Ying Bai

Rivaroxaban Versus Dabigatran or Warfarin in Real-World Studies of Stroke Prevention in Atrial Fibrillation: Systematic Review and Meta-Analysis

Background and Purpose— This study was designed to evaluate the effectiveness and safety of rivaroxaban in real-world practice compared with effectiveness and safety of dabigatran or warfarin for stroke prevention in atrial fibrillation through meta-analyzing observational studies. Methods— Seventeen studies were included after searching in PubMed for studies reporting the comparative effectiveness and safety of rivaroxaban versus dabigatran (n=3), rivaroxaban versus Warfarin (n=11), or both (n=3) for stroke prevention in atrial fibrillation. Results— Overall, the risks of stroke/systematic thromboembolism with rivaroxaban were similar when compared with those with dabigatran (stroke/thromboembolism: hazard ratio, 1.02; 95% confidence interval, 0.91–1.13; I2=70.2%, N=5), but were significantly reduced when compared with those with warfarin (hazard ratio, 0.75; 95% confidence interval, 0.64–0.85; I2=45.1%, N=9). Major bleeding risk was significantly higher with rivaroxaban than with dabigatran (hazard ratio, 1.38; 95% confidence interval, 1.27–1.49; I2=26.1%, N=5), but similar to that with warfarin (hazard ratio, 0.99; 95% confidence interval, 0.91–1.07; I2=0.0%, N=6). Rivaroxaban was associated with increased all-cause mortality and gastrointestinal bleeding, but similar risk of acute myocardial infarction and intracranial hemorrhage when compared with dabigatran. When compared with warfarin, rivaroxaban was associated with similar risk of any bleeding, mortality, and acute myocardial infarction, but a higher risk of gastrointestinal bleeding and lower risk of intracranial hemorrhage. Conclusions— In this systematic review and meta-analysis, rivaroxaban was as effective as dabigatran, but was more effective than warfarin for the prevention of stroke/thromboembolism in atrial fibrillation patients. Major bleeding risk was significantly higher with rivaroxaban than with dabigatran, as was all-cause mortality and gastrointestinal bleeding. Rivaroxaban was comparable to warfarin for major bleeding, with an increased risk in gastrointestinal bleeding and decreased risk of intracranial hemorrhage.

The Global Burden of Atrial Fibrillation and Stroke: A Systematic Review of the Clinical Epidemiology of Atrial Fibrillation in Asia

BACKGROUND: Our previous review reported great variability in the incidence and prevalence of atrial fibrillation (AF) in non‐Western cohorts, especially from Asian countries; in recent years, epidemiologic studies on AF have been increasingly reported from Asia. METHODS: The goal of this updated systematic review was to present the current knowledge base of AF epidemiology in Asian countries since our previous review. We also explored AF incidence and the risk of stroke in AF by using a meta‐analysis, with I2 testing the heterogeneity. Third, “real‐world” antithrombotic drug use for ischemic stroke (IS) prevention associated with AF was studied. RESULTS: A total of 58 articles from eight countries in Asia were included in the analysis. The summary annual incidence of AF was 5.38 (95% CI, 4.53–6.24; I2 = 99.5%; n = 10) per 1,000 person‐years, and the IS annual risk in AF was 3.0% (1.60%‐4.95%; I2 = 99.8%; n = 8) when meta‐analysis was performed on hospital‐ and community‐based studies. Hospital‐ and community‐based AF prevalence ranged from 0.37% to 3.56% and 2.8% to 15.8%, respectively. IS prevalence in AF ranged from 1.9% to 6.0% and 0.36% to 28.3% in community‐ and hospital‐based studies. Warfarin use in Chinese subjects is relatively low (1.0%‐4.1%) compared with Japanese subjects (49.1%‐70.0%) in community‐based studies. The rate of warfarin use was < 50% in hospital‐based studies. CONCLUSIONS: The incidence and prevalence of AF have increased in recent years, although great variability still exists in Asian countries. Variability in annual IS risk in patients with AF was apparent between hospital‐ and community‐based studies. However, the rate of warfarin use was < 50% in hospital studies from Asian countries.

Clinical scores for outcomes of rhythm control or arrhythmia progression in patients with atrial fibrillation: a systematic review

Patients with atrial fibrillation (AF) are commonly managed with rhythm control strategy, but the natural history of this common arrhythmia leads itself to progression from paroxysmal to persistent or permanent AF, and recurrences are evident despite rhythm control treatments using cardioversion or catheter ablation. Numerous clinical factors have been associated with outcomes of rhythm control or arrhythmia progression in patients with AF. The more common factors have been used to formulate risk stratification scores, to help predict the outcomes of rhythm control treatments or AF progression. This review article provides an overview on the published clinical risk scores related to outcomes of rhythm control strategy or AF progression.

Effectiveness and safety of oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-regression analysis

Background and objectiventhe study analysed the effectiveness and safety of warfarin use compared with warfarin non-use and non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients aged ≥65 years.nnnMethodsnafter searching PubMed and the Cochrane Library, 26 studies were included, with 10 comparing warfarin with warfarin non-use and 16 comparing warfarin with NOACs, in older AF patients (≥65 years).nnnResultsnwarfarin use was superior to no antithrombotic therapy [relative risk (RR) 0.59, 95% confidence interval (CI) 0.51-0.76, I2 = 12.3%, n = 8] and aspirin (RR 0.44, 95% CI 0.24-0.64, I2 = 0.0%, n = 5) for stroke/thromboembolism (TE) prevention. Warfarin use was associated with a non-significant increase in risk of major bleeding compared with no antithrombotic therapy (RR 1.26, 95% CI 0.99-1.52, I2 = 0.0%, n = 7) and aspirin (RR 1.20, 95% CI 0.91-1.50, I2 = 0.0%, n = 5). NOACs were superior to warfarin for stroke/TE prevention [hazard ratio (HR) 0.81, 95% CI 0.73-0.89, I2 = 56.6%, n = 9], and also were associated with reduced risk of major bleeding compared to warfarin (HR 0.87, 0.77-0.97, I2 = 86.1%, n = 9).nnnConclusionsnwarfarin use was superior to warfarin non-use, aspirin and no antithrombotic therapy in reducing the risk of stroke/TE in older AF patients, but with a possible increase in major bleeding. NOACs were superior to warfarin for stroke/TE prevention, with reduced risk of major bleeding.

Meta-Analysis of Effectiveness and Safety of Oral Anticoagulants in Atrial Fibrillation With Focus on Apixaban

We performed a meta-analysis of data on the effectiveness and safety of apixaban compared with other oral anticoagulants (warfarin or rivaroxaban or dabigatran or edoxaban) for stroke prevention in atrial fibrillation (AF) in different settings of randomized controlled trials, real-world studies, and radiofrequency ablation (RFA). Thirty studies were searched in PubMed, the Cochrane Library, and Clinicaltrials.gov databases reporting comparative effectiveness and safety of apixaban with warfarin (nu2009=u200923), rivaroxaban (nu2009=u200912), dabigatran (nu2009=u200913), or edoxaban (n = 2) for stroke prevention in AF. In real-world estimates, apixaban was similar to warfarin for the prevention of stroke or systematic thromboembolism (hazard ratio 0.93, 95% CI 0.71 to 1.14, I2u2009=u200982.9%, Nu2009=u20097), and safer than warfarin in the risks of major bleeding (hazard ratio 0.62, 95% CI 0.54 to 0.70, I2u2009=u200918.7%, Nu2009=u20099) in patients with AF. The risk of stroke or thromboembolism with apixaban was similar to rivaroxaban, dabigatran, and edoxaban in the settings of real-world studies and RFA. Major bleeding with apixaban was generally lower than rivaroxaban (relative risks 0.45, 95% CI 0.38 to 0.53, I2u2009=u20090%, Nu2009=u20095) and similar to dabigatran in real-world studies (relative risks 1.44, 95% CI 0.33 to 6.30, I2u2009=u200997.7%, Nu2009=u20095), but similar to rivaroxaban, dabigatran, and edoxaban in RFA. In conclusion, our meta-analysis provides a comprehensive estimate of the effectiveness and safety of apixaban compared with other oral anticoagulants (warfarin, rivaroxaban, dabigatran, and edoxaban) in patients with AF in different settings of randomized controlled trial, real-world studies, and RFA.

Ischemic stroke risk in East Asian patients with CHA2DS2-VASc score of 1: systematic review and meta-analysis

ABSTRACT Background: The use of anticoagulation for stroke prevention in patients with atrial fibrillation (AF) and CHA2DS2-VASc score of 1 has been debated, partially due to limited data on ischemic stroke risk and specific clinical trials in these patients. East Asian patients have a different stroke risk profile compared to non-East Asians. We performed a systematic review and meta-analysis of ischemic stroke risk in AF patients with a CHA2DS2-VASc score of 1 in East Asian countries. Methods: A comprehensive literature search for studies evaluating ischemic stroke risk related with AF with CHA2DS2-VASc score of 1 was conducted by two reviewers. We used a fixed-effect model first, then a random-effect model if heterogeneity was assessed with I2. Results: After pooling 6 studies, the annual rate of ischemic stroke in East Asian patients with AF and a CHA2DS2-VASc score of 1 was 1.66% (95% CI: 0.71%-2.61%, I2 = 98.4%). There was a wide range in reported pooled rates between countries, from 0.59% to 3.13%. Significant difference existed not only in the community-based studies (Chinese: 2.10% vs. Japanese: 0.60%), but also from the hospital-based studies (Chinese: 3.55% vs. Japanese: 0.42%). Confining the analysis to those on no antithrombotic treatment had limited effect on the summary estimate (eg. Chinese: 4.28% vs. Japanese: 0.6%). In Chinese studies, ischemic stroke rate was lower in females than males (female: 1.40% vs. male: 1.79%). However, the low event rate in Japanese studies may reflect unrecorded anticoagulation status at follow-up. Conclusions: Some regional differences between East Asian countries were observed for ischemic stroke risk in patients with a CHA2DS2-VASc score of 1. This may reflect methodological differences in studies and unrecorded anticoagulation use at followup, but further prospective studies are required to ascertain ischemic stroke risks, as well as the differences and reasons for this between East Asians and non-East Asians.

Modelling projections for the risks related with atrial fibrillation in East Asia: a focus on ischaemic stroke and death

AimsnIn the Far East, there has generally been low uptake of oral anticoagulants (OACs) using vitamin K antagonists (VKA, e.g. warfarin) for stroke prevention in atrial fibrillation (AF), but OAC use has been increasing more recently, with the introduction of the non-vitamin K antagonist oral anticoagulants (NOACs). To explore the risks of ischaemic stroke (IS) and death related to AF in East Asia using modelling projections.nnnMethods and resultsnWe performed a modelling analysis of possible trends of IS and death rates in AF patients from the time period of only VKA use to current increasing trends of NOAC use projecting until 2050 in East Asia. Data from published articles on the prevalence of AF, IS, and death were used to model estimated event rates. In 2030, the estimated AF population in East Asia will be 608xa0100, with the use of NOACs leading to a reduction of 82xa0259 ISs and 16xa0917 deaths. There was an estimated annual risk reduction of 5484 ISs and 1128 deaths from 2016 to 2030, respectively. The AF population is estimated to reach 861xa0900 in 2050, with a reduction of 206xa0315 ISs and 139xa0353 deaths.nnnConclusionnThis modelling analysis suggests that the transition from VKA to NOACs may greatly help in reducing the burden of IS and death caused by AF in the East Asian region.

Using the MB-LATER score for predicting arrhythmia outcome after catheter ablation for atrial fibrillation: The Guangzhou atrial fibrillation project

Several clinical scoring systems have been derived to predict the arrhythmia outcome of catheter ablation (CA) for atrial fibrillation (AF) but which is better is not clear. Simple clinical risk scores (that any clinician can use in the everyday clinic) can help assess the likelihood of recurrence of AF following CA and the simple MB‐LATER score has recently been described. We compare the predictive ability of seven existing clinical scoring systems (HATCH, CHADS2, CHA2DS2‐VASc, BASE‐AF2, APPLE, CAAP‐AF, and MB‐LATER) in a Chinese cohort of AF patients undergoing CA.

Differences of Matrix Metalloproteinase 2 Expression between Left and Right Ventricles in Response to Nandrolone Decanoate and/or Swimming Training in Mice

Background: Matrix metalloproteinase (MMP)-2 plays an important role in the remodeling of left ventricles (LVs) and right ventricles (RVs). We investigated the differences of MMP-2 expression between LV and RV in response to nandrolone decanoate (ND), swimming training (ST), and combined ND and ST (NS) in mice, based on their structural, functional, and biochemical characteristics. Methods: Totally 28 male C57B1 mice (6 weeks old; 20–23 g) were divided into four groups, including the control (n = 7), ND (n = 6), ST (n = 8), and NS (n = 7) groups. After respective treatments for 8 weeks, echocardiographic examination was used to assess the cardiac structure and function. Van Gieson stain was used to examine the fibrosis of LV and RV in response to different treatments, and Western blotting analysis was performed to explore different MMP-2 expressions between LV and RV in response to ND and/or ST. Analysis of variance was used for comparing the four groups. Results: At 8 weeks, right ventricular dimension/body weight in the ND group was larger than the other three groups (F = 7.12, P < 0.05) according to the echocardiographic examination. Fibrosis induced by ND administration was increased more in RV (2.59%) than that in LV (2.21%). MMP-2 expression of the ND group in RV was significantly greater than the control and NS groups in RV and the corresponding ND group in LV. Conclusion: The experimental data support the hypothesis that ND administration induces greater MMP-2 expression increase in RV compared to LV, leading to consequent RV dilation.

Estimated Effectiveness and Safety of Nonvitamin K Antagonist Oral Anticoagulants Compared With Optimally Acenocoumarol Anticoagulated “Real-World” in Patients With Atrial Fibrillation

Nonvitamin K antagonist oral anticoagulants (NOACs) have been proposed as an alternative to vitamin K antagonists in atrial fibrillation (AF) patients but the comparative benefits between NOACs and optimally anticoagulated patients is unknown. We estimated the absolute benefit in clinical outcomes rates of real-world effect of NOACs in optimally anticoagulated AF patients with acenocoumarol. We included 1,361 patients stable on acenocoumarol with time in therapeutic range of 100% and 6.5xa0years of follow-up. Estimation of clinical events avoided was calculated applying hazard ratio, absolute and relative risk reduction from the real-world meta-analysis. Compared with an optimally anticoagulated population, dabigatran 110xa0mg had the highest estimated stroke reduction (0.97%/year vs 1.47%/year; pu202f=u202f0.002), and the benefit was higher than in RE-LY trial. For major bleeding, apixaban showed the highest estimated reduction (1.81%/year vs 2.83%/year; p <0.001). For mortality, the largest estimated reduction was with apixaban (2.68%/year). For gastrointestinal bleeding, only apixaban had a significant reduction compared with acenocoumarol (0.69%/year vs 1.10%/year; pu202f=u202f0.004), and the reduction was significantly higher than in ARISTOTLE trial. All NOACs showed significantly lower rates for intracranial hemorrhage and had a positive Net Clinical Benefit compared with acenocoumarol. Apixaban showed the highest extended estimated Net Clinical Benefit 2.64 (95%CI 2.34 to 2.96). In conclusion, in optimally acenocoumarol anticoagulated AF patients, estimated reductions in all clinical outcomes with various NOACs are evident, with the best effectiveness and safety profile with apixaban. Indeed, the estimated effect with real world NOACs would probably be higher than that seen in phase-III clinical trials.