DOCSLIB.ORG

Antithrombotic Therapy in Patients with Coronary Artery Disease and Prior Stroke

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Antithrombotic Therapy in Patients with Coronary Artery Disease and Prior Stroke Journal of Clinical Medicine Review Antithrombotic Therapy in Patients with Coronary Artery Disease and Prior Stroke Elisa Bellettini and Leonardo De Luca * Department of Cardiosciences, U.O.C. of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, 00152 Roma, Italy; [email protected] * Correspondence: [email protected] or [email protected]; Tel.: +39-06-58704419; Fax: +39-06-5870-4361 Abstract: Patients with coronary artery disease (CAD) and prior cerebrovascular events (CVE) are frequently faced in clinical practice and present a high rate of both ischemic and bleeding events. For these reasons, the antithrombotic management is particularly challenging in this subgroup of patients. Recent trials suggest that, although a potent antiplatelet strategy is safe in the acute phases of myocardial ischemia for these patients, the risk of major bleeding complications, including intracranial hemorrhage, is extremely high when the antithrombotic therapy is prolonged for a long period of time. Therefore, especially in patients with chronic CAD and history of CVE, the antithrombotic management should be carefully balanced between ischemic and bleeding risks. The present review is aimed at critically evaluating the available evidence to help make these crucial clinical decisions regarding the better antithrombotic therapy to use in this high-risk subgroup Citation: Bellettini, E.; De Luca, L. of patients. Antithrombotic Therapy in Patients with Coronary Artery Disease and Prior Stroke. J. Clin. Med. 2021, 10, Keywords: antithrombotic therapy; clopidogrel; ticagrelor; prasugrel; aspirin; rivaroxaban; acute 1923. https://doi.org/10.3390/ coronary syndromes; prior stroke jcm10091923 Academic Editors: Wolfgang Dichtl and Andrzej Surdacki 1. Introduction Patients with ischemic stroke present a 4-fold increased risk for coronary artery disease Received: 28 February 2021 (CAD) compared to patients without cerebrovascular diseases (CVD) [1]. Patients with Accepted: 27 April 2021 both CAD and CVD present a 3 times higher risk for stroke and intracranial bleeding Published: 29 April 2021 compared with patients without history of CVD [1–5]. For these reasons, literature agrees in identifying this group of patients as particularly challenging to manage, especially when Publisher’s Note: MDPI stays neutral the right balance between safety and efficacy of antithrombotic treatment needs to be find. with regard to jurisdictional claims in published maps and institutional affil- 2. Prevalence of Stroke in Patients with CAD iations. Patients affected by CAD rarely report a history of stroke or transient ischaemic attack (TIA). In the Global Registry of Acute Coronary Events (GRACE) Registry, 8% of the overall population with acute coronary syndromes (ACS) enrolled reported a prior CVD [2]. Similar rates of CVD have been detected in recent nationwide registries on consecutive Copyright: © 2021 by the authors. ACS patients and in contemporary clinical trials including patients with ACS or stable Licensee MDPI, Basel, Switzerland. CAD [3–5] (Tables1 and2). Likewise, in a cohort of more than 26.000 patients with CAD This article is an open access article included in the REACH (REduction of Atherothrombosis for Continued Health) registry, distributed under the terms and the prevalence of previous CVD was approximately 17% [6]. conditions of the Creative Commons Patients with CAD and CVD are generally older, more likely to have history of Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ angina, myocardial infarction (MI), heart failure, coronary artery bypass surgery, diabetes, 4.0/). hypertension, dyslipidaemia, and atrial fibrillation [2,3,6]. J. Clin. Med. 2021, 10, 1923. https://doi.org/10.3390/jcm10091923 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 1923 2 of 12 Table 1. Major trials on antithrombotic therapies in ACS. Efficacy End Point in Safety end Point in Year Trial Population (n) Prior CVE (%) Drug Efficacy End Point Safety End Point Stroke Subgroup Stroke Subgroup Clopidogrel Reduced Increased VS Placebo MACE: 9.3% vs. 2001 CURE 12.562 4 Major bleeding: 3.7% vs. added to 11.4%, p < 0.001, HR 2.7%; RR 1.38; p = 0.001) ASA 0.80, 95% CI 0.72–0.90 Increased Increased Prasugrel Reduced TIMI Major bleeding Increased TIMI major non CABG VS Clopi- MACE: 9.9% vs. non-related to CABG 2.4% MACE: 19.1% VS 14.4%, TRITON-TIMI related bleeding: 5.0% vs. 2007 13.608 4 dogre, 12.1%, HR 0.81, 95% VS 1.8% HR 1.32; 95% CI p = 0.15, HR 1.37, 95% CI 38 2.9%, HR 2.46, 95% CI added to CI: 0.73–0.90; 1.03–1.68; p = 0.03. Fatal 0.89–2.13; interaction 0.94–6.42; p for ASA p < 0.001; bleeding (0.4% vs. 0.1%; p = 0.02 interaction = 0–22 p = 0.002) No interaction: MACE: Reduced No interaction: PLATO 19.0% vs. 20.8% (HR 0.87; Ticagrelor MACE 9.8% vs. 11.7% major bleeding: 14.6% vs. No significant increased 95% CI 0.66–1.13; vs. Clopi- (HR 0.84; 95% CI 14.9% (HR 0.99; 95% CI PLATO-major bleeding interaction p = 0.84) 2009 PLATO 18.624 6 dogre, 0.77–0.92; p < 0.001) 0.71–1.37) ICH 0.9% vs. 11.6% vs. 11.2%, HR 1.04, All-cause Death: 7.9% vs. added to CV Death 4.0% vs. 0.7%, HR 1, 95% CI 95% CI 0.95–1.13; p = 0.43 13.0% (HR 0.62; 95% CI ASA 5.1% (HR 0.79, 95% CI 0.25–3-99; interaction 0.42–0.91; interaction 0.69–0.91; p = 0.001) p = 0.38 p = 0.49) Not reduced MACE: Increased TIMI major Apixaban 5 Trend toward worse 7.5% vs. 7.9% (HR bleeding: 1.3% vs. 0.5% (HR 2011 APPRAISE-2 7.392 10 mg VS outcome (p for No interaction (p = 0.31) 0.95; 95% CI 0.80–1.11; 2.59; 95% CI 1.50–4.46; Placebo interaction = 0.08) p = 0.51) p = 0.001) Not reduced MACE, Increased moderate and No significant interaction: Vorapaxar recurrent ischemia, severe bleeding: 7.2% VS MACE, recurrent No significant interaction: VS Placebo, urgent coronary 5.2% HR 1.35; 95% CI 1.16 ischemia, urgent coronary Moderate and severe 2012 TRACER 12.944 4 added to revascularization: to 1.58; p < 0.001). ICH 1.1% revascularization: HR bleeding: 1.48 (0.77, 2.83) standard 18.5% vs. 19.9%; HR vs. 0.2%, HR 3.39; 95% CI 0.88 (0.63, 1.22), interaction p = 0.771) therapy 0.92; 95% CI 0.85–1.01; 1.78–6.45; p < 0.001 Interaction p = 0.795 p = 0.07 J. Clin. Med. 2021, 10, 1923 3 of 12 Table 1. Cont. Efficacy End Point in Safety end Point in Year Trial Population (n) Prior CVE (%) Drug Efficacy End Point Safety End Point Stroke Subgroup Stroke Subgroup Reduced Increased Rivaroxaban MACE: 8.9% vs. 10.7% TIMI major bleeding not No significant reduction Four events in 2.5 VS (HR 0.84; 95% CI ATLAS ACS related to CABG: 2.1% vs. MACE: HR 1.57, 95% CI rivaroxaban group; none 2012 15.526 3 Rivariaban 0.74–0.96; p = 0.008), -TIMI 51 0.6%, p < 0.001; HR 3.96, 0.75–3.31; p in placebo group (p for 5 mg VS CV death: 3.3% vs. 95% CI 2.46–6.38). ICH: interaction = 0.1 interaction not possible) placebo 4.1%, p = 0.04 (HR 0.6% vs. 0.2%, p = 0.009 0.80, 95% CI 0.65–0.99) Reduced primary end point Cangrelor (death from any cause, Not increased severe VS Clopi- CHAMPION MI, ischemia-driven GUSTO bleeding: 0.16% vs. No interaction No interaction 2013 11.145 5 dogrel, PHOENIX revascularization, 0.11% (OR 1.50; 95% CI 0.53 p = 0.97 p = 0.5 added to stent thrombosis) 4.7% to 4.22; p = 0.44) ASA vs. 5.9% (OR 0.78; 95% CI 0.6–0.93; p = 0.005) Table 2. Major trials on antithrombotic therapies in secondary prevention. Efficacy End Point Safety End Point in Year Trial Population (n) Setting Prior CVE (%) Drug Efficacy End Point Safety End Point in Stroke Subgroup Stroke Subgroup Not increased documented Reduced bleedings: 9.27% vs. RR reduction 14.9% CVD (prior MI, Clopidogrel vs. RR reduction 8.7%, 1996 CAPRIE 19.185 9.28%, p > 0.05; ICH (95% CI, 0.3–27.3; Not increased prior stroke, Aspirin 95% CI 0·3–16·5; 0·33% vs. 0·47%, p = 0.045) PAD) p = 0·043 p = 0.23 Reduced Clopidogrel vs. Not increased major RR reduction 27%, 2002 CREDO 2116 elective PCI 6 Placebo, added to bleeding (8.8% vs. Not reported Not reported 95% CI 3.9–44.4%; Aspirin 6.7%; p = 0.07) p = 0.02 J. Clin. Med. 2021, 10, 1923 4 of 12 Table 2. Cont. Efficacy End Point Safety End Point in Year Trial Population (n) Setting Prior CVE (%) Drug Efficacy End Point Safety End Point in Stroke Subgroup Stroke Subgroup Not significantly increased severe bleeding 1.7% vs. multiple CV risk Not increased 6.8% 1.3%; RR 1.25; 95% Reduced 7.3% versus Not increased 1.7% Clopidogrel vs. factors or vs. 7.3%, RR 0.93; CI 0.97–1.61 percent; 8.8%, p = 0.01; HR versus 1.5%, 2006 CHARISMA 21.6 3.245 Placebo, added to documented 95% CI 0.83–1.05; p = 0.09. Moderate 0.829, 95% CI p = 0.50; HR 1.114, Aspirin CVD p = 0.22 bleeding 2.1% vs.
Load more

Recommended publications
  • Rivaroxaban Versus Warfarin for Treatment and Prevention Of
    Costa et al. Thrombosis Journal (2020) 18:6 https://doi.org/10.1186/s12959-020-00219-w RESEARCH Open Access Rivaroxaban versus warfarin for treatment and prevention of recurrence of venous thromboembolism in African American patients: a retrospective cohort analysis Olivia S. Costa1,2, Stanley Thompson3, Veronica Ashton4, Michael Palladino5, Thomas J. Bunz6 and Craig I. Coleman1,2* Abstract Background: African Americans are under-represented in trials evaluating oral anticoagulants for the treatment of acute venous thromboembolism (VTE). The aim of this study was to evaluate the effectiveness and safety of rivaroxaban versus warfarin for the treatment of VTE in African Americans. Methods: We utilized Optum® De-Identified Electronic Health Record data from 11/1/2012–9/30/2018. We included African Americans experiencing an acute VTE during a hospital or emergency department visit, who received rivaroxaban or warfarin as their first oral anticoagulant within 7-days of the acute VTE event and had ≥1 provider visit in the prior 12-months. Differences in baseline characteristics between cohorts were adjusted using inverse probability-of-treatment weighting based on propensity scores (standard differences < 0.10 were achieved for all covariates). Our primary endpoint was the composite of recurrent VTE or major bleeding at 6-months. Three- and 12-month timepoints were also assessed. Secondary endpoints included recurrent VTE and major bleeding as individual endpoints. Cohort risk was compared using Cox regression and reported as hazard ratios (HRs) with 95% confidence intervals (CIs). Results: We identified 2097 rivaroxaban and 2842 warfarin users with incident VTE. At 6-months, no significant differences in the composite endpoint (HR = 0.96, 95%CI = 0.75–1.24), recurrent VTE (HR = 1.02, 95%CI = 0.76–1.36) or major bleeding alone (HR = 0.93, 95%CI = 0.59–1.47) were observed between cohorts.
    [Show full text]
  • FDA Approves ZONTIVITY™ (Vorapaxar), First-In-Class PAR-1
    NEWS RELEASE FDA Approves ZONTIVITY™ (vorapaxar), First-in-Class PAR-1 Antagonist, for the Reduction of Thrombotic Cardiovascular Events in Patients with a History of Heart Attack or with Peripheral Arterial Disease 5/12/2014 ZONTIVITY Added to Standard of Care Demonstrated Long-Term Benet Through Three Years Merck (NYSE:MRK), known as MSD outside the United States and Canada, today announced that the U.S. Food and Drug Administration (FDA) has approved ZONTIVITY™ (vorapaxar) for the reduction of thrombotic cardiovascular events in patients with a history of heart attack (myocardial infarction) or in patients with narrowing of leg arteries, called peripheral arterial disease (PAD). For patients with a history of heart attack or with PAD who had no history of stroke or transient ischemic attack (TIA), ZONTIVITY added to standard of care produced a signicant 17 percent relative risk reduction over the three years of the study for the combined events of cardiovascular (CV) death, myocardial infarction (MI), stroke, and urgent coronary revascularization (UCR) [event rate 10.1 percent vs. 11.8 percent for placebo]. For the key secondary composite ecacy endpoint of CV death, MI and stroke alone, ZONTIVITY produced a signicant 20 percent relative risk reduction in these patients [7.9 percent vs. 9.5 percent for placebo]. These results were driven by an 18 percent relative risk reduction in MI [5.4 percent vs. 6.4 percent for placebo] and a 33 percent relative risk reduction in rst stroke [1.2 percent vs. 1.6 percent for placebo]. The prescribing information for ZONTIVITY includes a boxed warning regarding bleeding risk.
    [Show full text]
  • Dabigatran, Rivaroxaban, and Warfarin in the Oldest Adults With
    CLINICAL INVESTIGATION Dabigatran, Rivaroxaban, and Warfarin in the Oldest Adults with Atrial Fibrillation in Taiwan Chao-Lun Lai, MD, PhD,*†‡§ Ho-Min Chen, MS,† Min-Tsun Liao, MD,* and Ting-Tse Lin, MD* mortality and cardiovascular mortality than those who OBJECTIVES: To compare the effectiveness and safety of used warfarin. Reduced-dose dabigatran was also associ- reduced-dose dabigatran, reduced-dose rivaroxaban, and warfa- ated with lower risk of intracranial hemorrhage than war- rin in individuals aged 85 and older with atrial fibrillation (AF). farin. J Am AmGeriatr GeriatrSoc Soc66:1567–1574, 2018. 2018. DESIGN: Retrospective cohort study. SETTING: Taiwan National Health Insurance claims database, 20112015. Key words: dabigatran; rivaroxaban; warfarin; effec- PARTICIPANTS: Individuals with AF aged 85 and older tiveness; safety; octogenarian (mean 88.6) with incident use of oral anticoagulants between June 1, 2012 and May 31, 2015 (N54,722; dabi- gatran 110 mg, n51,489; rivaroxaban 15 mg/10 mg, n51,736; warfarin, n51,497). MEASUREMENTS: Clinical outcomes included all-cause death, cardiovascular death, ischemic stroke, acute myocardial he risk of ischemic stroke is 5 times as high in individ- infarction, arterial embolism or thrombosis, intracranial hem- T uals with atrial fibrillation (AF) than in those with- orrhage, and gastrointestinal hemorrhage needing transfusion. out.1 Warfarin, the classic vitamin K antagonist, can reduce 2 Propensity score–matched analysis was performed, and the the risk of ischemic stroke by approximately 60%, but the marginal proportional hazards model was used to estimate the narrow therapeutic window and risk of bleeding complica- relative risk of various clinical outcomes in a matched tions associated with warfarin therapy have led to its being 1 dabigatran-warfarin cohort (n51,180 in each group) and a underused.
    [Show full text]
  • Edoxaban Switch Programme - Frequently Asked Questions
    Edoxaban Switch Programme - Frequently Asked Questions What should I tell patients? NHS Tayside is reviewing all patients currently receiving a Direct Oral Anticoagulant (DOAC) for stroke prevention in NV-AF(non-valvular atrial fibrillation) Edoxaban has been identified as the first choice DOAC. It is similarly effective to the other DOAC options but costs considerably less Clinical experts in Tayside are supporting the use of edoxaban All newly diagnosed NV-AF patients will be started on edoxaban as 1st choice for those unsuitable for warfarin Existing patients already on a DOAC for NV-AF are to be reviewed and considered for switch to edoxaban This will help to ensure that the money available to spend on medicines is being used appropriately Is edoxaban as good as the other DOACs? Yes, the evidence is that it is as effective as warfarin and the other DOACs. It is licensed for this indication and has been recommended by the Scottish Medicines Consortium Other Scottish Health Boards are also considering the use of edoxaban A recent Health Improvement Scotland (HIS) summary (http://www.healthcareimprovementscotland.org/our_work/cardiovascular_dis ease/programme_resources/doac_review_report.aspx) is consistent with this Tayside switch recommendation Lead clinicians from cardiology, stroke, vascular medicine, relevant MCN’s and haematology are all supportive of this Tayside guidance on the basis of current evidence Will we need to do a further switch if the price of other DOACs falls? The rebate on edoxaban is in place for five
    [Show full text]
  • Zontivity (Vorapaxar)
    HIGHLIGHTS OF PRESCRIBING INFORMATION antiplatelet drugs or with ZONTIVITY as the only antiplatelet These highlights do not include all the information needed to use agent. (2.2) ZONTIVITY safely and effectively. See full prescribing information for ZONTIVITY. --------------------- DOSAGE FORMS AND STRENGTHS --------------------- Tablets: 2.08 mg vorapaxar. (3) ZONTIVITY™ (vorapaxar) Tablets 2.08 mg*, for oral use *Equivalent to 2.5 mg vorapaxar sulfate ------------------------------- CONTRAINDICATIONS ------------------------------- Initial U.S. Approval: 2014 History of stroke, TIA, or ICH. (4.1) Active pathologic bleeding. (4.2) WARNING: BLEEDING RISK See full prescribing information for complete boxed warning. ----------------------- WARNINGS AND PRECAUTIONS ----------------------- • Do not use ZONTIVITY in patients with a history of stroke, Like other antiplatelet agents, ZONTIVITY increases the risk of transient ischemic attack (TIA), or intracranial hemorrhage (ICH); bleeding. (5.1) or active pathological bleeding. (4.1, 4.2) Avoid use with strong CYP3A inhibitors or inducers. (5.2) • Antiplatelet agents, including ZONTIVITY, increase the risk of bleeding, including ICH and fatal bleeding. (5.1) ------------------------------ ADVERSE REACTIONS ------------------------------ Bleeding, including life-threatening and fatal bleeding, is the most ----------------------------INDICATIONS AND USAGE ---------------------------- commonly reported adverse reaction. (6.1) ZONTIVITY is a protease-activated receptor-1 (PAR-1) antagonist indicated for the reduction of thrombotic cardiovascular events in To report SUSPECTED ADVERSE REACTIONS, contact Merck patients with a history of myocardial infarction (MI) or with peripheral Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-877­ arterial disease (PAD). ZONTIVITY has been shown to reduce the rate 888-4231 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. of a combined endpoint of cardiovascular death, MI, stroke, and urgent coronary revascularization.
    [Show full text]
  • DOACS COMPARISON and Faqs
    NOACS/DOACS*: PRACTICAL ISSUES AND FREQUENTLY-ASKED QUESTIONS OBJECTIVES: • To summarize characteristics of the direct oral anticoagulants (DOACs) currently available in Canada. • To address common practical issues related to DOAC use. • To address frequently asked questions regarding DOACs. BACKGROUND: The DOACs, which consist of apixaban, dabigatran, edoxaban, and rivaroxaban are used for the prevention and treatment of venous thromboembolism (VTE) and for stroke prevention in atrial fibrillation (AF). Practical advantages of DOACs over warfarin include fixed once- or twice-daily oral dosing without the need for coagulation test monitoring, relatively fewer known drug interactions and no known food interactions. Like warfarin, DOACs increase the risk for bleeding and should be administered under close clinical monitoring. Practical issues regarding the everyday use of DOACs will be addressed in this guide. PRACTICAL AND LIFESTYLE ISSUES: Can DOACs be taken with meals? Rivaroxaban should be taken with meals to enhance absorption; the tablet can be crushed and taken with soft foods such as applesauce. Apixaban, dabigatran, edoxaban can be taken with or without meals. However, taking dabigatran with meals can reduce dyspepsia. Dabigatran capsules should not be opened, broken or chewed before swallowing. Are there any foods or beverages that need to be avoided with DOACs? Unlike with warfarin, there are no known food interactions with DOACs, so there are no food restrictions when taking these medications. In addition, there is no evidence that drinking grapefruit juice affects the effectiveness or safety of DOACs. In general, it is acceptable for patients taking a DOAC to drink alcoholic beverages in moderation (e.g. a glass of wine with a meal) as it is for patients on warfarin.
    [Show full text]
  • XARELTO (Rivaroxaban) Safely and Effectively
    • Treatment of DVT, PE, and Reduction in the Risk of Recurrence of HIGHLIGHTS OF PRESCRIBING INFORMATION DVT and of PE: 15 mg orally twice daily with food for the first 21 days These highlights do not include all the information needed to use ® for the initial treatment of acute DVT or PE. After the initial treatment XARELTO (rivaroxaban) safely and effectively. See full prescribing period, 20 mg orally once daily with food for the remaining treatment information for XARELTO. and the long-term reduction in the risk of recurrence of DVT and of PE. XARELTO (rivaroxaban) tablets, for oral use (2.4) Initial U.S. Approval: 2011 • Prophylaxis of DVT Following Hip or Knee Replacement Surgery: 10 mg orally, once daily with or without food (2.5) WARNING: (A) PREMATURE DISCONTINUATION OF XARELTO --------------------DOSAGE FORMS AND STRENGTHS---------------------­ INCREASES THE RISK OF THROMBOTIC EVENTS, Tablets: 10 mg, 15 mg, and 20 mg (3) (B) SPINAL/EPIDURAL HEMATOMA See full prescribing information for complete boxed warning -------------------------------CONTRAINDICATIONS-----------------------------­ • Active pathological bleeding (4) (A) PREMATURE DISCONTINUATION OF XARELTO INCREASES • Severe hypersensitivity reaction to XARELTO (4) THE RISK OF THROMBOTIC EVENTS Premature discontinuation of any oral anticoagulant, including ---------------------------WARNINGS AND PRECAUTIONS------------------­ XARELTO, increases the risk of thrombotic events. To reduce this risk, • Risk of bleeding: XARELTO can cause serious and fatal bleeding. consider coverage with another anticoagulant if XARELTO is Promptly evaluate signs and symptoms of blood loss. (5.2) discontinued for a reason other than pathological bleeding or completion • Pregnancy-related hemorrhage: Use XARELTO with caution in of a course of therapy (2.2, 2.6, 5.1, 14.1).
    [Show full text]
  • Rivaroxaban and Aspirin in Peripheral Vascular Disease: a Review of Implementation Strategies and Management of Common Clinical Scenarios
    Current Cardiology Reports (2019) 21:115 https://doi.org/10.1007/s11886-019-1198-5 PERIPHERAL VASCULAR DISEASE (CJ COOPER AND R GUPTA, SECTION EDITORS) Rivaroxaban and Aspirin in Peripheral Vascular Disease: a Review of Implementation Strategies and Management of Common Clinical Scenarios Graham R. McClure1,2 & Eric Kaplovitch3 & Sukrit Narula2,4 & Vinai C. Bhagirath4,5 & Sonia S. Anand4,5 # The Author(s) 2019 Abstract Purpose of Review Peripheral artery disease (PAD) affects an estimated 200 million people worldwide and is associated with significant cardiovascular morbidity and mortality. Cardiovascular risk is further increased among individuals with polyvascular disease, where either cerebrovascular or coronary artery disease is present in addition to PAD. In this review, we present common clinical scenarios encountered when managing patients with PAD and provide an evidence-based approach to prescribing optimal antithrombotics in this population. Recent Findings The COMPASS trial recently demonstrated that rivaroxaban 2.5 mg BID + ASA daily significantly reduces major adverse cardiac and limb events in patients with PAD. Despite these advances, morbidity following MALE events remains high. Summary With widespread approval by federal health regulators, the COMPASS regimen should be strongly considered in PAD patients who do not have a high bleeding risk. Implementing the COMPASS regimen in patients with PAD, along with other vascular risk reduction strategies, will have a substantial impact on reducing atherothromboembolic risk in patients with established vascular disease. Keywords Peripheral artery disease . Antithrombotics . Rivaroxaban . Aspirin Introduction events (MALE), and mortality [2]. Following an index MALE, this risk increases even further [3•]. Aggressive sec- Over 200 million individuals, including approximately 10 ondary prevention strategies are required to lower this risk.
    [Show full text]
  • Anticoagulation Dosing Guideline for Adult COVID-19 Patients
    Anticoagulation Dosing Guideline for Adult COVID-19 Patients Enoxaparin is the preferred first line anticoagulant for patients diagnosed with COVID-19. The incidence of HIT with enoxaparin is less than 1%. VTE Prophylaxis: VTE prophylaxis will be considered for COVID-19 patients who are low risk. Low risk COVID-19 patient 1. Not receiving mechanical ventilation 2. D-Dimer < 6 mg/L 3. ESRD on iHD without clotting Kidney Function BMI (kg/m2) Dosing of Enoxaparin Concern for HIT or LMWH Failure CrCL ≥ 30 mL/min 18.5-39.9 30mg SUBQ Q12H Consult Hematology 40-49.9 40mg SUBQ Q12H ≥ 50 60mg SUBQ Q12H CrCL < 30 mL/min 18.5-39.9 30mg SUBQ Q24H Consult Hematology OR ≥ 40 40mg SUBQ Q24H ESRD/AKI on RRT Special Population: < 18.5 (or weight < 50kg) Heparin 2500 SUBQ Q8H Consult Hematology *Contraindications: Platelets < 25 K/uL or Fibrinogen < 50 mg/dL or active bleeding Therapeutic anticoagulation Therapeutic anticoagulation will be considered for COVID-19 patients who are considered high risk or diagnosed with an acute VTE. High risk COVID-19 patient (for all hospitalized patients): Receiving mechanical ventilation AND D-dimer > 6 mg/L OR Acute kidney injury (Scr increase 0.3 mg/dL above baseline) +/- CVVHD/AVVHD/SLED or IHD with clotting Anti-Xa level goals for enoxaparin therapy (when indicated): 1. Therapeutic peak LMWH level (Drawn 4 hours after 3rd dose): 0.6-1 anti-Xa units/mL 2. Therapeutic trough LMWH level (Drawn 1 hour prior to 3rd dose): < 0.5 anti-Xa units/mL Kidney Function BMI Dosing of Enoxaparin Concern for HIT or (kg/m2) LMWH
    [Show full text]
  • NEW ORAL ANTICOAGULANTS No
    NEW ORAL ANTICOAGULANTS No. 20, Oct 2012 Produced by NHS Greater Glasgow and Clyde Medicines Information Service . There are three new oral anticoagulants licensed Rivaroxaban Dabigatran Apixaban in the UK, rivaroxaban, dabigatran and apixaban. All three agents are licensed for the prevention of Prevention of On total Non- Non- venous thromboembolism (VTE) in hip and knee VTE following Formulary Formulary Formulary replacement surgery. Rivaroxaban is the only hip or knee with agent on the total Formulary for this indication. replacement restrictions . Rivaroxaban and dabigatran are licensed for the surgery prevention of stroke and systemic embolism in Prevention of On total On total _ patients with atrial fibrillation (AF). Both are on stroke and Formulary Formulary the total Formulary for this indication with systemic with with restrictions. embolism in restrictions restrictions . In AF, preference of rivaroxaban or dabigatran AF over warfarin for practical rather than clinical Treatment of On total reasons is non-Formulary. DVT and Formulary _ _ . Rivaroxaban is also licensed for the treatment of prevention of with deep vein thrombosis (DVT) and prevention of recurrent DVT restrictions recurrent DVT/pulmonary embolism (PE). It is on and PE the total Formulary as an alternative to warfarin when the intended treatment duration is 3 to 6 NB. New indications for these agents are at months. different stages of development and therefore they may be licensed for additional indications in the Introduction near future. There are three new oral anticoagulants licensed in the UK. The direct thrombin inhibitor, dabigatran and the two direct factor Xa inhibitors, rivaroxaban and apixaban.1 Apixaban is Evidence non-Formulary and should not routinely be prescribed in Prevention of VTE following hip and knee 2 NHS Greater Glasgow & Clyde (NHSGGC).
    [Show full text]
  • Annexes to the Annual Report of the European Medicines Agency 2014
    Annexes to the annual report of the European Medicines Agency 2014 Table of contents Annex 1 – Members of the Management Board ............................................................................. 2 Annex 2 – Members of the Committee for Medicinal Products for Human Use ................................... 4 Annex 3 – Members of the Pharmacovigilance Risk Assessment Committee ...................................... 6 Annex 4 – Members of the Committee for Medicinal Products for Veterinary Use ............................... 8 Annex 5 – Members of the Committee on Orphan Medicinal Products ............................................ 10 Annex 6 – Members of the Committee on Herbal Medicinal Products .............................................. 12 Annex 07 – Committee for Advanced Therapies .......................................................................... 14 Annex 8 – Members of the Paediatric Committee ........................................................................ 16 Annex 9 – Working parties and working groups .......................................................................... 18 Annex 10 – CHMP opinions in 2014 on medicinal products for human use ...................................... 22 Annex 11 – CVMP opinions in 2014 on medicinal products for veterinary use .................................. 36 Annex 12 – COMP opinions in 2014 on designation of orphan medicinal products ............................ 41 Annex 13 – HMPC European Union herbal monographs in 2014....................................................
    [Show full text]
  • Presentazione Standard Di Powerpoint
    EVALUATION OF ADHERENCE TO NEW ORAL ANTICOAGULANTS THERAPY BASED ON THERAPEUTIC SWITCHES: A DESCRIPTIVE STUDY. L. Gasperoni1, F. Ambrosini Spinella1, A.M. Resta1. 1 ASUR Marche, Territorial Pharmaceutical Service AV1, Fano, Italy Abstract number: 5PSQ-011 ATC code: B01 - Antithrombotic agents Background Regarding therapeutic adherence to new oral ITALY: the prescription of NOAC is possible from anticoagulants (NOAC), several studies [1] have shown Dabigatram July 2013 lower adherence in Dabigatran treated patients compared to Rivaroxaban and Apixaban. The NOAC Rivaroxaban October 2013 introduction has fueled the phenomenon of switch Apixaban March 2014 from vitamin K antagonists (VKA) to NOAC, and vice Edoxaban October 2016 versa, and also from NOAC to other NOAC. Purpose The aim of this descriptive study is to evaluate adherence to therapy among NOAC treated patients by basing the analysis on the therapeutic switches, ie the passages to another NOAC or VKA. Material and methods Through the informatic flow of pharmaceutical prescriptions, we extracted the NOAC prescriptions from July 2013 to June 2016 in the Area Vasta 1 of the Region. Patients who have taken Dabigatran, Rivaroxaban and Apixaban have emerged from these prescriptions (Edoxaban is excluded because it is available since October 2016). Adherent patient was that who did not switch to other anticoagulant therapy (NOAC or VKA) during the analysis period and in the following 6 months (until December 2016). Patients who had taken VKA before starting treatment with NOAC (the flow of prescriptions was investigated since January 2013) and patients who died during the analysis period or in the following 6 months were excluded from the study.
    [Show full text]