P5585Determinants of the use of direct oral anticoagulants in acute pulmonary thromboembolism in argentina

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M I Bernal ◽  
C E Scatularo ◽  
I M Cigalini ◽  
J C C Jauregui ◽  
J I Ortego ◽  
...  
Keyword(s):  
Heart Failure ◽  
Health Insurance ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Health Coverage ◽  
History Of ◽  
Lower Severity ◽  
Ischemic Attack ◽  
Acute Pe

Abstract Background In the last decade, direct oral anticoagulants (DOACs) were incorporated as an alternative for anticoagulation in patients with venous thromboembolism. Although they have a better pharmacologic profile than vitamin K antagonists (VKAs), the use of these drugs is not massive. Purpose Assess the rate of use of DOACs in acute pulmonary embolism (PE) patients (P) in Argentina and analyze the determinants of their use. Methods Based on a registry of 684 P admitted for acute PE in 75 academic centers between October 2016 and November 2017, we performed an analysis of DOACs prescription at discharge. A conventional statistical analysis was performed, to assess the differences between the P that received DOACs or other anticoagulants using univariate and multivariate models. Results 579 of 601 P who survived were discharged with anticoagulant treatment: 348 (60%) received VKA; 108 (19%) received DOACs (49% Rivaroxaban, 34% Apixaban, 17% Dabigatran) and 123 (21%) received low molecular weight heparins. Patients who received DOACs had lower severity of PE and less risk of bleeding. The main baseline characteristics are described in table 1. Also, those patients who received DOACs at discharge had fewer in-hospital complications (heart failure, infections or bleeding; all p<0.05). In the multivariate analysis, health insurance (OR 7.45, 95% CI: 1.74–31.9, p<0.01) was an independent predictor of DOACs prescription at discharge. The history of previous heart failure (OR 0.19, 95% CI: 0.04–0.84, p=0.03) or oncologic disease (OR 0.49; 95% CI: 0.27–0.89; p=0.02) were inversely and independent predictors for DOACs prescription. Variable DOACs Other anticoagulants P OR CI (95%) Male sex 51 (47.2%) 196 (41.6%) 0.29 – – Age 64.3±17.6 63.3±16.6 0.61 – – Health insurance 106 (98.1%) 402 (85.4%) 0.01 9.1 (2.2–37.7) CKD without dialysis 2 (1.9%) 34 (7.3%) 0.06 0.24 (0.06–1.03) Heart failure 2 (1.9%) 55 (11.7%) 0.01 0.14 (0.03–0.59) Oncology disease 16 (14.8%) 127 (27%) 0.01 0.47 (0.27–0.83) Previous anticoagulation 3 (2.8%) 44 (9.3%) 0.03 0.28 (0.08–0.91) sPESI 1±1.12 1.28±1.11 0.02 0.78 (0.64–0.96) RIETE 1.71±1.17 2.05±1.33 0.02 0.81 (0.68–0.97) CKD: Chronic kidney disease; TIA: Transient ischemic attack. Conclusions The rate of use of DOACs in survivors of an acute PE in Argentina was 19%, and this P present lower clinical risk, fewer co-morbidities and greater access to health coverage.

scholarly journals Direct oral anticoagulants: now also for prevention and treatment of cancer-associated venous thromboembolism?

Hematology ◽  
2017 ◽  
Vol 2017 (1) ◽  
pp. 136-143 ◽  
Author(s):  
Ingrid Pabinger ◽  
Julia Riedl
Keyword(s):  
Venous Thromboembolism ◽  
Primary Prevention ◽  
Cancer Patients ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Similar Efficacy ◽  
Prevention And Treatment ◽  
History Of ◽  
Meta Analyses

Abstract Data on specific studies in cancer patients using direct oral anticoagulants (DOACs) for the prevention and treatment of venous thromboembolism (VTE) are still scarce. For preventing VTE with DOACs, current experience is still very limited, so definite conclusions cannot yet be drawn. However, DOACs have so far been compared with vitamin K antagonists (VKAs) in patients with acute VTE in 5 studies, and several hundreds of patients included in these studies had either active cancer, a history of cancer, or a new occurrence of cancer during the course of disease. Meta-analyses have revealed an at least similar efficacy and safety profile of DOACs compared with VKAs. A number of studies of cancer patients investigating primary prevention and treatment are underway, and some will be finalized soon. Nevertheless, we might need further trials, specifically on the prevention of VTE in patients who are at particularly high risk. This article also includes a personal opinion on the use of DOACs in cancer patients. In conclusion, the currently available data show that DOACs might be safe and efficacious in the treatment of VTE, however, this has yet to be proven in specifically designed trials in patients with cancer. With regard to prevention, thus far, even less data exist, and the outcomes of the ongoing studies have to be evaluated before DOACs may be used for primary prevention.

scholarly journals Different Risk Profiles of European Patients Using Direct Oral Anticoagulants or Vitamin K Antagonists: a Rapid Review

2020 ◽  
Vol 7 (4) ◽  
pp. 290-299
Author(s):  
Katrin Krueger ◽  
Kathrin Jobski ◽  
Annemarie Voss ◽  
Ulrike Haug
Keyword(s):  
Vitamin K ◽  
Heart Diseases ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Careful Consideration ◽  
Rapid Review ◽  
Risk Profiles ◽  
History Of ◽  
Age Range

Abstract Purpose of Review We investigated the risk profiles of patients using direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) in European cohort studies to estimate the importance of potential (measured or unmeasured) confounding factors in analyses comparing these drugs. We searched MEDLINE and EMBASE (2008–2018) for relevant studies and extracted information on age, sex, comorbidity, Charlson comorbidity index, HAS-BLED score (assessing risk of bleeding) and CHA2DS2-VASc score (assessing risk of stroke). Recent Findings Overall, 66 studies with 2,808,757 patients were included. Most patients were from France (37%), Denmark (24%) and Germany (23%). In 56 studies (85%), the focus was on patients with atrial fibrillation. Of the 43 studies comparing DOAC with VKA users, 33% reported a higher and 16% a lower age of DOAC compared with VKA users. The mean age varied by about 1 year in most of these studies. Rivaroxaban was used in the widest age range. Patients with DOAC more often had a history of stroke or bleedings, and patients with VKA more often had a history of diabetes, renal failure, cancer, heart failure or other heart diseases. Most studies did not observe differences regarding the HAS-BLED score or the CHA2DS2-VASc score between groups. Summary Our review suggests that there are relevant differences in the risk profiles of DOAC versus VKA users and between users of individual DOACs. Reported HAS-BLED or CHA2DS2-VASc scores did not reflect these differences. These patterns require careful consideration in the interpretation of observational studies comparing the effectiveness and the risks of these drugs, also when comparing the results of studies conducted in different countries.

scholarly journals Risk of fracture in patients with non-valvular atrial fibrillation initiating direct oral anticoagulants vs. vitamin K antagonists

2020 ◽  
Author(s):  
Na He ◽  
Sophie Dell'Aniello ◽  
Suodi Zhai ◽  
Samy Suissa ◽  
Christel Renoux
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Lower Risk ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Incidence Rates ◽  
Risk Of Fracture ◽  
Cumulative Duration ◽  
History Of

Abstract Aims To determine the risk of fracture associated with direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF), accounting for cumulative duration of use. Methods and results Using Quebec administrative healthcare databases, we formed a cohort of all patients aged 40 years or older newly diagnosed with NVAF, who filled a first prescription for DOACs or VKAs between 2011 and 2014. Exposure was modelled as a time-varying variable whereby patients were considered unexposed up to 180 days of cumulative duration of use (to account for a biologically meaningful exposure) and exposed thereafter. The final cohort included 10 306 new users of DOACs and 15 357 new users of VKAs. After propensity score-based fine stratification and weighting, use of DOACs for 180 days or greater was associated with a 35% decreased risk of fracture [crude incidence rates 7.5 vs. 15.3 per 1000 person-years; adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.46–0.91] compared to VKA duration ≥180 days. Direct oral anticoagulants use was also associated with a lower risk of hip fracture (HR 0.51, 95% CI 0.31–0.86) compared with VKAs. There was no difference in the rate of fracture for shorter duration of use (HR 1.10; 95% CI 0.79–1.53). The risk was not modified by age, sex, chronic kidney disease, osteoporosis, history of fracture or falls. Conclusion Prolonged use of DOACs is associated with a lower risk of fracture compared with VKAs. These findings support the first-line recommendation for DOACs in patients with NVAF.

Medical Management Of Pulmonary Embolism

2018 ◽  
Author(s):  
Aaron B Waxman ◽  
Andrew J Schissler
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Pregnant Patient ◽  
Reperfusion Therapy ◽  
Medical Attention ◽  
Medium Risk ◽  
Evidenced Based ◽  
Acute Pe

Acute pulmonary embolism (PE) can be fatal and requires prompt medical attention. This chapter reviews the treatment of acute PE, including a detailed report of the acute- and long-term management of high-risk (“massive”), medium-risk (“submassive”), and low-risk thrombi. It summarizes the reperfusion therapies available in hemodynamically unstable patients with massive PEs such as thrombolysis, embolectomy, and percutaneous catheter-directed treatment. There is further in-depth examination of the various anticoagulants available including parenteral therapies, vitamin K antagonists, and direct oral anticoagulants. Recommendations on the treatment duration are discussed. Other considerations are described, including how management changes in the pregnant patient with acute PE, when venous filters should be considered and whether to initiate treatment before confirming a diagnosis. Overall this chapter serves as an excellent evidenced-based guide to better manage the various presentations of acute PE.   This review contains 3 figures, 5 tables and 47 references Key Words: anticoagulation, embolectomy, PE, pulmonary embolism, reperfusion therapy, thrombolysis, treatment

A Probable Life-Saving Switch from Apixaban to Phenprocoumon

2015 ◽  
Vol 18 (5) ◽  
pp. 186 ◽  
Author(s):  
Claudia Stöllberger ◽  
Josef Finsterer
Keyword(s):  
Diabetes Mellitus ◽  
Laboratory Tests ◽  
Prothrombin Complex Concentrate ◽  
Sick Sinus Syndrome ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Infrarenal Aortic Aneurysm ◽  
Life Saving ◽  
History Of

The direct oral anticoagulants (DOAC) dabigatran, rivaroxaban, and apixaban are increasingly prescribed in atrial fibrillation (AF) patients, although dosage in elderly patients, safety in chronic kidney disease, food- and drug-interactions, laboratory tests for monitoring, and antidote are not clarified. In a 78-year-old man with an acute stroke, paroxysmal AF and sick-sinus-syndrome were detected as he received a DDD-pacemaker and 5 mg apixaban/bid. He had a history of hypertension, hypothyroidism, diabetes mellitus, hyperlipidemia, sleep apnea, lumbar discopathy, and nephropathy. Renal function deteriorated after 2 months, and apixaban was changed to phenprocoumon. Three months later, he suffered from abdominal pain and hemorrhagic shock due to rupture of an infrarenal aortic aneurysm. After reversal of the anticoagulation with prothrombin-complex concentrate, a stent-graft with exclusion of the aneurysm was implanted. Switching from apixaban to phenprocoumon was probably life-saving. Vitamin-K-antagonists should be preferred to DOAC in patients with AF and vascular disease.

scholarly journals Vitamin K antagonists versus direct oral anticoagulants after cardiac surgery: a 31-country cohort study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Whitlock ◽  
E.P Belley-Cote ◽  
J Healey ◽  
P.J Devereaux ◽  
J Eikelboom ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cohort Study ◽  
Vitamin K ◽  
Major Bleeding ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Funding Source ◽  
Arterial Embolism ◽  
History Of

Abstract Background About 10% of patients undergoing cardiac surgery have a history of atrial fibrillation (AF). Among these patients, uncertainty exists regarding the safest and most effective oral anticoagulant (OAC) during the postoperative period. Purpose To evaluate practice patterns regarding OAC early after cardiac surgery in patients with a preoperative history of AF and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). Methods We conducted a nested cohort study within the Left Atrial Appendage Occlusion Study (LAAOS) III (NCT01561651). LAAOS III included patients with AF undergoing cardiac surgery with a CHA2DS2-VASC ≥2. In this substudy, we examined patients without end-stage renal dysfunction (eGFR &gt;30 mL/min/1.73m2) who were discharged on OAC. We evaluated bleeding and thromboembolism within 90 days postoperatively using logistic regression adjusting for CHA2DS2-VASC score. Results Recruitment started in 2012 and completed in 2018 in 113 centres in 31 countries. Of the 4811 patients enrolled in LAAOS III, 3725 (77%) were included in this substudy. Preoperatively, 58% of patients received OAC: 56% DOACs and 44% VKAs. At hospital discharge 23% received DOACs and 77% VKAs; 55% of patients on a DOAC at baseline were switched to a VKA while 5% of patients on a VKA were switched to a DOAC. Patients discharged on a DOAC were older, had a higher CHA2DS2-VASC, and were more likely to be male. Patients having undergone an isolated coronary bypass procedure were more likely prescribed DOACs than VKAs (41% vs 23%, p&lt;0.001) whereas isolated non-mechanical valve patients were more likely to be prescribed VKAs (43% vs 28%, p&lt;0.001). Switching from a DOAC to a VKA postoperatively occurred in 42% of patients In Australia/New Zealand, 49% in Europe, and 63% in North America. Major bleeding between 48 hours postoperatively and 30 days occurred in 1.5% in the DOAC group and 1.3% in the VKA group (aOR 1.14, 95% CI 0.60–2.15, p=0.69) while between 48 hours and 90 days, it occurred in 1.8% of patients in both groups (aOR 0.97, 95% CI, 0.54–1.17, p=0.91). Cardiac tamponade, the composite of stroke and systemic arterial embolism, and the composite of stroke, systemic arterial embolism and death did not differ significantly at 30 and 90 days between the DOAC and VKA groups. Conclusions VKAs was the dominant OAC used early after cardiac surgery, but postoperative OAC practices varied by region. After adjustment for CHA2DS2-VASC score, the early postoperative incidence of major bleeding and of the composite of stroke and systemic arterial embolism did not differ significantly when DOACs were compared with VKAs. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIHR, Heart and Stroke Foundation

PP181 Direct Comparison Of The Effectiveness And Safety Of Apixaban, Dabigatran, Rivaroxaban, And Warfarin: Subgroup Analyses Of Medicare Beneficiaries

2020 ◽  
Vol 36 (S1) ◽  
pp. 19-19
Author(s):  
Lanting Yang ◽  
Maria M. Brooks ◽  
Nancy W. Glynn ◽  
Yuting Zhang ◽  
Samir Saba ◽  
...  
Keyword(s):  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Patient Characteristics ◽  
P Value ◽  
Medicare Beneficiaries ◽  
Previous Stroke ◽  
History Of ◽  
Underlying Mechanisms ◽  
Ischemic Attack

IntroductionNo studies have directly compared the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in patients with atrial fibrillation (AF), with or without a history of ischemic stroke and transient ischemic attack (TIA). This is important for two reasons: first, previous research reports important differences between DOACs and warfarin across other patient subgroups, and second, patients with previous stroke or TIA have a high risk of recurrent stroke.MethodsUsing 2012–2014 Medicare claims data, we identified patients newly diagnosed with AF in 2013–014 who started taking apixaban, dabigatran, rivaroxaban, or warfarin. We categorized the patients according to whether they had a history of stroke or TIA. We constructed Cox proportional hazard models that included indicator variables for treatment groups, a history of stroke or TIA, and the interaction between them, and controlled for demographic and clinical characteristics.ResultsThe hazard ratio (HR) for stroke with dabigatran, compared with warfarin, was 0.64 (95% confidence interval [CI]: 0.48–0.85) for patients with a history of stroke or TIA and 0.94 (95% CI: 0.75–1.16) for patients without a history of stroke or TIA (p-value for interaction = 0.034). In patients with previous stroke or TIA, the risk of stroke was lower with dabigatran (HR 0.64, 95% CI: 0.48–0.85) and rivaroxaban (HR 0.70, 95%CI: 0.56–0.87), compared with apixaban, but there was no difference for patients in the other subgroup.ConclusionsDOACs were generally more effective than warfarin for preventing stroke. The superiority of dabigatran was more pronounced in patients with a history of stroke or TIA. The comparative effectiveness of DOACs differed substantially between patients with and without a history of stroke or TIA; specifically, apixaban was less effective in patients with a history of stroke or TIA. Our results reinforce the need to tailor anticoagulation to patient characteristics and to support the investigation of the underlying mechanisms associated with DOACs.

The Atrial fibrillation Better Care (ABC) pathway is associated to a lower incidence of cardiac complications in patients with atrial fibrillation: a report from the ATHERO-AF study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
D Pastori ◽  
P Pignatelli ◽  
F Violi ◽  
G.Y.H Lip
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Rank Test ◽  
Major Adverse Cardiovascular Events ◽  
Cardiac Complications ◽  
Kaplan Meier ◽  
Increased Risk

Abstract Background The integrated management of atrial fibrillation (AF) patients according to the Atrial fibrillation Better Care (ABC, A, Avoid stroke with anticoagulation; B, better symptom management; C, Cardiovascular and comorbidity risk management) pathway has associated with a reduced incidence of thromboembolic events and mortality. However, whether this approach also results in a lower rate of cardiac complications is unknown. Purpose To investigate the rate of major adverse cardiovascular events (MACE) in AF patients according to compliance with the ABC pathway. Methods This prospective single-center cohort study included 1157 patients with nonvalvular AF from the ATHERO-AF study. The A, B, and C groups were defined as follows: “A” by a Time in Therapeutic Range ≥70% in vitamin K antagonists-treated patients or appropriate dose for patients on direct oral anticoagulants; “B” by a European Heart Rhythm Association (EHRA) symptom scale I-II (vs. III-IV), and “C” as optimized cardiovascular comorbidity management (i.e. use of ACE inhibitors in heart failure patients, blood pressure &lt;140/90, use of statins and beta blockers in patients with prior ischemic heart disease). The primary end point was a composite of MACE including fatal/non-fatal myocardial infarction, coronary revascularization and cardiovascular death (progressive heart failure, sudden cardiac death and procedure-related death). Results Overall, 458 (39.6%) patients were optimally managed according to the ABC (ABC-compliant group), while the remaining 729 patients presented at least one uncontrolled component (ABC non-compliant group). During a mean follow up of 35 months, (2688 patient-years), 64 MACE were recorded 2.38%/year. Kaplan Meier curve analysis showed a significant higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (54 and 10 MACE in each group, respectively, log-rank test p=0.006, figure). The risk of MACE increased by the number of uncontrolled ABC components: Hazard ratio HR) for 1 component 1.697, 95% Confidence Interval 95% CI 0.814–3.537, p=0.158; HR for 2 components 4.157, 95% CI 1.994–8.665, p&lt;0.001); HR for 3 components 5.100, 95% CI 1.596–16.295, p=0.006. ABC non-compliant group remained associated with an increased risk of MACE using Cox proportional hazard regression analysis (HR 2.175, 95% CI 1.098–4.309, p=0.026) after adjustment for CHA2DS2VASc score, antiplatelet drugs and digoxin use. Conclusion The majority of AF patients is not currently optimally managed. An integrated care ABC approach is associated with a reduced risk of MACE in the AF population. Figure 1. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None

Cardiac tamponade from anticoagulant-related spontaneous haemopericardium in a patient with ischaemic cardiomyopathy and heart failure

2020 ◽  
Vol 13 (12) ◽  
pp. e238047
Author(s):  
Alicia Lefas ◽  
Neil Bodagh ◽  
Jiliu Pan ◽  
Ali Vazir
Keyword(s):  
Heart Failure ◽  
Cardiac Tamponade ◽  
Ventricular Dysfunction ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Left Ventricular ◽  
Heart Failure Therapy ◽  
Severe Left Ventricular Dysfunction ◽  
Ischaemic Cardiomyopathy ◽  
Common Causes

We describe the case of an 86-year-old man with a background of severe left ventricular dysfunction and ischaemic cardiomyopathy who, having been optimised for heart failure therapy in hospital, unexpectedly deteriorated again with hypotension and progressive renal failure over the course of 2 days. Common causes of decompensation were ruled out and a bedside echocardiogram unexpectedly diagnosed new pericardial effusion with tamponade physiology. The patient underwent urgent pericardiocentesis and 890 mL of haemorrhagic fluid was drained. Common causes for haemopericardium were ruled out, and the spontaneous haemopericardium was thought to be related to introduction of rivaroxaban anticoagulation. The patient made a full recovery and was well 2 months following discharge. This case highlights the challenges of diagnosing cardiac tamponade in the presence of more common disorders that share similar non-specific clinical features. In addition, this case adds to growing evidence that therapy with direct oral anticoagulants can be complicated by spontaneous haemopericardium, especially when coadministered with other agents that affect clotting, renal dysfunction and cytochrome P3A5 inhibitors.

Sign in / Sign up

Export Citation Format

Share Document