scholarly journals Residual Stroke Risk in Patients with Atrial Fibrillation Treated with Non-Vitamin K Oral Anticoagulants: An 8-Year Retrospective Cohort Study

2021 ◽  
pp. 9-14
Author(s):  
Cheuk Ling Charing Szeto ◽  
Kwok Fai Hui
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Diabetic Control ◽  
The Mean ◽  
Never Smokers ◽  
Ischemic Attack ◽  
Christian Hospital

<b><i>Background:</i></b> Use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in non-valvular atrial fibrillation (NVAF) is common and significantly reduces stroke occurrence. Yet little is known about patients who have a stroke despite treatment. <b><i>Objective:</i></b> The aim of this work was to study the epidemiology of patients with stroke despite being treated with NOACs. <b><i>Methods:</i></b> We identified a cohort of patients with NVAF admitted to the United Christian Hospital for acute ischemic stroke (AIS) or transient ischemic attack (TIA) while on NOACs. The baseline characteristics, type of NOAC, compliance, duration of use, and dosage were reviewed. <b><i>Results:</i></b> Of 2,090 patients admitted for AIS/TIA from 2012 to 2019, 143 were on NOACs before the index episode. After excluding patients with non-compliance and incomplete data, 109 patients were included in the analysis; 65.1% were female and 79.8% were never smokers, with a mean age of 78 years. The mean CHA2DS2-VASc score was 5; 83.5% had hypertension, 59.3% had hyperlipidemia, and 30.3% had diabetes mellitus. Overall, 52.9% presented with lacunar syndrome, suggesting an atherosclerotic cause of stroke. However, their risk factor control was unexpectedly good; none had HbA1c &#x3e;7% and only 23.9% had a low-density lipoprotein cholesterol level higher than 2.6 mmol/L. <b><i>Conclusions:</i></b> Stroke developed in NVAF patients despite being on NOACs, with the majority being female, older, and hypertensive. Surprisingly, in general they had reasonable lipid and diabetic control.

One decade of oral anticoagulation in stroke patients: Results from a large country-wide hospital-based registry

2017 ◽  
Vol 13 (3) ◽  
pp. 308-312 ◽  
Author(s):  
Christian Tanislav ◽  
Jens Allendörfer ◽  
Waltraud Pfeilschifter ◽  
Sven Fuest ◽  
Marco Stein ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
New Oral Anticoagulants ◽  
Federal State ◽  
Stroke Patients ◽  
Large Country ◽  
Previous Medication ◽  
Ischemic Attack

Background New evidence regarding stroke prevention in atrial fibrillation has been published. Implementing knowledge into clinical practice remains challenging. Aims To investigate oral anticoagulants in stroke patients documented in a nationwide registry. Methods The database is an obligatory federal-state-wide hospital-based registry that covers more than 95% of all ischemic strokes, transient ischemic attacks and intracerebral hemorrhages in a community of more than six million inhabitants (Hesse/Germany). We analyzed oral anticoagulants prescribed on discharge in patients with stroke or transient ischemic attack during 2006–2015. Results From 2006 to 2015, we annually selected median 20,895 patients. From 2006 to 2015, the proportion of patients treated with oral anticoagulants increased (9.8% to 24%). The annual proportion of patients with atrial fibrillation remained constant (median: 23%). In atrial fibrillation patients treated with oral anticoagulants, the age increased (median 2008/2009: 76.9 years vs. 2014/2015 79.4 years). The percentage of treated individuals in atrial fibrillation increased dramatically (2006: 30.1% to 2015: 74.5%); in 2015, 30.8% of these patients received vitamin K antagonists and 70.2% new oral anticoagulants. Independent factors associated with new oral anticoagulants therapy were a previous medication with new oral anticoagulants and a treatment on stroke unit. Between new oral anticoagulants- and vitamin K antagonists-treated patients (2015), no differences in age were noted (both mean: 79.4 years). Conclusions The new oral anticoagulants availability enhanced a general trend treating more target patients with oral anticoagulants.

Use of Non–Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients with Malignancy: Clinical Practice Experience in a Single Institution and Literature Review

2017 ◽  
Vol 44 (04) ◽  
pp. 370-376 ◽  
Author(s):  
Anna Rago ◽  
Andrea Papa ◽  
Federica Meo ◽  
Emilio Attena ◽  
Paolo Golino ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Cardiovascular Complications ◽  
Vitamin K Antagonist ◽  
Minor Bleeding ◽  
Bleeding Events ◽  
Study Population ◽  
Ischemic Attack

AbstractThis observational study aimed to investigate the efficacy and safety of non–vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with malignancy. A total of 76 patients (mean age: 73.2 ± 8.9; 28 females) with AF and malignancy treated with NOAC were included in the analysis. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 ± 1.2 and 2.2 ± 0.9, respectively. The study population was taking dabigatran 150 mg (25%) twice daily (BID), apixaban 5 mg BID (25%), dabigatran 110 mg BID (24%), rivaroxaban 20 mg (18%) once a day (OD), rivaroxaban 15 mg OD (5%), or apixaban 2.5 mg OD (3%). NOAC therapy began, on average, 248 ± 238 days before malignancy diagnosis for an average duration of 1,000 ± 289 days. Stroke, transient ischemic attack, major and minor bleeding events, other adverse effects, and major cardiovascular complications during the follow-up period were collected. In our study population, no patients experienced thromboembolic events during therapy with any NOAC. We recorded a low global incidence of major bleeding (3.9%) with a mean annual incidence of 1.4%. No hemorrhagic stroke or subarachnoid hemorrhage was observed. Only nine patients (11.8%) experienced minor bleeding. According to our data, anticoagulation therapy with NOACs seems to be an effective and safe treatment strategy for nonvalvular AF patients with malignancy.

scholarly journals Non-vitamin K oral anticoagulants (NOACs) in patients with stroke and atrial fibrillation

2020 ◽  
Vol 70 (5) ◽  
pp. 269-283
Author(s):  
Dejana Jovanović
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Vitamin K ◽  
Hemorrhagic Stroke ◽  
Small Vessel Disease ◽  
Oral Anticoagulants ◽  
Stroke Recurrence ◽  
Ischemic Attack

Patients with atrial fibrillation who had a previous transient ischemic attack or ischemic stroke had a significantly high risk of stroke recurrence and the introduction of oral anticoagulants should be mandatory. However, the long-term use of oral anticoagulants increases the risk of developing all types of intracranial hemorrhages. The advantages of non-vitamin K oral anticoagulants (NOACs) compared to warfarin are that they have a significantly lower risk for hemorrhagic stroke. They are preferred in elderly patients, those with small vessel disease, or those with previous intracerebral hemorrhage. The time of NOACs introduction after an ischemic stroke depends on its severity and the rule "1-3-6-12" days should be applied. The reintroduction of NOACs in patients with atrial fibrillation and previous intracerebral hemorrhage depends on its etiology and should be after about 4-8 weeks if the cardioembolic risk is high and the risk for intracranial hemorrhage small.

scholarly journals Pharmacist management of atrial fibrillation: a pilot educational intervention study

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Al-Arkee ◽  
J Mason ◽  
L Fabritz ◽  
W Chua ◽  
D.A Lane ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Time Of Day ◽  
Health Science ◽  
Therapeutic Area ◽  
Knowledge Gaps ◽  
Educational Session ◽  
The Mean

Abstract Introduction AF increases the risk of stroke by a factor of five [1], oral anticoagulants (OACs) can reduce stroke by ∼60% and death by ∼25% [2]. Pharmacists, especially those based in primary care are well placed to support patients in this therapeutic area. However, research indicates that pharmacists do not always feel confident in supporting patients on OACs, which are the mainstay of AF management [3]. Purpose The aim of this pilot study is to assess pharmacists' knowledge prior to an educational session on AF and its management. Training was provided on AF, its management and the use of an associated app, AF Manager (Figure) with the intention to re-assess pharmacists' knowledge and use of the app 3, 6 and 12-months post-training. Here, we report the assessment of pharmacist baseline knowledge. Methods Various social media platforms were used to invite UK-based, practicing primary care pharmacists to an educational session. Training was developed in collaboration with consultant pharmacists from an Academic Health Science Network, AF Programme. Participant knowledge was assessed immediately before the educational session by use of the Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ), adapted for use with pharmacists. Quantitative data were analysed using SPSS version 27. Results Twenty UK-based practicing pharmacists attended the educational session. Four pharmacists were excluded from analysis as they were not based in primary care. The mean practice experience of participants was 14.6±10.5 years; 62.5% were female and 50% had undertaken postgraduate qualifications. For this group of pharmacists, out of a maximum of 19 points, the mean score for the adapted JAKQ was 13.7±2.5. General knowledge about OACs (i.e. that which might be used to counsel patients taking OACs, such as time of day to take the medicines, side effects, drug interactions/contraindications) was high with knowledge about the different types of OACs similar (vitamin K antagonists (VKAs) 66.7±25.3% versus non-vitamin K antagonist oral anticoagulants (NOACs) 66.7±41.6%). However, several important knowledge gaps about AF and its management were identified. Only half of the participants knew that patients taking OACs for AF would continue to experience AF and only five participants (31.3%) knew that AF symptoms could be self-managed. Knowledge of INR monitoring frequency for VKAs and the use of NOAC patient alert cards was also lacking, with nine (56.2%) and thirteen (81.2%) of participants unable to answer these questions, respectively. Conclusions Primary care pharmacists are knowledgeable about the medicines used in AF management. However, there are specific knowledge gaps around AF management that need to be addressed via educational interventions to enable pharmacists to support patients effectively. Our follow-up research will investigate knowledge retention post-training and assess app usability for pharmacists in the management of patients with AF. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Screenshots of the AF Manager app

Three-month risk-benefit profile of anticoagulation after stroke with atrial fibrillation: The SAMURAI-Nonvalvular Atrial Fibrillation (NVAF) study

2016 ◽  
Vol 11 (5) ◽  
pp. 565-574 ◽  
Author(s):  
Shoji Arihiro ◽  
Kenichi Todo ◽  
Masatoshi Koga ◽  
Eisuke Furui ◽  
Naoto Kinoshita ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Major Bleeding ◽  
Transient Ischemic Attack ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Systemic Embolism ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Attack

Aims This study was performed to determine the short-term risk-benefit profiles of patients treated with oral anticoagulation for acute ischemic stroke or transient ischemic attack using a multicenter, prospective registry. Methods A total of 1137 patients (645 men, 77 ± 10 years old) with acute ischemic stroke/transient ischemic attack taking warfarin (662 patients) or non-vitamin K antagonist oral anticoagulants (dabigatran in 205, rivaroxaban in 245, apixaban in 25 patients) for nonvalvular atrial fibrillation who completed a three-month follow-up survey were studied. Choice of anticoagulants was not randomized. Primary outcome measures were stroke/systemic embolism and major bleeding. Results Both warfarin and non-vitamin K antagonist oral anticoagulants were initiated within four days after stroke/transient ischemic attack onset in the majority of cases. Non-vitamin K antagonist oral anticoagulant users had lower ischemia- and bleeding-risk indices (CHADS2, CHA2DS2-VASc, HAS-BLED) and milder strokes than warfarin users. The three-month cumulative rate of stroke/systemic embolism was 3.06% (95% CI 1.96%–4.74%) in warfarin users and 2.84% (1.65%–4.83%) in non-vitamin K antagonist oral anticoagulant users (adjusted HR 0.96, 95% CI 0.44–2.04). The rate of major bleeding was 2.61% (1.60%–4.22%) and 1.11% (0.14%–1.08%), respectively (HR 0.63, 0.19–1.78); that for intracranial hemorrhage was marginally significantly lower in non-vitamin K antagonist oral anticoagulant users (HR 0.17, 0.01–1.15). Major bleeding did not occur in non-vitamin K antagonist oral anticoagulant users with a CHADS2 score <4 or those with a discharge modified Rankin Scale score ≤2. Conclusions Stroke or systemic embolism during the initial three-month anticoagulation period after stroke/transient ischemic attack was not frequent as compared to previous findings regardless of warfarin or non-vitamin K antagonist oral anticoagulants were used. Intracranial hemorrhage was relatively uncommon in non-vitamin K antagonist oral anticoagulant users, although treatment assignment was not randomized. Early initiation of non-vitamin K antagonist oral anticoagulants during the acute stage of stroke/transient ischemic attack in real-world clinical settings seems safe in bleeding-susceptible Japanese population.

P2542Adherence to the 2016–2018 ESC guidelines for stroke prevention in atrial fibrillation: an Italian field practice in a cohort of geriatric patients

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Marinelli ◽  
M Zoli ◽  
P Calogero ◽  
M L Lunardelli ◽  
L Bastagli
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Geriatric Patients ◽  
Oral Anticoagulants ◽  
Real Life ◽  
Vitamin K Antagonist ◽  
Esc Guidelines ◽  
The Mean ◽  
New Onset

Abstract Background The 2016 and 2018 ESC guidelines for stroke prevention in atrial fibrillation (AF) recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) in all AF patients except for the EHRA type 1, for which remains the indication to vitamin K antagonist oral anticoagulants (VKAs). Purpose To evaluate the adherence to the ESC guidelines in the management of anticoagulant therapy (OAC) in the prevention of cardioembolism in geriatric (age ≥65) AF patients at 3 medical-geriatric inpatient wards of the Sant'Orsola Hospital in Bologna (Emilia Romagna region, Italy). Methods Between April 1st and October 1st 2018, 138 consecutive AF inpatients were prospectively enrolled at the start or at the change or at the interruption of the OAC. Results The main characteristics of the cohort were: mean age 84,6 years (range 65–102), M/F = 64/74, mean Charlson score 4,4, mean ADL/IADL 3,45/2,01 and mean CHA2DS2VASc/ HAS-BLED scores 5/3. Thirty-eight percent (N=52) of patients needed walking aids. Polypharmacy (intake of ≥5 drugs) was present in 31,9% (N=44) of patients and anemia in 50% (N=69: acute 6,5%, chronic 34,8%, mixed 8,7%). Half of the patients (N=69) presented new onset AF. Only 68% of patients (N=47) with known AF (N=69) were in OAC (37,6% in VKAs and 30,4% in NOACs). At the admission, the mean INR of AF in VKAs was 3,53 (range 1,54–10). The hospital decision on the anticoagulation in 91 patients (22 with known AF not in OAC at home, and 69 with new-onset AF), defined as “naïve” to OAC, was evaluated: 26,3% (N=24) started NOACs, 45% (N=41)VKAs, 8,7% (N=8) anticoagulant low molecular weight heparin (EBPM), and 20% (N=18) didn't start OAC. The decision was supported by consultant cardiologists and/or angiologists in 72,5% of cases (N=66). The choice of the VKAs was mainly due to chronic kidney disease (CKD) and acute kidney failure. Patients who started NOACs were significantly younger than those who started VKAs (age: 78,2 vs 86,5; p<0.001) and had a better preserved renal function (Cockroft-Gault GFR: 69,6 vs 48,1 ml/min; p<0.001). However, the mean GFR of VKAs patients was clearly above the lower limit set by the guidelines. The main causes of the switching between NOACs and VKAs (N=14, 10,1%) were stroke-TIA occurrence (N=7, 57,1%) and CKD (N=4, 28,5%). OAC was definitively interrupted (N=31, 22,4%) mostly for severe clinical conditions (N=16, 51,6%) and anemia (N=7, 22,5%). Conclusions In this “real life” cohort the deviation from the ESC guidelines was 52%. According to the guidelines only 11 (26,8%) of the patients who started VKAs would have been excluded from treatment with NOACs. Our experience underlines the presence of “fear” in the use of NOACs in geriatric patients, in particular with CKD. Probably it's worth to question if the current guidelines provide reliable indications regarding the safety and manageability of the NOACs in the presence of the most common geriatric syndromes.

A multicenter prospective hospital-based cohort study on the efficacy and safety of pitavastatin.

2020 ◽  
Vol 17 ◽  
Author(s):  
Abdullah Shehab ◽  
Asim Ahmed Elnour ◽  
Akshaya Srikanth Bhagavathula ◽  
Joseph Pulavelil Kurian ◽  
Gazi Hassan ◽  
...  
Keyword(s):  
Cohort Study ◽  
Adverse Events ◽  
United Arab Emirates ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Low Density ◽  
Efficacy And Safety ◽  
Onset Diabetes ◽  
The Mean ◽  
New Onset

Aims: We aim to investigate the efficacy and safety of pitavastatin 4 mg in a population of people living in the United Arab Emirates (UAE). Background: Pitavastatin is a member of the HMG-CoA reductase inhibitors family which was approved for use in adult subjects with primary hyperlipidemia or mixed dyslipidemia. To date, no published studies have assessed the efficacy and safety of pitavastatin in the United Arab Emirates. Objective: The main objective of the current study was to investigate the efficacy and safety of pitavastatin in subjects with dyslipidemia for primary prevention of cardiovascular diseases based on total cardiovascular risk. Methods: This was a multicentre (four private hospitals) prospective cohort study to analyze data on the use of pitavastatin for dyslipidemia in adult outpatients in Abu Dhabi and Dubai emirates, United Arab Emirates. We have followed-up the clinical profiles of subjects in four hospitals for six-weeks during the period from June 2015 to June 2017. Efficacy was based on the evaluation of the mean (± standard deviation) change in low-density lipoprotein cholesterol between baseline and week six after the initiation of pitavastatin therapy. Safety was reported as the incidence of adverse events occurred with the use of pitavastatin and the development of new-onset diabetes. Results: A total of 400 subjects who were receiving pitavastatin 4 mg were included. The mean age of subjects was 50.7 ±10.8 years, of these 79.0% were males. At the baseline, the mean level of total cholesterol was 185.4 ±41.5 mg/dL, low density lipoprotein was 154.9 ±48.55 mg/dL, high-density lipoprotein cholesterol was 40.5 ±11.23 mg/dL and fasting blood glucose was 115.0 (±16.63) mg/dl. At the end of six weeks, low density lipoprotein levels significantly decreased to 112.09 ±41.90 mg/dl (standard mean difference [SMD] (-42.8%), 95% CI: -42.88 [-49.17 to -36.58] mg/dl, P <0.001), while high density lipoprotein levels improved (SMD, 95% CI: 1.77% [0.25 to 3.28] mg/dl, P <0.022). There were 55 subjects (13.7%) reported various adverse events such as myalgia (7.5%), sleep disorders (2.5%), and myopathy (2.2%). Furthermore, 4 (1.0%) have had developed new-onset diabetes post six-weeks of initiation of pitavastatin therapy. Conclusion: Pitavastatin 4 mg had howed robust efficacy in reducing LDL-C levels and improving HDL-C levels in subjects with dyslipidemias. The use of pitavastatin was associated with a low discontinuation rate, fewer adverse events, and very limited cases of new-onset diabetes.

scholarly journals Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

2021 ◽  
Vol 10 (15) ◽  
pp. 3212
Author(s):  
Fabiana Lucà ◽  
Simona Giubilato ◽  
Stefania Angela Di Fusco ◽  
Laura Piccioni ◽  
Carmelo Massimiliano Rao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Thrombus Formation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Significant Advance ◽  
Thromboembolic Events ◽  
Thromboembolic Risk ◽  
Pharmacological Cardioversion

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

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