Abstract
Purpose
The purpose of this study was to analyze the association between bleeding events and coagulation assays including activated partial thromboplastin time (APTT) and prothrombin time (PT), and to determine the risk factors for bleeding in Chinese patients with non-valvular atrial fibrillation (NVAF) receiving dabigatran.
Methods
We conducted a retrospective cohort study including NVAF patients receiving dabigatran 110 mg twice daily between March 2016 and November 2017. We obtained the clinical features and demographic data from the medical records and compared the baseline characteristics of the bleeding group and the no bleeding group. Receiver operating characteristic(ROC) curves and a logistic regression model were used to determine the relation between APTT and bleeding events and the predictors of bleeding. Model performance was evaluated using the derivation cohort and an independent validation cohort by area under the ROC curve (AUC).
Results
A total of 346 patients were included and bleeding events occurred in 39 (11.2%) patients. Patients with age over 65 years (OR = 2.56 [95% CI 1.20–5.43]), hypertension (OR = 2.42 [95% CI 1.11–5.26]), decreased renal function (OR = 4.27 [95% CI 1.22–14.91]) and with concomitant use of an antiplatelet drug (OR = 3.53 [95% CI 1.28–9.74]) showed higher risk for bleeding, and APTT value of the bleeding group was higher than the no bleeding group (P = 0.014). By ROC analysis we found that the appropriate overall cut-off value the of APTT ratio was 1.30, with a sensitivity of 72% and specificity of 58%. Multivariate logistic regression showed that higher age (P = 0.003; OR = 1.05 [95% CI 1.02–1.09]) and APTT ratio > 1.30 (P = 0.002; OR = 3.20 [95% CI 1.23–6.73]) were independent risk factors for bleeding in patients with dabigatran therapy. The logistic regression model exhibited moderate discrimination ability, with an AUC of 0.73 [95% CI 0.65–0.81] and 0.77 [95% CI 0.59–0.96] in the derivation cohort (n = 346) and the validation cohort (n = 71) respectively.
Conclusions
Our study demonstrated that APTT ratio > 1.30 (at trough level) and higher age were independent risk factors for bleeding, and the logistic regression model based on these two predictors showed moderate performance, which may be useful for assessment of bleeding risk in NVAF patients with dabigatran therapy.
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References
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37(38):2893–2962. https://doi.org/10.1093/eurheartj/ehw210
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW (2014) 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 64(21):e1–76. https://doi.org/10.1016/j.jacc.2014.03.022
Kannel WB, Wolf PA, Benjamin EJ, Levy D (1998) Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 82(8a):2n–9n
Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151. https://doi.org/10.1056/NEJMoa0905561
Hori M, Connolly SJ, Zhu J, Liu LS, Lau CP, Pais P, Xavier D, Kim SS, Omar R, Dans AL, Tan RS, Chen JH, Tanomsup S, Watanabe M, Koyanagi M, Ezekowitz MD, Reilly PA, Wallentin L, Yusuf S (2013) Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation. Stroke 44(7):1891–1896. https://doi.org/10.1161/strokeaha.113.000990
Nishino M, Okamoto N, Tanaka A, Mori N, Hara M, Yano M, Makino N, Egami Y, Shutta R, Tanouchi J (2016) Different risk factors for bleeding and discontinuation between dabigatran and rivaroxaban. J Cardiol 68(2):156–160. https://doi.org/10.1016/j.jjcc.2015.08.019
van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, Clemens A (2010) Dabigatran etexilate--a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 103(6):1116–1127. https://doi.org/10.1160/th09-11-0758
Shimomura D, Nakagawa Y, Kondo H, Tamura T, Amano M, Hayama Y, Onishi N, Tamaki Y, Miyake M, Kaitani K, Izumi C, Hayashida M, Fukuda A, Nakamura F, Kawano S (2015) Relationship between plasma dabigatran concentration and activated partial thromboplastin time in Japanese patients with non-valvular atrial fibrillation. Journal of Arrhythmia 31(4):183–188. https://doi.org/10.1016/j.joa.2014.11.003
Owada S, Tomita H, Kinjo T, Ishida Y, Itoh T, Sasaki K, Horiuchi D, Kimura M, Sasaki S, Okumura K (2015) CHA2DS2-VASc and HAS-BLED scores and activated partial thromboplastin time for prediction of high plasma concentration of dabigatran at trough. Thromb Res 135(1):62–67. https://doi.org/10.1016/j.thromres.2014.10.025
Reilly PA, Lehr T, Haertter S, Connolly SJ, Yusuf S, Eikelboom JW, Ezekowitz MD, Nehmiz G, Wang S, Wallentin L (2014) The effect of dabigatran plasma concentrations and patient characteristics on the frequency of ischemic stroke and major bleeding in atrial fibrillation patients: the RE-LY Trial (Randomized Evaluation of Long-Term Anticoagulation Therapy). J Am Coll Cardiol 63(4):321–328. https://doi.org/10.1016/j.jacc.2013.07.104
Schulman S, Kearon C (2005) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. Journal of Thrombosis and Haemostasis: JTH 3(4):692–694. https://doi.org/10.1111/j.1538-7836.2005.01204.x
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 137(2):263–272. https://doi.org/10.1378/chest.09-1584
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010) A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138(5):1093–1100. https://doi.org/10.1378/chest.10-0134
Thomas IC, Sorrentino MJ (2014) Bleeding risk prediction models in atrial fibrillation. Current Cardiology Reports 16(1):432. https://doi.org/10.1007/s11886-013-0432-9
Eikelboom JW, Wallentin L, Connolly SJ, Ezekowitz M, Healey JS, Oldgren J, Yang S, Alings M, Kaatz S, Hohnloser SH, Diener HC, Franzosi MG, Huber K, Reilly P, Varrone J, Yusuf S (2011) Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial. Circulation 123(21):2363–2372. https://doi.org/10.1161/circulationaha.110.004747
Poli D, Antonucci E, Marcucci R, Fatini C, Alterini B, Mannini L, Falciani M, Abbate R, Gensini GF, Prisco D (2007) Risk of bleeding in very old atrial fibrillation patients on warfarin: relationship with ageing and CHADS2 score. Thromb Res 121(3):347–352. https://doi.org/10.1016/j.thromres.2007.05.014
Gong IH, Hwang J, Choi DK, Lee SR, Hong YK, Hong JY, Park DS, Jeon HG (2012) Relationship among total kidney volume, renal function and age. J Urol 187(1):344–349. https://doi.org/10.1016/j.juro.2011.09.005
Blech S, Ebner T, Ludwig-Schwellinger E, Stangier J, Roth W (2008) The metabolism and disposition of the oral direct thrombin inhibitor, dabigatran, in humans. Drug Metabolism and Disposition: the Biological Fate of Chemicals 36(2):386–399. https://doi.org/10.1124/dmd.107.019083
Friberg L, Rosenqvist M, Lip GY (2012) Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 33(12):1500–1510. https://doi.org/10.1093/eurheartj/ehr488
Nagarakanti R, Wallentin L, Noack H, Brueckmann M, Reilly P, Clemens A, Connolly SJ, Yusuf S, Ezekowitz MD (2015) Comparison of Characteristics and Outcomes of Dabigatran Versus Warfarin in Hypertensive Patients With Atrial Fibrillation (from the RE-LY Trial). Am J Cardiol 116(8):1204–1209. https://doi.org/10.1016/j.amjcard.2015.07.032
Brambatti M, Darius H, Oldgren J, Clemens A, Noack HH, Brueckmann M, Yusuf S, Wallentin L, Ezekowitz MD, Connolly SJ, Healey JS (2015) Comparison of dabigatran versus warfarin in diabetic patients with atrial fibrillation: Results from the RE-LY trial. Int J Cardiol 196:127–131. https://doi.org/10.1016/j.ijcard.2015.05.141
Dans AL, Connolly SJ, Wallentin L, Yang S, Nakamya J, Brueckmann M, Ezekowitz M, Oldgren J, Eikelboom JW, Reilly PA, Yusuf S (2013) Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 127(5):634–640. https://doi.org/10.1161/circulationaha.112.115386
Oldgren J, Wallentin L, Alexander JH, James S, Jonelid B, Steg G, Sundstrom J (2013) New oral anticoagulants in addition to single or dual antiplatelet therapy after an acute coronary syndrome: a systematic review and meta-analysis. Eur Heart J 34(22):1670–1680. https://doi.org/10.1093/eurheartj/eht049
Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY (2012) Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol 60(9):861–867. https://doi.org/10.1016/j.jacc.2012.06.019
Hijazi Z, Oldgren J, Lindback J, Alexander JH, Connolly SJ, Eikelboom JW, Ezekowitz MD, Held C, Hylek EM, Lopes RD, Siegbahn A, Yusuf S, Granger CB, Wallentin L (2016) The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study. Lancet (London, England) 387(10035):2302–2311. https://doi.org/10.1016/s0140-6736(16)00741-8
Huisman MV, Lip GY, Diener HC, Brueckmann M, van Ryn J, Clemens A (2012) Dabigatran etexilate for stroke prevention in patients with atrial fibrillation: resolving uncertainties in routine practice. Thromb Haemost 107(5):838–847. https://doi.org/10.1160/th11-10-0718
Cuker A, Siegal DM, Crowther MA, Garcia DA (2014) Laboratory measurement of the anticoagulant activity of the non-vitamin K oral anticoagulants. J Am Coll Cardiol 64(11):1128–1139. https://doi.org/10.1016/j.jacc.2014.05.065
Pipilis A, Makrygiannis S, Anagnostou G, Kaliampakos S, Tsakonas G, Sourlas N, Mallios P, Kostelidou T (2017) Dabigatran plasma levels, aPTT and thromboelastography in patients with AF: implications for allowing early non-elective surgical procedures. J Thromb Thrombolysis 44(1):9–13. https://doi.org/10.1007/s11239-017-1503-3
Douxfils J, Mullier F, Robert S, Chatelain C, Chatelain B, Dogne JM (2012) Impact of dabigatran on a large panel of routine or specific coagulation assays. Laboratory recommendations for monitoring of dabigatran etexilate. Thromb Haemost 107(5):985–997. https://doi.org/10.1160/th11-11-0804
Kawabata M, Yokoyama Y, Sasano T, Hachiya H, Tanaka Y, Yagishita A, Sugiyama K, Nakamura T, Suzuki M, Isobe M, Hirao K (2013) Bleeding events and activated partial thromboplastin time with dabigatran in clinical practice. J Cardiol 62(2):121–126. https://doi.org/10.1016/j.jjcc.2013.03.010
Ho MH, Ho CW, Cheung E, Chan PH, Hai JJ, Chan KH, Chan EW, Leung GK, Tse HF, Siu CW (2014) Continuation of dabigatran therapy in "real-world" practice in Hong Kong. PLoS One 9(8):e101245. https://doi.org/10.1371/journal.pone.0101245
Funding
This study was supported by the Project of Shanghai Key Specialty Clinical Pharmacy.
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Q.J., Q.L. and X.L. designed the study. Q.J., Q.X. and Z.W. performed the research. Q.J. and X.L. analyzed data. Q.J., Q.L and X.L. prepared the manuscript.
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Ji, Q., Xu, Q., Wang, Z. et al. Association between activated partial thromboplastin time, age and bleeding events in NVAF patients receiving dabigatran. Eur J Clin Pharmacol 75, 321–328 (2019). https://doi.org/10.1007/s00228-018-2583-5
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DOI: https://doi.org/10.1007/s00228-018-2583-5