Effect Of Anticoagulant Therapy Research Articles

Ultrasound elastography predicts anticoagulation in lower extremity deep vein thrombosis.

To investigate predictors of anticoagulation efficacy in deep venous thrombosis (DVT) by ultrasound elastography (UE). The basic clinical, laboratory and ultrasound treatment data of fifty-eight patients with DVT were collected and analyzed. Then the results of ultrasound after 3-month anticoagulation treatment were compared among different groups. Multiple logistic regression analysis was used to identify independent risk factors that affected anticoagulation efficacy. The predictive efficacy of each independent risk factor was accessed by drawing operating characteristic (ROC) curves. According to the regression analysis, the elastic modulus (OR = 0.631, P = 0.001) and strain rate ratio (OR = 0.332, P = 0.006) were identified as independent risk factors for the effectiveness of anticoagulation therapy in patients with DVT. According to the ROC curves, elastic modulus and strain rate ratio could predict effective anticoagulation therapy for DVT, and the optimal threshold values were 22.10 kPa and 1.80 respectively. The corresponding AUC values were 0.879 and 0.854, with a sensitivity of 71.4% and 59.5%, a specificity of 93.7%, and a Youden index of 65.1% and 62.7%, respectively. The elastic modulus (≤22.10 kPa) or strain rate ratio (≤1.80) of the thrombus were independent predictors for the effectiveness of anticoagulation therapy.

Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation [Letter

Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation [Letter

Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis.

An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.

Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation.

This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF). At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events. At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable. In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.

Analysis of the therapeutic effect and application of anticoagulant drugs

As the global population ages, the incidence of cardiovascular disease, stroke, and other diseases associated with thrombosis is also increasing, resulting in a great need for effective anticoagulant treatments. The purpose of this research is to summarize the development of anticoagulant drugs to date, including their drug types, version iterations, mechanisms of action, as well as current challenges and future development directions of anticoagulant drugs. The research will first review traditional anticoagulants, such as vitamin K antagonists and heparins, and discuss in detail their effects, advantages, and limitations. Next, it will give a detailed description of new anticoagulants, such as direct acting oral anticoagulants (DOACs), and analyse their advantages over traditional anticoagulants in terms of safety and efficacy. Finally, it will propose the strategy of individualized therapy for specific population and the combination therapy of anticoagulant therapy and other drugs, and look forward to the development of new anticoagulant drugs in the future. The application of anticoagulant drugs in medicine has a wide range of clinical significance. With the continuous deepening of research, new therapeutic strategies and drugs are constantly being developed and improved, aiming at providing more safe and effective anticoagulant therapy.

Prognostic risk factors for patients with hepatic sinusoidal obstruction syndrome caused by pyrrolizidine alkaloids.

Pyrrolizidine alkaloids induced hepatic sinusoidal obstruction syndrome (PA-HSOS) often occurs after consuming herbs or a dietary supplement containing the plant Tu-San-Qi. Limited data exists to identify patients with fatal outcomes for early interventions. We aimed to analyze the predictors for 3-month survival. We retrospectively enrolled PA-HSOS patients in 5 hospitals and extracted data from the onset of PA-HSOS to 36 months. Outcome measurements were 3-month and 36-month survival rates, baseline prognostic predictors for survival, and the effects of anticoagulant therapy. Among 49 enrollees, the median age was 60 and 49% male. At the onset of PA-HSOS, patients with Child-Turcotte-Pugh (CTP) class of A, B, or C were 8.2% (4/49), 42.8% (21/49) and 49.0% (24/49), respectively. None of them received a transjugular intrahepatic portosystemic shunt or a liver transplant. The 3-month and 36-month survival rates were 86% and 76%, respectively. Compared to the CTP class A or B, class C at baseline independently predicted lower survival rates at both 3 and 36 months. However, anticoagulation therapy treatment within the first 3 months independently predicted significantly higher survival rates at both time points. CTP class C and anticoagulant therapy were the independent predictors for short-term and long-term survival. Anticoagulant therapy could decrease mortality rate of CTP class C patients. The greatest benefit of anticoagulant evaluated by 3-month survival rate was in patients with CTP class C compared with those without treatment (93% vs 40%, P = .009). There were no bleeding complications reported in patients treated with the anticoagulant.

Effect of Anticoagulation Therapy in Management of Isolated Non-Occlusive Thrombosis of Non-Aneurysmal Aorta

Effect of Anticoagulation Therapy in Management of Isolated Non-Occlusive Thrombosis of Non-Aneurysmal Aorta

#3896 SAFETY OUTCOMES OF ORAL ANTICOAGULANT THERAPY IN PATIENTS WITH ATRIAL FIBRILLATION AND CHRONIC KIDNEY DISEASE

Abstract Background and Aims The comorbid conditions of atrial fibrillation (AF) and chronic kidney disease (CKD) leads to an increased risk of thromboembolic complications, but on the other hand is a risk factor for various bleeding. Oral anticoagulant therapy is the standard for the prevention of thromboembolic complications in AF. But with the deterioration of kidney function, the risk of hemorrhagic complications increases dramatically. This problem makes it difficult to choose an effective and safe oral anticoagulant therapy. Clinical data on the use of new oral anticoagulants (NOACs) in patients with AF and advanced CKD are limited, which determines the relevance of conducting studies in comparison with vitamin K antagonists. The aim of study was evaluation of safety parameters for the using of rivaroxaban in patients with stage 4 CKD with AF. Method The study included 109 patients over the age of 18 with a diagnosis of stage 4 CKD (eGFR – 15–29 ml/min/1.72 m2) and non-valvular AF. They were randomized in a 2:1 ratio to either rivaroxaban 15 mg (n = 73) or warfarin (n = 36). The mean follow-up period was 18 months. In the warfarin group, time in therapeutic range (TTR) &amp;gt;70% was achieved in 34 (94%) patients. Exclusion criteria were a history of bleeding that required hospitalization; decrease in hemoglobin level below 80 g/l, platelet count below 100 × 109/l; indications for taking antiplatelet therapy; chronic use of drugs that increase the risk of bleeding. The analysis of the observed hemorrhagic events was carried out using the BARC and ISTH scales. Classification of anemia was carried out according to the recommendations of the World Health Organization. Results Patients taking warfarin were significantly more likely to develop minor bleeding according to the BARC scales and ISTH and all clinically significant bleeding on the ISTH scale. In patients with AF and CKD receiving warfarin therapy, minor bleeding (MB) according to the BARC scale was observed in 72.2% (n = 26), minor clinically significant bleeding (MCSB) in 8.33% (n = 3), major bleeding in 8.33% (n = 3) of cases; and in the group of patients treated with rivaroxaban, MB was observed in 42.4% (n = 31, p&amp;lt;0.01), MCSB in 2.74% (n = 2, p = 0.32), major bleeding in 2.74% (n = 2, p = 0.32) of cases. When assessing bleeding on the ISTH scale during therapy with VKA, MB – 61.1% (n = 22), MCSB – 19.4% (n = 7), major bleeding – 8.33% (n = 3); against the background of NOACs therapy, MB – 36.9% (n = 27, p = 0.01), MCSB in 8.2% (n = 6, p = 0.06), major bleeding in 2.74% (n = 2, p = 0.32). All clinically significant hemorrhagic events according to the BARC scale in the warfarin group occurred more than 16.6% (n = 6) compared with the rivaroxaban group 5.4% (n = 4, p = 0.06); when analyzed according to the ISTH scale, the number of patients receiving VKA anticoagulant therapy 27.7% (n = 10) significantly prevailed over patients on the background of NOACs 10.9% (n = 8, p = 0.03). Analysis of hemoglobin level did not reveal significant dynamics and significant differences between the groups: the median hemoglobin level at inclusion was 129 g/l in the rivaroxaban group and 123 g/l in the warfarin group (p = 0.3), after 18 months - 130 g/l and 121 g/l, respectively (p = 0.7). Conclusion Data suggesting a favorable safety profile for NOACs (rivaroxaban) compared with VKAs (warfarin) in patients with AF and advanced CKD was obtained in this study. Taking rivaroxaban was accompanied by a significantly lower number of hemorrhagic events, which may indicate a safe effect of the drug. No significant changes in hemoglobin levels were found in both groups. Confirmation of these data may be key in choosing an anticoagulant in patients with AF and advanced CKD.

Investigation of cardiac adverse effects in COVID-19 ARDS patients treated with intravenous immunoglobulin.

The popularity of intravenous immunoglobulin (IVIG) therapy in Acute Respiratory Distress Syndrome (CARDS) secondary to COVID-19 infection is increasing day by day. In this study, we aimed to retrospectively evaluate the possible cardiac effects in our CARDS patients treated with IVIG. Demographic and clinical characteristics, mortality, sequential electrocardiography (ECG), echocardiography, cardiac markers, and other laboratory parameters of CARDS patients who received IVIG treatment were recorded. The mean age of the patients was 68.7±13.6%, and 70.5% were female. The mean number of days of hospitalization in the intensive care unit was 18.2±9.7, and the mortality rate was recorded as 35.2%. No pathological rhythm or ischemic change was observed in sequential ECG follow-ups. However, in consecutive ECO follow-ups, the sPAP values at the treatment end were numerically lower, although not statistically significant. Our study suggests that IVIG therapy may be used safely in COVID-19 patients with cardiovascular side effects. However, due to the high risk of coagulopathy in these patients, the use of IVIG therapy in COVID-19 infection should be monitored with close monitoring, as it may increase the potential for cardiovascular risk. Furthermore, monitoring cardiac parameters are also essential as it may predict high cardiovascular risk in patients. For this reason, patients need lower infusion rates, steroid combination, adequate hydration, and effective anticoagulation therapy to avoid these side effects.

DP-Filter, a Rapid and Ergonomic Device to Remove Direct Thrombin Inhibitor Argatroban from Plasma for Routine Hemostasis Tests

Argatroban is a direct thrombin inhibitor (DTI) used as an effective alternative anticoagulation therapy in patients suffering from heparin-induced thrombocytopenia (HIT), a serious and potentially life-threatening condition. One of its limitations is its need to be administered intravenously in a continuous manner because of its short half-life in patients without hepatic dysfunction. Thus, a transition towards another long-term anticoagulation therapy, for instance with anti-vitamin K drugs, is usually recommended once HIT is no longer acute and platelet count is stabilized. However, during the transition, remaining plasma levels of argatroban may interfere with hemostasis testing used to monitor the patient response to new anticoagulation drug dosage. The DP-Filter is a functional and user-friendly device used for plasma preparation. This device was already proven effective to substitute the second centrifugation step for platelet poor plasma preparation and to remove direct oral anticoagulants from citrated plasma. We aimed to assess the efficacy of the DP-Filter to remove argatroban from human plasma samples in a fast, practical, and ergonomic way. Argatroban was spiked in human normal pooled plasma (NPP) samples at six concentrations (0.0 [Hepes buffer], 0.1, 0.25, 0.5, 1.0 and 2.0 µg/mL). NPP samples were provided by NAB-X biobank from the University of Namur (Belgium) and were collected on March 23rd, 2022. NPP samples were collected from 8 men and 24 women, with mean age of 22 years old (min = 19 ; max = 48) and mean BMI of 23 (min = 19 ; max = 29). Blood samples were collected in accordance with the Declaration of Helsinki following approval by the Ethical Committee of the CHU UCL Namur (Yvoir, Belgium) under the approval number B03920096633. Argatroban levels were assessed in duplicates in spiked NPP samples before and after filtration with DP-Filter using argatroban-calibrated STA-ECAII testing (Argatroban Plasma Calibrator from Hyphen BioMed). Increasing concentrations of argatroban were measured in non-filtered spiked NPP samples while filtration through DP-Filter reduced argatroban levels close to 0.0 µg/mL, even when spiked concentration was as high as 2.0 µg/mL (Figure 1). Among routine coagulation tests, the activated partial thromboplastin time (aPTT) can be used to assess the anticoagulant effect of DTI. Thus, aPTT was used as a sensitive clotting test to assess the performance of the DP-filter to restore the baseline (i.e. in absence of argatroban) clotting capacity of the plasma. This was determined in duplicates using STA-PTT A5 testing with silica as activator. Filtration through DP-Filter was able to restore normal aPTT values, even at the highest tested argatroban concentration (i.e. 2.0 µg/mL). Similar results were obtained on filtered and non-filtered NPP samples spiked with 0.0 µg/mL of argatroban, confirming the absence of impact of DP-Filter on aPTT testing itself (Figure 2). Altogether, our results show that DP-Filter is an effective, rapid and ergonomic tool to remove argatroban from plasma. It can be used in clinical routine to remove the interference of argatroban with hemostasis tests and therefore avoid false positive or false negative results and unnecessary testing. It also emerges as a solution to ease the monitoring of the transition from patient anticoagulation with argatroban to another anticoagulation therapy such as anti-vitamin K drugs. This might be of particular importance in patients suffering from HIT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

High Incidence of Intra-Cardiac Supra-Centimetric Thrombosis and Embolic Complications in Sickle Cell Disease Patients with Dual Lumen Ports

In Sickle Cell Disease (SCD) patients with cerebral vasculopathy and/or other severe complications, a transfusion program is indicated. A sustainable venous access is vital for patients engaged in these programs (5-10% of patients with SCD). Dual lumen ports (Vortextechnology) have emerged has a way to bypass the frequent local complications associated with arteriovenous fistulae. Between July 2015 and December 2020, a dual lumen port was implanted in 27 SCD patients in transfusion program at Necker Hospital. Over a 30 months period, we observed 20 venous thromboembolic events (VTE) in 12 patients (44%): 18 were voluminous intracardiac thrombosis (Fig 1), asymptomatic (n=15) or complicated of pulmonary embolism (n=3), one jugular thrombosis and one superior cellar syndrome, leading to long-term curative anticoagulation, except in cases of contraindication such as Moya-Moya. VTE were diagnosed on average 18 months after implantation (range 1 to 29 months). This observation has considerably limited the use of the device, even though no complications were observed in 56% of patients, suggesting that a subgroup of patients may be at lower risk of thrombosis and could still benefit from a Vortex. We conducted a clinical study aiming to identify potential biological markers related to Vortex thrombosis in SCD patients. Among the biological markers, alterations of thrombin generation and fibrino-formation, as well as potentially procoagulants items altered in SCD, such as microvesicules (MV), red blood cell (RBC) deformability and the intensity of splenic dysfunction were explored. Between January and June 2021, 11 healthy donors and 58 patients with SCD treated by erythrapheresis in the biotherapy department of Necker Hospital were included, 23 patients with a Vortex with (n=12) or without (n=11) intra-cardiac and/or other VTE and 36 patients without a Vortex (including 8 with a history of VTE). Thrombin generation Assay (TGA) in plasma and standard coagulation assays were performed on pre-transfusion sample, including Prothrombin Time (PT), activated partial thromboplastin time (APTT) and fibrinogen, dosage of FII, FV, FVII, FX and FXII, Protein C (PC), Protein C (PS), Antithrombin (AT) dosage. All samples were pretreated by activated carbon for removal of Direct Oral Anticoagulants from plasma. Quantification and characterization of plasma MV, determination of erythrocyte deformability and point of sickling (ektacytometry with oxygenscan) and assessment of splenic function (quantification of pocked RBC and Howell Jolly bodies) were also performed. We found a significant decrease in the mean levels of PC (69.7 vs 109.1%, p=0.0002) and PS (58.4 vs 99.4, p<0.0001) in SCD patients when compared to healthy donors while AT levels were only slightly decreased (91 vs 98,6%, p=0,04). We also observed a significant decrease in vitamin-K dependent coagulation factors: FII (77.5 vs 100.6%, p<0,0001), FVII (61.9 vs 84.5% p=0.005) and FX (71.8 vs 96.8%, p=0.0001) while FV (80.1 vs 93.8% p=0.02) was only slightly decreased and fibrinogen levels were comparable (2.62 vs 2.57g/L p=0.86). No significant differences were noted between SCD patient groups (with or without thrombosis). Thrombin generation Assay (TGA) in plasma showed an increase in endogenous thrombin potential (ETP; 714 vs 451nM.min, p=0.04) and Peak (161 vs 95 nM.min, p=0.03) in SCD patients compared to healthy donors but no differences were found between patient groups. Assessment of splenic function, point of sickling in oxygenscan and deformability of RBC measured by ektacytometry showed no differences between patient groups. Patients with SCD had a significant increase of circulating CD235+ MV (93268 vs 15 207/µL, p<0.0001), Annexin 5 MV (473553 vs 248404 /µL) and CD235+ erythrocyte ghosts (1757 vs 61/µL) compared to healthy donors. Again, no differences were seen between patient study groups. In conclusion, no biological predictive factors for intra cardiac Vortex thrombosis could be demonstrated by our study despite an extensive study of biological factors known to date to favor thrombosis. Given the high incidence of intracardiac thrombosis and the impossibility to date of predicting the risk of occurrence, we recommend that Vortex technology be reserved for patients who are already receiving effective anticoagulant therapy or for whom no other solution can be found, while maintaining a close surveillance of echocardiography.

The effect of anticoagulation therapy on perioperative bleeding risk in patients undergoing heart transplantation

The effect of anticoagulation therapy on perioperative bleeding risk in patients undergoing heart transplantation

Anticoagulation and BMI: effect of high body weight on the safety and efficacy of direct oral anticoagulants.

Obesity is an epidemic with rising prevalence, and obese patients are predisposed to comorbid conditions that increase risk for thromboembolic events. It is critical to identify safe and effective anticoagulation therapy for use in this population. Direct oral anticoagulants (DOACs) are a preferred option for anticoagulation in patients of normal weight due to many benefits and equivalent safety and efficacy to their vitamin K antagonist counterparts. However, the safety and efficacy of DOACs in obese patients is not well understood. This review describes recent studies on the pharmacokinetics, safety and efficacy, and clinical outcomes of the DOACs apixaban, rivaroxaban, edoxabanand dabigatran in obese patient populations. DOACs may be a beneficial alternative to vitamin K antagonist therapy in obese patient populations.

The effectiveness of anticoagulant therapy in Covid-19 associated ischemic stroke

The effectiveness of anticoagulant therapy in Covid-19 associated ischemic stroke

Anticoagulant Therapy Is Associated With Decreased Long-Term Mortality in Splenic Infarction Patients: A Multicenter Study

Background: Patients with splenic infarction (SI) are associated with a prothrombotic state and are vulnerable to subsequent thromboembolic complications. However, due to its rarity, there is no established treatment modality in this population. We aimed to examine the effect of anticoagulant therapy in SI patients.Methods: We performed a multicenter retrospective cohort study of 86 SI patients. Patients were categorized as anticoagulant users and anticoagulant non-users. The associations between anticoagulant therapy, all-cause mortality, thromboembolic events and bleeding events were evaluated.Results: Forty-five patients (52.3%) received anticoagulant therapy during the follow-up periods. The all-cause mortality rate was 6.86 per 100 patient-years. Anticoagulant therapy was associated with 94% improved survival (HR = 0.06; Cl 0.007–0.48; p = 0.008), while the risk factors for all-cause mortality were prior stroke (HR = 13.15; Cl 2.39–72.27; p = 0.003) and liver cirrhosis (HR = 8.71; Cl 1.29–59.01; p = 0.027). Patients with anticoagulant therapy had a higher event-free survival curve for thromboembolic complications (p = 0.03) but did not achieve a significant difference after adjustment using the Cox regression model as a time-dependent covariate (HR = 0.57; Cl 0.13–2.45; p = 0.446). There was no significant difference in the risk of bleeding events between the groups (p = 0.728).Conclusions: Anticoagulant therapy in patients with SI was associated with better survival and was not related to an increased bleeding risk.

Abstract 10273: The Use of Direct Oral Anticoagulation Therapy in Transcatheter Aortic Valve Implantation in Patients with Concurrent Indications for Anticoagulation; A Systematic Review and Meta-Analysis

Introduction: The optimal antithrombotic regimen in patients after transcatheter aortic valve implantation (TAVI) in the setting of concurrent indication for anticoagulation remains unclear. Recently multiple studies have investigated the role of direct oral anticoagulation therapy (DOAC) in comparison to Vitamin K antagonist (VKA) in this category of patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of this approach Hypothesis: DOAC is a safe and effective alternative anticoagulation therapy in TAVI patients Methods: Unrestricted search of the PubMed, EMBASE, and Cochrane databases from inception till June 1, 2021, for studies comparing DOAC with VKA in TAVR patients with concurrent indication for anticoagulation. Relevant data were extracted and analyzed using Revman 5.3 software. Relative Risk (RR) and 95% Confidence interval (CI) were calculated using the random-effects model. Results: A total of 8 studies (7 Observational, and 1 Randomized clinical trial) were included examining 4,158 TAVI patients (1,500 DOAC vs 2,658 VKA). There was no difference between DOAC and VKA in terms of all-cause mortality RR 0.89 (95% CI 0.65-1.21), all-bleeding events RR 0.90 (95% CI 0.76-1.07), and stroke risk RR 1.42 (95% CI 0.96-2.11). Conclusions: DOAC is probably non-inferior to VKA in TAVI patients with concurrent indications for anticoagulation therapy. Further studies are needed to validate our findings.

Abstract 10269: Direct Oral Anticoagulation Therapy vs Vitamin K Antagonist in Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

Introduction: The use of direct oral anticoagulation therapy (DOAC) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) has recently increased, despite the scarce evidence to support their use in this condition. Our systematic review and meta-analysis aim to summarize the available data on the safety and effectiveness of DOAC. Hypothesis: DOAC is a safe and effective alternative anticoagulation therapy in CTEPH. Methods: Unrestricted search of the PubMed, EMBASE, and Cochrane databases from inception till May 1, 2021, for studies comparing DOAC with Vitamin K antagonist (VKA) in CTEPH patients. Relevant data were extracted and analyzed using Revman 5.3 software. Odds Ratio (OR) and 95% Confidence interval (CI) were calculated using the random-effects model. Results: A total of 3 observational studies were included examining 1,630 patients with CTEPH (386 DOAC vs 1,244 VKA). The most used DOAC was Rivaroxaban (79% of that population). There was no difference between DOAC and VKA in the incidence of recurrent venous thromboembolism OR 1.35 (95% CI 0.40-4.52), major bleeding OR 0.60 (95% CI 0.33-1.10), and clinically relevant non-major bleeding OR 1.42 (95% CI 0.86-2.33). Conclusions: DOAC is probably non-inferior to VKA in CTEPH patients. Since rivaroxaban is the most used DOAC in the included cohort, the safety, and efficacy of other DOAC remain unclear. Our findings need further validation with randomized clinical trials.

A retrospective study on the evaluation of the appropriateness of oral anticoagulant therapy for patients with atrial fibrillation.

The incidence of atrial fibrillation (AF) is increasing, and effective anticoagulation therapy can prevent adverse events. Selecting the appropriate OAC based on patient characteristics has become a challenge. Interventions are going to be a potential area of focus. To explore the discrepancies between clinician prescriptions and recommended guidelines of oral anticoagulants (OACs) for patients with atrial fibrillation (AF), and to provide direction for improving anticoagulation strategies for treating patients with AF. Data were collected from the electronic medical record system of Fuwai Yunnan Cardiovascular Hospital between July 2019 and January 2020. The suitability of prescribed OACs for patients with AF was assessed according to the Rules for Avoiding Prescription Inappropriateness, the prescribed medicine label, and any relevant antithrombotic guidelines for treating patients with AF. A total of 460 patients met the inclusion criteria. Of these, 53.7% received an appropriate prescription and 46.3% received an inappropriate prescription. Of the patients who received inappropriate prescriptions, 15.4% were prescribed without the presenting appropriate indicators, 1.3% were prescribed inappropriate drug selection, and 29.6% were prescribed inappropriate drug doses. For patients prescribed without providing appropriate indicators, 2.2% had no indication for medication and 13.3% had an indication for medication, but not a specific OAC. For patients with inappropriate drug selection, 1, 5 patients were on rivaroxaban, dabigatran respectively. The distribution of NOAC doses was as follows: dabigatran standard dose (45.2%), the low dose (54.8%). Rivaroxaban standard dose (58.9%), low dose (36.8%), high dose (4.3%). A total of 44 patients (9.6%) experienced bleeding events, 12 patients (2.6%) experienced embolic events, and 7 patients experienced other adverse events after dosing. In clinical practice, it is common for patients with AF to receive inappropriate prescriptions of OACs. Therefore there is a need to enhance anticoagulation management in patients with AF to improve the appropriate use of OACs.

Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation.

The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Difference in left atrial D-dimer level in patients with atrial fibrillation treated with direct oral anticoagulant

BackgroundAtrial fibrillation (AF) may cause cerebral and systemic embolism. An increased D-dimer level indicates hyperactivation of secondary fibrinolysis, resulting in predilection for thrombosis. To clarify the differential effects of anticoagulation therapy, we compared the D-dimer levels in peripheral and left atrial (LA) blood of atrial fibrillation patients scheduled for ablation.MethodsWe analyzed 141 patients with non-valvular AF (dabigatran, n = 30; apixaban, n = 47; edoxaban, n = 64; mean age: 68 years, male: 60%). Peripheral venous blood and LA blood was collected before pulmonary vein isolation. We examined the laboratory and echocardiographic parameters.ResultsAfter adjusting for baseline characteristics, D-dimer level in the LA was significantly higher in patients treated with edoxaban than that in those on apixaban (0.77 ± 0.05 vs. 0.60 ± 0.05 μg/mL, P = 0.047), although there were no significant differences in peripheral D-dimer levels. We classified the D-dimer value of the LA into a normal group (< 0.9) and a high value group (≥ 1.0); the peripheral prothrombin fragment F1 + 2 level (odds ratio [OR] 1.012; 95% confidence interval [CI]: 1.003–1.022; P = 0.008) and left ventricular ejection fraction (LVEF) (OR, 0.947; 95% CI, 0.910–0.986; P = 0.008) were potential predictors of high LA D-dimer levels.ConclusionsIn apixaban-treated patients, the D-dimer level in the left atrium was lower than in edoxaban-treated patients on the day of ablation, suggesting that the anticoagulant effect of apixaban on the left atrium is better than that of edoxaban in patients with AF.