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Kumano O, Suzuki S, Yamazaki M, An Y, Yasaka M, Ieko M. Age-related variation in coagulation factors in non-valvular atrial fibrillation patients receiving direct oral anticoagulants. Int J Hematol 2024; 119:407-415. [PMID: 38334914 DOI: 10.1007/s12185-024-03712-4] [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: 06/22/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
Age is a significant risk factor for ischemic stroke. However, the influence of aging on coagulation parameters in non-valvular atrial fibrillation (NVAF) patients treated with direct oral anticoagulants (DOACs) remains unclear. A total of 775 samples were collected from 224 NVAF patients receiving apixaban, edoxaban or rivaroxaban. The samples were categorized into three age groups: (i) ≤ 64 years, (ii) 65-74 years, and (iii) ≥ 75 years (apixaban: N = 48, 108, 119; edoxaban: N = 63, 68, 126; rivaroxaban: N = 115, 90, 38, respectively). Coagulation parameters including fibrinogen (Fbg), factor II, factor V, factor VII, factor X, and D-dimer, were compared between the three age groups for each drug. The slopes in the correlation between drug concentrations and modified diluted prothrombin time (mdPT) were also assessed. Fbg and factor V increased with age, while factor II and factor X decreased. Factor VII and D-dimer showed no significant differences across age categories. The slope in response to drug concentrations was similar between the age groups. In NVAF patients treated with apixaban, edoxaban and rivaroxaban, some coagulation parameters exhibited age-related variation. However, the response of mdPT to drug concentration was consistent across age categories.
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Affiliation(s)
- Osamu Kumano
- Sysmex Corporation, Kobe, Japan
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Masako Yamazaki
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
- Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan.
- Department of Nursing, Sapporo University of Health Sciences, 1-15, Nakanuma Nishi-4-2, Higashi-ku, Sapporo, Hokkaido, 007-0894, Japan.
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Nakamura M, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Yasaka M, Yamaguchi T, Teramukai S, Morishima Y, Fukuzawa M, Takita A, Hirayama A. Coronary events in elderly patients with non-valvular atrial fibrillation: a prespecified sub-analysis of the ANAFIE registry. Cardiovasc Interv Ther 2024; 39:145-155. [PMID: 38349574 PMCID: PMC10940374 DOI: 10.1007/s12928-024-00984-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/26/2023] [Indexed: 03/16/2024]
Abstract
Real-world data on coronary events (CE) in elderly patients with atrial fibrillation (AF) are lacking in the direct oral anticoagulant era. This prespecified sub-analysis of the ANAFIE Registry, a prospective observational study in > 30,000 Japanese patients aged ≥ 75 years with non-valvular AF (NVAF), investigated CE incidence and risk factors. The incidence and risk factors for new-onset CE (a composite of myocardial infarction [MI] and cardiac intervention for coronary heart diseases other than MI), MI, and cardiac intervention for coronary heart diseases other than MI during the 2-year follow-up were assessed. Bleeding events in CE patients were also examined. Among 32,275 patients, the incidence rate per 100 patient-years was 0.48 (95% confidence interval (CI): 0.42-0.53) for CE during the 2-year follow-up, 0.20 (0.16-0.23) for MI, and 0.29 (0.25-0.33) for cardiac intervention for coronary heart diseases other than MI; that of stroke/systemic embolism was 1.62 (1.52-1.73). Patients with CE (n = 287) likely had lower creatinine clearance (CrCL) and higher CHADS2 and HAS-BLED scores than patients without CE (n = 31,988). Significant risk factors associated with new-onset CE were male sex, systolic blood pressure of ≥ 130 mmHg, diabetes mellitus (glycated hemoglobin ≥ 6.0%), CE history, antiplatelet agent use, and CrCL < 50 mL/min. Major bleeding incidence was significantly higher in patients with new-onset CE vs without CE (odds ratio [95% CI], 3.35 [2.06-5.43]). In elderly patients with NVAF, CE incidence was lower than stroke/systemic embolism incidence. New-onset CE (vs no CE) was associated with a higher incidence of major bleeding.Trial registration: UMIN000024006.
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Affiliation(s)
- Masato Nakamura
- Division of Minimally Invasive Treatment in Cardiovascular Medicine, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-Ku, Tokyo, 153-8515, Japan.
| | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Masayuki Fukuzawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Hirayama
- Department of Medicine, Osaka Fukujuji Hospital, Neyagawa, Japan
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Akao M, Inoue H, Yamashita T, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Shimizu W. Relationship Between Direct Oral Anticoagulant Doses and Clinical Outcomes in Elderly Patients With Non-Valvular Atrial Fibrillation - ANAFIE Registry Sub-Analysis. Circ J 2023; 87:1765-1774. [PMID: 37482411 DOI: 10.1253/circj.cj-23-0143] [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] [Indexed: 07/25/2023]
Abstract
BACKGROUND This sub-analysis of the ANAFIE Registry, a prospective, observational study of >30,000 Japanese non-valvular atrial fibrillation (NVAF) patients aged ≥75 years, assessed the prevalence of direct oral anticoagulant (DOAC) under-dose prevalence, identified the factors of under-dose prescriptions, and examined the relationship between DOAC dose and clinical outcomes.Methods and Results: Patients, divided into 5 groups by DOAC dose (standard, over-, reduced, under-, and off-label), were analyzed for background factors, cumulative incidences, and clinical outcome risk. Endpoints were stroke/systemic embolic events (SEE), major bleeding, and all-cause death during the 2-year follow-up. Of 18,497 patients taking DOACs, 20.7%, 3.8%, 51.6%, 19.6%, and 4.3%, were prescribed standard, over-, reduced, under-, and off-label doses. Factors associated with under-dose use were female sex, age ≥85 years, reduced creatinine clearance, history of major bleeding, polypharmacy, antiplatelet agents, heart failure, dementia, and no history of catheter ablation or cerebrovascular disease. After confounder adjustment, under-dose vs. standard dose was not associated with the incidence of stroke/SEE or major bleeding but was associated with a higher mortality rate. Patients receiving an off-label dose showed similar tendencies to those receiving an under-dose; that is, they showed the highest mortality rates for stroke/SEE, major bleeding, and all-cause death. CONCLUSIONS Inappropriate low DOAC doses (under- or off-label dose) were not associated with stroke/SEE or major bleeding but were associated with all-cause death.
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Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | | | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital
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Shimizu W, Uchiyama S, Atarashi H, Inoue H, Kitazono T, Yamashita T, Ikeda T, Kamouchi M, Kaikita K, Fukuda K, Origasa H, Shimokawa H. Effectiveness and safety of reduced-dose rivaroxaban for elderly patients with non-valvular atrial fibrillation: A subanalysis of the EXPAND study. Int J Cardiol 2023; 391:131290. [PMID: 37619876 DOI: 10.1016/j.ijcard.2023.131290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Establishing the appropriate rivaroxaban dose in older patients with non-valvular atrial fibrillation (NVAF) is important because of the high risk of adverse events. In this EXPAND study subanalysis, we examined the safety and efficacy of standard-dose (15 mg/day) and non-recommended reduced-dose (10 mg/day) rivaroxaban in patients aged ≥65 years with NVAF and preserved renal function. METHODS The entire analysis population (ALL cohort [n = 3982]; ≥65 years) was divided into early elderly (ELD) (65-74 years [n = 1444]) and late ELD (≥75 years [n = 2386]) sub-cohorts. Each sub-cohort was divided into reduced-dose and standard-dose groups. Kaplan-Meier survival curves with adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were used to assess efficacy (thromboembolic events) and safety (hemorrhagic events) outcomes. RESULTS The aHR for major bleeding did not differ between the dosages in any of the cohorts (aHRs: 0.86-0.93). There were no significant differences in the occurrence of stroke + systemic embolism (SE) or stroke + SE + myocardial infarction (MI) + cardiovascular (CV) death among the cohorts. The aHR for MI/unstable angina + interventional/CV surgery + CV death was higher with 10-mg/day rivaroxaban than 15-mg/day rivaroxaban in the ALL cohort (aHR: 1.56 [95% CI 1.02-2.37], p = 0.039) and the late ELD sub-cohort (aHR: 1.86 [95% CI 1.01-3.42], p = 0.045). CONCLUSIONS Reduced-dose rivaroxaban may increase the risk of coronary artery events. The use of rivaroxaban 15 mg/day in patients with NVAF aged ≥75 years with preserved renal function was supported.
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Affiliation(s)
- Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | | | | | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Center for Cohort Study, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koji Fukuda
- Division of Heart Rhythm, International University of Health and Welfare Hospital, International University of Health and Welfare, Tochigi, Japan
| | | | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Chiba, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
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Arora P, Muehrcke M, Russell M, Ghanekar S. Utilization outcomes of direct oral anticoagulants in Medicare patients. Res Social Adm Pharm 2023; 19:1424-1431. [PMID: 37429747 DOI: 10.1016/j.sapharm.2023.07.002] [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: 12/19/2022] [Revised: 04/19/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To compare the adherence, persistence, discontinuation and switching rates of direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). METHODS This was retrospective observational cohort study design. Medicare Part D claims files were used for the study duration (2015-2018). Inclusion-exclusion criteria were applied to identify the NVAF and VTE sample using dabigatran, rivaroxaban, apixaban, edoxaban and warfarin during the identification period (2016-2017). Outcomes of adherence, persistence, time to non-persistence and time to discontinuation were assessed in those who did not switch the index drug in the follow-up period (365 days from the index date). Switching rates were assessed in those who switched the index drug at least once in the aforementioned follow-up period. Descriptive statistics were conducted for all the outcomes, and comparisons were made using t-tests, chi-square, and ANOVA. Logistic regression was conducted to compare the odds of being adherent and the odds of switching in NVAF and VTE patient cohorts. RESULTS Of all the DOACs, patients with NVAF or VTE were most adherent to apixaban (PDC = 76.88). Among all the DOACs, non-persistence and discontinuation rates were highest for warfarin. Majority of the switches were reported from dabigatran to other DOAC and to apixaban from other DOAC. Despite the better utilization outcomes reported for apixaban users, Medicare plans covered rivaroxaban favorably. It was associated with the lowest mean amount paid by the patient (NVAF: $76; VTE: $59), and the highest mean amount paid by the plans (NVAF: $359; VTE: $326). CONCLUSION Medicare plans need to consider adherence, persistence, discontinuation and switching rates of DOACs to make the coverage decisions.
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Affiliation(s)
- Prachi Arora
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Maria Muehrcke
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Molly Russell
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Saurabh Ghanekar
- Resultant, 111 Monument Circle, Suite 202, Indianapolis, IN, 46204, USA.
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Kang KW, Shin D, Shin SY, Kim J, Choi EK, Cha MJ, Lee JM, Kim JB, Park J, Park JK, Kim TH, Uhm JS, Shim J, Lee YS, Park HW, Kim C, Joung B. Comparative Bleeding Risk in Patients with Atrial Fibrillation with Cancer versus Without Cancer from Nationwide Prospective Cohort. Int Heart J 2023; 64:832-838. [PMID: 37704413 DOI: 10.1536/ihj.22-507] [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] [Indexed: 09/15/2023]
Abstract
Comparison of the bleeding risk for long-term oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF) with and without cancers has been inconsistent. This study aimed to clarify the differences in the bleeding risk in patients with AF with cancers and those without cancers during the long-term OAC.The CODE-AF prospective registry enrolled 5,902 consecutive patients treated for AF at 10 tertiary referral centers in Korea. Of the enrolled patients, 464 (7.8%) were diagnosed with cancers and were followed for all stroke and bleeding events (net composite events).The age, CHA2DS2-VASC, and HAS-BLED scores were similar between AF patients with and without cancers. Male population greatly comprised patients with AF with cancers. They were equally prescribed with direct OAC compared to those without cancers. The incidence rate for clinically relevant nonmajor (CRNM) bleeding events was higher in the patients with AF with cancers than in those without cancers (4.4 per 100 person-years versus 2.8 per 100 person-years, P = 0.023), and net composite events were also more frequent in patients with AF with cancers than in those without cancers (6.4 per 100 person-years versus 4.0 per 100 person-years, P = 0.004). Patients with AF with cancers showed a significantly higher rate of CRNM bleeding (hazard ratio [HR] 1.54, confidence interval [CI] 1.05-2.25, P = 0.002) than those without cancers.Based on the AF cohort, AF with cancers could face a significantly higher risk for CRNM bleeding events in the long-term OAC than those without cancers.
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Affiliation(s)
- Ki-Woon Kang
- Division of Cardiology, Chung-Ang University Hospital
| | - David Shin
- Division of Hematology and Oncology, University of California Los Angeles
| | | | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine
| | - Eu-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital
| | - Myung-Jin Cha
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine
| | - Jung-Myung Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University
| | - Jin-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University
| | - Junbeom Park
- Department of Cardiology, School of Medicine, Ewha Womans University
| | - Jin-Kyu Park
- Department of Cardiology, Hanyang University Seoul Hospital
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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Wu T, Wu S, Li L, Xiang J, Wang N, Chen W, Zhang J. The impact of ABCB1, CYP3A4/5 and ABCG2 gene polymorphisms on rivaroxaban trough concentrations and bleeding events in patients with non-valvular atrial fibrillation. Hum Genomics 2023; 17:59. [PMID: 37420302 DOI: 10.1186/s40246-023-00506-3] [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: 12/17/2022] [Accepted: 07/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The influence of genetic factors on the pharmacokinetics and clinical outcomes of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) is poorly understood. This study aimed to explore the effects of CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms on the trough concentrations and the bleeding risk of rivaroxaban in NVAF patients. PATIENTS AND METHODS This study is a prospective multicenter study. The patient's blood samples were collected to detect the steady-state trough concentrations of rivaroxaban and gene polymorphisms. We visited the patients regularly at month 1, 3, 6, and 12 to record bleeding events and medications. RESULTS A total of 95 patients were enrolled in this study, and 9 gene loci were detected. For the dose-adjusted trough concentration ratio (Ctrough/D) of rivaroxaban, the homozygous mutant type was significantly lower than wild type at ABCB1 rs4148738 locus (TT vs. CC, P = 0.033), and the mutant type was significantly lower than the wild type at ABCB1 rs4728709 locus (AA + GA vs. GG, P = 0.008). ABCB1 (rs1045642, rs1128503), CYP3A4 (rs2242480, rs4646437), CYP3A5 (rs776746), and ABCG2 (rs2231137, rs2231142) gene polymorphisms had no significant effect on the Ctrough/D of rivaroxaban. For the bleeding events, we found that there were no significant differences among genotypes of all gene loci. CONCLUSION This study found for the first time that ABCB1 rs4148738 and rs4728709 gene polymorphisms had a significant impact on the Ctrough/D of rivaroxaban in NVAF patients. CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms were not associated with the bleeding risk of rivaroxaban.
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Affiliation(s)
- Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Li Li
- Department of Pharmacy, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jing Xiang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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Wang X, Xu X, Wang W, Huang H, Liu F, Wan C, Yao Q, Li H, Zhang Z, Song Z. Risk factors associated with left atrial appendage thrombosis in patients with non-valvular atrial fibrillation by transesophageal echocardiography. Int J Cardiovasc Imaging 2023:10.1007/s10554-023-02841-x. [PMID: 37149503 DOI: 10.1007/s10554-023-02841-x] [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] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/20/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE This study investigated possible mechanism of left atrial appendage (LAA) thrombosis and constructed a model to evaluate the future risk of LAA thrombosis and spontaneous echo contrast (SEC) in non-valvular atrial fibrillation (NVAF) patients. METHODS This retrospective study included 2591 patients diagnosed with NVAF. Patients were divided based on the presence of transesophageal echocardiography (TEE) into a thrombus group, SEC group, and control group. General, biochemical, and echocardiography data of the three groups were analyzed. The variables independently associated with LAA thrombosis and SEC were determined by the logistic regression analysis. A nomogram was constituted based on the regression analysis and the discriminatory ability was analyzed by receiver operating characteristic (ROC) curve. RESULTS LAA thrombosis and SEC were present in 110 (4.2%) patients and 103 (3.9%) patients, respectively. AF type (OR = 1.857), previous stroke (OR = 1.924), fibrinogen (OR = 1.636), diameters of the left atria (OR = 1.094), left ventricular ejection fraction (OR = 0.938), and LAA maximum caliber (OR = 1.238) resulted as independent risk factors for LAA thrombosis and SEC. The area under curve of the nomogram established by multivariate logistic regression was 0.824. Conclusions; Through the study, 6 independent risk factors related to the LAA thrombosis and SEC were found, and an effective nomogram was constructed to predict the LAA thrombosis and SEC in NVAF patients.
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Affiliation(s)
- Xingpeng Wang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiang Xu
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Wenting Wang
- Department of Medical Ultrasonics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Haiyun Huang
- Department of Medical Ultrasonics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Feng Liu
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Chen Wan
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Qing Yao
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Huakang Li
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhihui Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China.
| | - Zhiyuan Song
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Army Medical University, Chongqing, China.
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure. Heart Rhythm 2023; 20:e1-e16. [PMID: 36990925 DOI: 10.1016/j.hrthm.2023.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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] [Indexed: 03/31/2023]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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Wu S, Guan C, Xu W, Zhang F, Huang N, Chen X, Zhang W, Hu W, Su J, Dai H, Gu P, Huang X, Du X, Li R, Zheng Q, Lin X, Zhang Y, Zou L, Liu Y, Zhang M, Liu X, Zhu Z, Sun J, Hong S, She W, Zhang J. Safety and efficacy of direct oral anticoagulation in patients with and without radiofrequency ablation of non-valvular atrial fibrillation: a multicenter retrospective cohort study. Thromb J 2023; 21:37. [PMID: 37016388 PMCID: PMC10074713 DOI: 10.1186/s12959-023-00483-6] [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: 11/03/2022] [Accepted: 03/29/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Based on the few available studies on the prognostic benefit of using direct oral anticoagulants (DOACs) after atrial fibrillation (AF) ablation. Therefore, this study aimed to evaluate the prognostic differences between patients who underwent radiofrequency ablation (RFA) and those without RFA taking DOACs. METHODS This is a multicenter retrospective cohort study enrolling 6137 patients with non-valvular AF (NVAF) at 15 hospitals in China. Patient information was collected through a mean follow-up of 10 months and medical record queries. Clinical outcomes included major bleeding, total bleeding, thrombosis, all-cause death, and a composite endpoint of bleeding, thrombosis, and all-cause death. RESULTS After adjusting for confounders and propensity score matching (PSM), patients with RFA of NVAF had a significantly lower risk of major bleeding [OR 0.278 (95% CI, 0.150-0.515), P<0.001], thrombosis [OR 0.535 (95% CI, 0.316-0.908), P=0.020] and the composite endpoint [ OR 0.835 (95% CI, 0.710-0.982), P=0.029]. In the RFA PSM cohort, dabigatran was associated with reduced all-cause death in patients with RFA of NVAF [OR 0.420 (95% CI, 0.212-0.831), P=0.010]. In the no RFA PSM cohort, rivaroxaban was associated with a reduction in major bleeding [OR 0.521 (95% CI, 0.403-0.673), P<0.001], total bleeding [OR 0.114 (95% CI, 0.049-0.266), P<0.001], and the composite endpoint [OR 0.659 ( 95% CI, 0.535-0.811), P<0.001]. CONCLUSION Among patients with NVAF treated with DOACs, RFA was a negative correlate of major bleeding, thrombosis, and composite endpoints but was not associated with total bleeding or all-cause mortality.
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Affiliation(s)
- Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Chengfu Guan
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Wenlin Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital, Fujian, 350001, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji(Wuhan) Hospital, Wuhan, 430000, China
| | - Xia Chen
- Department of Pharmacy, Fuling Hospital of Chongqing University, Chongqing, 408099, China
| | - Wang Zhang
- Department of Pharmacy, The First People's Hospital of Changde City, Hunan, 415000, China
| | - Wei Hu
- Department of Pharmacy, Xinyang Central Hospital, Xinyang Hospital Affiliated to Zhengzhou University, Henan, 464000, China
| | - Jun Su
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Anhui, 233004, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fujian, 350009, China
| | - Ping Gu
- Department of Pharmacy, Suining Central Hospital, Suining, 629000, Sichuan, China
| | - Xiaohong Huang
- Department of Pharmacy, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, 363000, China
| | - Xiaoming Du
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ruijuan Li
- Department of Pharmacy, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Shanxi, 030032, China
| | - Qiaowei Zheng
- Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiangsheng Lin
- Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fujian, 350400, China
| | - Yanxia Zhang
- Department of Pharmacy, The First Affiliated Hospital of Jiamusi University, Heilongjiang, 154002, China
| | - Lang Zou
- Department of Pharmacy, Second Affiliated Hospital, Army Medical University, Chongqing, 400037, China
| | - Yuxin Liu
- Department of Pharmacy, Huaihe Hospital of Henan University, Henan, 475000, China
| | - Min Zhang
- Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Shandong, 266041, China
| | - Xiumei Liu
- Department of Pharmacy, of People's Hospital He'nan University of Chinese Medicine (People's Hospital of Zhengzhou), Zhengzhou, 450003, China
| | - Zhu Zhu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, 215004, China
| | - Jianjun Sun
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia, China
| | - Shanshan Hong
- Department of Pharmacy, Quanzhou First Hospital, Fujian, 362000, China
| | - Weibin She
- Department of Medical Administration, Dongguan Kanghua Hospital, Guangdong, 523000, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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11
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Wang G, Li G, Hu F, Zang M, Pu J. Predicting a decrease in left atrial appendage flow velocity using left atrial diameter and CHA 2DS 2-VASc score in patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2023; 23:180. [PMID: 37013469 PMCID: PMC10071703 DOI: 10.1186/s12872-022-03033-6] [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: 05/14/2022] [Accepted: 12/27/2022] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Left atrial (LA) appendage flow velocity (LAAFV) is a classic but invasive predictor of thromboembolic events in patients with atrial fibrillation (AF). We aimed to explore the usefulness of LA diameter (LAD) combined with CHA2DS2-VASc score, which is easily available and non-invasive, as a novel score for predicting a decrease in LAAFV in non-valvular AF (NVAF). METHODS In total, 716 consecutive NVAF patients who underwent transesophageal echocardiography were divided into the decreased LAAFV (< 0.4 m/s) and preserved LAAFV (≥ 0.4 m/s) groups. RESULTS The decreased LAAFV group had a larger LAD and a higher CHA2DS2-VASc score than the preserved LAAFV group (P < 0.001). Multivariate linear regression indicated that brain natriuretic peptide (BNP) concentration, persistent AF, LAD, and CHA2DS2-VASc score were remained inversely associated with LAAFV. Moreover, multivariate logistic regression revealed that BNP concentration (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.001-1.005, P = 0.003), persistent AF (OR 0.159, 95% CI 0.102-0.247, P < 0.001), and LAD (OR 1.098, 95% CI 1.049-1.149, P < 0.001) were independent factors for a decrease in LAAFV. A novel score, LAD combined with CHA2DS2-VASc score, was more accurate for predicting a decrease in LAAFV among NVAF patients (area under the curve was 0.733). CONCLUSION Enlarged LAD was independent risk factor for a decrease in LAAFV among NVAF patients. LAD combined with CHA2DS2-VASc score enhanced the predictive ability for a decrease in LAAFV among NVAF patients.
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Affiliation(s)
- Guangyu Wang
- Department of Cardiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, No.160 Pujian Road, Pudong New District, Shanghai, 200120, China
| | - Guangyu Li
- Department of Cardiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, No.160 Pujian Road, Pudong New District, Shanghai, 200120, China
| | - Feng Hu
- Department of Cardiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, No.160 Pujian Road, Pudong New District, Shanghai, 200120, China
| | - Minhua Zang
- Department of Cardiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, No.160 Pujian Road, Pudong New District, Shanghai, 200120, China.
| | - Jun Pu
- Department of Cardiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, No.160 Pujian Road, Pudong New District, Shanghai, 200120, China.
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12
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Ding Y, Jiang H, Liu J, Chen D, Yang F. Effects of the theory of planned behavior and nudge strategy-based intervention on the adherence to anticoagulation treatment in patients with non-valvular atrial fibrillation. Geriatr Nurs 2023; 51:17-24. [PMID: 36871327 DOI: 10.1016/j.gerinurse.2023.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Non-valvular atrial fibrillation is associated with the incidence of thromboembolism. Current guidelines recommend preferential use of novel oral anticoagulants(NOAC) in patients with nonvalvular atrial fibrillation. Oral anticoagulation medication adherence rate was relatively low among discharged patients with non-valvular atrial fibrillation. AIM To investigate the effects of the anticoagulation programs based on the theory of planned behavior and nudge strategy among patients with non-valvular atrial fibrillation. METHODS 130 patients with non-valvular atrial fibrillation were randomized to the intervention group or control group, 72 patients in the intervention group, and 58 patients in the control group with a 6-month follow-up. Medication adherence,intention,attitude, perceived behavioral control and subjective norm and quality of life were assessed. RESULTS There were significantly differences in the attitude and subjective norm between the two groups at one month,three months and six months follow-up(P <0.01).There were significantly differences in the perceived behavioral control between the two groups at six months follow-up(P <0.01).There were significantly differences in the intention scale between the two groups at three months follow-up(P <0.01). The medication adherence scale score was higher in the intervention group than in the control group at six months follow-up.However, there were no differences in quality of life between the two groups at six months follow-up. CONCLUSIONS The program based on the theory of planned behavior and nudge strategy can improve medication adherence in patients with non-valvular atrial fibrillation.
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Berger JS, Ashton V, Laliberté F, Germain G, Bookhart B, Lejeune D, Boudreau J, Lefebvre P, Weir MR. Healthcare Resource Utilization and Costs of Rivaroxaban Versus Warfarin Among Non-valvular Atrial Fibrillation (NVAF) Patients with Diabetes in a US Population. Adv Ther 2023; 40:1224-1241. [PMID: 36658454 PMCID: PMC9988717 DOI: 10.1007/s12325-022-02422-9] [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] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The healthcare resource utilization (HRU) and costs of oral anticoagulant-naïve patients with non-valvular atrial fibrillation (NVAF) and diabetes initiated on rivaroxaban or warfarin in the United States (US) has not been previously evaluated. METHODS This retrospective study used data from the Optum's de-identified Clinformatics® Data Mart Database (1 January, 2012 to 30 September, 2021) to evaluate the HRU and costs of adult patients with NVAF and diabetes newly initiated on rivaroxaban or warfarin (on or after January 2013). Inverse probability of treatment weighting (IPTW) was used to adjust for confounding between cohorts. HRU and costs (USD 2021) were assessed per patient-year (PPY) post-treatment initiation. Weighted cohorts were compared using rate ratios (RR) from Poisson regression models, odds ratios (OR) from logistic regression models, and cost differences; 95% confidence intervals (CI) and p values were generated using non-parametric bootstrap procedures. RESULTS After IPTW, 17,881 and 19,274 patients initiated on rivaroxaban and warfarin were included, respectively (mean age: 73 years; 40% female). During 12 months of follow-up, the rivaroxaban cohort had lower all-cause HRU PPY across all components, including lower rates of inpatient stays (RR: 0.84, 95% CI 0.81, 0.88), outpatient visits (RR: 0.67, 95% CI 0.66, 0.68), and 30 day hospital readmission (OR: 0.75, 95% CI 0.66, 0.83; all p < 0.001) compared to the warfarin cohort. Moreover, rivaroxaban was associated with medical cost savings PPY (mean cost difference: - $9306, 95% CI - $11,769, - $6607), which compensated for higher pharmacy costs relative to warfarin (mean cost difference: $5518, 95% CI $5193, $5839), resulting in significantly lower all-cause total healthcare costs for rivaroxaban versus warfarin (mean cost difference: - $3788, 95% CI - $6258, - $1035; all p < 0.001). CONCLUSION Among NVAF patients with diabetes in a real-world US setting, rivaroxaban was associated with lower healthcare costs compared to warfarin.
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Affiliation(s)
| | | | - François Laliberté
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC, H3B 0G7, Canada
| | - Guillaume Germain
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC, H3B 0G7, Canada.
| | | | - Dominique Lejeune
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC, H3B 0G7, Canada
| | - Julien Boudreau
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC, H3B 0G7, Canada
| | - Patrick Lefebvre
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Tour Deloitte, Suite 1500, Montreal, QC, H3B 0G7, Canada
| | - Matthew R Weir
- University of Maryland School of Medicine, Baltimore, MD, USA
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Waranugraha Y, Lin LY, Tsai CT. Head-to-head comparison between left atrial appendage occlusion and non-vitamin K oral anticoagulants in non-valvular atrial fibrillation patients: A systematic review and meta-analysis study . Trends Cardiovasc Med 2023:S1050-1738(23)00020-8. [PMID: 36775218 DOI: 10.1016/j.tcm.2023.02.002] [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: 12/18/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Left atrial appendage occlusion (LAAO) was found to be non-inferior to warfarin. In non-valvular atrial fibrillation (AF), there is still a scarcity of data comparing LAAO versus non-vitamin K oral anticoagulants (NOACs). Our purpose was to compare the clinical benefits between LAAO and NOACs in non-valvular AF patients. The patient, intervention, comparison, and outcome principles were used to develop the research question in this systematic review and meta-analysis. Literature searches were conducted in online scientific databases such as ProQuest, PubMed, and ScienceDirect. All important information was extracted. The random-effect model was applied to estimate all pooled effects. The Mantel-Haenszel statistical method was used to determine the pooled risk ratio (RR) and 95% confidence interval (CI). A total of 4411 participants from 5 studies were involved. LAAO significantly decreased the cardiovascular mortality risk compared to NOACs (RR = 0.56; 95% CI = 0.42 to 0.75; p <0.01). Major bleeding risk in the LAAO group was significantly lower than in the NOACs group (RR = 0.66; RR = 0.53 to 0.82; p <0.01). A significantly lower risk of major bleeding or non-major bleeding in the patients receiving LAAO than NOACs was also observed in this meta-analysis (RR = 0.66; 95% CI = 0.54 to 0.81; p <0.01). LAAO was superior to the NOACs in reducing cardiovascular mortality, major bleeding, and major or non-major bleeding risks in non-valvular AF patients. In high-risk thromboembolism and bleeding patients, LAAO can be considered first as a long-term treatment strategy.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Universitas Brawijaya Faculty of Medicine and Hospital, Malang, Indonesia
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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Deitelzweig S, Keshishian A, Kang A, Jenkins A, Atreja N, Schuler P, Jiang J, Yuce H, Sun X, Lip GYH. Delaying clinical events among patients with non-valvular atrial fibrillation treated with oral anticoagulants: Insights from the ARISTOPHANES study. Eur J Intern Med 2023; 108:37-42. [PMID: 36456387 DOI: 10.1016/j.ejim.2022.10.021] [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: 05/26/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral anticoagulants (OACs) mitigate stroke and systemic embolism (SE) risk in non-valvular atrial fibrillation (AF) patients but can increase the risk of major bleeding (MB). This study analyzed the gains in event-free time for these outcomes among OAC treatment options represented in the ARISTOPHANES study. METHODS This sub-analysis consisted of NVAF patients who initiated warfarin, apixaban, dabigatran, or rivaroxaban from 01JAN2013-30SEP2015, with data pooled from Medicare and 4 US commercial claims databases. Propensity score matching was conducted between non-vitamin K antagonist OAC (NOAC) and warfarin cohorts in each database and results were pooled. Laplace regression was used to evaluate the delay in time to stroke/SE and MB events between NOACs and warfarin and between NOACs after the first 12-months of follow-up. RESULTS The population included 466,991 patients (167,413 warfarin; 108,852 apixaban; 37,724 dabigatran; and 153,002 rivaroxaban). Event-free time gain (95% confidence interval) for apixaban versus warfarin was 101 days (78- 124) for stroke/SE and 116 (103- 130) days for MB. The gain in event-free time for dabigatran versus warfarin was 45 days (3- 87) for stroke/SE and 92 (68- 116) days for MB. The gain in event-free time for rivaroxaban versus warfarin was 63 days (42- 84) for stroke/SE but event-free time decreased by 18 (-31-6) days for MB. CONCLUSIONS Over 12 months after initiation, apixaban and dabigatran conferred progressive increases in event free time for stroke/SE and MB vs warfarin, whereas rivaroxaban conferred an increase in stroke/SE-free time but a loss in MB-free time vs warfarin.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Nipun Atreja
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Xue S, Qiu X, Wei M, Kong Q, Dong J, Wang Q, Li F, Song H. Changing trends and factors influencing anticoagulant use in patients with acute ischemic stroke and NVAF at discharge in the NOACs era. J Stroke Cerebrovasc Dis 2023; 32:106905. [PMID: 36473400 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106905] [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: 10/09/2022] [Accepted: 11/20/2022] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES We sought to explore the trends and influencing factors of the use of anticoagulants in patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) at discharge in the era of novel oral anticoagulants (NOACs). METHODS We recruited consecutive inpatients with acute ischemic stroke and NVAF in a registered study (NCT04080830) from January 2016 to December 2021. The relevant data of patients were collected. We compared the proportions of anticoagulant treatment at discharge before and after NOACs entered China's medical insurance system. The proportion of each antithrombotic status as well as anticoagulant agents at discharge in every year were calculated, and the trends during the study period were analyzed. The relevant factors affecting anticoagulant use at discharge were further analyzed. RESULTS The proportion of anticoagulation at discharge increased significantly after NOACs entered China's medical insurance system in 2018 versus before (χ2 = 42.828, P < 0.001). There were statistically significant differences in antithrombotic status (χ2 = 69.954, P < 0.001) and in the proportion of different anticoagulant drugs (χ2 = 63.049, P<0.001) by year. Anticoagulant therapy (χ2 = 1.55, P = 0.671) and NOACs (χ2 = .178, P = 0.243) increased over 2016-2018 but was relatively stable during 2018-2021. Multivariate logistic regression analysis showed that age ≥75 years, coexisting cerebral artery stenosis, massive cerebral infarction and hemorrhagic transformation were independent risk factors affecting anticoagulants use (all P < 0.05). CONCLUSION NOACs have indeed improved anticoagulants use in patients with acute ischemic stroke and NVAF at discharge. However, some specific factors affect anticoagulation therapy use at discharge and hinder further improvement even in the NOACs era.
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Affiliation(s)
- Sufang Xue
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Xue Qiu
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Qi Kong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Jing Dong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Qiujia Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Fangyu Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Changchun street 45, Beijing 100053, China.
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Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Inoue H. Causes of Death in Elderly Patients With Non-Valvular Atrial Fibrillation - Results From the ANAFIE Registry. Circ J 2023. [PMID: 36653127 DOI: 10.1253/circj.cj-22-0614] [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] [Indexed: 01/18/2023]
Abstract
BACKGROUND Previous studies on mortality in atrial fibrillation (AF) included a limited number of elderly patients receiving direct oral anticoagulants (DOACs). This subanalysis of the ANAFIE Registry evaluated 2-year mortality according to causes of death of elderly non-valvular AF (NVAF) patients in the DOAC era.Methods and Results: The ANAFIE Registry was a multicenter prospective observational study. Mean patient age was 81.5 years and 57.3% of patients were male. Of the 32,275 patients completing the study, 2,242 died. The most frequent causes of death were cardiovascular (CV) death (32.4%), followed by infection (17.1%) and malignancy (16.1%). Incidence rates of CV-, malignancy-, and infection-related death were 1.20, 0.60, and 0.63 per 100 person-years, respectively. Patients aged ≥85 years showed increased proportions of non-CV and non-malignancy deaths and a decreased proportion of malignancy deaths compared with patients aged <85 years. The incidence of death due to congestive heart failure/cardiogenic shock, infection, and renal disease was higher in patients aged ≥85 than those aged <85 years. Compared with warfarin, DOACs were associated with a significantly lower risk of death by intracranial hemorrhage, ischemic stroke, and renal disease. CONCLUSIONS This subanalysis described the mortality according to causes of death of Japanese elderly NVAF patients in the DOAC era. Our results imply that a more holistic approach to comorbid conditions and stroke prevention are required in these patients.
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Affiliation(s)
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
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18
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Chen C, Chen Y, Qu L, Su X, Chen Y. 3-Year outcomes after left atrial appendage closure in patients with nonvalvular atrial fibrillation: cardiomyopathy related with increased death and stroke rate. BMC Cardiovasc Disord 2023; 23:27. [PMID: 36650429 PMCID: PMC9844026 DOI: 10.1186/s12872-023-03054-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Left atrial appendage closure (LAAC) is a novel treatment for stroke prevention in high-risk patients with non-valvular atrial fibrillation (NVAF). However, the long-term outcomes after LAAC in Chinese NVAF patients are still lacking. METHODS This was a single-center, bidirectional, nonrandomized registered study. Patients who underwent LAAC implantation from May 2014 to April 2021 in a large Chinese center were enrolled. The primary endpoint was combined all-cause death and stroke. RESULTS From May 2014 to April 2021, a total of 673 NVAF patients were enrolled. The overall successful implantation rate was 97.62% (657 of 673). The rate of perioperative adverse events was 1.19% (8 of 673), including 3 cardiac tamponades, 2 ischemic strokes, one device-related thrombus (DRT) and 2 device dislocations. 604 (92.24%) patients completed the follow-up, the median follow-up period was 36.9 months (IQR 24.8-56.5 months). 16 stroke events occurred in 15 patients (one patient suffered from both hemorrhagic and ischemic strokes). 13 patients (2.15%) had ischemic stroke, and the fatal rate was 0.33% (2 of 604). 3 patients (0.15%) suffered from hemorrhagic stroke, and the fatal rate was 0.17% (1 of 604). The overall stroke rate was 0.74% per-year. The combined death and stroke rate was 1.93% per-year. In the multivariate Cox regression analysis, age ≥ 75 (hazard ratio 2.264, 95% CI 1.074-4.772, P = 0.032) and ventricular cardiomyopathy (hazard ratio 2.738, 95% CI 1.060-7.071, P = 0.037) were independent predictors of combined mortality and stroke. CONCLUSION The overall successful implantation rate of LAAC was 97.62% and the rate of perioperative adverse events was 1.19% in this study, and the stroke rate was 0.74% per year during the long-term follow-up. Age ≥ 75 years and ventricular cardiomyopathy were independent predictors of the primary endpoint. Trial registration This study was retrospectively registered.
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Affiliation(s)
- Chunyu Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China ,grid.413247.70000 0004 1808 0969Department of Cardiology, The Second Affiliated Hospital of Wuhan University, Zhongnan Hospital, Wuhan, 430060 China
| | - Yuyi Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Lulu Qu
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Xi Su
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Yanhong Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
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Hammett C, Badve SV, Kerr PG, Tran HA, Dundon BK, Lo S, Wong A, Joseph JE, Deague J, Perkovic V. Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice. Heart Lung Circ 2022; 31:1604-1611. [PMID: 36336614 DOI: 10.1016/j.hlc.2022.09.003] [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: 05/17/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.
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Affiliation(s)
| | - Sunil V Badve
- Department of Nephrology, St George Hospital, and Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Vic, Australia
| | - Huyen A Tran
- The Alfred Hospital & Monash University, Melbourne, Vic, Australia
| | - Benjamin K Dundon
- MonashHeart, Monash Health and Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Sidney Lo
- Liverpool Hospital, SouthWest Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital and The University of Queensland, Brisbane, Qld, Australia
| | | | | | - Vlado Perkovic
- Royal North Shore Hospital and The George Institute for Global Health, Sydney, NSW, Australia
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20
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Alosaimi HM, Alqahtani S, Balkhi B, Alqahtani M, Alzamil F, Alhossan A, Alqahtany FS, Alharbi AA, Alqahtani NA, Albackr H, Elgohary G, Algahtani FH. A retrospective study of real-world effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation and venous thromboembolism in Saudi Arabia. PeerJ 2022; 10:e13974. [PMID: 36105646 PMCID: PMC9466595 DOI: 10.7717/peerj.13974] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023] Open
Abstract
Background Real-world evidence on factor Xa inhibitor (rivaroxaban) prescribing patterns, safety, and efficacy in patients with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) is rare. Herein, we sought to examine the above outcomes in the largest academic center in the Kingdom of Saudi Arabia (KSA). Methods This is a retrospective observational study designed to examine the prescribing pattern, safety and real-world effectiveness of the factor Xa inhibitor rivaroxaban in patients with NVAF and VTE. Data on rivaroxaban prescriptions were collected and analyzed. Bleeding outcomes were defined as per the International Society on Thrombosis and Hemostasis (ISTH) definition. Results A total of 2,316 patients taking rivaroxaban recruited through several departments of King Saud University Medical City (KSUMC). The mean age was 61 years (±17.8) with 55% above the age of 60 and 58% were females. Deep vein thrombosis and pulmonary embolism (VTE) was the most prevalent reason for prescribing rivaroxaban, followed by NVAF. A total daily dosage of 15 mg was given to 23% of the patients. The incidence rate of recurrent thrombosis and recurrent stroke was 0.2%. Furthermore, rivaroxaban had a 0.04 percent incidence rate of myocardial infarction. Half of the patients with recurrent thrombosis and stroke were taking 15 mg per day. The incidence rate of major bleeding was 1.1%. More over half of the patients who experienced significant bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score (>2 score), 48 percent of patients who experienced significant bleeding had a high risk of bleeding. Non-major bleeding occurred in 0.6% of cases. Similarly, 40% of patients with non-major bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score, just 6.6% of these individuals had a high risk of bleeding. 93.4% of the patients, on the other hand, were at intermediate risk. Conclusion The prescription of rivaroxaban in this real-life cohort study differs from the prescribing label and the outcomes of a phase 3 randomised clinical trial. However, for individuals with VTE and NVAF, the 20 mg dose looked to be more efficacious than the pivotal trial outcomes. Furthermore, among patients with VTE and NVAF, rivaroxaban was linked to a decreased incidence of safety events such as recurrent thrombosis, recurrent stroke, MI, major bleeding, and non-major haemorrhage in a real-world environment.
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Affiliation(s)
- Hind M. Alosaimi
- Clinical Pharmacy Department, College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia,Pharmacy Services, King Fahad Medical City, Riyadh Second Health Cluster, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Bander Balkhi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mishari Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faisal Alzamil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Fatmah S. Alqahtany
- Hematopathology Unit, Department of Pathology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf Abdullah Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hanan Albackr
- Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ghada Elgohary
- Department of Adult Hematology/Oncology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,Clinical Hematology and Bone Marrow Transplantation Unit, Division of Internal Medicine, Ain Shams University, Cairo, Egypt
| | - Farjah H. Algahtani
- Division of Oncology/Hematology, Department of Medicine, College of Medicine, King Saud University, Kind Saud University Medical City, Riyadh, Saudi Arabia
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21
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Belhassen M, Hanon O, Steg PG, Mahé I, Née M, Jacoud F, Dalon F, Cotté FE, Guitard-Dehoux D, Marant-Micallef C, Van Ganse E, Danchin N. Apixaban versus other anticoagulants in patients with nonvalvular fibrillation: a comparison of all-cause and event-related costs in real-life setting in France. Eur J Health Econ 2022:10.1007/s10198-022-01513-2. [PMID: 36030485 DOI: 10.1007/s10198-022-01513-2] [Citation(s) in RCA: 2] [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: 04/15/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Compare costs associated with all-cause healthcare resource use (HCRU), stroke/systemic thromboembolism (STE) and major bleedings (MB) between patients with non-valvular atrial fibrillation (NVAF) initiating apixaban or other oral anticoagulants (OACs). METHODS We performed a retrospective cohort study using the French healthcare claims database, including NVAF patients between 2014/01/01 and 2016/12/31, followed until 2016/12/31. We used 4 sub-cohorts of OAC-naive patients, respectively initiating apixaban, dabigatran, rivaroxaban or VKAs. We matched patients initiating apixaban with patients initiating each other OACs using 1:n propensity score matching. All-cause HCRU and event-related costs by OAC treatment were estimated and compared between matched patients using generalised-linear models with gamma-distribution and two-part models. RESULTS There were 175,766 patients in the apixaban-VKA, 181,809 in the apixaban-rivaroxaban, and 42,490 in the apixaban-dabigatran matched cohorts. Patients initiating apixaban had significantly lower HCRU costs than patients initiating VKA (€1,105 vs. €1,578, p < 0.0001), dabigatran (€993 vs. €1,140, p < 0.0001) and rivaroxaban (€1,013 vs. €1,088 p < 0.0001). They have had significantly lower costs related to stroke/STE and MB than patients initiating VKA (respectively, €183 vs. €449 and €147 vs. €413; p < 0.0001), rivaroxaban (respectively, €145 vs. €197 and €129 vs. €193; p < 0.0001), and lower costs related to stroke/STE than patients initiating dabigatran (€135 vs. €192, p < 0.02). Costs related to MB were not significantly different in patients initiating apixaban and those initiating dabigatran (€119 vs. €149, p = 0.07). CONCLUSIONS HCRU and most event-related costs were lower in patients initiating apixaban compared to other OACs. Apixaban may be cost-saving compared to VKAs, and significantly cheaper than other DOACs, although cost differences are limited.
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Affiliation(s)
- Manon Belhassen
- PELyon, Lyon, France.
- Département de Cardiologie, Hôpital Européen Georges Pompidou, Université de Paris, Paris, France.
| | - Olivier Hanon
- Service de Gériatrie, Université de Paris, APHP Centre, Hôpital Broca, 4468, Paris, EA, France
| | - Philippe Gabriel Steg
- FACT, Université de Paris, INSERM U-1148/LVTS, F ; Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018, ParisParis, France
| | - Isabelle Mahé
- APHP, Service de Médecine Interne, INNOVTE-FCRIN, Hôpital Louis Mourier, Université de Paris, Innovative Therapies in Haemostasis, INSERM, ColombesParisSaint Etienne, France
| | | | | | | | | | | | | | | | - Nicolas Danchin
- Département de Cardiologie, Hôpital Européen Georges Pompidou, Université de Paris, Paris, France
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22
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Song J, Zhang X, Wei M, Bo Y, Zhou X, Tang B. Association between lipoprotein(a) and thromboembolism in patients with non-valvular atrial fibrillation: a cross-sectional study. Lipids Health Dis 2022; 21:78. [PMID: 36002888 PMCID: PMC9404645 DOI: 10.1186/s12944-022-01682-2] [Citation(s) in RCA: 2] [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: 04/30/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is a recognized risk factor for ischemic stroke (IS); however, its role in thromboembolism in patients with non-valvular atrial fibrillation (NVAF) remains controversial. We aimed to assess the association of Lp(a) and IS and systemic embolism (SEE) in NVAF patients. METHODS In total, 16,357 patients with NVAF were recruited from the First Affiliated Hospital of Xinjiang Medical University from January 1, 2009, to December 31, 2021, and were divided into groups based on Lp(a) quartiles. Logistic regression models analyzed the association between Lp(a), IS, and SEE. The restriction cubic spline was used to assess the potential nonlinear relationship between Lp(a), IS, and SEE. We conducted subgroup analyses and estimated the multiplicative interaction between the stratified variables and Lp(a) to investigate whether the association between Lp(a) and IS and SEE was affected by age, sex, anticoagulants, and CHA2DS2-VASc score. RESULTS We identified 1319 IS and 133 SEE events. After correcting for CHA2DS2-VASc score and other potential confounders, each 1-standard deviation (SD) increase in log-Lp(a) was related to a 23% increased risk of IS (odds ratios [OR], 1.23; 95% confidence intervals [CI], 1.07-1.41). NVAF patients in the highest Lp(a) quartile were 1.23-fold more likely to have IS than those in the lowest quartile (OR, 1.23; 95% CI, 1.04-1.45). A positive linear relationship between Lp(a) and IS risk was observed (P for nonlinear = 0.341). In the fully adjusted model, subjects had a 1.78-fold increased risk of SEE for each 1-SD increase in log-Lp(a) (OR, 2.78; 95% CI, 1.78-4.36). Subjects in the highest Lp(a) quartile had a 2.38-fold elevated risk of SEE (OR, 3.38; 95% CI, 1.85-6.19) compared with the lowest quartile. Furthermore, Lp(a) had a nonlinear relationship with the risk of SEE (P for nonlinear = 0.005). CONCLUSIONS Elevated Lp(a) concentration was significantly associated with IS and SEE, suggesting that Lp(a) may be an emerging biomarker that can help clinicians identify patients at high risk of thromboembolism in this population.
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Affiliation(s)
- Jie Song
- Department of Cardiac Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, No. 137, Liyushan Road, Urumqi, 830054, PR China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China
| | - Xiaoxue Zhang
- Department of Cardiac Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, No. 137, Liyushan Road, Urumqi, 830054, PR China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China
| | - Meng Wei
- Department of outpatient, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China
| | - Yakun Bo
- Department of Cardiac Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, No. 137, Liyushan Road, Urumqi, 830054, PR China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China
| | - Xianhui Zhou
- Department of Cardiac Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, No. 137, Liyushan Road, Urumqi, 830054, PR China. .,Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China.
| | - Baopeng Tang
- Department of Cardiac Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, No. 137, Liyushan Road, Urumqi, 830054, PR China. .,Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, PR China.
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Sun S, Su B, Lin J, Zhao C, Ma C. A nomogram to predict left atrial appendage thrombus and spontaneous echo contrast in non-valvular atrial fibrillation patients. BMC Cardiovasc Disord 2022; 22:311. [PMID: 35820838 PMCID: PMC9277967 DOI: 10.1186/s12872-022-02737-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-valvular atrial fibrillation (NVAF) significantly increases the risk of stroke. Although there is availability of prediction models, their ability to predict the risk of stroke in NVAF patients remains suboptimal. Therefore, there is need to improve prediction of high-risk individuals, which is critical for efficient management of patients with NVAF.
Objective The objective of our paper is to develop a nomogram for predicting the risk of left atrial appendage thrombus (LAAT) and spontaneous echo contrast (SEC), thereby replacing the risk of stroke in NVAF patients. Design This was a retrospective cohort study that analyzed clinical data and echocardiographic indices of 387 patients with NVAF from October 2018 to June 2021. Multivariable logistic regression was used to evaluate independent factors that were used to construct the prediction nomogram. Analysis The discriminative ability and calibration of the nomogram to predict LAAT/SEC were tested using C-statistic and calibration plot. The performance of the nomogram was assessed against the CHA2DS2 score, CHA2DS2-VASc score and ATRIA score using the receiver operating characteristic curve (ROC), decision curve analysis (DCA), integrated discrimination index (IDI) and net reclassification index (NRI). Result Out of the total 387 patients enrolled in this study, 232 had LAAT/SEC. Multivariable analyses demonstrated that N-terminal pro-B-type natriuretic peptide (NT-proBNP), albumin (ALB), LAA ejection fraction (LAAEF) and LAA global peak longitudinal strain (LAA GPLS) were independent predictors of LAAT/SEC. The constructed nomogram had good discriminative (C = 0.886) and calibration (0.876) abilities after bias correction by the C-index. Compared with other models, the decision curve analyses demonstrated that the nomogram had greater net benefits. Besides, the nomogram had significant improvement in predictive performance, sensitivity and reclassification for LAAT/SEC compared with the CHA2DS2 [(c-index: 0.886 vs. 0.576, p < 0.05), (NRI: 0.539, p < 0.05), (IDI: 0.432, p < 0.05)], CHA2DS2-VASc [(c-index: 0.886 vs0.579, p < 0.05), (NRI: 0.513, p < 0.05), (IDI: 0.432, p < 0.05)] or ATRIA [(c-index: 0.886 vs0.583, p < 0.05), (NRI: 0.546, p < 0.05), (IDI: 0.432, p < 0.05)]. Conclusion Taken together, our data demonstrated that the developed nomogram was effective and had potential clinical application in the prediction of LAAT/SEC in patients with NVAF.
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Affiliation(s)
- Shikun Sun
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Bo Su
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Jia Lin
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Caiming Zhao
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
| | - Changsheng Ma
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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Yamashita T, Uchiyama S, Atarashi H, Okumura K, Koretsune Y, Yasaka M, Wakayama J, Fukaya T, Inoue H; J-Dabigatran Surveillance Investigators. Treatment strategy of dabigatran etexilate following the availability of idarucizumab in Japanese patients with non-valvular atrial fibrillation: J-Dabigatran Surveillance 2. J Cardiol 2022:S0914-5087(22)00096-X. [PMID: 35717283 DOI: 10.1016/j.jjcc.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Idarucizumab, a dabigatran-specific reversal agent, was launched in Japan in 2016. The J-Dabigatran Surveillance 2 study was designed to assess the characteristics and outcomes of dabigatran-treated patients after the launch of idarucizumab. METHODS Patient characteristics and outcomes, including thromboembolic and bleeding events, of dabigatran-naïve patients with non-valvular atrial fibrillation (NVAF) who received dabigatran etexilate [110 mg or 150 mg twice-daily (b.i.d.)] for the prevention of ischemic stroke and systemic embolism were investigated and presented descriptively. Absolute standardized differences (ASD) in baseline characteristics compared with the first J-Dabigatran Surveillance (J-Dabi1; 2011-2013) study were included. RESULTS In total, 5660 patients were enrolled and 5436 were analyzed in this study; 3516 and 1898 received 110 mg b.i.d. and 150 mg b.i.d. dabigatran, respectively; 22 received other doses. The overall duration of follow-up (mean ± standard deviation) was 287 ± 179 days. Baseline characteristics, including stroke/bleeding-risk scores, were typical of this patient population. Overall, paroxysmal, persistent, permanent, and symptomatic atrial fibrillation were observed for 53.2%, 27.1%, 13.7%, and 53.9% of patients, respectively (J-Dabi1 ASD: 0.2, 0.0, 0.3, and 0.2, respectively). Catheter ablation was selected in 27.9% of patients (J-Dabi1 ASD: 0.6). Rates of clinical outcomes were low in the study (mostly <2%/year). The incidence rate of major bleeding was 1.1%/year (n = 46) and stroke/transient ischemic attack/systemic embolism was 1.7%/year (n = 71). Twelve (0.2%) patients received idarucizumab, commonly for serious bleeding events, and most recovered. CONCLUSIONS Dabigatran continues to be safe and well tolerated in patients with NVAF for stroke and systemic embolism prevention and continues to be prescribed appropriately. Treatment outcomes have not changed since the availability of idarucizumab. Since the J-Dabi1 study, treatment guidelines for anticoagulation use in NVAF have been updated based on emerging clinical evidence, accounting for differences in patient characteristics, and making dabigatran a preference for distinct patient populations.
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Benini Tapias J, Flores-Umanzor E, Cepas-Guillén PL, Regueiro A, Sanchís L, Broseta JJ, Cases A, Freixa X. Prognostic impact of the presence of chronic kidney disease on percutaneous left trial appendage closure for atrial fibrillation: A single center experience. Nefrologia 2022; 42:290-300. [PMID: 36210618 DOI: 10.1016/j.nefroe.2022.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation (NVAF) to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with NVAF and chronic kidney disease (CKD), since they exhibit both high thromboembolic and bleeding risks. OBJECTIVE To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function. METHODS Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients. RESULTS The median age was 75,5 years (IQR 67,6-80) and 62,1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3-4) for both scores. Up to 57,3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs 4.06/100PY, P =,09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, P =,033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, P =,009), with an odds ratio of 2.711 (95% CI 1,96-6,95). In the multivariate analysis a preserved eGFR was independently associated with a lower mortality risk. CONCLUSIONS LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.
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Affiliation(s)
| | | | | | - Ander Regueiro
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
| | - Laura Sanchís
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
| | - José Jesús Broseta
- Departament de Cirurgia i Especialitats Medicoquirurgiques, Universitat de Barcelona, Barcelona, Spain
| | - Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Barcelona, Spain.
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
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Pan L, Yan B, Lu Q, Hui J. Association between γ-glutamyl transferase level and the onset of non-valvular atrial fibrillation in the Chinese population. Asian J Surg 2022; 45:1214-1215. [PMID: 35264300 DOI: 10.1016/j.asjsur.2022.01.115] [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: 12/14/2021] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lihua Pan
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China; Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Boyu Yan
- Department of Cardiology, Pingxiang People's Hospital, Pingxiang, 337000, China
| | - Qi Lu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, 226001, China.
| | - Jie Hui
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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Pérez AG, Balabanova Y, Sáez ME, Brobert G, García Rodríguez LA. Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom. Int J Cardiol 2022; 352:165-171. [PMID: 35122912 DOI: 10.1016/j.ijcard.2022.01.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/14/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation (NVAF) treated chronically with warfarin vs. some non-vitamin K antagonist oral anticoagulants. METHODS AND RESULTS Using primary care electronic health records from the United Kingdom we followed adults with NVAF and who started rivaroxaban (20 mg/day, N = 5338) or warfarin (N = 6314), excluding those with estimated glomerular filtration rate (eGFR) <50 ml/min/1.73m2, end-stage renal disease (ESRD) or no eGFR or serum creatinine (SCr) values recorded in the previous year. Outcomes were: doubling SCr levels, ≥30% decline in eGFR and progression to ESRD. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome. Average eGFR slope was estimated using mixed model regression. After a mean follow-up 2.5 years, the number of incident cases of adverse renal events within the two cohorts was: doubling SCr (n = 322), ≥30% decline in eGFR (n = 1179), and progression to ESRD (n = 22). Adjusted HRs (95% CIs) for the renal outcomes among rivaroxaban vs. warfarin users were: doubling SCr, 0.63 (0.49-0.81); ≥30% decline in eGFR, 0.76 (0.67-0.86); ESRD, 0.77 (0.29-2.04). Similar results were observed among patients with diabetes or heart failure. Estimated mean decline in renal function over the study period was 2.03 ml/min/1.73 m2/year among warfarin users and 1.65 ml/min/1.73 m2/year among rivaroxaban users (p = 0.03). CONCLUSIONS We found clear evidence that patients with NVAF, preserved renal function at baseline and treated with rivaroxaban had a markedly reduced risk and rate of renal decline compared with those treated with warfarin.
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Affiliation(s)
- Antonio González Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain; Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain; Pharmacoepidemiology Research Group, Institute for Health Research (IRYCIS), Madrid, Spain.
| | | | - María E Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain; Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
| | - Gunnar Brobert
- Integrated Evidence Generation, Bayer AB, Stockholm, Sweden.
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Sussman M, Barnes GD, Guo JD, Tao CY, Gillespie JA, Ferri M, Adair N, Cato MS, Shirkhorshidian I, Di Fusco M. The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review. Curr Med Res Opin 2022; 38:7-18. [PMID: 34632887 DOI: 10.1080/03007995.2021.1982684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes. METHODS An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents. RESULTS Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients. CONCLUSIONS Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.
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Affiliation(s)
- Matthew Sussman
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Jennifer D Guo
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Charles Y Tao
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Mauricio Ferri
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Nicholas Adair
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
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Deguchi I, Osada T, Takahashi S. Association Between Oral Anticoagulants and Stroke Severity at Onset in Elderly Patients with Cardioembolic Stroke Due to Non-Valvular Atrial Fibrillation. J Stroke Cerebrovasc Dis 2021; 31:106264. [PMID: 34963078 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106264] [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: 09/22/2021] [Revised: 11/26/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES This study aimed to determine whether oral anticoagulant therapy affects the severity of cerebral infarction at onset in elderly patients with non-valvular atrial fibrillation. MATERIALS AND METHODS This retrospective study included 330 elderly patients (aged ≥75 years) who were hospitalized for cardioembolic stroke due to non-valvular atrial fibrillation. Patients' medical history, stroke severity at onset (National Institutes of Health Stroke Scale score), and the prevalence of large vessel occlusion were compared between patients who received oral anticoagulant therapy (n = 109) and those who did not receive oral anticoagulant therapy (n = 221). RESULTS Stroke severity was significantly lower in patients who received anticoagulants than in those who did not receive anticoagulants (6 versus 12; P = 0.021). Patients who did not receive anticoagulants had a significantly higher prevalence of large vessel occlusion (52% versus 37%; P = 0.010). After resampling based on propensity score matching, both median stroke severity (7 versus 12; P = 0.046) and large vessel occlusion prevalence (36% versus 57%; P = 0.019) were significantly lower in patients who received anticoagulant therapy. CONCLUSIONS The results of this study suggest that elderly patients with non-valvular atrial fibrillation who are administered oral anticoagulant therapy before the onset of cerebral infarction develop less severe stroke than those who are not receiving oral anticoagulant therapy. Thus, oral anticoagulant therapy should be actively considered in patients with non-valvular atrial fibrillation as it does not only prevents cerebral embolism, but also reduces the risk of severe sequelae.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, 350-1298, Japan.
| | - Takashi Osada
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, 350-1298, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, 350-1298, Japan
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Abusnina W, Latif A, Al-Abdouh A, Mostafa MR, Radaideh Q, Alshebani Y, Aboeata A, Ben-Dor I, Michos ED, Dahal K. Sex differences in the clinical outcomes after left atrial appendage closure: A systematic review and meta-analysis. Cardiovasc Revasc Med 2021; 41:29-34. [PMID: 34952822 DOI: 10.1016/j.carrev.2021.12.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Left atrial appendage occlusion (LAAO) has emerged as a reasonable alternative to oral anticoagulation in a selective group of patients with atrial fibrillation (AF). While women are known have higher risk of AF-related stroke, the impact of sex differences on the clinical outcomes of LAAO has not been well studied. OBJECTIVE We sought to perform a meta-analysis evaluating sex differences on the outcomes of patients undergoing LAAO. METHODS We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases (from inception to October 2021) for studies evaluating the impact of sex difference on LAAO procedural outcomes. We used a random-effect model to calculate risk ratio (RR) with 95% confidence intervals (CI). In-hospital all-cause mortality and ischemic stroke were the primary endpoints. In-hospital pericardial effusion/cardiac tamponade, major bleeding, technical success, device related thrombus and hospital length of stay were secondary outcomes. RESULTS A total of 5 studies with 54,754 patients were included, of which 22,461 (41%) were females. Female sex was associated with higher rates of in-hospital all-cause mortality (RR 2.18; 95% CI 1.46-3.26; P = 0.0001) and in-hospital ischemic stroke (RR 1.67; 95% CI 1.06-2.61; P = 0.03) when compared with males. Females had higher rates of in-hospital major bleeding (RR 1.93; 95% CI 1.40-2.67; P < 0.0001) and hospital length of stay >1 day (RR 1.38; 95% CI 1.33-1.45; P < 0.00001). There was no differences between females and males in terms of technical success and device related thrombus (RR 1.00; 95% CI 1.00-1.00; P = 1.00) and (RR 0.94, 95% CI 0.31-2.82; P = 0.91), respectively. CONCLUSION In conclusion, women are more likely to experience worse periprocedural outcomes with longer hospital stay after LAA closure. Further efforts are needed to increase the participation of women in clinical studies and to assess these differences to properly address the discrepancy in outcomes between men and women.
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Affiliation(s)
- Waiel Abusnina
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Azka Latif
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | | | | | - Qais Radaideh
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Yazeid Alshebani
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Ahmad Aboeata
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khagendra Dahal
- Department of Cardiology, Creighton University School of Medicine, NE, USA.
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Deguchi I, Osada T, Arai N, Takahashi S. Differences in oral anticoagulant prescriptions between specialists and non-specialists in patients with cardioembolic stroke caused by non-valvular atrial fibrillation. Heart Vessels 2021; 37:867-874. [PMID: 34797401 DOI: 10.1007/s00380-021-01984-y] [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: 06/01/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is a common disease encountered in daily practice; however, few patients with AF received oral anticoagulant (OAC) therapy. This study focused on differences in OAC prescriptions and influencing factors between specialists (neurological and cardiovascular) and non-specialists. A retrospective comparative analysis was conducted on 480 patients with acute cardioembolic stroke caused by non-valvular AF who were admitted to our hospital between January 1, 2015, and December 31, 2020. All patients had visited our hospital or other hospitals for their underlying diseases. Overall, 232 (specialist group SG) and 248 patients (non-specialist group NSG) were examined by specialists and non-specialists, respectively. The NSG had a significantly lower percentage of OAC prescriptions on admission than the SG (P < 0.01), even after propensity score matching. Factors influencing OAC prescription in the SG were age, hypertension, paroxysmal AF, dementia, CHADS2 score, and antiplatelet drug use, while those in the NSG were a history of cerebral infarction, paroxysmal AF, dementia, and antiplatelet drug use [SG: age, odds ratio (OR) 0.919, 95% confidence interval (CI) 0.865-0.976; hypertension, OR 0.266, 95% CI 0.099-0.713; paroxysmal AF, OR 0.189, 95% CI 0.055-0.658; dementia, OR 0.253, 95% CI 0.085-0.758; CHADS2 score, OR 2.833, 95% CI 1.682-4.942; and antiplatelet drug use, OR 0.072, 95% CI 0.025-0.206; NSG: cerebral infarction, OR 5.940, 95% CI 1.581-22.309; paroxysmal AF, OR 0.077, 95% CI 0.010-0.623; dementia, OR 0.077, 95% CI 0.014-0.438; and antiplatelet drug use, OR 0.024, 95% CI 0.004-0.152]. In conclusion, the OAC prescription rate was higher in patients with non-valvular AF whose family physicians were specialists at the time of cerebral infarction onset. In addition, in the SG, advanced age and hypertension were associated with not prescribing OAC, whereas a higher CHADS2 score was associated with the prescription of OACs. In the NSG, a history of cerebral infarction was associated with the prescription of OACs. Further, paroxysmal AF, antiplatelet drug use, and dementia were associated with non-OAC therapy in both the groups.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
| | - Takashi Osada
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Noriko Arai
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
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Methavigul K, Sairat P, Krittayaphong R. Efficacy of R 2CHA 2DS 2-VA score for predicting thromboembolism in Thai patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2021; 21:540. [PMID: 34772351 PMCID: PMC8588707 DOI: 10.1186/s12872-021-02370-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background There is no data specific to the addition of renal dysfunction and age 50–64 years as risk parameters to the CHA2DS2-VA score, which is known as the R2CHA2DS2-VA score, among NVAF patients. Accordingly, the aim of this study was to validate the R2CHA2DS2-VA score for predicting thromboembolism in Thai NVAF patients. Methods Thai NVAF patients were prospectively enrolled in a nationwide multicenter registry from 27 hospitals during 2014–2020. Each component of the CHA2DS2-VA and R2CHA2DS2-VA scores was scored and recorded. The main outcomes were thromboembolism, including ischemic stroke, transient ischemic attack (TIA), and/or systemic embolism. The annual incidence rate of thromboembolism among patients in each R2CHA2DS2-VA and CHA2DS2-VA risk score category is shown as hazard ratio (HR) and 95% confidence interval (95% CI). The performance of the R2CHA2DS2-VA and CHA2DS2-VA scores was demonstrated using c-statistics. Net reclassification index was calculated. Calibration plat was used to assess agreement between observed probabilities and predicted probabilities of both scoring system. Results A total of 3402 patients were enrolled during 2014–2020. The average age of patients was 67.38 ± 11.27 years. Of those, 46.9% had renal disease, 30.7% had a history of heart failure, and 17.1% had previous stroke or TIA. The average R2CHA2DS2-VA and CHA2DS2-VA scores were 3.92 ± 1.92 and 2.98 ± 1.43, respectively. Annual thromboembolic risk increased with incremental increase in R2CHA2DS2-VA and CHA2DS2-VA scores. Oral anticoagulants had benefit in stroke prevention in NVAF patients with an R2CHA2DS2-VA score of 2 or more (adjusted HR: 0.630, 95% CI 0.413–0.962, p = 0.032). The c-statistics were 0.630 (95% CI 0.61–0.65) and 0.627 (95% CI 0.61–0.64), for R2CHA2DS2-VA and CHA2DS2-VA scores respectively. NRI was 2.2%. The slope and R2 of the calibration plot were 0.73 and 0.905 for R2CHA2DS2-VA and 0.70 and 0.846 for CHA2DS2-VA score respectively. Conclusions R2CHA2DS2-VA score was found to be at least as good as CHA2DS2-VA score for predicting thromboembolism in Thai patients with NVAF. Similar to CHA2DS2-VA score, thromboembolism increased with incremental increase in R2CHA2DS2-VA score.
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Affiliation(s)
- Komsing Methavigul
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Zhu Z, Shen Z, Shi A, Su C, Mao J, Tao H, Xu F, Hu Z, Pan J. Dabigatran plasma concentration indicated the risk of patients with non-valvular atrial fibrillation. Heart Vessels 2021. [PMID: 34694442 DOI: 10.1007/s00380-021-01974-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
This study aimed to evaluate the variability of dabigatran plasma concentration and the association with clinical events in Chinese patients treated with dabigatran etexilate (DE) for non-valvular atrial fibrillation (NVAF). The steady-state concentration of dabigatran (the active metabolite of DE) was determined at trough and peak. The effect of dabigatran concentration variability and related factors on clinical outcomes were explored. Data from 86 patients receiving a fixed dose of 110 mg showed that dabigatran trough concentration varied remarkably. Age, BMI and history of heart failure were identified as important covariates for dabigatran trough concentration. Dabigatran trough concentration (P = 0.002) and history of hypertension (P = 0.012) scores were identified as key factors for predicting the risk of bleeding events. Dabigatran trough concentration, affected by Age, BMI and history of heart failure, may serve as an independent risk factor for bleeding events in Chinese patients treated with DE for NVAF.
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Chen J, Zhou M, Wang H, Zheng Z, Rong W, He B, Zhao L. Risk factors for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA 2DS 2-VASc score. J Thromb Thrombolysis 2021. [PMID: 34476733 DOI: 10.1007/s11239-021-02554-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Risk factors of left atrial thrombus (LAT) or spontaneous echo contrast (LASEC) in non-valvular atrial fibrillation (NVAF) had been reported. However, information in the subgroup of NVAF patients with low CHA2DS2-VASc scores was limited. Here, we evaluated the risk factors of LAT/LASEC in NVAF patients with low CHA2DS2-VASc scores. METHODS Transesophageal echocardiography (TEE) file of NVAF patients with low CHA2DS2-VASc scores was reviewed (between June 2009 and Feb 2019) in this retrospective observational study. Binary logistic regression analysis was performed to identify risk factors other than the CHA2DS2-VASc score. Propensity score matching (PSM) was used to further evaluate independent risk markers for LAT/LASEC. The newly discovered factors were added to the CHA2DS2-VASc score, and receiver operating characteristic analysis was used to evaluate the ability of the model to predict LAT/LASEC. RESULTS TEE files of 3056 NVAF patients with low CHA2DS2-VASc scores were reviewed. Regression analysis revealed elevated fibrinogen and enlarged left atrium (LA) were risk factors for LAT/LASEC. Further PSM analysis confirmed that elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC. After including fibrinogen and left atrial diameter (LAD), the CHA2DS2-VASc score was more accurate for LAT/LASEC prediction in NVAF patients with low CHA2DS2-VASc scores (area under the curve difference is 0.241, 95% confidence interval (CI) 0.188-0.294, Z = 8.890, P < 0.0001). CONCLUSIONS Elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC in NVAF patients with low CHA2DS2-VASc scores. Taking fibrinogen and LAD into consideration may help improve LAT/LASEC risk evaluation, which warrants further validation studies.
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Waranugraha Y, Rizal A, Syaban MFR, Faratisha IFD, Erwan NE, Yunita KC. Direct comparison of non-vitamin K antagonist oral anticoagulant versus warfarin for stroke prevention in non-valvular atrial fibrillation: a systematic review and meta-analysis of real-world evidences. Egypt Heart J 2021; 73:70. [PMID: 34379219 PMCID: PMC8357866 DOI: 10.1186/s43044-021-00194-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 02/24/2021] [Accepted: 07/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background To overcome the several drawbacks of warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) were developed. Even though randomized controlled trials (RCTs) provided high-quality evidence, the real-world evidence is still needed. This systematic review and meta-analysis proposed to measure the safety and efficacy profile between warfarin and NOACs in non-valvular atrial fibrillation (NVAF) patients in preventing stroke. Results We collected articles about the real-world studies comparing warfarin and NOACs for NVAF patients recorded in electronic scientific databases such as Embase, ProQuest, PubMed, and Cochrane. The pooled hazard ratio (HR) and 95% confidence interval (CI) were estimated using the generic inverse variance method. A total of 34 real-world studies, including 2287288 NVAF patients, were involved in this study. NOACs effectively reduced the stroke risk than warfarin (HR 0.77; 95% CI 0.69 to 0.87; p < 0.01). Moreover, NOACs effectively lowered all-cause mortality risk (HR 0.71; 95% CI 0.63 to 0.81; p < 0.01). From the safety aspect, compared to warfarin, NOACs significantly reduced major bleeding risk (HR 0.68; 95% CI 0.54 to 0.86; p < 0.01) and intracranial bleeding risk (HR 0.54; 95% CI 0.42 to 0.70; p < 0.01). However, NOACs administration failed to decrease gastrointestinal bleeding risk (HR 0.78; 95% CI 0.58 to 1.06; p = 0.12). Conclusions In NVAF patients, NOACs were found to be more effective than warfarin at reducing stroke risk. NOACSs also lowered the risk of all-cause mortality, cerebral hemorrhage, and severe bleeding in NVAF patients compared to warfarin. Supplementary Information The online version contains supplementary material available at 10.1186/s43044-021-00194-1.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
| | - Ardian Rizal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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Tokuda K, Yamada Y, Uchida K, Sakakibara F, Sakai N, Imamura H, Yamagami H, Tanaka K, Ezura M, Nonaka T, Matsumoto Y, Shibata M, Ohta H, Morimoto M, Fukawa N, Hatano T, Enomoto Y, Takeuchi M, Ota T, Shimizu F, Kimura N, Kamiya Y, Shimamura N, Morimoto T, Yoshimura S. Effect of prior antiplatelet therapy on large vessel occlusion in patients with non-valvular atrial fibrillation newly initiated on apixaban. J Neurol Sci 2021; 428:117603. [PMID: 34384970 DOI: 10.1016/j.jns.2021.117603] [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: 05/15/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We evaluated the effect of prior antiplatelet therapy on large vessel occlusion (LVO) in patients with non-valvular atrial fibrillation (NVAF) newly initiated on apixaban. METHODS Patients with acute LVO with acute stroke due to NVAF or stenosis with NVAF started on apixaban within 14 days of onset were enrolled. We compared incidence of major bleeding, cerebral hemorrhage, ischemic events, cerebral infarction, and all-cause mortality between patients with and without prior antiplatelet therapy for acute LVO. We also compared these events between patients who continued antiplatelet therapy after onset (continued group) and those who discontinued it (discontinued group). Hazard ratios were estimated after adjusting for confounders; interaction was evaluated considering intravenous thrombolysis (IVT) or endovascular treatment (EVT) according to major bleeding. RESULTS The study comprised 686 eligible patients (excluded [n = 194]; enrolled [n = 492]). The antiplatelet group consisted of older patients (mean: 79 vs. 76 years; p = 0.006) and had a higher cumulative incidence of major bleeding (7.3% vs. 2.9%, p = 0.003). The incidence of ischemic events and all-cause mortality was similar between the groups. Among the 109 patients in the antiplatelet group, the cumulative incidence of major bleeding, ischemic events, and all-cause mortality was comparable between continued group (n = 26) and discontinued group (n = 83). There were no significant differences between groups with and without IVT/EVT. However, major bleeding occured more frequently in the antiplatelet group without IVT. CONCLUSION Prior antiplatelet therapy for LVO in patients with NVAF newly initiated on apixaban was associated with major bleeding, which was more frequent in the antiplatelet group without IVT.
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Affiliation(s)
- Kou Tokuda
- Department of Neurosurgery, Nishinomiya Kyoritsu Hospital, Nishinomiya, Japan
| | - Yoshitaka Yamada
- Department of Neurosurgery, Nishinomiya Kyoritsu Hospital, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Tadashi Nonaka
- Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Miyagi, Japan
| | | | - Hajime Ohta
- Department of Neurosurgery, Division of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Norihito Fukawa
- Department of Neurosurgery, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | | | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Norito Shimamura
- Department of Neurosurgery, Hirosaki University Hospital, Hirosaki, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
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Cheng X, Liu L, Li L, Zhao H, Li J, Shi J, Zhang W. Significance of CHA 2DS 2-VAS C on the severity and hemorrhagic transformation in patients with non-valvular atrial fibrillation-induced acute ischemic stroke. Intern Emerg Med 2021; 16:1155-1163. [PMID: 33386603 DOI: 10.1007/s11739-020-02558-y] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022]
Abstract
Atrial fibrillation causes a fivefold increase of stroke risk. CHA2DS2-VASC is widely used to evaluate the risk of cardiac embolism in patients with non-valvular atrial fibrillation (NVAF) and identify the patients eligible for anticoagulation therapy. This study aimed to identify the significance of CHA2DS2-VASC score on the severity and hemorrhagic transformation (HT) in patients with NVAF-induced acute ischemic stroke (NVAF-AIS). Total 113 patients diagnosed as NVAF-AIS were included in this study. Patients were categorized into severe stroke group (NIHSS > 10) and non-severe group (NIHSS ≤ 10), and the risk factors for severe stroke were investigated. Based on the results of repeated brain CT/MRI examination performed within 14 days from stroke onset or immediately in case of clinical worsening, patients were divided into HT group and non-HT group, and the predictors for HT were then analyzed. CHA2DS2-VASC score [median (interquartile range) 5 (3-5) vs. 3 (2-4); p = 0.002] in severe stroke group was significantly higher than that in non-severe group. The severe stroke group showed significantly increased prevalence of heart failure (20% vs. 48.5%, p = 0.002) and decreased hemoglobin (136.4 ± 18.0 vs.143.6 ± 15.6 g/L, p = 0.031) compared with non-severe group. Multivariate regression analysis revealed that CHA2DS2-VASc score was a powerful predictor for the severity of NVAF-AIS. Forty-seven of total recruited patients (43.2%) developed HT within 14 days after the onset of NVAF-AIS. CHA2DS2-VASc score as well as elevated glycated hemoglobin and intravenous rt-PA were the independent risk factors of HT. CHA2DS2-VASC score was closely associated with the severity of NVAF-AIS. Patients with higher CHA2DS2-VASC score were more likely to develop HT after NVAF-AIS.
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Affiliation(s)
- Xiaoling Cheng
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Liu
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lixia Li
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Zhao
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Li
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxin Shi
- Department of Internal Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Kusano K, Sugishita N, Akao M, Tsuji H, Matsui K, Hiramitsu S, Hatori Y, Odakura H, Kamada H, Miyamoto K, Ogawa H. Effectiveness and Safety of Rivaroxaban by General Practitioners - A Multicenter, Prospective Study in Japanese Patients With Non-Valvular Atrial Fibrillation (GENERAL). Circ J 2021; 85:1275-1282. [PMID: 33814525 DOI: 10.1253/circj.cj-20-1244] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Direct oral anticoagulants have become a standard therapy for non-valvular atrial fibrillation (NVAF). However, little is known about their effectiveness/safety when prescribed by general practitioners to treat high-risk populations such as the elderly, those who are frail or have cognitive dysfunction.Methods and Results:In this multicenter, prospective study, a total of 5,717 NVAF patients (mean age 73.9 years) receiving rivaroxaban were registered by general practitioners, with a maximum 3-year follow up (mean 2.0±0.5 years). The primary endpoint was a composite of stroke and systemic embolism (SE). The annual incidence (per 100 person-years) of stroke/SE was 1.23% and for major bleeding, it was 0.63%. Multivariate analyses identified age ≥75 years (hazard ratio [HR]; 2.67, P<0.001) and history of ischemic stroke (HR; 1.89, P=0.005) as significant risk factors of stroke/SE, with history of major bleeding (HR; 14.9, P<0.001) and warfarin use (HR; 2.15, P=0.002) as risk factors for major bleeding events. Neither cognitive dysfunction, defined by the receipt of anti-dementia medications, nor frailty, evaluated by the classification of the Japanese Long-term Care Insurance system, correlated with stroke/SE or major bleeding events. CONCLUSIONS The low incidence of adverse events, including stroke/SE and bleeding, in patients prescribed rivaroxaban by general practitioners supports its use as a safe and efficacious treatment in the standard clinical care of high-risk patient populations.
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Affiliation(s)
- Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | | | | | | | | | - Hiroyuki Kamada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Shinohara T, Takahashi N, Mukai Y, Kimura T, Yamaguchi K, Takita A, Origasa H, Okumura K. Catheter Ablation Energy Sources and Myocardial Injury and Coagulation Biomarkers During Uninterrupted Periprocedural Edoxaban Use - A Subanalysis of KYU-RABLE. Circ J 2021; 86:280-286. [PMID: 34275977 DOI: 10.1253/circj.cj-21-0247] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The effects of catheter ablation (CA) energy sources on myocardial injury and coagulation biomarkers among Japanese non-valvular atrial fibrillation patients receiving uninterrupted periprocedural edoxaban are unclear. This KYU-RABLE exploratory subanalysis compared the effects of CA using radiofrequency energy vs. cryoballoon on: (1) myocardial injury; and (2) plasma edoxaban and coagulation biomarker concentrations measured before and after CA.Methods and Results:Plasma creatine kinase (CK), edoxaban, D-dimer, and prothrombin fragment 1+2 (F1+2) concentrations within 1 h before CA were compared with concentrations the day after. All biomarkers increased after CA, regardless of the energy source, but especially with cryoballoon. Significantly higher increases in CK concentrations from before to the day after CA were seen with cryoballoon compared with radiofrequency energy (P<0.0001). Edoxaban concentrations were similar in both groups. Concentrations of D-dimer and F1+2 increased in both groups, but were significantly higher in the cryoballoon group (P<0.0001 and P=0.006, respectively). There were no significant between-group differences in the incidence of thrombotic or bleeding events. CONCLUSIONS Uninterrupted edoxaban concentrations were similar in both groups. Both myocardial injury and coagulation biomarkers increased after CA, especially with cryoballoon, but there was no difference in the incidence of thrombotic or bleeding events. These findings suggest the efficacy of uninterrupted edoxaban, regardless of the CA energy source. Periprocedural anticoagulation, particularly with cryoballoon, should be undertaken with care.
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Affiliation(s)
- Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Oita University Faculty of Medicine
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Oita University Faculty of Medicine
| | - Yasushi Mukai
- Cardiology Division, Japanese Red Cross Fukuoka Hospital
| | | | | | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
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Matsunaga M, Chen JJ, Jijiwa M, Lim E. The impact of diabetes and osteoarthritis on the occurrence of stroke, acute myocardial infarction, and heart failure among older adults with non-valvular atrial fibrillation in Hawaii: a retrospective observational cohort study. BMC Public Health 2021; 21:1183. [PMID: 34154554 PMCID: PMC8218453 DOI: 10.1186/s12889-021-11247-0] [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] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/31/2021] [Indexed: 01/31/2023] Open
Abstract
Background To date, little is known about cardiovascular disease risks among older adults with non-valvular atrial fibrillation by their association with diabetes and osteoarthritis status, based on longitudinal data with substantial amounts of non-white individuals. The objective of this study was to examine the risks for three cardiovascular diseases: stroke, acute myocardial infarction (AMI), and heart failure (HF), by diabetes and osteoarthritis status among older adults with non-valvular atrial fibrillation in Hawaii. Methods We conducted a retrospective observational cohort study for older adults (65 years and older) with non-valvular atrial fibrillation using the Hawaii Medicare data 2009–2017. Their risks for the three cardiovascular diseases by diabetes and osteoarthritis status (diabetes, osteoarthritis, diabetes and osteoarthritis, and without diabetes and osteoarthritis) were examined by multivariable Cox proportional hazard regression models. Results The analysis included 19,588 beneficiaries followed up for a maximum of 3288 days (diabetes: n = 4659, osteoarthritis: n = 1978, diabetes and osteoarthritis: n = 1230, without diabetes and osteoarthritis: n = 11,721). Among them, those diagnosed with the cardiovascular diseases were identified (stroke: diabetes n = 837, osteoarthritis n = 315, diabetes and osteoarthritis n = 184, without diabetes and osteoarthritis n = 1630)(AMI: diabetes n = 438, osteoarthritis n = 128, diabetes and osteoarthritis n = 118, without diabetes and osteoarthritis n = 603)(HF: diabetes n = 2254, osteoarthritis n = 764, diabetes and osteoarthritis n = 581, without diabetes and osteoarthritis n = 4272). After adjusting for age, sex, race/ethnicity, and other potential confounders, those with diabetes and osteoarthritis had higher risks for HF (hazard ratio: 1.21 95% confidence interval: 1.10–1.33) than those without diabetes and osteoarthritis. They also had higher risks than those with osteoarthritis for HF. Those with diabetes had higher risks for all three cardiovascular diseases than the other three groups. Conclusions Variation in cardiovascular disease risks for older adults with non-valvular atrial fibrillation in Hawaii exists with diabetes and osteoarthritis status. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11247-0.
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Affiliation(s)
- Masako Matsunaga
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA.
| | - John J Chen
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Mayumi Jijiwa
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Eunjung Lim
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
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Zhou G, Wang H, Zhang X, Yu L, Yao F, Li B, Fang Q. Cerebral arteriosclerosis stenosis predicts poor short-term prognosis in non-valvular atrial fibrillation related cardioembolic stroke treated by reperfusion therapy. Clin Neurol Neurosurg 2021; 207:106738. [PMID: 34147840 DOI: 10.1016/j.clineuro.2021.106738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the association between cerebral arteriosclerosis stenosis (CAS) and the short-term prognosis of non-valvular atrial fibrillation (NVAF) related cardioembolic stroke treated by reperfusion therapy. METHODS The data of 195 consecutive NVAF related cardioembolic stroke patients were retrospectively collected. We defined poor functional outcome as a modified Rankin scale (mRS) score of > 2 at 90 days. RESULTS Patients with CAS were more likely to be older (75.5 ± 6.8 vs. 72.5 ± 9.2 years, p = 0.001), more current smokers (35.6% vs. 24.1%, p = 0.018), with hypertension (88.1% vs. 65.6%, p < 0.001), diabetes mellitus (50.0% vs. 20.0%, p = 0.020), dyslipidemia (33.9% vs. 23.6%, p = 0.029), previous history of stroke (30.5% vs. 19.5%, p = 0.012), and congestive heart failure (32.2% vs. 22.6%, p = 0.041). Patients with CAS had higher National Institutes of Health Stroke Scale (NIHSS) (18 [13, 22] vs. 15 [9, 19], p < 0.001), and 90-day mRS scores (5 [3, 6] vs. 3[2, 5], p < 0.001). Multivariate logistic regression analysis showed that CAS (odds ratio [OR] 3.184, 95% confidence interval [CI] 1.314-7.713, p = 0.01), NIHSS score on admission (OR 1.228 [per 1 point], 95% CI 1.146-1.316, p < 0.001), congestive heart failure (OR 2.850, 95% CI 1.108-7.331, p = 0.030), and current smokers (OR 2.841, 95% CI 1.102-7.326, p = 0.031) were independent predictors of a poor functional outcome at 90 days. CONCLUSION We should give the coexistence of CAS and NVAF related cardioembolic stroke proper attention. CAS was an independent factor for predicting the short-term prognosis of NVAF associated cardioembolic stroke patients treated by reperfusion therapy.
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Berger JS, Laliberté F, Kharat A, Lejeune D, Moore KT, Jung Y, Lefebvre P, Ashton V. Real-world effectiveness and safety of rivaroxaban versus warfarin among non-valvular atrial fibrillation patients with obesity in a US population. Curr Med Res Opin 2021; 37:881-890. [PMID: 33733969 DOI: 10.1080/03007995.2021.1901223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Current evidence indicates that the pharmacokinetic profile of rivaroxaban is not significantly impacted by body weight. However, real-world data are needed to better assess the potential clinical benefits and risks associated with rivaroxaban in non-valvular atrial fibrillation (NVAF) patients with obesity. Thus, our objectives were to assess the real-world effectiveness and safety of rivaroxaban versus warfarin among NVAF patients with obesity in the US nationally representative commercially-insured population. METHODS Health insurance claims data from the IQVIA PharMetrics Plus database (January 2010-September 2019) were used to identify NVAF patients with obesity (based on diagnosis codes) initiated on rivaroxaban or warfarin. Inverse probability of treatment weighting (IPTW) was used to adjust for imbalances between groups. Study outcomes of interest were evaluated up to 36 months post-treatment initiation and included the composite of stroke or systemic embolism (stroke/SE) and major bleeding. Outcomes were compared using Cox proportional hazards regression models with hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS A total of 10,555 patients were initiated on rivaroxaban and 5080 patients on warfarin. Following IPTW, the risk of stroke/SE was 26% lower among patients prescribed rivaroxaban relative to warfarin (HR: 0.74, 95% CI: 0.60, 0.91, p = .004) at 36 months. Rivaroxaban-initiated patients had a risk of major bleeding similar to that of warfarin-initiated patients (HR: 0.85, 95% CI: 0.71, 1.02, p = .085). CONCLUSIONS These results suggest that rivaroxaban is an effective and safe treatment option among NVAF patients with obesity in a commercially-insured US population.
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Affiliation(s)
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Al-Abcha A, Saleh Y, Elsayed M, Elshafie A, Herzallah K, Baloch ZQ, Banga S, Rayamajhi S, Abela GS. Left atrial appendage closure versus oral anticoagulation in non-valvular atrial fibrillation; a systemic review and meta-analysis. Cardiovasc Revasc Med 2021; 36:18-24. [PMID: 33903038 DOI: 10.1016/j.carrev.2021.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 03/16/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) devices are an alternative therapy in non-valvular atrial fibrillation (NVAF) patients with contraindications to oral anticoagulation (OAC). However, there are limited data about the clinical outcomes of LAAC devices compared to medical treatment. METHODS A comprehensive research for studies comparing LAAC devices and OAC for patients with NVAF was performed from inception to January 1, 2021. A meta-analysis was performed using a random effect model to calculate odds ratios (OR) with 95% confidence intervals (CIs). RESULTS Five studies were eligible that included a total of 4778 patients with a median-weighted follow-up period was 2.6 years. Compared to OAC, the LAAC device arm was associated with a lower risk of the composite of stroke, systematic embolism, and cardiovascular death (OR 0.71; 95% CI 0.51-1.00; p = 0.05). LAAC device arm was also associated with a lower risk of all-cause mortality (OR of 0.60, 95% CI 0.46-0.77; p < 0.0001), cardiovascular mortality (OR of 0.57, 95% CI 0.46-0.70; p < 0.00001), hemorrhagic stroke (OR of 0.19, 95% CI 0.07-0.50; p= 0.0006), all major bleeding (OR of 0.61, 95% CI 0.43-0.88; p = 0.007) and non-procedural major bleeding (OR of 0.46, 95% CI 0.32-0.65; p < 0.0001). There was no significant difference in all stroke, ischemic stroke, and systematic embolization between the two groups. CONCLUSIONS Our meta-analysis showed lower all-cause mortality, cardiovascular mortality, hemorrhagic stroke, major bleeding, non-procedural major bleeding and the composite of stroke, systematic embolism, and cardiovascular death in the LAAC device arm when compared to OAC. However, the risk of all stroke, ischemic stroke, and systematic embolism were similar between the two arms.
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Affiliation(s)
- Abdullah Al-Abcha
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA.
| | - Yehia Saleh
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Mahmoud Elsayed
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Ahmed Elshafie
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | | | | | - Sandeep Banga
- Department of Cardiology, Michigan State University, East Lansing, MI, USA
| | - Supratik Rayamajhi
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - George S Abela
- Department of Cardiology, Michigan State University, East Lansing, MI, USA
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Atarashi H, Uchiyama S, Inoue H, Kitazono T, Yamashita T, Shimizu W, Ikeda T, Kamouchi M, Kaikita K, Fukuda K, Origasa H, Shimokawa H. Ischemic stroke, hemorrhage, and mortality in patients with non-valvular atrial fibrillation and renal dysfunction treated with rivaroxaban: sub-analysis of the EXPAND study. Heart Vessels 2021; 36:1410-1420. [PMID: 33728513 PMCID: PMC8332581 DOI: 10.1007/s00380-021-01810-5] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
The EXPAND Study demonstrated the effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) in routine clinical practice in Japan. This sub-analysis was conducted to reveal the effectiveness and safety of rivaroxaban in Japanese NVAF patients according to baseline creatinine clearance (CrCl) levels and rivaroxaban doses in the EXPAND Study. We examined 6806 patients whose baseline CrCl data were available and classified them into 2 groups: normal renal function group with CrCl ≥ 50 mL/min (n = 5326, 78%) and renal dysfunction group with CrCl < 50 mL/min (n = 1480, 22%). In the normal renal function group, 1609 (30%) received 10 mg/day (under-dose), while in the renal dysfunction group, 108 (7%) received 15 mg/day (over-dose). In the normal renal function group, under-dose of rivaroxaban was associated with higher all-cause mortality, while in the renal dysfunction group, over-dose was associated with higher incidence of major bleeding. In contrast, the incidence of stroke or systemic embolism was not different between the 2 groups regardless of the dose of rivaroxaban. In the propensity score matched analysis to adjust the difference in characteristics according to doses of rivaroxaban, the incidences of clinical outcomes were comparable between the 2 dose groups in both renal function groups. These results indicate that the dose of rivaroxaban should be reduced depending on the renal function, considering the balance between risks of bleeding and ischemia.
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Affiliation(s)
- Hirotsugu Atarashi
- Minamihachioji Hospital, Koyasu-cho 3-18-12, Hachioji, Tokyo, 192-0904, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Akasaka 8-5-35, Minato-ku, Tokyo, 107-0052, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, Kusunoki 33-1, Toyama, 931-8533, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Yamashita
- Cardiovascular Institute Hospital, Nishiazabu 3-2-19, Minato-Ku, Tokyo, 106-0031, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Sendagi 1-1-5, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Omorinishi 5-21-16, Ota-ku, Tokyo, 143-8540, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Center for Cohort Study, Kyushu University Graduate School of Medical Sciences, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 2-39-1, Kurokami Chuo-ku, Kumamoto, 860-8555, Japan
| | - Koji Fukuda
- Division of Heart Rhythm, International University of Health and Welfare Hospital, Iguchi 537-3, Nasushiobara, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine, Sugitani 2630, Toyama, 930-0194, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryomachi 1-1, Aoba-ku, Sendai, 980-8574, Japan. .,International University of Health and Welfare, Kozunomori 4-3, Narita, 286-8686, Japan.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine the safety and effectiveness of direct oral anticoagulants and provide recommendations for the treatment of venous thromboembolism and atrial fibrillation in obese patients, elderly patients, and patients with chronic kidney disease. RECENT FINDINGS Multiple retrospective cohort studies have shown no difference in bleeding, stroke, or venous thromboembolism outcomes between DOACs and warfarin in patients who are obese, elderly, or those with chronic kidney disease or on dialysis. Some studies have shown that DOACs have a lower bleeding risk than warfarin in these populations. DOACs may be a safe and effective alternative to warfarin for the prevention of stroke in atrial fibrillation patients who are obese, elderly, or those with chronic kidney disease or on dialysis. Apixaban may improve clinical outcomes by lowering the risk of bleeding versus warfarin. DOACs may also be an effective and safe alternative to warfarin for the treatment of venous thromboembolism in obese patients; however, additional studies are needed to assess their use in elderly patients and those with CKD.
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Kalaria SN, Zhu H, Liu Q, Florian J, Wang Y, Schwartz J. Influence of age on the relationship between apixaban concentration and anti-factor Xa activity in older patients with non-valvular atrial fibrillation. Int J Cardiol 2021; 331:109-113. [PMID: 33529664 DOI: 10.1016/j.ijcard.2021.01.025] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/29/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Despite lower major bleeding rates associated with direct oral anticoagulants (DOACs) as compared to conventional warfarin therapy, bleeding rates remain higher in older patients compared to younger patients suggesting a potential role for DOAC measurements. The objective of this study is to examine the effect of age on the relationship between apixaban concentrations and anti-Factor Xa activity in patients with non-valvular atrial fibrillation (NVAF). METHODS This is a retrospective analysis based on a database created using data from the ARISTOTLE study. Outpatient, stable adult patients with NVAF receiving apixaban were included in this study. Data collection consisted of apixaban concentration, anti-Factor Xa activity, age, weight, creatinine, and co-medications. RESULTS The database composed of 2058 patients receiving apixaban. Distribution of race, NVAF subtype, and aspirin use was fairly similar across each age quantile. Older patients received a higher number of co-medications and received the 2.5 mg apixaban dose more often as compared to younger patients (22% vs. < 1%). Linear regression demonstrated that the unadjusted slope for apixaban concentration effect on anti-Factor Xa activity was similar across each age quantile. Although, the overall adjusted linear regression analysis demonstrated that the age by concentration interaction was statistically significant, relative differences in anti-Factor Xa activity (< 8%) were not clinically meaningful. CONCLUSION Data on apixaban concentrations and anti-Factor Xa activity from a pivotal randomized double-blind study of apixaban for the prevention of stroke in NVAF patients have confirmed that the chromogenic anti-Factor Xa activity assay can accurately assess apixaban concentrations in patients regardless of age. Age was not associated with a clinically relevant change in the apixaban vs. anti-Factor Xa activity response relationship and target ranges are unchanged.
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Affiliation(s)
- Shamir N Kalaria
- Center for Translational Medicine, University of Maryland, School of Pharmacy, Baltimore, MD, United States of America
| | - Hao Zhu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Qi Liu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Jeffrey Florian
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Yaning Wang
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Janice Schwartz
- Department of Medicine, University of California San Francisco, School of Medicine, San Francisco, CA, United States of America.
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Sonaglioni A, Lombardo M, Nicolosi GL, Rigamonti E, Anzà C. Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion. Int J Cardiovasc Imaging 2021; 37:1539-1550. [PMID: 33389359 PMCID: PMC7778706 DOI: 10.1007/s10554-020-02127-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/30/2020] [Indexed: 01/18/2023]
Abstract
During the COVID-19 pandemic, transesophageal echocardiography (TEE) for left atrial appendage thrombosis (LAAT) detection should be limited to situations of absolute necessity. We sought to identify the main conventional and functional echocardiographic parameters associated with LAAT on TEE in non-valvular atrial fibrillation (NVAF) patients planned for electrical cardioversion (ECV). This retrospective study included 125 consecutive NVAF patients (71.5±7.8 yrs, 75 males), who underwent TEE at our Institution between April 2016 and January 2020, to exclude LAAT before scheduled ECV. All patients underwent a transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) analysis of left atrial (LA) strain and strain rate (SR) parameters. 28% of patients were diagnosed with LAAT, while 72% without LAAT. Compared to controls, patients with LAAT had significantly higher CHA2DS2-Vasc Score and average E/e’ ratio, and significantly lower left ventricular ejection fraction (LVEF). Moreover, LA-peak positive global atrial strain (GSA+) and LA-SR parameters were significantly reduced in patients with LAAT. Multivariate logistic regression revealed that, differently from CHA2DS2-Vasc Score, LVEF (OR 0.88, 95%CI 0.81–0.97, p = 0.01), average E/e’ ratio (OR 2.36, 95%CI 1.41–3.98, p = 0.001), and LA-GSA+ (OR 0.57, 95%CI 0.36-0-90, p = 0.01) were independently associated with LAAT. LA-GSA+ (optimal cut-off ≤ 9.1%, AUC 0.95) showed the highest diagnostic performance. Finally, a strong linear correlation of LA peak-to-peak SR with both LA appendage filling (r = 0.86) and emptying (r = 0.83) velocities was demonstrated. TTE implemented with STE analysis of LA mechanics improves thrombotic risk assessment of NVAF patients.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | | | - Elisabetta Rigamonti
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Claudio Anzà
- Cardiovascular Department, MultiMedica IRCCS, Via Milanese 300, 20099, Sesto San Giovanni (MI), Italy
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Berger JS, Laliberté F, Kharat A, Lejeune D, Moore KT, Jung Y, Lefebvre P, Ashton V. Healthcare resource utilization and costs of rivaroxaban versus warfarin among non-valvular atrial fibrillation (NVAF) patients with obesity in a US population. J Med Econ 2021; 24:550-562. [PMID: 33910464 DOI: 10.1080/13696998.2021.1915627] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM To assess the real-world healthcare resource utilization (HRU) and costs of patients with non-valvular atrial fibrillation (NVAF) and obesity newly initiated on rivaroxaban or warfarin in the US. METHODS This retrospective study used IQVIA PharMetrics Plus data (01/2010-09/2019) to evaluate patients (≥18 years) with NVAF and obesity (body mass index ≥30 kg/m2) initiated on rivaroxaban or warfarin (on or after 01/2013). Inverse probability of treatment weighting (IPTW) was used to adjust for confounding between cohorts. HRU and costs were assessed post-treatment initiation. Weighted cohorts were compared using Poisson regression models and cost differences, with 95% confidence intervals (CIs) and p values generated using non-parametric bootstrap procedures. RESULTS After IPTW, 10,555 and 5,080 patients were initiated on rivaroxaban and warfarin, respectively (mean age: 59 years). At 12 months follow-up, the rivaroxaban cohort had lower all-cause HRU, including fewer hospitalizations (rate ratio [RR]: 0.80, 95% CI: 0.74, 0.87), emergency room visits (RR: 0.89, 95% CI: 0.83, 0.97), and outpatient visits (RR: 0.72, 95% CI: 0.69, 0.77; all p < .05). Medical costs were also reduced in the rivaroxaban cohort (mean difference: -$6,759, 95% CI: -$9,814, -$3,311) due to reduced hospitalization costs (mean difference: -$5,967, 95% CI: -$8,721, -$3,327), resulting in lower total all-cause healthcare costs compared to the warfarin cohort (mean difference: -$4,579, 95% CI: -$7,609, -$1,052; all p < .05). The rivaroxaban cohort also had lower NVAF-related HRU and medical costs driven by lower hospitalization at 12 months post-treatment initiation. HRU and cost reductions associated with rivaroxaban persisted up to 36 months of follow-up. LIMITATIONS Claims data may have contained inaccuracies and obesity was classified based on ICD diagnosis codes given that patient BMI values were not available. CONCLUSIONS Rivaroxaban was associated with reduced HRU and costs compared to warfarin among NVAF patients with obesity in a real-world US setting.
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Affiliation(s)
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | | | - Young Jung
- Analysis Group, Inc, Montréal, QC, Canada
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Sussman M, Di Fusco M, Tao CY, Guo JD, Gillespie JA, Ferri M, Adair N, Cato MS, Shirkhorshidian I, Barnes GD. The IMPact of untReated nOn-Valvular atrial fibrillation on short-tErm clinical and economic outcomes in the US Medicare population: the IMPROVE-AF model. J Med Econ 2021; 24:1070-1082. [PMID: 34415229 DOI: 10.1080/13696998.2021.1970954] [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] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite treatment guidelines recommending the use of oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and moderate to high risk of stroke (CHA2DS2-VASc score ≥1), many patients remain untreated. A study conducted among Medicare beneficiaries with AF and a CHA2DS2-VASc score of ≥2 found that 51% of patients were not prescribed an OAC despite being eligible for treatment. When left untreated, NVAF poses an enormous burden to society, as stroke events are estimated to cost the US healthcare system about $34 billion each year in both direct medical costs and indirect productivity losses. This research explored the short-term clinical implications and budget impact (BI) of increasing OAC use among Medicare beneficiaries with NVAF. METHODS A decision-analytic model was developed from the payer and societal perspectives to estimate the impact of increasing treatment rates among Medicare-eligible NVAF patients with a moderate-to-high risk of stroke over 1 year. Results of the model compared (1) a base case scenario using literature-derived rates of OAC use, and (2) a hypothetical scenario assuming an absolute 5% increase in overall OAC use. Clinical outcomes included the incremental annual number of ischemic stroke, hemorrhagic stroke, and gastrointestinal bleeding events, and stroke-related deaths. Economic outcomes included incremental annual and per-member per-month (PMPM) direct medical costs for the payer perspective and the incremental sum of annual direct medical and indirect costs from productivity loss and caregiver burden for the societal perspective. RESULTS In total, 1.95 million Medicare patients with NVAF were estimated to be treated with OACs in the base case (3.8% of beneficiaries). In the hypothetical scenario analysis, nearly 200,000 more patients were treated resulting in 3,705 fewer ischemic strokes, 14 fewer gastrointestinal bleeds, 141 more hemorrhagic strokes, and 175 fewer deaths. The total incremental BI was $399.16 million ($0.65 PMPM) from the payer perspective and $377.10 million from the societal perspective due to indirect cost savings ($22.06 million). CONCLUSION Our findings suggest that increased overall OAC use has a positive clinical benefit on the annual number of ischemic stroke events and deaths avoided in the Medicare population, while maintaining a modest increase in the overall BI to the Medicare system.
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Affiliation(s)
- Matthew Sussman
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | - Manuela Di Fusco
- Health Economics & Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Charles Y Tao
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | - Jennifer D Guo
- Health Economics and Outcomes Research, Bristol Myers Squibb, Lawrence Township, NJ, USA
| | - John A Gillespie
- Health Economics & Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Mauricio Ferri
- Health Economics and Outcomes Research, Bristol Myers Squibb, Lawrence Township, NJ, USA
| | - Nicholas Adair
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | - Matthew S Cato
- Health Economics & Outcomes Research, Pfizer Inc, New York, NY, USA
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50
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Akhtar T, Fratti JDC, Mattumpuram J, Fugar S, Uprety A, Nwaichi C, Torres A, Mann H, Golzar Y. Factors associated with bleeding events in patients on rivaroxaban for non-valvular atrial fibrillation: A real-world experience. Int J Cardiol 2020; 320:78-82. [PMID: 32598991 DOI: 10.1016/j.ijcard.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the treatment of non-valvular atrial fibrillation (NVAF). Data related to the risk factors associated with rivaroxaban-induced bleeding in patients with NVAF remain scarce in the community setting. We sought to investigate these bleeding risk factors in a racially diverse patient population. METHODS We conducted a single-center, retrospective study based on a chart review of patients who received rivaroxaban from our outpatient pharmacy from January 2015 to April 2018 for NVAF. Any reported bleeding event (BE) was recorded as either major or minor bleeding event. Demographic and clinical data were collected and analyzed. RESULTS Of the 327 patients included in our analysis, 105 (32%) were female, and the mean age was 62 ± 12 years. Among the included patients, 176 (54%) patients were black, 71 (22%) were white, 51 (15.6%) were Hispanic, 13 (4%) were Asian, and 15 (4.6%) belonged to other races. 89 (27.2%) of the patients had co-prescription of aspirin. A total of 24 (7.3%) patients developed BE, out of which 9 (2.7%) patients had a major BE, and 15 (4.5%) patients had minor BE. Non-fatal gastrointestinal bleeding and epistaxis were the most common type of BE. On multivariable analysis, concurrent aspirin use (81 to 325 mg) (P = 0.03; odds ratio (OR) 2.60 [1.08-6.28]) and increasing age (P = 0.00; OR 1.06 [1.01-1.11]) were independent predictors of BE. CONCLUSION In community practice, aspirin co-prescription is common among NVAF patients prescribed rivaroxaban. Increasing age and concurrent aspirin use are independent predictors of BE.
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Affiliation(s)
- Tauseef Akhtar
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA.
| | - Juan Del Cid Fratti
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Jishanth Mattumpuram
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Setri Fugar
- Department of Cardiology, Rush University Medical Center, Chicago, USA
| | - Alok Uprety
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Chineme Nwaichi
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Andrea Torres
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Hashim Mann
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| | - Yasmeen Golzar
- Division of Cardiology, John H Stroger Jr Hospital of Cook County, Chicago, USA
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