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Epidemiology and importance
Published in Gregory YH Lip, Atrial Fibrillation in Practice, 2020
Despite the compelling evidence of the benefits of stroke reduction in patients with AF, antithrombotic therapy continues to be suboptimal, ranging from 11% to 44% in those eligible for oral anticoagulants. How to deliver anticoagulation therapy is an important consideration.
Thromboembolic Events in Prosthetic Valves
Published in Hau C. Kwaan, Meyer M. Samama, Clinical Thrombosis, 2019
J. Acar, P. L. Michel, J. Berdah
In these patients an anticoagulation therapy is used for the two or three first postoperative months. Beyond this date, in patients with aortic or mitral replacement, but without atrial fibrillation or previous thromboembolic accident, antivitamin K drugs can be discontinued. For some authors, antiplatelet therapy is useful in these cases, but the justification of this method is not proved.
General principles on caring for older adults
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
When a new cardiovascular drug is considered, clinicians should assess the incremental benefit and harm of the new drug in older patients who already receive a complex regimen. A post hoc analysis of a clinical trial of anticoagulation therapy in patients with atrial fibrillation showed that the efficacy of apixaban compared with warfarin on thromboembolic events was consistent across the number of concomitant drugs used, but the protective effect of apixaban on major bleeding diminished with increasing numbers of concomitant drugs (22). Since clinical trials often exclude patients with polypharmacy, the possibility of differential benefit and harm by the number of concomitant drugs remains uncertain for most cardiovascular drugs. In addition to the increased likelihood of drug-drug or drug-disease interaction with polypharmacy, patients with polypharmacy—who are more likely to have multimorbidity and frailty—may not live long enough to benefit from a preventive cardiovascular therapy. In a clinical trial of patients who had an estimated life expectancy less than a year and were taking statins for primary or secondary prevention, discontinuing statins resulted in better quality of life and cost savings without increasing the risk of CVD events or death (23).
Management dilemmas in restarting anticoagulation after gastrointestinal bleeding
Published in Baylor University Medical Center Proceedings, 2022
Hanish Jain, Garima Singh, Viren Kaul, Harvir Singh Gambhir
Anticoagulation therapy is commonly indicated in patients with conditions such as atrial fibrillation (AF), deep vein thrombosis, prosthetic heart valves, and acute coronary syndrome to decrease the risk of thromboembolic events. However, this therapy carries the inherent risks of bleeding, including serious gastrointestinal (GI) bleeding. Although many risk factors predispose to GI bleeding, the risk of bleeding is enhanced by the concomitant use of antithrombotic drugs: anticoagulants and antiplatelets. When GI bleeding occurs, it may require the interruption or permanent discontinuation of anticoagulation therapy. Rates of complete interruption of therapy have been reported to be as high as 69% in patients who experience GI bleeding, due to a high perceived risk of recurrent bleeding.1 When observed over 3 months, the risk of recurrent GI bleeding after the resumption of therapy approaches 10% to 15%, while the risk of venous thromboembolism (VTE) after discontinuation of therapy ranges from 5.5% to 8%.2,3 Restarting anticoagulation therapy is important, as there have been decreased mortality outcomes.2,4,5
Real-world persistence to direct oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis
Published in Current Medical Research and Opinion, 2021
Steven Deitelzweig, Manuela Di Fusco, Amiee Kang, Mirko Savone, Ruth Mokgokong, Allison Keshishian, Cynthia Gutierrez, Joseph C. Cappelleri
From this review, it is evident that of the currently available anticoagulation strategies, apixaban demonstrates the greatest likelihood for ensuring patient persistence to treatment. These findings have important implications and should be considered for future recommendations and guidelines for the clinical management of patients with NVAF. Given that most NVAF patients would benefit from appropriate lifelong anticoagulation therapy, insights into patterns of persistence across the currently available treatment strategies may have valuable implications and provide additional considerations for improving the quality of care and patient satisfaction in this population. This review may also help to inform education on anticoagulation therapy for both patients and primary care physicians.
Real-world comparison of direct-acting oral anticoagulants and vitamin K antagonists in chronic kidney disease: a systematic review and meta-analysis
Published in Expert Review of Hematology, 2021
Rongfang Xu, Fan Wu, Jiarong Lan, Peixin Duan
Where indicated, anticoagulation therapy is an essential intervention for preventing adverse cardiovascular or cerebrovascular events. Among CKD patients requiring anticoagulation, vitamin K antagonists (VKA) like warfarin have been in clinical use for several years [9]. However, in recent times, there has been a gradual shift and widespread adoption of direct-acting oral anticoagulants (DOAC) like apixaban, rivaroxaban, and dabigatran for preventing thromboembolism [10,11]. Since DOAC are predominantly excreted by the kidneys, their safety and efficacy have not been tested in large-scale randomized controlled trials (RCTs) wherein high-risk CKD patients were excluded [12,13]. Post-hoc analysis of such trials based on renal function has suggested that DOAC may have a favorable profile in patients with mild-moderate CKD as compared to warfarin [14]. However, to date, no clear clinical guidelines exist on the type of anticoagulant to be used for CKD patients. Despite limited efficacy and safety data, the US Food and Drug Administration (FDA) has approved reduced doses of apixaban, edoxaban, and rivaroxaban in patients with severe CKD. Low-dose dabigatran (75 mg twice daily) has also been approved based on pharmacokinetic data for CKD patients [8].