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Cureus Apr 2024This case report describes a 75-year-old female with a medical history including recurrent bowel obstruction due to sigmoid stricture, atrial fibrillation managed with...
This case report describes a 75-year-old female with a medical history including recurrent bowel obstruction due to sigmoid stricture, atrial fibrillation managed with rivaroxaban, a 50-year one pack-per-day smoking history, hypertension, hyperlipidemia, peripheral vascular disease with bilateral iliac stents (2015), stage III chronic kidney disease, and renal artery stenosis with bilateral stenting. She was transferred from outside hospital for an elective sigmoidectomy with ileorectal anastomosis following several recent admissions due to bowel obstruction that had been managed non-operatively. She was deemed optimized for surgery by the primary care team; however, during induction, she developed pulseless ventricular tachycardia requiring extensive resuscitative efforts. Intraoperative findings revealed biventricular failure and a clot in the right pulmonary artery. Despite aggressive treatment, including veno-arterial extracorporeal membrane oxygenation (VA ECMO), the patient's condition deteriorated, and life support was ultimately withdrawn. This case highlights the challenges of managing complex surgical patients and underscores the importance of multidisciplinary care in such cases.
PubMed: 38813292
DOI: 10.7759/cureus.59282 -
Cureus Apr 2024Spinal subdural hematoma (SSDH) is a rare medical emergency that can cause permanent neurological deficits. The disease is characterized by sudden onset back pain,...
Spinal subdural hematoma (SSDH) is a rare medical emergency that can cause permanent neurological deficits. The disease is characterized by sudden onset back pain, sensorimotor changes, and bladder and autonomic dysfunction. This is often associated with the use of anticoagulants, blood dyscrasias, and recent spinal procedures. We present a case of a 63-year-old male maintained on rivaroxaban for nonvalvular atrial fibrillation clinically presenting with abrupt onset back pain that rapidly progressed to sensorimotor deficits and bladder dysfunction. Rivaroxaban, a selective inhibitor of factor Xa, has been approved by the Food and Drug Administration (FDA) for the reduction of stroke risk and systemic embolism in nonvalvular atrial fibrillation. We postulate that rivaroxaban played a major role in triggering the spinal hemorrhage. This case highlights the very limited documented cases of spontaneous subdural spinal hemorrhages associated with rivaroxaban use.
PubMed: 38807840
DOI: 10.7759/cureus.59208 -
European Journal of Vascular and... May 2024There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences...
OBJECTIVE
There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand.
METHODS
After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength.
RESULTS
A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban.
CONCLUSION
This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.
PubMed: 38802038
DOI: 10.1016/j.ejvs.2024.05.034 -
Therapeutic Advances in Cardiovascular... 2024Atrial fibrillation (AF) accounts for 40% of all cardiac arrhythmias and is associated with a high risk of stroke and systemic thromboembolic complications. Dabigatran,... (Review)
Review
Atrial fibrillation (AF) accounts for 40% of all cardiac arrhythmias and is associated with a high risk of stroke and systemic thromboembolic complications. Dabigatran, rivaroxaban, apixaban, and edoxaban are direct oral anticoagulants (DOACs) that have been proven to prevent stroke in patients with non-valvular AF. This review summarizes the pharmacokinetics, pharmacodynamics, and drug interactions of DOACs, as well as new data from pharmacogenetic studies of these drugs. This review is aimed at analyzing the scientific literature on the gene polymorphisms involved in the metabolism of DOACs. We searched PubMed, Cochrane, Google Scholar, and CyberLeninka (Russian version) databases with keywords: 'dabigatran', 'apixaban', 'rivaroxaban', 'edoxaban', 'gene polymorphism', 'pharmacogenetics', '', '', '', '', and ''. The articles referred for this review include (1) full-text articles; (2) study design with meta-analysis, an observational study in patients taking DOAC; and (3) data on the single-nucleotide polymorphisms and kinetic parameters of DOACs (plasma concentration), or a particular clinical outcome, published in English and Russian languages during the last 10 years. The ages of the patients ranged from 18 to 75 years. Out of 114 reviewed works, 24 were found eligible. As per the available pharmacogenomic data, polymorphisms affecting DOACs are different. This may aid in developing individual approaches to optimize DOAC pharmacotherapy to reduce the risk of hemorrhagic complications. However, large-scale population studies are required to determine the dosage of the new oral anticoagulants based on genotyping. Information on the genetic effects is limited owing to the lack of large-scale studies. Uncovering the mechanisms of the genetic basis of sensitivity to DOACs helps in developing personalized therapy based on patient-specific genetic variants and improves the efficacy and safety of DOACs in the general population.
Topics: Humans; Atrial Fibrillation; Administration, Oral; Hemorrhage; Pharmacogenomic Variants; Risk Factors; Anticoagulants; Treatment Outcome; Stroke; Risk Assessment; Phenotype; Polymorphism, Single Nucleotide; Vitamin K; Drug Interactions
PubMed: 38801157
DOI: 10.1177/17539447241249886 -
Cureus Apr 2024Atrial fibrillation (AF) significantly heightens stroke risk, which can be mitigated through anticoagulation therapy. Although warfarin was traditionally employed for...
INTRODUCTION
Atrial fibrillation (AF) significantly heightens stroke risk, which can be mitigated through anticoagulation therapy. Although warfarin was traditionally employed for this purpose, the use of direct-acting oral anticoagulants (DOACs) is on the rise.
METHODS
This retrospective study, which spanned from June 2016 to January 2018, focused on adult patients diagnosed with AF. Their treatments, either via warfarin or DOACs (apixaban, rivaroxaban, and dabigatran), were evaluated. Data analysis was done using Statistical Product and Service Solutions (SPSS, version 21; IBM SPSS Statistics for Windows, Armonk, NY). This study aims to evaluate the safety and effectiveness of DOACs versus warfarin in preventing thromboembolic complications among Saudi patients with AF.
RESULTS
A total of 396 patients with AF, averaging 66 ± 14 years of age, were part of the study. Among them, there were slightly more female patients (205 or 51.8%). The majority of patients (223 or 56.3%) were treated with a DOAC, while the rest (173 or 43.7%) received warfarin. Furthermore, 93 patients (23.5%) were taking anti-platelet drugs. Statistically, the rate of ischemic stroke was significantly higher among patients treated with DOACs than with warfarin (p=0.005), but bleeding rates were similar in both groups. Specifically, the DOACs apixaban and rivaroxaban showed a significant association with the occurrence of stroke when compared to warfarin (p=0.012 and p=007, respectively).
CONCLUSION
Overall, both DOACs and warfarin presented similar results regarding hemorrhagic complications when treating AF patients. However, the DOACs apixaban and rivaroxaban displayed higher risks of ischemic stroke compared to warfarin.
PubMed: 38800246
DOI: 10.7759/cureus.58886 -
Veterinary World Apr 2024Cardiogenic embolism (CE) is a common complication of feline hypertrophic cardiomyopathy (HCM), leading to severe clinical symptoms. This study compared the effects of...
BACKGROUND AND AIM
Cardiogenic embolism (CE) is a common complication of feline hypertrophic cardiomyopathy (HCM), leading to severe clinical symptoms. This study compared the effects of rivaroxaban and enoxaparin combined with clopidogrel on cats.
MATERIALS AND METHODS
This was a single-center, prospective, randomized controlled trial. In this study, rivaroxaban or enoxaparin plus clopidogrel was prescribed to 23 cats for at least one of the following events: Abnormal movement of the anterior mitral leaflet during systole, enlargement of the left atrium, spontaneous echocardiographic contrast, or presence of arterial thromboembolism. Oral rivaroxaban (2.5 mg, q24 h) was prescribed to six cats. Subcutaneous injections of enoxaparin (1 mg/kg, q24 h) plus oral clopidogrel (3 mg/kg, PO q24 h) for 60 days were administered to 17 cats. Renal insufficiency and bleeding complications were observed. Plasma concentrations of D-dimer, prothrombin time (PT), partial thromboplastin time, and international normalized ratio (INR) were evaluated. We analyzed the relationship between echocardiography parameters and the effects of coagulation. Blood samples were collected from all cats at baseline and at 1 and 2 months post-treatment.
RESULTS
Rivaroxaban alone and in combination with enoxaparin and clopidogrel significantly affected PT and INR. In cats treated with 2.5 mg/kg rivaroxaban for 60 days, no bleeding or recurrence of thrombus formation was observed. These data support the use of rivaroxaban for the treatment of HCM-associated thromboembolism in cats.
CONCLUSION
Treatment of HCM-associated thromboembolism with rivaroxaban alone demonstrated clinical effectiveness with no clinical complications in cats.
PubMed: 38798301
DOI: 10.14202/vetworld.2024.796-803 -
Healthcare (Basel, Switzerland) May 2024Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF) by significantly reducing the risk of stroke. Direct oral anticoagulants...
Role of a National Health Service Electronic Prescriptions Database in the Detection of Prescribing and Dispensing Issues and Adherence Evaluation of Direct Oral Anticoagulants.
BACKGROUND
Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF) by significantly reducing the risk of stroke. Direct oral anticoagulants (DOAC) became preferred over warfarin due to their superior safety and efficacy profile. Assessing adherence to anticoagulation therapy is necessary in clinical practice for optimising patient outcomes and treatment efficacy, thus emphasising its significance.
METHODS
A retrospective study utilised the Latvian National Health Service reimbursement prescriptions database, covering prescriptions for AF and flutter from January 2012 to December 2022. The proportion of days covered method was selected for adherence assessment, categorising it into three groups: (1) below 80%, (2) between 80% and 90%, and (3) above 90%.
RESULTS
A total of 1,646,648 prescriptions were analysed. Dabigatran prescriptions started declining after 2020, coinciding with a decrease in warfarin prescriptions since 2018. The total adherence levels to DOAC therapy were 69.4%. Only 44.2% of users achieved an adherence level exceeding 80%. The rate of paper prescriptions decreased from 98.5% in 2017 to 1.3% in 2022. Additionally, the utilisation of international non-proprietary names reached 79.7% in 2022. Specifically, 16.7% of patients selected a single pharmacy, whereas 27.7% visited one or two pharmacies. Meanwhile, other patients obtained medicines from multiple pharmacies.
CONCLUSIONS
The total adherence level to DOAC therapy is evaluated as low and there was no significant difference in age, gender, or "switcher" status among adherence groups. Physicians' prescribing habits have changed over a decade.
PubMed: 38786385
DOI: 10.3390/healthcare12100975 -
Journal of the American Heart... Jun 2024Days alive out of hospital (DAOH) is an objective and patient-centered net benefit end point. There are no assessments of DAOH in clinical trials of interventions for... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Days alive out of hospital (DAOH) is an objective and patient-centered net benefit end point. There are no assessments of DAOH in clinical trials of interventions for atrial fibrillation (AF), and it is not known whether this end point is of clinical utility in these populations.
METHODS AND RESULTS
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) was an international double-blind, double-dummy randomized clinical trial that compared rivaroxaban with warfarin in patients with atrial fibrillation at increased risk for stroke. We assessed DAOH using investigator-reported event data for up to 12 months after randomization in ROCKET AF. We assessed DAOH overall, by treatment group, and by subgroup, including age, sex, and comorbidities, using Poisson regression. The mean±SD number of days dead was 7.3±41.2, days hospitalized was 1.2±7.2, and mean DAOH was 350.7±56.2, with notable left skew. Patients with comorbidities had fewer DAOH overall. There were no differences in DAOH by treatment arm, with mean DAOH of 350.6±56.5 for those randomized to rivaroxaban and 350.7±55.8 for those randomized to warfarin (=0.86). A sensitivity analysis found no difference in DAOH not disabled with rivaroxaban versus warfarin (DAOH not disabled, 349.2±59.5 days and 349.1 days±59.3 days, respectively, =0.88).
CONCLUSIONS
DAOH did not identify a treatment difference between patients randomized to rivaroxaban versus warfarin. This may be driven in part by the low overall event rates in atrial fibrillation anticoagulation trials, which leads to substantial left skew in measures of DAOH.
Topics: Humans; Atrial Fibrillation; Rivaroxaban; Female; Male; Stroke; Aged; Warfarin; Factor Xa Inhibitors; Anticoagulants; Double-Blind Method; Middle Aged; Time Factors; Treatment Outcome; Morpholines; Thiophenes; Aged, 80 and over
PubMed: 38780169
DOI: 10.1161/JAHA.122.028951 -
Clinical and Applied... 2024To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation. (Comparative Study)
Comparative Study
OBJECTIVES
To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation.
METHOD
This retrospective analysis includes data from 100 patients with deep vein thrombosis (DVT) who underwent IVC filter implantation due to a free-floating thrombus (n = 64), thrombus propagation (n = 8), or acute bleeding (n = 8) on therapeutic anticoagulation, catheter-directed thrombolysis (n = 8), or had previously implanted filter with DVT recurrence. Patients were treated with warfarin (n = 41) or rivaroxaban (n = 59) for 3-12 months. Symptomatic venous thromboembolism (VTE) recurrence and bleeding events were assessed at 12 months follow-up.
RESULTS
Three (7.3%) cases of VTE recurrence without IVC filter occlusion occurred on warfarin and none on rivaroxaban. The only (2.4%) major bleeding occurred on warfarin. Three (5.1%) clinically relevant non-major bleedings were detected on rivaroxaban. No significant differences existed between groups when full and propensity scores matched datasets were compared.
CONCLUSIONS
Rivaroxaban seems not less effective and safe than warfarin after IVC filter implantation.
Topics: Humans; Warfarin; Rivaroxaban; Retrospective Studies; Vena Cava Filters; Male; Female; Middle Aged; Aged; Venous Thrombosis; Anticoagulants; Adult; Administration, Oral; Hemorrhage
PubMed: 38778542
DOI: 10.1177/10760296241256938 -
Aging Clinical and Experimental Research May 2024Polypharmacy is a frequent situation in older adults that increases the risk of drug-drug interactions (DDIs), both pharmacokinetic (PK) and pharmacodynamic (PD). Direct...
PURPOSE
Polypharmacy is a frequent situation in older adults that increases the risk of drug-drug interactions (DDIs), both pharmacokinetic (PK) and pharmacodynamic (PD). Direct oral anticoagulants (DOACs) are frequently prescribed in older adults, mainly because of the high prevalence of atrial fibrillation (AF). DOACs are subject to cytochrome P450 3A4 (CYP3A4)- and/or P-glycoprotein (P-gp)-mediated PK DDIs and PD DDIs when co-administered with drugs that interfere with platelet function. The aim of our study was to assess the prevalence of DDIs involving DOACs in older adults and the associated risk factors at admission and discharge.
METHODS
This was a cross-sectional study conducted in an acute geriatric unit between January 1, 2018 and December 31, 2022, including patients over 75 years of age treated with DOACs at admission and/or discharge, for whom a comprehensive collection of co-medications was performed.
RESULTS
From 909 hospitalizations collected, the prevalence of PK DDIs involving DOACs was 16.9% at admission and 20.7% at discharge, and the prevalence of PD DDIs was 20.7% at admission and 20.2% at discharge. Factors associated with DDIs were bleeding history [adjusted odds ratio (ORa) 1.74, 95% confidence interval (CI) 1.13-2.68], number of drugs > 6 (ORa 2.54, 95% CI 1.88-3.46) and reduced dose of DOACs (ORa 0.39, 95% CI 0.28-0.54) at admission and age > 87 years (ORa 0.74, 95% CI 0.55-0.99), number of drugs > 6 (ORa 2.01, 95% CI 1.48-2.72) and reduced dose of DOACs (ORa 0.41, 95% CI 0.30-0.57) at discharge.
CONCLUSION
This study provides an indication of the prevalence of DDIs as well as the profile of DDIs and patients treated with DOACs.
Topics: Humans; Drug Interactions; Aged; Male; Female; Aged, 80 and over; Cross-Sectional Studies; Anticoagulants; Hospitalization; Administration, Oral; Atrial Fibrillation; Risk Factors; Polypharmacy
PubMed: 38776005
DOI: 10.1007/s40520-024-02768-w