Abstract 15163: Differences in Preferences Between Physicians and Patients for the Use and Dosing of Direct Oral Anticoagulants for Atrial Fibrillation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jennifer A Rymer ◽  
Debbe McCall ◽  
Mellanie T Hills ◽  
Tracy Y Wang
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Primary Care Providers ◽  
Severe Bleeding ◽  
Minor Bleeding ◽  
Care Providers ◽  
Reversal Agent ◽  
Physician Knowledge ◽  
Reduced Dose

Introduction: Direct oral anticoagulants (DOACs) are effective in reducing the risk of stroke for patients with atrial fibrillation (AF) only if prescribed at the labeled dose. Little is known about patient or clinician preferences for DOAC selection and dosing. Methods: We consented 240 physicians treating ≥20 patients with AF and 343 patients with AF. Physician knowledge of DOAC dosing was tested with 4 hypothetical patient case scenarios. Both patients and physicians were asked to grade the importance of 25 factors in anticoagulation decision-making. Results: Among physicians, the median age was 55 years, 13% were female, 23% were primary care providers. Most physicians (63%) stated empirically they would never/rarely use an adjusted lower dose if the patient did not meet dose adjustment criteria. However, in hypothetical case scenarios of a patient indicated for full dose DOAC, 40.8% of clinicians under-dosed apixaban (<5 mg bid daily) and 17.1% for rivaroxaban (<20 mg daily). In scenarios where a patient met dosing criteria for reduced dose DOAC, 64.6% (apixaban 2.5 mg bid daily) and 71.7% (rivaroxaban 15 mg daily) of physicians chose the reduced dose DOAC answer. Only 32.1% of clinicians answered all 4 scenarios correctly. Among patients with AF, the median age was 65 years, 74% were female, 85% had AF >1 year and 89% were currently anticoagulated. Patients and physicians both ranked stroke prevention and avoiding severe bleeding very important when choosing a DOAC. Physicians were more likely than patients to rank cost as very important, patients were more likely than physicians to consider the following very important: may cause minor bleeding, the dose of med can be reduced if need to, reversal agent available, and how long the drug has been on market ( Figure ). Conclusions: DOAC dosing strategies may be driven by gaps in physician knowledge, on top of varying treatment beliefs and preferences between physicians and patients.

scholarly journals Differences in Preferences Between Clinicians and Patients for the Use and Dosing of Direct Oral Anticoagulants for Atrial Fibrillation

2021 ◽  
Author(s):  
Jennifer A. Rymer ◽  
Laura Webb ◽  
Debbe McCall ◽  
Mellanie T. Hills ◽  
Tracy Y. Wang
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Severe Bleeding ◽  
Nonvalvular Atrial Fibrillation ◽  
Reduced Dose ◽  
Hypothetical Patient ◽  
Primary Care Clinicians ◽  
Anticoagulated Patients

Background Direct oral anticoagulants (DOACs) are effective in reducing the stroke risk for patients with nonvalvular atrial fibrillation if prescribed at the labeled dose, yet underdosing is frequent. Little is known about clinician knowledge and patient or clinician preferences for DOAC dosing. Methods and Results From April 2019 to March 2020, 240 clinicians and 343 patients with atrial fibrillation completed an assessment of anticoagulation knowledge/preferences. Clinician knowledge of DOAC dosing was tested with 4 hypothetical patient scenarios. Patients and clinicians were asked to grade the importance of 25 factors in anticoagulation decision making. Among clinicians, the median age was 55 years, and 23% were primary care clinicians. In scenarios of a patient indicated for full‐dose DOAC, 41.2% of clinicians underdosed apixaban and 17.6% underdosed rivaroxaban. In scenarios of a patient indicated for reduced‐dose DOAC, 64.6% and 71.7% of clinicians chose to use reduced‐dose apixaban and rivaroxaban, respectively. Only 35.0% of clinicians correctly answered all 4 scenarios with the label‐indicated dose; this knowledge gap was similar between clinicians who did and did not underdose. Among patients with atrial fibrillation, the median age was 65 years, and 89% were currently anticoagulated. Patients and clinicians ranked stroke prevention and avoiding severe bleeding as very important to anticoagulation decision making. Patients were more likely than clinicians to rank the ability to reduce anticoagulation dose if needed as very important (70.5% versus 43.6%; P <0.001). Conclusions There are considerable knowledge gaps regarding DOAC dosing in clinicians treating patients with atrial fibrillation, as well as significant differences in treatment dosing preferences between clinicians and patients.

Direct Oral Anticoagulants in Patients with Cancer

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 877-877 ◽  
Author(s):  
Surbhi Shah ◽  
Yvonne H Datta ◽  
Faye Norby ◽  
Alvaro Alonso
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Confidence Interval ◽  
Cancer Patients ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Morbidity And Mortality ◽  
Severe Bleeding ◽  
Diagnostic Codes

Abstract Introduction Cancer patients are at high risk for morbidity and mortality due to thrombosis and bleeding, in addition they may also have pre-existing conditions, such as atrial fibrillation (AF) and prior venous thromboembolism (VTE), for which chronic anticoagulation may be indicated. Historically, warfarin was the most commonly prescribed anticoagulant for stroke prevention in AF patients. Since 2010, the US FDA has approved 4 alternative direct oral anticoagulants (DOACs) - dabigatran, rivaroxaban, apixaban, edoxaban to reduce the risk of stroke and systemic embolism in patients with AF. There is limited literature to support the use of DOACs in cancer patients, but they are being prescribed by medical professionals nonetheless. Therefore, additional research is necessary to determine the effectiveness of the DOACs in cancer patients, to quantify their bleeding risks, and to identify patients that are more likely to benefit from these new medications in comparison to warfarin. Large randomized clinical trials of DOACs compared to warfarin in cancer patients have not been performed. Our aim was to determine the effectiveness and associated risk of DOACs vs. warfarin in a large, real-world population of cancer patients with AF. Methods We identified 532,743 AF patients initiating oral anticoagulant use in 2010-2014 continuously enrolled in MarketScan databases. We selected 41,036 cancer patients with inpatient or outpatient ICD9 code 140.x-172.x and 174.x-209.x (excluded 173.x, non-melanoma skin cancer), and then identified a subset of cancer patients being actively treated at the time of anticoagulant initiation. Active cancer patients were defined by the use of chemotherapy, radiation therapy or cancer surgery within 6 months prior to the start of anticoagulation. Patients were categorized according to the first anticoagulant prescribed after AF diagnosis. DOAC users were matched with warfarin users by age (±3 years), sex, enrollment date (90 days), and anticoagulant initiation date (90 days). Study endpoints, including ischemic stroke, severe bleeding (intracranial hemorrhage, gastrointestinal bleeding), other bleeding (genitourinary bleeding, hemopericardium, hemarthrosis, epistaxis, hemoptysis and unspecified hemorrhage) and VTE were identified using inpatient diagnostic codes, and VTE was additionally identified from 2 outpatient diagnostic codes within the same year. Cox proportional hazards models were used to access the association between type of anticoagulant and outcomes adjusting for high-dimensional propensity score, age, sex, CHA2DS2-VASc score, and the prevalent outcome. Results The demographic profile of the patients included in the analysis are depicted in Table 1, and Table 2 summarizes the outcomes data. In this analysis there were 6,075 cancer patients with AF who were on DOACs (rivaroxaban 2808, dabigatran 2189, and apixaban 1078) compared to 10,021 on warfarin, with a mean age of 74 years, and a mean follow-up time of 1 year. Approximately 40% of the patients were woman, and breast cancer was the most common cancer in each cohort. We found that for rivaroxaban and dabigatran users, the adjusted hazard ratios for severe bleeding was non significantly different to warfarin users, however, apixaban users had a lower risk of severe bleeding compared to warfarin users, with a hazard ratio 0.37 (95% confidence interval 0.17-0.79, p=0.01). The risk of other bleeding was lower in dabigatran users compared to warfarin users with a hazard ratio 0.58 (95% confidence interval 0.41-0.84, p=0.003). The risk of ischemic stroke did not differ significantly amongst different anticoagulant users. Each of the DOACs was superior to warfarin in lowering the risk of incident VTE, with p values < 0.0001. Conclusion Based on this analysis the DOACs seem to be well tolerated in cancer patients in regard to the management of atrial fibrillation, with lower or similar rates of bleeding and stroke compared to warfarin users. Importantly, the DOAC users had a significantly lower risk of incident VTE. Given that VTE events contribute to significant morbidity and mortality in cancer patients, prescription of DOACs in place of warfarin can be considered in cancer patients with AF, while we are awaiting prospective data from randomized trials. Disclosures No relevant conflicts of interest to declare.

scholarly journals Developments in the management and treatment of pulmonary embolism

2015 ◽  
Vol 24 (137) ◽  
pp. 484-497 ◽  
Author(s):  
Rachel Limbrey ◽  
Luke Howard
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Primary Care Providers ◽  
Similar Efficacy ◽  
Individual Risk ◽  
Care Providers ◽  
Outpatient Services ◽  
Risk Patients

Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended.

Abstract 13721: Is Single Dose Interruption of Direct Oral Anticoagulants Necessary Before Atrial Fibrillation Ablation? A Systematic Review and Meta-analysis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ali H Jafry ◽  
Khawaja H Akhtar ◽  
Amna M Chaudhary ◽  
Safi U Khan ◽  
Mohammad S Khan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Single Dose ◽  
Observational Studies ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Minor Bleeding ◽  
Randomized Controlled ◽  
Significant Difference ◽  
Silent Cerebral Infarction ◽  
Ischemic Attack

Background: In patients with atrial fibrillation taking direct oral anticoagulants (DOACS) and undergoing catheter ablation, it is unclear if interruption of a single dose of DOAC before the procedure is necessary. We assessed the peri-procedural adverse events between uninterrupted vs single-dose interrupted DOACS. Methods: A systematic review of Medline and EMBASE was conducted and all randomized controlled trials (RCTs) and observational studies that compared uninterrupted versus interrupted DOACS were included. Random effects model was used and risk ratios (RR) with 95% confidence intervals (CI) were reported using Mantel Haenszel method. All studies defined dose interruption as holding a single dose of DOAC before ablation. Separate analyses were conducted for RCTs and observational studies. Results: Eight RCTs with 2656 patients and 4 observational studies with 834 patients were included. In RCT restricted analysis, no significant difference was seen in major bleeding [RR 0.65 (CI 0.30-1.42)], minor bleeding [RR 0.98 (0.68-1.40)], stroke/transient ischemic attack/thromboembolism [RR 0.90 (CI 0.27-2.98)] and silent cerebral infarction [RR 0.51 (CI 0.14-1.89)]. In observational study restricted analysis, no significant difference was seen in major bleeding [RR 3.04 (CI 0.13-74.07)], minor bleeding [RR 0.88 (0.46-1.69)], stroke/transient ischemic attack/thromboembolism [RR 0.98 (CI 0.12-7.91)] and a statistically significant lower silent cerebral infarction [RR 0.45 (CI 0.31-0.67)]. Conclusion: Uninterrupted DOACS are safe for patients undergoing AF ablation and logistically easier for patients. Figure 1: Forest plot showing outcomes with uninterrupted vs interrupted direct oral anticoagulants in patients undergoing ablation for atrial fibrillation in randomized controlled trials.

scholarly journals Knowledge about specific reversal agent of Greek AF patients on direct oral anticoagulants

2021 ◽  
Vol 20 (Supplement_1) ◽  
Author(s):  
A Ioannidis ◽  
A Pechlevanis ◽  
A Pechlevanis ◽  
M Paraskelidou ◽  
M Paraskelidou ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Event ◽  
Antiplatelet Agents ◽  
City Hospital ◽  
Reversal Agent ◽  
Northern Greece ◽  
Waiting Room ◽  
Reversal Agents

Abstract Funding Acknowledgements Type of funding sources: None. Background Clinical guidelines recommend taking into account the patient’s preference when deciding on the options of direct oral anticoagulation (DOAC) therapy. Therefore, education is a prerequisite for informed, involved patients and patient-centred care. Purpose The aim of this study was to assess the patient’s awareness about the existence of the dabigatran specific reversal agent (Idarucizumab) and whether the patient was involved in the decision of the specific DOAC regimen. Methods Non-valvular atrial fibrillation (AF) patients on DOAC who visited the outpatient clinics of a city hospital in northern Greece were invited to participate. This project was part of the validation study of the Greek version of the Jessa Atrial fibrillation Knowledge Questionnaire. Analyses were performed by IBM SPSS Statistics. Results In total, there were 312 participants (168 females, 53.8%) with mean age: 64 ± 5.3 years old. The vast majority of patients (256, 82.1%) were not aware of the existence of any specific reversal agent regardless the socio-economic status (annual income, years of schooling) or the duration and type of AF. Patients that were switched from a vitamin-K antagonist (acenocoumarol) to a DOAC were more likely to be informed about specific reversal agents (31 out of 63 patients switched to DOAC, 49.2% vs. 10.0%, p &lt; 0.05). Similarly, patients taking more than 5 pills per day were more likely to know about the reversal agent (41 of the 193 patients, 21.2% vs. 12.6%). Moreover, the majority of patients that reported any bleeding event that lead to seeking medical advice (minor or major bleeding) were informed about the specific reversal agent (35 out of 52 patients reporting bleeding event, 67.3% vs. 8.1%, p &lt; 0.05). Inappropriately, only seven of the 38 patients (18.4%) that were also taking antiplatelet agents (mainly acetylsalicylic acid or clopidogrel) were aware of specific DOAC reversal agents. Patients with history of stoke or transient ischaemic attack were also better informed (38 out of 53 patients, 71.7% vs. 6.9%). Only about one of five patients on dabigatran (27 out of 129, 20.9%) knew about the dabigatran specific reversal agent, mainly from sources other than their doctor (e.g. journal in office waiting room). All patients agreed that they would prefer to have been informed about the current specific reversal agents when deciding on DOAC therapy. No data could be collected why patients who were informed about specific reversal agent were not prescribed dabigatran. Conclusions The sample of Greek non-valvular AF patients showed a noticeably low awareness of the existence of the specific DOAC reversal agent. It seems that DOAC prescription was a rather limited shared decision. Further research is warranted to confirm the aforementioned results.

Uninterrupted direct oral anticoagulants and vitamin K antagonists during ablation for atrial fibrillation: an updated meta-analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Brockmeyer ◽  
Y Lin ◽  
C Parco ◽  
A Karathanos ◽  
T Krieger ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Major Bleeding ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Funding Source ◽  
Minor Bleeding ◽  
Secondary Outcomes

Abstract Background Uninterrupted anticoagulation during catheter ablation of atrial fibrillation (CAAF) became standard of care after positive results of trials investigating vitamin K antagonists (VKA). Previous studies and meta-analyses of uninterrupted direct oral anticoagulants (DOAC) vs. VKA have given controversial results. We thus aimed to elucidate the risks and benefits of uninterrupted DOAC vs. VKA during CAAF in an updated meta-analysis of randomized controlled trials (RCTs). Methods Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing CAAF until September 2019. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (ACL) and mortality. Results Six eligible RCTs comprising 2,369 patients were included. Pooled meta-analysis showed no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30–1.56; p=0.37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20–4.72; p=0.97). There were no significant differences found in secondary outcomes (OR 0.73, p=0.49 for composite of major bleeding and stroke or TIA; OR 1.08, p=0.52 for minor bleeding; OR 1.12, p=0.59 for ACL; and OR=0.60, p=0.64 for all-cause mortality). Conclusion Our meta-analysis suggests that uninterrupted periprocedural anticoagulation with DOAC or VKA is characterized by a similar risk/benefit ratio in patients undergoing CAAF with comparable rates of major bleeding and stroke. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Medical faculty of the Heinrich-Heine-University Düsseldorf, Germany

Reduced Dose Direct Oral Anticoagulants in Older Adults with Atrial Fibrillation

2019 ◽  
Vol 8 (1) ◽  
pp. 43-48
Author(s):  
Silu Zuo ◽  
Billy Chen ◽  
Akash Kataruka ◽  
Sean M. Bell
Keyword(s):  
Atrial Fibrillation ◽  
Older Adults ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Reduced Dose
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