Risultati per: Associazione FANS e Warfarin

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Circulation, Ahead of Print. BACKGROUND:There is uncertainty surrounding the use of direct oral anticoagulants (DOACs) in patients with kidney dysfunction.METHODS:Using the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database (data from RE-LY [Randomized Evaluation of Long-term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], and ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48]), we performed an individual patient-level network meta-analysis to evaluate the safety and efficacy of DOACs versus warfarin across continuous creatinine clearance (CrCl). A multivariable Cox model including treatment-by-CrCl interaction with random effects was fitted to estimate hazard ratios for paired treatment strategies (standard-dose DOAC, lower-dose DOAC, and warfarin). Outcomes included stroke and systemic embolism (S/SE), major bleeding, intracranial hemorrhage (ICH), and death.RESULTS:Among 71 683 patients (mean age, 70.6±9.4 years; 37.3% female; median follow-up, 23.1 months), the mean CrCl was 75.5±30.5 mL/min. The incidence of S/SE, major bleeding, ICH, and death increased significantly with worsening kidney function. Across continuous CrCl values down to 25 mL/min, the hazard of major bleeding did not change for patients randomized to standard-dose DOACs compared with those randomized to warfarin (Pinteraction=0.61). Compared with warfarin, standard-dose DOAC use resulted in a significantly lower hazard of ICH at CrCl values

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Circulation, Ahead of Print. BACKGROUND:The benefit-risk profile of direct oral anticoagulants (DOACs) compared with warfarin, and between DOACs in patients with atrial fibrillation (AF) and chronic liver disease is unclear.METHODS:We conducted a new-user, retrospective cohort study of patients with AF and chronic liver disease who were enrolled in a large, US-based administrative database between January 1, 2011, and December 31, 2017. We assessed the effectiveness and safety of DOACs (as a class and individually) compared with warfarin, and between DOACs in patients with AF and chronic liver disease. The primary outcomes were hospitalization for ischemic stroke/systemic embolism and hospitalization for major bleeding. Inverse probability treatment weights were used to balance the treatment groups on measured confounders.RESULTS:Overall, 10 209 participants were included, with 4421 (43.2%) on warfarin, 2721 (26.7%) apixaban, 2211 (21.7%) rivaroxaban, and 851 (8.3%) dabigatran. The incidence rates per 100 person-years for ischemic stroke/systemic embolism were 2.2, 1.4, 2.6, and 4.4 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. The incidence rates per 100 person-years for major bleeding were 7.9, 6.5, 9.1, and 15.0 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. After inverse probability treatment weights, the risk of hospitalization for ischemic stroke/systemic embolism was significantly lower between DOACs as a class (hazard ratio [HR], 0.64 [95% CI, 0.46–0.90]) or apixaban (HR, 0.40 [95% CI, 0.19–0.82]) compared with warfarin, but not significantly different between rivaroxaban versus warfarin (HR, 0.76 [95% CI, 0.47–1.21]) or rivaroxaban versus apixaban (HR, 1.73 [95% CI, 0.91–3.29]). Compared with warfarin, the risk of hospitalization for major bleeding was lower with DOACs as a class (HR, 0.69 [95% CI, 0.58–0.82]), apixaban (HR, 0.60 [95% CI, 0.46–0.78]), and rivaroxaban (HR, 0.79 [95% CI, 0.62–1.0]). However, the risk of hospitalization for major bleeding was higher for rivaroxaban versus apixaban (HR, 1.59 [95% CI, 1.18–2.14]).CONCLUSION:Among patients with AF and chronic liver disease, DOACs as a class were associated with lower risks of hospitalization for ischemic stroke/systemic embolism and major bleeding versus warfarin. However, the incidence of clinical outcomes among patients with AF and chronic liver disease varied between individual DOACs and warfarin, and in head-to-head DOAC comparisons.

Annals of Internal Medicine, Ahead of Print.

Stroke, Volume 54, Issue Suppl_1, Page ATP116-ATP116, February 1, 2023. Introduction:Although the current guidelines recommend procoagulant reversal of elevated INR >= 2.0 (International Normalized Ratio) in patients with intracranial hemorrhage using warfarin, the benefit of procoagulant reversal is uncertain when patients have abnormal coagulation but are not fully anticoagulated.Hypothesis:For patients using warfarin (INR 1.5 to 1.9) who have intracranial hemorrhage the use of procoagulant reversal will improve functional outcome based upon dichotomized discharge mRS (modified Rankin scale) 0-3 vs 4-6.Methods:The Get With The Guidelines – Stroke registry was used to identify 239,681 patients with intracranial hemorrhage from hospitals using the comprehensive stroke center form between January 1, 2015 and January 4, 2022. Patients were excluded if they received thrombolytics, were using direct oral anticoagulants, if INR was not between 1.5 and 1.9, or if they were not using warfarin. To evaluate the association between procoagulant reversal and mRS at discharge, 1868 patients with non-missing mRS were analyzed for the primary outcome (mRS 0-3 vs. 4-6). Secondary outcomes that did not require mRS were analyzed among a possible 2569 patients. Propensity scores were estimated and overlap weighting was used to account for confounding. Logistic and negative binomial regression models were fit for binary and count variables, respectively.Results:There was an even distribution of patients into treatment and nontreatment (N=974 no reversal, N=894 reversal), and the groups were strikingly similar. Key outcomes are shown in the Table.Conclusions:Procoagulant reversal of warfarin for patients with acute intracranial hemorrhage and INR 1.5 – 1.9 was not associated with an improvement in functional outcome based upon mRS 0-3 vs 4-6. Patients that received a reversal agent had 25% lower odds of dying in the hospital or being discharged to hospice, but had a longer hospital stay and were less likely to be fully ambulatory at discharge.

Stroke, Volume 54, Issue Suppl_1, Page ATMP97-ATMP97, February 1, 2023. Introduction:Non-vitamin K antagonist oral anticoagulant (NOAC) has been the drug of choice for preventing ischemic stroke in patients with atrial fibrillation since 2014. In previous studies, the stroke risk while taking warfarin was known to be 2 per 100 patient-years and 1.5% per year while taking NOACs. We hypothesized that even if ischemic stroke occurred during anticoagulation therapy with NOACs, the prognosis was likely to be better than that of warfarin.Methods:We obtained data from the nationwide claim database from 2009 to 2019. Patients with atrial fibrillation were identified using the International Classification of Disease Codes. After the diagnosis of atrial fibrillation, patients who developed ischemic stroke during anticoagulation were extracted. The severity of ischemic stroke in the patients was evaluated by the stroke severity index (SSI) calculated by the combination of claim codes. Patients who died within 3-months and within 1-year after ischemic stroke were identified. The patients were divided according to the drug of anticoagulation (warfarin, dabigatran, apixaban, rivaroxaban, edoxaban).Results:A total of 206,848 patients who were newly diagnosed with atrial fibrillation and started anticoagulation therapy were analyzed. Among them, 10,658 patients developed ischemic stroke during follow-up. The anticoagulants administered to these patients were warfarin in 4,423, dabigatran in 965, apixaban in 2,320, rivaroxaban in 1,702, and edoxaban in 1,248. The SSI was highest in the warfarin group (11.43±3.85), and lower in the edoxaban group (8.93±4.03). The order of mortality at 3-months after ischemic stroke was warfarin (17.88%), rivaroxaban (12.34%), dabigatran (9.53%), apixaban (8.28%), and edoxaban group (8.25%). The 1-year mortality rate also showed the same trend. Among NOACs, apixaban had the lowest hazard ratio (HR), HR for 3-months mortality was 0.431 (95% CI 0.367-0.505, p

Ma questa volta la festa a sorpresa è in onore dei volontari

Circulation, Volume 146, Issue 23, Page 1746-1748, December 6, 2022.

Annals of Internal Medicine, Volume 175, Issue 11, Page 1627-1628, November 2022.

Circulation, Volume 146, Issue Suppl_1, Page A13427-A13427, November 8, 2022. Introduction:Direct Oral Anticoagulants (DOACs) have overtaken warfarin in the treatment of non-valvular Atrial Fibrillation (AF) and venous thromboembolism (VTE). However, there is very limited data that explores the safety of DOACs for patients that are morbidly obese (BMI >40).Methods:In this multi-center retrospective study, we sought to use the Michigan Anticoagulation Quality Improvement registry (MAQI) to see how treatment of non-valvular AF or VTE with DOAC vs. warfarin affects bleeding in morbidly obese patients. Specifically, we compared average major, clinically relevant non-major (CRNM), and minor bleeding events per 100 patient years that were adjusted for statistically significant baseline characteristics (p40 included in the registry between June 2015 and September 2019. 434 patients were treated with DOACs, while 594 patients were treated with warfarin. Baseline characteristics between the two groups included age (61.5 vs 57.8, p

Circulation, Volume 146, Issue Suppl_1, Page A10926-A10926, November 8, 2022. Introduction:Many prediction algorithms for warfarin maintenance dose (WD) were constructed based on the clinical and genetic information of the patients without extracorporeal circulation devices (ECDs). However, it is unclear whether might be useful for the patients with ECD, such as left ventricular assist devices (LVAD), who still require warfarin.Hypothesis:The WD algorithms constructed using non-ECD patients could be useful for LVAD patients.Methods:An observational study, the Human Genome Research Ethics Committee of OU approved (#756), was conducted at the Osaka University (OU) Hospital on 108 LVAD patients receiving warfarin therapy. Genetic polymorphisms of CYP2C9*1, *3, and VKORC1-1639G >A were tested using TaqMan genotyping assay kits. WD was defined as the administered dose during the periods when the PT-INR value was within its target range. We investigated the difference between the actual warfarin dose (AWD) and the calculated warfarin dose (CWD) using an algorithm proposed by the International Warfarin Pharmacogenetics Consortium (IWPC), which we verified with 125 Japanese non-ECD patients previously (Eur J Clin Pharmacol, 75:901).Results:The percentage of patients whose difference between CWD and AWD was within 20% of AWD showed no significant difference between the LVAD and the non-ECD (%; I, LVAD, 41.7, non-ECD, 49.6, p=0.23). The root mean squared percentage error (RMSPE) to the AWD was similar between the groups (%; LVAD, 42, non-ECD, 37). As the algorithm requires if amiodarone is concomitant with warfarin, we probed the effect of the amiodarone dose on the CWD. Interestingly, RMSPE of the LVAD with ≥ 200 mg/day of amiodarone (≥ 200A) was higher compared to those with < 200 mg/day (