Antithrombotic Treatments in Patients with Acute Ischemic Stroke and Non-Valvular Atrial Fibrillation Before Introduction of Non-Vitamin K Antagonist Oral Anticoagulants Into Practice in Korea

Background: There are limited data for non-vitamin K antagonist oral anticoagulants (NOACs) impact on outcomes for patients with atrial fibrillation (AF) and valvular heart diseases (VHDs). Methods: We identified patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHDs, and who had been naïve from the oral anticoagulants in the Korean National Health Insurance Service database between 2014 and 2016 (warfarin: n = 2671; NOAC: n = 3058). For analyzing the effect of NOAC on primary prevention, we excluded those with a previous history of ischemic stroke, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding events. To balance covariates, we used the propensity score weighting method. Ischemic stroke, ICH, GI bleeding, major bleeding, all-cause death, and their composite outcome and fatal clinical events were evaluated. Results: During a follow-up with a mean duration of 1.4 years, NOACs were associated with lower risks of ischemic stroke (hazard ratio (HR): 0.71, 95% confidence interval (CI): 0.53–0.96), GI bleeding (HR: 0.50, 95% CI: 0.35–0.72), fatal ICH (HR: 0.28, 95% CI: 0.07–0.83), and major bleeding (HR: 0.61, 95% CI: 0.45–0.80) compared with warfarin. Overall, NOACs were associated with a lower risk of the composite outcome (HR: 0.68, 95% CI: 0.58–0.80). Conclusions: In this nationwide Asian AF population with EHRA type 2 VHDs, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin use.

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Bleeding and thromboembolism due to drug-drug interactions with non-vitamin K antagonist oral anticoagulants—a Swedish, register-based cohort study in atrial fibrillation outpatients

European Journal of Clinical Pharmacology ◽

10.1007/s00228-020-03015-7 ◽

2020 ◽

Author(s):

Johan Holm ◽

Buster Mannheimer ◽

Rickard E Malmström ◽

Erik Eliasson ◽

Jonatan D Lindh

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Ischemic Stroke ◽

Vitamin K ◽

Cox Regression ◽

Oral Anticoagulants ◽

Outcome Data ◽

Vitamin K Antagonist ◽

Drug Register ◽

Increased Risk

Abstract Purpose To study the association between interacting drugs and bleeding or thromboembolism in atrial fibrillation outpatients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Population-based cohort study of outpatients treated with NOACs in Sweden from 2008 to 2017. Patients with atrial fibrillation and newly initiated NOAC treatment were identified in the Prescribed Drug Register. Comorbidities and outcome data were retrieved from the Patient Register and the Cause of Death Register. Cox-regression analyses were performed to evaluate the primary endpoints any severe bleed and ischemic stroke/transient ischemic attack/stroke unspecified during the first six months of treatment. Secondary endpoints were gastrointestinal bleeding, intracranial bleeding, ischemic stroke, and venous thromboembolism. Results Increased risk of any severe bleed was found when NOAC treatment, and drugs with pharmacodynamic effect on bleeding were combined, compared to NOAC only. An increased risk with these combinations was evident for apixaban (hazard ratio (HR) 1.47; 95% CI 1.33–1.63), rivaroxaban (HR 1.7; 95% CI 1.49–1.92), and dabigatran (HR 1.26; 95% CI 1.05–1.52). For apixaban, there was an increased risk of any severe bleed when combined with CYP3A4 and/or P-glycoprotein (P-gp) inhibitors (HR 1.23; 95% CI 1.01–1.5). The use of inducers of CYP3A4 and/or P-gp was low in this cohort, and effects on ischemic stroke/TIA/stroke unspecified could not be established. Conclusion Increased risk of bleeding was seen for pharmacodynamic and pharmacokinetic interactions with NOACs. Prescribers need to be vigilant of the effect of interacting drugs on the risk profile of patients treated with NOACs.

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Case Report of Endovascular Thrombectomy in Severe Acute Ischemic Stroke After Dabigatran Reversal with Idarucizumab

Journal of Stroke Medicine ◽

10.1177/2516608519864761 ◽

2019 ◽

Vol 2 (2) ◽

pp. 155-157

Author(s):

Sandeep Nayani ◽

Rajesh Reddy Chenna ◽

Rajesh Reddy Sannareddy ◽

Sandeep Bhapkar ◽

Sonesh Kalra ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Limited Data ◽

Nonvalvular Atrial Fibrillation ◽

Reversal Agent ◽

Endovascular Thrombectomy

Non-vitamin K antagonist oral anticoagulants have provided an optimization of management of patients in the prevention of stroke in nonvalvular atrial fibrillation. The lack of an effective reversal agent has remained a challenge to these agents’ widespread utilization. Idarucizumab, a specific reversal agent for dabigatran, is approved in many countries including India. However, there is limited data for its use for Indian patients. We are reporting one of the cases of its use in India where it successfully reversed dabigatran prior to mechanical thrombectomy in acute ischemic stroke.

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