Liver injury from direct oral anticoagulants

BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions.A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs.However,it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.METHODS A systematic search was conducted on multiple databases including PubMed,Science Direct,Reference Citation Analysis,and Google Scholar.The search terms included“Acute Liver Failure”OR“Acute-On-Chronic Liver Failure”OR“Acute Chemical and Drug Induced Liver Injury”OR“Chronic Chemical and Drug Induced Liver Injury”AND“Factor Xa Inhibitors”OR“Dabigatran”OR“Rivaroxaban”OR“apixaban”OR“betrixaban”OR“edoxaban”OR“Otamixaban”.The results were filtered for literature published in English and on adult patients.Only case reports and case studies reporting cases of DILI secondary to DOACs were included.Data on demographics,comorbidities,medication history,laboratory investigations,imaging,histology,management,and outcomes were extracted.RESULTS A total of 15 studies(13 case reports and 2 case series)were included in the analysis,comprising 27 patients who developed DILI secondary to DOACs.Rivaroxaban was the most commonly implicated DOAC(n=20,74.1%).The mean time to onset of DILI was 40.6 d.The most common symptoms were jaundice(n=15,55.6%),malaise(n=9,33.3%),and vomiting(n=9,33.3%).Laboratory investigations showed elevated liver enzymes and bilirubin levels.Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury.Most patients had a favourable outcome,and only 1 patient(3.7%)died due to liver failure.CONCLUSION DOACs are increasingly used for various clinical conditions,and DILI secondary to DOACs is a rare but potentially serious complication.Prompt identification and cessation of the offending drug are crucial for the management of DILI.Most patients with DILI secondary to DOACs have a favourable outcome,but a small proportion may progress to liver failure and death.Further research,including post-marketing population-based studies,is needed to better understand the incidence and risk factors for DILI secondary to DOACs.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that for esophagus,duodenum and colon cancer(around 2%-4%).Although investigations into the risk factors for post-ESD bleeding have identified several procedure-,lesion-,physician-and patient-related factors,use of antithrombotic drugs,especially anticoagulants[direct oral anticoagulants(DOACs)and warfarin],is thought to be the biggest risk factor for post-ESD bleeding.In fact,the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%,which is higher than that in patients not receiving anticoagulants.However,because clinical guidelines for management of ESD in patients receiving DOACs differ among countries,it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice.Given that the pharmacokinetics(e.g.,plasma DOAC level at both trough and T_(max))and pharmacodynamics(e.g.,anti-factor Xa activity)of DOACs are related to risk of major bleeding,plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

Direct oral anticoagulants for the treatment of splanchnic vein thrombosis:A state of art

Splanchnic vein thrombosis(SVT)is a manifestation of venous thromboembolism in an unusual site.Portal,mesenteric,and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis,although non-cirrhotic patients could be affected as well.Thrombosis of hepatic veins,also known as Budd-Chiari syndrome,is another manifestation of SVT.Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications.Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases.However,recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants(DOACs)in this setting.Available results are mainly based on retrospective studies with small sample size,but first clinical trials have been published in the last years.This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.

Paper Analysis of the WATCHMAN on the Reduction of Stroke Compared to Anticoagulants: A Systematic Review of the Literature

Objective: Anticoagulants have been approved and used for decades as highly effective blood thinners. The objective of this study is to analyze the clinical trials in order to determine if the Watchman reduces the risk of stroke in patients with atrial fibrillation compared to those prescribed the traditional anticoagulants. This will contribute to the current body of knowledge and possibly provide beneficial clinical guidance with respect to providing an alternative option for those suffering from non-valvular Atrial fibrillation. Methods: A systematic literature search through the Saint James School of Medicine library resources as well as PubMed, Medscape, Google Scholar was conducted. Studies were included if the literature examined the comparison between the Watchman device and four specific anticoagulants (Xarelto, Eliquis, Pradaxa, and Warfarin) in association with reduction of risks of strokes in an atrial fibrillation population. The study includes a qualitative sub-analysis to explore additional clinical aspects that may affect risk of stroke and response of treatment. Results: Outcomes were significant for similar stroke occurrence, when compared to published clinical trials. Alternatively, there was a significant reduction in risk of bleeding and all-cause mortality in the Watchman™ device compared to traditional NOACs and warfarin. While examining the studies and trials, overall, the Watchman™ device offers a better long-term outcome therapy for non-valvular atrial fibrillation populations who are not possibilities for extended anticoagulation. The studies used for analysis examining the dosage found higher fatality with increased use of NOACs and more hospitalizations with decreased use. Conclusion: From the presented data, it is safe to say that the Watchman™ device is a viable and effective alternative for stroke prophylaxis in certain patient populations. Compared to traditional anticoagulant therapies for non-valvular atrial fibrillation, these studies suggest that the Watchman™ device can reduce bleeding time and, in most cases, the risk of stroke is less than or equal to traditional anti-coagulants.

Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants

Objective:Photoselective vaporization of the prostate(PVP)is a widely performed surgical procedure for benign prostatic obstruction.This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants(NOACs).This study was to examine the perioperative outcomes in men on NOACs undergoing PVP,with particular reference to perioperative morbidity.Methods:A retrospective analysis of PVP datasets was undertaken from three centres in Sydney(Australia),Toulouse(France)and Boston(USA).Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified.Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo(CD)classification.Results:There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period.The mean age was 776.5 years.The mean prostate volume,energy utilization and vaporisation time was 9456 mL,301211 kJ,and 3521 min respectively.The mean postoperative duration of catheterization and duration of hospitalization was 2.22.4 days and 2.42.4 days respectively.There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions.Conclusions:This study supports the safety of men on NOACs undergoing PVP.Whilst this study represents the largest experience of PVP in these men,larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

Gastrointestinal bleeding in patients on novel oral anticoagulants:Risk,prevention and management

Novel oral anticoagulants(NOACs), which include direct thrombin inhibitor(dabigatran) and direct factor Xa inhibitors(rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding(GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran(150 mg b.i.d), rivaroxaban and high-dose edoxaban(60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.

Post-polypectomy bleeding and thromboembolism risks associated with warfarin vs direct oral anticoagulants

AIM To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants(DOAC).METHODS We collected data from 218 patients receiving oral anticoagulants(73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics(age-and sexmatched controls) who underwent polypectomy.(1) We evaluated post-polypectomy bleeding(PPB) risk in patients receiving warfarin or DOAC compared with controls;(2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge(HPB)(endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB.RESULTS PPB rate was significantly higher in warfarin users and DOAC users compared with controls(13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban(13.2%), dabigatran(11.1%), and apixaban(13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group(guideline recommendation) had a higher PPB rate(10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant group.CONCLUSION PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.

Evaluation of the safety and effectiveness of direct oral anticoagulants and low molecular weight heparin in gastrointestinal cancer-associated venous thromboembolism

BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulation treatment have an associated increase rate.GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants(DOAC),especially with active cancer therapies.AIM To evaluate patient risk factors,effectiveness(VTE)and safety(MB)of DOACs and low molecular weight heparin(LMWH)in patients with active GICA-VTE.METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed.Inclusion criteria included active GI cancer diagnosed at any stage or treatment+/-6 mo of VTE diagnosis,whom were prescribed 6 mo or more of DOACs or LMWH.The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events.Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.RESULTS A total of 144 patients were prescribed anticoagulation,in which 106 fulfilled inclusion criteria apixaban(27.3%),rivaroxaban(34.9%)and enoxaparin(37.7%),and 38 were excluded.Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event,with 62%males,80%Caucasian,70%stage IV,pancreatic cancer(40.5%),30%Khorana Score(≥3 points),and 43.5%on active chemotherapy.Sixty-four percent of patients completed anticoagulation therapy(range 1 to 43 mo).Recurrent VTE at 6 mo was noted in 7.5%(n=3),6.8%(n=2)and 2.7%(n=1)of patients on enoxaparin,apixaban and rivaroxaban,respectively(all P=NS).MB at 6 mo were 5%(n=2)for enoxaparin,6.8%(n=2)for apixaban and 21.6%(n=8)for rivaroxaban(overall P=0.048;vs LMWH P=0.0423;all other P=NS).Significant predictors of a primary or secondary outcome for all anticoagulation therapies included:Active systemic treatment(OR=5.1,95%CI:1.3-19.3),high Khorana Score[≥3 points](OR=5.5,95%CI:1.7-17.1),active smoker(OR=6.7,95%CI:2.1-21.0),pancreatic cancer(OR=6.8,95%CI:1.9-23.2),and stage IV disease(OR=9.9,95%CI:1.2-79.1).CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.

Efficacy and safety of non-vitamin K antagonist oral anticoagulants post-kidney transplantation

BACKGROUND Novel oral anticoagulants(NOACs)were developed as alternatives to vitamin K antagonists,primarily warfarin,as they do not require routine monitoring and have limited drug-drug and drug-food interactions.However,the efficacy and safety of these agents in kidney transplantation are not well studied.AIM To assess the profile and safety of NOACs for patients who had kidney transplantation,and to provide recommendations and guidelines on therapeutic strategies in these patients.METHODS This was a retrospective study carried out among adult patients who were actively on the following NOACs(apixaban,rivaroxaban or dabigatran)in our renal transplantation program from December 2015 to December 2016.The patients were identified primarily through electronic medical record system(patient data linkage).Data on the clinical and laboratory profile of the patients were retrieved and analyzed with SPSS 22.0.RESULTS Complete data on 42 renal transplant patients were retrieved:59.5%males,90.5%were whites and 66.7%were older than 60 years old.The mean duration since renal transplantation of the patients was 8.8±7.4 years.The most common risk factors for the development of end-stage renal disease in the subjects were hypertension(19.0%),polycystic kidney disease(19.0%),followed by diabetic nephropathy(16.7%)and chronic glomerulonephritis(16.7%).The main indications for NOACs use in the cohort were atrial fibrillation in 25 patients(59.5%)and venous thromboembolism in 10 patients(23.8%).Overall,29 patients(69%)were treated with apixaban,10 patients(23.8%)with rivaroxaban and 3 patients(7.14%)with dabigatran.No(0%)thromboembolic events were observed during the one-year period,but 3(7.1%)bleeding events occurred in the cohort consisting of 1 patient treated with rivaroxaban 15 mg daily and 2 patients who received apixaban 2.5 mg twice daily.There were no significant changes in serum tacrolimus level three days after the initiation of NOACs among patients treated with tacrolimus(pre-and post-NOACs tacrolimus levels were 7.2516 and 7.8867 ng/m L,P=0.55,respectively).Also,after one-year of treatment with NOACs there were no significant changes in the pre-and post-NOACs serum creatinine level(P=0.772)and estimated glomerular filtration rates(P=0.232).CONCLUSION No thromboembolic events or significant changes in renal profile were observed in our cohort of kidney transplant recipients who were treated with NOACs for at least a year.However,a few bleeding events were observed.This calls for further well-planned randomized controlled trials to assess the efficacy and safety of NOACs among renal transplant recipients.

Pancreatic cancer:A model cancer for the study of the therapeutic effects of anticoagulants

Cancer-related thromboembolic disease is a well recognized syndrome since first described by Armand Trousseau in 1865.Preventing the morbidity and mortality related to thromboembolism in these patients is becoming a priority research area with the advent of new anti-coagulants.It is only recently that randomized trials of improved quality are been undertaken to study this question.Many of these trials however are still not accounting for the heterogeneity of "cancer" in terms of anatomical site,histology,stage and treatment.This editorial review highlights why pancreatic cancer may serve as a model malignancy to study this question.

Peribulbar anesthesia in 750 patients treated with oral anticoagulants

AIM: To check the safety of continuation of oral anticoagulants in ophthalmic procedures requiring a peribulbar anesthesia. ·METHODS: A prospective case control study included 750 patients with oral anticoagulants in group A and 750 patients who had never been treated with oral anticoagulant in group B. Hemorrhages were graded as follows: 1) spot ecchymosis of eyelid and or subconjunctival hemorrhage; 2) eyelid ecchymosis involving half of the lid surface area; 3) eyelid ecchymosis all around the eye,no increase in intraocular pressure; 4) retrobulbar hemorrhage with increased intraocular pressure. ·RESULTS: In group A,grade 1 was observed in 13 patients(1.74%) and grade 2 in 2 patients(0.26%). In group B,grade 1 was observed in 12 patients(1.6%) and grade 2 was absent. No 3 or 4 hemorrhage grade was encountered in both groups. There was not significant difference in grade 1 hemorrhage between both groups(P =0.21). ·CONCLUSION: Oral anticoagulants were not associated with a significant increase in potentially sight-threatening local anesthetic complications.

Non-vitamin K antagonist oral anticoagulants for COVID-19 thrombosis

Thrombotic complications appear to be a major predictor of death in COVID-19 patients,and multiple studies have shown that anticoagulants can help to improve the outcome.The Food and Drug Administration’s acceptance of non-vitamin K antagonist oral anticoagulants(NOACs)has sparked much excitement about their potential as a replacement for existing oral anticoagulants.NOACs target a single clotting factor,often activated factor X or thrombin,and involve the coagulation factor Xa inhibitors including apixaban,edoxaban,and rivaroxaban,and the thrombin inhibitor dabigatran.COVID-19 is an infectious disease that causes thrombotic events by inducing a pro-inflammatory and prothrombotic condition.This article provides a comprehensive overview of the mechanism behind enhanced thrombogenicity accompanying COVID-19,the clinical range of NOACs,and the role of NOACs in treatment of COVID-19 based on recent investigations and clinical trials.

Laboratory Tests in Assessing the Bleeding Risk in Patients Receiving Direct Oral Anticoagulants (DOACs)

Direct oral anticoagulants (DOACs)—apixaban, rivaroxaban and dabigatran have become the first line medications for patients with thromboembolism. However, DOAC therapy-associated bleeding complications remain the major clinical concern for these patients.?This study compared laboratory test results from 82 patients with and 361 patients without DOAC-associated bleeding with the goal of determining the value of laboratory tests in assessing bleeding risk in these patients.?There was no age or gender difference between patients with and without DOAC therapy-associated bleeding complications. Both prothrombin time?(PT) and partial thromboplastin time (PTT) prolonged at the same time showed good correlation with bleeding complications for patients receiving dabigatran (91.7%) and rivaroxaban (41.2%). When comparing patients with bleeding and those without bleeding complications, impaired renal function showed high correlation (p??0.01),?impaired liver function?showed moderate correlation (p?=?0.03), and thrombocytopenia showed no correlation (p?>?0.05)?among patients with bleeding complications.?A small population of patients had never experienced bleeding complications, despite thelaboratory test results being similar to patients?who suffered?from bleeding complications. Laboratory tests may be useful in the assessment and prediction of bleeding complications in patients receiving DOAC therapy. However, it is important to incorporate both laboratory findings with the clinical information, such as concomitant antithrombotic agents and other underlying diseases in the decision making of DOAC therapy in order to reduce therapy-related bleeding risk.

Role of novel oral anticoagulants in the management and prevention of venous thromboembolism

Venous thromboembolism(VTE) encompasses deep vein thrombosis and pulmonary embolism and is a major health burden, both medically and economically. Anticoagulation is the primary treatment and can be divided into three stages: initial, long term and extended treatment. Initial anticoagulation is given to reduce the risk of complications including fatal pulmonary embolism, while long term and extended treatment are aimed at prevention of recurrent VTE. Until recently, initial anticoagulation has only been achievable with administration of parental agents such as unfractionated or low molecular weight heparin, while vitamin K antagonists such as warfarin, have been the mainstay of long term and extended treatment. Factor-Xa inhibitors and direct thrombin inhibitors are oral anticoagulants that are being increasingly utilized as an alternative form of anticoagulation. This article aims to review the current guidelines in the management of VTE, the recent literature regarding novel anticoagulants in VTE, suggested treatment regimes and limitations.

Acute compartment syndrome of the thigh following hip replacement by anterior approach in a patient using oral anticoagulants

Acute compartment syndrome(ACS) of the thigh following primary total hip arthroplasty(THA) is a highly uncommon complication and has not yet been reported before with regards to the anterior approach through the anterior supine interval. We present a case of a 69-year-old male patient with a history of stroke, who developed ACS of the thigh after elective THA while using therapeutic low molecular weight heparin as bridging for regular oral anticoagulation. ACS pathogenesis, diagnostic tools, treatment and relevant literature are discussed. The patient's ACS was recognized in time and treated by operative decompression with fasciotomy of the anterior compartment. Follow-up did not show any neurological deficit or soft-tissue damage.

Superior safety of direct oral anticoagulants compared to Warfarin in patients with atrial fibrillation and underlying cancer: a national veterans affairs database study

Background Studies evaluating safety of warfarin and direct oral anticoagulants(DOACs) for prevention of stroke in patients with atrial fibrillation(AF) are lacking. Methods & Results All patients(n = 196,521) receiving care at veteran’s affairs with active cancer and AF from 2010–2015 were included. One-year mortality was significantly higher in unadjusted analysis with warfarin(44.9%) compared to dabigatran(25%, P < 0.001), rivaroxaban(24.4%, P < 0.001) and apixaban(30%, P < 0.001) and after adjusting for age, sex and type of cancer mortality(OR = 2.66, 95% CI: 2.52–2.82, P < 0.001). Risk of ischemic stroke(13.5% vs. 11.1%, 12.0%, 14.0%) was similar, however risk of hemorrhagic stroke was significantly higher among patients receiving warfarin(1.2%) compared to patients receiving dabigatran(0.5%), rivaroxaban(0.7%) and apixaban(0.8%) respectively, P = 0.04. Conclusions We demonstrated the superior safety profile of DOACs compared to warfarin among patients with underlying cancer and AF. Warfarin was associated with higher mortality, similar ischemic stroke risk but higher risk of hemorrhagic stroke.

Dabigatran etixilate and traumatic brain injury: Evolving anticoagulants require evolving care plans

AIM: To investigate the outcomes of trauma patients with traumatic brain injury(TBI) on Dabigatran Etexilate(DE). METHODS: Following IRB approval, all patients taking DE who were admitted to our level 1 trauma service were enrolled in the study. Injury complexity, length of stay(LOS), intensive care length of stay, operative intervention, therapeutic interventions and outcomes were analyzed retrospectively. RESULTS: Twenty-eight of 4310 admissions were taking DE. Eleven patients were excluded on concurrent antiplatelet therapy. Average age was 77.14 years(64-94 years), and average LOS was 4.7 d(1-35 d). Thirty-two percent were admitted with intracranial hemorrhage. Eighteen percent received factor Ⅶ, and 22% received dialysis in attempts to correct coagulopathy. Mortality was 21%.CONCLUSION: The low incidence, absence of reversal agents, and lack of practice guidelines makes managing patients with TBI taking DE frustrating and provider specific. Local practice guidelines may be helpful in managing such patients.

The Use of Direct Oral Anticoagulants for Prevention of Stroke and Systemic Embolic Events in East Asian Patients with Nonvalvular Atrial Fibrillation

As patients in East Asia age,the prevalence of age-related and chronic disease,including nonvalvular atrial fibrillation,may increase.Although warfarin has been the primary choice of anticoagulant for the prevention of stroke and systemic embolic events,the use of direct oral anticoagulants(DOACs)is increasing.DOACs do not require monitoring of the international normalized ratio to determine the optimal dose,and have a lower potential for food and drug interactions,improved benefi t-risk profiles,and a quicker onset and offset of action relative to warfarin.The pivotal phase 3 trials for each of the DOACs– dabigatran,rivaroxaban,apixaban,and edoxaban– included at least some East Asian patients.Additionally,several clinical trials were conducted specifically for East Asian patients.This review discusses patterns and predictors of anticoagulant use in East Asian patients with nonvalvular atrial fibrillation,summarizes current guideline recommendations for East Asian patients,details the primary results demonstrating the safety and efficacy of DOACs in East Asian patients relative to non– East Asian patients,provides real-world data supporting the phase 3 testing results,and addresses the clinical profile of DOACs in East Asian populations,including patients at high risk of stroke.

Variance in Clinical Profile and Use of Anticoagulants in Valvular and Non Valvular Atrial Fibrillation

Introduction: Atrial fibrillation is the most common cardiac arrhythmia encountered in clinical practice that affects morbidity and mortality to a large extent. This study was intended to determine various clinical profile and etiological factors in valvular and non-valvular atrial fibrillation and evaluate the usage of anticoagulants in them in the settings of developing nation like ours. Methods: A hospital based cross-sectional observational prospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Nepal for a period of sixteen months. All the patients with atrial fibrillation who were admitted in the cardiology department were included. The demographic profile, etiology, clinical features and the usage of anticoagulants were recorded. Results: A total of 175 patients with atrial fibrillation were enrolled in the study with 62% nonvalvular and 38% valvular cases. The overall mean age was 60 ± 16.79 years but among valvular atrial fibrillation, it was 47.9 ± 14.013 and among nonvalvular atrial fibrillation, it was 67.85 ± 13.507 years. Majority of patients were female (56%). Sixty percent were from outside Kathmandu valley. Rheumatic heart disease was the most common cause (38.9%) followed by dilated cardiomyopathy, systemic hypertension, degenerative valvular heart disease, coronary artery disease, etc. The most common presentation was dyspnea. About 79% of valvular and 17% of nonvalvular atrial fibrillation patients were using anticoagulants. Conclusion: Atrial fibrillation was common in young females and rheumatic heart disease was the leading cause. There was inadequate use of anticoagulants in both valvular and nonvalvular atrial fibrillation probably due to the economic constraints and geographical hurdles.