Problem of prescribing anticoagulant therapy in patients with atrial fibrillation on the regional level

Introduction. Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, with heart rhythm disorders accounting for a significant proportion of them. Atrial fibrillation (AF) is an arrhythmia that poses a risk of thromboembolic complications and is difficult to treat with ongoing preventive anticoagulant therapy. Aim of the study. To analyze the prescription of anticoagulant therapy to patients with AF on the regional level. Methods and results. The study included 72 patients with the nonvalvular form of AF (from 41 to 82 years old) of the Department of Rhythm and Conductivity Abnormalities of the State Budgetary Institution of the Republic of Mordovia RCH № 4 for 2019. Three groups were singled out depending on the AF form: the first one – patients with the constant form (n = 22), the second one (n = 24) – with the persistent form, the third one (n = 24) – with the paroxysmal form. The risk of thromboembolic complications was assessed using the CHA2DS2-VASc scale and hemorrhagic complications using the HAS-BLED scale. All patients had a high risk of thromboembolism (index above 2 points), which reflects multiple risk factors and indicates the need for oral anticoagulants (OAC). According to HAS-BLED scale calculations, the risk of haemorrhagic complications was low in most patients (2 or less points) – there was no significant increase in the risk of bleeding, but careful monitoring is required. Analysis of the results revealed that only 54% of patients took OAC, despite the fact that all patients were shown anticoagulant therapy. When analyzing the cases of patients who did not take anticoagulants, it was found that 23% of patients, despite the doctor’s recommendations, refused to take the drugs, 47% of patients justified the inability to control IHR and 30% were unable to purchase expensive new OAC. Conclusion. Despite the recommendations for the management of patients with atrial fibrillation, only 54% were prescribed oral anticoagulants.

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HAS-BLED scor system for the assessment of risk of breathing of patients on oral anticoagulant therapy // HAS-BLED skor sistem bodovanja za procjenu rizika od krvarenja pacijenata na oralnoj antikoagulantnoj terapiji

SESTRINSKI ŽURNAL ◽

10.7251/sez0118011d ◽

2018 ◽

Vol 5 (1) ◽

pp. 11

Author(s):

Daniela Dobrovoljski

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Heart Rhythm ◽

Clinical Problem ◽

Coagulation Factors ◽

Heart Rhythm Disorders ◽

Anticoagulant Drugs

Oral anticoagulant drugs (OALs) are effective agents in the prevention and treatment of thromboembolic complications. However, despite standardization and application progression, OALs represent a significant clinical problem because they are small-therapeutic medicines that easily interact with food and medicine, which can substantially affect the increased or weakened therapeutic effect. Oral anticoagulants are 4-hydroxycoumarin derivatives and vitamin K antagonists, and their pharmacological activity is based on inhibition of the synthesis of coagulation factors in the liver. These drugs are effective in the prevention of venous thromboembolism, acute myocardial infarction (AIM), heart rhythm disorders by type of atrial fibrillation, stroke prevention, and the like. The most important and clinically commonly undesirable effect of OAL is bleeding. The risk of bleeding is greatest during the introduction of the drug in therapy and for the first few months of the onset of therapy. HAS-BLED scor is a skoring system developed to estimate the 1-year risk of major bleeding in patients with atrial fibrillation and is also used for other indications.

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Comparative Analysis of Antithrombotic Therapy in In-Patients with Atrial Fibrillation

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2019-15-1-49-53 ◽

2019 ◽

Vol 15 (1) ◽

pp. 49-53

Author(s):

V. I. Petrov ◽

O. V. Shatalova ◽

A. S. Gerasimenko ◽

V. S. Gorbatenko

Keyword(s):

Atrial Fibrillation ◽

High Risk ◽

Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Thromboembolic Complications ◽

Antithrombotic Agents ◽

Cardiology Department ◽

Number Of Patients

Aim. To study the frequency of prescribing antithrombotic agents in patients with non-valvular atrial fibrillation (AF) who were hospitalized in the cardiology department of a multidisciplinary hospital.Material and methods. A retrospective one-time study of medical records of 765 patients with non-valvular AF treated in the cardiology department of a multidisciplinary hospital in 2012 and 2016 was performed.Results. All patients were stratified in three groups depending on the CHA2DS2-VASc score. The frequency of prescribing antithrombotic agents was evaluated in each group. A low risk of thromboembolic complications was found in 1% (n=3) of patients in 2012 and 0.6% (n=3) in 2016. All these patients received antithrombotic agents. CHA2DS2-VASc=1 was found in 6% (n=15) of patients with AF in 2012 and in 3.4% (n=17) in 2016. A significant number of patients in this group received anticoagulant therapy with vitamin K antagonists (warfarin) or with direct oral anticoagulants. A high risk of thromboembolic complications (CHA2DS2-VASc≥2) was found in 93% of patient (n=245) in 2012 and in 96% (n=482) in 2016. Anticoagulant therapy was prescribed in 70.2% (n=172) patients with high risk in 2012 and 80% (n=387) in 2016. However, some patients with high risk of thromboembolic complications did not have the necessary therapy.Conclusion. Positive changes in the structure and frequency of prescribing anticoagulant drugs in patients with AF and a high risk of thromboembolic complications were found during the years studied.

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Direct oral anticoagulants in atrial fibrillation patients aged 75 years or older: Efficacy and safety balance

Terapevticheskii arkhiv ◽

10.17116/terarkh20178944-7 ◽

2017 ◽

Vol 89 (4) ◽

pp. 4-7 ◽

Cited By ~ 2

Author(s):

V V Fomin ◽

A A Svistunov ◽

D A Napalkov ◽

A A Sokolova ◽

M A Gabitova

Keyword(s):

Atrial Fibrillation ◽

Elderly Patients ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Research Programme ◽

Heart Rhythm ◽

Scientific Data ◽

Treatment And Prevention ◽

Heart Rhythm Disorders ◽

Prevention Of Thromboembolic Events

Atrial fibrillation (AF) is one of the most common heart rhythm disorders in the population. Researchers revealed a direct relationship between their incidence and a patient’s age long ago. One of the most challenging issues of clinical practice in patients with AF is anticoagulant therapy used in the so-called very elderly patients aged 75 years and older when age itself is a risk factor for developing both thromboembolic and hemorrhagic events due to anticoagulants, regardless of the mechanism of action of the latter. However, scientific data regarding the treatment and prevention of thromboembolic events in elderly and senile patients with AF are very scarce and often uninformative. The data from the EURObservational Research Programme-Atrial Fibrillation Registry Pilot Phase (EORP-AF Pilot) and the randomized clinical studies RELY, ROCKET AF, ARISTOTLE, and AVERROES were analyzed to identify the most safe and most effective anticoagulant for elderly patients (over 75 years). Relying on the analyses of literature data, the authors propose an algorithm based on clinical characteristics for choosing the anticoagulant for patients older than 75 years.

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PHARMACODYNAMICS OF ORAL ANTICOAGULANTS IN PATIENTS WITH ATRIAL FIBRILLATION IN THE ACUTE PERIOD OF ISCHEMIC STROKE

Pharmacy & Pharmacology ◽

10.19163/2307-9266-2020-8-4-222-232 ◽

2021 ◽

Vol 8 (4) ◽

pp. 222-232

Author(s):

V. I. Petrov ◽

A. S. Gerasimenko ◽

V. S. Gorbatenko ◽

O. V. Shatalova

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Cochrane Library ◽

Optimal Time ◽

Thromboembolic Complications ◽

Acute Period ◽

History Of ◽

Patient’S History

Background. Every fifth ischemic stroke is caused by a patient’s history of atrial fibrillation. Nowadays, direct and indirect oral anticoagulants are widely used to prevent thromboembolic complications in patients with atrial fibrillation. However, despite the prescription of this group of drugs, every year 1–2% of patients with atrial fibrillation have an ischemic stroke. In this situation, a number of questions take rise: if it is possible to carry out thrombolytic therapy in the patients who have been taking anticoagulants; if it is worth resuming anticoagulant therapy after a stroke; when exactly this should be done; and what drugs should be used to prevent another stroke.The aim of this review was to summarize the available clinical guidelines and research results on the study of the anticoagu- lant therapy characteristics in patients with atrial fibrillation after an ischemic stroke.Materials and methods. For this review, the information presented in the scientific literature from open and available sourc- es, has been used. The information had been placed in the following electronic databases: PubMed, Scopus, Web of Sci- ence Core Collection, Cochrane Library, ClinicalTrials.gov; Elibrary, Cyberleninka, Google Academy. The covering period was 1997–2020. The search queries were: “ischemic stroke + atrial fibrillation + anticoagulants”; “ischemic stroke + atrial fibrillation + direct oral coagulants” and “atrial fibrillation + ischemic stroke + warfarin” in both Russian and English equivalents.Results and conclusion. Currently, the problem of the use of anticoagulants for the prevention of recurrent thromboembolic complications in patients with AF in the acute period of a stroke, is studied insufficiently. The difficulties are caused by the delivery of TLT in the patients who have been taking DOACs, first of all, due to the impossibility of an accurate assessment of the hemostasis state because of the unavailability of routine specific tests; and second, as a result of the lack of registered antidotes for most drugs, and their high costs. Besides, there are no RCTs dedicated to the study of the optimal time for the resumption or initiation of anticoagulant therapy in the acute period of an IS, and the optimal drugs for this group of patients. Most of the existing recommendations on these aspects, are based on the consensus of experts, and this fact indicates the need for further research in the area under review.

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Pharmacoeconomic aspects of warfarin and new oral anticoagulants use as prevention of thromboembolic complications in patients with atrial fibrillation

Ukrainian Journal of Cardiology ◽

10.31928/1608-635x-2020.4.4553 ◽

2020 ◽

Vol 27 (4) ◽

pp. 45-53

Author(s):

N. V. Bezditko

Keyword(s):

Atrial Fibrillation ◽

Health Care ◽

Anticoagulant Therapy ◽

Direct Action ◽

Oral Anticoagulants ◽

Drug Consumption ◽

Thromboembolic Complications ◽

Total Consumption ◽

Number Of Patients ◽

The Cost

The aim – assessment of pharmacoeconomic feasibility of use for the prevention of thromboembolic complications (cerebral or systemic embolism) in patients with atrial fibrillation indirect anticoagulant warfarin compared with oral anticoagulants direct action in the modern Ukrainian health care system.Materials and methods. Used pharmacoeconomic methods to minimize costs, the mysterious cost of the disease. The supply of medications was determined according to the methodology of PBX/DDD, the economic affordability of medications was determined according to the value of the indicator Ca.s.Results and discussion. Drug consumption was determined according to the ATC/DDD methodology based on the data of the drug market research system Pharmexplorer, the economic availability of drugs was determined according to the value of Ca.s. An analysis of the comparative efficacy and safety of NOAC and warfarin according to the latest systematic reviews and meta-analyzes. According to the results of the analysis of the pharmaceutical market, it is established that currently in active retail sale in Ukraine there are 15 drugs NOAC (2 drugs apixaban, 6 drugs dabigatran and 7 drugs rivaroxaban) and 11 medications warfarin from 4 manufacturers. It is determined which drugs containing the same substance are the cheapest in terms of the cost of one DDD. It is established that the indicator of Ca.s. 80 % of warfarin drugs are moderately available, and all NOAC s are not available. The level of total consumption of anticoagulant drugs in Ukraine in 2019 was 1.7 DDDs, which, taking into account the prevalence of AF, suggests the existence of a significant number of patients with AF who do not receive appropriate anticoagulant therapy. It is established that the level of drug consumption does not depend on the cost of the drug.Conclusions. Under the current conditions of the health care system of Ukraine, warfarin is a more cost-effective drug for the treatment of atrial fibrillation in comparison with NOAC, which should be taken into account when implementing individualized pharmacotherapy of patients. According to the analysis of consumption volumes, it can be assumed that in Ukraine there is a large number of patients with AF who do not receive anticoagulant therapy.

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Anticoagulant therapy in patients with atrial fibrillation and concomitant chronic kidney disease: the results of a prospective study

Medical Council ◽

10.21518/2079-701x-2019-5-14-19 ◽

2019 ◽

pp. 14-19

Author(s):

I. S. Daabul ◽

A. A. Sokolova ◽

I. L. Tsarev ◽

D. A. Napalkov ◽

V. V. Fomin

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Kidney Function ◽

Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Thromboembolic Complications ◽

Hemorrhagic Events

In recent years, both Russian and foreign authors have published many papers on anticoagulant therapy for atrial fibrillation (AF). The largest are devoted to the study of direct oral anticoagulants (DOACs), which have appeared in this field since 2009, and their comparison with vitamin K antagonists (VKAs) in terms of efficacy, safety and other important characteristics. There are far fewer studies on DOACs and their comparison with VKAs and with each other in patients with AF and reduced kidney function. Most of them are retrospective. Meanwhile, the prevalence of chronic kidney disease (CKD) in the population is very high, and doctors are faced with a problem of selecting anticoagulant therapy for these patients.Purpose. To assess the effect of VKAs and DOACs on renal function in real clinical practice in patients with AF depending on the stage of CKD.Materials and methods. A prospective single-centre non-randomized non-interventional observational study in parallel groups was conducted. The study included 92 patients with AF and CKD of 1-4 stages (S1-S4). The comparison group consisted of 35 patients with AF without concomitant CKD. The patients’ age ranged from 44 to 94 years (mean age was 72.2 ± 8.5 years). Patients of both groups received anticoagulant therapy with VKA (warfarin) or one of the registered in the Russian Federation DOACs (dabigatran, rivaroxaban, apixaban). During the observation (median was 10 months), follow-up visits were every 3 months. On visits we conducted the evaluation of effectiveness (strokes / TIA and thromboembolic complications) and safety (major and minor hemorrhagic events) of anticoagulant therapy, as well as the dynamics of kidney function (CC by Cockroft-Gault, GFR by CKD-EPI).Results. The main results are devoted to patients with AF and concomitant CKD. Significant dynamics of the kidney function depending on the anticoagulant taken (VKA or representatives of the DOACs class) were not identified. There were not any thromboembolic complications and major bleedings during the observation period. Statistically significant more minor bleedings on any dose of rivaroxaban in comparison with other anticoagulants were identified.Conclusions. In patients with AF and CKD, there was no significant effect of one or another anticoagulant on the kidney function, which is probably related to the concomitant nephroprotective therapy obtained in a large percentage of cases (ACE inhibitors / ARA, calcium antagonists, statins). Therapy with DOACs and warfarin in patients with AF and CKD for an average of 10 months of followup was effective and safe. In case of AF and CKD combination, the use of dabigatran or apixaban seems to be more preferable in relation to minor bleedings, the use of which less often leads to the development of hemorrhagic events.

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Anticoagulant therapy in practice

Orvosi Hetilap ◽

10.1556/oh.2012.29357 ◽

2012 ◽

Vol 153 (19) ◽

pp. 732-736

Author(s):

Gergely Hofgárt ◽

Csilla Vér ◽

László Csiba

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Ischemic Stroke ◽

Acute Stroke ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Health Science ◽

Science Centre ◽

Improper Use ◽

Current Guidelines

Atrial fibrillation is a risk factor for ischemic stroke. To prevent stroke oral anticoagulants can be administered. Old and new types of anticoagulants are available. Nowadays, old type, acenocumarol based anticoagulants are used preferentially in Hungary. Aim: The advantages and the disadvantages of anticoagulants are well known, but anticoagulants are underused in many cases. Method: The authors retrospectively examined how frequent atrial fibrillation was and whether the usage of anticoagulants in practice was in accordance with current guidelines among acute stroke cases admitted to the Department of Neurology, Medical and Health Science Centre of Debrecen University in 2009. Results: Of the 461 acute stroke cases, 96 patients had known and 22 patients had newly discovered atrial fibrillation. Half of the patients did not receive proper anticoagulation. Only 8.4% of them had their INR levels within the therapeutic range. Conclusions: The findings are similar to those reported in other studies. Many factors may contribute to the high proportion of improper use of anticoagulants, and further investigations are needed to determine these factors. In any case, elimination of these factors leading to a failure of anticoagulation may decrease the incidence of stroke. Orv. Hetil., 2012, 153, 732–736.

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ANTICOAGULANT THERAPY IN CANCER PATIENTS WITH ATRIAL FIBRILLATION. CONSIDERING AGE FACTOR

Успехи геронтологии ◽

10.34922/ae.2020.33.1.013 ◽

2020 ◽

pp. 99-106

Author(s):

В. И. Потиевская ◽

А. А. Ахобеков ◽

М. Ф. Баллюзек

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Current Data ◽

Related Factors ◽

Age Related ◽

Liver And Kidney ◽

After Cancer

Рассматривается современное состояние вопроса выбора антикоагулянтной терапии при фибрилляции предсердий (ФП) у онкологических больных. Отмечается, что сложность выбора антикоагулянта при злокачественных новообразованиях (ЗНО) определяется такими факторами, как коморбидные сердечно-сосудистые заболевания, нарушения функции печени и почек, метаболические дисфункции, свойственные, прежде всего, пациентам старшей возрастной группы. Приводятся актуальные данные по оценке риска геморрагических и тромбоэмболических осложнений ФП при ЗНО в аспекте возраста. Обсуждаются возможные причины увеличения риска развития ФП во время и после лечения ЗНО, в том числе и в связи с возраст-ассоциированностью этих патологий. Рассмотрены вопросы выбора антикоагулянтов у пациентов, находящихся на активной противоопухолевой терапии, особенно на препаратах из группы прямых оральных антикоагулянтов (ПОАК). Согласно данным обсервационных исследований, именно ПОАК являются перспективным, относительно безопасным и эффективным выбором для онкологических пациентов с ФП, в связи с чем их применение должно активно изучаться в рандомизированных клинических исследованиях с учетом фактора возраста. Подчеркивается, что подбор схемы антикоагулянтной терапии у пациентов с ФП и ЗНО требует междисциплинарного участия кардиологов и онкологов, а часто и гериатров, чтобы индивидуализировать лечение и предложить наиболее эффективную терапию. The current issue of the choice of anticoagulant therapy of atrial ﬁbrillation (AF) in cancer patients is considered. It is noted that the difﬁculty of choosing an anticoagulant in malignancies is largely determined by age-related factors, such as comorbid cardiovascular diseases, liver and kidney dysfunction, metabolic disorders common for in elderly patients. Current data on the risk assessment of hemorrhagic and thromboembolic complications of AF in cancer patients in the aspect of age presented. During and after cancer treatment, the risk of developing AF can increase, also in connection with the age-associated pathology. Possible reasons of it are discussed. The choice of different anticoagulants groups in patients treated with anticancer therapy, including direct oral anticoagulants (DOAC) is considered. According to available data from observational studies, it is the DOAC that is a promising, relatively safe and effective choice for cancer patients with AF, and therefore their use should be actively studied in randomized trials, considering the factor of age. It is particularly noted that solving this problem requires the interdisciplinary involvement of cardiologists, oncologists, and sometimes, geriatrics, to individualize treatment for each case and to offer the most effective therapy.

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Features of anticoagulant therapy of atrial fibrillation in combination with impaired renal function

Kardiologiia ◽

10.18087/cardio.2021.10.n1767 ◽

2021 ◽

Vol 61 (10) ◽

pp. 81-88

Author(s):

T. N. Novikova

Keyword(s):

Atrial Fibrillation ◽

Kidney Function ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Alternative Therapy ◽

Favorable Effect ◽

Randomized Controlled ◽

Randomized Controlled Studies ◽

Negative Effect

This review focuses on issues of anticoagulant therapy in patients with atrial fibrillation (AF) associated with chronic kidney disease (CKD). Such patients are at high risk of stroke whereas the choice of an anticoagulant is difficult. A wealth of information about a negative effect of warfarin on the kidney function has accumulated. A need for an alternative therapy to warfarin for patients with stage 3-4 CKD has become imminent. In this regard, rivaroxaban seems to be an appropriate replacement for warfarin in such patients. In randomized, controlled studies that evaluated the efficacy of direct oral anticoagulants in comparison with warfarin, the efficacy and safety profile of a “kidney” dose in moderate disorders of kidney function has been studied only for rivaroxaban. Moreover, both randomized, controlled studies and studies performed in the conditions of clinical practice, have demonstrated a more favorable effect of rivaroxaban on kidney function compared to warfarin. Patients with AF associated with CKD require a comprehensive protection, which, according to results of clinical studies, may be provided by rivaroxaban.

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Recommendations on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation (Based on 2018 European Heart Rhythm Association Practical Guide)

Kardiologiia ◽

10.18087/cardio.2019.5.2633 ◽

2019 ◽

Vol 59 (5) ◽

pp. 68-79

Author(s):

L. V. Popova ◽

T. B. Kondratieva ◽

M. B. Aksenova ◽

T. V. Khlevchuk ◽

M. Z. Kanevskaya

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Randomized Clinical Trials ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Heart Rhythm ◽

Vitamin K Antagonist ◽

Advanced Liver Disease ◽

Clinical Variants

Non-vitamin K antagonist oral anticoagulants (NOACs) – direct oral anticoagulants – are getting the ever-broadening use in clinical practice. However, many problems related to optimal use of NOACs in specific clinical situations remain unresolved. European Heart Rhythm Association in April 2018 issued the renovated recommendations on the use of NOACs in patients with atrial fibrillation. The authors of recommendations presented some specific clinical variants for which they formulated practical advices based on the evidence obtained in randomized clinical trials. They also outlined the indications for use of NOACs, formulated practical start-program and scheme of subsequent follow-up management of patients taking NOACs. Recommendations contain information on pharmacokinetics of NOACs and their interactions with other drugs, consideration of feasibility of NOACs use in patients with chronic renal insufficiency or advanced liver disease. Many other practical problems are covered as well.

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