Most Important Outcomes Research Papers on Anticoagulation for Cardiovascular Disease

Abstract

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of anticoagulation for cardiovascular disease. (Circ Cardiovasc Qual and Outcomes. 2012;5:e65-e74.) T hrombosis is the leading cause of acute coronary syndromes, stroke, and venous thromboembolism.1 Accordingly, anticoagulants have been successfully used in each of these settings. 2,3Since the discovery of unfractionated heparin in the early 1900s, the number of anticoagulant choices has increased at an accelerating rate. For treatment of acute coronary syndromes, these include low-molecular weight heparins, fondaparinux, as well as direct thrombin inhibitors such as bivalirudin. 4 While warfarin and other vitamin K antagonists have long been the dominant oral anticoagulants, novel oral agents such as dabigatran, rivaroxaban, and apixaban have expanded the number of therapeutic options. 5All of these agents have potential pros and cons. For example, unfractionated heparin is relatively inexpensive and easily monitored. However, it may increase bleeding compared with direct thrombin inhibitors such as bivalirudin. Analogously, for patients with atrial fibrillation, warfarin is inexpensive and has a long track record of preventing thromboembolic events; however, it is subject to multiple potential food and drug interactions and requires close monitoring to maintain optimal time in therapeutic range. In contrast, the novel oral anticoagulants have been shown to be noninferior compared with warfarin for stroke prevention in atrial fibrillation without the need for intensive monitoring.6-8 Use of these new agents was also associated with significantly fewer intracranial bleeds and a trend toward reduced mortality that reached statistical significance for apixaban. 8 However, these new options may entail considerable expense, have no currently available antidote, and lack information on long-term efficacy and safety. In the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial, concerns were raised about an increased risk of myocardial infarction in patients taking dabigatran compared with warfarin; this risk was further supported in a subsequent meta-analysis. 9Given the increasing scope of anticoagulant therapy and the introduction of multiple novel agents in recent years with unique efficacy and safety profiles, we have chosen to dedicate this series of Circulation: Cardiovascular Quality and Outcomes clinical summaries to the topic of therapeutic anticoagulation. We have included articles on topics such as the efficacy, safety, and costeffectiveness of bivali...

Quantifying low levels (<0.5% w/w) of warfarin sodium salts in oral solid dose forms using Transmission Raman spectroscopy

“…Warfarin is administered orally and is available in either a liquid solution or in a solid dose form. It is the most prescribed oral anticoagulant and one of the most prescribed medicines in the US [1]. Warfarin is available in 9 dose strengths ranging from 1 mg up to 10 mg.…”

Thrombotic and Thromboembolic Complications in Patients with Adult Congenital Heart Disease

“…Thrombosis and thromboembolism are the most common etiology for acute coronary syndromes, stroke, and venous thromboembolism (VTE) and thereby considered as the leading cause of death worldwide [1,2]. With remarkable improvements in medical and surgical care to patients with congenital heart disease, many of them now survive into adulthood [3].…”

Bivalirudin bewilderment

“…(1) Appropriate procedural anticoagulation is essential to ensure successful PCI and optimal clinical outcomes. Although unfractionated heparin was the dominant peri-procedural anticoagulant for a long time,(2) other agents including low-molecular weight heparins(3) and more recently bivalirudin(4,5) have been trialed as alternatives. In several studies comparing bivalirudin with heparin plus a glycoprotein (GP) IIb/IIIa inhibitor, the former standard of care, the direct thrombin inhibitor bivalirudin, demonstrated a reduced risk of bleeding and an overall favorable profile including reduced cardiovascular mortality.…”