Improving Antithrombotic Management in Patients With Atrial Fibrillation: Current Status and Perspectives

Levi, Marcel; Hobbs, FD Richard; Jacobson, A.; Pisters, Ron; Prisco, Domenico; Bernardo, Artur; Haas, Markus; Heidrich, Jens; Rosenberg, Matt T.; Nielsen, Jørn Dalsgaard; Wuillemin, Walter A.

doi:10.1055/s-0029-1240013

Cited by 27 publications

(22 citation statements)

References 116 publications

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“…7 An intensity of anticoagulation that maintains an optimal international normalized ratio (INR) is necessary to prevent stroke and bleeding complications effectively. 8 Recently, novel therapies for anticoagulation and rhythm control have been tested in large clinical trials. 9,10 In the near future, the use of these new agents will likely increase in view of their ease of administration and improved safety profile.…”

mentioning

confidence: 99%

Temporal Trends in Medication Use and Outcomes in Atrial Fibrillation

Pilote¹,

Eisenberg²,

Essebag³

et al. 2013

Canadian Journal of Cardiology

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mentioning

confidence: 99%

Temporal Trends in Medication Use and Outcomes in Atrial Fibrillation

Pilote¹,

Eisenberg²,

Essebag³

et al. 2013

Canadian Journal of Cardiology

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“…The majority of studies examining treatment setting in regards to the quality/ safety of oral anticoagulation management report that specialized anticoagulation clinic services are associated with better INR control and reduced rates of hospitalizations/emergency visits due to adverse events related to anticoagulation, compared with standard community care (usual care/health maintenance organization care). 4,[13][14][15][16] Patients in anticoagulation clinic settings are in the therapeutic INR range 63% of the time. Although this is far from ideal, it is much better than for patients in community care settings who spend 11-12% less time in the therapeutic range.…”

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confidence: 99%

“…Although this is far from ideal, it is much better than for patients in community care settings who spend 11-12% less time in the therapeutic range. 4,16 Given the data, it is not surprising that the American College of Chest Physicians recommends the use of specialized anticoagulation management services to improve the quality and safety of anticoagulation care. 17 The exact number of patients receiving their anticoagulation care in the community versus the specialty clinic is unknown.…”

mentioning

confidence: 99%

Clinical trials for pharmacogenomics testing for warfarin dosing: Relevance to general community practices

Sidiropoulos

2011

Genetics in Medicine

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O ral anticoagulation with warfarin requires a relatively individualized therapeutic approach to establish appropriate dosing. It is of the utmost importance to administer correct initial dosing given warfarin's narrow therapeutic index and devastating complications. Warfarin pharmacogenomic testing is one element of many that may be used to appropriately tailor therapy. Numerous studies have evaluated the clinical benefit of genotyping, and many times the results are equivocal. The majority of these studies have been performed in the specialized anticoagulation clinic setting.In this issue of the journal, Caldwell and coworkers 1 reported on "A randomized, controlled trial of genetic-based Coumadin initiation." The study setting is an anticoagulation clinic and they found, despite improved initial therapeutic dose estimation when genotype was known, outcomes were ultimately impacted by clinical management regardless of genotype knowledge. It is important when interpreting these conclusions, however, to acknowledge that there are two main oral anticoagulation management settings in the United States: specialized anticoagulation clinics and community clinics (usual care, health maintenance organization setting); the services and outcomes of which are not equivalent for numerous reasons. These differences prohibit meaningful generalization of results that universally invalidate the clinical impact of pharmacogenomics testing.Warfarin is the primary drug prescribed for long-term oral anticoagulation therapy in the United States with close to 4 million patients taking this medication. 2 It is used for the prevention of thromboembolic complications of various disorders including atrial fibrillation, venous thromboembolism, and valvular heart disease. 3 Despite the fact that this is a highly efficacious therapy when titrated to the appropriate therapeutic range, the titration and dosing of warfarin are the most challenging and labor-intensive aspects of this therapy. There are many factors that influence its pharmacokinetics and pharmacodynamics including patient age, concurrent medications, diet, comorbidities, and genetics. 4 Patient comprehension/health literacy, education, receptivity to details regarding medical illness, and various patient demographic and psychosocial factors that are associated with adherence to therapy and the associated monitoring also play a significant role in achieving a desirable therapeutic range. [5][6][7] All these factors combined, many of which are in a state of constant flux, result in significant inter-and intraindividual variability. This makes it difficult to accurately determine individual therapeutic dose to maintain a stable and appropriate international normalized ratio (INR). Accuracy in this regard, however, is crucial given warfarin's very narrow therapeutic index and the strong association between the time spent in the therapeutic range with risk of morbidity and mortality due to bleeding and thromboembolism. 8 -12 Ultimately, correct initial dosing and appropriate moni...

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“…Despite warfarin's widespread availability and overwhelming benefit in preventing stroke associated with AF, numerous patients with AF eligible for anticoagulation remain untreated [1][2][3]. Barriers, including frequent prothrombin time monitoring, dose adjustments, drug and food interactions, and bleeding events have all been postulated as potential causes for the underutilization of anticoagulation with warfarin.…”

Section: Introductionmentioning

confidence: 99%

Review of race/ethnicity in non vitamin K antagonist oral anticoagulants clinical trials

Jackson

Peterson

Okeagu

et al. 2014

J Thromb Thrombolysis

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Non vitamin K antagonist oral anticoagulants (NOACs) have advantages relative to traditional vitamin K antagonist oral anticoagulants and represents an important advance in the management of patients with atrial fibrillation and venous thromboembolism. Yet it is unclear whether the clinical trials evaluating these agents were inclusive of diverse populations. To assess the inclusion and reporting of race and ethnicity in clinical trials of NOACs across disease states including, atrial fibrillation, venous thromboembolism, and acute coronary syndromes, we queried PubMed and ClinicalTrials.gov for trials of NOACs between 2007 and 2013. We determined the reporting rate and inclusion of the following ethnic groups: whites, blacks, Asians, and Hispanics. We reviewed data from 30 randomized clinical trials of NOACs that enrolled 184,414 patients. Among these trials, 21 (70%) reported race/ethnicity data in the primary manuscript or on ClinicalTrials.gov. Principal investigators provided race/ethnicity data for two additional trials. Enrollment by race included: 109,729 (75.2%) white, 20,901 (14.3%) Asian, 5,718 (3.9%) Hispanic, and 2,941 (2.0%) black. Hispanic ethnicity was only reported in 10 trials. The major clinical trials of NOACs inconsistently reported race/ethnicity and overall black and Hispanic patient enrollment was poor. As such, the relative safety and efficacy of NOACs in minority populations remains uncertain.

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Improving Antithrombotic Management in Patients With Atrial Fibrillation: Current Status and Perspectives

Cited by 27 publications

References 116 publications

Temporal Trends in Medication Use and Outcomes in Atrial Fibrillation

Temporal Trends in Medication Use and Outcomes in Atrial Fibrillation

Clinical trials for pharmacogenomics testing for warfarin dosing: Relevance to general community practices

Review of race/ethnicity in non vitamin K antagonist oral anticoagulants clinical trials

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