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Direct Oral Anticoa...
Direct Oral Anticoagulants Versus Warfarin Across the Spectrum of Kidney Function : Patient-Level Network Meta-Analyses From COMBINE AF
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- Harrington, Josephine (författare)
- Duke Univ, Dept Med, Div Cardiol, Durham, NC USA.;Duke Clin Res Inst, Durham, NC USA.
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- Carnicelli, Anthony P. (författare)
- Med Univ South Carolina, Dept Med, Div Cardiol, Charleston, SC USA.
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- Hua, Kaiyuan (författare)
- Duke Clin Res Inst, Durham, NC USA.
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- Wallentin, Lars, 1943- (författare)
- Uppsala universitet,Kardiologi,Uppsala kliniska forskningscentrum (UCR)
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- Patel, Manesh R. (författare)
- Duke Univ, Dept Med, Div Cardiol, Durham, NC USA.;Duke Clin Res Inst, Durham, NC USA.
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- Hohnloser, Stefan H. (författare)
- Goethe Univ Frankfurt, Dept Cardiol, Frankfurt, Germany.
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- Giugliano, Robert P. (författare)
- Brigham & Womens Hosp, Cardiovasc Div, TIMI Study Grp, Boston, MA USA.;Harvard Med Sch, Boston, MA USA.
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- Fox, Keith A. A. (författare)
- Univ Edinburgh, Div Med & Radiol Sci, Edinburgh, Scotland.
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- Hijazi, Ziad (författare)
- Uppsala universitet,Kardiologi
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- Lopes, Renato D. (författare)
- Duke Univ, Dept Med, Div Cardiol, Durham, NC USA.;Duke Clin Res Inst, Durham, NC USA.
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- Pokorney, Sean D. (författare)
- Duke Univ, Dept Med, Div Cardiol, Durham, NC USA.;Duke Clin Res Inst, Durham, NC USA.
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- Hong, Hwanhee (författare)
- Duke Clin Res Inst, Durham, NC USA.
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- Granger, Christopher B. (författare)
- Duke Univ, Dept Med, Div Cardiol, Durham, NC USA.;Duke Clin Res Inst, Durham, NC USA.
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Duke Univ, Dept Med, Div Cardiol, Durham, NC USA;Duke Clin Res Inst, Durham, NC USA. Med Univ South Carolina, Dept Med, Div Cardiol, Charleston, SC USA. (creator_code:org_t)
- Lippincott Williams & Wilkins, 2023
- 2023
- Engelska.
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Ingår i: Circulation. - : Lippincott Williams & Wilkins. - 0009-7322 .- 1524-4539. ; 147:23, s. 1748-1757
- Relaterad länk:
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https://urn.kb.se/re...
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https://doi.org/10.1...
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Abstract
Ämnesord
Stäng
- Background:There is uncertainty surrounding the use of direct oral anticoagulants (DOACs) in patients with kidney dysfunction. Methods:Using the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database (data from RE-LY [Randomized Evaluation of Long-term Anticoagulation 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], ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], and ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48]), we performed an individual patient-level network meta-analysis to evaluate the safety and efficacy of DOACs versus warfarin across continuous creatinine clearance (CrCl). A multivariable Cox model including treatment-by-CrCl interaction with random effects was fitted to estimate hazard ratios for paired treatment strategies (standard-dose DOAC, lower-dose DOAC, and warfarin). Outcomes included stroke and systemic embolism (S/SE), major bleeding, intracranial hemorrhage (ICH), and death. Results:Among 71 683 patients (mean age, 70.6 +/- 9.4 years; 37.3% female; median follow-up, 23.1 months), the mean CrCl was 75.5 +/- 30.5 mL/min. The incidence of S/SE, major bleeding, ICH, and death increased significantly with worsening kidney function. Across continuous CrCl values down to 25 mL/min, the hazard of major bleeding did not change for patients randomized to standard-dose DOACs compared with those randomized to warfarin (P-interaction=0.61). Compared with warfarin, standard-dose DOAC use resulted in a significantly lower hazard of ICH at CrCl values <122 mL/min, with a trend for increased safety with DOAC as CrCl decreased (6.2% decrease in hazard ratio per 10-mL/min decrease in CrCl; P-interaction=0.08). Compared with warfarin, standard-dose DOAC use resulted in a significantly lower hazard of S/SE with CrCl <87 mL/min, with a significant treatment-by-CrCl effect (4.8% decrease in hazard ratio per 10-mL/min decrease in CrCl; P-interaction=0.01). The hazard of death was significantly lower with standard-dose DOACs for patients with CrCl <77 mL/min, with a trend toward increasing benefit with lower CrCl (2.1% decrease in hazard ratio per 10-mL/min decrease in CrCl; P-interaction=0.08). Use of lower-dose rather than standard-dose DOACs was not associated with a significant difference in incident bleeding or ICH in patients with reduced kidney function but was associated with a higher incidence4 of death and S/SE. Conclusions:Standard-dose DOACs are safer and more effective than warfarin down to a CrCl of at least 25 mL/min. Lower-dose DOACs do not significantly lower the incidence of bleeding or ICH compared with standard-dose DOACs but are associated with a higher incidence of S/SE and death. These findings support the use of standard-dose DOACs over warfarin in patients with kidney dysfunction.
Ämnesord
- MEDICIN OCH HÄLSOVETENSKAP -- Klinisk medicin -- Kardiologi (hsv//swe)
- MEDICAL AND HEALTH SCIENCES -- Clinical Medicine -- Cardiac and Cardiovascular Systems (hsv//eng)
Nyckelord
- anticoagulants
- atrial fibrillation
- kidney
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- art (ämneskategori)
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Harrington, Jose ...
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Carnicelli, Anth ...
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Hua, Kaiyuan
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Wallentin, Lars, ...
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Patel, Manesh R.
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Hohnloser, Stefa ...
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Giugliano, Rober ...
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Fox, Keith A. A.
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Hijazi, Ziad
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Lopes, Renato D.
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Pokorney, Sean D ...
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Hong, Hwanhee
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Granger, Christo ...
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