Direct Oral Anticoagulants Group Research Articles

Evaluation of the efficacy of direct oral anticoagulants (DOACs) in comparison to warfarin in morbidly obese patients

ABSTRACTPurpose: There is limited clinical data evaluating anticoagulation with the direct oral anticoagulants (DOACs) in morbidly obese patients. We sought to examine the efficacy in preventing stroke or other systemic embolic events and safety of apixaban, dabigatran, and rivaroxaban, in comparison to warfarin in patients with either a body-mass index (BMI) over 40 kg/m2 and/or a weight over 120 kg.Methods: After approval from IRB, we collected retrospective data from our institution’s records on 180 patients. We analyzed the rates of stroke and systemic embolic events as defined as ischemic stroke, pulmonary embolism (PE), deep vein thrombosis (DVT), and myocardial infarction (MI) as well as major bleeding in morbidly obese patients receiving apixaban, dabigatran, or rivaroxaban in comparison to warfarin for anticoagulation due to nonvalvular atrial fibrillation, postoperative thrombus prophylaxis, or DVT/PE treatment and/or reduction in risk for recurrence.Results: The final analysis included 90 patients in both arms. Fifty-two percent (n = 41) of patients in the DOAC group were on apixaban therapy, 12% (n = 11) on dabigatran, and 37% (n = 33) on rivaroxaban. The average BMI and weight in the DOAC group were 46.7 kg/m2 and 139.3 kg, respectively. In the warfarin group, average BMI and weight were 45.8 kg/m2 and 135.9 kg, respectively. There were 11 patients who developed a stroke or thromboembolic event in the DOAC group and 10 in the warfarin group (OR 1.11, 95% confidence interval [CI] 0.45–2.78; p = 0.82). The events in the DOAC group consisted of three patients who developed ischemic stroke, three patients who developed DVTs, one who developed a PE, and four patients who developed MIs. There were two major bleeding events in the DOAC group and three events in the warfarin group (p = 0.65).Conclusions: Anticoagulation therapy with DOACs in morbidly obese patients may be a safe and effective alternative to warfarin for prevention of stroke or systemic embolic events. However, additional studies are necessary to confirm these findings.

Comparing quality of life and treatment satisfaction between patients on warfarin and direct oral anticoagulants: a cross-sectional study.

Introduction and aimPatient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC).MethodsThis was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2).ResultsA total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069).ConclusionCompared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.

Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation.

Heparin dosing of patients anticoagulated with direct oral anticoagulants (DOACs) undergoing atrial fibrillation (AF) ablation can be challenging as they require more heparin than those on warfarin therapy. We sought to compare periprocedural activated clotting times (ACTs) of patients on warfarin vs. DOAC and determine an optimal weight-based heparin dosage strategy. Patients who underwent AF ablation over 28months were reviewed for type of anticoagulation, intraprocedural heparin dosing, ACTs, and adverse outcomes. A heparin dosing strategy was then tested in a prospective validation cohort. There were 89 patients in the DOAC group and 43 in the warfarin group. Demographics, comorbidities, and complication rates were similar. Mean ACT and percentage of therapeutic ACTs were lower in the DOAC group, most significantly in those with a weight > 90kg. In DOAC patients, a higher initial heparin bolus ≥ 150units/kg yielded a higher percentage of therapeutic intraprocedural ACTs (49% ± 10 vs. 29% ± 7, p = 0.0008). In a prospective validation cohort of 25 patients administered an initial heparin bolus ≥ 150units/kg, the mean ACT was 295 ± 33 and 49% of the ACTs collected were therapeutic, similar to findings of our high-dose retrospective subgroup. Patients on DOACs require more heparin during AF ablation to achieve therapeutic ACT. We suggest an initial heparin dose of at least 150units/kg in this subset of patients, particularly in those with a weight > 90kg.

Shorter Hospital Stay and Fewer Hospitalizations in Patients With Visible Hematuria on Direct Oral Anticoagulants Compared to on Vitamin K Antagonists

ObjectiveTo investigate the influence of type of anticoagulation – direct oral anticoagulants (DOAC) vs vitamin K antagonists (VKA) – on length of hospital stay (LOS) and hospitalization rates in patients with visible hematuria, as visible hematuria in anticoagulated patients can be distressing, difficult to control and even life-threatening. MethodsThis retrospective cohort study was conducted at the emergency department (ED) of a tertiary university hospital in Switzerland. All patients admitted with visible hematuria from January 1, 2013 to December 31, 2016 were included. We compared the primary clinical outcome parameters (hospitalization rate and LOS) as well as secondary outcomes (ICU admission, ED LOS, and in-hospital mortality) in patients with visible hematuria on either DOAC therapy, VKA therapy or no anticoagulants. ResultsWe included 811 (100%) patients with visible hematuria; 53 (6.5%) patients were on DOAC, compared to 85 (10.5%) on VKA and 673 (83.0%) patients without any anticoagulation. In confounder-adjusted multivariable testing, there were fewer hospitalizations (odds ratio: 2.2, 95% confidence interval [CI]: 1.1-4.9, P = .028) and shorter LOS (geometric mean ratio: 2.2, 95% CI: 1.3-4.0, P = .006) on DOAC than on VKA. The secondary outcomes were not significantly associated with the anticoagulation groups. No differences were found between the DOAC and no-anticoagulant groups for any outcome. ConclusionVisible hematuria in patients on DOAC therapy is associated with shorter hospital stays and fewer hospitalizations compared to VKA.

Direct oral factor Xa inhibitors for the treatment of acute cancer-associated venous thromboembolism: A systematic review and network meta-analysis.

e23156 Background: A direct meta-analysis was performed to explore the efficacy and safety of direct oral factor Xa inhibitors with dalteparin in patients with cancer associated acute venous thromboembolism (VTE). Also, the comparative efficacy and safety of apixaban, rivaroxaban, and edoxaban was assessed with a network meta-analysis. Methods: MEDLINE, CENTRAL, and EMBASE were searched for trials comparing direct oral anticoagulants (DOACs) to dalteparin for the management of cancer associated acute VTE. A network meta-analysis using both frequentist and Bayesian methods was performed to analyze VTE recurrence, major and clinically relevant non-major bleeding (CRNMB). Results: Three randomized control trials, at low risk of bias, enrolled 1,739 patients with cancer associated VTE. Direct comparison showed a lower rate of VTE recurrence in DOAC compared to dalteparin groups (odds Ratio [OR]:0.48, 95% Confidence interval [CI]:0.24-0.96; I2:46%). Indirect comparison suggested that apixaban had greater reduction in VTE recurrence compared to dalteparin (OR: 0.10; 95% CI: 0.01–0.82), but not rivaroxaban or edoxaban. Apixaban also had the highest probability of being ranked most effective. By direct comparisons, there was an increased likelihood of major bleeding in the DOAC group compared to dalteparin (OR: 1.70; 95% CI: 1.04–2.78). CRNMB did not differ. Indirect estimates were imprecise. Subgroup analyses in gastrointestinal cancers suggested that dalteparin may have the lowest risk of bleeding whereas estimates in urothelial cancer were imprecise. Conclusions: DOACs appear to lower the risk of VTE recurrence compared to daltaparin while increasing major bleeding. Apixaban may be associated with the lowest risk of VTE recurrence compared to the other DOACs.

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis

PurposeWe sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy.BackgroundDirect oral anticoagulants have become a popular choice...

Prescription Patterns and Outcomes of Patients With Atrial Fibrillation Treated With Direct Oral Anticoagulants and Warfarin: A Real-World Analysis.

Direct oral anticoagulants (DOACs) have been found to be similar or superior to warfarin in reducing ischemic stroke and intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF). We sought to examine the anticoagulation prescription patterns in community since the advent of DOACs and also evaluate the outcomes in terms of gastrointestinal (GI) bleeding, ischemic stroke, and ICH in real-world patients with AF receiving anticoagulation. This is a retrospective study comprising patients who were newly diagnosed with nonvalvular AF and were prescribed anticoagulants for stroke prevention. Prescription pattern of the anticoagulants based on CHA2DS2Vasc score was studied. Clinical outcomes of GI bleeding, ischemic stroke, and ICH were analyzed using a multivariate logistic regression model. Of the 2362 patients with AF on anticoagulation, 44.7% were prescribed DOACs. Patients with CHA2DS2VASc score of ≥3 received a prescription for warfarin more often than DOACs (P < .001). Multivariate logistic regression analysis revealed that the incidence of GI bleed (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.62-1.35, P = .66) and stroke (OR: 0.77, 95% CI: 0.57-1.05, P = .10) was similar between warfarin and DOAC users. However, there was a trend toward lower ICH in the DOAC group (OR: 0.60, 95% CI: 0.36-1.01, P = .06). Prescription rate of DOACs for nonvalvular AF has increased significantly, with apixaban being the most commonly used agent. Patients with higher CHA2DS2-VASc score (≥3) are prescribed DOACs less often than warfarin. The reason for this discrepancy is unclear. Given the favorable risk-benefit profile of DOACs, further studies are needed to identify factors that determine anticoagulant selection in patients with AF with high thromboembolic risk.

Application of prothrombin complex concentrate for reversal of direct oral anticoagulants in clinical practice: indications, patient characteristics and clinical outcomes compared to reversal of vitamin K antagonists

BackgroundProthrombin complex concentrate (PCC) is widely used to reverse the action of direct oral anticoagulants (DOACs) in accordance with current guidelines and because of a lack of specific reversal agents. Indications, clinical characteristics and patient outcomes of patients might differ in comparison to reversal of vitamin K antagonists where reversal with PCC is well established.MethodsOur cohort study explores patient characteristics, indications and clinical outcomes for reversal of all DOAC patients receiving PCC at our university emergency department from 01.06.2012 to 01.07.2017, in comparison with patients on VKA.ResultsOut of 199,982 consultations, we studied 346 patients who were given PCC for reversal of either DOAC (n = 74) or VKA (n = 272). The most common reason for treatment was acute bleeding; in 86.7% of both groups. 37.3% of bleeding was traumatic (p = 0.666). The most frequent bleeding location was intracranial (61.6%, p = 0.881). Gastrointestinal bleeding was more often found in the DOAC group (18.9% vs. 8.8%, p = 0.014). More erythrocyte concentrates (ECs) were given to DOAC patients with blood transfusion (p = 0.014). Tranexamic acid was used more often in DOAC patients than in VKA patients (28.4% vs. 7.4%, p < 0.001). No significant group differences were found for the following patient outcomes: in-hospital mortality, ICU stay, and length of stay at the ICU or in hospital.ConclusionIn DOAC treated patients, PCC was applied more often because of gastrointestinal bleeding and patients received higher numbers of ECs as well as tranexamic acid. No differences were observed with regard to important clinical outcomes.

DIRECT ORAL ANTICOAGULANTS: A COMPARISON OF EFFICACY AND SAFETY, ERRORS IN THEIR APPLICATION, AND THE USAGE OF REVERSAL AGENTS

This review is devoted to updating the existing knowledge about pharmacology of the drugs from the group of direct oral anticoagulants (DOACs). Special attention is paid to comparison of the anticoagulant properties of DOACs with traditional (indirect) anticoagulants at various dosage regimens and to study drug interactions of DOACs with drugs from different pharmacological groups. Widely analyzed the side effects associated with errors in the application of DOACs and provided recommendations for their correction, including the using of reversal agents therapy. Based on this, the presented article will be useful to clinicians to familiarize themselves with modern medical strategies based on the use of drugs from the DOACs group for the prevention and treatment of diseases associated with increased blood clotting ability and using of DOACs specific antagonists for treatment overdose of DOACs.

Abstract 223: Adherence to Warfarin and Oral Anticoagulants: Outcomes of 12 Months Follow-up in Patients With Non-valvular Atrial Fibrillation

Adherence to direct oral anticoagulants (DOACs) or vitamin K antagonists (warfarin) is an essential element of anticoagulation effectiveness and can be related to the outcomes of long-term therapy. Multiple studies have proved that patients with atrial fibrillation (AF) can be effectively treated with oral anticoagulants, achieving reduced morbidity and mortality which is mostly associated with stroke due to thromboembolism. However, despite these DOACs offering some potential advantages over vitamin K antagonists, their usage in the US has been slow to increase, and information on adherence and clinical outcomes based on real-world data is still limited. The goal of this retrospective study was to identify any distinct characteristics of patients with atrial fibrillation who received initial anticoagulation therapy with warfarin versus those who received DOACs. In addition, follow-up for at least the first 12 months of anticoagulation therapy was assessed for adherence to the prescribed anticoagulant or the reasons for change. Methods: This IRB approved study was conducted at Hartford Hospital using data from the Cardiology/Cardiac Arrhythmia clinic database to identify patients with non-valvular atrial fibrillation. Out of more than 4,000 encounters during 2014-2016, 100 patients on anticoagulation therapy with full records of follow-up for at least 12 months were randomly identified (35 on warfarin and 65 on DOACs). Patients’ CHA 2 DS 2 -VASc scores and clinical baseline clinical characteristics were recorded at the onset of anticoagulation treatment. Patients were followed for at least 12 months in order to assess the outcomes and reasons for changes in anticoagulation therapy. Results: The patients initially started on warfarin had a higher mean CHA 2 DS 2 -VASc score (4.54 vs. 3.69) and higher mean age (76.63 vs 72.73 years) than the composite DOACs group. At the time of initial prescription, the warfarin group tended to have a higher percentage of co-morbidities than patients on DOACs, such as previous MI - 17.14% vs 7.69%, previous CVA - 22.85% vs 15.38%, diabetes - 40.0% vs 26.15 %, CAD - 42.85% vs 29.23%, previous CABG - 22.85% vs 9.23%, and CHF - 22.85% vs 16.93 %. The 12 month follow-up showed that 22.9% of the patients on warfarin were switched to a DOAC versus only 6.2% of patients on DOACs being switched to warfarin. The most common reasons for patients on warfarin being switched to DOACs were individual patient preference or difficulties with INR monitoring. DOACs were most commonly changed to warfarin due to cost. Conclusions: Patients placed on warfarin may initially have more severe co-morbidities and higher CHA 2 DS 2 -VASc scores. The change in anticoagulation treatment from warfarin to DOACs may suggest greater patient or provider satisfaction with this new class of anticoagulants, but patient preference and cost are also important factors.

Outcomes of Direct Oral Anticoagulants in Patients With Mitral Stenosis

BackgroundPatients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis. ObjectivesThe aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis. MethodsThe study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage. ResultsA total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26). ConclusionsIn patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial.

Oral Anticoagulants in Japanese Patients with Atrial Fibrillation and Active Cancer.

Objective Oral anticoagulants (OACs), which include direct oral anticoagulants (DOACs) and warfarin, are widely used for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Cancer is associated with a prothrombotic state as well as an increased bleeding risk. Few data are available on the efficacy and safety of OACs in Japanese cancer patients with AF. We sought to investigate the efficacy and safety of OACs in this population. Methods This retrospective cohort study included active cancer patients in whom AF was recorded by electrocardiography in our hospital from January 2014 to December 2016 and who were treated with DOACs or warfarin. Patients were followed for 1 year. The study outcomes were stroke or systemic embolism and major bleeding. Result A total of 224 patients with AF and active cancer were treated with OACs (DOACs, n=127; warfarin, n=97). Overall, stroke or systemic embolism and major bleeding occurred in seven (3.8%/year) and eight (4.9%/year) patients, respectively. Stroke or systemic embolism occurred in three patients in the DOAC group (2.8%/year) and four patients in the warfarin group (5.4%/year). Major bleeding occurred in four patients in the DOAC group (4.0%/year) and four patients in the warfarin group (6.5%/year). Conclusion The rates of stroke or systemic embolism and major bleeding events were not negligible among Japanese cancer patients with AF receiving OACs. Further investigations on the optimal management of Japanese patients with AF and cancer are needed.

Safety of tooth extraction in patients receiving direct oral anticoagulant treatment versus warfarin: a prospective observation study

The aim of this study was to compare the safety of tooth extraction in patients receiving direct oral anticoagulants (DOACs) or warfarin without cessation of their antithrombotic treatment. This prospective observational study included 367 patients undergoing tooth extraction (119 receiving DOACs and 248 receiving warfarin). All extractions in DOAC patients were performed 6–7h after taking DOACs in consideration of the half-life in blood under continued antithrombotic treatment. To examine the potential postoperative bleeding risk related to the time of extraction and the drug concentration of blood, activated partial thromboplastin time (APTT) in dabigatran and prothrombin time (PT) in rivaroxaban were measured three times after administration. A total of 390 tooth extractions were performed: 128 in the DOAC patients and 262 in warfarin patients. Postoperative bleeding occurred in four extractions (3.1%) in the DOAC group and in 23 (8.8%) in the warfarin group. There was no statistically significant difference between the two groups (odds ratio: 2.362, 95% confidence interval (CI) 0.819–6.815, p=0.112). APTT and PT prolongation in almost all cases decreased with time after taking the medicine. Our findings suggest that interruption of DOAC therapy is not necessary for tooth extraction if the procedure is performed at least 6h after the last dose.

Abstract WP183: Clinical Outcome in Cardioembolic Stroke Patients Receiving DOACs versus Warfarin: K-PLUS Registry

Introduction: Relationship between the selection of oral anticoagulants after acute stroke as secondary prevention and clinical outcome is not elucidated. Our aim is to compare clinical outcome in patients receiving direct oral anticoagulants (DOACs) versus warfarin after their stroke. Methods: In the regional stroke registry, K-PLUS, 1,019 consecutive patients with cardioembolic stroke who were prescribed anticoagulants were retrospectively enrolled from April 2011 to May 2016. Patients with premorbid modified Rankin Scale score of 3 or more and those with incomplete clinical data were excluded. The residual 323 patients were divided into 2 groups by their receiving anticoagulants after their stroke: the warfarin group and the DOACs group. Clinical characteristics, length of hospital stay, Functional Independence Measure (FIM) scores on admission and at discharge of rehabilitation hospital, and mean daily FIM gain were compared between the 2 groups. Results: In the 323 patients, median age was 79 (interquartile range: 73-85) years and 176 (54.5%) were men. A total of 146 patients (46.2%) was prescribed DOACs (dabigatran in 15, rivaroxaban in 46, apixaban in 72, and edoxaban in 13). Median age (81 vs. 79 in median, p = .03) and NIHSS score on acute hospital admission (10 in DOACs vs. 17 in warfarin, p &lt; .01) were lower, and length of acute hospital stay was shorter (13 vs. 17 days, p &lt; .01) in the DOACs group than the warfarin group. In rehabilitation hospitals, both FIM score on admission (86 vs. 32, p &lt; .01) and daily FIM gain (0.22 vs. 0.10, p &lt; .01) was significantly higher in the DOACs group. On multivariate analysis, DOACs prescription (odds ratio 1.79; 95% CI, 1.10-2.93) and NIHSS on acute hospital admission (1.04 per 1 point; 1.01-1.08) were correlated with daily FIM gain ≥ 0.15, independent of other factors including age, length of acute hospital stay, and FIM on admission of rehabilitation hospital. Conclusion: Patients receiving DOACs after their cardioembolic stroke might achieve better clinical outcome than those with warfarin.

Perioperative Safety in Patient Under Oral Anticoagulation During Holmium Laser Enucleation of the Prostate.

To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications. Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients. A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001). Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.

Preliminary therapeutic outcomes of using direct oral anticoagulants to treat venous thromboembolism in gynecological cancer patients.

Venous thromboembolism (VTE) is often a problematic complication in patients with gynecological cancer. Despite increasing opportunities to use direct oral anticoagulants (DOACs) to treat VTE, there are no reports on the therapeutic outcomes of DOACs in patients with gynecological cancer; however, there are some studies on cancer patients in general. We retrospectively examined the efficacy and safety of using DOACs to treat VTE in such patients. The study cohort comprised 43 patients with gynecological cancer and VTE who received treatment between May 2005 and April 2016. They were divided into two groups: DOACs used (DOAC group, n=21) and only unfractionated heparin (UFH) and warfarin used (standard group, n=22). The rates of improvement and recurrence of VTE and incidence of adverse events were compared between these groups. At 6 months, the VTE of 85% of patients in the DOAC group and of 75% in the standard group had improved (p=0.59). No recurrences of VTE occurred in the DOAC group; where VTE recurred in 12.5% of patients in the standard group. Adverse events occurred in three patients in the DOAC group (15.3%) and one in the standard group (7.7%). Chemotherapy significantly impacted improvement in VTE (p=0.01). Rates of VTE improvement and of recurrence of VTE and adverse events did not differ significantly between the study groups.

AS A PREDICTOR OF BLEEDINGS IN ELDERLY PATIENTS WITH ATRIAL FIBRILLATION TAKING DIRECT ORAL ANTICOAGULANTS

The purpose of the study is to assess the contribution of senile asthenia level to hemorrhagic complications quantity in elderly patients with atrial fibrillation (AF) taking direct oral anticoagulants (DOAC). Material and methods . Elderly patients >75 y.o. with AF taking dabigatran, apixaban or rivaroxaban in full or reduced dosages and without special features of bleeding (such as double and triple antithrombotic therapy) were included in the study. If a patient was under anticoagulants before the study (but not earlier than one became 75 y.o.), this experience was also analyzed. All bleedings during the first 18 months of anticoagulating were taken in mind. Patients in different DOAC groups were comparable in age and concomitant pathology. The «fragility» index was evaluated at the stage of inclusion in the study; an adapted Rockwood scale was used. Results and discussion. 102 patients with AF >75 y.o. taking dabigatran, apixaban or rivaroxaban in dosages corresponding to the instructions were included in the study. During the analyzed period, 19 small clinically significant hemorrhagic events that did not require hospitalization or cancellation of DOAC were recorded. Patients with and without bleeding in anamnesis were significantly differed only by «fragility» index score ( р = 0,001). The differences between concomitant pathology level which are mentioned in scale, is also not statistically significant. The average age of patients with and without bleeding anamnesis was not also significantly different (p = 0.12). In the future, it is advisable to continue the study using several scales for assessing the severity of the «fragility» index. Thus, it is advisable to calculate the «fragility» index in patients >75 years of age with AF taking DOAC.

Effects of Direct Oral Anticoagulants on Quality of Life During Periprocedural Management for Dental Extractions

Direct oral anticoagulants (DOACs) have many advantages over warfarin regarding periprocedural management for dental extractions. They avoid the need to assess and possibly adjust warfarin therapy to achieve appropriate hemostatic status before and after extraction. The present study evaluated the real-life data regarding quality of life (QoL) and burden for patients with atrial fibrillation receiving long-term treatment with warfarin or DOACs during periprocedural management for dental extraction. We implemented a multicenter study. The sample was composed of 205 patients who had been receiving long-term anticoagulation treatment with warfarin (n=133) or DOACs (n=72). The Duke Anticoagulation Satisfaction Scale (DASS) was used to assess the QoL. Periprocedural management for dental extraction was recorded using the questions designed by us. Warfarin created a significantly greater burden for patients during periprocedural management for dental extraction compared with DOACs. The DASS results showed that the QoL of patients was significantly better for the DOAC group than for the warfarin group (score, 75.19±18.52 and 90.12±17.28, respectively; P=.0001). Of the patients in the DOAC group, 45 had used warfarin as their previous therapy and had undergone another tooth extraction while using warfarin. Of these patients, 91.1% chose DOACs as their anticoagulant of choice for dental extraction. The present findings suggest that DOACs have many advantages compared with warfarin regarding the reported QoL and periprocedural management of dental extraction.

Prescription patterns of direct oral anticoagulants in pulmonary embolism: A prospective multicenter French registry

BackgroundData regarding the use of direct oral anticoagulants (DOACs) for the treatment of acute pulmonary embolism (PE) are sparse. We conducted a prospective multicentre registry study to describe patterns of DOAC prescription for the treatment of acute PE, and the associated risk of 6-month adverse events in daily practice. MethodsWe included all PE patients discharged since the availability of DOACs for the dedicated indication of acute PE treatment. Clinical data and 6-month outcomes, including death, recurrent venous thromboembolism (VTE), bleeding, and chronic thromboembolic pulmonary hypertension (CTEPH) were recorded prospectively. Temporal trends in DOAC prescription were tested. ResultsBetween 09/2012 and 04/2017, 1082 patients were included: 60.6% (n = 656) were treated with DOACs and 39.4% (n = 426) with another anticoagulant. The prescription rate of DOACs increased sharply just after their release on the market to reach a plateau over time, between 56% and 72% of the total prescription per year in PE patients (p for trend = 0.33). Active malignancy and renal function impairment were factors independently associated with non-prescription of DOACs. Overall, prescription of DOACs was appropriate in 95.3% of patients. The rate of use of non-recommended DOAC doses was 4.2% (n = 28). The rate of death, recurrent VTE, bleeding and CTEPH were 2.4%, 1.2%, 7.2%, and 1.9%, respectively in the DOAC group. ConclusionThe choice to prescribe DOACs or not is related to patient characteristics. The overall appropriateness of prescription is high, while the rate of adverse events observed in patients treated with DOAC is low in our registry.

Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants

The correlation between direct oral anticoagulants (DOACs) or Vitamin K Antagonist (VKAs) intake and the incidence of intracranial complications after minor head injury (MHI) is still object of debate: preliminary observation seems to demonstrate lower incidence in intracranial bleeding complications (ICH) in patients taking DOACs than VKA. METHODS. This prospective and observational study was performed to clarify the incidence of ICH in patients in DOACs compared to VKAs. Between January 2016 and April 2018 we have recorded in our ED patients with MHI taking oral anticoagulants. Their hemorragic risk score was calculated and recorded for each patient (Has Bled, Atria and Orbit). RESULTS A total of 402 patients with MHI taking anticoagulant were collected: 226 were receiving one of the four DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) while 176 patients were in therapy with VKA. The rate of intracranial complications was significantly lower in patients receiving DOACs than in patients treated with VKA (p < 0.01). In the VKA group two patients died because of intracranial bleeding. No deaths were recorded in the DOACs group. DISCUSSION patients with MHI who take DOACs have a significant lower incidence of intracranial bleeding complications than those treated with vitamin k antagonists. This statement is supported by the observation that the hemorrhagic risk, measured according to the chosen scores, was similar between the two groups.