scholarly journals Direct Anticoagulants and Risk of Myocardial Infarction, a Multiple Treatment Network Meta-Analysis

Angiology ◽  
2019 ◽  
Vol 71 (1) ◽  
pp. 27-37 ◽  
Author(s):  
Péter Kupó ◽  
Zsolt Szakács ◽  
Margit Solymár ◽  
Tamás Habon ◽  
László Czopf ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Relative Risk ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Credible Interval ◽  
Control Group ◽  
Cardiovascular Safety ◽  
Coronary Syndrome

We assessed the cardiovascular safety of long-term direct-acting oral anticoagulant (DOAC) treatment. A search of the medical literature was performed from inception until May 31, 2019. Inclusion criteria were (1) randomized trial that assessed the clinical efficacy and/or safety of 1 or more DOAC, (2) control group including oral anticoagulation and/or antiplatelet and/or placebo treatment, and (3) the incidence of acute coronary syndrome during follow-up was reported. Fixed-effect and random-effects models were applied. The analyzed outcomes were myocardial infarction (MI), major bleeding, and mortality. Twenty-eight randomized clinical trials (196 761 patients) were included. Rivaroxaban was associated with a 21% reduction in the relative risk of MI when compared to placebo (relative risk [RR]: 0.79 [95% credible interval, CrI: 0.65-0.94]) and a 31% reduction (RR: 0.70 [95% CrI: 0.53-0.89]) when compared to dabigatran. Apixaban resulted in 24% (RR: 0.76 [95% CrI: 0.58-0.99]) and vitamin K antagonists anticoagulation resulted in 19% (RR: 0.81 [95% CrI: 0.65-0.98]) risk reduction compared to dabigatran. The computed probability of being the first best choice of treatment was 61.8% for rivaroxaban. Cardiovascular safety shows considerable heterogeneity among oral anticoagulants. Treatment with rivaroxaban is associated with reduced rate of MI.

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

2020 ◽  
pp. 107424842096764 ◽  
Author(s):  
John M. Cochran ◽  
Xiaoming Jia ◽  
Jessica Kaczmarek ◽  
Kristen A. Staggers ◽  
Mahmoud Al Rifai ◽  
...  
Keyword(s):  
Controlled Trial ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Left Ventricular ◽  
Left Ventricular Thrombus ◽  
Coronary Syndrome ◽  
Ventricular Thrombus ◽  
Existing Data

Aim: To compare the safety and efficacy of direct oral anticoagulants (DOAC) relative to vitamin K antagonists (VKA) for the treatment of left ventricular thrombus (LVT). Methods: This retrospective study enrolled patients diagnosed with LVT from 2014-2017. Patient characteristics and outcomes within 12 months of LVT diagnosis were recorded and analyzed. A meta-analysis was also performed by pooling our results with existing data in literature. Results: 14 DOAC and 59 VKA patients were included. Baseline demographic and clinical characteristics were similar except for age. Although more strokes within 12 months occurred in VKA (15%) than in DOAC (0%) patients, this was not statistically significant (p = 0.189). There were no significant differences in outcomes between patients on DOAC and VKA for acute coronary syndrome (ACS) (7%, vs 3.4%, p = .477), LVT resolution (86% vs 76%, p = .499) or bleeding (14% vs 14%, p = 1) within 12 months. The meta-analysis included 6 studies (n = 408 for DOACs; n = 1207 for VKA). There were no significant differences between DOACs versus VKAs with respect to odds for unresolved thrombus (OR 0.61, 95% CI 0.26,1.41), embolic events (OR 1.24, 95% CI 0.90,1.69), embolic events and death (OR 1.10, 95% CI 0.84,1.45) or bleeding events (OR 1.13, 95% CI 0.74,1.72). Conclusions: Our study and meta-analysis suggest similar efficacy and safety of DOACs in the treatment of LVT compared to VKA. These findings underscore the need for a randomized controlled trial.

scholarly journals Stroke prevention for non-valvular atrial fibrillation: how to make the right choice of directly acting oral anticoagulants?

2019 ◽  
pp. 94-102
Author(s):  
N. N. Kryukov ◽  
E. V. Sayutina ◽  
A. M. Osadchuk ◽  
M. A. Osadchuk
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Vitamin K ◽  
Randomized Clinical Trials ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Individual Risk ◽  
Stroke Risk Factor ◽  
Coronary Syndrome

Patients with atrial fibrillation have a high risk of developing stroke and death, which requires constant anticoagulant support. In this regard, the physician faces the difficult task of selecting the appropriate oral anticoagulant for patient with individual risk factors and comorbidities. Currently, three non-vitamin K antagonist oral anticoagulants or directly acting oral anticoagulants have been registered in the Russia, which in large randomized clinical trials (RCTs) were compared with warfarin in the prevention of stroke and systemic embolism. The present article analyzes the data of RCTs, postmarketing studies of oral anticoagulants, and presents groups of patients for whom these drugs are preferred. The choice of oral anticoagulants for the prevention of stroke in the following subgroups of patients with atrial fibrillation is discussed: patients with one stroke risk factor (CHA2DS2VASc1 in men or 2 in women), patients of different age groups, patients with concomitant coronary artery disease/acute coronary syndrome, a history of stroke, patients with chronic kidney disease, patients with a high risk of gastrointestinal bleeding, and a group of patients with concomitant arterial hypertension and chronic heart failure. We compared the efficacy and safety of oral non-vitamin K antagonist oral anticoagulants or directly acting oral anticoagulants with vitamin K antagonists in patients with non-valvular atrial fibrillation.

scholarly journals Patient with myocardial infarction, atrial fibrillation and high risk for hemorrhage: reasonable choice of anticoagulant for effective prevention of ischemic events

2019 ◽  
Vol 7 (4S) ◽  
pp. 135-145 ◽  
Author(s):  
T. B. Pecherina ◽  
V. O. Zlydneva ◽  
V. V. Kashtalap ◽  
O. L. Barbarash
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Clinical Practice ◽  
High Risk ◽  
Randomized Clinical Trials ◽  
Case Reports ◽  
Oral Anticoagulants ◽  
Effective Prevention ◽  
Continuous Increase ◽  
Coronary Syndrome

Current clinical practice faces the challenges in selecting optimal drugs and the duration of antithrombotic treatment in patients with acute coronary syndrome with atrial fibrillation. A continuous increase of using non-vitamin K oral anticoagulants (NOAC), dabigatran, rivaroxaban, apixaban, edoxaban, and novel antiplatelet agents, prasugrel and ticagrelor, has complicated the decision-making process in this group of patients. The presented clinical case reports the use of dabigatran as a part of double antithrombotic therapy in an elderly patient with type 2 myocardial infarction, paroxysmal AF and a high risk for hemorrhage. The drug choice and its dosage were chosen using the personalized risk assessment. The presented approach has been early proved by the results of the recent randomized clinical trials and, therefore, may be translated into routine clinical practice.

scholarly journals Intensive treatment of hyperglycemia in the acute phase of myocardial infarction: the tenuous balance between effectiveness and safety – a systematic review and meta-analysis of randomized clinical trials

2019 ◽  
Vol 65 (1) ◽  
pp. 24-32 ◽  
Author(s):  
Paulo H. Negreiros ◽  
Adriana Bau ◽  
Wilson Nadruz ◽  
Otavio R. Coelho Filho ◽  
José Roberto Matos-Souza ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Clinical Trials ◽  
Blood Glucose ◽  
Acute Phase ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Blood Glucose Control ◽  
Cochrane Library ◽  
Control Group ◽  
Average Blood Glucose

SUMMARY INTRODUCTION In acute myocardial infarction (AMI), each 18 mg/dl (1 mmol/L) increment is associated with a 3% increase in mortality rates. All strategies applied for reducing blood glucose to this date, however, have not presented encouraging results. METHODOLOGY We searched the Medline (PubMed) and Cochrane Library databases for randomized clinical trials (RCTs) from 1995 to 2017 that used the intensive strategy or GIK therapy for blood glucose control during the acute stage of the AMI. We included eight studies. In order to identify the effects of GIK or insulin therapy, we calculated a overall risk ratio (RR) with meta-analysis of fixed and random effects models. A two-tail p-value of < 0.05 was considered statistically significant. RESULTS A total of 28,151 patients were included: 1,379 intensively treated with insulin, 13,031 in GIK group, and 13,741 in the control group. The total mortality was 10.5% (n=2,961) and the RR of 1.03 [95%CI 0.96–1.10]; I2 = 31%; p = 0.41 for the combined intensive insulin plus GIK groups in comparison with the control group. In meta-regression analyses, intense reductions in blood glucose (> 36 mg/dL) in relation to the estimated average blood glucose (estimated by HbA1c) were associated with higher mortality, whereas lower reductions in blood glucose (< 36 mg/dL) were not associated with mortality. The lowering of blood glucose in the acute phase of MI compared with the average blood glucose was more effective around 18 mg/dL. CONCLUSION This meta-analysis suggests that there may be a tenuous line between the effectiveness and safety of reducing blood glucose in the acute phase of MI. The targets must not exceed a reduction greater than 36 mg/dL in relation to estimated average blood glucose.

scholarly journals Efficacy and safety of direct oral anticoagulants for secondary prevention of cancer associated thrombosis: a meta-analysis of randomized controlled trials

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Ruchi Desai ◽  
Gautam Krishna Koipallil ◽  
Nelson Thomas ◽  
Rahul Mhaskar ◽  
Nathan Visweshwar ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Increased Risk ◽  
Recurrent Vte ◽  
Cancer Associated Thrombosis

Abstract Direct oral anticoagulants (DOACs) may be good alternatives to low molecular weight heparin (LMWH) or vitamin K antagonists (VKA) for treatment of cancer associated thrombosis (CAT). We conducted a meta-analysis of ten randomized clinical trials to evaluate the efficacy and safety of DOACs in patients with CAT. All had study populations composed in entirety or in part of patients with CAT. The primary outcome (efficacy) was recurrent VTE and the secondary outcomes (safety outcomes) included major bleeding, clinically relevant non-major bleeding (CRNMB), and all bleeding (major bleeding + CRNMB). Participants treated with DOACs had lower risk of recurrent VTE, overall (RR 0.63; 95% CI 0.51–0.79; p < 0.0001), compared to LMWH (RR 0.57; 95% CI 0.40–0.83; p = 0.003), but not compared to VKA (RR 0.69; 95% CI 0.44–1.06; p = 0.09). Compared to LMWH, DOACs showed no difference in major bleeding risk (RR 1.31; 95% CI 0.78–2.18; p = 0.31), though had higher risk of CRNMB (RR 1.60; 95% CI 1.13–2.26; p = 0.008) and all bleeding (RR 1.49; 95% CI 1.10–2.01; p = 0.010). These results indicate that DOACs are more effective than LMWH for prevention of recurrent VTE with CAT though carry an increased risk for non-major bleeding compared to standard of care, LMWH.

scholarly journals Updated Meta-Analysis of Randomized Controlled Trials on Primary Ambulatory Thromboprophylaxis (PATP) in Patients with Advanced Pancreatic Cancer (APC) Receiving Chemotherapy

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3469-3469 ◽  
Author(s):  
Kyaw Zin Thein ◽  
Donald P. Quick ◽  
Thein H. Oo
Keyword(s):  
Relative Risk ◽  
High Risk ◽  
Cancer Patients ◽  
Fixed Effects ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Advanced Pancreatic Cancer ◽  
Control Group ◽  
Number Needed To Treat ◽  
Solid Cancer

Introduction: Thrombosis is the second leading cause of death in cancer patients and patients with APC are categorized as high-risk of developing venous thromboembolism (VTE). Many trials had failed to demonstrate improvement in survival with PATP. Despite decreasing VTE events, PATP in solid cancer patients is not routinely recommended. We conducted an updated meta- analysis of RCTs to determine the benefit and risk of PATP with low-molecular weight heparins (LMWH) and direct oral anticoagulants (DOAC) in patients with APC receiving chemotherapy. Methods: We performed a comprehensive literature search using MEDLINE and EMBASE databases through June 30, 2019. The references of all potential studies were also reviewed for any additional relevant studies. The RCTs with reduction in VTE as a primary or secondary endpoint and the major bleeding (MB) as a safety outcome were incorporated in the analysis. The primary meta- analytic approach was a random effects model using the Mantel-Haenszel (MH) method. It was used to calculate the estimated pooled risk ratio (RR), and risk difference (RD) with 95% confidence interval (CI). Heterogeneity was assessed with Cochran's Q- statistic. Results: A total of 1,013 patients with APC from two RCTs and a subgroup of another three RCTs were included in our meta-analysis. The prophylactic, intermediate and therapeutic doses of LMWH and prophylactic dose of DOAC (rivaroxaban) were used in the studies. The duration of LMWH and DOAC ranged from 3 to 6 months. The randomization ratio was 2 to 1 in PROTECHT study and 1 to 1 in all other studies. The I2statistic for heterogeneity was 60, suggesting some heterogeneity among RCTs. The VTE incidence was 28 (5.43%) in PATP group and 60 (12.07%) in control group with a RR of 0.44 (95% CI: 0.20 to 0.99, P = 0.05) and RD of -0.06 (95% CI: -0.11 to -0.01, P = 0.01). In fixed effects model, the pooled RR was 0.45 (95% CI: 0.29 to 0.70, P = 0.0003) and the absolute RD in VTE was -0.07 (95% CI: -0.10 to -0.03, P = 0.0002) with an estimate of the number needed to treat (NNT) of 15 to prevent one VTE event. MB events were reported in 9 (4.11%) patients in PATP group compared to 7 (3.27%) in control group according to an analysis of 2 RCTs. The pooled relative risk for MB was statistically non-significant at 1.25 (95% CI: 0.47 to 3.31, P = 0.65). Conclusions: In our study, PATP in APC may statistically significantly decrease VTE events, approximately with relative risk reduction of 55% and a NNT of 15, without increasing MB events. Proper selection of patients who are high risk for VTE in outpatient setting is important. More RCTs are required to further define high risk subsets of APC patients receiving chemotherapy who may benefit from PATP. Disclosures Oo: Medical Education Speakers Network: Honoraria; Janssen and Janssen: Other: Research: site co-investigator .

Abstract 14950: Meta-analysis of Oral Anticoagulants With Dual vs Single Antiplatelet Therapy in Patients After Coronary Intervention

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Alexandros Briasoulis ◽  
Shikha Sharma ◽  
Sagar Mallikethi-Reddy ◽  
Nikolaos Papageorgiou ◽  
Mohan Palla ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cohort Studies ◽  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Antithrombotic Therapy ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Coronary Syndrome ◽  
All Cause Mortality ◽  
Triple Antithrombotic Therapy

Background: Combined use of dual antiplatelet therapy with oral anticoagulation (OAC) is required in some patients with after coronary artery stenting or acute coronary syndrome (ACS). Methods: We performed a meta-analysis of the comparative effects of triple antithrombotic therapy (TT) vs OAC with single antiplatelet therapy (DT) on all-cause mortality, stroke, cardiovascular death, myocardial infarction, target vessel revascularization and major bleeding. We conducted an EMBASE and MEDLINE search for prospective controlled trials and cohort studies of patients requiring anticoagulation after coronary stenting. Results: We identified 3 prospective controlled studies and 5 cohort studies, which compared TT vs dual therapy (DT). We identified 4 prospective controlled and 6 cohort studies with 4564 patients on TT and 1848 on DT with an average follow up duration of 10.1 months. TT is associated with similar rates of all-cause mortality, stroke and major bleeding but significantly lower rates of myocardial infarction compared to DT (mainly OAC plus clopidogrel). Conclusion: Triple antithrombotic therapy is associated with similar mortality and bleeding rates but less myocardial infarctions compared with OAC and single antiplatelet therapy.

Safety and efficacy of direct acting oral anticoagulants and vitamin K antagonists in nonvalvular atrial fibrillation – a network meta-analysis of real-world data

VASA ◽  
2019 ◽  
Vol 48 (2) ◽  
pp. 134-147 ◽  
Author(s):  
Mirko Hirschl ◽  
Michael Kundi
Keyword(s):  
Real World ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Nonvalvular Atrial Fibrillation ◽  
Real World Data ◽  
Hazard Ratios ◽  
Direct Acting ◽  
Event Rates

Abstract. Background: In randomized controlled trials (RCTs) direct acting oral anticoagulants (DOACs) showed a superior risk-benefit profile in comparison to vitamin K antagonists (VKAs) for patients with nonvalvular atrial fibrillation. Patients enrolled in such studies do not necessarily reflect the whole target population treated in real-world practice. Materials and methods: By a systematic literature search, 88 studies including 3,351,628 patients providing over 2.9 million patient-years of follow-up were identified. Hazard ratios and event-rates for the main efficacy and safety outcomes were extracted and the results for DOACs and VKAs combined by network meta-analysis. In addition, meta-regression was performed to identify factors responsible for heterogeneity across studies. Results: For stroke and systemic embolism as well as for major bleeding and intracranial bleeding real-world studies gave virtually the same result as RCTs with higher efficacy and lower major bleeding risk (for dabigatran and apixaban) and lower risk of intracranial bleeding (all DOACs) compared to VKAs. Results for gastrointestinal bleeding were consistently better for DOACs and hazard ratios of myocardial infarction were significantly lower in real-world for dabigatran and apixaban compared to RCTs. By a ranking analysis we found that apixaban is the safest anticoagulant drug, while rivaroxaban closely followed by dabigatran are the most efficacious. Risk of bias and heterogeneity was assessed and had little impact on the overall results. Analysis of effect modification could guide the clinical decision as no single DOAC was superior/inferior to the others under all conditions. Conclusions: DOACs were at least as efficacious as VKAs. In terms of safety endpoints, DOACs performed better under real-world conditions than in RCTs. The current real-world data showed that differences in efficacy and safety, despite generally low event rates, exist between DOACs. Knowledge about these differences in performance can contribute to a more personalized medicine.

scholarly journals EXPRESS: Stroke risk following traumatic brain injury: systematic review and meta-analysis

2021 ◽  
pp. 174749302110042
Author(s):  
Grace Mary Turner ◽  
Christel McMullan ◽  
Olalekan Lee Aiyegbusi ◽  
Danai Bem ◽  
Tom Marshall ◽  
...  
Keyword(s):  
Systematic Review ◽  
Stroke Risk ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Cochrane Library ◽  
Control Group ◽  
Large Sample Size ◽  
Hazard Ratios ◽  
Increased Risk ◽  
The Cochrane Library

Aims To investigate the association between TBI and stroke risk. Summary of review We undertook a systematic review of MEDLINE, EMBASE, CINAHL, and The Cochrane Library from inception to 4th December 2020. We used random-effects meta-analysis to pool hazard ratios (HR) for studies which reported stroke risk post-TBI compared to controls. Searches identified 10,501 records; 58 full texts were assessed for eligibility and 18 met the inclusion criteria. The review included a large sample size of 2,606,379 participants from four countries. Six studies included a non-TBI control group, all found TBI patients had significantly increased risk of stroke compared to controls (pooled HR 1.86; 95% CI 1.46-2.37). Findings suggest stroke risk may be highest in the first four months post-TBI, but remains significant up to five years post-TBI. TBI appears to be associated with increased stroke risk regardless of severity or subtype of TBI. There was some evidence to suggest an association between reduced stroke risk post-TBI and Vitamin K antagonists and statins, but increased stroke risk with certain classes of antidepressants. Conclusion TBI is an independent risk factor for stroke, regardless of TBI severity or type. Post-TBI review and management of risk factors for stroke may be warranted.

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