/europace/euy160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/13/2018] [Accepted: 07/06/2018] [Indexed: 11/13/2022] Open
Abstract
AIMS Based on Phase III data, non-vitamin K antagonist oral anticoagulants are recommended for stroke prevention in patients with atrial fibrillation. To determine whether trial outcomes translate into similar event rates in unselected patients, this analysis compared outcomes from the real-world XANTUS study with those from the Phase III ROCKET AF study. METHODS AND RESULTS Individual patient data from 4020 XANTUS patients were re-weighted to match the proportion of selected baseline characteristics in 7061 rivaroxaban-treated patients from ROCKET AF, using the matching-adjusted indirect comparison (MAIC) method. For the primary analysis, CHADS2 scores and gender were selected as relevant variables. Adjusted annualized incidence rates for XANTUS were calculated and compared with incidence rates from ROCKET AF-the ratio of these rates ('MAIC ratio') was used as a relative effect estimate. Rates of major bleeding [3.10%/year vs. 3.60%/year; MAIC ratio 0.86; 95% confidence interval (CI) 0.67-1.12] and stroke/non-central nervous system systemic embolism (1.54%/year vs. 1.70%/year; MAIC ratio 0.91; 95% CI 0.62-1.32) were similar between XANTUS and ROCKET AF. The rate of all-cause death was higher in XANTUS (3.22%/year vs. 1.87%/year; MAIC ratio 1.72; 95% CI 1.31-2.27), but the rates of vascular death were similar (1.83%/year vs. 1.53%/year; MAIC ratio 1.19; 95% CI 0.84-1.70). Sensitivity analyses weighted by different baseline characteristics supported these results. CONCLUSION The low rates of major bleeding and stroke in XANTUS were consistent with results from ROCKET AF. All-cause death, but not vascular death, was higher in XANTUS, as expected in an unselected real-world population.
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Affiliation(s)
- A John Camm
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK
| | - Pierre Amarenco
- Department of Neurology and Stroke Centre, Paris-Diderot-Sorbonne University, Paris, France
| | - Sylvia Haas
- Formerly Institute for Experimental Oncology and Therapy Research, Technical University of Munich, Germany
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell and West Birmingham Hospitals NHS Trusts, Birmingham, UK
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Camm AJ, Amarenco P, Haas S, Bach M, Kirchhof P, Kuhls S, Lambelet M, Turpie AGG. Impact of gender: Rivaroxaban for patients with atrial fibrillation in the XANTUS real-world prospective study. Clin Cardiol 2020; 43:1405-1413. [PMID: 32896928 PMCID: PMC7724214 DOI: 10.1002/clc.23452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/03/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The XANTUS study (NCT01606995) demonstrated low rates of stroke and major bleeding in patients with atrial fibrillation (AF) receiving rivaroxaban in clinical practice for the prevention of thromboembolic events (N = 6784). HYPOTHESIS Because previous real-world studies have not reported gender-dependent responses to rivaroxaban treatment, this sub-analysis of the XANTUS study investigated the effect of gender on outcomes. METHODS The centrally adjudicated outcomes were compared between genders. Primary outcomes were major bleeding and all-cause death. Secondary outcomes included symptomatic thromboembolic events. Multivariable Cox regression analysis was performed to assess the effect of risk factors on outcomes between genders. RESULTS A total of 2765 female and 4016 male patients were included in the analysis. Baseline characteristics were generally similar. No nominally significant interaction between gender and risk factors for the study outcomes was observed. Rates of major bleeding, all-cause death and symptomatic thromboembolic events in patients with non-valvular AF receiving rivaroxaban for stroke prevention were similar in men and women; no significant differences in risk factors for these outcomes were observed between genders. CONCLUSIONS Further research is needed to better characterize the relative importance of different risk factors on outcomes in men vs women and to determine whether gender differences exist in patients treated with non-vitamin K antagonist oral anticoagulants.
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Affiliation(s)
- A John Camm
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK
| | - Pierre Amarenco
- Department of Neurology and Stroke Centre, Paris-Diderot-Sorbonne University, Paris, France
| | - Sylvia Haas
- Formerly Technical University Munich, Munich, Germany
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, University Hospital Birmingham NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.,Department of Cardiology, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Silvia Kuhls
- Integrated Analysis Statistics, Bayer AG, Wuppertal, Germany
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Bassand JP, Apenteng PN, Atar D, Camm AJ, Cools F, Corbalan R, Fitzmaurice DA, Fox KA, Goto S, Haas S, Hacke W, Jerjes-Sanchez C, Koretsune Y, Heuzey JYL, Sawhney JP, Oh S, Stępińska J, Cate VT, Verheugt FW, Kayani G, Pieper KS, Kakkar AK, Garfield-Af Investigators FT. GARFIELD-AF: a worldwide prospective registry of patients with atrial fibrillation at risk of stroke. Future Cardiol 2020; 17:19-38. [PMID: 32696663 DOI: 10.2217/fca-2020-0014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 01/06/2023] Open
Abstract
The Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) examined real-world practice in a total of 57,149 (5069 retrospective, 52,080 prospective) patients with newly diagnosed AF at risk of stroke/systemic embolism, enrolled at over 1000 centers in 35 countries. It aimed to capture data on AF burden, patients' clinical profile, patterns of clinical practice and antithrombotic management, focusing on stroke/systemic embolism prevention, uptake of new oral anticoagulants, impact on death and bleeding. GARFIELD-AF set new standards for quality of data collection and analysis. A total of 36 peer-reviewed articles were already published and 73 abstracts presented at international congresses, covering treatment strategies, geographical variations in baseline risk and therapies, adverse outcomes and common comorbidities such as heart failure. A risk prediction tool as well as innovative observational studies and artificial intelligence methodologies are currently being developed by GARFIELD-AF researchers. Clinical Trial Registration: NCT01090362 (ClinicalTrials.gov).
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Affiliation(s)
- Jean-Pierre Bassand
- Department of Cardiology, University of Besançon, Besançon 25000, France.,Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | | | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo PO Box 4956, Norway.,Institute of Clinical Science, University of Oslo, Oslo PO Box 4956, Norway
| | - A John Camm
- Molecular & Clinical Sciences Research Institute, St George's University of London, London SW17 0RE, UK
| | - Frank Cools
- Department of Cardiology, AZ Klina, Brasschaat 100, 2930, Belgium
| | - Ramon Corbalan
- Department of Cardiology, Catholic University, Santiago 8330024, Chile
| | | | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Shinya Goto
- Department of Medicine(Cardiology), Tokai University School of Medicine, Kanagawa 259-1143, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich 80333, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg 69120, Germany
| | | | - Yukihiro Koretsune
- Institute for Clinical Research, Osaka National Hospital, Osaka 540-0006, Japan
| | - Jean-Yves Le Heuzey
- Department of Arrhythmia, European Hospital Georges Pompidou, René Descartes University, Paris 75015, France
| | | | - Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 110-799, Republic of Korea
| | - Janina Stępińska
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw 04-628, Poland
| | - Vincent Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht 6200, The Netherlands
| | - Freek Wa Verheugt
- Depertment of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam NL-1091-AC, The Netherlands
| | - Gloria Kayani
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Karen S Pieper
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK.,Department of Surgery, University College London, London WC1E 6BT, UK
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Haas S, Sørensen MJ, Lundby L, Pedersen AG. Injection of freshly collected autologous adipose tissue into non-healing wounds after closed incision pilonidal surgery. Tech Coloproctol 2020; 24:1301-1306. [PMID: 32648140 DOI: 10.1007/s10151-020-02276-9] [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: 05/20/2020] [Accepted: 06/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Chronic non-healing wounds are a major problem after closed incision pilonidal surgery. Freshly collected autologous adipose tissue injected into perianal fistulas in patients with Crohn's disease seems to promote healing. We investigated this technique in patients with non-healing wounds after cleft-lift surgery for pilonidal sinus disease (PSD). METHOD In a prospective interventional pilot study conducted at our institution autologous adipose tissue from the abdominal wall was harvested, and injected into chronic non-healing PS wounds after surgical revision, healing rate being the primary outcome. The wounds were left open. Patients were followed every 2 to 3 weeks until complete healing (skin coverage, no undermining). RESULTS 7 male patients were included (mean age 24 ± 0,6 SD years) and complete healing was achieved in 6 patients (86%). Median time to healing was 90 days (range 36-403 days ) and mean follow-up time was 388± 45 days. All patients reported major symptom relief shortly after the procedure. The mean operation time was 80 ± 23 minutes and the mean amount of freshly collected adipose tissue injected was 27.4± 12 ml. There were no complications. CONCLUSIONS Freshly collected autologous adipose tissue injected into chronic non-healing pilonidal wounds seems safe and efficient.
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Affiliation(s)
- S Haas
- Department of Surgery, Randers Regional Hospital, Skovlyvej 15, 8930, Randers NØ, Denmark.
| | - M J Sørensen
- Department of Surgery, Randers Regional Hospital, Skovlyvej 15, 8930, Randers NØ, Denmark
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - A G Pedersen
- Department of Surgery, Randers Regional Hospital, Skovlyvej 15, 8930, Randers NØ, Denmark
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Bounameaux H, Haas S, Farjat AE, Ageno W, Weitz JI, Goldhaber SZ, Turpie AG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Schellong S, Mantovani LG, Prandoni P, Kakkar AK. Comparative effectiveness of oral anticoagulants in venous thromboembolism: GARFIELD-VTE. Thromb Res 2020; 191:103-112. [DOI: 10.1016/j.thromres.2020.04.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/28/2022]
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Weitz JI, Haas S, Ageno W, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Farjat AE, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK, Loualidi A, Colak A, Bezuidenhout A, Abdool-Carrim A, Azeddine A, Beyers A, Dees A, Mohamed A, Aksoy A, Abiko A, Watanabe A, Krichell A, Fernandez AA, Tosetto A, Khotuntsov A, Oropallo A, Slocombe A, Kelly A, Clark A, Gad A, Arouni A, Schmidt A, Berni A, Kleiban AJ, Machowski A, Kazakov A, Galvez A, Lockman A, Falanga A, Chauhan A, Riera-Mestre A, Mazzone A, D’Angelo A, Herdy A, Kato A, Salem AAEEM, Husin A, Erdelyi B, Jacobson B, Amann-Vesti B, Battaloglu B, Wilson B, Cosmi B, Francois BJ, Toufek B, Hunt B, Natha B, Mustafa B, Kho BCS, Carine B, Zidel B, Dominique B, Christophe B, Trimarco B, Luo C, Cuneo CA, Diaz CJS, Schwencke C, Cader C, Yavuz C, Zaidman CJ, Lunn C, Wu CC, Toh CH, Chiang CE, Elisa C, Hsia CH, Huang CL, Kwok CHK, Wu CC, Huang CH, Ward C, Opitz C, Jeanneret-Gris C, Ha CY, Huang CY, Bidi CL, Smith C, Brauer C, Lodigiani C, Francis C, Wu C, Staub D, Theodoro D, Poli D, Acevedo DR, Adler D, Jimenez D, Keeling D, Scott D, Imberti D, Creagh D, Helene DC, Hagemann D, Le Roux D, Skowasch D, Belenky D, Dorokhov D, Petrov D, Zateyshchikov D, Prisco D, Møller D, Kucera D, Esheiba EM, Panchenko E, Dominique E, Dogan E, Kubat E, Diaz ED, Tse EWC, Yeo E, Hashas E, Grochenig E, Tiraferri E, Blessing E, Michèle EO, Usandizaga E, Porreca E, Ferroni F, Nicolas F, Ayala-Paredes F, Koura F, Henry F, Cosmi F, Erdkamp F, Kamalov G, Dalmau GB, Damien G, Klein G, Shah G, Hollanders G, Merli G, Plassmann G, Platt G, Poirier G, Sokurenko G, Haddad G, Ali G, Agnelli G, Gan GG, Kaye-Eddie G, Le Gal G, Allen G, Esperón GAL, Jean-Paul G, Gerofke H, Elali H, Burianova H, Ohler HJ, Wang H, Darius H, Gogia HS, Striekwold H, Gibbs H, Hasanoglu H, Turker H, Franow H, Bounameaux H, De Raedt H, Schroe H, ElDin HS, Zidan H, Nakamura H, Kim HY, Lawall H, Zhu H, Tian H, Yhim HY, Cate HT, Hwang HG, Shim H, Kim I, Libov I, Sonkin I, Suchkov I, Song IC, Kiris I, Staroverov I, Looi I, De La Azuela Tenorio IM, Savas I, Gordeev I, Podpera I, Lee JH, Sathar J, Welker J, Beyer-Westendorf J, Kvasnicka J, Vanwelden J, Kim J, Svobodova J, Gujral J, Marino J, Galvar JT, Kassis J, Kuo JY, Shih JY, Kwon J, Joh JH, Park JH, Kim JS, Yang J, Krupicka J, Lastuvka J, Pumprla J, Vesely J, Souto JC, Correa JA, Duchateau J, Fletcher JP, del Toro J, del Toro J, Paez JGC, Nielsen J, Filho JDA, Saraiva J, Peromingo JAD, Lara JG, Fedele JL, Surinach JM, Chacko J, Muntaner JA, Benitez JCÁ, Abril JMH, Humphrey J, Bono J, Kanda J, Boondumrongsagoon J, Yiu KH, Chansung K, Boomars K, Burbury K, Kondo K, Karaarslan K, Takeuchi K, Kroeger K, Zrazhevskiy K, Svatopluk K, Shyu KG, Vandenbosch K, Chang KC, Chiu KM, Jean-Manuel K, Wern KJ, Ueng KC, Norasetthada L, Binet L, Chew LP, Zhang L, Cristina LM, Tick L, Schiavi LB, Wong LLL, Borges L, Botha L, Capiau L, Timmermans L, López LE, Ria L, Blasco LMH, Guzman LA, Cervera LF, Isabelle M, Bosch MM, de los Rios Ibarra M, Fernandez MN, Carrier M, Barrionuevo MR, Gamba MAA, Cattaneo M, Moia M, Bowers M, Chetanachan M, Berli MA, Fixley M, Faghih M, Stuecker M, Schul M, Banyai M, Koretzky M, Myriam M, Gaffney ME, Hirano M, Kanemoto M, Nakamura M, Tahar M, Emmanuel M, Kovacs M, Leahy M, Levy M, Munch M, Olsen M, De Pauw M, Gustin M, Van Betsbrugge M, Boyarkin M, Homza M, Koto M, Abdool-Gaffar M, Nagib MAF, Dessoki ME, Khan M, Mohamed M, Kim MH, Lee MH, Soliman M, Ahmed MS, Bary MSAE, Moustafa MA, Hameed M, Kanko M, Majumder M, Zubareva N, Mumoli N, Abdullah NAN, Makruasi N, Paruk N, Kanitsap N, Duda N, Nordin N, Nyvad O, Barbarash O, Gurbuz O, Vilamajo OG, Flores ON, Gur O, Oto O, Marchena PJ, Angchaisuksiri P, Carroll P, Lang P, MacCallum P, von Bilderling PB, Blombery P, Verhamme P, Jansky P, Bernadette P, De Vleeschauwer P, Hainaut P, Ferrini PM, Iamsai P, Christian P, Viboonjuntra P, Rojnuckarin P, Ho P, Mutirangura P, Wells R, Martinez R, Miranda RT, Kroening R, Ratsela R, Reyes RL, de Leon RFD, Wong RSM, Alikhan R, Jerwan-Keim R, Otero R, Murena-Schmidt R, Canevascini R, Ferkl R, White R, Van Herreweghe R, Santoro R, Klamroth R, Mendes R, Prosecky R, Cappelli R, Spacek R, Singh R, Griffin S, Na SH, Chunilal S, Middeldorp S, Nakazawa S, Schellong S, Toh SG, Christophe S, Isbir S, Raymundo S, Ting SK, Motte S, Aktogu SO, Donders S, Cha SI, Nam SH, Marie-Antoinette SP, Maasdorp S, Sun S, Wang S, Essameldin SM, Sholkamy SM, Kuki S, Goto S, Yoshida S, Matsuoka S, McRae S, Watt S, Patanasing S, Jean-Léopold SN, Wongkhantee S, Bang SM, Testa S, Zemek S, Behrens S, Dominique S, Mellor S, Singh SSG, Datta S, Chayangsu S, Solymoss S, Everington T, Abdel-Azim TAA, Suwanban T, Adademir T, Hart T, Béatrice T, Luvhengo T, Horacek T, Zeller T, Boussy T, Reynolds T, Biss T, Chao TH, Casabella TS, Onodera T, Numbenjapon T, Gerdes V, Cech V, Krasavin V, Tolstikhin V, Bax WA, Malek WFA, Ho WK, Ageno W, Pharr W, Jiang W, Lin WH, Zhang W, Tseng WK, Lai WT, De Backer W, Haverkamp W, Yoshida W, Korte W, Choi W, Kim YK, Tanabe Y, Ohnuma Y, Mun YC, Balthazar Y, Park Y, Shibata Y, Burov Y, Subbotin Y, Coufal Z, Yang Z, Jing Z, Jing Z, Yang Z. Cancer associated thrombosis in everyday practice: perspectives from GARFIELD-VTE. J Thromb Thrombolysis 2020; 50:267-277. [DOI: 10.1007/s11239-020-02180-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Corbalan R, Bassand JP, Illingworth L, Ambrosio G, Camm AJ, Fitzmaurice DA, Fox KAA, Goldhaber SZ, Goto S, Haas S, Kayani G, Mantovani LG, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation: A Report From the GARFIELD-AF Registry. JAMA Cardiol 2020; 4:526-548. [PMID: 31066873 DOI: 10.1001/jamacardio.2018.4729] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 12/31/2022]
Abstract
Importance Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes. Objective To assess the treatment strategies and 1-year clinical outcomes of antithrombotic and CHF therapies for patients with newly diagnosed AF with concomitant CHF stratified by etiology (ischemic cardiomyopathy [ICM] vs nonischemic cardiomyopathy [NICM]). Design, Setting, and Participants The GARFIELD-AF registry is a prospective, noninterventional registry. A total of 52 014 patients with AF were enrolled between March 2010 and August 2016. A total of 11 738 patients 18 years and older with newly diagnosed AF (≤6 weeks' duration) and at least 1 investigator-determined stroke risk factor were included. Data were analyzed from December 2017 to September 2018. Exposures One-year follow-up rates of death, stroke/systemic embolism, and major bleeding were assessed. Main Outcomes and Measures Event rates per 100 person-years were estimated from the Poisson model and Cox hazard ratios (HRs) and 95% confidence intervals. Results The median age of the population was 71.0 years, 22 987 of 52 013 were women (44.2%) and 31 958 of 52 014 were white (61.4%). Of 11 738 patients with CHF, 4717 (40.2%) had ICM and 7021 (59.8%) had NICM. Prescription of oral anticoagulant and antiplatelet drugs was not balanced between groups. Oral anticoagulants with or without antiplatelet drugs were used in 2753 patients with ICM (60.1%) and 5082 patients with NICM (73.7%). Antiplatelets were prescribed alone in 1576 patients with ICM (34.4%) and 1071 patients with NICM (15.5%). Compared with patients with NICM, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (72.6% [3439] vs 60.3% [4236]) and of β blockers (63.3% [2988] vs 53.2% [3737]) was higher in patients with ICM. Rates of all-cause and cardiovascular death per 100 patient-years were significantly higher in the ICM group (all-cause death: ICM, 10.2; 95% CI, 9.2-11.1; NICM, 7.0; 95% CI, 6.4-7.6; cardiovascular death: ICM, 5.1; 95% CI, 4.5-5.9; NICM, 2.9; 95% CI, 2.5-3.4). Stroke/systemic embolism rates tended to be higher in ICM groups compared with NICM groups (ICM, 2.0; 95% CI, 1.6-2.5; NICM, 1.5; 95% CI, 1.3-1.9). Major bleeding rates were significantly higher in the ICM group (1.1; 95% CI, 0.8-1.4) compared with the NICM group (0.7; 95% CI, 0.5-0.9). Conclusions and Relevance Patients with ICM received oral anticoagulants with or without antiplatelet drugs less frequently and antiplatelets alone more frequently than patients with NICM, but they received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers more often than patients with NICM. All-cause and cardiovascular death rates were higher in patients with ICM than patients with NICM. Trial Registration ClinicalTrials.gov Identifier: NCT01090362.
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Affiliation(s)
- Ramon Corbalan
- Division of Cardiovascular Diseases, Catholic University School of Medicine, Santiago, Chile
| | - Jean-Pierre Bassand
- University of Besançon, Besançon, France.,Thrombosis Research Institute, London, England
| | | | | | - A John Camm
- St George's University of London, London, England
| | | | | | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly at Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Lorenzo G Mantovani
- Center for Public Health Research, University of Milan Bicocca, Monza, Italy
| | | | - Karen S Pieper
- Thrombosis Research Institute, London, England.,Duke Clinical Research Institute, Durham, North Carolina
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