scholarly journals Direct oral anticoagulants for prevention of stroke and other cardiovascular outcomes in patients aged 80 years or older with atrial fibrillation

2021 ◽  
Vol 30 (1) ◽  
pp. 16-23
Author(s):  
S. Moiseev
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Elderly Patients ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Very Elderly ◽  
Once Daily ◽  
Increased Risk ◽  
Reduced Kidney Function

Over the last decade, the number of people aged 80 years or over in Russia increased by 41% up to 5.7 mln. At least 10% of these individuals develop atrial fibrillation (AF). Treatment of rhythm disorders in the very elderly patients is challenging due to the high occurrence of comorbidities, including cognitive dysfunction, changes in the pharmacokinetics of drugs as a result of reduced kidney function, increased risk of interaction of drugs. The very elderly patients with AF have a higher risk of ischemic stroke and other cardiovasculat outcomes, including myocardial infarction, and should be treated with oral anticoagulants. The results of randomized controlled trials and prospective and retrospective observational studies suggest that in patients aged 80 years or older with non-valvular AF direct oral anticoagulants (DOAC) are at least as effective as vitamin K antagonists for prevention of ischemic stroke and are associated with a lower risk of intracerebral haemorrhage. The use of DOAC (once daily rivaroxaban in particular) impoves compliance to anticoagulation in the very elderly patients with non-valvular AF.

scholarly journals Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation

2020 ◽  
Vol 10 (2) ◽  
pp. 44-49
Author(s):  
Michela  Giustozzi ◽  
Giancarlo Agnelli ◽  
Silvia Quattrocchi ◽  
Monica Acciarresi ◽  
Andrea Alberti ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Medical Information ◽  
Treatment Guidelines ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Anticoagulant Treatment ◽  
Anticoagulation Treatment

Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value <2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.

scholarly journals Direct oral anticoagulants versus vitamin K antagonists after recent ischemic stroke in patients with atrial fibrillation

2019 ◽  
Vol 85 (6) ◽  
pp. 823-834 ◽  
Author(s):  
David J. Seiffge ◽  
Maurizio Paciaroni ◽  
Duncan Wilson ◽  
Masatoshi Koga ◽  
Kosmas Macha ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants

Oral Anticoagulants in Atrial Fibrillation Patients With Recent Stroke Who Are Dependent on the Daily Help of Others

Stroke ◽  
2021 ◽  
Author(s):  
Louisa Meya ◽  
Alexandros A. Polymeris ◽  
Sabine Schaedelin ◽  
Fabian Schaub ◽  
Valerian L. Altersberger ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Proportional Hazards ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cox Proportional Hazards ◽  
Composite Outcome ◽  
Unique Identifier ◽  
The Individual

Background and Purpose: Data on the effectiveness and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with stroke attributable to atrial fibrillation (AF) who were dependent on the daily help of others at hospital discharge are scarce. Methods: Based on prospectively obtained data from the observational Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-longterm registry from Basel, Switzerland, we compared the occurrence of the primary outcome—the composite of recurrent ischemic stroke, major bleeding, and all-cause death—among consecutive patients with AF-stroke treated with either VKAs or DOACs between patients dependent (defined as modified Rankin Scale score, 3–5) and patients independent at discharge. We used simple, adjusted, and weighted Cox proportional hazards regression to account for potential confounders. Results: We analyzed 801 patients (median age 80 years, 46% female), of whom 391 (49%) were dependent at discharge and 680 (85%) received DOACs. Over a total follow-up of 1216 patient-years, DOAC- compared to VKA-treated patients had a lower hazard for the composite outcome (hazard ratio [HR], 0.58 [95% CI, 0.42–0.81]), as did independent compared to dependent patients (HR, 0.54 [95% CI, 0.40–0.71]). There was no evidence that the effect of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome differed between dependent (HR dependent , 0.68 [95% CI, 0.45–1.01]) and independent patients (HR independent , 0.44 [95% CI, 0.26–0.75]) in the simple model ( P interaction =0.212). Adjusted (HR dependent , 0.74 [95% CI, 0.49–1.11] and HR independent , 0.51 [95% CI, 0.30–0.87]; P interaction =0.284) and weighted models (HR dependent , 0.79 [95% CI, 0.48–1.31] and HR independent , 0.46 [95% CI, 0.26–0.81]; P interaction =0.163) yielded concordant results. Secondary analyses focusing on the individual components of the composite outcome were consistent to the primary analyses. Conclusions: The benefits of DOACs in patients with atrial fibrillation with a recent stroke were maintained among patients who were dependent on the help of others at discharge. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03826927.

Reduced dose of rivaroxaban and dabigatran vs. vitamin K antagonists in very elderly patients with atrial fibrillation in a nationwide cohort study

EP Europace ◽  
2019 ◽  
Author(s):  
Laurent Fauchier ◽  
Patrick Blin ◽  
Frédéric Sacher ◽  
Caroline Dureau-Pournin ◽  
Marie-Agnès Bernard ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Real Life ◽  
European Medicines Agency ◽  
Very Elderly ◽  
Clinical Events ◽  
First Time

Abstract Aims The real-life benefits and risks of the non-vitamin K antagonist oral anticoagulants for stroke prevention in very elderly patients with atrial fibrillation (AF) are still debated. Methods and results Cohorts of new users of rivaroxaban 15 mg, dabigatran 110 mg, or vitamin K antagonists (VKA) for AF ≥85 years old in 2013 or 2014 were identified in the nationwide French claims database and followed-up for 1 year. Cohorts were compared after 1:1 matching using high-dimensional propensity score. Compared to VKA use and considering 1-year cumulative incidences, risk of stroke, and systemic embolism was not different with rivaroxaban use [hazard ratio 1.14, 95% confidence interval (CI): 0.93–1.40] and lower with dabigatran use (0.77, 95% CI: 0.60–0.99), risk of major bleeding was not different with rivaroxaban use (0.91, 95% CI: 0.74–1.11) and with dabigatran use (0.81, 95% CI: 0.64–1.03), risk of all-cause death was borderline to significance lower with rivaroxaban use (0.91, 95% CI: 0.83–1.00), and lower with dabigatran use (0.87, 95% CI: 0.78–0.97). The risk for a composite of all events above was not different with rivaroxaban use (0.96, 95% CI: 0.88–1.04) and lower with dabigatran use (0.87, 95% CI: 0.79–0.96) as compared with VKA use. The risk for the composite of all events was not different with rivaroxaban use as compared with dabigatran use (1.09, 95% CI: 0.97–1.23). Conclusion This study shows for the first time in more than 25 000 new real-life anticoagulant users for AF aged ≥85 years a neutral overall benefit-risk of rivaroxaban 15 mg vs. VKA and a favourable overall benefit-risk of dabigatran 110 mg vs. VKA on relevant clinical events. Study registration European Medicines Agency EUPAS14567 (www.encepp.eu) and Clinicaltrials.gov id NCT02864758.

scholarly journals Direct Oral Anticoagulants after Ischemic Stroke: Which Patient? Which Drug? And How Early?

2021 ◽  
Vol 41 (01) ◽  
pp. 031-034
Author(s):  
Gian Marco De Marchis
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trials ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Randomized Clinical Trials ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Reversal Agents

AbstractDirect oral anticoagulants (DOACs) are recommended over vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and ischemic stroke. The main advantage of DOAC over VKA is the lower rate of bleeding and mortality. This review covers challenges clinicians can encounter when treating patients with AF and ischemic stroke, including timing of DOAC start and ongoing randomized clinical trials, appropriate dosing, and available comparative evidence across DOACs. For patients without AF but with an ischemic stroke, the review outlines the role of DOACs. Finally, the risk of thrombotic events associated with specific DOAC reversal agents and DOAC pausing is reviewed.

New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention

Stroke ◽  
2021 ◽  
Author(s):  
Gian Marco De Marchis ◽  
Luciano A. Sposato ◽  
Michael Kühne ◽  
Tolga D. Dittrich ◽  
Leo H. Bonati ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Interdisciplinary Approach ◽  
Left Atrial Appendage Occlusion ◽  
High Risk Populations

One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.

scholarly journals Laboratory bleeding predictors in elderly patients with atrial fibrillation taking direct oral anticoagulants

2020 ◽  
pp. 40-43
Author(s):  
M. A. Gabitova ◽  
P. M. Krupenin ◽  
A. A. Sokolova ◽  
D. A. Napalkov ◽  
V. V. Fomin
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Anticoagulant Therapy ◽  
Patient Monitoring ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Laboratory Methods ◽  
Increased Risk ◽  
Hemorrhagic Events ◽  
Clinically Significant

Atrial fibrillation (AF) is one of the most common arrhythmias in patients ≥75 years of age. The increased risk of thrombosis due to age and the large number of concomitant diseases makes it evident that anticoagulant therapy is necessary. However, the same factors increase the risk of hemorrhagic complications, which are among the most dangerous side effects of anticoagulant therapy. That is why it is very important to identify patients with the highest probability of bleeding, whether large or small clinically significant and minor. The purpose of our study was to study the prognostic value of laboratory methods of examination with regard to the development of hemorrhagic events in elderly patients with AF taking direct oral anticoagulants (DOAC). The study enrolled 102 patients ≥75 years of age with AF of non-valve etiology taking dabigatran, apixaban, rivaroxaban at full or reduced doses. Anticoagulants were administered by outpatient and inpatient physicians. Both previous experience with DOAC prior to inclusion in the trial (if DOAC was previously prescribed) and prospective patient monitoring after inclusion in the trial were analyzed. The minimum analyzed period of DOAC intake was 18 months. Patients who underwent (n = 19) and did not undergo (n = 83) hemorrhagic events (all events were considered small by ISTH criteria) did not differ in any of the laboratory indicators potentially considered as predictors of hemorrhagic events.

scholarly journals Drug-drug interactions in atrial fibrillation patients receiving direct oral anticoagulants

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Ji Yun Lee ◽  
Il-Young Oh ◽  
Ju-Hyeon Lee ◽  
Seok Kim ◽  
Jihoon Cho ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Drug Interactions ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Multiple Logistic Regression Analysis ◽  
Common Data Model ◽  
Concomitant Treatment ◽  
Increased Risk

AbstractPolypharmacy is common in patients with atrial fibrillation (AF), making these patients vulnerable to the occurrence of potential drug-drug interactions (DDIs). We assessed the risk of ischemic stroke and major bleeding in the context of concomitant treatment with potential DDIs in patients with AF prescribed direct oral anticoagulants (DOACs). Using the common data model (CDM) based on an electronic health record (EHR) database, we included new users of DOACs from among patients treated for AF between January 2014 and December 2017 (n = 1938). The median age was 72 years, and 61.8% of the patients were males, with 28.2% of the patients having a CHA2DS2-VASc score in category 0–1, 49.4% in category 2–3, and 22.4% in category ≥ 4. The CHA2DS2-VASc score was significantly associated with ischemic stroke occurrence and hospitalization for major bleeding. Multiple logistic regression analysis showed that increased risk of ischemic stroke and hospitalization for major bleeding was associated with the number of DDIs regardless of comorbidities: ≥ 2 DDIs was associated with ischemic stroke (OR = 18.68; 95% CI, 6.22–55.27, P < 0.001) and hospitalization for major bleeding (OR = 5.01; 95% CI, 1.11–16.62, P < 0.001). DDIs can cause reduced antithrombotic efficacy or increased risk of bleeding in AF patients prescribed DOACs.

The Atrial fibrillation Better Care (ABC) pathway is associated to a lower incidence of cardiac complications in patients with atrial fibrillation: a report from the ATHERO-AF study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
D Pastori ◽  
P Pignatelli ◽  
F Violi ◽  
G.Y.H Lip
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Rank Test ◽  
Major Adverse Cardiovascular Events ◽  
Cardiac Complications ◽  
Kaplan Meier ◽  
Increased Risk

Abstract Background The integrated management of atrial fibrillation (AF) patients according to the Atrial fibrillation Better Care (ABC, A, Avoid stroke with anticoagulation; B, better symptom management; C, Cardiovascular and comorbidity risk management) pathway has associated with a reduced incidence of thromboembolic events and mortality. However, whether this approach also results in a lower rate of cardiac complications is unknown. Purpose To investigate the rate of major adverse cardiovascular events (MACE) in AF patients according to compliance with the ABC pathway. Methods This prospective single-center cohort study included 1157 patients with nonvalvular AF from the ATHERO-AF study. The A, B, and C groups were defined as follows: “A” by a Time in Therapeutic Range ≥70% in vitamin K antagonists-treated patients or appropriate dose for patients on direct oral anticoagulants; “B” by a European Heart Rhythm Association (EHRA) symptom scale I-II (vs. III-IV), and “C” as optimized cardiovascular comorbidity management (i.e. use of ACE inhibitors in heart failure patients, blood pressure &lt;140/90, use of statins and beta blockers in patients with prior ischemic heart disease). The primary end point was a composite of MACE including fatal/non-fatal myocardial infarction, coronary revascularization and cardiovascular death (progressive heart failure, sudden cardiac death and procedure-related death). Results Overall, 458 (39.6%) patients were optimally managed according to the ABC (ABC-compliant group), while the remaining 729 patients presented at least one uncontrolled component (ABC non-compliant group). During a mean follow up of 35 months, (2688 patient-years), 64 MACE were recorded 2.38%/year. Kaplan Meier curve analysis showed a significant higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (54 and 10 MACE in each group, respectively, log-rank test p=0.006, figure). The risk of MACE increased by the number of uncontrolled ABC components: Hazard ratio HR) for 1 component 1.697, 95% Confidence Interval 95% CI 0.814–3.537, p=0.158; HR for 2 components 4.157, 95% CI 1.994–8.665, p&lt;0.001); HR for 3 components 5.100, 95% CI 1.596–16.295, p=0.006. ABC non-compliant group remained associated with an increased risk of MACE using Cox proportional hazard regression analysis (HR 2.175, 95% CI 1.098–4.309, p=0.026) after adjustment for CHA2DS2VASc score, antiplatelet drugs and digoxin use. Conclusion The majority of AF patients is not currently optimally managed. An integrated care ABC approach is associated with a reduced risk of MACE in the AF population. Figure 1. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None

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