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Patients Are Undertreated NABOR Warfarin/Warfarin + Aspirin No Treatment Patients, % Waldo AL, et al. J Am Coll Cardiol. 2005;46:1729-1736. [3] Retrospective.

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Presentation on theme: "Patients Are Undertreated NABOR Warfarin/Warfarin + Aspirin No Treatment Patients, % Waldo AL, et al. J Am Coll Cardiol. 2005;46:1729-1736. [3] Retrospective."— Presentation transcript:

1 Patients Are Undertreated NABOR Warfarin/Warfarin + Aspirin No Treatment Patients, % Waldo AL, et al. J Am Coll Cardiol. 2005;46: [3] Retrospective cohort study of inpatients at 21 teaching, 13 community, and 4 Veterans Affairs hospitals in the United States

2 Patients Are Undertreated Meta-analysis Ogilvie IM, et al. Am J Med. 2010;123: [5] Patients with prior stroke/transient ischemic attack –25 of 29 studies reported undertreatment –21 of 29 studies reporting oral anticoagulant use < 60% Patients with CHADS 2 ≥ 2 –7 of 9 studies reporting treatment < 70%

3 AVERROES: Apixaban vs Aspirin Primary Outcome Connolly SJ, et al. N Engl J Med. 2011;364: [7] Outcome ApixabanAspirinApixaban vs Aspirin Annual Rate Hazard Ratio (95% Confidence Interval)P Value Stroke or systemic embolism ( )<.001 Stroke ( )<.001 –Ischemic ( )<.001 –Hemorrhagic ( ).45 –Disabling or fatal ( )<.001 Systemic embolism ( ).01

4 New Oral Anticoagulants Stroke or System Embolic Event (vs Warfarin) a. Connolly SJ, et al. N Engl J Med. 2009;361: [7] ; b. Patel MR, et al. N Engl J Med. 2011;365: [9] ; c. Granger CB, et al. N Engl J Med. 2011;365: [10] ; d. Giugliano RP, et al. N Engl J Med 2013;369: [11] Risk Ratio (95% Confidence Interval)P Value RE-LY a Dabigatran 150 mg 0.66 ( )<.001 ROCKET AF b Rivaroxaban 0.88 ( ).12 ARISTOTLE c Apixaban 0.79 ( ).01 ENGAGE AF-TIMI 48 d Edoxaban 60 mg 0.87 ( ).08

5 a. Connolly SJ, et al. N Engl J Med. 2009;361: [7] ; b. Patel MR, et al. N Engl J Med. 2011;365: [9] ; c. Granger CB, et al. N Engl J Med. 2011;365: [10] ; d. Giugliano RP, et al. N Engl J Med 2013;369: [11] ; e. Ruff CT, et al. Lancet. 2014;383: [8] New Oral Anticoagulants (cont) Stroke or Systemic Embolic Event (vs Warfarin) Risk Ratio (95% Confidence Interval)P Value RE-LY a Dabigatran 150 mg 0.66 ( )<.001 ROCKET AF b Rivaroxaban 0.88 ( ).12 ARISTOTLE c Apixaban 0.79 ( ).01 ENGAGE AF-TIMI 48 d Edoxaban 60 mg 0.87 ( ).08 Combined (Random) e 0.81 ( )<.0001 Intracranial hemorrhage (Combined) e 0.48 ( )<.0001

6 Some Foods High in Vitamin K NIH website. [12] Kale Spinach Brussels sprouts Turnip greens Lettuce Broccoli Endive Parsley Swiss chard Mustard greens Collards

7 New oral anticoagulants reduced the risk for intracranial hemorrhage compared with warfarin New oral anticoagulants have minimal food and drug interactions Long-term adherence to this treatment is absolutely necessary Clinicians should develop patient education strategies New oral anticoagulants do not require monitoring Summary

8 Abbreviations ACE = angiotensin-converting enzyme AF = atrial fibrillation ARISTOTLE = Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation AVERROES = Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients who have Failed or are Unsuitable for Vitamin K Antagonist Treatment CAD = coronary artery disease CHA 2 DS 2 -VASc = congestive heart failure (or left ventricular systolic dysfunction), hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, and sex category (ie, female sex) ENGAGE AF-TIMI 48 = Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation— Thrombolysis in Myocardial Infarction 48 INR = international normalized ratio NABOR = National Anticoagulation Benchmark and Outcomes Report RE-LY = Randomized Evaluation of Long-Term Anticoagulant Therapy 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

9 References 1. Hohnloser SH, Duray GZ, Baber U, Halperin JL. Prevention of stroke in patients with atrial fibrillation: current strategies and future directions. Eur Heart J Suppl. 2008(Suppl H):H4-H Granger CB. Newer oral anticoagulants should be used as first-line agents to prevent thromboembolism in patients with atrial fibrillation and risk factors for stroke or thromboembolism. Circulation. 2012;125: Waldo AL, Becker RC, Tapson VF, Colgan KJ. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J Am Coll Cardiol. 2005;46: Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115: Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GYH. Underuse of oral anticoagulants in atrial fibrillation: A systematic review. Am J Med. 2010;123:

10 References (cont) 6. Warfarin drug interactions. Accessed November 5, Connolly SJ, Ezekowitz MD, Yusuf S, et al; and the RE-LY Steering committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361: 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 randomized trials. Lancet. 2014;383: Patel MR, Mahaffey KW, Garg J, et al; for the ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365; Granger CB, Alexander JH, McMurray JJV, et al; for the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:

11 References (cont) 11. Giugliano RP, Ruff CT, Braunwald E, et al; ENGAGE AF-TIMI 48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369: National Institutes of Health. Important information to know when you are taking Coumadin® and Vitamin K. Accessed November 5, Wanek MR, Horn ET, Elapavaluru S, Baroody SC, Sokos G. Safe use of hemodialysis for dabigatran removal before cardiac surgery. Ann Pharmacotherapy. 2012;46:e21.


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