Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation

Shields, Adrian M; Lip, Gregory Y.H.

doi:10.1111/joim.12360

Cited by 66 publications

(61 citation statements)

References 127 publications

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“…In phase 3 clinical trials, rivaroxaban did not demonstrate any superiority in either primary efficacy or safety end points, whereas dabigatran 150 mg had better efficacy, and dabigatran 110 mg, apixaban, and edoxaban all had better safety 34, 35, 36, 37. Current expert opinion regarding which NOAC to choose only recommends rivaroxaban in patients who prefer low pill burden 38. Our data suggested this primary advantage of rivaroxaban may not exist at all—apixaban may actually be associated with better adherence.…”

Section: Discussionmentioning

confidence: 95%

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Yao

Abraham

Alexander

et al. 2016

JAHA

394

329

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BackgroundIn comparison to warfarin, non–vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.Methods and ResultsWe performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow‐up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA 2 DS 2‐VASc (risk based on the presence of congestive heart failure, hypertension age 65–74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1–3 months: hazard ratio [HR] 1.96, 3–6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA 2 DS 2‐VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA 2 DS 2‐VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA 2 DS 2‐VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.ConclusionsAdherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA 2 DS 2‐VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA 2 DS 2‐VASc score 0 or 1.

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Section: Discussionmentioning

confidence: 95%

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Yao

Abraham

Alexander

et al. 2016

JAHA

394

329

View full text Add to dashboard Cite

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“…Their main pharmacologic properties, efficacy and safety profiles compared with VKAs, and practical use in several clinical conditions have been extensively reported [57][58][59][60][61]. Although the single molecules have shown variable efficacy and safety compared to warfarin, as a class they have an equal or greater efficacy, with a strikingly reduced risk of intracranial hemorrhage [62][63][64][65][66].…”

Section: Direct Oral Anticoagulantsmentioning

confidence: 99%

“…Abbreviations: y = years; OD = once daily; VKA = vitamin K antagonist; HAS-BLED = hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly N 65 years, drugs/alcohol concomitantly; GI = gastrointestinal. Modified from [61].…”

Section: Re-ly [74]mentioning

confidence: 99%

“…Selection of the "right" anticoagulant drug for stroke prevention in the elderly should be based on a global evaluation of patient's characteristics, including age, comorbidity, kidney function, overall and gastrointestinal bleeding risks, ischemic or hemorrhagic stroke history, patient's preference for low pill burden and, obviously, costs [39,61,107] (Fig. 1).…”

Section: Re-ly [74]mentioning

confidence: 99%

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Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

Grisoglio

Brunetti

et al. 2017

European Journal of Internal Medicine

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“…11 In our view, a comprehensive geriatric evaluation should be routinely included as a part of the clinical evaluation of older patients with AF, and a high level of surveillance should be maintained on those receiving OAT, in order to make available in the next future valuable information on the net clinical benefit of these drugs in complex real-world older patients. …”

Section: Discussionmentioning

confidence: 99%

Oral anticoagulant therapy for older patients with atrial fibrillation

Brunetti

2017

Geriatr Care

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Atrial fibrillation (AF) is one of the most common cardiac arrhythmias. Its incidence and prevalence increase with age, representing a significant burden for health services in western countries. The most feared consequence of AF is cardio-embolic stroke, accounting for roughly one third of ischemic strokes in the elderly. Oral anticoagulant therapy is currently recommended for patients with AF and a CHA 2 DS 2 -VASc score ≥2 in men and ≥3 in women, but it is widely underused, particularly in the oldest patients who, in reason of their higher risk of stroke, might benefit more from it. Among the main reasons for anticoagulant underuse in older patients, advanced age itself, physician's perceived high risk of age-related and fall-related bleedings, and difficulties in monitoring vitamin K antagonists-based therapies are the most frequently reported. General considerations on oral anticoagulant therapy under-prescription in older patientsAtrial fibrillation (AF) is one of the most common cardiac arrhythmias. Its incidence and prevalence increase with age, representing a significant burden for health services in western countries. 1,2 Oral anticoagulant therapy (OAT) is currently recommended for patients with AF and a CHA 2 DS 2 -VASc score ≥2 in men and ≥3 in women, 3 but it is widely underused, particularly in the oldest patients 4-7 who, in reason of their higher risk of stroke, might benefit more from it. Studies consistently demonstrate that less than half of octogenarians are currently treated with OAT. 1,4,6,7 Although temporary or permanent contraindications may partially account for this under-prescription, 6,7 advanced age and short life-expectancy, fear of bleeding, perceived harm greater than benefit, poor health and geriatric syndromes appear to be the most common reasons why physicians withhold anticoagulants. [4][5][6][7]8 Noteworthy, geriatric syndromes such as frailty and functional dependence were not considered in most trials in AF patients both on vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). In the absence of robust evidence driving the best use of anticoagulation in frail and complex older patients, a multidimensional algorithm covering both a standard ischemic and bleeding risk assessment and an additional anticoagulation-focused frailty assessment has been recently suggested to achieve a tailored approach in older AF patients. 9 Unfortunately by now there are not validated and widely acknowledged methods to identify those older patients who, in reason of their poor general health and/or functional status, are expected not to derive a net clinical benefit from anticoagulation, and should therefore not be prescribed OAT.It seems plausible that this persisting therapeutic reluctance relies on intimate skepticism that the clinical benefits demonstrated in randomized trials and observational studies may not be observed at the same extent in more vulnerable older patients. Specifically, safety rather than efficacy concerns appear to be the major responsible for uncer...

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Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation

Abstract: Abstract. Shields AM, Lip GYH

Cited by 66 publications

References 127 publications

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

Oral anticoagulant therapy for older patients with atrial fibrillation

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