How much does international normalized ratio monitoring cost during oral anticoagulation with a vitamin K antagonist? A systematic review

Background: Current guidelines recommend against the use of direct oral anticoagulation (DOAC) therapy in patients with atrial fibrillation (AF) in the setting of significant liver disease (LD) due to lack of evidence in safety and efficacy studies. However, recently studies have investigated the role of DOAC in comparison to Vitamin K antagonist (VKA) in this category of patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of this approach. Hypothesis: DOAC is safe and effective compared to VKA in AF with LD patients. Method: Unrestricted search of the PubMed, EMBASE, and Cochrane databases performed from inception until June 1, 2020 for studies comparing DOAC with VKA including more than 100 AF patients with LD. Relevant data were extracted and analyzed using Revman 5.3 software. Hazard ratio (HR) and 95% Confidence interval (CI) were calculated using the random-effects model. Result: A total of 5 studies (3 retrospective and 2 post hoc analysis) were included examining 39,064 patients with AF and LD (25,398 DOAC vs 13,669 VKA). DOAC is associated with lower risk of major bleeding compared to VKA with a HR of 0.68 (95% CI 0.47-0.98; I 2 =53%), all-cause mortality (HR 0.74;95% CI 0.59-0.94; I 2 =61%), and intracranial bleeding (HR 0.48; 95% CI 0.40-0.58; I 2 =0). There was no significant difference in ischemic stroke risk (HR 0.73; 95% CI 0.47-1.14; I 2 =72%) and gastrointestinal bleeding risk (0.96; 95% CI 0.61-1.51; I 2 =41%) between DOAC and VKA. Conclusion: DOAC is non-inferior to VKA regarding ischemic stroke prevention in AF patients with LD. Moreover, DOAC is associated with a lower risk of major bleeding, intracranial bleeding and all-cause mortality. Further randomized trials are needed to validate our findings.

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Abstract WP438: Hematoma Expansion and Outcomes in Vitamin K versus Non-Vitamin K Antagonist Oral Anticoagulation Related Intracerebral Hemorrhages

Stroke ◽

10.1161/str.50.suppl_1.wp438 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Malgorzata M Miller ◽

Jessica Lowe ◽

Muhib Khan ◽

Muhhamad U Azeem ◽

Adalia H Jun-O'Connell ◽

...

Keyword(s):

Vitamin K ◽

Oral Anticoagulation ◽

Vitamin K Antagonist ◽

Hematoma Expansion ◽

Intracerebral Hemorrhages

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Real-world comparisons of reduced-dose non-vitamin K antagonist oral anticoagulants versus warfarin in atrial fibrillation: a systematic review and meta-analysis

Heart Failure Reviews ◽

10.1007/s10741-019-09887-x ◽

2019 ◽

Vol 25 (6) ◽

pp. 973-983 ◽

Cited By ~ 1

Author(s):

Xiaoping Wang ◽

Lili Fang ◽

Bin Liu ◽

Yongliang Zheng ◽

Junquan Zeng

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Vitamin K ◽

Real World ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Reduced Dose

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P6163Promotion of coronary plaque progression associated with different anticoagulation agents - a longitudinal CTA analysis

European Heart Journal ◽

10.1093/eurheartj/ehz746.0769 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

C Beyer ◽

M Wildauer ◽

G Feuchtner ◽

G Friedrich ◽

F Hintringer ◽

...

Keyword(s):

Vitamin K ◽

Oral Anticoagulation ◽

Vitamin K Antagonist ◽

Controlled Study ◽

Time Interval ◽

Plaque Volume ◽

Equal Distribution ◽

Anticoagulation Agents ◽

Progression Of Atherosclerosis

Abstract Objective Possible antithrombotic effect of anticoagulants in coronary artery disease have been proposed but mechanism are poorly understood. Experimental and clinical data indicate a key role of coagulation factors in the progression of atherosclerosis. We sought to evaluate the effect of different oral anticoagulation agents on the progression of atherosclerosis. Methods This retrospective matched case controlled study included patients with atrial fibrillation (AF) who underwent repeated CT angiography for ablation planning. Patients with known structural cardiac pathologies or significant comorbidities were excluded. Patients were stratified according to their anticoagulation into 3 groups: vitamin K antagonist (VKA), direct oral anticoagulation (DOAC) and control (CR; aspirin or no therapy) with equal distribution of age and cardiovascular risk factors. Baseline and follow-up CT exams for repeated AF ablations were evaluated for the CAD profile and (semi)automated quantitative plaque analysis. Results One-hundred sixty-one patients were included (mean CT time interval: 31 months). The three cohorts did not differ in patient characteristics or CT findings at baseline. Absolute plaque volume progression was significantly higher in patients using VKA (66.5±136.7 mm3) compared to both CR (27.2±73.6 mm3) and DOAC (−7.1±42.1 mm3, p<0.001), translating into an annual change of 23.2±47.0 mm3 for VKA, 12.3±4.3 mm3 for CR and −4.6±22.9 mm3 for DOAC (p=0.003). The number of affected segments (SIS) increased by 1.2±1.3 compared to 0.6±1.3 in the control group and 0.2±0.7 in the DOAC group (p<0.0001). Baseline CTA findings Control (n=61) DOAC (n=50) VKA (n=50) p Vessel Volume (mm3) 26.9±42.9 23.1±43.3 27.9±40.7 0.85 Lumen Volume (mm3) 15.7±24.8 13.3±25.1 16.6±27.0 0.82 Coronary Calcium Score (AU) 63.4±187.2 42.0±114.6 53.8±118.6 0.75 Segment Involvement Score 1.8±2.1 1.8±2.3 1.9±2.2 0.96 Stenosis Average Area (%) 19.0±21.7 0.5±0.7 0.5±0.7 0.71 Maximal Plaque Thickness (mm3) 0.5±0.7 0.5±0.7 0.5±0.7 0.69 Total Plaque Volume (mm3) 33.6±60.0 30.0±55.6 34.2±48.0 0.92 AU, Agatston units; DOAC, direct oral anticoagulation; SIS, segment involvement score; VKA, vitamin K antagonist. Changes between baseline and follow-up Conclusion In serial coronary CTs, patients using vitamin K antagonists showed the highest plaque volume progression while patients using a direct oral anticoagulant showed a regression of total plaque volume. Therefore, direct anticoagulation may have a beneficial effect on atherosclerosis.

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