Effectiveness and Safety of Non–vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses

Almutairi, Abdulaali R.; Zhou, Lili; Gellad, Walid F.; Lee, Jeannie K.; Slack, Marion; Martin, Jennifer; Lo-Ciganic, Wei Hsuan

doi:10.1016/j.clinthera.2017.05.358

Cited by 136 publications

(116 citation statements)

References 74 publications

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“…We identified and updated 2 Cochrane systematic reviews, 1 addressing DVT and the other addressing PE. 8,13 The number of studies addressing PE was expected to be small and therefore the ASH VTE treatment panel decided to search for prospective observational studies in addition to RCTs for the management of PE. For each search, Medline (1996 to week 3 of July 2019), Embase (1974 to week 3 of July 2019), and the Cochrane Central Register of Controlled Trials (until week 3 of July 2019) were searched.…”

Section: Search Strategymentioning

confidence: 99%

“…4,5 These results prompted updates in clinical practice guidelines 6,7 The introduction of DOACs for VTE treatment removes the need for injectable coagulants and close laboratory anticoagulant monitoring, making home management even more possible. 8 Despite these recommendations and the increasing evidence that home treatment is safe and efficacious, many patients, even those with low risk of complications, are admitted for hospital management. 9,10 In this report, we provide a comprehensive and systematic review of the literature and elect to incorporate prospective observational studies in addition to RCTs to determine whether any evidence to avoid home management of DVT or PE exists, particularly among those with "low-risk PE.…”

Section: Introductionmentioning

confidence: 99%

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Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Khatib,

Ross,

Kennedy

et al. 2020

Blood Advances

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Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in metaanalyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR 5 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR 5 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.

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Section: Search Strategymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Khatib,

Ross,

Kennedy

et al. 2020

Blood Advances

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“…Because of the complexity of treatment options for higher-risk PEs, many institutions have developed PE response teams (PERTs) to rapidly coordinate teams of specialists to advise and coordinate these therapies. 7,8 Importance While long-term AC can be achieved with oral agents, 9 AC in the acute phase is typically achieved with parenteral heparinoids. Because of its short halflife and availability of a reliable reversal agent, unfractionated heparin (UFH) may be used when a percutaneous or surgical intervention is being considered and for patients at high risk of bleeding.…”

mentioning

confidence: 99%

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Prucnal

Jansson

Deadmon

et al. 2019

Academic Emergency Medicine

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Objective The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment. Methods Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6‐hour time periods during the first 48 hours of AC were collected and analyzed. Results A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values. Conclusions The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.

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“…23,24 Clinical trials and real-world setting data provide consistent observations of a lower incidence of intracranial bleeding with DOACs; however, there is a higher risk of gastrointestinal hemorrhage when compared with VKAs. 25,26 Data from dabigatran registry (Global Registry on Long-term Oral Anti-thrombotic Treatment in Patients with Atrial Fibrillation) and real-world data show that the majority of major bleeding events in dabigatran occur during the first 12 months of therapy. 27,28 In our study, one patient on dabigatran developed gastrointestinal bleeding with hemopericardium that required reversal with the antidote.…”

Section: Discussionmentioning

confidence: 99%

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

Sharma

Kumar

Rout

et al. 2019

J of Gastro and Hepatol

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Background and Aim Anticoagulants play an important role in the management of Budd–Chiari syndrome. There is a paucity of data on the efficacy and safety of direct‐acting oral anticoagulants—dabigatran, among patients with Budd–Chiari syndrome. Methods In a retrospective analysis of prospectively maintained data, the stent patency rates, major bleeding episode, and a composite endpoint of major bleed and/or mortality rates were compared between Budd–Chiari syndrome patients treated with dabigatran (n = 36) or vitamin K antagonists (n = 62) following endovascular intervention. Results The baseline characteristics, including sites of block and types of interventions, were similar between the two groups. The mean duration of follow‐up in the dabigatran and vitamin K antagonist groups was 10.5 ± 6.7 and 14.1 ± 6.9 months (P = 0.006), respectively. The endovascular stent patency rates were comparable between the dabigatran and vitamin K antagonist groups at 6 months (91% vs 96.5%) and 12 months (91% vs 93%), P = 0.296 (log‐rank test), respectively. Major bleeding events were comparable between the dabigatran and vitamin K antagonist groups at 6 months (3.5% vs 2%) and 12 months (3.5% vs 6.5%), P = 0.895 (log‐rank test), respectively. The composite endpoint of mortality and major bleed was comparable between dabigatran and vitamin K antagonists at 6 months (4% vs 5%) and 12 months (4% vs 8%), P = 0.875 (log‐rank test), respectively. Conclusions Dabigatran, as compared with vitamin K antagonists, is associated with similar stent patency rates and complications among patients with Budd–Chiari syndrome post‐endovascular intervention.

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Effectiveness and Safety of Non–vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses

Cited by 136 publications

References 74 publications

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

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