Introduction Of Novel Oral Anticoagulants Research Articles

Secular Trends in Outcomes and Impact of Novel Oral Anticoagulants in Atrial Fibrillation-Related Acute Ischemic Stroke.

Novel oral anticoagulants (NOACs) are currently recommended for the secondary prevention of stroke in patients with acute ischemic stroke (AIS) accompanied by atrial fibrillation (AF). However, the impact of NOACs on clinical outcomes in real-world practice remains ambiguous. This study analyzes the trend of clinical events in patients with AF-related AIS and determines how much the introduction of NOACs has mediated this trend. We identified patients with AIS and AF between January 2011 and December 2019 using a multicenter stroke registry. Annual rates of NOAC prescriptions and clinical events within 1 year were evaluated. The primary outcome was a composite of recurrent stroke, myocardial infarction, and all-cause mortality. To assess the mediation effect of NOACs on the relationship between the calendar year and these outcomes, we used natural effect models and conducted exposure-mediator, exposure-outcome, and mediator-outcome analyses using multivariable regression models or accelerated failure time models, adjusting for potential confounders. Among the 12 977 patients with AF-related AIS, 12 500 (average age: 74.4 years; 51.3% male) were analyzed after excluding cases of valvular AF. Between 2011 and 2019, there was a significant decrease in the 1-year incidence of the primary composite outcome from 28.3% to 21.7%, while the NOAC prescription rate increased from 0% to 75.6%. A 1-year increase in the calendar year was independently associated with delayed occurrence of the primary outcome (adjusted time ratio, 1.10 [95% CI, 1.07-1.14]) and increased NOAC prescription (adjusted odds ratio, 2.20 [95% CI, 2.14-2.27]). Increased NOAC prescription was associated with delayed occurrence of the primary outcome (adjusted time ratio, 3.82 [95% CI, 3.17 to 4.61]). Upon controlling for NOAC prescription (mediator), the calendar year no longer influenced the primary outcome (adjusted time ratio, 0.97 [95% CI, 0.94-1.00]). This suggests that NOAC prescription mediates the association between the calendar year and the primary outcome. Our study highlights a temporal reduction in major clinical events or death in Korean patients with AF-related AIS, mediated by increased NOAC prescription, emphasizing NOAC use in this population.

Development and Validation of a Dynamic Nomogram for Predicting 3-Month Mortality in Acute Ischemic Stroke Patients with Atrial Fibrillation.

Acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) carries a substantial risk of mortality, emphasizing the need for effective risk assessment and timely interventions. This study aimed to develop and validate a practical dynamic nomogram for predicting 3-month mortality in AIS patients with AF. AIS patients with AF were enrolled and randomly divided into training and validation cohorts. The nomogram was developed based on independent risk factors identified by multivariate logistic regression analysis. The prediction performance of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUC-ROC), calibration plots, decision curve analysis (DCA), and Kaplan-Meier survival analysis. A total of 412 patients with AIS and AF entered final analysis, 288 patients in the training cohort and 124 patients in the validation cohort. The nomogram was developed using age, baseline National Institutes of Health Stroke Scale score, early introduction of novel oral anticoagulants, and pneumonia as independent risk factors. The nomogram exhibited good discrimination both in the training cohort (AUC, 0.851; 95% CI, 0.802-0.899) and the validation cohort (AUC, 0.811; 95% CI, 0.706-0.916). The calibration plots, DCA and Kaplan-Meier survival analysis demonstrated that the nomogram was well calibrated and clinically useful, effectively distinguishing the 3-month survival status of patients with AIS and AF, respectively. The dynamic nomogram can be obtained at the website: https://yanxiaodi.shinyapps.io/3-monthmortality/. The dynamic nomogram represents the first predictive model for 3-month mortality and may contribute to managing the mortality risk of patients with AIS and AF.

Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population.

Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the ‘Geisinger Neuroscience Ischemic Stroke’ (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62–1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.

Female Sex as a Thromboembolic Risk Factor in the Era of Nonvitamin K Antagonist Oral Anticoagulants

Sex-specific differences have been definitively demonstrated in cardiovascular (CV) diseases. These differences can also impact on the effects of CV therapies. Female sex is recognized as an independent predictor of thromboembolic risk, particularly in older patients. Most of strokes are due to atrial fibrillation (AF). Women affected by AF have higher stroke risk compared to men. The introduction of novel oral anticoagulants (NOACs) for long-term anticoagulation completely changed the anticoagulant therapeutic approach and follow-up of patients affected by nonvalvular atrial fibrillation (NVAF). CHA2DS2-VASc stroke risk scoring in use in the current international guidelines attributes 1 point to “female sex”. Besides, no anticoagulation is indicated for AF female patients without other risk factors. Interestingly, NOACs seem to normalize the differences between males and females both in terms of safety and efficacy, whereas residual higher stroke risk and systemic embolism persist in AF women treated with vitamin K antagonist anticoagulants VKA with optimal time in therapeutic range. Based on the CHA2DS2-VASc score, NOACs represent the preferred choice in NVAF patients. Moreover, complete evaluation of apparently lower risk factor along with concomitant clinical conditions in AF patients appears mandatory, particularly for female patients, in order to achieve the most appropriate anticoagulant treatment, either in male or in female patients. The present review was performed to review sex differences in AF-related thromboembolic risk reported in the literature and possibly highlight current knowledge gaps in prevention and management that need further research.

Real-world data on the incidence, mortality, and cost of ischaemic stroke and major bleeding events among non-valvular atrial fibrillation patients in England.

Rationale, Aims, and ObjectivesSeveral novel oral anticoagulants (NOACs) are licensed for atrial fibrillation (AF) treatment in the United Kingdom. We describe the incidence and mortality from ischaemic stroke and major bleeding in non‐valvular atrial fibrillation (NVAF) patients in England, including treatment patterns before/following introduction of NOACs, healthcare resource utilization (HRU), and costs post‐onset of these events.MethodData were extracted from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics secondary care and Office for National Statistics mortality data.ResultsOf 42 966 patients with a first AF record between 2011 and 2016, 9143 patients (21.3%) remained without AF (antiplatelets/antithrombotics) treatment post‐index diagnosis. The proportion of patients receiving aspirin for ≥3 months post‐index declined during the study (50.6%‐5.5%), irrespective of CHA2DS2‐VASc score, while the proportion prescribed NOACs increased (2.0%‐70.1%). Rates of ischaemic stroke per 1000 patient‐years (95% CI) were 9.4 (3.8‐15.0) with NOACs, 10.4 (8.0‐12.9) with warfarin, 20.1 (16.4‐23.8) with aspirin, 21.3 (5.3‐37.2) with other antiplatelets and 43.6 (39.3‐47.8) in patients without AF prescription. Major bleeding occurred at a similar rate with different treatments. All‐cause mortality rates were 42.8 (31.4‐54.3) with NOACs, 46.3 (41.1‐51.5) with warfarin, 56.5 (50.5‐62.4) with aspirin, 102.2 (76.2‐128.3) with other antiplatelets and 412.8 (399.6‐426.0) with no AF prescription. Mean annual National Health Service healthcare costs up to 1 year post‐index were lowest in patients receiving aspirin plus other antiplatelets without an event (£6152), and highest in patients with an event without AF prescriptions (£17 957). By extrapolation, national AF HRU in the United Kingdom in 2016 was estimated at £8‐16 billion annually.ConclusionsThese data provide temporal insights into AF treatment patterns and outcomes for NVAF patients in England and highlight the need to review higher stroke risk AF patients not receiving antiplatelet/antithrombotic prescriptions.

NOACs Now Mainstream for the Use of Anticoagulation in Non-Valvular Atrial Fibrillation in Australia

The management of stroke risk in patients with non-valvular atrial fibrillation has changed over the past few years. This change has occurred due to the introduction of novel oral anticoagulants (NOACs) such as apixaban, rivaroxaban and dabigatran for the management of non-valvular atrial fibrillation. These agents have shown comparable stroke risk reduction to warfarin in large international multicentre trials [1-3]. This has changed the clinical practice of many treating physicians since their introduction from 2011 to 2013. The purpose of this review was to highlight the now mainstream use of NOAC administration in preference to warfarin, by comparing the trends in the number of prescriptions filled since all three forms of oral anti-coagulant became available in 2013. These agents are being increasingly prescribed due to their ease of use compared to warfarin, which not only requires ongoing monitoring due to narrow therapeutic range but also has many drug and food interactions. Since November 2015, NOACs have become the mainstream choice for anticoagulation in atrial fibrillation likely given their ease of use compared to warfarin. The use of each anticoagulant remains divergent with the use of warfarin continuing to decrease.

Laboratory aspects of novel oral anticoagulant treatment

The introduction of novel oral anticoagulants (NOAC) have long been expected drugs and they quickly became used widespread as their clinical effectiveness was as good as, or even better than the previously used only oral anticoagulant drug, the coumarins. Thus, the direct thrombin inhibitor dabigatran and the activated factor X inhibitors (rivaroxaban, apixaban, edoxaban) have become the part of daily therapeutic practice. Their permeation was facilitated by the guideline which suggested that no laboratory monitoring was required during NOAC treatment and this was very convenient for both patients and doctors. The clinical experience obtained in the past years, however have proved that the 'one size fits all' view is oversimplified and there are numerous situations when the determination NOAC levels is unavoidable or highly recommended. This review discusses the laboratory aspects of NOAC treatment, primarily summarizing their effect on the screening tests and special assays of hemostasis and we also describe the correct methods to determine their plasma concentrations. Orv Hetil. 2017; 158(49): 1930-1945.

Influence of novel oral anticoagulants on anticoagulation care management.

Anticoagulation treatment was recently improved by the introduction of novel oral anticoagulants (NOACs). Using a combination of qualitative and quantitative methods, this study explores the effects of the introduction of NOACs on anticoagulation care in Slovenia. Face-to-face interviews with key stakeholders revealed evolvement and challenges of anticoagulation care from different perspectives. Obtained information was further explored through the analysis of nationwide data of drug prescriptions and realization of health care services. Simplified management of anticoagulation treatment with NOACs and their high penetration expanded the capacity of anticoagulation clinics, and consequentially the treated population increased by more than 50 % in the last 5 years. The main challenge concerned the expenditures for medicines, which increased approximately 10 times in just a few years. At the same time, the anticoagulation clinics and their core organisation were not affected, which is not expected to change, since they are vital in delivering high-quality care.

Almanac 2013: cardiac arrhythmias and pacing--an editorial overview of selected research that has driven recent advances in clinical cardiology.

Important advances have been made in the past few years in the fields of clinical cardiac electrophysiology and pacing. Researchers and clinicians have a greater understanding of the pathophysiological mechanisms underlying atrial fibrillation (AF), which has transpired into improved methods of detection, risk stratification, and treatments. The introduction of novel oral anticoagulants has provided clinicians with alternative options in managing patients with AF at moderate to high thromboembolic risk and further data has been emerging on the use of catheter ablation for the treatment of symptomatic AF. Another area of intense research in the field of cardiac arrhythmias and pacing is in the use of cardiac resynchronisation therapy (CRT) for the treatment of patients with heart failure. Following the publication of major landmark randomised controlled trials reporting that CRT confers a survival advantage in patients with severe heart failure and improves symptoms, many subsequent studies have been performed to further refine the selection of patients for CRT and determine the clinical characteristics associated with a favourable response. The field of sudden cardiac death and implantable cardioverter defibrillators also continues to be actively researched, with important new epidemiological and clinical data emerging on improved methods for patient selection, risk stratification, and management.This review covers the major recent advances in these areas related to cardiac arrhythmias and pacing.

Peri-procedural Anticoagulation in Catheter Ablation for Atrial Fibrillation: A Review.

Catheter ablation for rhythm control in atrial fibrillation has been recognized as an established treatment. Patients with atrial fibrillation suffer from an increased risk of thromboembolic events. Long-term stroke risk and mortality have been shown to be reduced after catheter ablation, still the procedure per se is associated with an additive peri-procedural thromboembolic risk. Maintenance of the thrombotic - bleeding equilibrium in such patients during interventional procedures is compelling. Lack of data from randomized studies along with the recent introduction of novel oral anticoagulants in clinical practice has resulted in a wide variance of antithrombotic treatment approaches. Procedural interruption of anticoagulants, switching of anticoagulation scheme (i.e. from novel oral anticoagulants to vitamin K antagonists), bridging with heparin, timing of re-initiation of therapy and/or utilization of novel oral anticoagulants have all been points of dispute. In the present review we present the available data regarding optimal peri-procedural anticoagulation strategies in patients undergoing catheter ablation for atrial fibrillation.

Effects of policy interventions on the introduction of novel oral anticoagulants in Stockholm: an interrupted time series analysis.

The aim of the present study was to assess the effect of policy interventions - i.e. reimbursement decisions, guidelines and regional recommendations - on the prescribing of oral anticoagulant treatment in patients with atrial fibrillation (AF). Interrupted time series analyses were carried out using monthly data on all patients with a recorded diagnosis of AF newly initiated (switchers and anticoagulant-naïve patients alike) on warfarin, dabigatran, rivaroxaban or apixaban in the Stockholm region from April 2011 until February 2016. A total of 34 165 initiations in 27 942 patients were included. The publication of the European Guidelines was associated with an increase in novel oral anticoagulant (NOAC) initiations of 12.5% [95% confidence interval (CI) 7.3, 17.7] after 5months. The choice between the different NOACs was mainly associated with changes in the regional recommendations, with apixaban initiations increasing by 19.5% (95% CI 16.3, 22.7) 5months after the drug was recommended as a first-line alternative to warfarin. Dabigatran received a second-line recommendation but initiations decreased by -9.5% (95% CI -12.6, -6.4), and initiations of rivaroxaban, which had no specific recommendation, decreased by -9.2% (95% CI -12.7, -5.7). A steady decrease in warfarin and increase in NOAC initiations was seen throughout the study period and from November 2015, AF patients were more likely to receive apixaban than any other anticoagulant, while less than 20% of the initiations were with warfarin. After reimbursement and inclusion in the European guidelines, the NOACs started gaining in popularity, while changes in regional recommendations were associated with the biggest change in prescribers' choice between the different NOACs.

Optimizing Stroke Prevention in Patients With Atrial Fibrillation: A Cluster-Randomized Controlled Trial of a Computerized Antithrombotic Risk Assessment Tool in Australian General Practice, 2012-2013.

IntroductionClinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. The objective of this study was to evaluate the impact of a computerized antithrombotic risk assessment tool (CARAT) on general practitioners’ prescribing of antithrombotics for patients with atrial fibrillation.MethodsA prospective, cluster-randomized controlled trial was conducted in 4 regions (in rural and urban settings) of general practice in New South Wales, Australia (January 2012–June 2013). General practitioner practices were assigned to an intervention arm (CARAT) or control arm (usual care). Antithrombotic therapy prescribing was assessed before and after application of CARAT.ResultsOverall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm. Compared with control patients, intervention patients (n = 206) were 3.1 times more likely to be recommended warfarin therapy (over any other treatment option; P < .001) and 2.8 times more likely to be recommended any anticoagulant (in preference to antiplatelet; P = .02). General practitioners agreed with most (75.2%) CARAT recommendations; CARAT recommended that 75 (36.4%) patients change therapy. After application of CARAT, the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); however, anticoagulant use increased slightly (from 89.3% to 92.2%), and antiplatelet use decreased (from 9.7% to 6.8%).ConclusionTools such as CARAT can assist clinicians in selecting antithrombotic therapies, particularly in upgrading patients from antiplatelets to anticoagulants. However, the introduction of novel oral anticoagulants has complicated the decision-making process, and tools must evolve to weigh the risks and benefits of these new therapy options.

COMPARISON OF TREATMENT PERSISTENCE IN THE REAL-WORLD USE OF NOVEL ORAL ANTICOAGULANTS AMONG PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATION

As oral anticoagulation reduces thromboembolic stroke risk in patients with atrial fibrillation, it is important that patients continue therapy. With the introduction of novel oral anticoagulants (NOACs) in Europe, clinicians and payers are interested in real-world data comparing persistence between

Neurologic Complications of Commonly Used Drugs in the Hospital Setting.

This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.

Rationale for Development of New Oral Anticoagulants.

The development of new or direct oral anticoagulants was triggered by the disadvantages of classic oral anticoagulation, which was isolated in Link's laboratory in 1940. Some of these limitations are the individual variation in response to these drugs, drug interaction and the need for regular laboratory monitoring. With increasing comorbidity and life expectancy in populations these limitations led to interruption of treatment or even underuse of treatment in light of potential side effects. With the introduction of novel oral anticoagulants some of these drawbacks are targeted whereas even these drugs also have some limitations and should be given with cautions and not to all patients having an indication for anticoagulation.

Characteristics and Treatment Patterns of Patients with Deep Vein Thrombosis and/or Pulmonary Embolism in the US Hospital Setting

Introduction:Current practice guidelines in the United States (US) recommend that anticoagulation treatment for deep vein thrombosis (DVT) and/or pulmonary embolism (PE) is initiated with parenteral administration of low-molecular-weight heparin (LMWH), fondaparinux or low-dose unfractionated heparin (UFH), followed by the use of warfarin or other vitamin K antagonist therapies (Kearon et al Chest 2012). Given the relatively recent introduction of novel oral anticoagulants (NOACs), it is essential to understand the demographic and clinical characteristics of DVT/PE patients receiving these therapies. The objective of this study was to evaluate characteristics and treatment patterns of patients with DVT and/or PE in the US hospital setting.Methods:This retrospective observational cohort study used hospital administrative claims data spanning 11/1/2011-12/31/2013 from more than 600 hospitals. Patients ≥18 years old with a primary discharge diagnosis of DVT and/or PE in the inpatient setting during the identification period (11/1/2012-12/31/2013) were selected. The first-observed hospitalization for DVT/PE during the identification period was defined as the index hospitalization, and thus the principal event for analysis. Patients with a secondary diagnosis of atrial fibrillation, atrial flutter, cardiomyopathy, or a coagulation disorder during the index hospitalization were excluded. Patients needed to have had a complete hospital stay defined as (1) observed admission and discharge dates and (2) a discharge status other than expired or unknown. Patients were categorized into mutually-exclusive treatment cohorts based on the anticoagulant (AC) treatment regimen received during the index hospitalization, including lack of receipt of any AC treatment. Parenteral anticoagulant (PAC) therapy was defined as LMWH, fondaparinux or UFH. Demographic, hospital, and clinical characteristics were assessed during the index hospitalization. A logistic regression was conducted to assess the likelihood of receiving rivaroxaban with PAC and/or warfarin (vs. rivaroxaban alone) adjusting for the following covariates: age, sex, race, geographic region, payer type, primary or secondary diagnosis of DVT and/or PE, history of DVT/PE, discharge status, receipt of thrombolytic drugs, presence of primary malignancy, presence of renal disease, attending provider specialty, hospital setting, and hospital size.Results:In this study, 46,214 patients met the selection criteria (mean age: 61 years; 53% female). Sixty-eight percent of all patients were white and 50% were Medicare beneficiaries. The majority of patients received a primary diagnosis of PE during the index hospitalization (54%), followed by those with a primary diagnosis of DVT without mention of PE (38%) and primary diagnosis of DVT and secondary PE (8%). The most common AC treatment during the index hospitalization was PAC + warfarin (70%), PAC alone (16%), PAC + rivaroxaban (6%), PAC + warfarin + rivaroxaban (4%), warfarin alone (1%), rivaroxaban alone (1%), and no AC therapy (2%). Among the patients who received rivaroxaban, more than 90% additionally received PAC. The mean [SD] Deyo-Charlson Comorbidity Index scores were lowest for the cohorts receiving rivaroxaban (rivaroxaban alone, 1.1 [1.7]; PAC + rivaroxaban, 1.2 [1.8]; and PAC + warfarin + rivaroxaban cohorts, 1.2 [1.6]). In logistic regression analyses, patients with a primary PE diagnosis (odds ratio (OR): 1.49; 95% CI 1.17-1.88), a primary DVT diagnosis with a secondary PE diagnosis (OR 2.07; 95% CI 1.31-3.26), receipt of thrombolytic drugs (OR: 12.45; 95% CI 3.95-39.23), presence of renal disease (OR: 1.61; 95% CI 1.02-2.54), and receipt of care in an urban hospital (OR: 1.53; 95% CI 1.16-2.00) were significantly more likely to receive rivaroxaban with PAC and/or warfarin compared to rivaroxaban alone.Conclusion:This study evaluated characteristics and treatment patterns among patients with DVT and/or PE in the US hospital setting, following the introduction of the NOACs. Our findings indicate that the standard of care (PAC + warfarin) remains the dominant treatment regimen despite the availability of newer NOACs. Future studies of treated patients with DVT and/or PE should examine whether these preliminary observations of treatment patterns change with increased clinical experience with NOACs. DisclosuresLim:Boehringer Ingelheim Pharmaceuticals Inc.: Employment. Sander:Boehringer Ingelheim Pharmaceuticals Inc.: Employment.

Abstract 14902: The Introduction of Novel Oral Anticoagulants Has Improved Overall Oral Anticoagulation Rates in Atrial Fibrillation: Insights From the NCDR PINNACLE Registry

Introduction: For patients with atrial fibrillation (AF), novel oral anticoagulants (NOACs) provide effective alternatives to warfarin. However, a better understanding is needed of how the introduction of NOAC therapy has improved use of any oral anticoagulation (OAC) for patients with AF. Methods: Within the NCDR PINNACLE registry, we identified 447,770 patients comprising 1,428,660 outpatient encounters with non-valvular AF and CHADS-VASc &gt;1 between April 1, 2008 and September 30, 2014. We examined use of any OAC, any NOAC, and of dabigatran, rivaroxaban, and apixaban individually over time. Multivariable logistic regression was performed to identify factors associated with any OAC and NOAC use at the end of the study period, including CHADS-VASc score, age, weight, CAD, PAD, dyslipidemia, stroke/TIA, heart failure, gender, hypertension, and diabetes. Results: Use of any OAC increased from 52.1 to 61.2% during the study period among patients without a documented contraindication (p for trend &lt;0.01) (Figure). Although warfarin use decreased from 52.1% to 36.8% (p for trend &lt;0.01), use of NOACs increased from 0% to 24.4% (p for trend &lt;0.01). Rivaroxaban was the most frequently prescribed NOAC at the end of the study period (12.1%), followed by dabigatran (6.6%), and apixaban (5.7%). Patient factors associated with use of OAC and NOACs are presented in the Table. Conclusions: In a large U.S. outpatient registry, introduction of NOACs into clinical practice has improved the use of any OAC for AF patients at high risk for stroke. However, more than 1 in 3 high risk patients without a documented contraindication were not treated with any OAC.

Antiplatelet Therapy During PCI for Patients with Stable Angina and Atrial Fibrillation.

The pharmacological treatment options for anticoagulation in patients with atrial fibrillation (Afib) have increased with the introduction of novel oral anticoagulants, compared with earlier times, when vitamin K antagonist was the drug of choice. As they age, many Afib patients require percutaneous coronary intervention (PCI), necessitating antiplatelet medication in addition to anticoagulation therapy. Choosing the appropriate combination and duration of anticoagulation and antiplatelet therapies may be challenging in stable coronary artery disease (CAD) and even more complicated during and after coronary intervention with the introduction of additional antithrombotic drugs. In this article, we review the scientific basis for the recent guidelines for anticoagulation and antithrombotic therapy in patients with Afib and stable CAD before, during, and after elective PCI.

Factors Driving Anticoagulant Selection in Patients With Atrial Fibrillation in the United States

With the introduction of novel oral anticoagulants (NOACs), the factors driving anticoagulant selection in atrial fibrillation (AF) in real-world practice are unclear. The goal was to examine whether and to what extent utilization has been driven by predictions of stroke risk (treatment benefit), bleeding risk (treatment harm), or prescription benefits' coverage. We extracted a cohort of patients with nonvalvular AF initiating anticoagulation from October 2010 to December 2012 from a large US database of commercial and Medicare supplement claims. Multivariable regression examined associations between ischemic stroke (CHA2DS2-VASc) and bleeding (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA]) risk scores and benefits' generosity (proportion of costs covered by patients relative to total) with warfarin and novel oral anticoagulant (NOAC) selection and also between dabigatran and rivaroxaban. C-statistics and partial chi-square statistics were used to assess the variation explained. Of 70,498 patients initiating anticoagulation, 29.9% and 7.9% used dabigatran and rivaroxaban, respectively. Compared with warfarin, patients were less likely to receive an NOAC with high ischemic stroke risk (CHA2DS2-VASc ≥2; adjusted relative risk [aRR] 0.75, 95% confidence interval [CI] 0.72 to 0.77) and high bleeding risk (ATRIA ≥5; aRR 0.66, 95% CI 0.64 to 0.69) but more likely with good benefits' generosity (≤20% of costs borne by patient; aRR 2.03, 95% CI 1.92 to 2.16). Prescription generosity explained almost twice the model variation as either risk score. Compared with dabigatran, patients were more likely to fill rivaroxaban with high bleeding risk (aRR 1.16, 95% CI 1.09 to 1.24). In conclusion, patients with greater bleeding and ischemic stroke risk were more likely to initiate warfarin, but generous benefits more strongly predicted NOAC usage and drove more selection.

Novel oral anticoagulants and valvular atrial fibrillation: are they always contraindicated?

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia, and is associated with an increased risk of death, stroke, and other thromboembolic events. Valvular heart disease (VHD) frequently coexists with AF, mostly in elderly patients. After the introduction of novel oral anticoagulants (NOACs) approved for the prevention of stroke in non-valvular atrial fibrillation (NVAF) on the basis of recent trials, the importance of a universal definition of NVAF was raised in clinical practice. In the most recent guidelines, the term valvular AF is used to imply that AF is related to rheumatic valvular disease (predominantly mitral stenosis), or prosthetic heart valves. In all the trials comparing NOACs and warfarin, a significant percentage of patients presented any type of VHD, excluding rheumatic mitral stenosis and mechanical heart valve. The subgroups analysis performed, so far showed no significant differences in terms of efficacy in the VHD subgroup compared to the general AF population. A restrictive definition of valvular AF (i.e., rheumatic mitral stenosis and mechanical heart valve) seems to be the most appropriate to contraindicate treatment with NOACs for AF thromboprophylaxis. In the remaining AF patients with significant valvular disease who per se would not require oral anticoagulation, NOACs should be allowed.