scholarly journals Failure of non-vitamin K antagonist oral anticoagulants in preventing stroke in elderly patient: a case report of multiple strokes on standard of care treatment for atrial fibrillation

2021 ◽  
Vol 8 (1) ◽  
pp. 1-6
Author(s):  
Frank Bernard Ebai ◽  
Azam Mohiuddin
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Treatment Options ◽  
Anticoagulation Therapy ◽  
Standard Of Care ◽  
The Elderly ◽  
Vitamin K Antagonist ◽  
Heart Arrhythmia ◽  
Standard Of Care Treatment

Atrial fibrillation (AF) is the most common type of treated heart arrhythmia. Generally, the treatment goals for atrial fibrillation are to reset the rhythm or control the rate and prevent the development and subsequent embolization of atrial thrombi. These thromboembolic events can occur with any kind of atrial fibrillation that is paroxysmal, persistent or permanent. In patients who are candidate for anticoagulation therapy, major practice guideline provides vitamin K antagonist (VKA) oral anticoagulant and non-VKA oral anticoagulants as treatment options. The risk of AF increases with age and despite treatment on standard of care anticoagulation therapy, recrudescent cardioembolic events may still arise especially in the elderly as we will see in this case.

Improving Patient Outcomes in Preventing Atrial Fibrillation-related Stroke with Non-Vitamin K Antagonist Oral Anticoagulants

2016 ◽  
Vol 11 (1) ◽  
pp. 1a
Author(s):  
Peter Kelly ◽  
Carlos Molina ◽  
Christian T. Ruff ◽  
Roland Veltkamp ◽  
◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Subgroup Analysis ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Vitamin K Antagonist ◽  
Effective Option ◽  
Rising Incidence ◽  
Prior Stroke

The rising incidence of atrial fibrillation (AF) is increasingly resulting in a substantial worldwide increase in AF-related stroke, particularly in elderly patients and this is creating an increasingly serious healthcare burden. Guidelines recommend the use of AF-related stroke prophylaxis but adherence to these remains poor. Studies conducted in the 1990s showed that warfarin reduced the risk of AF-related stroke by an overall 64% compared with placebo. Subsequently, prophylactic treatment was further improved with the development of non-vitamin K antagonist oral anticoagulants (NOACs). More recently, a meta-analysis of four large clinical trials on NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) showed there was a relative risk reduction of 0.81 (p<0.0001) favouring NOAC treatment over warfarin for stroke or systemic embolic events in patients with AF. The largest trial of NOACs in AF-related stroke, to date, was the ENGAGE AF-TIMI 48 study (n=21,105) which showed that edoxaban was non-inferior to warfarin for ischaemic stroke reduction but significantly reduced bleeding and cardiovascular mortality. A recent subgroup analysis of this study showed that with edoxaban the incidences of intracranial haemorrhage (ICH) subtypes (all ICH, fatal ICH, fatal, subdural and epidural bleed) were significantly lower with 60 mg of edoxaban (p=0.013–<0.001). Edoxaban was also shown to be an effective option in patients with prior stroke. In addition, edoxaban was shown to reduce deaths due to fatal bleeds compared with warfarin. The results of current studies, especially the ENGAGE AF-TIMI 48 subgroup analysis therefore, show that the benefits of anticoagulation therapy in patients with AF substantially outweigh the risks.

scholarly journals Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword

2017 ◽  
Vol 3 (2) ◽  
Author(s):  
Francesco Vetta ◽  
Gabriella Locorotondo ◽  
Giampaolo Vetta
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Anticoagulant Therapy ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Treatment Strategies ◽  
The Elderly ◽  
Hemorrhagic Events

Prevalence of non-valvular atrial fibrillation is increasing over time. Particularly in elderly population, treatment strategies to reduce the rate of stroke are challenging and still represent an unsolved cultural question. Indeed, the risk of thromboembolism increases in the elderly in parallel with the risk of bleeding. The frequent coexistence of several morbidities, frailty syndrome, polypharmacy, chronic kidney disease and dementia strengthens the perception that risk-benefit ratio of anticoagulant therapy could be unfavorable, and explains why such treatment is underused in the elderly. Recently, the introduction of non-vitamin K oral anticoagulants (NOACs) has allowed us to overcome the large number of limitations imposed by the use of vitamin K antagonists. In this manuscript, the benefits of individual NOACs in comparison with warfarin in elderly patients are reviewed. Targeted studies on complex elderly patients are needed to test usefulness of a geriatric comprehensive assessment, besides the scores addressing risk of thromboembolic and hemorrhagic events. In the meantime, it is mandatory that use of anticoagulant therapy in most elderly people, currently excluded from randomized controlled trials, is prudent and responsible.

Voorkamerfibrillatie en niet-vitamine K-antagonist orale anticoagulantia: van klinische studies tot gebruik in de dagelijkse praktijk

2021 ◽  
Author(s):  
A. CAPIAU ◽  
M. GRYMONPREZ ◽  
T. DE BACKER ◽  
S. GEVAERT ◽  
K. BOUSSERY ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Practice ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Real Life ◽  
Vitamin K Antagonist ◽  
Fixed Dose ◽  
Stroke Risk Factor

Atrial fibrillation and non-vitamin K antagonist oral anticoagulants: from clinical trials to real-world clinical practice. For decades, vitamin K antagonists (VKAs) were the only oral anticoagulants available for the prevention of thromboembolism in patients with atrial fibrillation (AF). Since 2012, non-vitamin K antagonist oral anticoagulants (NOACs) are available for this indication, which have proven to be at least as effective and safe as VKAs in randomized controlled trials (RCTs). NOACs have additional benefits, such as a fast onset of action, a fixed-dose regimen without requiring regular monitoring, less interactions and less intracranial bleeding. Their emergence has caused a paradigm shift in anticoagulation therapy, with NOACs being the anticoagulant of choice compared to VKAs. Since strict in- and exclusion criteria were used in the pivotal RCTs, concerns have risen regarding the generalizability of these results to real-life clinical practice in patients with multiple comorbidities. In this manuscript, this extrapolation is discussed, focusing on 4 different topics regarding appropriate NOAC use: the management of AF patients with a single stroke risk factor, the importance of an optimal therapy adherence, potential drug-drug interactions with NOACs and addressing a geriatric AF patient after a fall. Hopefully, this manuscript will help guide clinicians in the optimal use of NOACs in their daily clinical practice.

scholarly journals Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011–2016

BMJ Open ◽  
2019 ◽  
Vol 9 (4) ◽  
pp. e026645 ◽  
Author(s):  
Géric Maura ◽  
Cécile Billionnet ◽  
Jérôme Drouin ◽  
Alain Weill ◽  
Anke Neumann ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Antiplatelet Therapy ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Vitamin K Antagonist ◽  
Secondary Outcome ◽  
Patterns Of Use

ObjectivesTo describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France.Design(i) Repeated cross-sectional study and (ii) population-based cohort study.SettingFrench national healthcare databases (50 million beneficiaries).Participants(i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015–2016.Primary and secondary outcome measures(i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF.ResultsBetween 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (−22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015–2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing.ConclusionsOAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.

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.

P4793Comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in the elderly Asian patients with atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T F Chao ◽  
J N Liao ◽  
G Y H Lip ◽  
S A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Elderly Patients ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
The Elderly ◽  
Vitamin K Antagonist ◽  
Research Database

Abstract Background Stroke prevention in elderly patients with atrial fibrillation (AF) can be challenging. Comparisons of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in the elderly, at different age strata (age 65–74, 75–89, ≥90) in the daily practice have not been well described, particularly in Asians. We aimed to assess the clinical outcomes of NOACs compared warfarin for stroke prevention in elderly patients with AF. Methods A total of 64,169 AF patients aged ≥65 years receiving NOACs or warfarin prescription were identified from the Taiwan National Health Insurance Research Database. The risks of adverse events were compared between NOACs and warfarin in all patients age ≥65 and specifically, with different age strata; that is 65–74 years, 75–89 years and >90 years. Results Overall NOACs were associated with a significantly lower risk of ischemic stroke (adjusted hazard ratio [aHR] 0.869, 95% confidence interval [CI] 0.812–0.931), ICH (aHR 0.524, 95% CI 0.456–0.601), major bleeding (aHR 0,824, 95% CI 0.776–0.875), mortality (aHR 0.511, 95% CI 0.491–0.532) and composite adverse events (aHR 0.646, 95% CI 0.625–0.667) compared to warfarin. There was heterogeneity in treatment effect for NOACs versus warfarin in different age strata, but the results still favored NOACs even among the very elderly (>90 years). The absolute risk difference and reductions in ICH and composite adverse events with NOAC use were even greater among the elderly compared to warfarin (Figure). Conclusions Compared to warfarin, NOACs were associated with a significantly lower risk of adverse events, with heterogeneity in treatment effects among different age strata. Overall, the clear safety signal in favor of NOACs over warfarin was evident irrespective of age strata, being most marked in the most elderly.

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