New Oral Anticoagulants Research Articles

USO DE ANTICOAGULANTES EM PACIENTES COM FIBRILAÇÃO ATRIAL: UMA REVISÃO SISTEMÁTICA

Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias, associated with a high risk of thromboembolic complications such as stroke. The use of anticoagulants is essential to prevent these events, with warfarin being widely used for many years. However, new oral anticoagulants (NOACs), such as apixaban and rivaroxaban, have emerged as saferand more effective alternatives, especially in vulnerable subgroups like patients with chronickidney disease and the elderly. This study reviews recent literature on the use of anticoagulants in AF patients, comparing NOACs with warfarin in terms of efficacy, safety,and adherence. Nine studies were selected from PubMed and ScienceDirect databases. Theresults indicate that NOACs have a better safety profile concerning hemorrhagic events and are easier to use due to the lack of frequent monitoring requirements. However, warfarin is still widely used, especially in lower-income countries, due to its more accessible cost. It is concluded that while NOACs represent a significant advancement in AF management, their widespread implementation depends on financial accessibility and the individual suitability ofeach patient.

RARE CASE OF SPONTANEOUS HEMOPERICARDIUM IN A PATIENT RECEIVING APIXABAN: CASE REPORT

Apixaban is a new oral anticoagulant (NOAC) available since 2012, indicated particularly for the prevention of embolic events in patients with non-valvular atrial fibrillation [1]. It is a direct inhibitor of factor Xa, with a half-life of around 12 hours. This new anticoagulant is associated with a lower risk of bleeding than vitamin K antagonists (VKAs) such as warfarin and requires less monitoring [2]. However, several recently published cases have demonstrated a correlation between Apixaban and the occurrence of pericardial effusion. We report the case of a 75-year-old hypertensive man diagnosed with atrial fibrillation 3 months ago, treated with Apixaban 5mg twice daily. He presented to the emergency department with rapidly worsening dyspnea, and echocardiography revealed a large pericardial effusion requiring drainage. A full etiological work-up was carried out, revealing no underlying pathology or triggering event to explain his pericardial effusion. We believe that his recently introduced anticoagulant therapy is the true cause.

Safety and Efficacy of Newer Oral Anticoagulants Versus Vitamin K Antagonists in the Management of Cerebral Venous Thrombosis: A Single-Center Ambispective Study from South India.

Cerebral Venous Thrombosis (CVT) poses a rare but life-threatening challenge, warranting meticulous treatment approaches. Traditional therapy involves Vitamin K Antagonists (VKAs), but Newer Oral Anticoagulants (NOACs) offer potential advantages. This study addresses a crucial knowledge gap in the Indian context, analyzing real-world data to guide CVT management decisions. A single-center, ambispective cohort study included consecutive adult CVT patients. Data collection encompassed demographics, clinical data, imaging, and treatment details. Patients were categorized into VKA and NOAC groups. Outcomes measured recanalization status, functional outcomes, bleeding events, and adverse drug reactions. Among 181 enrolled patients, NOAC-treated (Group B) individuals had significantly higher rates of complete recanalization (58.5% vs. 31.1%) with a similar incidence of adverse events and also displayed better functional outcomes at weeks 8 and 12 compared to VKA-treated (Group A) patients. Recurrent thromboembolic events were absent in both groups during follow-up. This study highlights NOACs' potential advantages in CVT management, including improved functional outcomes, enhanced recanalization, and similar bleeding risk. Adverse events were milder with NOACs. While acknowledging limitations, these findings support NOACs as a promising alternative to VKAs, advancing CVT care and outcomes.

#1313 Dicumarinics and the direct thrombin or factor Xa inhibitors (NOAs) their usefulness in advanced chronic renal disease

Abstract Background and Aims Our population with advanced chronic kidney disease (ACKD), is more prone to thrombotic and hemorrhagic processes so the indication of anticoagulation before the appearance of atrial fibrillation (AF) is complex. Since AF is the most common cardiac arrhythmia, its main complications are thromboembolism and stroke. New treatments are being developed, such as the new oral anticoagulants (NOAs), but their safety in ACKD is still uncertain. To see anticoagulation needs, safety and major adverse effects (major or minor bleeding) in population with ACKD and taking dicumarinics or NOAs. Method Retrospective study of 234 patients followed in our ACKD practice, at least two revisions, with a mean follow-up 25.5 months, in which we recorded cause of anticoagulation, type and major adverse effects. Results 26% of patients have indication for anticoagulation (66 patients), of which 55 remain anticoagulated during follow-up (45% Dicumarinics, 44% NOAs). The indication for anticoagulation was 23% AF (56 patients) and 3% mechanical prostheses (7 patients). Table 1 shows the characteristics of the overall population and the comparison between anticoagulated patients with different types of anticoagulation and non-anticoagulated patients. Non-anticoagulated patients are younger and have less ischemic heart disease, with no differences in the non-anticoagulated population. Throughout follow-up, we found a higher incidence of bleeding with NOAs (compared to the rest) and higher mortality in patients with dicumarinics (compared to the rest). There were no differences in age, sex and ischemic heart disease between the two anticoagulant treatments. Conclusion Our CKD population has a high need for anticoagulation but also a high risk of bleeding. NOAs can be used in ACKD although they are associated with a higher incidence of bleeding than dicumarinics but lower mortality. More studies are needed to conclude which is the best approach for these patients.

The impact of different anticoagulants and antiplatelets regimens on acute epistaxis outcomes

BackgroundThe impact of anticoagulants (AC) and antiplatelets (AP) on the management of acute epistaxis remains unclear. This study investigated the association between AC/AP therapy and treatment outcomes in patients with acute epistaxis.MethodologyA retrospective analysis of patients presented to the otolaryngology emergency room with acute epistaxis (2014–2022). Patients were categorized based on their regular medications: AP, dual AP therapy (DAPT), new oral anticoagulants (NOAC), vitamin K antagonists (VKA), or no regular AC/AP use (control group). Outcome measures included rates of minor interventions (chemical or electrical cautery, nasal tamponade), major interventions (endoscopic ligation, embolization), recurrent emergency department visits, admission rates, and duration.Results786 patients were included with an average follow-up period of 52.56 ± 20.4 months. Compared to the control group, patients on AP, DAPT, or VKA had significantly higher rates of minor interventions (63.1% vs. 74.4%, 79.6%, and 77.3%, respectively, p < 0.05). DAPT users exhibited a higher rate of major interventions than the control (5.6% vs. 1.3%, p = 0.053). NOAC users showed no significant difference in minor interventions compared to control and required no major interventions. Both NOAC and VKA users had significantly higher rates of recurrent epistaxis events and prolonged hospitalization compared to the control (p < 0.01 and p < 0.05, respectively).ConclusionsNOAC demonstrated more favorable outcomes than VKA in patients with acute epistaxis, and DAPT use was associated with an increased need for major interventions. These findings suggest a more conservative approach in NOAC users than other AC/AP agents.

Dual-pathway inhibition in patients with chronic limb-threatening ischemia requiring reintervention for infrapopliteal occlusions.

Our study aimed to assess the influence of incorporating new oral anticoagulant (NOAC) therapy on clinical outcomes among patients who underwent endovascular intervention for below-the-knee (BTK) occlusions necessitating reintervention. The inclusion criteria encompassed patients with chronic limb-threatening ischemia (CLTI) and had undergone a successful endovascular intervention for BTK artery occlusion, necessitating reintervention. Patients who underwent endovascular interventions for BTK reocclusion were compared to those who received dual-pathway inhibition with NOAC (rivaroxaban 2.5mg 2 × 1) and clopidogrel (NOAC group), or dual-antiplatelet therapy with clopidogrel and aspirin (DAPT group). The primary endpoints were target vessel reocclusion and target lesion revascularization (TLR) at the 1-year follow-up, while major and minor amputations served as the secondary endpoint. Additionally, a one-year comparison was conducted between the two groups for major bleeding events. 64 patients in our clinic treated with endovascular reintervention (NOAC = 28, DAPT = 34). The TLR rate is 10.7% in NOAC group (N = 3) and 32.4% in DAPT group (N = 11, p = 0.043). The target vessel reocclusion rate is 17.8% in NOAC group (N = 5) and 41.2% in DAPT group (N = 14, p = 0.048). Minor or major amputation rate at 1-year follow-up was 3.6% in NOAC group (N = 1) and 11.7% in DAPT group (N = 4, p = 0.245). The patency rate is significantly higher, and the TLR rate is significantly lower in the NOAC group compared to the DAPT group, with no significant difference in major bleeding between the two groups. Although no statistically significant difference exists in amputation rates, a numerical distinction is evident.

On the relationship between various anticoagulants and robot-assisted radical prostatectomy: a single-surgeon serial analysis

Prostate cancer patients often have other health conditions and take anticoagulants. It was believed that surgery under anticoagulants could worsen surgical results. This study aims to explore the safety of robot-assisted prostatectomy in anticoagulated patients, without any exclusion criteria. The study included 500 patients who underwent RARP by a single surgeon between April 2019 and August 2022. Patients were divided into two groups: Group 1, consisting of 376 men (75.2%), did not receive any anticoagulation, while Group 2, with 124 patients (24.8%), received different forms of anticoagulation. Then, the anticoagulation group was divided into 4 subgroups according to their definite anticoagulation: the aspirin 15.6%, new oral anticoagulants (NOAC) 5.4%, Vitamin K antagonist (VKA) 2%, and dual-antiplatelet therapy (DAPT) 1.8% subgroup. Postoperative complications and readmission rates were compared between the two study groups and subgroups. Patients in the combined group 2 were older and they also carried more comorbidities compared to men in group 1 (p = 0.03, p = 0.001).The study groups had similar oncological results, with 40.4% of patients having locally advanced cancers. Catheter days were longer in the anticoagulation group (4.5 vs 4 days, p = 0.001). No significant differences were observed between study groups for overall, minor, and major complications (p = 0.160, 0.100, and 0.915, respectively). In addition, readmissions were low (5.6%) and similar between the study groups (p = 0.635). Under cautious management, RARP under diverse anticoagulation regimes is safe and has comparable results to men with no medications. Further prospective studies must be conducted to confirm our findings.

Multiple thromboses, including intracardiac thrombi, accompanied by HIT during ECMO successfully treated with NOACs: A case report.

Unfractionated heparin remains the mainstay of anticoagulation therapy during extracorporeal membrane oxygenation (ECMO) maintenance. However, its continued use in clinical practice exposes patients to the risk of developing heparin-induced thrombocytopenia (HIT). A 50-year-old male was diagnosed with multiple thromboses, including an intracardiac thrombi, accompanied by HIT during ECMO after cardiogenic shock related to acute myocardial infarction. The patient was successfully treated with new oral anticoagulants (NOAC), without significant complications. HIT during ECMO resulting in multiple thromboses is rare. To our knowledge, this is the first reported case of NOAC use in this context. Although thrombocytopenia and thrombosis can occur for various reasons during ECMO maintenance, it is important to consider HIT as a potential cause. NOACs can be considered as a therapeutic option.

Therapeutic strategies during cenobamate treatment initiation: Delphi panel recommendations.

The goal of epilepsy treatment is seizure freedom, typically with antiseizure medication (ASM). If patients fail to attain seizure control despite two trials of appropriately chosen ASMs at adequate doses, they are classified as having drug-resistant epilepsy (DRE). Adverse events (AEs) commonly occur in people with DRE because they are typically on ⩾2 ASMs, increasing the potential for drug-drug interactions. Early emerging AEs may impact adherence, decrease quality of life, and delay achieving optimal treatment dosages. Cenobamate is an oral ASM with a long half-life which has proven to be highly effective in clinical trials. An international Delphi panel of expert epileptologists experienced in the clinical use of cenobamate and other ASMs was convened to develop consensus best practices for managing patients during and after cenobamate titration, with consideration for its known pharmacokinetic and pharmacodynamic interactions, to allow patients to reach the most appropriate cenobamate dose while limiting tolerability issues. The modified Delphi process included one open-ended questionnaire and one virtual face-to-face meeting. Participants agreed that cenobamate can be prescribed for most patients experiencing focal-onset seizures. Patients initiating cenobamate therapy should have access to healthcare professionals as needed and their treatment response should be evaluated at the 100-mg dose. Patients with intellectual disabilities may need additional support to navigate the titration period. Proactive down-titration or withdrawal of sodium channel blockers (SCBs) is recommended when concomitant ASM regimens include ⩾2 SCBs. When applicable, maintaining a concomitant clobazam dose at ~5-10 mg may be beneficial. Patients taking oral contraceptives, newer oral anticoagulants, or HIV antiretroviral medications should be monitored for potential interactions. Because clinical evidence informing treatment decisions is limited, guidance regarding dose adjustments of non-ASM drugs was not developed beyond specific recommendations presented in the Summary of Product Characteristics.

Could transperineal interstitial laser ablation of the prostate be the right option for highly-comorbid patients with lower urinary tract symptoms due to benign prostatic obstruction? A preliminary single-center experience focusing on functional and safety outcomes.

In this paper, we aimed to highlight functional and safety outcomes of highly-comorbid patients undergoing transperineal laser ablation (TPLA) of prostate at a referral academic center. Patients undergoing TPLA from April 2021 and February 2023 with moderate to severe lower urinary tract symptoms (LUTS), prostate volume ranging from 30 to 100 mL, and an American Society of Anesthesiologists (ASA) Score ≥3 were included. All patients were evaluated as unfit for standard surgery. Procedures were performed in an outpatient setting using local anesthesia. Failure after the procedure was defined as the shift to other ultra-minimally invasive surgical treatment or the need for long-term indwelling catheter replacement. Overall, 23 patients were enrolled with a median age of 76 years. Median ASA Score and Charlson Comorbidity Index were 3 and 5, respectively. Of these, 11 (48%) were under antiplatelets, 4 (17%) under new oral anticoagulants (NOACs) and 3 (13%) under warfarin. Six (26%) patients had an indwelling catheter preoperatively. Median prostate volume was 42 mL. Median follow-up was 12 months. No Clavien-Dindo Grade ≥2 complications were recorded. Four/six (66%) patients with an indwelling catheter before TPLA achieved spontaneous micturition. Treatment failure occurred in 2 (8.5%) patients. Of the remaining 21 patients, 12/21 (57%) patients reported an improvement in International Prostate Symptoms Score (IPSS) symptoms class (i.e., severe to moderate, moderate to mild, etc.); all patients whose IPSS symptoms class remained stable (N.=8 [38%]) had a significant improvement of the IPSS score as compared to the preoperative period, while 1 (4.5%) patient reported worsening of LUTS. In conclusion, TPLA appears to be a safe and feasible ultra-minimally-invasive option for LUTS due to benign prostatic obstruction (BPO) in patients with significant comorbidities at high-risk for standard surgical options.

OP176 Integrating Real-world Compliance In The Assessment Of Left Atrial Appendage Closure Versus Anticoagulation Therapy In Non-valvular Atrial Fibrillation

IntroductionIn patients with non-valvular atrial fibrillation (NVAF), left atrial appendage closure (LAAC) has demonstrated non-inferior efficacy and safety relative to life-long oral anticoagulation therapy (OAT) in a four-year randomized controlled trial (RCT) (PRAGUE-17). Sub-optimal compliance to OAT in the real-world setting (Simmons 2016) has been associated with increased risk of stroke (Ozaki 2020) and may alter efficacy estimates derived from RCTs in which compliance is generally higher. The study aims to model disease outcomes in NVAF patients treated with LAAC versus lifelong OAT when applying trial versus real world compliance to OAT.MethodsReal-world compliance to OAT in the Australian setting was investigated in a 10 percent Pharmaceutical Benefits Schedule (PBS) sample scripts analysis which measured treatment adherence and persistence to new oral anticoagulants (NOACs) and warfarin. Design of the 10 percent PBS analysis was informed by the compliance to medicine working group report and included the longest follow-up of any OAT compliance study identified in the literature. A Markov cohort model was developed to estimate the expected numbers of strokes and major bleeding events in NVAF patients.ResultsRates of NOAC discontinuation in PRAGUE-17 was higher at 20 months median follow-up (6.5%) versus compliance in the Australian setting (35.4% and 30.0% according to 3 and 6 month ceasing rules at 20 months follow-up). Applying sub-optimal compliance to lifelong OAT demonstrated in the Australian setting resulted in higher numbers of strokes over a life time modelled time horizon compared with LAAC.ConclusionsReal world compliance to medicines should be a consideration in economic analysis comparing lifelong medications to one-off surgical interventions.

Preclinical loading in patients with acute chest pain and acute coronary syndrome - PRELOAD survey

Guidelines on myocardial infarction (MI) recommend antithrombotic and anticoagulatory treatment at time of diagnosis. MI with ST segment elevation (STEMI) is mostly acertain diagnosis. Acute coronary syndrome without ST segment elevation (NSTE-ACS) has diagnostic uncertainty and remains aworking diagnosis in the prehospital setting. Assessment of prehospital loading with aspirin and heparin depending on ACS subtype and pretreatment with oral anticoagulants. The PRELOAD survey was anationwide German study. STEMI/NSTE-ACS scenarios were designed and varied in pretreatment: I)no pretreatment, II)new oral anticoagulants (NOAC), III)vitaminK antagonist (VKA). Loading strategy was assessed and included: a)aspirin (ASA), b)unfractionated heparin (UFH), c)ASA + UFH, d)no loading. A total of 708 emergency physicians were included. In NSTE-ACS without pretreatment, 79% chose loading (p < 0.001). ASA + UFH (71.4%) was the preferred option. In corresponding STEMI scenario, 100% chose loading and 98.6% preferred ASA + UFH (p < 0.001). In NSTE-ACS with NOAC pretreatment, 69.8% favored loading (p < 0.001); in VKA pretreatment the corresponding rate was 72.3% (p < 0.001). In each scenario, ASA was the preferred option. In STEMI with NOAC pretreatment, 97.5% chose loading (p < 0.001); analogous rate was 96.8% in STEMI with VKA pretreatment (p < 0.001). ASA was the preferred option again. Prehospital loading was the preferred treatment strategy despite the diagnostic uncertainty in NSTE-ACS and guidelines recommending loading at time of diagnosis. Pretreatment with oral anticoagulants resulted in astrategy shift to loading with only aspirin. In STEMI patients, this indicates potential undertreatment.

Oral anticoagulation in heart failure complicated by atrial fibrillation: a nationwide routine data study

Abstract Background/Introduction Heart failure (HF) is frequently complicated by atrial fibrillation (AF). The co-occurrence of both conditions worsens the overall patient prognosis (1). To reduce the risk of thromboembolic complications, current guidelines highly recommend an oral anticoagulant (OAC) therapy in the majority of patients affected (2). Purpose Aim of this study was to evaluate whether a permanent OAC therapy in patients with HF and AF leads to favourable outcomes. Additional benefits of new oral anticoagulants (NOACs), compared to vitamin K antagonists (VKA), were further assessed. Methods Anonymous routine data of patients who were medically insured at the largest German health insurance provider and had a claims record for hospitalisation with the main diagnosis of HF and AF (2017-2019) were included. Admission due to HF in the previous year, incomplete medication data within 90 days after hospital stay as well as the diagnoses of congenital anomaly, transplantation, asthma, and age under 30 years were exclusion criteria. The endpoints of mortality and readmission rate for all-cause and stroke/intracranial bleeding (ICB) 91-365 days after the index hospitalisation were analysed. For this, information about the medications was taken from the pharmacy database. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. Patient age, sex, and comorbidities were evaluated as independent factors, including all variables of the CHA2DS2-VASc score. Results We included n = 180,316 cases (see figure 1). The median age was 81 years (interquartile range of 76-86) with 55.6% of the patients being female. 96.81% had a CHA2DS2-VASc score of ≥ 2. We found OAC prescription in 80.6% (VKA: 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%). In 8,087 cases, more than one OAC was prescribed. The mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9% during the observed time span. As presented in figure 2, the risk of death was lower with any OAC (HR 0.77, 95% CI 0.75-0.79) but without significant differences in OAC type (VKA: HR 0.73, 95% CI 0.71-0.76; FXaI: HR 0.77, 95% CI 0.75-0.78; DTI: HR 0.71, 95% CI 0.66-0.77). The total readmission rate (HR 0.97, 95% CI 0.94-0.99) and readmission for stroke/ICB (HR 0.71, 95% CI 0.65-0.77) was likewise lower with OAC use. Conclusion(s) Routine data confirm the beneficial outcome of OAC therapy in patients with HF complicated by AF regarding mortality and readmission for all-cause as well as for stroke/ICB. No additional benefits were visible with the use of NOACs.Figure 1.Patient selection criteria.Figure 2.Kaplan-Meier survival (OAC).

Sclerobanding in the treatment of second and third degree hemorrhoidal disease in high risk patients on antiplatelet/anticoagulant therapy without suspension: a pilot study.

Around 20% of population in western countries is under anticoagulant treatment. However, there is paucity of evidence about the treatment of HD in patients under anticoagulant/antiplatelet therapy, although both suspension and continuation in the perioperative period may increase the risk of severe complications. The aim of this pilot study was to confirm the feasibility and safety of sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy), an office-based procedure, for the treatment of second-and third-degree HD in patients under anticoagulant/antiplatelet therapy without suspension. Patients affected by second-third-degree haemorrhoids unresponsive to conservative treatment and under anticoagulant/antiplatelet were enrolled between November 2019 and October 2021. Postoperative complications, readmission, mortality and reintervention during the follow-up were evaluated. Fifty-one patients were recruited, 23 female (45.1%) and 28 male (54.9%), with an average age of 65 years ± 11.4 SD (range 42-90). Twenty-seven patients (52.9%) had II-degree haemorrhoidal disease, and 24 (47.1%) had grade III-degree. The most frequently taken medications were dual antiplatelet therapy (51%) and new oral anticoagulants (NOACs) (21.6%). The mean follow-up was 23 months. No intraoperative complications were recorded. The rate of complications in the first postoperative month was 13.7%, represented by mild complications: 6 cases of moderate to severe pain and 1 case (2%) of thrombosis of a residual haemorrhoidal nodule, all regressing after conservative therapy. No severe complications were reported. Postoperative complications were not statistically significantly associated with the number of nodules treated (1, 2, or 3), the disease grade (2nd vs. 3rd) or the specific anticoagulant/antiplatelet regimen. During follow-up, 2 patients (4%) required a new procedure for recurrent bleeding: one an infrared photocoagulation as outpatient, and another a haemorrhoidectomy after 3 months. No cases of intraoperative or postoperative mortality occurred. Sclerobanding is a safe and effective technique in treating intermediate-grade haemorrhoidal disease in patients at high risk on anticoagulant/antiplatelet therapy. Sclerobanding is repeatable, usually does not require anaesthesia, and is cost-effective. Observational multicentre studies with a larger number of patients and controlled clinical trials will be needed to confirm these results.

New Oral Anticoagulants – What’s New? A Systematic Review

Introduction: Anticoagulant therapy is defined as the standard prevention and treatment method for systemic thromboembolism. Thus, despite heparin and vitamin K antagonists being used as traditional methods, the new oral anticoagulants (NOACs), such as activated factor X inhibitors and direct thrombin inhibitors have been emerged, based on their safety and efficacy analyses appropriate to clinical practice, in addition to its convenience in clinical management. Objectives: To evaluate anticoagulant therapy with the use of NOACs. Methods: This is a systematic review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes criteria. Studies from the National Library of Medicine (PubMed.gov) and Embase databases were included, through randomized clinical trials (RCTs), published from 2011 until June 2021, which comprised the investigation question. Data were extracted about the NOACs, the conventional anticoagulant, use in renal patients, clinical outcomes and side effects. Results: 384 results were identified through the search strategy, proceeding to the analysis of 315 after exclusion of duplicates. Then, after the application of the eligibility criteria, 33 studies progressed to full reading and 18 were included in the qualitative analysis of the review. The included studies demonstrated the analysis of specific comorbidities, and most comprised the adult population and warfarin as a conventional anticoagulant used. Edoxaban was the most evaluated NOAC, being included in 7 studies. Bias analysis found 3 “low risk” studies and 7 overall “high risk” studies. Conclusion: The comparison of conventional therapy and NOACs demonstrates similarity in the efficacy clinical outcomes analyzed by the studies, with similar reductions of the risk of thromboembolic events. From the analysis of the occurrence of bleeding, NOACs represent reduced rates of such outcomes. Regarding the analysis of the risk of bias of the studies, 15 of the 18 studies analyzed were classified as “high risk of bias” or as “some concerns”, especially in the criteria of “missing outcome data. In general, although no methodologically strong evidence has been identified about NOACs, their use is a reasonable alternative to conventional therapy in clinical management.

A Case Report of Korean Medicine Treatment on Clinical Symptoms in a Patient with Post-stroke Deep Vein Thrombosis

This case report shows the effect of Korean medicine treatment in a patient with deep vein thrombosis (DVT) after cerebral infarction who is suspected of having post-thrombotic syndrome (PTS) due to the loss of thrombus after receiving new oral anticoagulant (NOAC) treatment. The patient was treated with Korean medicine (&lt;i&gt;Boyanghwano-tang&lt;/i&gt; and &lt;i&gt;Hyulbuchuko-tang&lt;/i&gt;) three times a day. Acupuncture, moxibustion, infrared, and extra-physical therapy were given to the patient for 24 days. Clinical assessment - grading of edema and circumference of the left lower extremity were observed twice a week until the end of the treatment. NOAC treatment was continued for 24 days. After treatment, the patient’s edema grade and circumference of the extremity improved. On the 24th day, the patient’s chief complaints improved, and she requested termination of treatment. The results suggest that Korean medicine treatments, including &lt;i&gt;Boyanghwano-tang&lt;/i&gt;, &lt;i&gt;Hyulbuchuko-tang&lt;/i&gt;, and acupuncture therapy, can be effective in improving the clinical symptoms of DVT and PTS.

Oral anticoagulation in heart failure complicated by atrial fibrillation: A nationwide routine data study

BackgroundThis nationwide routine data analysis evaluates if oral anticoagulant (OAC) use in patients with heart failure (HF) and atrial fibrillation (AF) leads to a lower mortality and reduced readmission rate. Superiority of new oral anticoagulants (NOACs), compared to vitamin K antagonists (VKA), was analyzed for these endpoints. MethodsAnonymous data of patients with a health insurance at the Allgemeine Ortskrankenkasse and a claims record for hospitalization with the main diagnosis of HF and secondary diagnosis of AF (2017–2019) were included. A hospital stay in the previous year was an exclusion criterion. Mortality and readmission for all-cause and stroke/intracranial bleeding (ICB) were analyzed 91–365 days after the index hospitalization. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome. Results180,316 cases were included [81 years (IQR 76–86), 55.6% female, CHA2DS2-VASc score ≥ 2 (96.81%)]. In 80.6%, OACs were prescribed (VKA: 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%; with multiple prescriptions per patient included). Mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9%. Risk of death was lower with any OAC (HR 0.77, 95% CI [0.75–0.79]) but without significant differences in OAC type (VKA: HR 0.73, [0.71–0.76]; FXaI: HR 0.77, [0.75–0.78]; DTI: HR 0.71, [0.66–0.77]). The total readmission rate (HR 0.97, [0.94 to 0.99]) and readmission for stroke/ICB (HR 0.71, [0.65–0.77]) was lower with OAC. ConclusionsNationwide data confirm a reduction in mortality and readmission rate in HF-AF patients taking OACs, without NOAC superiority.

Outcomes and Safety of Direct Oral Anticoagulants (DOACs) versus Vitamin K Antagonists (VKAs) amongst Patients with Valvular Heart Disease (VHD): A Systematic Review and Meta-Analysis

Background: Both valvular heart disease (VHD) and atrial fibrillation (AF) frequently coexist. AF is an important cause of arrhythmias with a definitive cardiovascular morbidity. The use of either vitamin K antagonists (VKAs/warfarin) or direct oral anticoagulants (DOACs) (also known as new oral anticoagulants (NOACs)) has been the mainstay for preventing stroke and systemic embolism in patients with VHD and/or AF, and this has been broadly discussed. However, there are limited studies on anticoagulation therapy for patients with valvular atrial fibrillation (VAF). The main aim of this meta-analysis was to evaluate the outcomes (stroke–vascular events and intracranial bleeding) following DOAC and VKA treatment amongst patients with VAF. Methods: We identified clinical trials and observational studies published in the last 10 years. A systematic review and a meta-analysis were performed to evaluate the outcomes of patients with valvular atrial fibrillation following DOAC vs. VKA treatment. Data evaluation was performed using Review Manager 5.4; the endpoints were stroke–vascular events and intracranial bleeding following DOAC and VKA treatment amongst VAF patients. Risk ratios (RR) were evaluated with 95% confidence intervals. Using random effects models, forest plots were obtained. Heterogeneity was assessed by using the I2 statistic. Results: Eight studies were included in this metanalysis, and a total of fifteen thousand two hundred and fifteen patients (DOAC (8732) and VKA (6483)) were pooled. We found a significant risk reduction in stroke–vascular events when using DOACs in comparison with using VKAs (pooled RR: 0.76; 95% CI: 0.64–0.90, p = 0.002). A total of 14862 patients (DOAC (8561) and VKA (6301)) were pooled from a total of six studies for intracranial bleeding. We found a significant risk reduction in terms of intracranial bleeding when using DOACs in comparison with using VKAs (pooled RR: 0.43; 95% CI: 0.24–0.77, p ≤ 0.05). Conclusions: When compared to VKAs, DOAC agents were found to have less risk of stroke–vascular events and intracranial bleeding. Further prospective studies are essential to establish the efficacy and safety of DOAC agents in patients with various subtypes of VAF.

Trends in oral anticoagulant use - A 10-year retrospective analysis from a general medicine department of a tertiary care hospital in south India.

The prescribing practice of newer oral anticoagulants (NOACs) has not been adequately studied in the Indian scenario. We aimed to describe the prescribing practices of oral anticoagulants, the patient profile and medical comorbidities among patients admitted in a general medicine unit. In this retrospective study of the 2742 patients prescribed vitamin- K antagonists (VKAs), during the study period, 150 cases were randomly taken for analysis to match the 105 NOACs cases. Their demographic details, clinical characteristics and treatment details were analyzed. More than 95% of anticoagulants prescribed were VKAs. The prescription of anticoagulants was more common in men (median age 63 years) for prescription of NOACs and 52 years for VKAs. Dabigatran (60.9%) and warfarin (81.3%) were the most prescribed drugs in their respective classes. The most common indication was for cardiovascular diseases with atrial fibrillation (32%). Diabetes and hypertension were the most common comorbidities in patients prescribed oral anticoagulants with a larger proportion of patients with heart failure being prescribed VKAs ( P < 0.01). Patients in the NOACs group had a higher HAS-BLED high-risk score (33.3% vs. 17.3%; P = 0.002). Logistic regression analysis revealed that patients with co-morbidities of congestive heart failure were more likely to be prescribed VKAs while diabetics were more likely to receive NOACs. VKAs were the most prescribed anticoagulants; congestive heart failure, diabetes, and hypertension were the commonest comorbidities; and atrial fibrillation was the commonest indication. Patients with a high HAS-BLED score were prescribed NOACs more often.

PATTERN OF ANTICOAGULANT THERAPY IN CARDIOEMBOLIC STROKE

Background: Cardioembolic stroke is a category of ischemic stroke that manifests more severe, is prone to recurrence, and is related to a higher mortality rate than the other categories of ischemic stroke. Anticoagulant therapy is recommended in cardioembolic stroke, both for primary and secondary prevention. Objective: The objective of this study is to understand the pattern of anticoagulant therapy in cardioembolic stroke patients admitted at Hasan Sadikin General Hospital Bandung. Methods: The methodology of this study uses retrospective descriptive cross-sectional and use data from medical records collected during January 2015 to December 2020 at Neurology Department of Hasan Sadikin General Hospital with total sampling method. The inclusion criteria were cardioembolic stroke patients that received anticoagulant therapy. Anticoagulant therapy was stratified into Warfarin and New Oral Anticoagulants (NOACs) which consist of dabigatran, rivaroxaban, and edoxaban. To assess stroke severity outcome between warfarin and NOACs we use the National Institutes of Health Stroke Scale (NIHSS) Score. Results: From the 162 cardioembolic stroke patients, the most common oral anticoagulant used was warfarin (90.12%), followed by dabigatran (4.94%), rivaroxaban (3.70%), and edoxaban (1.23%). Only 1 (0.62%) patient who experienced complications from anticoagulant therapy, the complication was non-major bleeding and occurred in warfarin users. Both warfarin and NOACs mainly had NIHSS on discharge in a moderate category with the mean of NIHSS 7.615 and 7.276 for warfarin and NOACs respectively. Conclusion: Warfarin is the most common oral anticoagulant used for cardioembolic stroke based on this study. Both warfarin and NOACs groups have similar stroke severity outcomes measured by NIHSS on discharge and NOACs have lower incidence of bleeding compared to warfarin group.