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Anticoagulant Therapy in Patients with Non-valvular Atrial Fibrillation in Real Clinical Practice: in Appropriate Dose Reductions

https://doi.org/10.20996/1819-6446-2021-03-04

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Abstract

Aim. To study the frequency of administration of direct oral anticoagulant (DOACs) in doses recommended and not recommended by the instructions of the drugs in non-valve atrial fibrillation (AF) patients.

Material and methods. 10663 case histories of patients hospitalized for 5 years (2014-2018) were studied, 1307/10663 (12,3%) case histories of patients with AF were selected. In patients with AF, the risk of stroke and systemic embolism, the risk of bleeding, the anticoagulant therapy (ACT) recommended at the prehospital stage and its adequacy was evaluated.

Results. 1 261/1 307 (96,5%) patients had a non-valve AF. The risk of stroke and systemic embolism was 4,7±1,5 (CHA2DS2-VASс), 97,5% of patients with non-valve AF (1229/1261) needed ACT. Only 665/1229 (54.1%) patients with AF received ACT at the time of hospitalization and 578/1229 (47,0%) of patients did not receive ACT. Before hospitalization 281/665 (42,3%) patients received vitamin K antagonist (warfarin). The international normalized ratio in the target range (2,0-3,0) was in 111/281 (39,5%) patients. 57,7% (384/665) outpatients with AF received NOAC: rivaroxaban - 180/384 (46,9%) patients, dabigatran etexilate - 110/384 (28,6%) patients, apixaban - 94/384 (24,5%) patients. Inappropriate reduced doses of DOAC were revealed in 68/384 (17,7%) patients: apixaban - 23,4%, dabigatran - 16,4% and rivaroxaban - 15,6% (p>0,05).

Conclusion. In real clinical practice 42,3% AF patients used warfarin, only 39,5% of them had INR in target values. DOAC in inappropriate reduced doses used 17,7% patients.

About the Authors

V. A. Ionin
Almazov National Medical Research Centre; Pavlov University
Russian Federation

Valery A. Ionin - eLibrary SPIN 4882-7962

Saint-Petersburg



O. I. Bliznuk
Pavlov University
Russian Federation

Olga I. Bliznyuk - eLibrary SPIN 9444-2993

Saint-Petersburg



E. I. Baranova
Almazov National Medical Research Centre; Pavlov University
Russian Federation

Elena I. Baranova - eLibrary SPIN 2569-0316

Saint-Petersburg



E. V. Shlyakhto
Almazov National Medical Research Centre; Pavlov University
Russian Federation

Evgeniy V. Shlyakhto - eLibrary SPIN 6679-7621

Saint-Petersburg



References

1. Timmis A, Townsend N, Gale CP, et al. European Society of Cardiology: Cardiovascular Disease Statistics 2019 (Executive Summary). Eur Heart J Qual Care Clin Outcomes. 2020;6:7-9. DOI:10.1093/ehjqcco/qcz065.

2. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developedin collaboration with EACTS. Eur J Cardiothorac Surg. 2016:50(5):e1-e88. DOI:10.1093/ejcts/ezw313.

3. de Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart disease: Current status and perspectives (Section III): Position paper of the ESC working group on thrombosis - Task force on anticoagulants in heart disease. Thromb Haemost. 2013;110:1087-107. DOI:10.1160/TH13-06-0443.

4. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. Lancet. 2014;383:955-62. DOI:10.1016/S0140-6736(13)62343-0.

5. Steinberg BA, Shrader P, Thomas L, et al. Off-Label Dosing of Non-Vitamin K Antagonist Oral Anticoagulants and Adverse Outcomes: The ORBIT-AF II Registry. J Am Coll Cardiol. 2016;68:2597-604. DOI:10.1016/j.jacc.2016.09.966.

6. Mazurek M, Halperin JL, Huisman MV, et al. Antithrombotic treatment for newly diagnosed atrial fibrillation in relation to patient age: the GLORIA-AF registry programme. Europace. 2020;22:47-57. DOI:10.1093/europace/euz278.

7. Ionin VA, Barashkova EI, Filatova AG, et al. Atrial fibrillation in St Petersburg cohort: frequency, risk factors, antiarrhythmic therapy and thromboembolism prevention. Arterial Hypertension. 2020;26:192- 201 (In Russ.) DOI:10.18705/1607-419X-2020-26-2-192-2018.

8. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857-67. DOI:10.7326/0003-4819-146-12-200706190-00007.

9. Wallentin L, Yusuf S, Ezekowitz MD, et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: An analysis of the RE-LY trial. Lancet. 2010;376:975-83. DOI:10.1016/S0140-6736(10)61194-4.

10. Wallentin L, Lopes RD, Hanna M, et al. Efficacy and safety of apixaban compared with warfarin at different levels of predicted international normalized ratio control for Stroke prevention in atrial fibrillation. Circulation. 2013;127:2166-76. DOI:10.1161/CIRCULATIONAHA.112.142158.

11. Singer DE, Hellkamp AS, Piccini JP, et al. Impact of global geographic region on time in therapeutic range on warfarin anticoagulant therapy: data from the ROCKET AF clinical trial. J Am Heart Assoc. 2013;2. DOI:10.1161/JAHA.112.000067.

12. Loukianov MM, Martsevich SY, Yakushin SS, et al. The control of international normalised ratio in patients with atrial fibrillation treated with warfarin in outpatient and hospital settings: Data from RECVASA registries. Rational Pharmacotherapy in Cardiology. 2018;14:40-6 (In Russ.) DOI:10.20996/1819-6446-2018-14-1-40-46

13. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med. 2010;363:1875-6. DOI:10.1056/NEJMc1007378.

14. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2009;361:1139-51. DOI:10.1056/NEJMoa0905561.

15. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med. 2011;365:883-91. DOI:10.1056/NEJMoa1009638.

16. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2011;365:981-92. DOI:10.1056/NEJMoa1107039.

17. Lip GYH, Clemens A, Noack H, et al. Patient outcomes using the European label for dabigatran: A post-hoc analysis from the RE-LY database. Thromb Haemost. 2014;111:933-42. DOI:10.1160/TH13-09-0734.

18. Xing LY, Barcella CA, Sindet-Pedersen C, et al. Dose reduction of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: A Danish nationwide cohort study. Thromb Res. 2019;178:101-9. DOI:10.1016/j.thromres.2019.04.007.

19. Pharithi RB, Ranganathan D, O'Brien J, et al. Is the prescription right? A review of non-vitamin K antagonist anticoagulant (NOAC) prescriptions in patients with non-valvular atrial fibrillation. Safe prescribing in atrial fibrillation and evaluation of non-vitamin K oral anticoagulants in stroke prevention (SAFE-NOACS) group. Ir J Med Sci. 2019;188:101-8. DOI:10.1007/s11845-018-1837-7.

20. Steinberg BA, Shrader P, Pieper K, et al. Frequency and outcomes of reduced dose Non-Vitamin K antagonist anticoagulants: Results from ORBIT-AF II (The outcomes registry for better informed treatment of atrial fibrillation II). J Am Heart Assoc. 2018; 7(4):e007633. DOI:10.1161/JAHA.117.007633.

21. Jacobs MS, van Hulst M, Campmans Z, et al. Inappropriate non-vitamin K antagonist oral anticoagulants prescriptions: be cautious with dose reductions. Neth Heart J. 2019;27:371-7. DOI:10.1007/s12471-019-1267-9.

22. Ono T, Ikemura N, Kimura T, et al. Contemporary trend of reduced-dose non-vitamin K anticoagulants in Japanese patients with atrial fibrillation: A cross-sectional analysis of a multicenter outpatient registry. J Cardiol. 2019;73:14-21. DOI:10.1016/j.jjcc.2018.09.003.

23. Cho MS, Yun JE, Park JJ, et al. Pattern and Impact of Off-label Underdosing of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation Who are Indicated for Standard Dosing. Am J Cardiol. 2020;125:1332-8. DOI:10.1016/j.amjcard.2020.01.044.

24. Steffel J, Verhamme P, Potpara TS, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330-93. DOI:10.1093/eurheartj/ehy136.

25. Yao X, Shah ND, Sangaralingham LR, et al. Non-Vitamin K Antagonist Oral Anticoagulant Dosing in Patients With Atrial Fibrillation and Renal Dysfunction. J Am Coll Cardiol. 2017;69(23):2779-90. DOI:10.1016/j.jacc.2017.03.600.

26. Kim IS, Kim HJ, Kim TH, et al. Appropriate doses of non-vitamin K antagonist oral anticoagulants in high-risk subgroups with atrial fibrillation: Systematic review and meta-analysis. J Cardiol. 2018;72:284-91. DOI:10.1016/j.jjcc.2018.03.009.

27. Frost C, Nepal S, Wang J, et al. Safety, pharmacokinetics and pharmacodynamics of multiple oral doses of apixaban, a factor Xa inhibitor, in healthy subjects. Br J Clin Pharmacol. 2013;76:776-86. DOI:10.1111/bcp.12106.

28. Eikelboom JW, Weitz JI. “Real world” use of non-vitamin K antagonist oral anticoagulants (NOACS): Lessons from the dresden NOAC registry. Thromb Haemost. 2015;113:1159-61. DOI:10.1160/TH15- 02-0158.


For citation:


Ionin V.A., Bliznuk O.I., Baranova E.I., Shlyakhto E.V. Anticoagulant Therapy in Patients with Non-valvular Atrial Fibrillation in Real Clinical Practice: in Appropriate Dose Reductions. Rational Pharmacotherapy in Cardiology. 2021;17(2):206-211. (In Russ.) https://doi.org/10.20996/1819-6446-2021-03-04

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ISSN 1819-6446 (Print)
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